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PICKLE POT - ESTABLISHMENTS pickle Pot f ftt4 - � � m UNV•12110 uwEwus& Wm= � vaeEoaxEE� I i road io&RAt-rPl, City, of Salem, Massachusetts rnf Board of Health r 120 Washington Street, 4' Floor kimberley driscoll Tel. (978) 741-1800 Mayor ; 1��` Fax (978) 745-0343 © Iramdina,saletncom Larry ramdin, rs/rehs, cho, ep-fs Health Agent t ® Fees,New Fs1a61ishment-$180.00 Remodel,$90.00 Make Checks nav ble to:The City of Salem No cash is accented FOOD ESTABLISHMENT PLAN REVIEW APPLICATION NEW _X—REMODEL _CONVERSION Date: 8/l/2011 Name of Establishment: The Picklepot Category: RestaurantInstitution_,Daycare_, Retail Market X_, Other Address: 75 Wharf St. Phone if available: (978) 744-6678 Name of Owner: Jennifer Bowie Mailing Address: 75 Wharf St. Salem MA 01970 Telephone: (978) 744-6678 Applicant's Name: David Bowie Title (owner, manager, architect, etc.): Manager Mailing Address: 14 Beach Ave. Salem MA 01970 Telephone: (978) 745-2255 I h e sub ed plans/applications to the following authorities on the following dates: Licensing and N/A Plumbing /A Zoning N/A—Electric N/A Planning ," 191„:,Pcfn olice N/A Building Fire (n'1 N/A Conservatio ' Other r ) ours of Operation: Sun_1 6 huts 10-6_ Mon_I0-6 Fri _10-6- Tues 10-6 Sat 10-6 Wed 10-6 Number of Seats: 0 Number of Staff:_1 (Maximum per shift) Total Square Feet of Facility: _900_ Number of Floors on which operations are conducted - aximum Meals to be Served: Breakfast n/a (approximate number) Lunch n/a Dinner n/a Projected Date for Start of Project: _8/1/11 Projected Date for Completion of Project: _9/1/11 Type of Service: Sit Down Meals (check all that apply) Take Out Caterer Mobile Vendor Other X Please enclose the following documents: _N/A_Proposed Menu(including seasonal, off-site and banquet menus) _N/A_Manufacturer Specification sheets for each piece of equipment shown on the plan _X_ Site plan showing location of business in building; location of building on site including alleys, streets; and location of any outside equipment(dumpsters, well, septic system -if applicable) _X Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services and mechanical ventilation _N/A_Equipment schedule CONTENTS AND FORMAT OF PLANS AND SPECIFICATIONS 1. Provide plans that are a minimum of 11 x 14 inches in size including the layout of the floor plan accurately drawn to a minimum scale of 1/4 inch= 1 foot. This is to allow for ease in reading plans. 2. Include: proposed menu, seating capacity, and projected daily meal volume for food service operations. 3. Show the location and when requested, elevated drawings of all food equipment. Each piece of equipment must be clearly labeled on the plan with its common name. Submit drawings of self- service hot and cold holding units with sneeze guards. 4. Designate clearly on the plan equipment for adequate rapid cooling, including ice baths and refrigeration, and for hot-holding potentially hazardous foods. 5. Label and locate separate food preparation sinks when the menu dictates to preclude contamination and cross-contamination of raw and ready-to-eat foods. 6. Clearly designate adequate hand washing lavatories for each toilet fixture and in the immediate area of food preparation. 7. Provide the room size, aisle space, space between and behind equipment and the placement of the equipment on the floor plan. 8. On the plan represent auxiliary areas such as storage rooms, garbage rooms,toilets,basements and/or cellars used for storage or food preparation. Show all features of these rooms as required by this guidance manual. 9. Include and provide specifications for: a. Entrances, exits, loading/unloading areas and docks; b. Complete finish schedules for each room including floors,walls,ceilings and coved juncture bases; c. Plumbing schedule including location of floor drains, floor sinks,water supply lines, overhead waste-water lines,hot water generating equipment with capacity and recovery rate,backflow prevention, and wastewater line connections; d. Lighting schedule with protectors; (1)At least 110 lux(10 foot candles) at a distance of 75 cm(30 inches) above the floor, in walk-in refrigeration units and dry food storage areas and in other areas and rooms during periods of cleaning; (2)At least 220 lux(20 foot candles): (a)At a surface where food is provided for consumer self-service such as buffets and salad bars or where fresh produce or packaged foods are sold or offered for consumption; (b)Inside equipment such as reach-in and under-counter refrigerators; (c)At a distance of 75 cm(30 inches)above the floor in areas used for hand washing,ware washing, and equipment and utensil storage, and in toilet rooms; and (3)At least 540 lux(50 foot candles) at a surface where a food employee is working with food or working with utensils or equipment such as knives, slicers, grinders,or saws where employee safety is a factor. e. Food Equipment schedule to include make and model numbers and listing of equipment that is certified or classified for sanitation by an ANSI accredited certification program (when applicable). f. Source of water supply and method of sewage disposal. Provide the location of these facilities and submit evidence that state and local regulations are complied with; g. A color coded flow chart demonstrating flow patterns for: -food(receiving,storage,preparation, service); -food and dishes (portioning, transport, service); -dishes (clean, soiled, cleaning, storage); -utensil (storage,use,cleaning); -trash and garbage (service area,holding, storage); h. Ventilation schedule for each room; i. A mop sink or curbed cleaning facility with facilities for hanging wet mops; j. Garbage can washing area/facility; k. Cabinets for storing toxic chemicals; 1. Dressing rooms, locker areas, employee rest areas, and/or coat rack as required; m. Completed Section 1; n. Site plan (plot plan) FOOD PREPARATION REVIEW Check categories of Potentially Hazardous Foods (PHF's)to be handled,prepared and served. ATEGORY* (YES) (NO) 1. Thin meats, poultry, fish, eggs(hamburger; sliced meats; fillets) ( ) (X) . Thick meats,whole poultry (roast beef;whole turkey, chickens,hams) ( ) (X) 3. Cold processed foods (salads,sandwiches, vegetables) ( ) (X) . Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles) ( ) (X) 5. Bakery goods (pies, custards, cream fillings &toppings) ( ) 1 (X) 6. Other * A generic HACCP plan for each category of food may be available from the egulatory authority for reference. PLEASE CIRCLEIANSWER THE FOLLOWING QUESTIONS FOOD SUPPLIES: 1. Are all food supplies from inspected and approved sources?YES/NO 2. What are the projected frequencies of deliveries for frozen foods_N/A Refrigerated foods_N/A , and Dry goods-1/WK 3. Provide information on the amount of space(in cubic feet)allocated for: Dry storage 160 cubic feet Refrigerated Storage N/A and Frozen storage N/A 4. How will dry goods be stored off the floor? Wire rack shelving. COLD STORAGE: t. Is adequate and approved freezer and refrigeration available to store frozen foods frozen and refrigerated foods at 41°F (5°C)and below?YES/NO N/A Provide the method used to calculate cold storage requirements. 