POLONUS EUROPEAN DELI & ICE CREAM - ESTABLISHMENTSPol oAus �vfof=ua Pe I i 4
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CamwFiibosawin9 POSTCONS�RdER
IMI -A,
THE COMMONWEALTH OF MASSACHUSETTS
0 15j0F 17. �
Board of Health
FOOD ESTABLISHMENT INSPECTION REPORT Tel("\ 41 1 d UO
Name
(� I (�
Dnate
/y_
Type of Operation(s)
I
Type of Inspection
( CJl-tit llX�,(�,J� R @
_ n
.Rlisk
Food Service `,�
,4�''{xRetail
gRoutine
1'1 Re -inspection
Address ' G (\ �d`'
S P v
Level
❑ Residential Kitchen
❑ Mobile �.
Previous Inspection
Date:
Telephone �l -') Y `
'�
❑ Temporary)-"-,-
❑
❑ Pre-operation
❑
:__-
Owned ; '�
HACCP Y/N
Caterer 1
Suspect Illness
Person in Charge (PIC)'�Q
Time
Out:
❑ Bed & Breakfast
Permit No.
ElGeneral Complaint
❑ HACCP
❑ Other
Inspector
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) r�7 590.009 (F) L7
action as determined by the Board of Health. Local La ❑
FOOD PROTECTION MANAGEMENT
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
[13. Personnel with Infections Restricted / Excluded
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source
❑ 5. Receiving / Condition
❑ 6. Tags / Records /Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures / HACCP Plans
PROTECTION FROM CONTAMINATION
❑ 8. Separation / Segregation / Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑❑ 10Proper Adequate Handwashing
11. Good Hygienic Practices
Violations Related to Good Retail Practices (Blue
Items) Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Non-critical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C N
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protection (FC -3)(590.004)
25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
27. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.008)
29. Special Requirements (590.009)
30 Other
'W12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIMEJEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time as a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
X22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions
and Risk Factors (Red Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/Federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE -INSPECTION: c, -q_ jJ
Inspector's Signature:
Print:
t
PIC's Signature:/ -h)( .J
Print:
Lof�Pagesj
Page1
FORM 734A (REV. 712000) HOBBS & WARREN, - BOSTON This Form Approved by the Massachusetts Department of Public Health
Violations Related to Foodborne Illness
Interventions and Risk Factors (Red Items 1-22)
FOOD PROTECTION MANAGEMENT
1€ 590.003(A)Ass, nment of Responsibility*
590.003(6) Demonstration of Knowledge*
2-103.11I Person in Charge - Duties
EMPLOYEE HEALTH
2.
590.003(C)
Responsibility of the Person in Charge to
Compliance with Food Law*
3-201.12
require reporting by Food Employees and
3-201.13
Fluid Milk and Milk Products*
Applicants*
Shell Eggs*
590.003(F)
Responsibility of a Food Employee or an
3-202.16
Ice Made from Potable Drinking Water*
Applicant to Report to the Person in
Drinking Water from an Approved System*
590.006(A)
Charge*
590.006(6)
590.003(G)
Reporting by Person in Charge*
3 <
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
N
FOOD FROM APPROVED SOURCE
*Denotes critical item in the federal 1999 Food Code or 1415 CMR 5911.01111.
�
PROTECTION FROM CONTAMINATION
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Food in a Hermetically Sealed Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.14
Eggs and Milk Products, Pasteurized*
3-202.16
Ice Made from Potable Drinking Water*
5-101.11
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(6)
Water Meets Standards in 310 CMR 22.0*
Shellfish and Fish From an Approved Source
3.201.14
Fish and Recreationally caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
4-501.111
Game and Wild Mushrooms Approved by
Regulatory Authority
3.202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
4-602.11
Receiving/Condition
3-202.11
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated*
2-301.1 I
Tags/Records: Shellstock
3-202.18
Shellstock Identification*
3-203.12
Shellstock Identification Maintained*
Tags/Records: Fish Products
3402.11
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(1)
Labeling of Ingredients*
Conformance with Approved Procedures
/HACCP Plans
3-502.11
Specialized Processing Methods*
3-502.12
Reduced Oxygen Packaging, Criteria*
8-103.12
Conformance with Approved Procedures*
*Denotes critical item in the federal 1999 Food Code or 1415 CMR 5911.01111.
�
PROTECTION FROM CONTAMINATION
Cross -contamination
3-302.11(A)(])
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-302.11(A)(2)
Raw Animal Foods Separated from Each
Other*
Contamination from the Environment
3-302.11(A)
Food Protection*
3-302.15
Washing Fruits and Vegetables
3.304.11
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing - Hot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization - temp., pH,
Concentration and Hardness*
4-601.11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*
4-702.11
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization - Hot Water and
Chemical*
Proper, Adequate Handwashing
2-301.1 I
Clean Condition - Hands and Arms*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
Good Hygienic Practices
2-401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventing Contamination When Tasting*
Prevention of Contamination from Hands
590.004(E)
t
Preventing Contamination from
Employees*
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11
Handwashing Cleanser, Availability
6-301.12
Hand Drying Prov,sion
Establishment Name:$Ui
ItemCode C — Critical Item
No. Reference I R —Red Item
CITY OF SALEM
pBOARD OF HEALTH
Qr , cow (n n.inM Dater
DESCRIPTION OF VIOLATION / PLAN OF
`l . PLEASE PRINT CLEARLY
L J _ v N1 mel,, -r r- -
Page: of
V al X
at Dsl,,. - O,r0
r
y ,1
Discussion With Person in Charge:
Corrective Action Required:
P
No
Yes
I have read this report, have had the opportunity to ask questions and agree to correct all
voluntary compliance El
Employee RestrictionIK /
violations before the next inspection, to observe all conditions as described, and to
❑ Re -inspection Scheduled
❑
Exclusion
Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of tylenty-five dollars or suspension/revocation of
o Embargo
❑
Emergency Closure
your food permit. , qr 1`r,4 0 z/ MA '
V/ X 1
❑ Voluntary Disposal
❑
Other:
Violations Related to Foodborne fitness Interventions and Risk
Factors (#ams i-22) (Cont)
PROTECTION FROM CHEMICALS
14
16
17
18
TIME(TEMPERATURE CONTROLS
Food or Color Addftives
3-202.12
Additives*
3-302.14
Protection from Unapproved Additives*
3-501.16(B)
590.004(F)
Poisonous or Toxic Substances
7-101..1.1
Identifying Information - Original
Containers*
7-102.11,
Common Name -Working Containers*
7-201.11
1 Separation - Storae*
7-202. ] 1
. Restriction - Presence and Use*
7-202.12
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions*
7-204,11
Sanitizers. Criteria - Chemicals*
7-204.12
Chemicals for Washing Produce, Criteria"
7-204.14
Drying Agents. Criteria*
7-205.11
Incidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria*
7-206.12
Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Monitoring*
TIME(TEMPERATURE CONTROLS
* Denotes critical item in the federal 1999 Fuad Cade" 105 CMR 590.000.
C
3-561.14(C)
Proper Cooling Temperatures for
3-501.15
PHFs
3-401A IA(1)(2)
Eggs- 155°F 15 See.
3-501.16(B)
590.004(F)
Eggs- immediate Service 145'F15sec*
3401. i i(A)(2)
Comminuted Fish. Meats & Game
3-501,16(A)
Animals - 155°F 15 sec.
3401.11(B)(1)(2)
Pori: and Beef Roast -130°F 121 min*
3-401.11(A)(2)
Ratites, Injected Meats -155°F 15
590.004(H)
sec. *
3-401.1 UA)(3)
Poultry, Wild Game, Stuffed PHFs,
27. -
Stuffing Containing Fish, Meat,
FC-6
Poultry of Ratites -165°F 15 sec.
3-401.11(C)(3)
Whole -muscle, Intact Beef Steaks
! FC -7
145°F *
3-401.12
Raw Animal Foods Cooked in a
Microwave 165'F *
3-401:11(,A)(1)(b)
All Other PHFs -145°F 15 sec.
Reheating for Hot Holding
3-403,11(A)&(D)
PHFs 165°F 15 sec. *
3403.11(B)
Microwave -165° F 2 Minute Standing
Tom*
3-403.11(C)
Commercially Processed RTE Food -
140°F*
3-403.11(E) -
Remaining Unsliced Portions of Beef
Roasts*
Proper Cooling of PHFs
3-501.14(A)
Cooling Cooked PHFs from 140'F to
70°,F Within 2 Hours and From 70'F
to 41°F/45'F Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41017/45'17
Within 4 Hours*
* Denotes critical item in the federal 1999 Fuad Cade" 105 CMR 590.000.
C
3-561.14(C)
PHFs Received at Temperatures
According to Law Cooled to
41'F/45°F Within 4 Hours.
3-501.15
-Cooling Methods for PRFs
3-801.I1(B)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold PHFs Maintained at or below
410/45' F*
3-501.16(A)
Hot PHFs Maintained at or above
140°F. *
3-501,16(A)
Roasts Held at or above 130°F.
25.
Time as a Public Health Control
3-501A9
Time as a Public Health Control*
590.004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801.11(.A)
Unpasteurized Pre-packaged Juices and
Bever es with Warning Labels*
530.0000
3-801.I1(B)
Use of Pasteurized Ems*
FC -2
3-801,11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Spirtnats Not Served. *
Food and Food Protection
3-801.11(C)
Unopened Food Package Not Re -served.
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for Consumption of
530.0000
23.
Animal Foods That are Raw. Undercooked or
FC -2
A09
Not Otherwise Processed to Eliminate
Food and Food Protection
FC- 3
Pathogens.*
25.
3-302.13
Pasteurized Eggs Substitute for Raw Shell
.005
26.
1 E *
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements,
(Items 23-30)
Critical, mrd non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following sectionsofthe Food Code and 105 CMR
590.000.
ttem
Good Retail Practices
FC
530.0000
23.
Management and Personnel
FC -2
A09
24.
Food and Food Protection
FC- 3
.004
25.
E ui rent and Utensils
FC -4
.005
26.
Water. Plumbingand Waste
FC -5
.006
27. -
Physical Facili
FC-6
.007
28.
Poisonous or Toxic Materials
! FC -7
.008
29.
Special Requirements
.009
30.
Other
S,vW�
0176 ESSEX STREET 1 Polonus European Deli & Ice Cream
Telephone:
740-3203
Owner:
Katherine Murawski & Ewa
PIC:
Katherine Murawski
Inspector:
Elizabeth Salandrea
Date Inspected: Correct By:
5/8/2009
Risk Level
Permit Number:
BHP -2009-0107
Status:
VIOLATION
# of Critical Violations:
4
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
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item Status Violation Critical Urgency
PROTECTION FROM CONTAMINATION
Separation Segregation/ Protection FAIL Critical ❑� RED
VComment: Fridge in back room had meats stored above ready to eat items. Organize fridge to properly separate PHFs from RTE
foods.
Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED
V6mment: Sanitizer not available in any areas. Sanitizer of proper concentration (50-100ppm) must be available at all workstations
at all times.
licers both had accumulations of food debris. Thoroughly clean and sanitize slicers.
bay sink obstructed. 3bay sink must be accessible and free from obstructions at all times to properly wash, rinse and sanitize all
utensils and equipment.
Handwash Facilities
FAIL Critical
W RED
VComment: Front handwash sink had a coffee spoon in it. Handwash sinks must be used only for handwashing and must be kept
free from obstructions.
Violations Related to Good Retail Practices (Blue Items)
Food andelFood Protection FAIL Critical BLUE
almment: Employee drink stored in meat case. Store employee items in separate designated area to prevent cross contamination.
Some containers of baked goods are not labeled. All bakery items must have proper labeling.ku "Dcfaz P¢/�
Equipment and Utensils FAIL Non -Critical 6n V_ety -i8y BLUE
60115,omment: Meat case needs general cleaning, including in door tracks. 1"el3
tAidge in backroom needs general cleaning.
oriC's servsafe certificate must be hung up in establishment with 2009 food permit.
60-Aandwash sink in back must be labeled "handwash sink only".
Reinspection in one week, all violations to be corrected.
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. May 11,2009) Page 1 oft
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
Item
Status Violation Critical Urgency
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. May 11,2009) Page 2 oft
KINfBERLEY DRISCOLL
MAYOR
LARRY RANWIN, RS/RVI IS, C[ 10, CP -I5
H(:Al,I'II AGI'wr
CITY OF SALEM, MASSACHUSE`I"IS
BOARD otE HEAL'n I
120 WASHINGTON STREET, 41'' FLOOR.
TEL. (978) 741-1800
FAX (978) 745-0343
Iramdin�ia salem.coin
QUESTIONAIRE - GREASE TRAPS 2009
2. ADDRESS OF ESTABLISHMENT:I CJ f�SS�FA STI SASm Ali 611D
3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? Y40
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS (o
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?
101
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?
ffl
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street, 4th Floor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/03/2011
ESTABLISHMENT NAME:
File Number: BHF -2004-000047
LOCATED AT:
Kimberley Driscoll
Mayor
Polonus European Deli & Iee Cream
176 Essex Street
Salem MA 01970
0176 ESSEX STREET 1
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
RETAIL FOOD BHP -2011-0032 Jan 1, 2011 Dec 31, 2011 $70.00
Total Fees: $70.00
PERMIT EXPIRES iDecember3l,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
KIMBERLEY DRISCOId,
MAYOR
DAVID GREENBAum, RS
ACTING HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD or., HEALTH
120 WASHINGTON STREET, 4°1 FLOOR
TEL. (978) 741-1800
FAx (978) 745-0343
DGREENBAUNI&ALEM CONI
2011 APPLICATION FOUR, 1PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT3OLONUS W PFRN t ( IJ L #69 T9 ' I/`
ADDRESS OF ESTA3L!cunIEN"l'.146 �� :T S m FR.X#�!I q -q.0 Ay1l
MAILING ADDRESS (if different)
EMAIL - Business':
OWNER'S
ADDRESS
Website:
CERTIFIED FOOD MANAGER'S NAME(S) LCAT (NF i1 LW,")5k, I CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)p�
EMERGENCY RESPONSE PERSON,F}i�i�iKIPJE MLJ n��n / HOME TEL#
JW 90//� 1i2$3_
DAYS OF'OPERATION. :. 1Monday ,=,;f.
Tuesday;^"' ."•Wednesdayj I,tThursday�.: ,{ c Fdday% Saturday ...'i,,., -Sunday,
HOURS OF OPERATION
Please write in time of day. RAM - 01
1W-V010AM-W, (OAM-OPh1 (0AM-31P
_(For example 1 tam-11pm)
TYPE OF ESTABLISHMENT
RETAIL STORE OYESNO
FEE (check only)
less than 1000sq.ft.
1000-10,000sq.ft. = 0
more than I0,000sq.ft. =$420
RESTAURANT YES NO
less than 25 seats
=$140
(O! Itdoor Stationary Food Cart $210)
25-99 seats
=$280
more than 99 seats
=$420
--- -------------------------------------------------------------------------------------------------------------------------------------------------------------
BED/BREAKFAST/ YES NO
$100
CHILDCARESERVICES/NURSING HOM---------------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE
YES NO
$25
TOBACCO VENDOR
YES NO
$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 MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
retugas and paid all state taxes required under the law. t
k 19 IO
Date
Social Security
Revised 10/7/11 FOODAP2011.adm Check# &Dace —40 .GO
Number
i
DATE PRINTED:
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street, 4th Floor
SALEM, MA 01970
Food/Retail Establishment Permit
01/11/2010
ESTABLISHMENT NAME:
File Number: BHF -2004-000047
Kimberley Drisooll
Mayor
Polonus European Deli & Ice Cream
176 Essex Street
Salem MA 01970
LOCATED AT: 0176 ESSEX STREET 1
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires . Fee Restrictions / Notes
RETAIL FOOD BHP -2010-0216 Jan 4, 2010 Dec 31, 2010 $70.00
PERMIT EXPIRES
Total Fees: $70.00
2010
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all
plans for such must be submitted to and approved by the Salem Board of Health.. Paye 1
Cr;
KIMBERLEY DRISCOLL
MAYOR
DAVID GREENBALim,
ACTING HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4" FLOOR
TEL. (978) 741-1800
FAX (978) 745-0343
DGREENBAUM&ALEM.CONI
2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT fQLDIYUS ehe OPS DSI C/ TEL # 'R'I �,p-N0 32 03
ADDRESS OF ESTABLISHMENT j46i�S� ST & f O MA t'7/q-7UFAX#9?$ q-qO o2Y#j
MAILING ADDRESS (if different)
EMAIL - Business':
OWNER'S
ADDRESS
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) **THC -2f BT Mc J PAW Sal CERTIFICATE#(S) 510 I R S�
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON kf}741f-&1V `M!/d2A4-9--1 A?FN�MllL?Q2 HOME TEL # /9E4t7oqSW
Dql $(®F'0„PERATIOWM m,41Montlayb'Tuesda
c«Wed estlay Thursday1 Fid"ayi�Saturtlay' `;,
Sunday
FOURS OF OPERATION 1
Please write in time of day.
1
'
Forexam e11am-ttpm
1
TYPE OF ESTABLISHMENT
RETAIL STORE YES NO
RESTAURANT YES
(Outdoor Stationary Food Cart $210)
FEE (check only)
less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
less than 25 seats =$140
25-99 seats =$280
more than 99 seats =$420
----- -------------------------------------------------.............................. ---................. ---.......
BED/BREAKFAST! YES NO $100
AUUI I IVNAL YtKMIIJ
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $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 and belief, have fled all state tax
returns nit paid all state taxes required under the law.
or
Revised 424/07 FOODAP2008.adm Check# & Date
Number.
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street, 4th Floor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/23/2008
ESTABLISHMENT NAME:
File Number: BHF -2004-000047
Kimberley Driscoll
Mayor
Polonus European Deli & Ice Cream
176 Essex Street
Salem MA 01970
LOCATED AT: 0176 ESSEX STREET 1
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
RETAIL FOOD BHP -2009-0107 Dec 23, 2008 Dec 31, 2009 $70.00
PERMIT EXPIRES
Total Fees: $70.00
2009
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
KIMBERLEY DRISCOLL
MAYOR
JANET DIONNE,
ACTING HEALTH AGENT
CITY OF SALEM, MASSACHUSEITS
BOARD OF HEALTH
120 WASHINGTON STREET, 4" FLOOR
TEL. (978) 741-1800
FAx (978) 745-0343 Jqt
7DtONNE&AL11M COM 1 DEC
1f j ?7MA
DOAhtU lJr r,
2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENTPOL-ONUS evL045tV IGC
ADDRESS OF ESTABLISHMENT FAX# 9'�T j4f•2 A44�I
MAILING ADDRESS (if different)
EMAIL - Business':
OWNER'S
ADDRESS IV�PP'90n �ci` T%WT-'"
T'"
CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S)'KA7}QlF-Q,(p1C- p'j(Jk4 j A CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON HOME TEL #
DAY-SOFOP.ERATION Monda Tuesday -`;Wednesday . -�:<- Thursday -z <FddaY_ ""^Saturoa . :=! .. 'Sunda "
HOURS OF OPERATION J I�__QL�n'� n1ee.
Please verde in time of day. !Cc,.OSa� �Q�"''iTt# (�+7rt` �r �Qr'irt'"r(Jn`ti tQrn'�`%i°rJ ��'r4+'+"" A7?int-3ri p
(Forexample Ilam-11pm
TYPE OF ESTABLISHMENT
FEE (check only),
RETAIL STORE •YNO
less than 1000sq.ft.
(--;$;7:00/1
1000-10,000sq.ft.
80
more than I0,004sgA
=$420
RESTAURANT YES ..
- ......*------•--------ies
... ----------- ---------
less than 25 seats
---•-.......
=$140
(Outdoor Stationary Food Cart $210)
25-99 seats
=$280
more than 99 seats
=$420
— —-----••----•-•--YE-S'-••----------—
----------------------------------...-----------....----••----------------
BEDI6REAKFASTJNO
$-1,0,0, ------
0
CHILDCARE SERVICES--,--------•,•-----
------•-------------------•--------------- •------•--------------*
ADDITIONAL PERMITS
------------ .-------------
• •------••------
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE
TOBACCO VENDOR
YES NO
$25
YE NO
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 MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returK and paid all state taxes required under the law. ,
Signature
Date
Revised 424/07 FOODAP2008.adm Check# & Date
or
r
Number
f�
Renin T,,.
100 Pleasant Street
BnnvswkA, ME 04011
PEST,SERVICES
1 -Sou 121 -PEST p37s1
d(li ng
1-11n0-004-0900
INVOICE # WORK DATE TIME DAY ASSOCIATE LKENSEACCOUNT
511348 3/19108 11:36 AM Wednesday Roland McDonald 34046 3415950
POLONUS
176 ESSEX ST
SALEM, MA 01970-3736
976-740-3203
KATHEUN
COMMENTS
SERVICED 13 OF 13 INTERIOR RODENT BAIT SrrATIONS, i OF 1 MOUSEMASTERS , REPLACED GLUEBOARDS AS NEEDED
BACK ROOM
BACKROOM
BEHIND MEAT CUT
DISPLAY
FRONT COUNTER
MAIN STORE
ASwcIaIC Slgda11Ri1
D362
_. WWW.rnOdernpeSLcom
Td Wd6t1:£0 6002 8Z 'unr 29P9SP2-aGT: -ON XBd AHdHNEIOlOHcl 39H1NIO S,W3'1HS: WO2U
Remit To
100 PL;,¢;,�nl : b!•CI
drtwvwick, ME ()4111'1
ern.
