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PETSMART INC 1197 - ESTABLISHMENTS PETSMART INC. #1197 10 TRADERS WAY i. id 1 i N , a Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4th Floor Salem,MA 01970-3523 Tel. (978)741-1800 Fax (978) 745-0343 City/Town of �Jew, Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name ( Date Type of Operation(s) Type of Inspection 1 E] Food Service f Routine Address Risk EjrRetail ❑Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection _ ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑Pre-operation ❑ Caterer ❑Suspect Illness Person-In-Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint D In: ❑HACCP Inspector Out: Permit No. ❑Other Each violation chec ed requIres an explanation on the narrative page(s)and a citation of specific provision(s)violated. Noncompliance with: Violations Related to Foodborne Illness Interventions and Risk FactorsjRed Anti-Choking 590.009(E) ❑ oat ons marked may pose an imminent health hazard and require immediate Tobacco 690.009(F) [3 Allergen Awareness 690.009(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 PROTECTION FROM CHEMICALS ❑ 3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE ❑ 15.Toxic Chemicals ❑ 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 Pans ❑ 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 HIGHLYSUSCEPTIBLE.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): LJJ 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 (FC4)(5g0.005) 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)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPEC77ON:kexr D U+1 s: umo Inspector's Signature: Print: Ijf PICS Signature: Pri pl-e-e - Page of Pages 0 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 1 590.003(A) sci Ammem of Res onsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicantO 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* - Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306A4(A)(f3) Returned Food and Reservice of Food* 590.003(6) Reporting by Perso in Charge* Disposition of Adulterated or Contaminated 3 590.003(D Exclusions and Restrictions* Food - 590.003(E) Removal of L"xclusions 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-H) Compliance with Food Law* Sanitization Temperatures* 3-201. 2 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-2112.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products, Pasteurized* concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and 3-202.16 ice Made From Potable Drinking Water* Utensils Clean* 5.101.1 I Drinking Water from an Approved System* 4-602.11 Cleaning Frequency of Equipment Food- 590,006(A) Bottled DrinkingWater* Contact Surfaces and Utensils* 590.006 H Water Meets Standards in 310 CMR 22.0* 4-702.11 Frequency ol'Sanitization of Utensils and Shellfish and Fish From an Approved Source Food Contact Surfaces of E ui ment* 3-201.14 Fish and Recreationally Caught Molluscan 4-703.11 Methods of Sanitization-liot Water and Shellfish* Chemical* 3-201.15 Molluscan Shellfish from NSSP Listed 10 Proper,Adequate Handwashing ources 2-301.11 Clean Condition-Hands and Anus* Game and Wild Mushrooms Approved by 2-301.12 Cleaning Procedure* Re ulato Authoht 3-202.18 Shellslock 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* Montt* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tas(in * 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* 3-207.12 Shellslock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish ProductsConveniently Located and Accessible 3402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance 590,004(JLabeling of Ingredients' 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying Devices IHACCP Plans 6-301.11 liandwashing Cleanser,Availability 3-502.11 Specialized Processing Methods* 6-301.12 Hand Drying Provision 3-502.12 Reduced oxygen packaging,criteria* 8-103.12 Conformance with Approved Procedures* Denotes critical item in the rederal 1999 Food Code or 105 CNIR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 1-inc , Date: O�012-0_� Page: 2— of Z Rem Cods C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No, Reference R—Red Rem VMfied PLEASE PRINT LEARLY r o v w 2 20 112 s ` al r 4z Y- - -f 'Wl r. 7_G 5 5 2s' kw G k Noio,` L/ v Discussion With Person in Charge: Corrective Action Required: o No o as I have read this report, have had the opportunity to ask questions and agree to correct all o voluntary Compliance o Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dolls or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 1/ ❑ voluntary Disposal (3 Other: , Violations Related to Foodborne Illness Interventions and Risk 3-501.15 Cooling Methods for PHFs Factors(Items 1-22) (Cont.) 19 PHF Hot and Cold Holding PROTECTION FROM CHEMICALS 3-501.16(13) Cold PI Ws 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 U approved Additives* 140°F * 15 Poisonous or Toxic Substances 3-501.16(A) Roasts field 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-Stora e* 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* 2] 3-801.11(A) Unpasteurized Pre-packaged Juices 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 Drying Agents,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* 7-206.13 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.* - PHFs 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 1450Fl5sec* 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 IS sec. * catering,mobile food, tem ora ry and 3-401.11(6)(1)(2) Pork and Bee1'Roast- 130°F 121 min* residential kitchen operations should be 3-401.1 l(A)(2) Ratites,Injected Meats-155°F 15 sec. debited under the appropriate sections 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, 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 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 165°F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-401.1 I(A)(1)(b) All Other PHFs- 145°F 15 sec. * (Items 23-30) 17 Reheating for Hot Holding Critical and non-critical violations, which do not relate to the 3 403:1 I(A)&(1)) PIFs 105'F 15 sec. * foodbome illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 3-403.11(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(E) Remaining thisliced portions of Beef 25. Equipment and Utensils FC-4 .005 Roasts* 26. Water,Plumbing and Waste FC-5 .006 18 Proper Cooling of PHFs 2T Physical Facility FC-6 .007 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(A) Cooling Cooked PIFs from 140°F to 29, Special Requirements .009 70°F Within 2 Hours and From 70°F to 30. Other .. 410F/450I' Within 411011rs. * sssor�e.xo-=ate 3-501.14(!3) Cooling PIIFs Made From Ambient "Temperature Ingredients to 41°F/45°F Within 4 Hours* 3-501.14(C) PHFs Received at Temperatures According 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. 3^ CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4"FLOOR MAYOR TEL(978)741-1800 FAx(978)745-0343 LARRY RAMDIN,RS/RENS,CHO,CP-FS LRAMDINQSALHM.COM HEALTH AGENT COMPLAINT INTAKE FORM Date: Time: V Received By: Complaint Number: 0658 / Complainantl Address: p pSA� Phone: Investigated By: T). (-71 Date: Property Owner/Occupant Name Telephone #: 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 Citi /Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name -WrLn: z Type of Operation(s) T��YYYPPPe of Inspection 47 VAC r+- ❑ Food Service Routine Address �a/ _ Retail Re-inspection Tele hone ClQ/ Residential Kitchen Previous nspe on P _ S_ ❑ Mobile Date:yJab�Owner Temporary ❑Suspe t Illtltlonl ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) ❑ Bed 8 Breakfast ❑ General Complaint ❑ HACCPInspector Permit No. ❑.Other Each violation checkea 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) ❑ pose an imminent health hazard and require immediate Tobacco 590.009(F) Violations marked may ❑ y p 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 - _. _ _ - - _ . . -- - __ . .PROTECTIONFROWCHEMICALS _ _ _ ❑ 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded _. _ _.. - - _--_- - - ❑ 15.Toxic Chemicals FOOO'FROM APPROVEDSOURCE� _ _ _ - .. ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE"CONTROLS.(Potentlelty Haaidous Foods) ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling _ ,PROTECTION FROM CONTAMINATION - _ - _ ❑19.Hot and Cold Holding El8.Separation/Segregation/Protection _ ❑20.Time as a Public Health Control -- - .. - __.,. ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ,REQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATIONS;----- -..i ❑ 10. Proper Adequate Handwashing [121. Food and Food Preparation for HSP _ _ F-111. Good Hygienic Practices ,CONSUI EkADVISORY a ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 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 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc-aXs90.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food ( 26. Water, Plumbing and Waste (FCSX590.006) 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 REdNSPECTION: S: &radoc Inspector's Signature: Print: PLCs Signature: Print: 1 - Pagel of�Pages r 1 Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 ICross-contamination 1 590.003(A) Assignment ofResnsibiht * 3-302.11(A)(I) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* Contamination from Raw Ingredients 2-103.1 t Person in charge-duties 3-302.11(A)(2) Raw Anitmtl 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) FWd Protection* - require reporting by food employees and 3-302.15 Washing Fruits and Vegetables a Responsibility 3-304.11 Food Contact with Equipment and 590.003(P) Responsibility Of A Fcxxl Employee(h An * Utensils Applicant To Report The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003 G Re c n b Person in C:har>z* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Res r et ons 3-771.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE food* .4 Food and Water From Regulated Sources FT 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 Seated Container" Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products" 4-501.1 t2 Mechanical W'arewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 Eggs andMilk Products.Pasteurized* 4-50I A 1,4 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and baroness. ' 5-101A I Drinking Water from an Approved System* 4-601_11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Bets to Water' 4-602.11 Cleaning Frequency of-Equipment Food- 540.006(Il) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Souroe 4.702 11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Moliusaen Food Contact Surfaces of Equipment* Shellfish* Food Methods of Sanitization-Hot Water and 3-20LI5 Molluscan She[]fish from Nssp11sted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock identification.Present* 2-301.1.2 Cleaning Procedure* 590,004(C) Wild Mushrooms* 2-301.14 When to Rash* 3-201.17 Game Animals** 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11. Eatin ,Drinking or Using Tobacco* 3-202.1.1. PHFs Received at Proper Temperatures* 2401.12 Discharges.From the Eyes,Nose and 3-202.15 Package hue it`* Mouth* 3-101.1 i Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin * 6 TeysMecords: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" --II Em plo es* TagstRecords:Fish Products I 13 Handwash Facilities 3=402.11 Parasite Destruccioa* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11. . Numbers and Capacities* 7 - 590,004(1) Labeling of Ingredients' 5-204.11. Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Sp ecializsd Processing Methods* Devices 3-502:12 Reduced oxygen packaging,criteria* 6-301.11 Handwashin Cleanser,�Availabilit 8-103.!2 Conformance with roved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in-the Weral 1999 rood Code or 105 C-k4R 590.0(X). i CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: I j At-[13— Page:? of 2 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY u rf pit ryJ Ljo L4,Jr ( r o 1-7 Gtai2l- Cie d 11I R G Or A� 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 alluntary Compliance LlEmployee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension r comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-fiu ollars or suspension/revocation of ❑ Embargo L3 Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other. 3-501, _ 4(C) PHFs Received at Temperature t 1 ry Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to 4 Factors(Items 1-22) (Cont.) 41'F/45°F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501.15 C<wlin Met Col for PHFs 14 Food or Color Additives 19 PHF Hot and otd Holding i 3-5 3-202.12 Additives* 0L16(B) Cold PHFs Maintained at or below 1 Poisonous or Toxic 590.004(F) 4101450 F* ' 3-302.14 Protection from Unapproved Additives[ 3-501.16(A) - Hat PHFs Maintained at or above gg c Subslences _ * 7-101,11 Identifying Information-Original 140°F. 3-501.16(A) Roasts Held at of above 130°F.* Cordamers* - 20 Time as a Public Health Control 7-102,11. Compton Name-Working Containers* � * 3-501;t9 Time as a Public Health Contra 7?Ol.t I Separation-Stora [* 59Q.Otki{Hl Variance Requirement 7-202.11 .Restriction-Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE E 7-204.11 Sanitize"..Criteria-Chemicals* POPULATIONS NSF 21 3-8Q1.11(A) Unpasteurized Pre-packaged Juices and 7-204.1 Chemicals for Washing Produce,Criteria* Beveraees with Warning labels* 7-204.14 Drying Agents.Criteria* - 3-801.11(13) Use of Pasteurized E - 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* - Raw Seed Sprouts Net Served.' 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Packs E Not Re-served. S 7-206.13 Tracking Powders, Pest Control and Monitotin * CONSUMER ADVISORY TiMElTEMPERATURE CONTROLS - 22 3-(143.11 Consttmei Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or r 16 Proper Cooking Temperatures far Not Otherwise Processed to Eliminate PHF9 - Pio *Exaceve rn;zcxrr 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Egos-Immediate Service 145°Fl5sec* 3-302.13 Pasteari.wd Eggs Substitute for Raw Shell 3-001.11(A)(2) Comminuted Fish.Meats&Game E * Aminals-155°F 15 sec. SPECIAL REQUIREMENTS 3-401.11(8x1)(2) Pork and Beef Roast-130°F 121 moo* 3-40IA I(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.649(A)-(D)in i sec.* catering,mobile fold,temporary and t - 3-401.11(.A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other j 145*F" 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#39- Microwave 165F* Special Requirements. y 3-40LI l(A)(1)(b) All Other PHFs-145°F 15 sec. 7 fl7 Reheating for Hot Holding - - VIOLATIONS RELATED TO GOOD RETAIL PRACTICES C 3-403.11(A)&{D) PHFs 16ST 15 sec. * (Items 23-30) 3-403.11(13) Microwave--165°F 2 Minute Standing -Critical,and non-critical violations,which do not relate to the Time* - foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.060. y 3403.11(E) Remaining Unsliced Portions of Beef - t�GoodR"Practices I .FC 590.1700 Roasts* :_rM mpament and personnel FC-2 .003 Ig Proper Gaoling of PHFs 1 24. Food and Food Protection FC-3 .004 25. 1 Equipment and Utensils i FG-4 .1765 I l 3-501.14(A) Cooling Cooked PHFs from 140°F to 128, Water.Plumbing and waste 1 FC-5 .468 ' 70°F Within 2 Hours and From 70°F 27. j Ph sicai Faci' FC-8 007 to 41`F/45'F Within 4 Hours.* 128" Poisonous br Toxic Materials ! FC-7 .068 3-501.14(6) Cooling PRFs Made From Ambient X29. Special Requirements i 009 t Temperature Ingredients to 41°Ff456F 30. i Other i ! I Within 4 Hours* I 3 tknotw critical jam in the federal 1999 Foal Cade or 105 CMR 590.000. ti Commonwealih ot`Mas`sachusetts'- City of Salem01 K ` Board of Health �' Kimberley DnS6011 120 Washington Street,4th Floor T m _ Mayor,� _ SALEM,MA01970 Food/Retail Establishment'Permrt DATE PRINTED:6 12%11/2012 ESTABLISHMENT NAME: y ^!Petsmart;Inc.41.197 a p' 'File Number:BHF-2007-006601 nn�® Io Trader3Way b '- y yry- '` ten., , '.' SALEM �� MA 01970 " �- 1 LOCATED AT: 0010 TRADERS,WAY, FF SALEM; MA 01970 '� Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes e- RETAIL FOOD BHP-2013-0141 ; Jan,11 2013 "Dec 31,2013 $70.00 l Total Fees: $7Q.00 w < „ : � , - * r s - - 'S c'• - s 4 a' ax '•"� °' ' 8 .3 w s x x q 41 r PERMIT EXPIRES December 31 2013 :' F, w �A 1 Board of Health 9 7V J, �. '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: " ` a `• x r= In accordance with the State Sanitary Code beofre an .revonations,improvements,o'r equipment chan es are made` ,. � - ., Y YS , "all plans for such must be submitted to and approved by the Salem Board of Health , Page 1 , ,s• k _ k n �. _f ba c c PC, ; 4 ib " r CITY OF SALEM, ce MASSACHUSETTS ruwt�xeaim °,,, — _ BoARDofHeA1:01 ._ 12ASI[INc ON S"112cG"r,4",FI,00R IUMBERLEY DRISCOIS. TI;t..