2. Will raw meats,poultry and seafood be stored in the same refrigerators and freezers with cooked/ready-to-eat foods?YES/NO N/A If yes,how will cross-contamination be prevented? N/A 3. Does each refrigerator/freezer have a thermometer?YES/NO N/A Number of refrigeration units: N/A_ Number of freezer units: N/A 4. Is there a bulk ice machine available?YES/NO THAWING FROZEN POTENTIALLY HAZARDOUS FOOD: Please indicate by checking the appropriate boxes how frozen potentially hazardous foods (PHF's)in each category will be thawed. More than one method may apply. Also, indicate where hawing will take place. Thawing Method *THICK FROZEN *THIN FROZEN FOODS FOODS Refrigeration N/A N/A Running Water Less than N/A N/A 70°F(21°C) Microwave (as part of N/A N/A cooking process) Cooked from Frozen state N/A N/A Other(describe) *Frozen foods: approximately one inch or less =thin, and more than an inch=thick. COOKING: 1. Will food product thermometers be used to measure final cooking/reheating temperatures of PHF's?YES/NO N/A What type of temperature measuring device: N/A Minimum cooking timen m convection conduction heating ' m n beef roasts 130°F (121 in) solid seafood pieces 145°F (15 sec) other PHF's 145°F (15 sec) eggs: Immediate service 145°F (15 sec) pooled* 1557 (15 sec) (*pasteurized eggs must be served to a highly susceptible population) pork 1457 (15 sec) comminuted meats/fish 155°F (15 sec) poultry 165°F(15 see) reheated PHF's 165°F (15 sec) 2. List types of cooking equipment. N/A HOT/COLD HOLDING: 1. How will hot PHF's be maintained at 140°F(60°C) or above during holding for service? Indicate type and number of hot holding units. N/A 2. How will cold PHF's be maintained at 41°F (5°C) or below during holding for service? Indicate type and number of cold holding units. N/A COOLING: Please indicate by checking the appropriate boxes how PHF's will be cooled to 41°F(5°C) within 6 hours (140°F to 70°F in 2 hours and 70°F to 41°F in 4 hours). Also, indicate where the cooling will take place. COOLING THICK THIN THIN THICK RICE/ METHOD MEATS MEATS SOUPS/ SOUPS/ NOODLES GRAVY GRAVY Shallow Pans N/A N/A N/A N/A N/A Ice Baths N/A N/A N/A N/A N/A Reduce N/A N/A N/A N/A N/A Volume or Size Rapid Chill N/A N/A N/A N/A N/A Other (describe) REHEATING: 1. How will PHF's that are cooked,cooled, and reheated for hot holding be reheated so that all parts of the food reach a temperature of at least 165°F for 15 seconds. Indicate type and number of units used for reheating foods. N/A 2. How will reheating food to 165°F for hot holding be done rapidly and within 2 hours? N/A PREPARATION: 1. Please list categories of foods prepared more than 12 hours in advance of service. N/A 2. Will food employees be trained in good food sanitation practices?YES/NO Method of training: ServSafe training Number(s) of employees: 1 Dates of completion: 7/19/ 11 3. Will disposable gloves and/or utensils and/or food grade paper be used to prevent handling of ready-to-eat foods?YES/NO NZA 4. Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions?YES/NO ISL® Please describe briefly: _Workers who are sick are not allowed to work with food, or to interact with customers. Will employees have paid sick leave?YES/�Q 5. How will cooking equipment, cutting boards,counter tops and other food contact surfaces which cannot be submerged in sinks or put through a dishwasher be sanitized? Chemical Type: _N/A Concentration: N/A Test Kit: YES/NO LCL® 6. Will ingredients for cold ready-to-eat foods such as tuna, mayonnaise and eggs for salads and sandwiches be pre-chilled before being mixed and/or assembled?YES/NO N/A If not,how will ready-to-eat foods be cooled to 41'F? N/A 7. Will all produce be washed on-site prior to use?YES/NO N/A Is there a planned location used for washing produce?YES/NO N/A Describe If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses. 8. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger zone(41'F - 140T)during preparation. N/A 9. Provide a HACCP plan for specialized processing methods such as vacuum packaged food items prepared on-site or otherwise required by the regulatory authority. 10. Will the facility be serving food to a highly susceptible population?YES /N If yes, how will the temperature of foods is maintained while being transferred between the kitchen and service area? A.FINISH SCHEDULE Applicant must indicate which materials(quarry tile, stainless steel,4"plastic coved molding, etc.)will be used in the following areas. Kitchen FLOOR COVING WALLS CEILING Bar N/A Food Storage VCT Vinyl coved Paint Paint molding Other Storage VCT Vinyl coved Paint Paint molding Toilet Rooms VCT Vinyl coved Paint Paint molding Dressing N/A Rooms Garbage& Covered cans All trash to be Refuse collected Refuse Storage within space stored in refuse weekly under containers in contract with dedicated room landlord. Mop Service VCT Vinyl coved Paint Basin Area molding Ware washing N/A Area Walk-in N/A Refrigerators and Freezers B.INSECT AND RODENT CONTROL APPLICANT.Please check appropriate boxes. YES NO NA 1. Will all outside doors be self-closing and rodent proof? (X) ( ) ( ) 2.Are screen doors provided on all entrances left open to the outside? (X) ( ) ( ) 3. Do all openable windows have a minimum#16 mesh screening? ( ) ( ) (X) 4. Is the placement of electrocution devices identified on the plan? O O (X) 5. Will all pipes & electrical conduit chases be scaled; ventilation systems exhaust and (X) O ( ) intakes protected? 6. Is area around building clear of unnecessary brush, litter,boxes and other (X) O ( ) harborage? 7. Will air curtains be used? If yes, where? ( ) (X) ( ) C.GARBAGE AND REFUSE 8. Do all containers have lids? (X) ( ) ( ) 9. Will refuse be stored inside? ( ) (X) ( ) If so, where? Trash container behind POS <> <> <> station 10. Is there an area designated for garbage can or floor mat cleaning? ( ) (X) ( ) Outside 11. Will a dumpster be used? ( ) (X) ( ) Number Size Frequency of pickup Contractor 12. Will a compactor be used? Number Size Frequency of pick up O (X) ( ) Contractor 13. Will garbage cans be stored outside? O (X) ( ) 14. Describe surface and location where dumpster/compactor/garbage cans are to be stored N/ A 15. Describe location of grease storage receptacle N/ A 16. Is there an area to store recycled containers? O (X) ( ) Indicate what materials are required to be recycled; ( ) Glass ( ) Metal O Paper O Cardboard O Plastic 17. Is there any area to store returnable damaged goods? (X) () ( ) D.PLUMBING CONNECTIONS AIR AIR *INTEGRAL *"P" VACUUM CONDENSATE GAP BREAK TRAP TRAP BREAKER PUMP 18.Toilet 19. Urinals N/A 20.Dishwasher N/A 21.Garbage N/A Grinder 22.Ice N/A machines 23.Ice storage N/A bin 24.Sinks a. Mop b.Janitor c.Hand wash d.3 Compartment e.2 Compartment El Compartment g. Water Station 25.Steam N/A tables 26.Dipper N/A wells 27. N/A Refrigeration condensate/ drain lines 28.Hose N/A connection 29.Potato N/A peeler 30.Beverage N/A Dispenser w/ carbonator 31. Other * TRAP: A fitting or device which provides a liquid seal to prevent the emission of sewer gases without materially affecting the flow of sewage or waste water through it. An integral trap is one that is built directly into the fixture, e.g., a toilet fixture.A ?P?trap is a fixture trap that provides a liquid seal in the shape of the letter?P.?Full?S?traps are prohibited. 