PEST SERVICES
531472 5/21/08 9-.W AM NMdnesdaV Roland McDonald 34046
POLONIIS 978.740-3203
176 ESSEX ST
SALEM, MA 01970-3736
S<Nic'
1-800-:1213_PFtii (G318)
Billing
1-8W894 H800
COMMENTS
SERVICED 13 OF 13 INTERIOR RODENT BAR STATIONS, 1 OF I HOUSEMASTER WITH 1 MOUSE CAUGHT, REPLACED GWEBOAROS AS
NEEDED
TARGET PEST MATERIAL EPA REG, K CON.% AREA AMOUNT METHOD EQUIPMENT
MICE - DTTRAC BLOX - 12455-80 0 13 Owxe Rodenticide Place
.:.i Tax $DAO
TOL'd1 $51.00
e
u�umodompo�toom
2d Wd9S:£9 8902 82 'unf
e9b95tL8L6T: 'ON X84
Mc U8BOlOHd
30UiNIn S.W3l1JS:
WOdzl
0176 ESSEX STREET 1 Polonus European Deli & Ice Cream
City o. f'Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone:
Violations Related to Good Retail Practices (Blue Items)
740-3203
Food and Food Protection FAIL Critical BLUE
OWner:.
Comment: Food stored directly on the floor in the walk-in freezer. All food must be stored at least 6.8 inches off the floor.
Katherine Murawski & Ewa
Equipment and Utensils FAIL Non -Critical BLUE
PIC:
Jennifer Olejnik
Comment: Walk-in freezer missing thermometer. Provide visible, accurate internal thermometer for this freezer.
Inspector:
Same unit needs a general cleaning on the bottom.
Elizabeth Saiandrea
Date Inspected.' Correct By:
Deli case reading 43°F. Turn down to ensure temperature is 41°F or below.
6/23/2008
Pierogi freezer, Pepsi fridge and nantucket nectars fridge are missing thermometers. Provide visible, accurate internal thermometer
for these units.
Risk Level:
Permit Number:
BHP -2008-0084
Status:
# of Critical Violations:
Time
Urgency Description(s)
BLUE: . Owner to notify Board of Health within one week that violations listed have been corrected.
Violations Related to Good
Retail Practices (Critical 'Please fax April and May extermination invoices to the Board of Health within one week.
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 24,2008 ) Page 1 oft
RED: - -
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
Item Status Violation Critical Urgency
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 24,2008) Page 2 oft
w.w f
F - .� - �}. ✓.q �w .� :. epi,. ai.}''M+'4 }� �� �.d5 �sY Y.., � �dx��.��t'N'i'ii
Commonweaith of Massachusetts; +tau - a�it {;' }�
City of Salem
-Board of Health
120 Washington Street, 4th Floor - IGmbedey Oft oil
-Mayor'_
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01103/2008
ESTABLISHMENT NAME:
File Number: BHF -2004-000047
LOCATED AT:
Polorms European Deli & Ice Cream
176 Essex Street
Salem
0176 ESSEX STREET 1
SALEM, MA 01970
MA 01970
Permit Type
Permit No.
Permit Issued
Permit Expires
Fee Restrictions/ Notes
FROZEN DESSERTS
BHP -2008-0052
Jan 3, 2008
Dee 31, 2008
$25.00
RETAIL FOOD
BHP -2008-0084
Jan 3, 2008
Dec 31, 2008
$70.00
Total Fees: $95.00
PERMIT EXPIRES December 31, 2008
Board of Health
This Permit is not transferable and must be'reissuedmpon change of ownership or location. The permit must 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 17of 46
KII IBERLEY DRISCOLL
MAYOR
JOANNE SCOTT,
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 41' FLOOR R!
TEL. (978) 741-1800 U
FAX (978) 745-0343 d' q
IDQI:Y["rJSALEM.COM
G oo, V
`pCE41
�Lry
1i: A • • • •� •�s 1
NAME OF ESTABLISHMENT?OLdiMQ,>
(0k)PEW D.EL- Ll TEL #1
less than 1000sq.ft.
fcri 32Q3
ADDRESS OF ESTABLISHMENT 1-} G ESStJr'
ST SkFn MA 01 FAX #
more than 10,000sq.ft,
9 tf U oto I
MAILING ADDRESS (if different)
EMAIL - Business': N IA- Website:
OWNER'S
AD
CERTIFIED FOOD MANAGER'S NAME(S) -KA 1}f9j N F I'f USA WS4-I CERTIFICATE#(S) SOI '1 J q
(Required in an establishment where potentially hazardous food is prepared) c r ,
EMERGENCY RESPONSE PERSON -�fl-i-ft-FUNF MUM-kNSHOME TEL # �t161
DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday
nuuno ur vrun i ivn _ /
Please wile in time of day, IGLc%s ' t�"t'�' tQ-110-0 (� ` 7 (/ Q'- �rj V
TYPE OF ESTABLISHMENT
RETAIL STORE YE NO
RESTAURANT YES NO
!Outdoor Stationary Food Cart $210)
--- --- - --•- ...-- --•--------------------- -•-------K ...
.----------- --------
..
BED/BREAKFAST/ YES NO
CHILDCARE SERVICES..__,-___--,,._
--- *----------------------------------
MAKE
------------------------------.MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE
TOBACCO VENDOR
ALL NOM -PROFIT (such as church kitchens)
FEE (check only)
less than 1000sq.ft.
70
1000-10,000sq.ft.
=$280
more than 10,000sq.ft,
=$420
--- ---
less than 25 seats
=$140
25-99 seats
=$280
more than 99 seats
=$420
$100
-... ---------
YES NO
------------..
25
YES NO
$135
YES NO
$25
"Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returnpaid all state taxes required under the law. % /
IVR a , A .. , \-Pn it 1 1 r / , l /-xJ 9 _ r-7 !!' ..!' .`7r—
Date ' Social Security or Federal Identification Number
-------------- .'---'------------------------------'- ----------------- 4-- -- - --------------------------------------
Revised 4/24/07 FOODA P2008.adm 0 yao s q- rg0
0176 ESSEX STREET 1
(Telephone: m
1740-3203
Owner:
Katherine Murawski & Ewa
PIC:
Katherine Murawski
l Inspector:
IDavid Greenbaum
'Date Inspected: Correct By:
12/12/2007
Risk Level:
Permit Number:
BHP -2007-0097
Status:
COMPLY
PARTIAL
of Critical Violations:
1#
2
Time IN: --
Time OUT.
Urgency Description(s): i
BLUE: i
,violations rtelateo to u000
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately I
or within 90 days) I
Polonus European Deli & Ice Cream
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item Status Violation Critical
Urgency
PROTECTION FROM CONTAMINATION
Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d
RED
Comment: Sanitizing found too strong. Provide chlorine sanitizing solution at proper concentration at all times.
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection FAIL Critical
BLUE
Comment: There is food stored directly on the walk in floor. Store all food at least 6-8 inches off the Floor.
Food stored in the restroom. Storage in the restroom is prohibited. Store all food in an appropriate storage area.
Equipment and Utensils FAIL Non -Critical
BLUE
Comment: The microwave needs a thorough cleaning.
The deli case door tracks need thorough cleaning.
The Nantucket Nectars True reach in needs a visible, accurate thermometer.
GENERAL COMMENTS:
Owner to notify the Board of Health within ine week that the above violations have been corrected.
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. Dec 13,2007 ) Page I oft
RED:
4Violations Related to
Foodborne Illness Interventions]
and Risk Factors (Require i1
immediate corrective action)
Item
Status Violation Critical Urgency
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. Dec 13,2007 ) Page 2 oft
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
Salem Board of Health
120 Washington Street, 4th Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name D "� p
UC/0/7V5 6-Ve,o oAgpl LAG `�(� (V�q
Date
j 3i/0�
TVDe of Operationfs)
Tvpe.of Inspection
❑'Food Service
❑ Retail
❑ Residential Kitchen
❑ Mobile
❑ Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
®'Routine
❑ Re -inspection
Previous Inspection
Date:
ElPre-operation
❑ Suspect Illness
❑ General Complaint
❑ HACCP
❑ Other
Address / 76 ��� r ro t
Risk' '
Level
Telephone 7
3.20 3
Owner/
✓i v {rG k.), c ,
HACCP YM
Person in Charge (PIC)
Time
In:
Out:
Inspector
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 r"TM,,;,,„„„m.�� ,,�A,,,,®,,;�,"if•..
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH
a
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3.. Personnel with Infections Restricted/Excluded
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM
.. ad».««,,,�i4®.,...:�2�...,N»..a.,.,.ma
El14. Approved Food or Color Additives
❑ 15 Toxic Chemicals
FOOD FROM APPROVED SOURCE'-',�u'
❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) - l
AJ, 5 F,J,-Jst
E]5. Receiving/Condition El16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
PROTECTION FROM CONTAMfNATK1N - s -tr y
=A-,»e,�,., .;Feel
❑ x8. Separation/ Segregation/ Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices
Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Non-critical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protection (FC -3)(590.004)
25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
27. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.001)
29. Special Requirements (590.009)
30. Other
S. 5901nVw Fom 14.dw
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
REQUIREMENTS FOR HIGiiLY SUSCEPTIBLE POPULATIONS(HSP),
❑ 21. Food and Food Preparation for HSP
CONSUMERAOVISO`
Ry -
El 22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions
and Risk Factors (Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE -INSPECTION:
Inspector's Signature.
Print: '�O i
�
!!
PIC'sSignature: rij////�
�d�
Print:
Page t of-31'ages
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 596.003(A) Assi nment of Responsibility*
590.003(B) Demonstration of Knowledge*
2-103.11 Person in charge -- duties
EMPLOYEE HEALTH
2
590.003(C)
Responsibility of the person in charge to
Com xlianoe with Food Law*
3-201.1.2
require reporting by food employees and
3-201.13
Fluid Milk and Milk Products*
applicants*
Shell Fees*
590.003(F)
Responsibility Of A Food Employee Or An
3-202.16
Ice Made From Potable Drinking Water-
ater*5-101.11
Applicant To Report To The Person In
Drinking Water from an Approved System*
590.006(A)
Charge*
590.006(B)
590.003(G)
Reporting by Person in Charge*
3
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
C
[a
C
C
FOOD FROM APPROVED SOURCE
* Denotes critical item in the (etlert0 19991 oaJ Cale or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
8
Food and Water From Regulated Sources
590.004(A -B)
Com xlianoe with Food Law*
3-201.1.2
Food in a Hermetically Scaled Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Fees*
3-202. l4
Eggs and Milk Products. Pasteurized*
3-202.16
Ice Made From Potable Drinking Water-
ater*5-101.11
5- t0t. I I
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 220*
Washing Fruits and Ve etables
Shellfish and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Iisted
Sources*
Contamination from the Consumer
Game and Wild Mushrooms Approved by
Reulato Authori
3-202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
3-701.11
Receiving/Condition
3-202.1.1,
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated
Togs/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained*
Tags/Records; Fish Products
3-40211
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(7) -
Labeling of Ingredients'
Frequency of Sanitization of Utensils and
Fad Contact Surfaces of Equipment*
Conformance with Approved Procedures
/HACCP Plans
3-502.11
Specialized Processing Methods*
3-502.12
Reduced oxygen paging, criteria*
8-103.12
Conformance with Approved Procedures*
* Denotes critical item in the (etlert0 19991 oaJ Cale or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
8
Crass-oontaminatron .