(978)741 1800 F.\\"(978)745-0343 LAItltY RAMDIN,RS/RHi-IS,CHO,CP-I,-8 MAYOR tramdin 2salcm.com - HF,\vrvi AGENT ,,,,Food"�stablishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: C 1 ail Nil TOC Q 2) Establishment Address: Lj 3)Establishment MailingAddress_(ifcIifferent):_A ;�°___ .. tN�e- - 4) Establishment Telephone No:. 5) Applicant Name&Title: N,1 gMr- I , Tw,, 6) Applicant Address: 1810/81 °o�� fb AJC �ygC�Ut � ��a 7) Applicant Telephone No: 24 Hour Emergency No: Email: 8) 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 association Name Title Home Address cor oar ions An indivirTual Pl - A partnership Other legal entity 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: m RRl< 6C yj Address: Telephone No: ZI1"7/ Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: / \ Check#: y Date/ 4/'a— Amount: Food Establishment Information 14) Water Source: o B u ti 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) TU b k4 16) Days and Hours of Operation:m-e3rK 'JtW (Q17) 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): D Yes No 20) Location: 22) Establishment Type(check all that apply) (check enel Retail( Sq. Ft) ❑ Caterer <]; pgnt Str� ucture ❑ 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 RESTAANT UR ---------------------------- Annual Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 Temporary/Dates/Time: - -------------------------------------------------------------------------------------------------------- ❑Bed&BreakfaW-hildcare Services/Nursing Home $100 ------------ ----------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare&private clubs) 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PRFs-non-potentially hazardous food(no timeltemperature controls required) check all that apply): - RTE-readydo=eat foods-(Ex.sandwiches,salads, muffins which need no further processing §,-A"f Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held V 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 „I Retail Sale Events or Institutional Food Service "I Offers RTE PHF in Bulk Quantities � To be completed by the Board ofHealth Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: .b Payment is due with application I� e 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 Applican `ifGl//1� '�uFiS� d l rriL�511 f >✓B�yt %�j117iY/yl,(yV�- , Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1,to my best knowledge and belief, Have filed all state tax returns and paid state taxers required under law. 25) Social Security Number or Federal ID: zl-30o249,25/1 26) Signature of Individual or Corporate Name: ~ '11 I PetSmart,Inc. OFFICERS Executive Chairman of the Board & Chief Executive Officer Robert F. Moran 19601 N 27th Ave. Phoenix, Arizona 85027 President & Chief Operating Officer David K. Lenhardt 19601 N 27th Ave. Phoenix, AZ 85027 Executive Vice President & Chief Financial Officer Lawrence P. Molloy 19601 N 27th Ave. Phoenix, Arizona 85027 Senior Vice President, General Counsel & Secretary Paulette Dodson' 19601 N 27th Ave. Phoenix, Arizona 85027 Vice President, Assistant Secretary & Deputy General Counsel J. Dale Brunk 19601 N 27th Ave. Phoenix, Arizona 85027 R Massachusetts Department of Public Health Salem Board of Health Division 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 7HACCP Type of Operation(s) of Inspection ❑ Food Service Routine -Address Retail ❑Re-inspection Telephone 1 a Residential Kitchen Previous i7pyion S^ ai( ❑ Mobile Date: 1 to Owner YIN ❑ Temporary ❑Pre-op ra on Q T ❑ Caterer ❑Suspect Illness Person-in-C rge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In; '3 0� ❑ HACCP Inspector Out:r 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) ❑ Vipose an imminent health hazard and require immediate Tobacco 590.009(F) Violations marked may ❑ y p q Allergen Awareness 580.009(G) ❑ corrective action as determined by the Board of Health. , r .�: , F000P_ROTECTION.MANAGEMENT__. 71 ❑ 12. Prevention ofContamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑13. Handwash Facilities - f EMPLOYEE HEALTH-, 'PROTECTION FROWCHEM)CALS� El 2. Reporting of Diseases by Food Employee and PIC E] 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded 7OOD __� ' , ❑ 15 Toxic Chemicals FOOD FROM.APPROVED SOURCE-___'- TIMEITEMPERATURE CONTROLS(PoteMlally'Harardous F.o'o'da) F1 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION_FROM CORTAMINATION ❑ 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.HIGHLY4USCEPTI6LE-POPULATIORS;;(H8P): El21.Food and Food Preparation for HSP El 10. Proper Adequate Handwashirig _ El11.Good Hygienic Practices 'CONSUME RAADMSQRY ❑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 23. Management and Personnel (Fc-2g59o.o03) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations 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 Water, Plumbing and Waste (FC-5X590.006) the 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-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: I ��tY� Inspector's Signature: Print: �"``VVU J PICsSignature: V Print: (,� 2S(,- fageLofdPages i^. Yj^i-r -� ' �. - �!.-�4 `l L, . .1 �-.,/:a ... �. x r•'Y. .h`t.r,v..`..-'J Violations Related to Foodborne Illness _ Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(.0) Asia meat of Respoosibih[y* -� Cooked and RTE Fonds* 590.003(6) Demonstration of Knowledge"` - Contamination from Raw ingredients 2-103.11 Person in charge-duties 3-302A I(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590,003(C) Responsibility of the person in charge to 3-302.11(A - Food Protection* require reporting by food employees and 3-302.15 Washing Fruits.and Vegetables applicants* 3-304,11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Applicant To Report To The Person In Utensils Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003G) Reporting b Personinions*Charge* Disposition of Aduterated or Contaminated 3 .590.003(D) Ezelusions and Restrictions* Food 590,003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1 Food and Water From Regulated Sources 9 _ Food Contact Surfaces 590.004(A-B) Cem liance with Food Law* -- 4-501.17 t Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing- ,Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures*. 3-202.14 _ULs and Milk PrLdnCLS,Pasteurized* 4-501.11.4 Chemical Sanitization-temp.,pH, 3-202.1.6 h:e Made From Potable Drinking Water* concentration and hardness. * 5-'101.11 Drinking Water from any roved System* 4-60 L 11(A) Equipment Food Contact Surfaces and 590,006(A) Bottled Drinking Water" Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Shelrsh and Fish Fran an Approved Source Contact Surfaces and Utensils* 4-702.1 t Frequency of Sanitization of Utensils and Shellfish* 3-201.14 Fish and Roc ea onal[y Caught Maliuscan Food Contact Surfaces of Equipment* 4-703-11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from N55F lasted Chemical* Gameeand Sources*m10 Proper,Adequate Handwashing Re utatoAuRnAurWiltorl AAashrooms Approved by 2-301.11 - Clean Condition-Hands and Atms* _ 3-202.18 Shellstc.ck identification Present" 2-301.12 Cleaning Procedure* 590.004 C) Wild Musluooms* 2-301.24 When to Wash* 3-201.17 Game.Animals* - 11 Good Hygienic Practices $ Receiving/Condition 2401.11. Eating,Drinking or Using Tobacco* 3-202.11 PRFs Received at Proper Tem ratures$ 2-401.12 Discharges.From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.1 l _ _Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Rerwds:Shelistock 12 . Prevention of Contamination from Hands 3-202.18 -Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* - Employees* Tags/Records;Fish Products 13 Handwash Facilities 3-40^<.1I 1 Parasite Dcetructiori* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11. Numbers and Capacities* 590.004( Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.1,1Accessibil ty,Operation and Maintenance /HACCP Plans Supphad with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502:12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures" -6-301.12 Hand Drying Provision 'Denotes criticafitem inthe Weral 1999 17w)d Code m 105 CMR 590.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: 02- of Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 140. Reference R—Red Item Verified PEASE PRINT CLEARLY �GVL C l I V N Y Y<.QCA c v Discussion With Person in Charge: Corr lve Action Required: C3No Yes I have read this report, have had the opportunity to ask questions and agree to correct all voluntary Compliance L3 Employee Restriction r Exclusion violations before the next inspection, to observe all conditions as described,and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code.!,uR4erstand that noncompliance may result in daily fines of tw y-five d rs suspension/revocation of ❑ Embargo El Emergency Closure your food permit. ❑ voluntary Disposal ❑ Other: - 3-501.14(0) PHFs Received at Temperatures Violations Related to Foodttonne Illness.Interventions and Risk According to law Cooled to Factors(Itetns 1-22) (Cant.) 41'F/45°F Within Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs - 19 _ PNF Hot and Cold Holding 14 Food or Color Additives 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41'035'F* 3-302.14 Protection from Una Duel.odd aves'f 3-50L16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances _ - 140`F * - 7-101.11 Identifying Information-original 3.501.16(A) Roasts Held at or above 130'F. Containers* 20 Time as a Public Health Contra] 7-102.11, Common Name-Working Containers* 7-201.11 Separation-Stora * 3-501:19 - Tuna as a Public Health Control* 590.004(H) Variance Requirement 7-202.11 .Restriction-Presence and Use* 7-202.12 Conditions of Use* 7-203POP .11 'Toxic Containers-Prohibitions* REQUIREMENTSFOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(A) BeverngesUnpasteurwit Pre-packaged Juices and .Beveraues with Warning Labels* 7-204.14 Drying Agents.Criteria' 9-801.1 I(B) Use of Pasteurized Eggs* - 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or,Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,'Criteria* Raw Seed Sprouts Not Served, 7-206.12 Rodent Bait Station,* 3-$01.11(C) Unopened Fax]PackageNot Reserved. 7-206.13 Tracking Powders,Pest Control and Monitoring' CONSUMER ADVISORY TIMET TEMPERATURE CONTROLS 22 3-603'11 1 Consumer Advisory Pasted for Consumption of 16 Proper Cooldng Temperatures for Animal Foods That are Raw-,Undercooked or PHFs - Not Otherwise-Processed to Eliminate 3-401.I1A(i)(2) Eggs- 155°F 19 Sec. Pathogens.'eRe n�,n za l Egg:Immediate Service 145°FlSset:a 3-302.13. PEasteurized Eggs Substitute for Raw Shell 3.4011(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec. * SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.3I(A)(2) Ratites,Injected Meats-155'F 15 sec.* catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meet, debited under the appropriate sections Poultry or Ratites-1 tis°F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to goal retail 3-401.12 Raw Animal Fowls Cooked in a practices should be debited under#39- Microwave 165F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec. try Reheating for Not Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165"F 15 see. * (Itairs 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness internentions and riskfacrors listed above, can he l 3-403,11(C) Commercially Processed RTE Ford- found in the follonzng sections-of the Food Code and JOS CMR 140°F* 590.000. 3-403.11(E) - Remaining Unsliced Purtimi of Beef - Itern I Good Retail Practices .FC 59II.OD0 !, Roasts* 123. 1 Man and Management Personnel -0-2 .003 ` 1- 1S Proper Cooling of PRFs 24 i Food and Food Protection ' FC-3 -3 .004 1 25. 1 Equipment and Utensils _! FC-d .005 i 3-501.14(A) Cooling Cooked PHFsfrom 140°F to ! 26, 1 Water.Plumbing and Waste I FC-5 .006 1 70°F Within 2 Hours and From 70°F 27. Physical Faditty W7 i to 41°F/45'F Within 4 Hours.* X28. Pasmwus or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made Fmm Ambient ' 29. ecial Requirements i _009 I Temperature Ingredients to 41°F/45°F 30 1 Other Within 4 Hours* Denotes uitical ivm in the fedora) w( Food Cale ur 10 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 Cit /Town of Address: FOOD ES7*BLlSHMltWT IN PECTION REPORT Tel. Name Date Type of Operatlon(s) Type of Inspection Address 1 1W Ris ❑ FoodService �R=ine ��' ❑ Re-inspection Telephone Level El Residential Kitchen Previous Inspection �- ❑ Mobile Date: Owner HACCP YfN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Ch rgeIC) Time ❑ Bed 8 reakfast El General Complaint In: � 1110 ElHACCP Inspector Out, ^ Permit N!ZgUon I ❑.Other Each violatio eked re uires an explanation on the narrative Va (s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) - Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) El - q ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD PROTECTION MANAGEMENT _ C312. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH - ❑ 13. Handwash Facilities - `- ''• .PROTECTION FROM'CHEMICALS a F-12. Reporting of Diseases by Food Employee and PIC ❑ - 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ... _. _ _ ._ ❑ 15. Toxic Chemicals El 4.Food APPROVED SOURCE o TIME TEMPERATURE-..CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source - .. . ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling PROTECTION FROM CONTAMINATION _y _ ! _ _ __ _ - , ❑ 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-SUSQEPTIBLE=POPULATIQNS'(HSP)`_ I El 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP _ F1 11. 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)t 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-2xs90.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3xs90.o94)) 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 (Fcsx590.006) 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-7x590.006) and submitted to the Board of Health at the above address 29. Special is (590.009) within 10 days of receipt of this order. 30. r UI t3 DATE OF RE-�tN/$q�PECT(ON: Inspector's St - �t�'U�✓�' PPd✓nit: {• •v PICS Signature: Print: ✓� Page-10 f Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 1 Cross-contamination 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) _Assig man ent of Res�onsibilit * Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* _ - Contamination from Raw Ingredients r2-103.11. Person in charge-duties 3-302.1.1(A)(2) Raw Animal Fonds Separated from Each Other* EMPLOYEE HEALTH Contamination tram the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Ve etables applicants* - 3-304.11 Food Contact with.Equipment and 59R003(F) Responsibility Of.4 Food Employee Or An Utensils* Applicant To Report To The Person In Chat * Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003 G Re orcin b Person in Charlie* 3 590.003(D) Eiclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-901,i'( Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Ford* 4 Food and Water From Regulated Sources 9 Food Contact surfaces 590.004(A-B) Compliance with Food Law* 4-501..11 I. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Seated Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.1 t2 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* - Sanitization Te eratures* 3-202.14 Eggs and 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 from an Approved System* 4-60 1A I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water' Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From, an Approved Source Contact Surfaces and Utensils*. 