32. Are floor drains provided& easily cleanable, if so, indicate location: E.WATER SUPPLY 33. Is water supply public (X) or private( )? 34. If private,has source been approved?YES ( )NO ( )PENDING( ) Please attach copy of written approval and/or permit. 35. Is ice made on premises ( ) or purchased commercially( )? N/A If made on premise, are specifications for the ice machine provided?YES ( )NO ( ) Describe provision for ice scoop storage: Provide location of ice maker or bagging operation 36. What is the capacity of the hot water generator? 37. Is the hot water generator sufficient for the needs of the establishment? Provide calculations for necessary hot water(see Part 5 &Part 9 Under Section III in this manual) 38. Is there a water treatment device?YES ( )NO (X) If yes, how will the device be inspected &serviced? 39. How are backflow prevention devices inspected &serviced? F. SEWAGE DISPOSAL 40. Is building connected to a municipal sewer?YES (X)NO ( ) 41. If no, is private disposal system approved?YES ( )NO( )PENDING( ) Please attach copy of written approval and/or permit. 42. Are grease traps provided?YES ( )NO (X) If so, where? Provide schedule for cleaning &maintenance G.DRESSING ROOMS 43. Are dressing rooms provided?YES ( )NO(X) 44. Describe storage facilities for employees'personal belongings (i.e.,purse, coats,boots, umbrellas, etc.) H. GENERAL 45. Are insecticides/rodenticides stored separately from cleaning&sanitizing agents? YES (X)NO ( ) Indicate location: _Separate locker for any poisons. 46. Are all toxics for use on the premise or for retail sale(this includes personal medications), stored away from food preparation and storage areas?YES (X)NO( ) 47. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES (X)NO ( ) 48. Will linens be laundered on site?YES ( )NO (X) If yes, what will be laundered and where? If no, how will linens be cleaned? 49. Is a laundry dryer available?YES ( )NO(X) 50. Location of clean linen storage: N/A 51. Location of dirty linen storage: N/A 52. Are containers constructed of safe materials to store bulk food products?YES ( )NO ( ) Indicate type: N/A 53. Indicate all areas where exhaust hoods are installed: N/A LOCATION FILTERS SQUARE FIRE AIR AIR &/OR FEET PROTECTION CAPACITY MAKEUP EXTRACTION CFM CFM DEVICES 54. How is each listed ventilation hood system cleaned? I. SINKS 55. Is a mop sink present?YES ( )NO(X) If no,please describe facility for cleaning of mops and other equipment: Bathroom sink/Mop bucket with wringer 56. If the menu dictates, is a food preparation sink present?YES ( )NO ( ) N/A J.DISHWASHING FACILITIES 57. Will sinks or a dishwasher be used for ware washing? N/A Dishwasher( ) Two compartment sink( ) Three compartment sink( ) 58. Dishwasher N/A Type of sanitization used: Hot water(temp. provided) Booster heater Chemical type Is ventilation provided?YES ( )NO ( ) 59. Do all dish machines have templates with operating instructions?YES ( )NO ( ) N/A 60. Do all dish machines have temperature/pressure gauges as required that are accurately working?YES ( )NO ( ) NA 61. Does the largest pot and pan fit into each compartment of the pot sink?YES O NO O N/A If no,what is the procedure for manual cleaning and sanitizing? 62. Are there drain boards on both ends of the pot sink? N/A YES ( NO O 63. What type of sanitizer is used? Chlorine ( ) Iodine ( ) Quaternary ( ) ammonium ( ) Hot Water ( ) Other 64. Are test papers and/or kits available for checking sanitizer concentration? YES ( )NO( ) K.HANDWASHING/TOILET FACILITIES 65. Is there a hand washing sink in each food preparation and ware washing area?YES ( )NO ) N/A 66. Do all hand washing sinks,including those in the restrooms,have a mixing valve or combination faucet?YES (X)NO( ) 67. Do self-closing metering faucets provide a flow of water for at least 15 seconds without the need to reactivate the faucet?YES ( )NO ( ) ISL® 68. Is hand cleanser available at all hand washing sinks?YES (X)NO ( ) 69. Are hand drying facilities (paper towels, air blowers, etc.)available at all hand washing sinks?YES (X)NO ( ) 70. Are covered waste receptacles available in each restroom?YES (X)NO ( ) 71. Is hot and cold running water under pressure available at each hand washing sink?YES (X) NO ( ) 72. Are all toilet room doors self-closing?YES( )NO(X) 73. Are all toilet rooms equipped with adequate ventilation?YES (X)NO ( ) 74. Is a hand washing sign posted in each employee restroom? YES (X)NO ( ) L.SMALL EQUIPMENT REQUIREMENTS 75. Please specify the number, location, and types of each of the following: Slicers N/A Cutting boards_N/A Can openers N/A Mixers N/A Floor mats N/A Other ************ STATEMENT: I hereby certify that the above information is correct, and I fully understand that any deviation from the above withou nor permission from the Salem Board of Health may ullify nal a rova Signature(s) owner(s) or responsible representative(s) Date: y/Q• (� ************ Approval of these plans and specifications by the Salem Board of Health does not indicate compliance with any other code, law or regulation that may be required--federal, state, or local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place& operational will be necessary to determine if it complies with the local and state laws governing food service establishments. .. L�ce,J�.s SDEPARTMENT OF ETREASURY RNAL REVENUE IINT CINCINNATI OH 45999-0023 Date of this notice: 03-30-2011 Employer Identification Number: 45-1263097 Form: SS-4 Number of this notice: CP 575 G DAVID J BOWIE SALEMSPICE 14 BEACH AVE For assistance you may call us at: SALEM, MA 01970 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN) . We assigned you EIN 45-1263097. This EIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. A limited liability company (LLC) may file Form 8832, Entity Classification Election, and elect to be classified as an association taxable as a corporation. If the LLC is eligible to be treated as a corporation that meets certain tests and it will be electing S corporation status, it must timely file Form 2553, Election by a Small Business Corporation. The LLC will be treated as a corporation as of the effective date of the S corporation election and does not need to file Form 8832. To obtain tax forms and publications, including those referenced in this notice, visit our Web site at www.irs.gov. If you do not have access to the Internet, call 1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office. IMPORTANT REMINDERS: * Keep a copy of this notice in your permanent records. This notice is issued only one time and the IRS will not be able to generate a duplicate copy for you. * Use this EIN and your name exactly as they appear at the top of this notice on all your federal tax forms. * Refer to this EIN on your tax-related correspondence and documents. If you have questions about your EIN, you can call us at the phone number or write to us at the address shown at the top of this notice. If you write, please tear off the stub at the bottom of this notice and send it along with your letter. If you do not need to write us, do not complete and return the stub. Thank you for your cooperation. Business Certificate City of 6atem, fflaggactugettg ifg�/�S�ar�q"i DATE FILED --�OUloci Type: ❑ New Expiration Date C" is ❑ Renewal, no change Number 200,9-308 -1� Renewal with change In conformity with the provisions of Chapter one hundred and ten, Section five of the Massachusetts General Laws, as amended, the undersigned hereby declare(s) that a business is conducted under the title of: ti Tinecict t_� 11.I'C / at. --1 �S u- air(- ` i�C Tel.