3-302.11(A)(1)
-
Raw Animal Foods Separated from
Cooked and RTE Foals*
Contamination from Raw Ingredients
3-3021.1(A)(2)
Raw Annual Foods Separated from Each
Other*
Contamination from the Environment
3-302.11(A)
Food Protection*
-
3-302.15
Washing Fruits and Ve etables
3-304.11
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Foal*
9
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-601.11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*
4-702.11
Frequency of Sanitization of Utensils and
Fad Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization- Hot Water and -
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301.-1.2
Cleaning Procedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-30112
Preventing Contamination When Tasting*
12
Prevention of Contamination from Hands
59(W04(E)
Preventing Contamination from
Employees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11.
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
- Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11
y
Handwashin Cleanser, Availability
6-301..12
Hand Drying Provision -
BOARD OF HEALTH
Establishment Name:. 'i�- (o Date: In 7Z-- Page: Z of _ M
Item
NO.
Code
Reference
C - Critical Item. DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
R — Red Item
PLEASE PRINTCLEARLY
Date
Verified
0 C, 6P .
J
ZS
tt^ op VP o a y vt5 a,ro u [e
2
t Va �Avtve� 2Vt2v t C�GG In
Z.5
A W �I h iU fG _ tl ✓t.. Jc3
2
' vy- t V r) L 1 \sfit S C �.�,V .Lt�+ S 1 h
JZtj= IM. W
CC _ vv o s Vti �vti Ytl 1vtl v
j
� I
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
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
noncompliance may result in daily fines of twenty five dollars or suspension/revocation of
your food permit. %
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Emersion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
IJ
Violations Related to Foodborne Illness Interventions and Risk
Factors (items 1-22) (Cont)
PROTECTION FROM CHEMICALS
14
15
16
17
18
3-202.12
Food or Color Additives
Additives"
3-302.14
Protection from Una roved Additives*
3-401.1 -A(] )(2)
Poisonous or Toxic Substances
7-101.11
Identifying Information - Orig inal
Containers*
7-102.11
Common Name- Working Containers'
7201.11
7-202.11
Se oration-St'oraga"`
Restriction - Presence and User
7-202.12
Conditions of Use*
7-203.'11
Toxic Containers - Probibitions*
7-204.11
Sanitizers. Criteria - Chemicals*
7-204.12
Chemicals for Washing Produce, Criteria',
7-204.14
Drying Agents. Criteria"
7-205.11
Incidental Food Contact. Lubrietmts*
7-20(.11.
Restricted Use Pesticides. Criteria*
7-206.12
7-206.13
Rodent Bait Stations'
' rackmg Powders. Pest Control and
Monitoring^
TIME/TEMPERATURE CONTROLS
'' Denotes conical item in the iedexal 1999 Food Code or 105 CNIR 590.000.
I9
20
3-501,14(C)
Proper Cooking Temperatures for
3-SOL15
PHFs
3-401.1 -A(] )(2)
Eggs- 1.55`1715 Sec.
3-501.16(B)
590.004(F)
Eggs -Immediate Service I45TF15sec-
3-401.11(A)(2)
Comminuted Fish, Meats & Game
3-501.16(A)
Animals - 155'F 15 sec. *
3-40LI l(B)(1}(2)
Pork and Beef Roast - IXT 121 min*
3-401.11(A)(2)
Ratites, Injected Meats - 155`F 1.5
i90.004(H)
sec.
3-401 11
Poultry, Wild Game, Stuffed PHFs,
.008
Stuffing Containing Fish, Meat,
Poulfr or Ratites -165".17 IS sec. *
3-401.11(C)(3)
Whole -muscle, Intact Beel Steaks
145'F
3-401.12
Raw Animal Foods Cooked in a
Microwave 165`1 *
3-401.11(A)(1)(b)
All Other PHFs-- 145°F 15 sec.
Reheating for Hot Holding
3-403.11(A)&(D)
PHFs 165'F 15 sec.
3-403.11 (B)
Microwave- 165' F 2 Minute Standing
Time*
3-403.11(0)
Commercialk Rocessed RTE Food -
140'F*
3-403.11(17.)
Remainingg Unsliced Portions of Beef
Roasts*
Proper Cooling of PHFs -
3-501.14(A)
Cooling Cooked PHFs from 140`17 fo
70°F Within 2 Hours and From 70'F
to 41'F/45°'F Within 4 Hours. *
3-50L14(B)
Carling PHFs Made FromArnbient
Temperature Ingredients to 41'F/45`F
Within 4 flours)'
'' Denotes conical item in the iedexal 1999 Food Code or 105 CNIR 590.000.
I9
20
3-501,14(C)
PHFs Received at Temperaturets
According to Law Cooled o
41`F/45`F Within 4 Hours.
3-SOL15
Cooting.Methods for PHFs
3-801.11(H)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold P1117s Maintained at or below
4P/45° F*
3-501.16(A)
Hot PHFs Maintained at or above
140'F.*
3-501.16(A)
Roasts Held at or above 130'F.
26. Water, Plumbinq and Waste
Time as a Public Health Control
3-501-'(9
Time as a Public Health Control*
i90.004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP
}
21
3-801.11(A)
Unpasteurized Pre-packaged Juices and
Beverages with Warning Iatbels*
23.
-Management and Personnel_._--
3-801.11(H)
Use of Pasteurized Eves*
24. Food and Food Protection
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed S trouts Not Served. ="
25. Equipment and Utensils
3-801.11(C)
Unopened Food Packa e Not Re -served.
•
22
3-603-11
Consumer Advisory Posted for Consumption of
23.
-Management and Personnel_._--
FC -2
Animal Foods'1'hat are Raw. Undercooked or
24. Food and Food Protection
FC - 3
Not Otherwise Processed to Eliminate
25. Equipment and Utensils
_
4
Pathogens.* eencnva v;aawi
26. Water, Plumbinq and Waste
3-30113
Pasteurized Eggs Substitute for Raw Shell
27. Ph sical Faoility
_
FC - 6
Eggs*
SPECIAL REQUIREMENTS
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering. mobile food, temporary and
residential kitchen operations should be
debited wider the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under X729 -
Special Requirements.
11i+)RiiY£tl�Trl� F�7
(Items 23-30)
Critical and non-critical violations. which do not relate to the
foodborne- illness inter venlion.s and risk factots listed above, can be
found in the following sections of the Food Code and 105 CMR
590.000.
ifs Good Retail Practices
FC
590.o00
23.
-Management and Personnel_._--
FC -2
.003
24. Food and Food Protection
FC - 3
.004
25. Equipment and Utensils
_
4
.005
26. Water, Plumbinq and Waste
_FC_-
FC -5
.006_
27. Ph sical Faoility
_
FC - 6
.007
28. Poisonous or Toxic Materials
FC - 7
.008
2- Special Requirements
.008
30. Other
RrvOfoiv�M1�d:6-2:4s
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: w �� t� t ) S Date: �'3�/h Page: of
Item
No.
Code
Reference
C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
R - Red Item
PLEASE PRINT CLEARER
Date
Verified
oI
11116-\ S LU4 V Le&J\ve S 4 OYtiv',l' 110 h
J
C �2. � , s �1 C.Q. ✓ ,� c) ve.e C, -P / %..4 r? K �l �I (/2
(}
(.� >1
�X i..Q./V1--e✓ V -e Cic U L ✓Q P V e % f .t iq ✓ d
u
Q�t kryv a / G C� C( C,C (C ✓- -PCU k vv Oin I C Le C( r1 by
2
� U I I cst \ lsil�l,e ✓ vv\c,,�, � �✓�vv1(lo
V 1 S) 6LC a tnCt G G uvc Y11 ✓ -
// tv/o /�f 0"< ) 6" e-arw C' �� w f� one
6 s
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
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
noncompliance may result in daily fines of twenty-five'dollars or suspension/revocation of
your food permit.
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
0 Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors (Items 1-22) (Cont.)
lci+yi;ft rni'I�ii t
14
Food or Calor Additives
3-501.15
3-202.12 Additives'" --^^-
3-40'1-11A(1)(2)
3-30214 Protection trent Unar roved Additives*
15
Poisonous or Toxic Substances
3-401.11(A)(2)
7-101.11 Identifying Information - Original
Containers*
3-501.16(A)
7-102.11 Common Name- Workinv Containers*
3-401.11(R)(L){2)
7-201.11 Se aradon - Storarta"
3-401A I (A)(2)
7-202.11 Restriction- Presence and Use
590.004(H)
7-202.12 Conditions of Use -
se's7-203.11
1-401,11 (A)(3)
7 -203 . I IToxic Containers - Prohibitions"
7-204.11 Sanitizers,Criteria- Chemicals*
28.
7-201.12 Chemicals for Washin � Produce, Criteria"
FC -7 li
7-204.14 Drying Agents. Criteria"
3-401.11(C)(3)
7-205.11 Incidental Foul Contact. Lubricants*
009
06.11 Restricted Use Pesticides. Criteria*
3401.12
6.12 Rodent Bait Stations"
6.13 Tracking Powders, Pest Control and
r
16
17
18
'.Denotes cricical nem in the federal 1999 1ood Code or 105 CMR 590,000.
20
3-501.1.4(C)
Proper Cooking Temperatures for
3-501.15
PHFs
3-40'1-11A(1)(2)
_
Eggs- 155°F'15Sec.
3-501.16(8)
590.004(F)
Eggs - limnediate Service 145°1715sec*
3-401.11(A)(2)
Comminuted Fish, Meats & Game
3-501.16(A)
Animals - 155`F 15 sec.
3-401.11(R)(L){2)
Pork and Beef Roast - 130°F 121 min*
3-401A I (A)(2)
Ratites, Injected Meats - 155".F 15
590.004(H)
sec. *
1-401,11 (A)(3)
Poultry, Wild Game, Stuffed PHFs,
28.
Stuffing Containing Fish, Meat,
FC -7 li
Poultry or Ratites -165°F 15 sec.
3-401.11(C)(3)
Whole muscle, intact Beat Stealeg
009
145'17 *
3401.12
Raw Animal Foods Cooked in a
Microwave 165°F *
3401_11(A)(1)(b)
All Other PHFs-145°F 15 sec.