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recrea oaally Caught Mollusc"nFoal Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Flot Water and 3-201.15 Molluscan Shellfish from NSSF listed Chemical* Sources* 10 Proper;Adequate Handwashing Re MatoAuthorh Game and uARushrooms.4pp;oved by 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present` 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* t1 Good Hygienic Praagces S ReceivinglCondition 2-401.11 Eating,Drinking or Usi92 Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 . Discharges.From the Eyes,Nose and 3-202.15 Package Irate,it * _ Mouth* 3-101.1 i _ _food Safe and Unadulterated * 3-301.12 Preventin Contamination When Tasting* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-20312 Shellstock Identification Maintained* � Employees* Tags/Records:Flash 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* F7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Su lied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced ox en acka "ng,criteria 6-361.11 Handwashing Cleanser,Availability 8-103.!2 Confomancew hA ;oved Procedures* 6-301.1.2 HandD Provision *Denotes ciaical item in.the fmleral 1999 Pmrd eodc or 105 CMR 5911.0IX1. s Mag"sVchusetts Department Of `.Publlc Health; Salem Board of Health 120 Washington Street,4' Floor DivisiotYof Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name I'- 1 D e Type of Ooeration(s) Tvoe of Inspection r G C �" o� ❑ Food Service (�C Routine Address I _- ' u CES joJAV Risk 2rRetail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone f ❑ Mobile Date: r ) Owner I El Temporary ElPre-o/ritlon HACCP YM S rT- ❑ Caterer ❑ Suspect Illness Person in C argej(PIC) Time ❑ Bed&Breakfast ❑General Complaint In:�a a El HACCP Inspector Out:/ Permit No. ❑Other Each violation`c hecke 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) E] 590.009(F) E]action as determined by the Board of Health. II i FOOD PROTECTION T MANAGEMEN _. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties __ El 13. Handwash Facilities [EMPLOYEE HEALTH.. - --- --- I PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC i ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with,Infections Restricted/Excluded El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE_ _ El 4. Food and Water from Approved Source TIMErrEMPERATURE CONTROLS(Potentially Hazardous FOOda) . ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating El 7. 18. Cooling 7. Conformance with Approved Procedures/HACCP Plans 9 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), ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER..ADVISORY. ' t •. ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected ' To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel FC-3)( 90.0 4)) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(Sso.00a) 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 oL 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 PP29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 9w � 5:580116 dFw 14.E r / Inspector's Signature: Print: ` PIC's Signature: �� Print: /J Page oPages . 4 Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION $ Cross-comaminatton FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foals Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302.11(.0)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(0 Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting,by food employees and 3-302.15 1 Washing Fruits and Vegetables applicants* 3-304.11. Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Char 590.003 G) Reporting y b Person in Char e* 3-306.14fA)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3701.I I Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A-B) Compliance with Food_Law* 4-501.111 Manual Warewashing-HotWater 3-201.12 Food in a Hermetically Seated Container* Sanitization Ten eratures* 3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HotWatex 3-202.73 Shell Eggs* Sanitization Tem eratures* 3-202.1.4 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkin Water* concentration and hardness. * 5-101.11 u Drinking Water from an Approved System*tent* 4-601.,11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils` 4-702.11. Frequency of Sanitization of Utensils and - 3-201.14 Fish and Rmeationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1(1 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Author 2-301.11 Clean Condition-Hands and Arms* 3-202.18 ShellstoekIdentificationPresent* 2-301.12 Clearrine Procedure* 590.004(0 Wild Mushrootns* 2-301.14 When to Wash* 3-201.17 Game Animals* Il Good Hygienic Practices g ReceivingrCondition 2-401.11 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* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shelistoclt 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 gees* 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 Capacifies* 590.0040) Labeling of Ingredients' 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205Ell 11 Accessibility,Operation and Maintenance 7HACCP Pians Supplied with Soap and Hand Drying Devices 3-502.12 Specialized dux gen pack Methods* H-1...-bin Cleanser,.Availabilit 3-502.12 Reduced oxygen packaging,criteria* 8-103.12 Conformance with Approved Procedures* HandDrying Provision *Denotes crifiad item in the federal 1999 Food Cage or 105 CbtR 590.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: IT1 SfA�, ^�e: J/ Date: Page: Of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Verified PLEASE PRINT CLEARLY h r �- f Discussion With Person in Charge: Correctiv Action Required: ❑ No U yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your-.food permit. ----_.__- ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures -`'• Victorious Related to Foodborne Illness.Interventions and Risk According to Iaw Cooled to Factors(fte m;1-22) (Cont.) _41.=F,145°F Within 4 Hairs. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 29 PHF Not and Cold Holding * 3-501J(i(B) Cold PRFs Maintained at or below _ 3-202.12 Pot12 -- uvea.. ._.. 590.00Y7(f�1 410145"F* 3-302.14 eetion.from Unapproved Additives* 3-50116(X) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 1400F. ° 7-301,11 Identifying Information-Original 3.501.16(A) Roasts Held at or above 1300F. Containers* 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* 7-201.11 Separation-Stora e* - 3-501.19 Time as a Public Health Control* 7-202.11 ,Restriction-Presence and Use* 590.004(H) Varbram Requirement 7-202.12 Conditions of t-lse* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204A I Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria* 21 -3-801.17(A) Unpasteurized Pre-packaged else and 7-204.14 Drying ants.Criteria" :Use of es with Waning Labels* 7-205.11 Incidental Food Contact,Lubricants* - 3-80I.11(B) Use a Pasteurized t Egos" 7-206.11 Restricted Use Pesticides,Criterias` 3-801.11{D} Raw at Partially Cooked Animal Food and Raw Seed S Its Not Served- 7 erved. 7-206.12 Rodent:Bait Stations* 3-801.11(C) UnapenedFood Packs Not Re-served. 7-206.13 Tracking Powders, Peat Control and Monitoring* CONSUMER ADVISORY 7IMEITE6APERATURE CONTROLS 22 3-60111 1 Consumer Adviscm+Pasted for C"sumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Na wi Otherse-Processed to Eliminate 3401.1IA(l)(2) Eggs- 155 F 15 Sec. Pathorens.*r"° nrmr Eggs-immediate Service 145'Fl5sec* 3302.13. Pasteurized Eggs Substitute for Raw Shell E F 3401.11(A)(2) - Comminuted Fish.Meats&Game Animal's-155'F 15 sec. IREMENTS 3-401,1(B)(1)(2) Pork and Beef Roost- 130OF121 min* SPECIAL REOUnsofSeti 3-401,1I(A)(2) Ratites,Injected Meats-155`F 15 590.009(X}-(D) Violations of Section 590.(X}9(A)-(13).in sec.* catering,mobile fool,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 Ratitea-165'F 15 sec, " above it related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. tither 145°F* 590,009 violations relating to goal retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401:11fA)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sce. * (Iteins 23-30) 3-403.11(B) Microwave- I6.5'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Fiord- found in the following sections of the Food Code and 105 CMR 140'F* 590.000. 3403.1I(E) Remaining Unsliml Portioae of Beef Ilam s Good Retail Practices i .FC 530.700 _ Roasts* i 28- 1 Mlanagement and Personnel ' FG-2 .003 78 - Proper Cooling of PHFs 1 24.. Food and Food Protection FC-3 .004 1 25. Equipment and Utensils 1 FC-4 .005 3-501.14(A) Cooling Cooked PRFs from 140`F to i 28. I Water.Plumbing and Waste i FC-5 X06 1 700F Within 2 Hours and From 70'F 27. 1 Ph sicat Facility ' FC--6 to 41`F/45'F Within 4 Hours. * 1 28. ' Poisonous or Toxic Materials FC-7 .008 3-501,14.8) Cooling PHFs Made From Ambient 1 29. Special Ratuiremants '009 1 Temperature Ingredients to 41'Ff45`F 30. i Other Within 4 Hours* 'Dmclu s aitnal nelm in the L-dernl 099 Food Code a 10 CMR 590.000. Commonwealth of Massachusetts s City of Salem Board of Health 120 Washington Street,4th Floor Kimberley Driscoll SALEM,MA 01970 Mayor Foo&Retail Establishment Permit DATE PRINTED: 01/03/2012 ESTABLISHMENT NAME: Petsmart, Inc. #1197 File Number:BHF-2007-000001 10 Traders Way SALEM MA 01970 LOCATED AT: 0010 TRADERS WAY SALEM; MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2012-0279 Jan 1,2012 Dec 31;.2012. $70.00 Total Fees: $70.00 PERMIT EXPIRES Oecember 31, 2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted Ina prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 \r CITY OF SALEM, MASSACHUSETTS BO.,1RD OF HEkLTH 120 WASIiING'I'ON STREET,4"' FLOOR TEL. (978) 741-1800 KINIBERLEY DRISCOLL F.�x(978) 745-0343 MAYOR liamdin a salcm.com LARRY RAMI)IN,I6/RP.I IS,(:[Rl,CP-PS I� HvAAla'IiiA(l �i;N'I® 1 � 201,aAPPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABL'SHMENT �R ' J 2- �/--- ---.-- T- —------ ---------- - r ADDRESS OF ESTABLISHMENT((/® 20-b FAX# 19% 1455- ©fi'(l MAILING ADDRESS(if different) N; o Ut P9 &k 4m9. me o, Y- -560 zo EMAIL- Business': Website: 6J Wt) . &-Ts bI ART, Wirt OWNER'S NAME ]��—r, /`�3 '(;, TEL# h3 -9300 ADDRESS -)5&01 n�, �'� /h E PH-Ocwoo k 9 ^I STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) N/: CERTIFICATE#(S) (Required in an establishment where potentially hazar ous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS.OFOPERATION ' Monda Tuesday Wednesday.:- ! Thursday-,, 'Friday- Saturda Sunda HOURS OF OPERATION Please wrde in time of da ! For example 11 am-11 pm TYPE OF ESTABLISHMENT FEE (check only) -?RwPAWN CCb WAT-60 RETAIL STORE YES NO less than 1000sq.ft. =$ 70 /)i9b 56PIr L * 1000-10.000sq.ft. 0 more than 10,000sq.ft. =$420 - ------ -- y oV - RESTAURANT YE° -1-s-+ha-n 25 tee,is =-$-1-40---- (Outdoor Stationary Focti Car,$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YF_S N $-l--O-O---- CHILDCARE SERVICES/NURSING HOME ------------------------ ---------=-------- - - ----- --------------- - - ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES N $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge snbelief,have filed all state tax returns and paid a I state taxes required under the law. Signature Date7[, Social Security or Federal Identification Number Updated 523/11 FOODAP201 Ladm Check#&Date (-I —r�'V OI Y'-- $ --- -_---------------------------- �.BD Y t� �tY Ai t r - f CITY OF SALEM, MASSACHUSE:I'T:S \V i�. ✓j " BOARD o HF�u Tx 120 WAST TINGI ON'SI:RL+:ET,4'" I'LOoR Tra_ ()78) 741-1800 K MBIAW'y DRISc:DI:[' Pres ()78) 745-0343 MAYOR Ira MAn@Q IIC-1D S_0M LrAttRV RANJ1)1N,RIS fR.1:11S,C(10,CP-FS FIFA1;17-3 AGI ni'I. MEMORANDUM Date: December 7,2011 To: Food Establishment Owners From: Larry Ramdin, Health Agent RE: 2412 Food Permit(application enclosed) AWE DECEMSER2Tn 41 Enclosed is the 2012"Food Permit application. A check and the completed application must be received in this office by DECEMBER 27,2011 L 1, You will be issued a $100 ticket for late submission of application and/or fee. Partially completed`applications will be considered late and subject to ticketing A few reminders: • All'City taxes and water bills miisf be paid in order to receive a 2012 permit. • You may not operate after December 31, 2011 without a valid 2012 permit. • Food preparation employees must cover body hair'with hats, hair coverings nets, beard restraints or clothing that covers body hair. There is no bam -,arid contact of ready to eat foods. ;loves must be changed when they become contaminated, such as when the face or hair is touched. Then hands must be washed, and new gloves put on. • Exterior openings must be screened or protected from entrance by insects or rodents. • The 2011 Food Permit is valid only for the owner listed on the application. Change in ownership, requires a new application, a.plan review application and a review of the floor plan j and menu of the establishment by the Health Agent. Any change in the establishment including a change in.the menu or renovation must receive prior approval by the Board of Heafth and a plan review application must be filled out. • The Food Code requires, that each establishment having a seating capacity of 25 persons or more shall Have on the premise's someone trained and certified to remove food lodged in the throat, and to have insurance adequate to cover such employees. Please see the enclosed flyer for convenient, local choke-saving classes. • Thank you for your cooperation. 4 �,��'. }, t�� 1` ��V ``� ;;0��d P� ',.:R�:_� 4.- - '�� a e..- ry Rt -_ -. .. A t fi U.S. dollars. PE"ETSHAAART Canadian Business, Tax, Misc. License Form 12/21/11 Vendor Number: 73258 Vendor Name: CITY OF SALEM, MASSACHUSETTS Invoice Date: 12/01/11 Invoice Number: 12 FSL-1197 Amount $ 70.00 Request/Prepared by: Lmann Request Due: 12/21/11 Account/Permit No: 68800 1197-00 $ 70.00 84100-Penalty 1197-00 $ - 84100 -Interest 1197-00 $ TOTAL AMOUNT of CHECK: $ 70.00 / SIGNATURE: PRINT NAME: Terry Laster TITLE: Corporate Legal Department Director of Government Affairs and Business Licensing FOR QUESTIONS PLEASE CONTACT: Contact Lynda Mann PH: 623-388-8300 Fax: 623-580-6137 E-mail: (mann@ssg.petsmart.com E-mail: Subject Line- Business License 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 Type of Operations) Tvoe of Inspection ❑ Food Service Routine Address it JOA f Risk Retail Re-inspection Level Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: OwnerV HACCP YM ❑❑ Caterer Temporary ElPre-operation ❑ Suspect Illness Person in Charge(PIC) / Time ❑ Bed 8 Breakfast ❑General Complaint In: ❑HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an/explanation on the narrative page(s) and a citation of specific provision(s)violated. kJ 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) Q 590.009(F),] action as determined by the Board of Health. TODD PROTECTION MANAGEMENT _ ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties __ ❑ 13. Handwash Facilities EMPLOYEE HEALTHY 4� - _ PROTECTION FROM CHEMICALS1; ❑ 2. Reporting of Diseases by Food Employee and PIC `�' ❑ 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives __ El 15.Toxic Chemicals �.FOOD FROM APPROVED SOURCE. TIMENEMPERATURE CONTROLS(Potentially Hazardous Fooda [1 4 Food and Water from Approved Sourccee I� w_.-_) ❑ 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 SCEPTIBLE 0. Poroper Adequate Handwashing od Contact Surfaces Cleaning and Sanitizing [0 21l.RFood and Food lP epa action for HSP POPULATIONS(HSP_) El ' ❑ 11. Good Hygienic Practices CONSUMER.ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 4)) order of the Board of Health. Failure to correct violations n F Protection FC- 5so.00a 24. Food and pod otec ( a)( ) 25. Equipment and Utensils (FC-4)(590.005) cited food this report may result in suspension or revocation ocatioof 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.o06) 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: 5:590Ina IFam 14.d hl.l u CA ci-,k f,Ias Inspector's Signature: Print: PIC's Signature: ,,� - Print: '� Pagel of �GP.ages ^ ,L Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION f1 Cross-contamination FOOD PROTECTION t MANAGEMENT 3-302.11(A)(]) Raw Animal Foods Separated from 1 590A03(A) Assignment - Cooked and RTE Faxls* 590.003(B) Demonstration of Knowledge* Contamination from Raw ingredienfs 2-103.11 Person in charge-duties 3-302.1.1(A)(2) Raw Anirua]Foals Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) - Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables a lficants* 3-3(k1.1I Food Contact with Equipment and 590.003(17) Responsibility Of A Food Employee Or An * Applicant To Report To The Person In Utensils Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions'" Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Foal* Discarding or Reconditioning Unsafe 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 Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanifization Temperatures* 3.201.13 Fluid Milk and Milk Products* 4-501.112 MechanicalWarewashing-Hot Water 3-202.13 Shell Eggs* 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 S•stem* 4-601.11(A) Equipment Food Contact Surfaces and' 590.006(A) Battled Drmkin Water* 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* She/tlish and Fish Froman Approved Source 4-702.11 Frequencv of Sanitization of Utensils and - 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* p Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1p Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301._1.2 Cleanin Procedure* 590.004(C) Wild Mushrooms* 2-.301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 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 3-242.1.5 Package Integrity* Mouth* 3-IOL)l Food Safe and Unadulterated* 3-301.12 Preventin Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590D04(E) Preventing Contamination font 3-203.12 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(1) Labeling of Ingredients, 5-204.11 Location and Placement* � Conformance with Approved Procedures 5-245.11 Accessibility.Operation and Maintenance (HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced ox gen Packaging,criteria* 6-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-307..12 HandDang Provision *Denotes"critical icem in the federal 1999 Pax!Cate or 105 C44R 590.000. CITY O7 F SALEM 1 BOARD OF HEALTH Establishment Name: P ��.�(�c C_._ Date: �� Page:_ of s1 Rem Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date. No. Reference R-Red Rem''', - - PLEASE PRINT CLEARLY Y Verified 2 SA'- ",: I V X'✓W V!1�I i T .(O � .A') _R-r/I .te�i "' �) l�/1 Q a A _YV")'F-'�J l - U Discussion With Person in Charge: Corrective Action Required: ❑ `'Wo ❑: :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 comply with all mandates of the Mass/Federal Food Code. I understand that 13 Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-fie dollars.or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 10 your Voluntary Disposal ❑ Other. 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors,(item 1-22) (Cont.) 410F/45'F Within 4 Hours. * PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 410/45'F$ 3-302.14 Protection from Unapproved Additives' 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140T.3-501.16(A)35Ol.i 6(A) Roasts Held at or above 1300F, Containers* 7-102.11 Common Name-Working Container%* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* - 1-204.14 Drying Agents.Criteria* Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(8) Use of Pasteurized EW* 3-801.11(D) Raw or PartiallyCooked Annual Food and 7-206.11 Restricted gait Stations*Use Pesticides,Criteria* Raw Seed Sprouts Not Served, * 7-206.12 Rodent 3-801AI(C) Uno ned Food PackageNot Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11. Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Ani mal Foods That are Raw,Undercooked or PRFs_ Not Otherwise Processed to Eliminate Patho ns.*[a `intra„ Eggs-immediate Service 145oF15sec 3 401.!lA{1}(2) Eggs- mSec, * 3-302.13 Pasteurized Eggs Substitute for Raw Shell med 3401.11(A)(2) - Comminuted Fish,Meats&Game E Animals-155'F 15 sec. 3401.11(B)(1)(2) Pork and Beef Roast- 130'F 121.nun* SPECIAL REQUIREMENTS 3.401.11(A)(2) Ratites,Injected Meats-155'F 15 590.0109(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering,mobile food, temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401,11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401s11(A)(1)(h) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Harding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3403AI(A)&(D) PHFs 165T 15 sec.* (Itettts 23.30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical.and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercial ly Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000, 3403.11(E) Remaining Unsliced Portions of Beef nem I Good Retail Practices I FC 590.000 Roasts* 23. Management and Personnel � FC-2 .003 lg Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004_ 25. Ego! ment and Utensils FC-4 =5 I, 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water,Plumbing and Waste ' FC-5 006 700F Within 2 Hours and From 70'F21 7, -Physical Facility FC-6 007 to 4VF/450F Within 4 Hours.* 281 28. Poisonous or Toxic Materials_ FC-7 .008 3-501.14(B) Cooling PRFs Made From Ambient 29. Special Requirements ,009 Temperature Ingredients to 41'F/45'F 30, Other _ Within 4 Hours* ':41pfoinhif`�"" * LX-notes critied item in the federal 1999 Food Code or 105 CMR 590.000. Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Petsmart, Inc. #1197 File Number:B14F-2007-000001 10 Traders Way SALEMMA 01970 LOCATED AT: 0010 TRADERS WAY SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-201 -0073 Jan 1,2011 Dec 31,2011 $280.00 Total Fees: $280.00 PERMIT EXPIRES December 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 "` • r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH a 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 NLNYOR DGREENBAUMI& Alma.COM D NT13 GREENBAUM,RS �, E j� �1-- p?G--P-4t T � ACTING HEALTH AGENT TO IV[M I `or 01i OL 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT . PRTZRAZT, yw+ 'i" (\V ri TEL# �`/7� ADDRESS OFESTAEiLISHMENT O TRA�R6 A FAX# -lpprl�_ Jn (5 MAILINGADDRESS(ifdifferent) _� N;_�,j1SSll �-�ICbt��' EMAIL- Business': Website: (OWL r P6T*MA1& a 01Y1 OWNER'S NAME TEL#nn 93 ADDRESS Me61 tJr 41 STREET rr CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially haza ous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# iDAYS'OFOPERATIONL ",;.:Monday :,:! ,i Tuesday'` 1H °;Wednesday Nl • Thursdayalx'+' , 1 friday I .uw Saturday _;I& ..Sunday: HOURS OF OPERATION Please write in time of day. Por example Ilam-11pm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YE NO less than 1000sq.ft. $7 1000-10,000sq.ft. =$280 more than 10,000sq.ft. ----------------------------------------- --------------------------------------------------------------------------------------- RESTAURANT YES � less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 -------------------------------------------------------------- --------------------------------------------------------------------------------------------- BED/BREAKFAST/ YES O $100 CHILDCARE SERVICES-NURSING HOME------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to M L 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 retums and pal all state taxes required under the law. Si�gnatt& Date Social ec6rity or Federal Identification Number Revised 10n1I I FOODAP2011.adm Check#&Date $ �^ 1 Le I' �� ++ftf� .'J� t „ � - :i' . . {p � , _. S� }� d� '' � ��M .� ,�V �� I + s . .., . .. _.. _ - ._ F"� i r �. ..� - U.S. dollars. PETSMART Canadian Business, Tax, Misc. License Form 12/02/!0 Vendor Number: 73258 Vendor Name: CITY OF SALEM MASSACHUSETTS Invoice Date: 12/01/10 Invoice Number: I 1 FSL-1197 Amount $ 280.00 Request/Prepared by: Lmann Request Due: 12/02/10 Account/Permit No: NOWAWMW13450 1197-00 $ 280.00 84100 -Penalty 1197-00 $ - 84100 -Interest 1197-00 $ TOTAL AMOUNT of CHECK: $ 280.00 SIGNATURE: PRINT NAME: Geoffrey Hawkins TITLE: Corporate Legal Department Manager of Government Affairs and Business Licensing FOR QUESTIONS PLEASE CONTACT. Contact Lynda Mann PH: 623-388-8300 Fax: 623-388-8317 E-mail: AccountsPayable@ssg.petsmart.com E-mail: Subject Line-Business License `� . . . ;. S1'a ��, si' a(I a9 !�!� S� S ;,� �d' S� ��`Y`YyJJy,, �=�'Iry�f ! � ilk.. �SW d 1N� �p� . .. 0010 TRADERS WAY Petsmart, Inc. #1197 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) (978)745-2112 Food and Food Protection FAIL Critical BLUE Owner: Comment:Some sodas stored directly on the floor in storage room.Store all items at least 6-8 inches off the floor. Petsmart, Inc. 21 outdated Mountain Dews were removed from the soda fridge.Owner to closely monitor all expiration dates. PIC: Equipment and Utensils FAIL Non-Critical BLUE Art Lobie Comment:Soda fridge needs general cleaning along bottom and in door tracks. Inspector. Elizabeth Salandrea Date Inspected:Correct By: 6/27/2008 Risk Level: Permit Number: BHP-2008-0055 Status: SIGNED OFF #of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Owner to notify Board of Health within one week that violations noted have been corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2008 ) Page 1 oft ' Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2008 ) Page 2 oft Commonwealth of Massachusetts City of Salem Board of Health Klmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: . 01/11/2010 ESTABLISHMENT NAME: Petsmart, Inc. #1197 File Number:BHF-2007-000001 10 Traders Way SALEM MA 01970 LOCATED AT: 0010 TRADERS WAY SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0178 Jan 4,2010 Dec 31,2010 $280.00 Total Fees: $280.00 PERMIT EXPIRES December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS • _ BOARD OF HEALTH 120 WASHINGTON STREET,4n'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUMQSALEM.COM DAVID GREENBAUAf, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 6—T6(Y A7e-,T I I '� TEL# ADDRESS OF ESTABLISHMENT-1 0 T9A_1� _ FAX# ��- `�4!i- C4 I L MAILINGNDDRESS(ifdifferent) Ar;A . 60,-gtox--S9 �l@js�nnG i 1" rX1X 4zonq t tioaDcw oc,h2- gS0?0 EMAIL- Business': r-� Website: �f �'f�1/Yl /�/2T, �•k`1/Yl OWNER'S NAME '{ 1;,QfMer, '1YlC TEL# F7,/�CC� ADDRESS 11(c©/ ��1 �IlEm)L� P/'✓OZeNU`p -?� �?&O J STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) Itj CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# " " ` ' Fr tla "Saturda yD'A.NSIONPRER4TIOV, ontl '; Tuesday °u W@dhesda„ Thursday � y HOURS OF OPERATION Please write in time of day.- gfpA- PU v ' Forexam lellam-11 m I - TYPE OF ESTABLISHMENT FEE (check only) �\ AP RETAIL STORE YES NO less than 1000sq.ft. - 7 1000-10,000sq.ft. 0 / more than 1 0,000sq.ft. =$420 V° b ------------------------------------------ ------ ....................................... �f RESTAURANT YES NO less than 25 seats =$1404' (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ------------• ............................. BED/BREAKFAST/ YES $100 u CHILDCARE SERVICES/NURSING HOME v ---- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES O $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In 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. Pursuantto M L 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 return nd paid II state taxes required under the law. �IeFy�srr� /�-9-0 Skgnatufe Date Social Security or Federal Identification Number. Revised 424/07 FOODAI?2008.adm Check#&Date /a $ � i Commonwealth of Massachusetts F City of Salem Board of Health lQmbetiey Driscoll 120 Washington Street,4th Floor mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/30/2008 ESTABLISHMENT NAME: Petsmart,Inc. #1197 File Number:BtIF-2007-000001 10 Traders Way SALEM MA 01970 LOCATED AT: 0010 TRADERS WAY SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0292 Dec 30,2008 Dec 31,2009 $280.00 Total Fees: $280.00 PERMIT EXPIRES December 31,2Q09 —.... Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 AN" . 0 a ?3 UB 04r44p Joanne Scott Salem BOH 979 745 47343 r' P^ e (• CI'TY OF SALEM, MASSACHTJ;,E'1-fS I)CiAlti'74it HLrt.T: 12(1V,'. 4ii2t 4't'<}C: 'REill,4'°FLttc,;l i EL,(t}78)`41-1 ilk:) KIAEBALEY DRI<C(7L1, !' '978)744-0.343 ACn}r.naN. UNYOR , rz Dx)rd ►» VE D D€CQ ZnnnBKFAiTH AGLvT Cr r Y OF SALE&& BOARD OF HATH 2009 APPLICATION FOR PERMITTOTO OPERATE A FOOD ESTABLISHMENT NAME OF ES7A81JSHIa1FNT PF.`T.�rYJ fJ` - I7�Qi' _ TEt#./ r� 4/!C;_ ADDRESS OF ESTABUSHMENT�vT�g GfW� T/ _ _ FAX# MifuLtNG AnOkt : ._L_Vxem.�.P1f�1 t..�.a,. ,r�r��2qq -________�-_.... EMAIL.Business': 071NER'S NAIAE- � Te?J�,LL rT -Inq� ._ __.�.7EL# ADDRESS l q b't o�? t`� 11yerufY6 •..S7ReF.T C- c iTn, STATE 2if CERTIFIEDFCCDh1ANA;;-ER'SNANIE(S) AVA CERTIFIGATEri($i.,,„ _,— (Raquwed in an estabtlshwenr whera.paigy"aty haaardaus fuaa i;wevew'It) EMERGENCY RESPONSE PERSON 6,, 604�, 0MF TEL#-( Q „ ?4 d Z111 _—'- _fir-4—T --- _Qw XlPEwE N Ma,ca� _ ;_ Ta&sda�, wc�o�ofty ! L>urs3dr_ Fnda�._ "4�;0�a� .- NCuRS OP C f Q Please wnte A it"%g 44Y. L 1For Omni*llp�ltarl TYPE OFESTABLI§HMENT PE! (uhackonty) RETAIL STORE YES NO Irks than 10G0 q.tt. -!!17U t:HIO-tp40Usq.h, Mara than Ir"WtOt. �agLgl RESTAURANT t'ES �v'J lois than 25 mats =5140 7ut�oor stationary Fwd Can ti'21v) '" ... 25-99 seats x$250 more than 99 seats 3420 CN71 ARS s.F.R. 0 - .. YES NC $100 WTIONAL PERMIT Aftt,E(notlustserve)ICE CREAM YCGURTISOrI SeRvF YES $25 TOBACCO VENDOR YES N $13fs ALL NON-PROFIT(suds as ahtmh kttcherra) YES $25 'Please pay total with one crack paywltie tQ the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prumhtent location in the rrstabtiahrnant, In a.cosdenu.-whh the State Sanitary Lode,before any renovations,improvements.or equipment changes to a made,all pians for such must be submined to and approved by the Salem Board of Health, Pursuant WWI.Ghapttr d:X,Sedknt 49A,I Cert ly under the Dams anc pen4k tS a Dai]ury mac i.ID my het,101 w1c90 m,d DE!irr,hair h;ed el stat.ra, rstUrn paid all PjWir taros requlrM ender tho yaw. L„ �a mag Sign ixntt Paw Soca!i,_w:`-t),7r lwoo sal l&.):1ficabok N aml'cr ttr*v,rN�^wN1 FUGt),ViWB.r:lai UtockP Sltai��.� -/✓"-t11--.._..{� ..-,...i_ ._. .. T/ra p U.S. dollars S ART Canadian Business, Tax, Misc. License Form /224/08 Vendor Number: 73258 Vendor Name: CITY OF SALEM,MASSACHUSETTS, Invoice Date: 12/01/08 Invoice Number: 09 FSL-1197 Amount $ 280.00 Request/Prepared by: Lmann Request Due: 12/24/08 Account/Permit No: 13450 1197-00 $ 280.00 84100-Penalty 1197-00 $ - 84 100 -Interest 1197-00 $ TOTAL AMOUNT of CHECK: $ 280.00 0 SIGNATURE: PRINT NAME: Lynda Bleichroth TITLE: Manager of Accounting Operations FOR QUESTIONS PLEASE CONTACT. Contact Lynda Mann PH: 623-388-8300 Fax: 623-388-8317 E-mail: AccountsPayable@ssg.petsmart.com E-mail: Subject Line- Business License 0010 TRADERS WAY Petsmart, Inc. #1197 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: (978)745-2112 Owner: Petsmart, Inc. PIC: Art Lobie Inspector: Elizabeth Salandrea Date Inspected:Correct By: 112612009 Risk Level: Permit Number: BHP-2009-0292 Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Establishment carries a limited amount of pre-packaged candy, snacks and soda. Violations Related to Good Retail Practices (Critical No health code violations noted at this time. 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 26,2009 ) Page 1 oft ',..�. Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 26,2009 ) Page 2 oft nolo nUDEQSWIY Befta" dam #3197 City of Salem RETAIL FOOD - Food Establishment Item Satua violation Type UroWw Practices(Cdtkal violations must be corrected imrrrediately or within 10 days)(Non-crustal violations must be corrected immediatey or within 90 days) RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) OA7ersakm WM IM OlMpb ws(97NM-lMra(970)7411.07�7 SWT7ae 2M aft 6.9rw. r r.c COMMONWEALTH OF MASSACNUSETTS r r p 'a.i. G' YLL4A.�. cN ,p+k A j.Y ➢ �'� C M p e, ,Tr s ` 1...,,o •. 7 ilrs� <' 3�'�..> v*��# 1�'r J'. �. .:.`yy,a �ri � i'�s�."x•. �a zf 1 w. + dx.m fi z *., Commonwealth of Massachus..R.r etts . 