# CI -7A 7U`t �D�D 7 �71 type of business _—_—amu �`— J It t SV by the following named person(s): (Include corporate name and title if corporate officer) Full Name Residence Tel.# 1 vin, ("c'vt•��.a -�- • i� Ri^��c�, v� C�LQiu YUiy� R7� �4S ,���5 - Sine atur - - - - - --- _- ------------ ------------- ----- --------------- - -- - ------ ---�-- - ------------------- ----------------------------------------------------- o ���'• 20 ° —the above named person(s) personally appeared before me and made an oath that the foregoing statement is true. O a_V,,;�---------------- ----------------------------------------------------- ------ ------------ t rT v CLERK Notary Public (seal) Date Commission Expires Identification Presented C State Tax I.D. # 013 .6 6 ( S.S.# (if available) In accordance with the provision of Chapter 337 of the Acts of 1485 and Chapter 110, Section 5,of Mass. General Laws, business certificates shall be in effect for four(4) years from the date of issue and shall be renewed each four years thereafter. A statement under oath must be hied with the town clerk upon discontinuing, redring, or withdrawing from such business or partnership. Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished on request during regular business hours to any person who has purchased goods or services from such business. Violations are subject lo a fine of not more than three hundred dollars ($300.00) for each month during which such violation continues. °.0 Massachusetts Department of Revenue ST-1 ) ..�, Customer Service Bureau PO Box 7010 Boston, MA 02204 The vendor herein named is registered to sell tangible personal property at retail or for resale, pursuant to the General Laws, Chapters 62C,64H and 641.This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct ST-1 can be issued. a q z H'i�L�1 _ IDENTIFICATION NUMBER x TrIr 01LI(LcPtil ANL - f. 1 ]% NA,,ii i;iGI uN ill- 11d u4 ISSUE DATE ;iALA, Iii U1 ` `? ALAN LC'60lIDGl This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OF REVENUE ---- ,.— —,� RES Electric PO Box 495 Peabody, MA 01960 NAME OF PROPERTY: ADDRESS: DATE: BLDGS OR FLOORS TESTED: WHOLE BLDG. LOCATION �SQUANTITY I TYPE OF DEVICE RESULTS-COMMENTS BASEMENT HORN/STROBES PULL STATIONS HEAT DETECTORS SMOKE DETECTORS EMERGENCY LIGHTS ' tW9 114 rAmM LOCATION QUANTITY TYPE OF DEVICE RESULTS-COMMENTS 1 FWSTOREFRONT FIRE ALARM PANEL HORN/STROBES PULLSTATIONS HEAT DETECTORS SMOKE DETECTORS EMERGENCY LIGHTS LOCATION UAN'TI'TY TYPE OFDE ICE RESULTS-COMMENTS 2 FLOOR UNITS/HALLWAYS FIRE ALARM PANEL HORN/STROBES PULL STA DETECTORS SMOKE DETECTORS EMERGENCY LIGHTS ex LOCATION QUANTITY TYPE OF DEVICE RESULT'S-COMMENTS 3 FLOOR UNITS/HALLWAYS FIRE ALARM PANEL HORN/STROBES PULL STATIONS HEAT DETECTORS SMOKE DETECTORS EMERGENCY LIGHTS INS O SIG LICENSE DATE: 1r NOTES' TVA�� I UG-Up j 7 60, Al - Corporate Offices Cape Cod New Hampshire i 63 Shepard Street 72 Main Street,Suite#7 361 South Broadway e-mail Lynn,MA 01902 W.Harwich,MA 02671 Salem,NH 03079 At info@ (781)592-2731 (508)432-5866 (603)893-8099: Al Exterminators.com A-1 Exterminators (800)525.4825 (800)499.5866 (800)525.4825 Fax(781)592-7641 Fax(508)432.5299 " Fax (603)890-3761 Commercial, Industrial Pest Control Service Agreement Date: // Customer Tel.# Cell# Address Fax e-mail City State Zip Code Service 1 otm{��t(on a d Location Customer C1/ /C �C j4, 0Tel.# Cell# / _71e)_71e)fe Address `7 " Fax e-mail City 'e- A�? State f / Zip Code 41/, Multiple Locations (see attachment) Control: This Agreement is for the control of the following pests: ( -46aches ( -rAnts (-r'Rats (')'Mice { )*Other 'Does not include Carpenter Ants,Pharaoh Ants,Bed Bugs,Termites,Wood Boring Insects orFlying Insects unless otherwise specifically mentioned. Special Instructions: G,/a/LE "t e Service schedule:A-1 Exterminators will prow _intensive service and will also provide Regular Post Control Services: { 1x month ( ) 2x:.;anth ( ) weekly. Exterior Rodent Control: { )1x, month ( ) 2x month ( ) weekly. Exterior Insect Control: ( ) 1x month ( ) 2x month ( ) weekly. Bird Control: ( )1x month ( ) 2x month ( ) weekly. Fly Control: { )1x month ( ) 2x month ( ) weekly. Fly Trap Maintenance: ( ) 1x month ( ) 2x month ( ) weekly. Drain Treatment: ( ) 1x month ( ) 2x month ( ) weekly. Payment:In consideration of the services provided byA-1 Exterminators,the customer agrees to payA-1 Exterminatorsf its successors or assigns the following sums: , �-- 7[ � �yc Xle(r Sf`'_1d ail / $ - for each intensive service.- � $"� yp fCr'eac,"regular serwce. _ ,... '_ �r'�%(G � GGA �/�+_�JG _ . $— for'each exterior rodent service. �? $- for each exterior insect control service. $ YUP for each exterior bird control service. _ $� -for each fly control service. $ �/l for each fly trap maintenance. $ A � for each drain treatment. $ /�,vo estimated product cost.-Total product cost may vary t 20%. Payment Terms: ( ) COD ( ) Charge. Payment due upon receipt of invoice. { )Total Annual Payment in Advance$ less %discount$ Customer Obligation: The customer agrees to cooperate fully with A-1 Exterminators. Whenever conditions conducive to the breeding and harborage of pests covered by this contract are reported in writing byA-1 Exterminators to the customer,the customer shall take the necessary steps to correct such conditions. Pest Damage: The customer agrees that A-1 Exterminators is not responsible for any business disruptions or damage caused by insects and/or rodents,on,or to the customer's premises or its contents,and the customer specifically releases A-1 Exterminators from liability for any such claims. Additional No Cost Service: A-1 Exterminators shall promptly provide additional service between regular scheduled visits as deemed necessary by A-1 Exterminators. Services:Service is the inspection and/or application of pesticidesfor the control of the above mentioned pests. All services shall be performed in accordance with Federal and State requirements,and EPA and USDA standards. Material; All materials used to control pests shall conform to Federal,State and local laws and regulations. A-1 Exterminators reserves the right to re-enter the customer premises and remove any chemicals inchMing rodent and insect baits upon termination of this agreement. Equipment and Products: The customer agrees to pay A-1 Exterminators for any equipment installed or placed on the customer's property necessary for the control of the above mentioned pests. Insurance:Upon Request,A-1 Exterminators will furnish to the Customer a certificate of insurance showing coverage in effect. Terms of Contract: •This contract shall be effective for an original period of one year. Thereafter,this contract shall renew itself from month to month until terminated by either party upon thirty days written notice. Rate subject to periodic review and increase byA-1 Exterminators after initial 12 month period. •The customer further agrees to additionally pay for tiw any equipment or products ordered or installed on the customer's premises as determined to be necessary by A-1 Exterminators fpr the control of the above mentioned pests. Such items may include, but not be limited to the following: Balt Stations,Glue Traps,Multiple Ketch Traps,Fly Spray,etc. A-1 Exterminat rs Acce t Dabe yy , t" Pr 1 Nam mat Tide Title �".