Reheating for Hot Holding
3-10111(A)&([))
PHFa 165°F 15 sec. x`
3-403.11 (B)
Microwave- 165° F 2 Minute Standing
Time"
3-403.11(C)
Commercially Processed I2TE Food -
140°F`
3-403.1.1(E)
Remaining Unslieed Portions of Reef
Roasts*
Proper Cooling of PHFs
3-501,14(A)
Cooling Cooked PRFs from 140`F to
7W F Within 2 Hours and From 70°F
to 41'F145`F Within 4 Hours. *.
3-501.14(B)
Coolinor PHFs Made From Ambient
Temperature Ingredients to 41`17145°F
Within 4 Hours`
'.Denotes cricical nem in the federal 1999 1ood Code or 105 CMR 590,000.
20
3-501.1.4(C)
PHFs Received at Temperatures
According to Law Cooled to
41°F/45°F Within 4 Hours.
3-501.15
Coolim" Methods for PRFs
3-801.1 1.(D)
PHF Hot and Cold Holding
3-501.16(8)
590.004(F)
Cold PHFs, Maintained at or below
41V45° F*
3-501.16(A)
Hof PHFs Maintained at or above
t40°F. *
3-501.16(A)
Roasts Held at or above 130°F.
25.
---------_.
26.
Time as a Public Health Control
7501.19
Time as a Public Health Control*
590.004(H)
Variance Re uirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21 3-801.11(A)
Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
3-S01.11(B)
Use of Pasteurized
3-801.1 1.(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. '"
3-801.11(Cl)
Unopened Food Package Not Re -served. "
CONSUMER ADVISORY
22
3fiO3-11
Consumer Advisory Posted for Consumption of
500.000
23.
Animal Foods That are Raw, Undercooked or
FC - 2
.003
Not Otherwise Processed to Eliminate
Food and Food Protection -
- 3
Pathogens.* vvsoni
25.
---------_.
26.
3-302.13
Pasteurized Eggs Substitute for Raw Shell
.005
-----
.006
27.
Eggs:'
e
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to Foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail.
practices should be debited under #{29 -
Special Requirements.
(,Items 23-30)
Critical and non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in rite following sections of the Food Code and 10.5 CMR
590.000.
Item
I Good Retail Practices
FC
500.000
23.
Management and Personnel_
FC - 2
.003
24.
Food and Food Protection -
- 3
.004
25.
---------_.
26.
Equipment and Utensils -
Water, Plumbin and Waste
_ _FC
FC - 4
__-----
FC -5
.005
-----
.006
27.
PhysicalFaclitY__,_________
FC - 6
.007-
28.
Poisonous or Toxic Materials
FC -7 li
.008
29.
30...
S ectal Re uirements
Other
009
tts1om1mm,ts a ax
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
Salem Board of Health
120 Washington Street, 4" Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name ( '
Date
Tvpe of.Operation(s)
Tyne of Inspection
❑iFood Service
❑ Retail
❑ Residential Kitchen
❑ Mobile
❑ Rou 'ne
❑,Re -inspection
Previous Inspection
Date:
w� f0 �(�
h l �� i
Address 7 (,p i4
-4
Risk'
Level
Telephone
l fL-32�
ElTemporary
❑ Caterer
ElPre-operation
ElSuspect Illness
OwnerHACCP
�
Y/N
U r
ElBed &Breakfast
[I General Complaint
Person in Charge (PIC)
Time
In:
Out:
Permit No.
❑ HACCP
❑ Other
Inspector ka
U-p(--v
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.�;„`��, p.,m,®..;.,;„„.,„w„' eTm�'.
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
71 PROTECTION FROM CHEMICALS `"�11
'""�
,.i.aw ...'E i( vkk+iv.
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
_FOOD FROM APPROVED SOURCE .;�_„ ,„�re�m„�„W„.„;�„. RRR
❑ 4. Food and Water from Approved Source ° TIMEREMPERATURE CONTROLS (Pptentralry Hazardous Fo- ,
PP `.-@,.,x l=, .atl ..zv ab
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
PROTECTION FROMCONTAMINATION'"'
❑ 8. Separation/ Segregation/ Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
[111. Good Hygienic Practices
Violations Related to Good Retail Practices
Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Non-critical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
c; X
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protection (FC -3)(590.004)
25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
27. Physical Facility (FC -6)(590.007)'
28. Poisonous or Toxic Materials (FC -7)(590.008)
29. Special Requirements (590.009)
30. Other
5: 5801nspectFormS-14.dvc
❑ 17. Reheating
❑ 1 B. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
(`,`REQUIREMENTS FOR HIONLY SUSCEPTIBLE POPULATIONS (H$P)' j}a
❑ 21. Food and Food Preparation for HSP
CONSUMER u. �mka ,'.2,v,I: .,P.v
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions Gj
and Risk Factors (Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE -INSPECTION:
Inspector's Signatur
Print: Iwo C',,S
n
PIC's Signature:
Print:
Page. � of. -Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A} Assignment of Responsibility*
T510.003(B) Demonstration of Knowledge*
2-103.11, Person in charge- duties
EMPLOYEE HEALTH
2
590.003(C)
Responsibility of the person in charge to
Compliance with Food Law*
3-201.12
require repotting by food employees and
3-20'1.13
Fluid Milk and Milk Products*
applicants*
Shell Eggs*
590.003(F)
Responsibility Of A Food Employee Or An
3-202.16
Ice Made From Potable Drinking Water*
Applicant To Report To The Person In
Drinking Water from an Approved System*
590.006(A)
Char *e'
590.006(B)
590.003(G)
Reporting by Person in Charge*
3
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Res rictions
LE
In
FOOD FROM APPROVED SOURCE
'* Denotes critical item in the federal 1999 rood Code or 105 Ci4R 590.000.
PROTECTION FROM CONTAMINATION
8
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Food in a Hermetically Seated Container*
3-20'1.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.14
Eggs and Milk Products, Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-101.1.1
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Watcr*
590.006(B)
Water Meets Standards in 310 CMR 22.0*
Washing Fruits and Vegetables
Shellfish and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
Contamination from the Consumer
Game and Wild Mushrooms Approved by
Regulatory Authority
3-202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
3-701.11
Receiving/Condition
3-202.11 -
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated
Tags/Records: Shelistock
3-202.1$
Shellstock Identification *
3-203.12
Shellstock Identification Maintained"
-
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(1)
Labeling of Ingredients'
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Conformance with Approved Procedures
/HACCP Pians
3-502.11
Specialized Processin Methods*
3-502.12
Reduced ox en acka 'ng. criteria*
8-103.12
Conformance with Approved Procedures*
'* Denotes critical item in the federal 1999 rood Code or 105 Ci4R 590.000.
PROTECTION FROM CONTAMINATION
8
Cross -contamination
3-302.11(A)(])
Raw Animal Foods Separated from
Cooked and RTE Fouls*
Contamination from Raw Ingredients -
3-302.11(A)(2)
Raw Antral Foods Separated from Each
Other"
Contamination from the Environment
3-302.11(A)
Food Protection*
3-302.15
Washing Fruits and Vegetables
3-304.11
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food'*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
9
Food Contact Surfaces
4-501.1.11
Manual Warewashing - Hot Water
Sanitization Ten eratares" -
4-501.112
Mechanical Warewashing- Ilot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-601.11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*
4-702.11
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization - Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.1.1
Clean Condition - Hands and Arms*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventin Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(F)
Preventing Contamination from
Employees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied wkh Soap and Hand Drying
Devices
6-301.11
Hindwashing Cleanser, Availability
fi-301..1.2
Hand. D h«Provision
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: T- It J& (ve, A Date: bhfi 7 Page; of
Item
No.
Code
Reference
C - Critical Item
R — Red Item�.
DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION`
4
PLEASE PRINT CLEARLY -•
P
Date
Verified
tt �
✓f �� 11/D1S On 116-7 4 v -e
µ:
y
a
0
I
t'
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
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
noncompliance may result in daily fines of t my -five dollars or+suspension/revocation of
our food permit. o
y L. )(L /(��w�
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
❑ Re -inspection cheduled ❑ Emergency Suspension
❑1Em argo ❑ Emergency Closure
O Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors (Items 1-22) (Cont.)
PROTECTION FROM CHEMICALS
la
15
17
18
* Denotes critical item in fila ruderal 1999 Food Code or 105 CMR 590.0100.
N
20
3-501.1
Food or Color Additives
3-202.12
Additives*
3-302.14
Protection from Unapproved Additives*
FC - 2
Poisonous or Toxic Substances
7-101.11
Identifying Information- Original
Cantainers*
7-102.11
Common Name - Working Containers -
7 -201.11
Separation - Suaage"
7-202.11
Restriction - Presence and Use*
7-202.12
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions-
7-204.11
Sanitizers.Criterin- Chemicals'
7-204.12
Chemicals for Washing Produce, Criteria*
7-204.14
Ch��
7-205.11
Incidental Food Contact, Lubricants*
7-206,11
Restricte.dlise Pesticides. Criteria*
7-206.12
Rodent Bait Stations"
7-206.13
Tracking Powders, Pest Control and
Monitoring"
* Denotes critical item in fila ruderal 1999 Food Code or 105 CMR 590.0100.
N
20
3-501.1
" Proper Cooking Temperatures for
Ptff`s Received at Temperatures
According to 1.,aw Cooled to
' I- Within Within 4 Hours.
PHFs
3-401.11A(1)(2)
Eggs- 155'F 1.5 Sec.
�i
FC - 2
Eggs-humediateService 145°F15see*
3-401.11.(A)(2)
Comminuted Fish, Meats & Game
Cold PHFs Maintained at or below
41'/45° F-
*3-SOL
Animals - 155'F I5 sec. *
3 401.11.(B)(1)(2)
Pork and Beef Roast - 130°F 121 min*
3-401.11(A)(2)
Ratites, Injected Meats - 155`17 1.5
Roasts Held at or above 130, F,
Timeas a Public Health Control
sec.
3-401.11(A)(3)
Poultry, Wild Game, Stuffed PRFs,
590.004(H)VaroineeRe
Stuffing Containing Fish, Meat,
FC -6
Poultry or Ratites -165°F 15 sec.
3-401.11(,C)(3)
Whole -muscle, latact Beef Steaks
FC - 7
145°F *
3401.12
Raw Anitnal Foods Cooked in a
Microwave 165'b *
3-401A I(A)(1)(b)
_
All Other PHFs- 145'F 15 sec.
Reheating for Hot Holding
3-403.11(A)&(t))
PHFs 165°F 15 sec. k'
3-403.11(B)
Microwave- 165' F 2 Minute Standing
Time"
3 403.11(C:)
Commercially Processed RTE Food -
14WF
3-403A I(E)
Remaining Unsliced Portions of Beef
Roasts*
Proper Cooling of PHFs
3-501..14(A)
Cooling Cooked PHFs from 140'F to
70'F Within 2 Hours and From 70".F
to 41'F/45'F Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature htgredients to 41"F/45°F
Within 4 Hours`
* Denotes critical item in fila ruderal 1999 Food Code or 105 CMR 590.0100.