7r City of Salem 4 Board of Health - IGmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Petsmart, Inc.#1197 File Number.BHF-2007-000001 10 Traders Way SALEM MA 01970 LOCATED AT: 0010 TRADERS WAY SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0055 Jan 3,2008 Dec 31,2008 $280.00 Total Fees: $280.00 PERMIT EXPIRES December 31,2008 Board of Health This Permit is not transferable and must be reissued.upon change of ownership or location.The permit must be posted in a prominent location in the Establishment In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 16 of 46 f a 3v� >. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4' FLOOR TSL.(978) 741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR IScoTTO)SALENL COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT-J� 4 I q-1 TEL# 1 18 ` l J Z/(ii'(2— ADDRESS OF ESTABLISHMENT j� �h'�C�vS W Gc �1 FAX# MAILING ADDRESS (if different)_ PBT T-eumem1-cenaa PO Boa 43007 EMAIL-Business': PB.'..AZ B5080 Website: DP `l V pjt -� •c-oV✓) OWNER'S NAME pQYVY``A)1f �JN`Cl TEL#, ADDRESS (%Ob1 Yy 21t" M \ A/ N,6K ` ?� �Ps67 STREET �/�. CITY STATE 71P �\ (1 CERTIFIED FOOD MANAGER'S NAME(S) I " `o CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) G c EMERGENCY RESPONSE PERSON r v �('1 HOME TEL# , U( ✓ DAYS OF OPERATION 1 Monday Tuesday- Wednesday hursda Friday Saturday Sunda HOURS OF OPERATION 1� Please wite in fime of day. For example 11 am-11 m TYPE OF ESTABLISHMENT FEE (check only) f14 RETAIL STORE YES NO less than 1000sq.ft.1000-10,000sq.ft.more than 10,000sq.ft.--------------------------- - ---YES Olessthan25seats (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 - ----- ---- BED/BREAKFAST/ YES O $100 CHILDCARESERVICES --------- ------------- ----------- - -------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. orequipment than es are made all plans for In accordance with the State Sanitary Code, before any renovations, improvements, g p 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 fled all state tax return d paid all state taxegrired r the law.f127/0— 7 9g 36zg 325 Signature Date Social Security or Federal Identification Number ------------------------------------------------------------- -------.----- -----------------------� ------- --------- Revised 4/24/07 FOODAP2008.adm CltcckN&Dat�� S 0010 TRADERS WAY Petsmart, Inc. #1197 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency tTelephone: FOOD PROTECTION MANAGEMENT (978)745-2112 PIC Assigned/Knowledgeable/Duties PASS Q RED i)Owner: Non-compliance with: Petsmart, Inc. Anti-Choking PASS tPIC: y Tobacco PASS Inspector: EMPLOYEE HEALTH David Greenbaum Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑ RED #11/27/2007 Personnel with Infections Restricted/Excluded PASSN❑ RED Risk Level FOOD FROM APPROVED SOURCE I Permit Number: Food and Water from Approved Source PASSd❑ RED g BHP-2007-0368 Receiving/Condition PASS Q RED Status: I SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS RED (#of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS ❑d RED s0 3Time IN: TimeOUT:- I Urgency Description(s): i BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately ' or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 27,2007 ) Page I of Item Status Violation Critical Urgency RED: m—a PROTECTION FROM CONTAMINATION ,Violations Related to l Separation/Segregation/Protection PASS RED Foodborne Illness Interventions I and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED immediate corrective action) Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS 0 RED Prevention of Contamination from Hands PASS 0 RED Handwash Facilities PASS ❑d RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS Q RED Toxic Chemicals PASS ❑J RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 27,2007 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Management and Personnel PASS BLUE Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Physical Facility PASS BLUE Water, Plumbing and Waste PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: Establishment sell a limited quantity of pre-packaged candy and snacks. No health code violations cited at this time. ( W City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 27,2007 ) Page 3 of 0010 TRADERS WAY Petsmart, Inc. #1197 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT (978) 745-2112 PIC Assigned/Knowledgeable/Duties PASS RED Owner: Non-compliance with: Petsmart, Inc. Anti-Choking PASS PIC: Melanie Osborne Tobacco PASS Inspector: John Gehan EMPLOYEE HEALTH Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 4/25/2007 Personnel with Infections Restricted/Excluded PASS RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS RED BHP-2007-0368 Receiving/Condition PASS ❑d RED Status: SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS 0 RED #Of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 25,2007 ) Page I of c. • Item Status Violation Critical Urgency RED; PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED immediate corrective action) Proper Adequate Handwashing PASS 0 RED Good Hygienic Practices PASS 0 RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS 0 RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS 0 RED Toxic Chemicals PASS RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑d RED Reheating PASS ❑d RED Cooling PASS RED Hot and Cold Holding PASSd❑ RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS E/1 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®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 25,2007 ) 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: No violations found at this time. Thank you. �p0916& no City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 25,2007 ) Page 3 of 3 ..n .w...i•.•.y wrr t.�,.-...�»r�y w w ,r r i7` 1 pY` . Ry „ +e wavr ;.p ,✓ 3.r.`gRx . mmi -ua,�w� wy:sr u w•� h r- ».:rr. .a t�+w'x=tno-Ayxa - `. a•s �k'•Mk; T. °St A+ 'A::.sx+.'.•. a. . -^sx•x.1`.. .« -r��'Wi#� "ts'�z.+� r.acs:wa+ �.,+f •w»�;.'a..�• $^,} ,I+a*'Se; Commonwealth of Massachusetts c . City of Salem Board of Health IGmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/08/2007 ESTABLISHMENT NAME: Petsmart, Inc. 91197 File Number.BHF-2007-000001 10 Traders Way SALEM MA 01970 LOCATED AT: 0010 TRADERS WAY SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0368 Jan 8,2007 Dec 31,2007 $200.00 Total Fees: $200.00 PERMIT EXPIRES ,December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1 CITY OF SALEMO MASSACHUSETTS BOARD4 RECEIVED 120 WASHINGTONN STREET, T, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 DEC 19 2046 FAX 978-745-0343 Oily OF SALEM Kimberley Driscoll www.SALEM,COM BOARD OF HEALTH Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT �7 NAME OF ESTABLISHMENT Y P .rt�]S � 1 � q TEL# "1 �` 7 LfE � (( 2G. ADDRESS OF ESTABLISHMENT ( C) 4 (a A i YS Wf Lt4 7 FAX# MAILING ADDRESS (if different)_ eEre r'"a 'U.. PlropMx AZ %086 - EMAIL--Business': Owner's: G OWNER'S NAME �.tr �QQ '�4"C 'c Le� —TEL# (D7 :� ?7c� S �i ADDRESS STREET \ (�- CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON P8MgAkr t>Yl &J-1-V HOME TEL# 1I-7 i� 45 DAYS OF OPERATION Monday Tuesday Wednesday _ Thursday Friday Saturday Sunday HOURSOFOPERATION Pleasesewrite in timemeof day. (for example Ilam-flpm) _. TYPE OF ESTABLISH T FEE (check only) RETAIL STORE ES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ... .........-------- -------- ............_......_...._ _ --------------------------- . . ------ ------------ RESTAURANT YES O less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 - .......... . .. - - - ... --- ... ...._.--- -....._...... -......... .......... ---- - ------ -...- -- ._....... BED/BREAKFAST YES NO $100 -- ---------------------I—---.. ------- -.. ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES fl $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. P suant to MGL Chapte C, Secli 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief. h ve til ail state tax tur sand � all state taxes required under the law. nature Date Social Security or Federal Identification Number - -- - --------------------/---------------------- ---------------------------------------- ----------------------------------- --- _------------ Revised 11/13/06 FOODAP2007.adm Check#8 Datep17,-�-Qt) [ / 5 '_(,h(�,-0 D Pj'Tj;ffiffiART DIRECTORS Philip L.Francis Chairman Rita V.Foley 196o1 N 271h Ave. 196o1 N. 271h Ave. Phoenix,Arizona 85027 Phoenix,Arizona 85027 Ronald Kirk Jeffrey W. Yabuki 196o1 N 271h Ave. 196o1 N. 271h Ave. Phoenix,Arizona 85027 Phoenix,Arizona 85027 Lawrence Del Santo Thomas G.Stemberg 196o1 N 271h Ave. 196o1 N 271h Ave. Phoenix,Arizona 85027 Phoenix,Arizona 85027 Walter J.Salmon Barbara A.Munder 196o1 N 271h Ave. 196o1 N. 271h Ave. Phoenix,Arizona 85027 Phoenix,Arizona 85027 Richard K.Lochridge Gregory P.Losefowicz 196o1 N 271h Ave. 196o1 N 271h Ave. Phoenix,Arizona 85027 Phoenix,Arizona 85027 Amin L Khalifa Joseph Hardin,Jr 196o1 N. 271h Ave 19601 N 271h Ave. Phoenix,Arizona 85027 Phoenix,Arizona 85027 Rakesh Gangwal 196o1 N. 271h Avenue Phoenix,Arizona 85027 OFFICERS CEO&Chairman President&COO Philip L. Francis Robert Moran 196o1 N 27th Ave. 196o1 N 271h Ave. Phoenix,Arizona 85027 Phoenix,Arizona 85027 Sr. Vice President&CFO Timothy Kullman 196o1 N 271h Ave. Phoenix,AZ 85027 Secretary Assistant Secretary Scott A. Crozier Kevin J. Groman 196o1 N 27th Ave. 196o1 N 27th Ave. Phoenix,Arizona 85027 Phoenix,Arizona 85027 Revised 1125/o6 I r U.S.dollars P „?' 'MART Canadian Business, Tax, Misc. License Form 11/13106 Vendor Number: 73258 Vendor Name: CITY OF SALEM,MASSACHUSETTS Invoice Date: 12/01/06 Invoice Number: 06 FSL-1197 Amount $ 200.00 Request/Prepared by: Dcamelia Request Due: 12/14/06 Account/Permit No: 13450 1197 $ 100.00 84600-Penality 8807 $ 100.00 84100-Interest 8807 $ - TOTAL AMOUNT of CHECK: $ 200.00 SIGNATURE: PRINT NAME: Lynda Bleichroth TITLE: Manager of Accounting Operations XWccte=R&siness License\Procedures\Coding coversheet-format inshuctious.AsKeying Cover Sheet i 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, RS, CHO HEALTH AGENT MEMORANDUM Date: November 24, 2007 To: Food Establishment Owners From: Joanne Scott RE: 2007 Food Permit (application enclosed) DUIE DECEMBER 8M The enclosed 2007 Food Permit application and check must be received in this office by DECEMBER 8, 2006. The fee is as indicated on the application, EXCEPT all non-profit agencies pay$25. You will be issued a $100 ticket for late submission of application and/or fee. Partially completed applications will be considered late and subject to ticketing. Please note the updated form that includes space for an e-mail address. A few reminders: • All City taxes and water bills must be paid in order to receive a 2007 permit, • You may not operate after December 31, 2006 without a valid 2007 permit. • There is no bare hand contact of ready to eat foods. When using gloves, remember they must be removed if they become contaminated (touch hair, skin, sneeze, etc.), hands must be washed, and new gloves put on. • The 2007 Food Permit is valid only for the owner listed on the application. Change in ownership, during the year, requires a new application to be submitted to the Board of Health, as well as a review of the floor plan and menu of the establishment by the Health Agent. • Any change in the establishment including a change in the menu or renovation must receive prior approval by the Board of Health. • The Food Code requires that each establishment having a seating capacity of 25 persons or more shall have on the premises someone trained and certified to remove food lodged in the throat, and to have insurance adequate to cover such employees. Enclosed is a list of certified businesses that offer CPR and Choke Saving classes. • Thank you for your cooperation. CPR & CHOKE SAVING CLASSES American Red Cross CPR & Choke Saving Classes Tim Brown / Mon. - Fri. 8:30am— 4:30pm 1800-564-1234 x 285 8 + people for onsite classes email address Brownti@usa.redcross.org When Seconds Count CPR Classes Shawn Lerner NREMT-I/C 978-744-4799 website : www.whensecondscount.com American Heart Association Affiliates North Shore Medical Center / Salem Hospital CPR Training 81 Highland Ave 978 741-1215 x3027 website: www.nsmc.partners.or Save A Life CPR Carla Brogna CPR Training Peabody 978977-0282 email address savealilecpr(o,C0mcast.nct i PETSMAFIT 19601 N. 27TH AVE., PHOENIX, AZ 85027 (623)580-6100 482200 Vendor: CITY OF SALEM, MASSACHUSETTS, 73258 Document # Date Invoice # Trn Invoice Amt Disc % Disc Amt Net Amount 11021479 12/01/2006 06 FSL-1197 KR 200.00 0.000 0 .00 200 .00 CheckTotals 200.00 0.00 200.00 Key: KR / RE - Vendor Invoice, KG / RA - Vendor Credit, Z1 - A/R Coupon Receivable, DR - Customer Invoice, DG - Customer Credit Memo 2560E � � wWw acUpn�t�oID - 65�'?S�' pcoFri�� SW i \1 1 ,\ t l i 1 0010 TRADERS WAY Petsmart, Inc. #1197 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 978-745-2112 PIC Assigned/Knowledgeable/Duties PASS 0 RED Owner: Non-compliance with: Petsmart, Inc. Anti-Choking PASS PIC: Tobacco PASS Inspector: John Gehan EMPLOYEE HEALTH Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 10/31/2006 j Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS 0 RED BHP-2006-0394 Receiving/Condition PASS RED Status: SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS 0 RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS 0 RED 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS0 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 31,2006 ) Page I of Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS Q RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED immediate corrective action) Proper Adequate Handwashing PASS 0 RED Good Hygienic Practices PASS 0 RED Prevention of Contamination from Hands PASS OV RED Handwash Facilities PASS RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑d RED Reheating PASS RED Cooling PASS ❑d RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS 0 RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 31,2006 ) 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: No violatoins found at this time. 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. Oct 31,2006 ) Page 3 of 0010 TRADERS WAY t Petsmart, Inc. #1197 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT -:978-745-2112 PIC Assigned/Knowledgeable/Duties PASS Q RED Owner Non-compliance with: art, Inc. Petsmw Anti-Choking PASS PIC _ 2 Tyler Ray Tobacco PASS Inspectof = '' EMPLOYEE HEALTH David Greenbaum Reporting of Diseases by Food Employee and PIC PASS ❑d RED Date t N . Correct By:: 166 Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: .. a9 FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2006-0394 :F- Receiving/Condition PASS ❑Q RED Status: SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS RED sm :; #of Critical Violations: v Conformance with Approved Procedures/HACCP Plans PASS _ RED 0 Time IN: 't Time OUT ' =- Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical a violations must becorrected 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 GeoTMS82006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 16,2006 ) Page I of ' Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASSd❑ RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED immediate corrective'action)" Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS ❑d RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS ❑d RED Toxic Chemicals PASS RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑d RED Reheating PASS J❑ RED Cooling PASSJ❑ RED Hot and Cold Holding PASS �/❑ RED Time As a Public Health Control PASSd❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS ❑d RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 16,2006 ) 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: 657:Establishment sells a limited supply of prepackaged candy, snacks and soda. No health code violations cited at this time. 