---�.. r" S.YCC'±�iY By Sgn Name White-0111MCOPY Yellow-Customer Copy Ifr Commonwealth of Massachusetts' r _ `City of Salem N Board of Health 1GRlbedey Drisco11 .rte 120 Washington Street,4th Floor� m p 0 Mayor SALEM,MA 01970 . Food/Retail Establishment Permit' >3 G DATE PRINTED: 11/2.9/2012 f- � Lek ESTABLISHMENT NAME: S The Plcklepot ;$—he` '" ' File Number BHF-2003-000007 m :. x;75 Wparf Street . t Salem MA ,01970 '� .s_.� •` n � LOCATED AT ' v0073 WHARF STREET s SALEM, MA 01970 V " a r^g t'y Permit Type Permit No Permit Issued • PermitExpiresY .Fee Restrictions!Notes '� ` .x r 'v RETAIL FOOD BHP-2013-0623 Jan 1,2013 Dec 31,2013 $70.00 #J. Total Fees ,$70.00 '� IPAp a 0 2. „� 'has .e ,ten t r •��'J ., k ;R r C Kai e "ss 17, lz , ., „_ sg PERMIT EXPIRESecember 31, 2013 Board of Health MVi vi - r %T his 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 Establishments , s' 0 ,, t ` In accordance with the State Sanitary Code,beofre+any revonations,improvements;or equipmentchanges are made,- all ade,all plans for such must be submitted to and approved by the Salem Board of Health. Page t y' up F`. .p Ski h 4 `i N*em2- E i i S e t n- P ei"S g -� �. - CITY OF SALEM, MASSACHUSETTSu�xesith r` BO RDorHrnt:rH ���4..���e � Wr\S]rIN LON S neat r 41,1 Fi,OOH 11 KIMBERLEY DRISCQuNOV 2 8 2012 TI;,1-(978)741-1800 FAX(978)745-Of ftj LrVZRY RAMIOIN,]LS/RE liS,CHO,CY-FS CI IminEn@salein.com Itl1, MAYOR $OARR�OFHE;TH CITY OF e BOA DOFVHEHLiH Hlia\L'1'It AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: n — 2) Establishment Address: ;�5 cj�qR 01916 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: q 7 `l0 7 5) Applicant Name&Title: ,, P 6) Applicant Address: — t _ 7) Applicant Telephone No: x)78. 7,e — 24 Hour Emergency No: Email: T, ecy 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 A corporation An individual A partnership Other legal entity 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: qt/i d 'J eo� - Address: /c1 E A ^4 0 7b Telephone No: 97 . IV . Fax: Email:POIJ Q c e 1 Co Emergency Telephone No: . 7 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: `� Date: d`' Amount: �V L Food Establishment Information 2 . ^I`F �ater Source: "� 15) Sewage Disposal: P Public Water Supply No: (if applicable) pilbi,c cS4V(L m-F lo_b 16) Days and Hours of Operation: D - u,t la l0 17) No. of Food Employees: q 18) Name of Person in Charge Certified in Food Protection Management: )j pot d Sod t C- Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): [3 Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) [� etail( 900 Sq. Ft) ❑ Caterer Vermantent Structure ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: ----------------------------------- ...................................... reakfast Establishments---------------.-------- (check one) RETAIL-STORE RESTAURANT dual esm ss 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 13 More than 99 seats $420 Temporary/Dates/Time: -- ------------------------------------------------- ------------------------------------ ❑ Bed &Breakfast/Childcare Services/Nursing Home $100 ----__­ --------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare&private clubs 23) Food Operations: Definitions: PHF—potentially hazardous food(time/temperature controls required) Non-PHFs—non-potentially hazardous food(no time/temperature controls required) check all that apply): RTE—ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further processing "Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only separation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I ceify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"'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 Dat (( Type of Operation(s) Type of nspectfon ❑ Food Service utine Address Risk Q5,artail ❑ Reinspection Telephone nQ Level Residential Kitchen Previous Inspection LJ ❑ Mobile Date: Owner < - HACCP YIN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Ch rge(PIC) Time ❑ Bed a BFeak(ast ❑General Complaint In: r ❑ HACCP Inspector Out: Permit No. ❑.Other Each violation SWMd requir s an pl anon on the narrative page(s)and a citation efspe-eW provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) AntiChoking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate tobacco 590.009(F) ❑ Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. ,,F000:PROTECTIONMANAGEMENT;_ _i ❑12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH - - -- - - ''�PROTECTIONFROM`CNEMICALS_-__ __._�,_ ❑ 2. Reporting of Diseases by Food Employee and PIC El __ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded - 4-_ _- .._ --, ___ _ ,�..�_�_ _ _� ❑ 15.Toxic Chemicals FO „ OD:FROMAPPROVEDSOURCE ... -._.� __,a, _ _ "-" iTIMEREMPERATURE:CONTROLS P.otenilal RH ❑ 4. Food and Water from Approved Source (_ ty_ a¢aaMousFoods)�R� ❑ 5. Receiving/Condition ❑16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling .__._ _ 19. Hot and Cold Holding _�PROTECTION FROM CONTAMINATION 9 ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and SanitizingREQUIREMENTS-FOR HIGHLYSUSCEPTIBtE=POPULAT10N3',(HSP),a El 10. Proper Adequate Handwashing El21.Food and Food Preparation for HSP _ ❑ 11. Good Hygienic Practices ICONSUMERADVISORY__ __ __ ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3X590.0044))) 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 (FC5X590.006) 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: Inspector's Siglure: i Print PICS Signature: Print: Pagel 0fges f. Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assigwent of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTF Foods* 590.003(6) 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 applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Charge* har"Applicant To Report To The Person In Contamination from the Consumer Char 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrict ons 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) Compliance with.Food Law* 4501.11 I. 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 W'arewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Te eratures*. 3-202.14 Eggs and i`dilk Products.Pasteurized* 4-501.114 Chemical:Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkm''Water* concentration and hardness. * 5-101.1.1 Drinking Water from an Approved System* 4-601.11(N) Equipment Food Contact Surfaces and- 590.006(A) Bottled Drinking Water' - Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food She 590.006(B) Water Meets Standards r, CMR 22Contact Surfaces and Utensils* lflish and Fh rom an rsFApproved oved Sourcece 3-201.14 Fish and Recreatitxtally Caught tvlol)uscaa 4-7021 I Frequency of Sanitization of Utensils and Shellfish* Foal Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan She0fish from NSSP lasted _ Chemicat* Sources* Game and Wild AAushroomS Approved by 10 Proper,Adequate Handwashing Re ulato Authont 2-301..1.1 Clean Condition-Hands and Arms* 3-202.13 Shellstock Identification Present* 2701..12 Cleaning Procedure* 590.004(0 Wild Mushrooms* 2-301.14 When to Wash* 3-201.17; Game Animals* 1.1 Good Hygienic Practices 5 - Receiving/Condition 2401.11 Eatin ,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-!02.LI Food Safe and Unadulterated* 3-30L12 Preventing Contaminafion When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.13 Shellstock Identification* 590.004(F,) Preventing Contamination from 3-203.1.2 Shellstock.Identification Maintained* -Employees* Tags/Records:Fish Products - 13 Handwash Facilities 3=402.11 Parasite Destruction* ConvenienW Located and Accessible 3-402.12 . Records.Creation and Retention* 5-203.11 1 Numbers and Capacities* - 590.004(J) Labeling of Ingredients* 5-204.11 I Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.17. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen acka g,criteria* - 6-301.11 Hatalwashing Cleanser,Availability 8-103A2 Conformance with Approved Procedures* 6-301.12 Hand DUjU Provision *Denotes critical item in-the federal 1999 food Code or 101 CMR 590MO, CITY OF SALEM BOARD OF HEALTH {� Establishment Name: t(, Date: Page: �of C/ Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLA O CORRECTION Date. No. Reference R-Red Item PLEASE Verified P NT CLEARLY 1 Discussion With Person in Charge: Corrective Action Required: o ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. understan noncompliance may result in daily fines of twenty-f' a dol rs or pension/re on of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: f 3-501.14(C) PHFs Received at Temperatures t vtowlans Related to Foodborne Illness interventions and Risk According to Law Cooled to r Factors(hands 1-22) (Cont.) 41017145`17 Within 4 Hours. i CHEMICALS 3-501.15 Coolie Methods for PHFs PROTECTION FROM CHEM 14 Food or ICAColoAdditives 19 PtiF Not and Cold Holding 3-501.16(B) Cold PRFs Maintained at or below 3-202.12 Additives* - 590.004(F) 4101450 F* i 3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances _ * 7-101,11 Identifying Information-Original 1�� 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* - * - - 3-501:i9 Time as a Public Health Control* 7-301.11 Separation-Stora 590.004(H) Variance Requirement 7-202.11 .Restriction-Presence and Use* 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for WashingProduce,Criteria* 2l 3-&01.11(A) Unpasteurized Pre-packaged iuices and Beverages with Warning Labels" ( 7-204.14 Drying AgLent&Criteria* 3-i301.11(B) Use of Pasteurized E as* 7-205.11 Restricted Pool PesticidContames, ,Crueants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.31 -Restricted Use Pesticides;Criteria{ Raw Seed Sprtxits Not Served, 7-206.12Relent Bait Stations* 3- LII(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 71MEJFEMPERATURE CONTROLS 22 3-603.11 1 Consumer Adiisory Posted for Consumption of 16 Proper Cooking Temperatures for a Animal Foods That are Raw'.Undercooked or Pr rop P - - NOtherwise-Processed to Eliminate 3-401.i1A(1)(2) Eggs- 155'F 15 Sec. pyho * «ee n xt Eggs-Immediate.Service 145'1715sec- 3-302.13 1 EPasteurized Eggs Substitute for Raw Shell t. 3.801.31(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec. * SPECIAL REQUIREMENTS 3-461.11(13)(1)(2) Pork and Beef Roast- 130'F 121 min* 3-401.1 I(A)(2) Ratites Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sea.* catering,.mobile Pard,temporary and 3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poul or Ratites-165'F 15 sec, ' above if related to foodborne illness i3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and TU-factors. Other S 145°F* 590,009 violations relating to good retail 3-40132 Raw Animal Fords Cooked in a practices should be debited under#29- s Microwave I65"F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRAC77CES 3-403A I(A)&(D) PHFs 165"F 15 sec. * (Iterits 23-30) 3-403.11(B) Microwave 165'P 2 Minute Standing Crilical,and non-critical violations,which do not relate to the Tiasc* foodborne illness intenentions and risk{actors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 1400P 590.000. 3-403.11(E) Remaining 6nslicedPortionsofBeef t ltem ' GocdRetallPracftces FC 590.000 ; 23. i Man mant and Personnel FC-2 .603 Roosts': 18 -_+u-- Proper Cooling of PHFs 1 24.. 1 Foal and Food Preler"M FC-3 .004 25. E vi meld and Utensils _ FG-4 .005 3-501.14(A) Cooling Cooked PHF%from 14VF toI?_6. Water,Pitimbitm and Waste f EC-5 .606 70'F Within 2 Hours and From 70`F 27. 1 Physical Facility FC-6 .067 to 41`F145'F Within 4 Hours.* 28. Poisonous or Toric Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient ~29. �Special ft uitemonts .003 Temperature Ingredients to 41'F/45'F 30 1 Other Within 4 Hours* "Dmvtu critical iwm in the federal 1999 Food Cale uc I W CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"'Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABLISKMENMSPECTION REPORT Tel. Name Dat Type of Operation(s) T f Inspection ❑ Fo ervice Routine Address Risk stall ❑Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ElPre-operation ❑ Caterer ❑Suspect Illness Person-in arge(PIC) Tim ❑ Bedkoffe ast ❑ General Complaint /�n ❑ HACCPInspector Out: ern 'W ❑.Other Each violatiob,6hicked requires an explanation on the narrative page(s)and a citation of specific proviston(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) ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ _FOOD PROTECTION MANAGEMENT__ _ [112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH � ❑ 13. Handwash Facilities OM_CHEMICACS ❑ 2. Reporting of Diseases by Food Employee and PIC (PROTECTIONFR _ �� ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals tFrD FROM APPROVED SOURCE _- -..._,. �_,_ ❑ 4. Food and Water from Approved Source rTIMEITEMPERATURE"C,ONTROLS(P.oteMialty Ha ardous F4otls_) ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements. ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling RT_ECT_ION FROM CONTAMINATION -T� ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and SanitizingREQUIREMENTS FOR HIGHLYSUSCEPTIaLE=POPULATIONS';(H6P)' El21.Food and Food Preparation for HSP ❑10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2x590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-axsso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (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 Req ' e ents (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Print: PICS Signature: Print: L PageL oCiPages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Coss-contamination 3-302.1.1(A)(1) Raw Animal Foals Separated from 590.003(B) Demonstration of Knowowled Y 590.003(A) Asia meat of Responsibility*de* Cooked and RTE Foals* Contamination from Raw Ingredients 2-103.11` Person in char e-duties 3-302.1.1(A)(2) Raw Animal Foals Separated from Each EMPLOYEE HEALTH Other* Contamination from the Environment 2 590003(C) Responsibility of the person in charge to 3-302.t 1(A) Food Protection* require reporting by food employees and 3-302,B Washin 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 hat Contamination from the Consumer C 3-306.14(A)(B Returned Food and Reservice of 590.003 G Reporting b Person in Charge* -Food* Disposition of Adulterated or Contaminated 3 590.003(0) Exclusions and Restrictions Food 990.003(E) Removal of Exclusions and Restrict ons 3-101.