N
20
3-501.1
d(C)
Ptff`s Received at Temperatures
According to 1.,aw Cooled to
' I- Within Within 4 Hours.
3-507.15
3-801.11(6)
Comin"Methods for PHFs,
FC - 2
3-801A 1(D)
PHF Hot and Cold Holding
3-5Ot.16(B)
590.004(F)
Cold PHFs Maintained at or below
41'/45° F-
*3-SOL
' -SO 1,
16(A)
Hot PHFs Maintained at or above
140"F *
3-501.16(A)
.005
Roasts Held at or above 130, F,
Timeas a Public Health Control
3-501.19
FC
Time as a Public Health Control*
590.004(H)VaroineeRe
uircmeni
REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801 A I(A)
Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
590.00o
3-801.11(6)
Use ofPaste",IzedEgvs*
FC - 2
3-801A 1(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served *
_ _ _
Food and Food Protection
3-80L 11(C)
Uno ened Food Pucka re Not Re -served,
CONSUMER ADVISORY
22
3-603.7 I
Consumer Advisory Posted for Consumption of
590.00o
23.Manu
Animal Foods That are Raw- Undercooked or
FC - 2
.003
Not Otherwise Processed to Eliminate
_ _ _
Food and Food Protection
FC - 3
Pathogens.*recNverrsooi
25
3-302.13
Pasteurized Eggs Substitute for Raw Shell
.005
26.
E �s"
0f C1L4AL r6C4PCt1I5C1Yt CIV It)
590.009(A) -(D) Violations of Section 590.009(A) -(ll) in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements.
1Mr*]1Fili`TVRM
(.items 23-30)
Critical wel non-critical violations, which do not relate to the
foodborne Illness interventions and risk factors listed above, can be
foatnd nt the following sections of !he Food Code and 105 C12R
590.000.
Item
Good Retail Practices
FC
590.00o
23.Manu
ement and Personnel
FC - 2
.003
24.
_ _ _
Food and Food Protection
FC - 3
.004
25
_ _ _
Equipment and Utensils
_
FC 4
.005
26.
Water, Plumbin and Waste
FC
27.
Physical Facilites_-. _
FC -6
.007
28.
Poisonous or Toxic Materials
FC - 7
.008
29.
Special Re uirements
.009
30
Other
S:5wRennb,d6 21m
a
CITY OF SALEM, MASSACHUSETTS
a s BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR R E E -V-
SALEM, MA 01970
TEL, 978-741-1800 DEC 13 2006
FAx 978-745-0343 CITY OF SALEM
Kimberley Driscoll t WW.SALEM.COM BOARD OF HEALTH
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
TQ ,
NAME OF ESTABLISHMENT ,06(I JS �� eOPG-1�NI Ilt�l C FYP�1 TEL #_ �+9
ADDRESS OF ESTABLISHMENT II10 SS S f 4 S _FAX # -}1:%O--L _�tj _,.--
MAILING ADDRESS (if different)
EMAIL -- Business': Owners:
OWNER'S NAME OW T fTEL #_ W t - 556!4
T
N STa t� III Fir, 0I o�
ADDRESS g2m' SP2t NCa S7. `�Ri� u1 0191+0
STREET CITY STATE r� 2 ZIP
CERTIFIED FOOD MANAGER'S NAME(S)iV r (� A2U�AUS ( CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared) �,, v
EMERGENCY RESPONSE PERSON 'K&T+fEV O {Y�i WW k HOME TEL #
TYPE OF ESTABLIS T / FEEEchecckk on
RETAIL STORE YES NO Jless than 1000sq.ft. C=$.50
1000-10,000sq.ft. $100
more than 10,000sq.ft. =$250
. ... ................. - ...----- --- --.---- - _..... _..... - ......_..--- eaI ---......_.....--
RESTAURANT YE5 NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
- --._.....------ YES .._....NO ..................._.....-----------...--- - ...._ -- -------
..---- --------------
BED78REAKFAST $100
----------- - -----------------_.........................__...... ... ............ ...._.------_.......__...
ADDITIONAL P .RMITS
(
not'ust serve) ICE CREAM, YOGURT, SOFT SERVE YE NO $5
TOBACCO VENGM YES NO �-- o
ALL NON-PROFIT (such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a
prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are
made, all plans for such must be submitted to and approved by the Salem Board of Health,
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief,
have filed all state fa/{7eturns and paid all state taxes required under the law.
/ I- n I I n
Signature D to Social Security or Federal Identification Number
---------------------------------------------- ----------------- - - --- ----------------------- -----
Revised --- -----------
Revised 11/13/06 FOODAP2007.adm V Check# 8 Date
w !✓r. b pF x,120 Washington Street;'4th Floor.
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/19/2006
ESTABLISHMENT NAME:
File Number: BHF -2004-000047
LOCATED AT:
Polonus European Deli & Ice Cream
176 Essex Street
Salem MA " 01970
0176 ESSEX STREET 1
SALEM, MA 01970
Permit Type Permit No.
Permit Issued
Permit Expires
Fee Restrictions / Notes
FROZEN DESSERTS BHP -2007-0096
Dec 19, 2006
Dec 31, 2007
$5.00
RETAIL FOOD BHP -2007-0097
Dec 19, 2006
Dec 31, 2007
$50.00
Total
Fees:
$55.00
PERMIT EXPIRES
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 2 of 2
"'0176 ESSEX STREET 1
Telephone:
740-3203
Owner:
Katnerme MurawSKl 6 twa i
PIC:
Katherine Murawski
Inspector:
David Greenbaum
Date Inspected: Correct By:
11/17/2006
Risk Level:
Permit Number:
BHP -2006-0179
Status:
SIGNED OFF
# of Critical Violations:
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)
Polonus European Deli & Ice Cream
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item
PROTECTION FROM CONTAMINATION
Good Hygienic Practices
Status Violation
PASS Critical
Critical Urgency
RED
Comments: Employees drinks observed in food prep areas. Employees must eat and drink in a designated area or in the dining
area to prevent cross contamination.
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection PASS Critical BLUE
Comments: There is food stored directly on the floor of the store. Store all food at least 6-8 inches off the floor.
There is unwrapped meat stored directly on the shelves of the front deli case. Store meat on deli paper or trays and keep wrapped
when not in use.
There is food stored directly on the Floor of the back walk in. Store all food at least 6-8 inches off the floor.
The back True reach in has unwrapped meat stored sirectly on the shelves. Store meat on deli paper or trays and keep wrapped in
storage.
There is food products stored in the bathroom. Storage of food in a bathroom is prohibited. Store all food in an appropriate
storage area.
Equipment and Utensils PASS Non -Critical BLUE
Comments: The ice cream freezer needs athorough cleaning and defrosting.
The tracks of the deli case have an accumulation of food debris. Thoroughly clean the door tracks.
Physical Facility PASS Non -Critical BLUE
Comments: The bathroom ceiling is in disrepair. Repair or replace the bathroom ceiling.
GENERAL COMMENTS:
990:AII violations cited in the 11/9/06 inspection report have been corrected.
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 17,2006) Page 1 oft
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
Item
Status Violation Critical Urgency
0(�� J"��
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 17,2006 ) Page 2 oft
Gy
0176 ESSEX STREET 1
Telephone:
740-3203
Owner:
Katherine Murawski & Ewa
PIC:
Katherine Murawski
Inspector:
David Greenbaum
Date Inspected: Correct By:
111912006
Risk Level:
Permit Number:
BHP -2006-0179
Status:
VIOLATION
# of Critical Violations:
2
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)
Polonus European Deli& Ice Cream
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item
PROTECTION FROM CONTAMINATION
Status Violation Critical Urgency
Good Hygienic Pr ices FAIL Critical LJ RED
C ment: Employees drinks observed in food prep areas. Employees must eat and drink in a designated area or in the dining area
o prevent cross contamination.
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection FAIL Critical BLUE
C ment: There is food stored directly on the floor of the store. Store all food at least 6-8 inches off the floor.
Th reis unwrapped meat stored directly on the shelves of the front deli case. Store meat on deli paper or trays and keep wrapped
cl_wOhen in use.
ere is food stored directly on the floor of the back walk in. Store all food at least 6-8 inches off the floor.
The ck True reach in has unwrapped meat stored sirectly on the shelves. Store meat on deli paper or trays and keep wrapped in
VrZes
d products stored in the bathroom. Storage of food in a bathroom is prohibited. Store all food in an appropriate
a.
Equipment and tensils FAIL Non -Critical BLUE
Co me The ice cream freezer needs a thorough cleaning and defrosting.
T tracks of the deli case have an accumulation of food debris. Thoroughly clean the door tracks.
Physi al Facility FAIL Non -Critical BLUE
C mentThe bathroom ceiling is in disrepair. Repair or replace the bathroom ceiling.
GENER L COMM:ENTS:
968:11einspection in one week. All violations to be corrected.
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. Nov 09,2006) Page 1 oft
Item
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
Status Violation Critical Urgency
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 09,2006) Page 2 oft
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street, 4th Floor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/03/2006
WHO'S PLACE OF BUSINESS IS:
File Number: BHF -2004-0047
LOCATED AT:
Polonus European Deli & Iee Cream
176 Essex Street
Salem MA 01970
0176 ESSEX STREET 1
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
FROZEN DESSERTS BHP -2006-0180 Jan 3, 2006 Dec 31, 2006 $5.00
RETAIL FOOD BHP -2006-0179 Jan 3, 2006 Dee 31, 2006 $50.00
PERMIT EXPIRES
Total Fees: $55.00
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all
plans for such must be submitted to and approved by the Salem Board of Health. Page 4 of 10
I
CITY OF SALEM, MASSACHUSETTS
ll �i
BOARD OF HEALTH gc
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 DEC 2 9,2005
TEL. 978-741-1800
FAx 978.745-0343
wW W.SALEM.COM
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
CITY OF SALEM
BOARD OF HE
ALfiH
2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT DIODU. Jl Prti JiYAa 'r�va 1 TEL#_ q„ 52- }
ADDRESS OF ESTABLISHMENT l �I& C SSF-X ST tS (t l 0l9 aq� Q
MAILING ADDRESS (if different)
�(iTH�PIN,E 1t'JtJ1�f�tIS)=f
OWNER'S NAMETEL#
ADDRESS � � lUGrJ ���� JT' L-YN N / Mfl, Gly'G✓r
S r r/ tv S r S Ln1, rtlt? Cil
CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) 44ITI-fr hir P, jPA0 WCERTIFICATi
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSONEwA Jl-1MPo? HOME TEL QjJ
HOURS OF OPERATION: Mon.C'LOki7Tue.Io_+{ Wed. 10-4 Thu. /o- Fri.l�at. t�Sun. /0 --
TYPE oF_ESTABLISHME
CRETAIL-STOREJ ES NO
----- --- ---- ---------------- --------••..........