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. Jun 16,2006 ) Page 3 of ` Lo Commonwealth of Massachusetts vQ' City of Salem Kimberley Driscoll Z Board of Health Mayor ` y 120 Washington Street,4th Floor - SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 02/06/2006 WHO'S PLACE OF BUSINESS IS: Petsmart, Inc. #1197 File Number:BHF-2004-0058 Tax&Licensing, 19601 N. 27th Ave Phoenix AZ 85027 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0394 Feb 2,2006 Dec 31,2006 $100.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 �_•_:•• Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. 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 b the Salem Board of Health. p PP Y . Page 2 of 5 rl." ,� . ' �r+,T� uw�i>9�;y.#�7•k' 'i"Fµ �, �A�a��., 5 r� x�� is } 4y� r�A w` .Ar 5•'r'p .lR �tv.»„ "kA.thr......7'.- ...r. . y � .Y!Fu., ti�'�'°' 'e..-,a f ,... .o.. Dr w.:"" �i=^ �� ,l�K� "G ? �«°" •t.�"3F �}4„•�i +� O6-rcl- -119% 1 ��D /gq�S?b _1199-06 Jan 23 06 O3120P Joanne Scott Salem BOH 878 745 0343 P, 2 / C^ITY__ J OF SALEM, MASSACHUSETTS BOARD OF HEALTH . 120 WASHINGTON Smear,4TH FLooR SALEM, MA 01970 T". 978-741.1800 FAX 978.746.0343 Kimberley Driscoll WWW,SALEM.COM Mayor JOANNE S4•o7T, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OP5RATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT• ;L #I/ nf 9�T TEL# q'7g-- ry I ADDRESS OF ESTABI ISHMENT1�< a MAILING ADDRESS(if different) Soho-3oc OWNERSNAME -> TEL# -g3 -38K-6'26b ADDRESS I of CITY STATE Zip 9-5"oc�7 CERTIFIED FOOD MANAGE NAME(S)�noY4 CERTIFICATE#(s) -(required Irean eytablishment where potentially hacardous food is preparod.) - EMERGENCY RESPONSE PERSON HOME TEL# HOUI tS OF OPERATION-Mon. Yue. _ Wed. - Thu-_f-�_Frl.,�- Sat •- Syn,/ TYPE OF ESTABLISF FEE (check only) RETAIL STORE Oft -NU less than 1000sq.ft 1000A0,000sq.ft. =$1 more than 10,000sq.ft =$250 RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 - ---....---...--... ............. _...,. REAKF....- - •............:. ......... . ... BEDBAST YES NOS $104 ...-...•..............'15E-----t.-............. ----------------------------------...........................----------.....-..,--,.•-....SCANNED taD„DITIONAL PERM;TS MAKE(not Just serve)ICE CREAM,YOGURT,SOFT SERVE YES 6D $5 TOBACCO VENDOR YES C��IJ $50 JAN 2 5 71r'l ALLIfOftl-ial2OFIT(such as church kitchens) YES N $25 AC(;TSPAYABLE 'Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change or ownership.The,Pcrmit must be posted in a prominent location In the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by tine Salem Board of Hoalth._ Pursuant to MGL Chapter 62C, Section 49A,Ir certify under the pains and.penalties of perjury that I, to my best knovA a nd hay' ed ail to tax returirs and paid all state taxon required under the law 9� _-3o a . Signator ate Social Security or Federal Identification Number _---_-------------------------- — - — -------- -- - ------- �.. - Revised t 110=5 f0C VAP2.adm Check#8 ua,034 (wLO.. ll� �� t. r mOD R m 'Z jpm r ' ° COURTT DOCKET NO. CITATION NO CITY OF SALEM VIOLATION NOTICE PD 0390 'z Z NA E(LAST,FIRST,INITIAL) m S S 7` Vr. I STREETADORESS %ITYROWN STATE ZIP (] . m LICENSE NO. LIC.EXP.DATE DATE OF BIRTH r y ❑ DNO� _ * m OW R'S NAME(LAST,FIRST,IN LD m O * W Ts•naRY NC � D o # X 1 STREETADDRESS -jW, j/jq4e."SfVA}�R.OWN STATE ZIP l �2 (n * D 3 /9401 Al-,A'9'�Act YIX�IYKf/7 �jSA°Zy = DZ2D REGISTRATION NO. STATE EXP.DATE MAKEr YPE YEAR COLOR O LL7 m m # 0 QD O # m DATE OF VIOLATION TIME DATE CITATION WRITTEN PERMNe m J Z ❑AM IWUR D p ❑PM 1--z7-e6 VES - y (D .'D N 05/ .� LOCATION OF VIOLATION OI Q ENFORCING DEPT. 9 'XU) m iD # df c r n --1 OFFENSE f CHAP. SECT. FINES �+ m c # 9U IT, R o m (n vocy, fazU Q CN. GSl t/l7I f o O LIl 3 �:.» � y 7J a N C0 0 .� N �, OFFICER I.D.NO. TOTAL /�. i M1�"' '� �:.0. _ FINE ,$ m DUE 0 o �m m � OFFICER CERTIFIES COPY GIVEN TO VIOLATOR x ,/ }' ❑/IN HAND � �' x /y' /��p IJ BV MAIL O W O n DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY f ORDER OR BY CHECK MADE PAYABLE TO: m m CITY CLERK o -i CITY HALL -3 m 93 WASHINGTON STREET n, SALEM,MA 01970 r ,. D ' TEL.(508)745-9595 X 251 = 7J � m m. :"' 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON f7 REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE o �� x PAYMENT IN THE AMOUNT OF O D $ CASE k y' n m • RI ;c O Z SIGNATURE * 41 * p j N SEE OTHER SIDE FOR FURTHER INFORMATION m ut 41 ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 00 0 O O p C O O) W m * A COURT DOCKET NO. CITATION NO. CITY OF SALEM VIOLATION NOTICE PD Oigo NAME(LAST,FIRST,INITIAL) PL s;lti 7- a //9? STREET ADDRESS ITY/TOWN STATE ZIP �refn,l r h7 LICENSE NO. / LIC.EXP ATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) /'krS'f)aA7'- -We, STREETADDRESS 7A(H LJCe"S`jj'v WN STATE ZIP /fcof /L A?l . j - e1 acsaa7 REGISTRATION NO. STATE EXP.DATE MAKEITYPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN P%W.AL Am NJ Ry /-!'-.(!�p ❑PM / ❑ry�� YES.[3NO LOCATION OF VIOLATION l1�j�pFORCING DEPT. !/1 74'A &lef hvfz 1r(: OFFENSE CHAP. SECT. FINES t A /,-y �S 1/RL' +0/S(q//� /��/!77/ Si BJ��Yo �Ro1cE K� 1717' C OFFIC // 7 ` I.D.NO. T-INEDOUTAE L -1$ fVf OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ❑ IN HAND X /( 0 BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 f TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT INTHIS ENVELOPE,PEEL AND SEAL CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH s 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, RS, CHO HEALTH AGENT January 26, 2006 Ron Shamsie Petsmart, Inc. #1197 Tax & Licensing, 19601 N, 271h Ave Pheonix, AZ 85027 Dear Ron Shamsie: You are currently operating your Food Establishment, Petsmart, Inc. #1197 located at 10 Trader's Way, without a Food Permit. This is in violation of the State Food Code, 105 CMR 590.000, section 8-301.11. In order to receive a 2006 Food Permit, you must: • Pay outstanding tax bills, if any • Pay outstanding tickets from the Board of Health • Pay for your 2006 Permit • Submit a completed 2006 Food Permit Application You are hereby ordered to obtain a 2006 Food Establishment Permit forthwith. Failure to do so by Monday, February 6, 2006, will result in a Board of Health Order to cease all food operations at your establishment immediately. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. An attorney may represent you. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Sincerely, Joanne Scott Health Agent EMPORTANT MESSAGE FOR y DATE I TIME 3 .M M P c r OF PHONE AREA CODE NUMBER EXTENSIO ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU w WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAG � bo CL S O I o ll ]' �r SIGNED ;FORM 4009 E IN U.S.A. NOTES i 1r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH a 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, RS, CHO HEALTH AGENT Facsimile Transmittal To: 5/vim - 76 �' Grey st 9 Fax# S-019- RE: eRE: � rrr�kr Sfnkl/97- 1ema ra/9�i6 Date : i/Rn/ Page(s): including this cover# Message:, Le4ycy L��Qc�' hla'508'y /u Y e ,arnen�r OT- /00 ^ 1H s 0-r-27" tvf�c- -/o e �hJ add' 7z1 c�rfi5j a ,r ��9ia.y �Ja : Aa c/ e 7�U�T r X00 a �r1 /k1 Paeiy»ek,f 0 i � 0390 rvhic� was /ssvQ�/ pec �c�5e F la �e /rnn n a/t� "067 91errrPe Re 17L2Z/J. Board of Health News ----------------------------------------------------------------For Your Information OFFICE HOURS: Monday, Tuesday, & Wednesday 8:00 AM to 4:00 PM Thursday 8:00 AM to 7:00 PM Friday 8:00 AM to 12:00 Noon Do Salem Residents Know ? -Applications for a permit to remove exterior paint are required by the Salem Board of Health. No fee for permit and electric sanding is not permitted. Regulations for home owners and painting contractors are available. HP Fax Series 900 Fax History Report for Plain Paper Fax/Copier Joanne Scott Salenr00H 978 745 0343 Jan 34 2006 2:23pm Inst Fax D= - Time Twe ldeutificatidn Duration Pzges' result Jan 31 2:23pm Sent 916235806502 0:28 1 OK Result: OK - black and white fax CITY OF SALEM,MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR c 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: RETAIL FOOD Name of Establishment: Petsmart, Inc. #1197 Address of Establishment: 10 Traders Way Owner's Name: Petsmart, Inc. Restrictions: Application Date: 12/01/2004 Permit for Food Establishment 111-05 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, MASSACHlUSE C g flVo o BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR NOV 3 0 2004 SALEM, MA 01970 ,) TEL. 978-741-1800 CITY OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1(� [�INC .� I�grl� TEL#19'T�-9145-21 k ADDRESS OF ESTABLISHMENT ,mal�MO__�a_�o n MAILING ADDRESS (if different)(�{}t 'l I�CfllS1( Q rnN �1W� tmke �JB xIAZ��7� 1 OWNER'S NAME TEL# (6Z3-228-e0z p ADDRESS CITY .(111C STATE ZIP as CERTIFIED FOOD MANAGER'S NAME(S) NIA CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON , __ _ HOME TEL# HOURS OF OPERATION: Mon.RA-Tue.9 Wed.q-q Thu. '�-gFri._�Sat.q-Sun]0 7 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE S NO less than 1000sq.ft. 1000-10,000sq.ft. -$100 more than 10,000sq.ft. 2 RESTAURANT YES I I l '� less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 'A I I MON-PROFIT(such as church kitchens; YES N. $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best �H^owled a and belief, have filed all state tax returns and paid all state taxes required under the law. �r,� 9�4-�2432� Signature U Date Social Security or Federal Identification Number ------------------------------------------------------------ ------------------------ - -- ----------------------------- �------- ---/-7-�--/--�----�--- ---- -------- Revised 11/03/03 FOODAP2.adm Check#&Dat-�qq- �7 IMPORT"T MESSAGE V FOR '✓L J�'r7�s ew) (l� DATE �!j TIME �f01. M ,ZS1 F e)rUn w p f/S OF PHONE AREA CODE NUMBER EXTENSION O FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE.YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU ESSAGE C014]lhl rt1�5 Q LfOlI��o�.�� 1S (d� o`�caa01A 70_53 Oaf. ck I > > A4 a (W . SIGNED `_�/Y_ FORM 009 VT_I I. MADE 1 .S.A. COTES - ��' � SPo�� _io 1 N�S�R� mCz�. tl�. ST�i4,D tR P��b�_Cx�T 1 a �1iE, s�R��i-s was R�,r-av��\�2 3 �HyS wt�e Yldee.P��i�N?043�c�S_ 116 V i oL3i yaw ��l t.��1' � T��15—�m��—---- -�� --- �_`-- �4 Tax & Licensing, 19601 N. 27th Ave Petsmart, Inc. #1197 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone:' Item Status Violation Critical Urgency Nature of problem or correction ..978-745-2112 x; -- Non-compliance with: Not Done Owner: Anti-Choking PASS ❑ .i Petsmart,lnc. T im <. - Tobacco PASS ❑ :PIC: 'Kerry,GUltfre " �,�.; + FOOD PROTECTION MANAGEMENT Not Done !Inspector: PIC Assigned/Knowledgeable/Duties PASS d❑ RED DavidGreenbaunl _ EMPLOYEE HEALTH Not Done Date Inspected: Correct By. s Reporting of Diseases by Food Employee and PIC PASS ❑d RED 8/22/2005 ` Personnel with Infections Restricted/Excluded PASS RED Risk Level: - FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASSd❑ RED 13HP-2005-0191 Receiving/Condition PASSd❑ RED Status._' r Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED OFF: Conformance with Approved Procedures/HACCP PASS RED #of Critical Violations:' Plans G PROTECTION FROM CONTAMINATION Not Done Time IN: Time OUT: Separation/Segregation/Protection PASS RED Notes: Food Contact Surfaces Cleaning and Sanitizing PASSJ❑ RED 245: Proper Adequate Handwashing PASSd❑ RED Urgency Description(s): Good Hygienic Practices PASS J❑ RED BLUE: ' c Prevention of Contamination from Hands PASS RED Violations Related to Good Retail Practices (Critical Handwash Facilities PASS 0 RED violations must be corrected immediately or within 10 days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 22,2005 ) Page 1 oft .e Tax & Licensing, 19601 N. 27th Ave Petsmart, Inc. #1197 must be corrected Immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) , ;: Approved Food or Color Additives PASS ❑d RED RED: -_ Violations Related to Toxic Chemicals PASS RED Foodborne Illness I nterve'ntlOnSTIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASS RED immediate corrective action)' Reheating PASS RED Cooling PASS 0 RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS Q 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 FAIL Critical ❑ BLUE There were some outdated chips and snacks. Removed at time of inspection. Equipment and Utensils PASS ❑ BLUE 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 No other health code violations noted at this time. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 22,2005 ) Pa¢e 2 oft 08/03/05 WED 13:36 FAX 0001 PIJ I.i DEPAR -ME I;T PACE iNCIDEN.-F REPORT T7=53 -705 shift : C ami Int, C 441 A."N_MID L -ALL.. '13"71E Tz; x!'C v't t---i 11-4 10io # 12 TRADERS WY SAL 441 Aw,. ;:;F A."C'."ARLS Pi.-ARN, 'As: 12 64 - 705 PETS MART UiNIT (s) '�fr- avi 3AL M DONPL.'."� FAM K 17215 do i7: 15 a) 17: 15 cY QQ5 k) h? `,r. 7:-, lz�i.OG C-D-44 EN OF 2.0 AT THE REQUES F OF THE_ 5UNKE4U OF P4N.IlylAi.- i --i -:,.RYINS -10IFT- c'.0 SAL I lit-il-3 DPY SERVED IN HAND TO MRTYLER RAY THE STORE Xla=3% 705- 20 ;JAL_ Llit." DU-11'y f` ORTKER OF QUARAIQTI'14E FOR R!-L iRODP4\jT;-' T;-;(*;.I\i JZ--j- 2".6 SPL GUINEA PIG,-� AND RABBITS, ThiS ORDER W).;..L STPY IN EFF'EC'4 70,51- 20 E-AL UNFilL FURTHER NU_1(.C. THE ORDER 13 FOR CF 705-- 20 SAt L.G-M VIRLJ-S705- 20 SAL ORDER FEGUESTED �LAHIL PiND -uY .1.N!.PECIFJF. OF (f1;5-- .6A L AN-l"MaLS DF-11NALD 700- o1v f i a e r date Massachusetts Department of Public Health Salem Board ofS Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name �n Date Tvoe of Operation(sl Type of Inspection NC +r7 fi t t Food Service 19-R6utine AddressGY M r Risle 1 P-�tail El Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone t r ��f2 �, ElMobile Date: t HACCP Y/N El Temporary ElPre-operation Owner ❑ Caterer El Suspect illness Parson in Charge(PIC) Time ❑ Bed&Breakfast [I General Complaint In: ❑HACCP Inspector,944110 (^r" K g A Out: Permit No. ❑Other-- Each ther _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" ,"j ' ; , ..` ,` ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned i Knowledgeable/Duties ❑ 13. Handwash Facilities r EMPLOYEE HEALTH ' AS ' ,PROTECTION FROM CHEMf `._ ❑�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 TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling ' PROTECTION FROM CONTAMINATION17119. 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) ; ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ I',CONSUMER ADVISORY 11. Good Hygienic Practices ❑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 Q 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 N'` by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044)} 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: S'S99MspecfFomi614.tla A Inspector's Signatu e: _Print: - PIC's Signature: Print: / Q iorc,o Pagel OPa Pages Violations Related to Foodborne illness Interventions and Rask Factors(items 1-22) PROTECTION FROM CONTAMINATION_ FOOD PROTECTION MANAGEMENT 8 Cross-contamination I 590.003(A) Assignment of Responsibility- 3-302.11(A)0) Raw Animal Foods Separated from 590.003(8) Demonstration of Know ledge" Cooked and RTE Foods* 2-103.11_ Person in charge-duties Contamination from Raw ingrodients 3-302.1.1(A)(2) Raw Amaral Foods Separated fxomEach EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require repoiling by food employees and 3-302.11(A) Food Protection* applicants* _ 3-302.15 Washin Fruits and Vey*etables 590.003(F) Responsibility Of A FCxxl Employee Or An 3-304.11. Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char*e* Contamination from the Consumer 590.001(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(3) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* d Food and Water From Regulated Sources 9 Food Contact Surfaces 590.0(M(A-B) Cotn tliance with Food Law* 4-501..111 Manual Warawashmg-Hot Water 3-201.1.2 Food in a Hermeticall •Sealed Container* Sanitization Temperatures* 3.201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashino Hot Water 3-202.13 ShellEoas* Sanitization Temperatures* 3-202.14 Eg-g-s and Milk Ptvducts.Pasteur zed* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking-Water` concentration and hardness. 5-101..1.1 . 