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Fold Law* 4-501..1.1 L Manual Warcwashmg-Hot Water 3-201.12 Food in a.Hermetically Seated Container* Sanifization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eons* Sanitization Temperatures* & 3-202.14 E nand iMilk Products.Pasteurized* 4-501.114 � Chemical:Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drink n Water* concentration and hardness. * 5-101.11 Donkin Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Ddnkim�Water* Utensils Clean* 4-6011.1 Cleaning Frequency of Equipment Foai-' Shel 590.D06tB) Water hanMeets Standards in 310 CMR 223)x' Contact Surfaces and Utensils*' - �sand Fish Froman Approved Source - 4-702.11 Frequency of Sanitization of Utensils and - 3-201..14 Fish and Recrea6onaliy CaupJrt Moliascan She1L'ish* Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSF Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Redulata Auttionl 2_;pCondition1.1 I Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Presem* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game.Animals* 11 - Good Hygienic Practices 3 Receiving/Condition 2-401.11 Eating,Drinking or UsiR&Tobacco* 3-202.11. PHFs Received at Proper Tem eratureO 2-401.12. Discharges:From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-EO .i t Food Safe and Unadulterated* 3-301.12 - Preventin Contartion When Tasting* 6 TagstRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock identification* 590.004(E) Preventing Contamination from 3-203:12 Shellstock Identificatin Maintained= Employees* Tags/Records;Fish Product3 13 Handwash Facilities Conveniently Located and Accessible 3-402.11 � Parasite Destruction* „ 3-402.1^_ Records,Creation and Retention" 5-203.11 . Numbers and Capacities* 590.0040 - Labeling ofingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502:12 Reduced oxygen packagin&criteria* - - 6-30L1t Handwashing Cleanser,.Availabdit 8-103.12 Conformance with Approved Procedures* - 6-301.12 Hand-Dr -n Provision '*Denotes ch ical item inthe federal 1999 rood Code or 105 CMR 590A00, CITY OF SALEM BOARD OF HEALTH 'Z (2 g Establishment Name: � Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dom` No. Reference R-Red nem Verified PLEASE PRI T CLEARLY Discussion With Person in Charge: Corrective Action Required: 0 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/ oc of ❑ Embargo ❑ Emergency Closure your food permit. i _ 0 Voluntary Disposal ❑ Other: ,i € 3-50IA4(C) PHFs Received at Temperatures 'T Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to Factors((terns 1-22) (Cont.) 41'F/45'F Withia 4 Hours.* . PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PHFs ,) 19 PHF Not and Cold Holding f 14 Food or Color Additives t 3-202.12 Additives* 3-501.16(6) Codd PHFs Maintained at or below ° 3-302.14 Protection from Un roved Additives* 590.004(F) 4101450 F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 4 7-101.11 Identifying Information-Original � - 3-501.16(A) Roasts Held at of above. 130'F. -Containers"` Tias a Public Hea 7-102.11, Common Name-Working3-SD1:19 Timee as a Public Health Control*Containers* mControl i 7-201.11 S.1 aration-SYoia * i 7-202.11 .Restriction-Presence and Use' - 590.004(H) Variance Requi f 7-20212Conditions of Use* 7-203.11 Tonic Containers-Prohibitions* - REQUIREMENTS FOR HIGHLY-SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals° POPULATIONS HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 'j 7-204.14 Drying Agents.Criteria* _ Beverages with Warning Labels* t Use of Pasteurized Eggs* 7-2D5.£I Incidental Fuad Contact Lubricants* 3-801.1 lt6 7-205.11 Restricted Use Pesticides;Criteria* 3-801..11(D) Raw or Partially Cooked Animal Food and i 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. 3-$01.11 C Un Food cwd Pack *e Not Re-served. 7-206.13 Tracking Powders,Pest Control and Momtrxin * - CONSUMER ADVISORY �lr TIMElTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted fctt Consumption of { lb Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Pmcessed to Eliminate Pathogens., 3-40LI IA(I)(2) Eggs- 155°F 15 Sec. Eggs-Immediate Service 145`FL5sec* 3-3D2.13 PE *asteurized Eggs Substitute for Raw Shell 3-401 A I(A)(2) Comminuted Fish.Meats&Game Animals-155`F 15 sec. 3.401.11(6)(1X2) Pork and Beef Roast: 130'F 121 min*' SPECIAL REQUIREMENTS 1590.OD9IA}(D) violations of Section 590.009(A)-(D)in 3-401.11(A)(2) ,Ratites,Injected Meats-155`F 15 sec.$ catering,,mobile food,temporary and 3.401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3-401,11(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3-403.4I(A)&(D) PHFs 165T 15 scc. * (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 inter endans and risk factors listed above, canbe 3403.tl(C) Commercially Processed RTE Food- found in the fallowing sections-of the Food Code and 105 CMR 1400F* 590.400. 3403.11(E) Remaining Unsliced Portions of Beef j Item i Good Retail Practices FC 590.00() Roasts` j 23. 1 Management and Personnel FC-2 .003 18 Proper Cooling of PHFs 24. i Food and Food Protection FC-3 .004 25. Equipment and Utensils I FC-4 .005 i 3-541.14(A) Cooling Cooked PHFs front 740`F to ! 26. I Water.Plumbinq and Waste I FC-5 .006 , 70'F Within 2 Hours and From 70`F 27. i Physical Facility FC-6 .007 i { to 4I`F/45'F Within 4 Hours. * 126 Poisonous w Toxic Materials ' FC-7 .008 ' 3-501.14(.B) Cooling PHFs Made From Ambient ~ZB. nal Requiremems .009 J Temperature Ingredients to 41'F/45°F 30. I Other --�-- Within 4 Hours"' 'Denotes critical nein in the federal 1999 Food Code a105 C;MR 590.000, 1 I 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: 12/13/2011 ESTABLISHMENT NAME: The Picklepot File Number:BHF.-2003-000007 . 75 Wharf Street Salem MA 01970 LOCATED AT: 0073 WHARF STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-20120009 Jan 1, 2012 Dec 31,2012 $70.00 Total Fees: $70.00 PERMIT EXPIRES IDeomber 31,2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 • CITY OF SALEM, MASSACHUSETTS ! BoARD OF HF-ALTH 120 WASHINGTON STRM,4O.FLOOR TEL. (978)741-1800 hINBERL.EY DRISCOLL F-1F(978)745-0343 KYOR Iremdi t Salem-com LARRY I(ANMIN,RS/RI?I IS,CI IO,CP IN f- i:Ai xiI A(;i4N'i' 201c�APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT pdoelr TEL# (97R) 7•/�LLTS ADDRESS OF ESTABLISHMENTl/' X5' !. 41eF ,A7. FAX# ` same MAILING ADDRESS(if different) I EMAIL-Business': Aaldo PleolY? Website: e1AJJ. Aek(.2dT. &M OWNER'S NAME Ao4J iiC TEL# ¢7L, ��Sg ADDRESS i1( 811l,N Ar1, .gRliyfJ /I)A n197d STREET I CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON I HOME TEL# DAYSOFOPERATION. Monday.. ! T Wed • Thulsd F' SaturdaySu��il HOURS OF OPERATION Please write in tine ol day. �O . rp _ �j /O— � !�_6 /D— �_ Forexam e11sm4lpm I I TYPE OF ESTABLISHMENT ! FEE (check only) RETAIL STORE YE NO less than 1000sq.fL 1___=�$70 1000-10,000sq.ft. . =$280 more than 10,000sq.ft. =$420 --- ------ --------------------------------------- ....j -------------...---.---*----------•--------I-------- -------------------------- ------- ----- RESTAURANT Y S � less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ----------------------------------- -------- .............. BED/BREAKFAST/ - YES $100 CHILDCARE SERVICES/NURSING HOME --- ------ 4' --.-...-._.................... .................. _ ......-....--------------------------------..-.-...........-_...........----------------.......