..- ...-------•-----••-------
RESTAURANT YES NO
_...... - ------------- ---------N6
BED/BREAKFAST YES NO
FEE (check only)
less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
less than 25 seats =$i 00
25-99 seats =$150
more than 99 seats =$200
$100
..... .... .... ........•• - ...... ....... .... ........ -.......
-... .... -
ADDITIONAL_PERMITS:
MAKE (not just serve) -ICE CREAM; YOGURT SOFT SERV X70 $5
TOBACCO VENDOR --`� YES NO $50
ALL NON-PROFIT (such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem .
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes
are made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best
knowledge and beXf, have filed all state tax returns and paid all state taxes required under the law.
Social Securitv or
-----------------------------------------------------------------------------------------------------------------------
Revised 11/03/05 FOODAP2.adm Check# & Date���, la -d -a5'
S Us'
STANLEY J. USOVICZ, JR.
MAYOR
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Polonus European Deli & Ice Cream
Address of Establishment: 176 Essex Street
Owner's Name: Katherine Murawski & Ewa Jamroz
Restrictions:
Application Date: 12/01/2004
Permit for Food Establishment 109-05
Frozen Desserts/Ice Cream 003-05
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, MASSACHUSE
.� BOARD OF HEALTH t�j#,
- 120 WASHINGTON STREET, 4TH FLOOR
S SALEM, MA 01970
TEL. 978-741-1800 NOV 3 0 2004
FAX 978-745-0343
STANLEY J. USOVICZ, JR.JOANNE SCOTT, MPH, RS, CHO CITY OF SALEM
MAYOR - HEALTH AGENT BOARD OF HEALTH
2005 APPLICATION
��FOR
rr��PERMIT 1T,��O� �/O�P��EERATE A FOOD ESTABLISHMENT
2 � �,
NAME OF ESTABLISHMENT7'(�A L WVXJf'EAN rFQ TEL # 97 7q� �/3
ADDRESS OF ESTABLISHMENT ISE ESSt.X ST- S07LFM I Pi Ofq?
MAILING ADDRESS (if different)
15�75
OWNER'S NAM 5 tZ TEL # '75 t1cI5SOyu-w 94q56
ADDRESS 13 S ,0 W8 ST.SS46;C 11 N(Y)A 0f(5)7ci
CITY_ STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(SKIiI�IEPJNE hl (7 CERTIFICATE#(s)= .
(required in an establishment where potentially hazardous
Ufood is prepared.)
EMERGENCY RESPONSE PERSON � TA?f1(C E7C� HOME TEL #�
HOURS OF OPERATION: Mon. ue.10:�f _Wedjq::� Thu. A04 Fri. 10-6 Sat. 10-6 Sun. 10-3
TYPE OF ESTABLISHMENT 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 NO , b ,4 less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS //
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE XQ NO $5
TOBACCO VENDOR ()6.3-25 YES NO $50
ALL NON-PROFIT (such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Date
Revised 11/03/03 FOODAP2.adm Check# &
Social Securitv or Federal Identification Number
cQ+/11 v d �1r2,�Ze�S
Vol
Ca00i'42 s
s
STANLEY J. USOVICZ, JR.
MAYOR
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Polonus European Deli & Ice Cream
Address of Establishment: 176 Essex Street
Owner's Name: Katherine Murawski & Ewa Jamroz
Restrictions:
Application Date: 12/11/2003
Permit for Food Establishment 162-04
Frozen Desserts/Ice Cream 007-04
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
F CITY OF SALEM, MASSACHUSETT {SSV e ( I)
V .� �"'
"� '� BOARD OF HEALTH
3 120 WASHINGTON STREET, 4TH FLOOR DEC 4 -2003a SALEM, MA 01970
4 TEL. 978-741-1800 CITY OF SALEM
Fax 978-745-0343
STANLEY USOVICZ, JR. -JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH
MAYOR HEALTH AGENT
2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT TOLONOS ,� ICo �TE°L"# qI9 ?903203
ADDRESS OF ESTABLISHMENT I70 1_SSth� STSlq w M p O/ /c J
MAILING ADDRESS (if different) _
OWNEF
CITY SIAIL LIF
CERTIFIED FOOD MANAGER'S NAME(S} 11(ti&1?jFlt" N1Q_0gJ3L CERTIFiCATE#(s) d2a.2-.
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON 1C4T /F Rf/Yff M01e94JSL'( HOME TEL # 7915CJE 057 -
HOURS OF OPERATION: Mon.—Tue.lD"I Wed.JD' 'Thu./0-6 Fri. �Sat.ry 4'Sun.10-
TYPE OF ESTABLISH ME
FEE check only
RETAIL STORE E NO
less than 1000sq.ft.
=$ 50
1000-10,000sq.ft.
=$100
O
more than 10,000sq.ft.
=$250
RESTAURANT YES NO
less than 25 seats
=$100
25-99 seats
=$150
more than 99 seats
=$200
BED/BREAKFAST YES NO
$100
PERMITS
ADDITIONAL
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE
<a NO
$5
TOBACCO VENDOR
YES NO
$50
ALL NON-PROFIT (such as church kitchens)
YES NO
$25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Revised 11/03/03 FOODAP2.adm Check#&
��j,s
Number
i
Massachusetts Department of P
Division of Food and Drugs
FOOD ESTABLISHMENT' INSPECTION REPORT
ublic HealthSalem Board of Health
`i20 Washington Street; 4 th Floor
Salem; MA 01970=3523 P,,A ,
Tel. (978) 741-.1800 Fax (978) 745-0343
Name .
Date
T e of O eration(s)pjof
Inspection
Food Service
❑ Retail❑
[TI Routine
Re inspection'
/ 22/i 5 �r L
A 3 /- Ori
Address '
176ES
Risk
FX
Telephone /
Level
❑ Residential Kitchen
Previous Inspection
❑Mobile
[_1 Temporary
Date:q_y.G9
E]Pre-opera"
Owner
HACCP YM
Pi e /7%a i T n7 N L
El Caterer
❑ Bed & Breakfast
❑Suspect Illness
❑ General Complaint
Person in Charge (PIC)
Time
wa
In.
Out:
Permit No.
El HACCP
E] Other
Inspector l % Oil Tia f L S
• Wa.V11 WnWUncU rryUnrs an expiananon on me 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.
.l. FOOD PROTECTION MANAGEMENT
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH ._. - _..".. .m...�_.. _.. .... ,.
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE `.. sm "`
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
PROTECTION FROM CONTAMINATION'
❑ 8. Separation/ Segregation/ Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices
Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Non-critical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C ., -N,'
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protection (FC -3)(590.004)
25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
27. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.008)
EE29. Special Requirements (590.009)
30. Other
s: 5X',,WFo m -ia m
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
[119. Hot and Cold Holding
❑ 20. Time As a Public Health Control
REQUIREMENTS FOR HIGHLY. SUSCEPTIBLE POPULATIONS (HSP)
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY,
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions
and Risk Factors (Items 1-22): U
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/federal Food Code. -This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE -INSPECTION:
Insp ' Sig atur Print:
PIC's Signature:/Print: L` 7 / 1 !)) 2 PageJ- of -c2 -Pages
i L 7
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) I Assignment of Responsibility'
590.003(6) Demonstration of Knowledge"
2-103.11 Person in charge - duties
EMPLOYEE HEALTH
2
590.oW(C)
Responsibility of the person in charge to
Compliance with Food Law''
3-201.12
require reporting by food employees ar d
3-201.13
Fluid Milk and Milk Products*
applicants,*
Shell Eggs*
590.0031,F)
Responsibility Of AFood Employee Or An
3-202.16
'Ice Made From Potable Drinking Water*
Applicant To Report'ro The Person In
Drinking Water from an A roved System*
590.006(A)
Charge*
590.006(B)
590.0(13 G)
Reporting by Person in Charge*
3
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
4
In
6
Fjr@j#Tjjg,75j9♦ ♦
_
Food and Water From Regulated Sources
590.004(A-6)
Compliance with Food Law''
3-201.12
Foal in a Hermeticall • Seated Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.14
Eggs and Milk Products, Pasteurized"
3-202.16
'Ice Made From Potable Drinking Water*
5-1.01.11
Drinking Water from an A roved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0*
Washln Fruits and Ve.*stables
Sheitfwh and Fish From an Approved Source
3-201.14
Fish and Reerearionally Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources"
Contamination from the Consumer
Game and Wild Mushrooms Approved by
Re ulato Aufhorit
3-202.18
Shellstock. Identification Present*
590.004(0)
Wild Mushrooms*
3-20117
Game Animals*
3-701.11
Receiving/Condition
3-202.11.
PHF's Received at Pro er Tem eratures"
3-202.15
Package hue it v*
3-101.11
Food Safe and Unadulterated
Tags/Records: Sheilstock
3-202.18
Shellstock Identification *
3-203.12
Shellstockidentification Maintained*
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records. Creation and Retention*
550.0040)
Labeling of Ingredients'
Frequency of Sanitization of Utensils and
Food Contact Surfaces of E ui ntent*
Conformance with Approved Procedures
/HACCP Plans
3-502.11
1 Specialized Processing Methods*
3-50212
Reduced oxygen packaging, criteria*
8-103.12
Conformance with Approved Procedures*
* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
g
Cross -contamination
3-302.11(A)(1)
Raw Animal Fords Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-30111(A)(2)
Raw Animal Foods Separated from Each
Other"
Contamination from the Environment
3-302.11(A)
Food Protection*
3-302.15
Washln Fruits and Ve.*stables
3-304.11
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discardmg or Reconditioning Unsafe
Food"
9
_
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Teat eratures*
4-501.112
-
Mechanical Warewashina Hot Water
Sanitization Temperatures*
4-501..114
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-601.11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency ofEcluipmentFood-
Contact Surfaces and Utensils's
4-702.1 t
Frequency of Sanitization of Utensils and
Food Contact Surfaces of E ui ntent*
4-703.11
Methods of Sanitization- Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2401.11
Eating, Drinking or Using "robawo*
2-401.12
Discharges ,From the Eyes, Nose and
Mouth*
3-301..12
Preventing Contamination When Tastin *'
12
Prevention of Contamination from Hands
590.004(F)
Preventing Contamination from
Em to ees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
Accessibility. Operation and Maintenance
Supplied wrfh Soap and Hand Drying
Devices
6-301.11
Handwa4drig Cleanser, Availability
6-301.12
Hand Drying Provision
ITY OF SALEM
BOARD OF HEALTH
Establishment Name: do-241pt's J%L✓ Date:-----,? .3 /-67 1/ Pago: of 2—
Item
No.
Code
Reference
C - Critical Item
R - Red Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
PLEASE PRINT CLEARLY
Date
Verified
P061-17,11c.