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- Sheltfuh 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 Satutzation-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources' to Proper,Adequate Handwashmg Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Re Mato Autharit 3-202.18 Shellstock Identification Present' 2-301..1.2 Cleaning-Procedure* 590.004(C) 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 Usin Tobacco* 3-202.11 PIIFs Received at Proper Tem eratues* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package integrity' Mouth* 3-101.11 Food Safe and Unadulterated* - 3-301.12 Preventine Contamination tiVlien Tastin " (; Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.()04(3) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* - Conformance with Approved Procedures 5-205.11 Aecessibilit Operation and Maintenance JHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging.criteria* 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures" c 6-301.12 Hand Drying Provision *Denotes critical item in the federal 1999 Food Code or 1051 CMR 590.090, CITY OF SALEM BOARD OF HEALTH / 2 Establishment Name: e§.r-- PyA4_r— INC //77 Date: /�1� ��`f Page: 2 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION bate No. References.. R-Red Item Verified PLEASE PRINT CLEARLY Lr Iswd. _njc L C P k 7N t ra 07 /' aJ'trtrr r4 N jO t0rtm e4 f teA i Vc4 tog 4A r r ab TSJV ii 7 r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty f've dollars or suspensionlrevo ation of ❑ Embargo ❑ Emergency Closure your food permit. /�7 r ❑ Voluntary Disposal ❑ Other: 3-501.14(C) Fs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to Factors(Items 1.22) (Cont.) 41'F/45'F Witten 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Conlin-Methods forPILFs ---- Foo 19 PHP Hot and Cold Holding 14 Food iv Calor Additives - 01.16(B) Cold PRFs Maintained at or below 3-202.12 Addtttveck 590.004(F) 41°145° E' 3-302.14 Ppo so, at from Una roved Additives* 3-501.16(A) Itot PHFs Maintained at or above LS Poisonous or Toxic Substances 40'F, * 7-101.11 nO Containers tyme Information-Original 3-501,16(A) Roasts Held at or above 130°F. Gm 7-102.11 Common Nat -A6'orkin�Cantainers* 2{I Time as a Public Health Control 7-201.1 1 Separation-Storace* 3-501.19 Time as a Public Health Control* 7-202'11 Restriction-Presence and Use* 590.004(H) Variance Re uirennent 7-20212 Conditions of Use, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2(}3.11 'CoxicContainers-Prohlhikions°` POPULATIONS(HSP} 7-204.11 Sanruzers,Critetia-Chemicals 7-204.1.2 Chemicals for Washine Produce,Criteria* ZI 3-801.1I(A) Unp isteurized Pre-packaged Juices and r 7-204.14 Dr'in Agents.Criteria* Beverages with Warning Labels* 4 7-205.11 Incidental Food Contact.Lubncmts"' 3-801.11(B) Use at Pasteurized hoes* 7-206.11 Restricted Use Pesticides,Criteria` 3-801.1.1(D) Rau or Partially Cooked Animal Fad and Raw Seed S gouts Not Served.'x 7-2(76.12 Rodent Bait Stations" 3-s01.1 I(C) Uno oened Food Packs>e Not Re-served. 7-206.13 'Pricking Powders,Pest Control and Monitoring' CONSUMER ADVISORY TIMET EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Ani ivil Foods'Ihat are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.I1A(1)(2) Eggs- 155°F 15 Sec. Path oEns Eft"v- I Eees-hmmedure Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for[taw Shell 3-40111(A)(2) Comminuted Fish,Meats&Game E .'" Animals- 155°F 15 sec. 3-401.1IB)(1)(2) Pork and Beef Roast- 130°F 121 ntin* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,injected Meats-155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sea rc: 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 Poultr y or Ratites-165'F 15 sec. * above if related to fbadborne i'tlness 3-401.11(C)(3 Whole-nniscle, Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401 A2 Raw Animal Foods Cooked in a practices should be debited under#29- Micmwave 165°F* Special Requirements, 3-401.11(A)(1)(b) All Other PHFS- 145'F 15 sec 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403,11(A)&(B) PHFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to Fite Time* foodborne illness interventions and risk factors listed above can be 3-403.11(C) Commercially Processed RTE Food- ,firund in the following sections of the Food Cotte and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 580.000 _ Roasts" 23. Mans ement and Personnel__..-----FTG--3 __ FC-2 .003 1g Proper Cooling of PHFs 24. Food and food Protection ____ _ FC-3 .004 25 _ Equi ment and Wonsiis FC 4 ,005 3-501,14(A) Cooling Cooked PHFs from 140°F to - - - -- - -- -- 06 26 Water,Plumpin and Waste FC-5 _ ,006 70"P Within 2 Hours and From 70'F 27. Physical Facility FC-6 007 to 41'F/45'F Within 4 Hours. ` 2& Poisonous or Toxic MaterialsFC-7 .008 3--0M 14(B) Cooling PRFs Made From Ambient 29. S eels(Re uirements __ _ { .009 Temperature Ingredients to 41°F/45'F 30_1Other_ Within 4 Hours* ssrata�.,ea-z.a,x '"'Denotes critical item in the 4^deral 1999 Food Code or 105 CMR 590.004. CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 59 120 WASHINGTON STREET, 4TH FLOOR /If' SALEM, MA O 1970 TEL. 978-741-1800 �4'y�udlFAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS 'PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Petsmart, Inc. #1197 Address of Establishment: 10 Trader's Way Owner's Name: Petsmart, Inc. Restrictions: Application Date: 11/5/2003 Permit for Food Establishment 001-04 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 Oct 01 03 02: 32p Joanne SC.ott Salem BOH 979 745 0343 p. 2 CITY OF SALEM, MASSACHLISETTS C � f � ROAR O DF HEALTH s 120 WASHINGTON STRFrT, 4TH FLoor �� '] SALr M, MAO 1970 OCT TEL 976-741-1800 FAx 978-745-0343 CITY OF SALEM(�}''�BOARD pyo^ STANI..FY USOVECL. -1H, JOANNE SCOT-r. MPH, RS, CHO BOARD l..Jl- HEALTH MAYOR HEALTH AaCNT 2003 APPLICATION FORPERMITTO OPERATE AyF�O}rOD ESTABLISHMENT NAML= OF ESTABLISHMENT �tE1�I�YaII��.._ II 1 / EL# �}q(jLr1/�tS `LIf� ADDRESS OF ESTABLISl IMCNT 1 S\l� l (.. M4N C)T7V ( -�� MAILING ADDRESS (if different) t t( txt� '�`�� 1 /� rt ", — � ry Z hbsu� 7 OWNER'S NAME_- !�crt��11.�nn�-114nn�_�^—.. TEL ADDRESS E�� DC)it1' rsV' �.}`4't� _ CITY �l11 �,� STATE ZIP a T CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s} (required in an establishment where potentially hazardous food is prepared.} EMERGENCY RESPONSE PCR-,ON ,0 17I _—HOME TEL# HOURS OF OPERATION, Mon.�Tue. l-q We=dq-01, ,Thu. Fri,- Sat, TYPE OF ESTABLISHMENT FEE check only RETAIL STORE 4iEN' Oless than 1000sq.ft 50 1300-10,000sq ft =$1 (P�e-PaC�-k4fkC3 (/ more than 10,000sq ft =$250 RESTAURANT 0 YES NO less than 25 seats =$100 seats =$150 more mare than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE 16E CREAM, YOGURT, SOFT scrvc YES $5 ,d TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES O $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership The Permit must be posted in a prominent location in the Establishment. In 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 ow1odg and t7elief, Have fil��Ilstate tax rOturnS and paid all statet2xeS required under the IeW. Signature (/ e , Social Security or Federal Identification Number ----------- -------------_----------- -----—------------"-------. ..------------------------------- -------- ---- Revised 11125!02 FOODAP2 adm Checks K E Y E D N 0 T E S y 2003 Crl `r OF .` AL M NEALTH ❑ II --0-� _LE N E R A L N O T E S pig COG FLOORING COLOR / FINISH- N I__ .wmv.m ry.f S g Ell -jI 1�d F i12� amw Inm K E Y P L N N II IIa s 1 Y a y I MYHRE `2 I FLOOR FINISH PLAN A .,�,� 1 � o su. 100 V A- 1 M... 303033 «.: ._.:.--,-...�.�,-.�„.�.. .•-...._..�,-.-._._a.:ra+rwww.w�. v°„wv,:.ar-v - -' v.`c,..-.,,...,r,: ,. ,n..-.�.....,.-.,d...r.:--�. �.-. t 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 Name � Date Type of Operation(s) Type of Inspection /e7SrrJf1?7> #�/ //� �v3 ❑ Food Service ❑ Routine Address Risk O'Retail ❑ Re-inspection Level / ❑ Residential Kitchen Previous Inspection Telephone ` ❑ Mobile Date: cJ�ar:ra Owner HACCP Y/Ni ElTemporary E Pre-operation Tfr,,4 r x c El Caterer El Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint In: /':JO ❑ HACCP Inspector -,.. w� Out: Permit No. o0/_o� ❑ 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 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 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 El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) [116. Cooking Temperatures El 5. Receiving/Condition El 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling ❑ 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: � Print: PIC's Signature: Print: ` Page / of�J Pages FORM 734A HOBBSB WARREN -BOSTON -.-. _.may.... 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 1; 590.003(A) Assi nment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Chare-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment AV 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* ""` require reporting by Food Employees and ;..�y * 3-302.15 Washing Fruits and Vegetables Applicants* 3304.11 Food Contac[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 ir3590.003(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 r 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-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* 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* Y07 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* 3-201.17 Game Animals* it Good Hygienic Practices 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 G' Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* r''.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(1) Labeling of Ingredients* 5-205.11 Accessibility, Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of .D .' Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item - - - Verified: PLEASE PRINT CLEARLY C NW' 2c F 1 / �ir<..7n ��-ia✓ i'�.e,� �r fes, �e� �e / a C a Td eX_'1 v r A. ,r t 3 r r , S Discussion With Person in Charge: Corrective Action Required: W_-No ❑ Yes E I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ Exclusion y' 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 K, your food permit. ❑ Voluntary Disposal ❑ Other: , ti 1 . >v 3-561.14(C) PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I:aw Ccwled to Factors(Items 1-22) (Cont.) _ 41.'F/45'F Within 4_Hours. PROTECTION FROM CHEMICALS 3-501_15 Ccmling Mer(ru is for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives„ 3-501-16(B) Cold PHFs Maintained atorbelow 590.004(F) 41°/45'F 3-302.14 Protection from Una> roved Addimcs* 3-501.16(A) Hot PIIFs Maintained at oi:above 15 Poisonous or Toxic Substances 140"T" 7-101.11 ldenntjnng Information Original 3-501.16(A) Roasts Held at or above t30'F. * Containers* 7-102.11 Cornmon Name-Working Containers` 20 Time as a Public Health Control 7-201.1.1 Se.aration-Sto]aec' 3-50119 Time as a Public Health Control* 7-20211 Restriction-Presence and Use, 590.004(8) Variance Rc u tnent 7-202.12 Conditions of List* 7-203.11 'toxic Containers-Prohibitions* REOUIREMENTSFORHIGHLYSUSCEPTIBLE 7-204.11Sanitizers.Criteria-Chemicals: POPULATIONS(HSP) 7-204-12 Chemicals for Washing Produce,Criteria" 21 3-W l,11(A) Unpesteuriz�d Pre packaged Juices and 7-204.14 Drying Agent,,.Criteria* ra Beveees with Warninv Labels* 7-205.11 Incidental Food Contact Lubricants* 3-80L17.(B) Use ofPasteurized Eg 7-206.11 Restricted Use Pesticides,Criteria` 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Secd S goats Not Served " 7-200.12 Rodent Bait Stations* 3-801.11(C) IJno.ened Ford Parka=e Not Re-served. "` 7-206.13 To Powders, Pest Control and Monitorine'" CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consurner Advisory Posted for Consumption of 1h Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PRFs Not Otherwise Processed to Eliminate Pthm r ,anal 3-401.11A(1)(2) ;ets 15 Sec F -s Immediate Service l4i`FlSsec* 3-30213 Pasteurized Eggs Substitute fr Raw Site]] 3-401,11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals- 155'F 15 sec. '' 3-401.11(B)(1)(2) Pork and Beef Roast- 130°'F 121.min* SPECIAL REQUIREMENTS 3-401.1 l(A)(2) Ratites,Injected Meats-155'F 15 J90-009(A){D) Violations of Section 590.009(A)-(I))in sec > catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuflin;Contahtin„Fish,Meat, debited tinder the appropriate suctions Poultryor Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.'1l(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 he debited under//29- Microwave 165'F* Special Requirements. 3-401.17(A)(1)(b) All Other PHFs-145'F'I5 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-463.1 i(A)&(D) PHHs 165'F 15 sec. * (Items 23-30) _ 31103.11(6) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time„ foodborne illness interventions and risk factors listed abocg can be 3.403.11(C) Commercially Processed RTE Food- _found ie the follor ing sections of the Iood Code and 105 CMR l4WF' 590.000. 3-403-11(E) Remaining Unsticed Portions of Beef item I Good Retail Practices FC 590.000 Roasts* # 23 Management and Personnel FC-2 .003 13 Proper Cooling of PHFs 24 Food and Food Protection FC-3 .004 25 -quipmentt and- t t { End Utensils 3>OL14(A) Cooling Conked PHFs from 140°F to 26 Water Plumbing and Waste FC-5 .006 70°F Within 2 Hours and From 70'F 27, Physical Facility FC-6 .007 to 41'F/45'F Within 4 Hours. * { 28- Poisonous or Toxic Materials FC-7 ,008 3-501.14(6) Cooling PHFs Made From Ambient � .Special Requirements 009 30 Other. _ Temperature.tngacdients to 41'F145`F � -- �_ __......-.. - � Within 4 Hours* 16Lr`°:,"''T0-2."" *Denote,critical Stem in the tWeral 1999 Food Cale or 105 CMR 390.000. 0010 TRADERS WAY Amt Eahn t Inc. #1197 City of Salem RETAIL FOOD - Food Establishment Item States Violation Type Urgency Violations RelatedtoGood Retail Practices (Blue Items) Address: 0010 TRADERS WAY Food and Food Protection FAIL Critical BLUE Telephone: (978) 745-2112 COMMENTS: Some sodas stored directly on the floor in storage room.Store sh items at Owner: Petsnta(t, Inc. hest 6-8 inches off the floor. 21 outdated Mountain Dews were removed from the soda fridge.Owner to closely monitor all a(pirsdon dates. PIC: Art Lobie Inspector: Elizabeth Salandrea Equipment and Utensils FAIL Non-Critical BLUE Date: 6/27/08 COMMENTS: Soda fridge needs general cleaning along bottom and in door tracks. Risk Level. GENERAL COMMENTS: Owner to notify Board of Health within one week that violations noted have been corrected. HACCP: No Coined By: PermltNember: BHP-2008-0055 Status: SIGNED OFF s of Critical Violatdons: l 411 Time IN: OUT: Urgency Description(s): BLUE: Violations Related to Good Retail CftV*f9wkw a.ardofhmM twwu.r. . "Mor SALEM NA weron.w:(srs)sor•raOFu:(s7s)ras-aw CMTNM Slue M(..na.rm (s.Yro...r.a. COMMONWEALTH OF MASSACHUSETTS e.r.i lWassachusetts 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 ate Tvpe of Operations) Tvpe of Inspection LJFood Service ❑ Routine Address , n ^ C . IQ v Risk LJ Retail ❑ Re-inspection V Level Q Residential Kitchen Previous Inspection Telephone ( ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-operation P-e�w 11 r- ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) -10 I Time ❑ Bed& Breakfast ElGeneral Complaint CP Inspector Out: Permit No. ElA LrOther our 4 ❑ Each violation checked requiresa 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)-E] action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT _ _., _ [112. Prevention of Contamination from Hands ❑ 11 PIC Assigned/Knowledgeable/Duties E] 13. Handwash Facilities [EMPLOYEE HEALTH _--_ PROTECTION FROM CHEMICALS . a ., ❑ 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded �_Y El15.Toxic Chemicals FOOD FROM.APPROVED SOURCE __ _ _ _ _ TIMEITEMPERATURE CONTROLS Patentlell Hazardous ods 4 Food and Water from Approved Source ( Y �Fo__ ) ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION 3' •. - ❑ 19. Hot and Cold Holding k8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing fREOUIREMENTS FOR HIGHLY_SUSCEPTIBLPOPULATIONS(HSP)' El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices [CGNSUMER_ADVISORY ' ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions ) immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations.must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below C x 23. Management and Personnel (FC-2)(5by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590O04)) 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 )0os) 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: n Inspector's Signature: � Print: PIC's Signatures Print: Page`of ZPages v Violations Related to Foodborne Illness Interventions and Risk Factors(Nems 1-22) PROTECTION FROM CONTAMINATION_ 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assia tment of Responsibillt�_ Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11. Person in charge--duties 3-302.1l(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 co _ 3.302.11(A) Foal Protection* require reporting by f xid employees and 3-302.15 Washing Fruits and Vegetables a licwits* 3-304.1 I. Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* Disposition ofAdutterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-701.17 Disau�ding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE rood* 4 Food and Water From Regulated Sources F9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Scaled Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products*� 4-501.112 Mechanical Warewashing-HotWater 3-202.J3 Shell Ed 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.* 4 5-'101.11 DrinkingWater fix)m an Approved System* -601.1](A) Utensils lEqu sill Clean* Contact Surfaces and- 5%.006(A) Bottled DrinkingWater" ean* * 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 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 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 14 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority2-301.11 Clean Condition-Hands and Arms* 3-202.1.8 Shellstock.Identification Present* 2-301..12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices - - g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and 3-202.15 Packajze hate it * Mouth* 3-101.11 Foal Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 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* Em to ees* Tags/Records; Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 1 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.0040) Labeling of ingredienW 5-204.11 Location and Placement* q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance fHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Meth(xls* - Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.1-1 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision Denotes critical item in the federal 1999 IVa Cate or 10a CR9R 590.000. b CITY OF SALEM BOARD OF HEALTH Establishment Namea;)P , tilr� Date: —IU Page: C54, of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Rem _ Verified r PLEASE PRINT CLEARLY 1A Ad Od _ ( 0 nAA O AA ,1j�Q� /Q 01 i7 s OM \ w p _ JrJ i ,t�- 1 �rrnn t � x� ,2 \� -P of x r r'Le'u) U '�'V�t C, o . 1 Discussion With Person in Charge: Corrective Actlon Required: ❑ No \ :Yes I have read this report, have had the 0 i�Voluntary Compliance ❑ Employee Restriction/ p opportunity to ask questions and agree to correct all �� XT < ` Exclusion violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled ❑ Emergency Suspension npncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) _ 41=F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16($) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 4101450 F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presenceand Use* 590.004(H) - Variance Requirement 7-202.12 Conditions of Ilse* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washin Produce,Criteria* 21 3-801.I1(A) Unpasteurized Pre-packaged Juices and 7-204.14 - DrvinR Agents.Criteria* Beverages with Wanting Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(13) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-80L I l(D) Raw or Partially Cooked Animal Food and 7-206.12 Rodent Bait Stations* I Raw Seed Sprouts Not Served. * 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) I Unopened Food Package Not Re-served. ^' Monitoring* - CONSUMER ADVISORY TIME(TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PRFs Not Otherwise Processed to Eliminate 3-401.11A(i)(2) Eggs- 155°F 15 Sec. Patho ens.* Eggs-Immediate Service 145°Fl5sec* 3-302.1.3 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 1.30°F 121 min* 3401.11(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 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3.401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(6) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk,jtctors listed above,can be 3.403.11(C) Commercially Processed RTE Food- found in the follondng sections of the Food Code and 105 Offs? 140°F* 590.000. _ 3403.11(E) Remaining Unsticed Portions of Beef em I Good Retail Practices FC 590.000 Roasts* 23Man ementand Personnel FC-2 - 18 Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004 3-501.14(A) CoolingCooked PHFs from 140°F to 2� 6- Equipment and Utensils FC-4 .005 26. Water,Plumbing and Warts I FC-5 006 70°F Within 2 Hours and From 70*F 27. Physical FacilityFC-6 .007 to 41°F/45°F Within 4 Hours.* 26. Pdsonous or Toxic Materials i FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S inial Requirements .003 Temperature Ingredients to 41°F/45°F X Oma - - - Within 4 Hours* _ s:swro�roset-Zm •p notes critical item in the federal 1999 Food Cale ro 105 CMR 590.000. CITY OF SALEM, MASSACHUSETTS lu BOARD OF HFA-LTH 120 WASHINGTON STREET,4'"FLOOR P11t1)t{CH@A11:11 Prc.m,u.Promote.Protect. TEL. (978) 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL Hamelin e salenxotn - - LARRY RANRIDIN,RS/RI:I-IS,CHH CP—PS MAYOR .. . . HI3/\I GI'I AGJ?N'P. :'t . This Form will be collected during your next Board of Health inspection. QUE'STIONAIRE - GREASE TRAPS 2012 1. NAME OF ESTABLISHMENT: �t G�5►�1 /- tib lq'1 2. ADDRESS OF ESTABLISHMENT: T(2./k� 014t,f �VT�IY` /i I� OI�i7D 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? NO 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 5. HOW IS THE GREASE TRAP MAINTAINED? ON A.DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4h Floor Salem MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name D9j Type of Operation(s) ype of Inspection Aa-t- -Swllq Food Service 11,4 Routine -Address Rik I IiRetail Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection �. ( ❑ Mobile Date: Owner HACCP YIN El Temporary ElPre-operation C ❑ Caterer ❑Suspect Illness Person-in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint 77 In: aO [j HACCP Inspector Ou : Permit No. ❑Other Each violation checked re uires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compNance 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 ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD:PROTECTIONMANAGEMENT,_- r _-. _..._ -. � El 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _ EMPLOYEE HEALTH _._ _- ❑ 13. Handwash Facilities .-_ -. ;PROTECTION_,_._FROM'CHEMICAG _ S �,,,___ - -� ❑ 2. Reporting of Diseases by Food Employee and PIC - -- El 3, Personnel with Infections RestrictedlExcluded ❑ 14.Approved Food or Color Additives _- _ - ._ _ _ _�. W_ ❑ 15.Toxic Chemicals FOOD'FROM APPROVED SOURCE ,,._ -T. _ _ - - - - -- - - '- TimErrEMPEiaruRE:coNTROLS.Potential - ' ❑ 4. Food and Water from Approved Source ( IY Hazardous Foods)' , ❑ 5. Receiving/Condition ❑16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17,Reheating ❑ 7. Conformance Wth Approved Procedures/HACCP Plans ❑18. Cooling "' - " PROTECTION FROM CONTAMINATION 19. Hot and Cold Holding .�_ _ _ _ - 9 ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and SanitizingREQUIREMENTS FOR;NIGHLYSUSCEPTIBLE=POPULATION$((H8P),;. , El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMERADVISORY,_ __ _ E]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. C N 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 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc-aX59o.o05) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-4X59o.005) the food establishment permit and cessation of food 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 e,4A Inspector's Signature: PICS Signature: Print: vPage_of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION $ Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 7 590.003(A) Asia mint of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge Contaminat in from Raw Ingredients 2-103.11 Person in charge-rut es 3-302.11(A)(2) Raw Animal Foods Separated from - Other' EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3302.1.1(A) Fuad 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 Fad Employee Or An Utensils* Applicant To ReportTo The Person In Contamination from the Consumer Charge* 590.003 G RMortip4 bj Person in Charge' 3-306.14(A)(B) Returned Food and Reserviee of Food* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 5,I,t3(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fad* q 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501..111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Coniainer* Sanitization Te ramres', 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water . . 3-202.13 Shell Eggs* - Sanitization Temperatures* 3-202.14 Eggs mid'Milk Products.Pasteurized4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water from an Approved S•stem* 4-601..11(A) &lu 1111"t Food Contact Surfaces and' 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards.in 31.0 CNIR 22.0* 4-602.11 Cleaning Frequency of Equipment Food Contact Surfaces and Utensils*, Shelfth 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 NSSF lastcd SourcChemical* Game n 10 Proper,Adequate Handwashing Game and Aut1 o2E.Musowns Approved by 2-301.11 Clean Condition-Hands and Arms* Re u/ato Author@ 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms*� 2-:301.14 When to Wash* 3-201.17 Game Animals* -. 11 Good Hygienic Practices 3 RecelvingXondition 2401.11 Eatin ,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Tem rantres* 2401.12 Discharges:From the Eyes,Nose and 3-202.15 Packaaelute.rt * Mouth* 3-!0L11 _ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin 6 Taus/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identificationn^armained* � Employees* , Tags/Records;Fish Products 13 Handwash Facilities - 3402,11 Parasite Dzstructiun* --- Conveniently Located and Accessible 3-402.12Records,Creation and Retention" 5-203.11 Numbers and Capacities* 590.004(J} La6eiing o1 Ingredients' 5-204.11 Location and Placement* q Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance IHACCP Plans Suppled with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced Oxygen packaging,criteria* 6301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301.1.2 Hand Drying Provision *Denotes critical item inthe federal 1999 Foci Code or 105 CMR 590.0(8). .-4 Massachusetts Department of Public Health Salem Board of Health I__._ 120 WaAingtodStreet,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. Name rHACCP Type of Operation(s) Type of Inspection ❑ Food Service �Routine Address Retail ❑Re-inspection ou A-. ❑ Residential Kitchen Previous Inspection Telephone 5 ❑ Mobile Date: Owner YlN ❑ Temporary ❑ Preoperation ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) ❑ Bed&Breakfast ❑ General Complaint In: �� ❑ HACCP Inspector - Ou : Permit No. ❑.Other Each violation checked"requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. NoMcompliance with: -Violations Related to Foodborne Illness Interventions and Risk Factors-(Red Anti-Choking 590.009(E) ElIViolat ons marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) w -'�� Sr)O- 1:000 PROTECTION MANAGEMENT _ _ , [112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties O ❑ 13. Handwash Facilities EMPLOYEE HEALTH _ . _ _ _ _ •- -PROTECTIONFROM'CHEMICALS _. F1 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives f ❑ 3. Personnel with Infections Restricted/Excluded _ - .. ❑ 15. Toxic Chemicals „FOODFROM APPROVED SOURCE - - TIMEr EMPERATURE CONTROLS(P.otantlalty Haiardous Foods)'. - ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition [116. Cooking Temperatures 0-6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling 1 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION __ p �� _ ❑ 9 ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUSCEPTIBLE-POPULATtONSt(Hip)` 17110. 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-(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 24. Food and Food Protection (FC-3)(590.004).0oo4)) 23. Management and Personnel (FC-2x59order 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-4x590.005) the food establishment permit and Cessation of food 26. Water, Plumbing and Waste (FCSx590.006) 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-7x590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s o-aaa Inspector's Signature: / Print:" Jk.o PICs Signature: / Print: Page_of Pages Violations Related to Foodbome Illness intervenntions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION E8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 540.003(B) Demonstr mon of Knowe* „� Contamination from Raw Ingredients 2 103 1] Person in charge-duties 1 7362.1I(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.603(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(.B Retuned Food and Reservice of Foal* 59().003(G) Re ortir! by Person in Charge" Disposition of Aduttarafed or Contaminated 3 .590.003(D) ExclusionsandRestriclions* Food 590.003(2) Removal of Exclusions and Restrictions 3-70,.it Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 4 Food and Wafer From F7ogutated Sourre, 9 Food Contact Surfaces t590.1004{A-E} Cem Iiancewith.FatdLaw'r 4-501-111 Manual Warewashing-Hot Water 1� Sanitization Temperatures"0l.L2 Foal3n a HertneticaII•Sealed Container* 4-501.112 Mechanical Warewashin Hort Water 01.13 Fluid Milk and Milk Products* Sanitization Tem eratur s*02.33 Stell Eggs* 4-501.114 Chemical.Sanitization-to H, 02.1=1 E d and Milk Products.Pasteurized* ss, P concentration and hardness. 3-2f?2.16 IceMade From Potable Drint.un Water 4-G01.I l f,A' Equipment Food Contact Surfaces and 5-]01.11 Dunk n Water from approved System* Utensils Clean 590.006(A) Bottled Drmkin Water` 4-602.11 Cleaning Frequency of Equipment Fo.od- 590.006(B) 4Yater Meets Stands in 310 CMP.-22-0" Contact Surfaces and Utensils* Shelilish and Fist,From an Approved SaJroe 4-702.11 Frequency of Sanitization of Utensils and - 3-201.14 Fish and Recrewivaaby 0110tt Tv[0ljWT',!a Food Contact Surfaces of Equipment* Shellfish* �l 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shelifisb fr:nn`iSSP Luted Chemical* Sources* to Proper,Adequate Handwashing Game and Wiid Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-202.18 Sbellstoch identification 1'resen:"� ?-300 12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals" _ 11 Good Hygienic Practices 5 Rece]vingrConditton 2401.11 Eating,Drinking or Using Tobacco* M3-202.18Shellstock HFs Rec;:ived.at Proper Temperahns* 244)1.12 Liischarges.From the Eyes,Nose and acka ;rite.tt " Month* '2vdSafe earn-Unadulternted* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records;$1te[istack 1:2 Prevention of Contamination from Hands ck Identification 590.004(2) Preventing Cuntam nation from Em to ees* hellstock Identification RRaimained'F 14 Handwash Facilities TagslRecords Fish Products ; Conveniently Located and Accessibie 3-402.11 kReduced estruction" --)il 5-203.11 . Numbers and Capacities* 3-402.12 Creation and RetentwoAt 5-204.11 Location and Placement* 590.004(1) of ingredients' snce with Approved Procedures 5-205.11 - Accessibility,Operation and Maintenance Conformance pians Supplied with Soap and Hand Drying Davh7es 3-50?.11 ed Processing Methods* 6-301.11 Handwashin Cleanser,.Availabilit 3-502:12 oz gen cka"ng,criteria* 6-301.12 Hand8-10112 ance with Approved Procedures* ' Denotes criftai;tene in the f:decal t99Q Fnai Code 01 105 CARR 590Sk' ,