----------- ADDITIONAL PERMITS 1 I MAKE (not just serve)ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR I YES ® $135 ALL NON-PROFIT(such as church AItchens) YES $25 'Please pay total with one check pa I ble to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Penult must be posted in a prominent location in the Establishment In accordance with the State Sanit iry Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C Section 49A,1 certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns anti id all state tax squired under t rI Irl . Y. // Signature ' Date Social Seventy or Federal Identification Number Uodated 523/11 FOODAP201 lsdm cgwko&.Date *,sal frit•2-(l s_Z_6 ` CITY OF SALEM, MASSACHUSETTS BOARD OF HEArrH 120 WASHING ON STREET,4"' fto >R KIMBERLEY DRISCOLL TEL. (978)741-1800 FAX(978) 745-0343 MAYOR Iramdin(@sgcm.com LARRY R\\1DI N,IIS/RFI IS,CHO,Cl-Fti HIiiV:n I ACIiNP This Forin wilt be collected during your next Board of Health inspection. OUESTIONAIRE-GREASE TRAPS 2009 1. NAME OF ESTABLISHMENT: I ISE C`CICIC� 2. ADDRESS OF ESTAI LISHMENT: ZF ,ST: - picKEg,4. wL,4 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? O 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLI NS WA 5. HOW IS THE GREAS TRAP MAINTAINED_? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? S. WHAT IS THE DATE iPF YOUR LAST INVOICE FROM THE REMOVAL FIRM? AAA AIL 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: 08/25/2011 ESTABLISHMENT NAME: The Picklepot File Number:BHF-2003-000007 75 V✓harf Street Saleca MA 01970 LOCATED AT: 0073 V6'HARF STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0588 Aug 25,2011 Dec 31, 2011 $70.00 Total Fees: $70.00 PERMIT EXPIRES December 11, 2011 Board of Health MIA I Mi 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 revonttions,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 A o City of Salem, Massachusetts �md Board of Health 120 Washington Street,40'Floor kitnberley driscoll ^ , ® Tel. (978) 741-1800 MayorA Fax (978) 745-0343 G1p�1 ramriin .salemcom Tarry ramdin,rs/rehs,cho,cp-fs Au � 4 Health Agent 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT The Pickleoot TEL# (978)744-6678 ADDRESS OF ESTABLISHMENT 75 Wharf St. Y. FAX# nl/i MAILING ADDRESS(if different) EMAIL-Business': entroov(o),oickleoot.com Website: www.picklepot.com OWNER'S NAME Jeff Bowie TEL# _ (978)744-6678 ADDRESS 14 Beach Ave. Salem LSA 01970 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) David Bowie CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON David Bowie HOME TEL# 978 45-2255 DAYS OF OPERATION I Monday Tuesday Wednesday Thursday.' Friday Saturday Sunda HOURS OF OPERATION - Please write lnJrnaofday. 10am-6pm 10am-6pm 10am-6pm 10am-6pm 10am-6pm 10am-6pm 12pm-6pm Forexam m lellam-11 TYPE OF ESTABLISHMENT FEE (check only] RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NQ $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM,YOGURT/SOFT SERVE YES NQ $25 TOBACCO VENDOR YES HQ $135 ALL NON-PROFIT(such as church kitchens) YES h Q $25 *Please pay total with one check payable to the City of Salem. This Permit Is not transferable and must be reissued upon change of ownership.The Permit must be posted In a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,Improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state lax returns and paid all state taxes required under the law. Signature r Date 8�l�,ll Social Security or Federal Identification Number -------- -- --------�---^/-�— --/-��- -7 --------- --------------------- Updated 5/23/11 F D l l.adm Checkp&.Date ---10d 1 1 V 1 I 1 s CITY OF SALEM BOARD OF HEALTH Establishment Name: Tom, '17I C.K L:t✓P�11� Date: (Z—,2 5^^/ I Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date' No. Reference R-Red Item Verified PLEASE PRINT CLEARLY CC^tid W� a, i 11 17I�r"' F\-:Z)'Am AN YvVVV\ \1 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I u derstand that noncompliance may result in daily fines of twenty-fiv dolla or suspension/r ation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to law Cooled to Factors(Renta 1-22) (Cont.) 41'F145`F Within 4 Hours, I3-501,15 Coolo Methods for PRFs PROTECTION FROM CHEMICALS Ig PHF Not and Cold Holding 14 - - Food or Color Additives - 3-501,16(B) Cold PHFs Maintained at or below 3-302.14 Protection from Una rove 590.004{F} 4101450 F* 3-202.12 Additives* - �-- -- d Additivesr 3-50116(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 14007. * 7-10111. Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'7." Containers* - 20 Time as a Public Health Control 7-102.11, Common Name-Working Containers* * - 3-5(11:i9 Time as a Public Health Control* 7-201.11 Separation-Stora 7-202.11 .Restriction-Presenceand Use* - 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 1 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.1)(A) Unpasteutized Pte-packaged Intros and 7-204.14 n Agents.Criteria° Severnses with Warton Labels* 3-801-i1tB Use of Pasteurized S * 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Choked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed S Its Not Served ' 7-206.12 Rodent Bait Stations* 3-801.11 C Unopened Food Package Not Re-served. 7-206.13 Tracking Powders, Pest Control and Monitoring' CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Cwtsumptiom of i F6 Proper Cooking Temperatures forAnimal Foods That are Raw.Undercooked or I Not Otherwise Processed to Eliminate PHFs S pathogens.*e"° " n 3-401.11A(l)(2) Eggs- 155°F 15 Sec. E -lmmediate Service 145`F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell Eggs* i 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals-155°F 15 sec. 3-40Lll(B)(1)(21 Port:and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 9-401,11(A}(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section .590.009(A)-(1))in sec.* catering,mobile ftxd,temporary and ' 3401.1 t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited udder the appropriate sections Poultry or Ratites-1650F 15 see.* above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1 145°F* 590.009 violations relating to good retail t 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 34011I(A)(1)(b) All Otber PHFs- 145'F l5 sec. ff 17 Reheating for Not Holding _ VIOLA770AIS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165"F 15 see.* (Items 23-30) 1 3-403.11(B) Microwave--165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Tits* foodborne illness interventions and risk factors listed above, can he 3403.11(C) Commercially Processed RTE Food- found in the foilawing sections of the Food Cade and 105 CMR 'i 140°F* 590.000. 3403.11(E) Remaining Unsiiced Portions of Beef Item i Good Retail Pracdces FC 590.000 Roasts* ` 23_ 1 Manatlament and Porsoxtnel ''FG-2 .003 i lg Ptoper Cooling of PHFs 24. Food and Food Protection I FC-3 n04 1 25. i Equipment and utensils FC-4 .005 - 3-50L14(A) Cooling Cooked PHFs from 140`7 to 26, 1 Water.Plumbi and Waste i FC-5 .006 70'F Within 2 Hours and From 70°F 27. Pt s cal Faci1 FC--6 007 j to 41`F145OF Within 4 Hours.* L28. Pdsonous or Toxic Materials I FC-7 .008 i � 3-501.14(53) Cooling'PHFs Made From Ambient 29. S�iecia!R uiremerts i - ,008 } Temperature Ingredients to 41°F/45°F 30, 1 Other Within 4 Hours* Di ou%critical mm is the fedi 1999 FooA Code of 105 CMR 590.000. t