P �/ff, G o'ee& — fay/ / _'yr s -/a t /— /
s-
2S
/�s Pac/ — , of ° /s
d
Q 7 lei o
2 -r—
ye oU�
r
.. LIiGiS� "VC
t cv cl
s/ z/n9,
lP � lL f
biscussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
inspection, to observe all conditions as described, and to
violations before the next ins P
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
your food permit.
`_�qa
/
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
LI Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors (items 1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
5
16
17
18
•
Food or Color Additives
3-202.12
Additives"
3-302.14
Protection frontUnar>roved Additives"
3-501.16(B)
590.004(F)
Poisonous or Toxic Substances
7-101.11
Identifying Information - Original
Containers*
7-102.11
CommonName- Working, Containers'
7-201.1.1
Separation - Stora *e"
7-20211
Restriction -Presence and Use*
7-202.12
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Srmitizers. Criteria -Chemicals*
7-204.12
Chemicals for Washin * Produce. Coterie -
7 -20t.14
Drying Agents, Criteria*
7-205.11
Incidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria -
7 -206.12
Rodent Bait Stations"`
7-206.13
Tracking Powders, Pest Control and
Monitoring,"
•
* Denotes crfficat item in ihefederal 1499 Food code or 105 C0IR 590.000.
1
3-501,14(C)
Proper Cooking Temperatures for
3-501.15
PHFs
3-401.11A(1)(2)
Eggs- 155'F 15 Sec.
3-501.16(B)
590.004(F)
Eees- Immediate Service 145'Fl isecl,
3401,11(A)(2)
Comminuted Fish. Meats & Game
3-501.16(A) I
Animals - IWF 15 sec. *
3-401.11(8)(1)(2)
Pork and ;Beef Roast - 1.30"F 121. min*
3-401A l(A)(2)
Ratires, Injected Meat, - 155°F 15
590.004(4)
sec.
3-401.11(A)(3)
Poultry, Wild Game. Stuffed PHFs,
.008
009 -..
Stuffing, Containing Fish, Meat,
Poultry or Ratites -165'F 15 sec.
3-401.11(C)(3)
Whole-musele,intact Beef Steaks
145°F *
3-401.12
Raw Anhnal Foods Cooked in a
65°F
Microwave 165'1-
3
3-401.11.(A)(1)(b)
Ail Other PHFs -'145'F15sec.
Reheating for Hot Holding
3-403,1.1(A)&(D)
PFIFs 165'F 15 sec. s
3403.11(13)
Microwave- 165' F 2 Minute Standing
Time*
3-403.11(0)
Commercially Processed RTE Food -
140°F*
3-403.11(E)
Remaining Uosliced Portions of Beef
Roasts*
Proper Cooling of PHFs
3-501.14(A)
Cooling Cooked PFIFs from 140'F to
70"F Within 2Hours and From 70°F
to 41"F/45°F Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41"F/45'F
Within 4 Hours*
* Denotes crfficat item in ihefederal 1499 Food code or 105 C0IR 590.000.
1
3-501,14(C)
PHFs Received at Temperatures
According to law Cooled to
4I'F/45'F Within 4 Hours.
3-501.15
Cooling Methods for PHFs
3-80 Li 1(B)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold PRFs Maintained at or below
41/45° F*
3-501.16(A)
Hot PHFs Maintained atorabove
140`F,
3-501.16(A) I
Roasts Held at or above '130°F.
---
26 W ate m -Plumb nq and Waste
Time as a Public Health Control
3-501.19
Time as a Public Health Control'
590.004(4)
Variance Recuhernent
t•
t
21.
3-801.11(A)
Unpasteurized Pre-packaged .Juices and
Beveraees with Warning t-abels*
23. Management and Personnel
3-80 Li 1(B)
Use of Pastern ized Ems*
24 Food and Food Protection
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served.
25,
3-801.1.1(C)
Uno. erred Food oi kc -served.
22
3-603.11.
Consumer Advisory Posted for Consumption (if'
23. Management and Personnel
FC -2
Animil Foods That are Raw. Undercooked or
24 Food and Food Protection
FC 3
Not Otherwise Processed to Eliminate
25,
Pathogens,=err 'r-ezmr
---
26 W ate m -Plumb nq and Waste
3-302.13
Pasteurized Eggs Substitute for Raw Shelf
27. Phnisical Facilit
FC -6
E., .s*
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under#29 -
Special Requirements.
RFTAII PRACTICES
(Items 23-30)
Critical and non-critical violations, which do not rotate to the
foodborne illness interventions and risk factaa listed above, can be
found in thefollowing sections of the Food Code and 105 CMR
590.0(10.
Item Good Retail Practices
FC
590.000
23. Management and Personnel
FC -2
.003
24 Food and Food Protection
FC 3
004
25,
5�
---
26 W ate m -Plumb nq and Waste
FC 5
0 06
27. Phnisical Facilit
FC -6
.007
28_' Poisonous or Toxic Materials
F29 Special Requirements
- - ----
FC 7
.008
009 -..
-
30 Other _.._
o CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
e 120 WASHINGTON STREET, 4TH FLOOR
Pa. SALEM, MA 01970
s TEL. 978-74 1-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT. MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter
94, Section 305A and Chapter III, Section 5 of the General Laws, to operate
a Food Establishment in the City of Salem is hereby granted to:
Owner's Name: Katherine Murawski & Ewa Jamroz
Name of Establishment: Polonus European Deli & Ice Cream
Address of Establishment: 176 Essex Street
Type of Establishment: FOOD SERVICE
Application Date: 12/30/2002
Restrictions:
Permit for Food Establishment 159-03
Frozen Desserts/Ice Cream 10-03
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2003
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code,.before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTSO (� ��
BOARD OF HEALTH f` ' II
g ° 120 WASHINGTON STREET, 4TH FLOOR DEC
SALEM, MA 01970 2 0 2002
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR, JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT tl L/(,Ul'lJJ C/,AVLA"tft NA)rLLI`FEL#
ADDRESS OF ESTABLISHMENT 17,6 ESS' � ST SM I M -A . 01 Q 7
MAILING ADDRESS (if different)
1 (i8t� 6 057
OWNER'S NAME i *T+fC-ef l e -f4 1�L JY4 C,.NA TPP��?L TEL #rq ig) 7YAr-55�(.
of
ADDRESS � SPt2iPrC"S SF}(FntiN mil , 0 (' f 70
CITY _ STATE._,__ ZIP_
CERTIFIED FOOD MANAGER'S NAME(S)KA--JIEi?r(Ji f1yQ4W9ePCERTIFICATE#(s) _YL.2X
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON th f 4feel(A 5- IvIU eA W Sif,( HOME TEL #fl—ek-Ct 57'�-
HOURS OF OPERATION: Monr f'ue.(O-Lh Wed. to -Lf Thu. )D-6 Fri. 2:& Sat. (4"6 Sun.(0-4-
TYPE OF ESTABLISHM
RETAIL STORE NO
/--3-
�1-631
RESTAURANT YES NO
ADDITIONAL PERMITS �
MAKE ICE CREAM, YOGURT, SOFT SERVE 'l�-�.�/
TOBACCO VENDOR YES
ALL NON-PROFIT (such as church kitchens) YES
FEE check only
less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than I0,000sq.ft. =$250
less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
$100
NO b.o 3 $5
NO $50
NO $25
Please pay total with one cheek
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 1, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
THE COMMONWEALTH OF MASSACHUSETTS
CITY OF SALEM
BOARD OF HEALTH
FOOD ESTABLISHMENT INSPECTION REPORT.
Address: 120 Washington Street, 4th Floor
Salem, MA 01970-3523
Tel: (978) 741-1800 Fax: (978) 745-0343
NameTvoe
_Ib�'
Dae r;Zj
of Ooeration(s)
g Food Service
ElRetail
❑Residential Kitchen
❑Mobile
❑ Temporary
❑ Caterer
ElBed & Breakfast
Permit No.
Type of Inspection
rN r-� Routine
ElRe-inspection
Previous Inspection
Date:
❑ Pre-operation
❑ Suspect Illness
❑ General Complaint
[7HACCP
❑ Other
Address/, /
(fi V
Risk
Level hA
Telephone 4"'7SJ - _ Y���
v J
Owner
HACCP Y/N
Person in Charge (PIC)Time
/
In:
Out:
Inspector
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
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted / Excluded
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source
❑ 5. Receiving / Condition
❑ 6. Tags / Records / Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures / HACCP Plans
PROTECTION FROM CONTAMINATION
❑ 8. Separation / Segregation / Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices (Blue
Items) Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Non-critical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C N
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protection (FC -3)(590.004)
25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
27. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.008)
29. Special Requirements (590.009)
30. Other
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16.
Cooking Temperatures
❑ 17.
Reheating
❑ 18.
Cooling
❑ 19.
Hot and Cold Holding
❑ 20.
Time as a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions
and Risk Factors (Red Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/Federal Food Code. This report; when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE -INSPECTION:
Inspector's Signat re: - - �/� `^ C
Print:
PIC's Signature: ( A r p i �1
hLt
Print:
Page / ofzPages
r -
FORM 734A HOBBS a WARREN - BOSTON
7
Violations Related to Foodborne Illness
Interventions and Risk Factors (Red Items 1-22)
FOOD PROTECTION MANAGEMENT
11] 590.003(A) Assignment of Responsibility*
590.003(B) Demonstration of Knowledge*
2-103.11 Person in Charge - Duties
EMPLOYEE HEALTH
4
5
I
FOOD FROM APPROVED SOURCE
590.003(C)
Responsibility of the Person in Charge to
Compliance with Food Law*
3-201.12
require reporting by Food Employees and
3-201.13
Fluid Milk and Milk Products*
Applicants*
Shell Eggs*
590.003(F)
Responsibility of a Food Employee or an
3-202.16
Ice Made from Potable Drinking Water*
Applicant to Report to the Person in
Drinking Water from an Approved System*
590.006(A)
Charge*
590.006(B)
590.003(G)
Reporting by Person in Charge*
r.`3:`'
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
4
5
I
FOOD FROM APPROVED SOURCE
* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
9
10
PROTECTION FROM CONTAMINATION
Food and Water From Regulated Sources
590.004(A-9)
Compliance with Food Law*
3-201.12
Food in a Hermetically Sealed Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.14
Eggs and Milk Products, Pasteurized*
3-202.16
Ice Made from Potable Drinking Water*
5-101.11
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0*
Shellfish and Fish From an Approved Source
3.201.14
Fish and Recreationally caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
4-501.111
Game and Wild Mushrooms Approved by
Regulatory Authority
3.202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
4-602.11
Receiving/Condition
3-202.11
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated*
3-202.18
Tags/Records: Shellstock
Shellstock Identification*
3-203.12
Shellstock Identification Maintained*
2-301.14
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(J)
Labeling of Ingredients*
3-301.12
Conformance with Approved Procedures
/HACCP Plans
3-502.11
Specialized Processing Methods*
3-502.12
Reduced Oxygen Packaging, Criteria*
8-103.12
Conformance with Approved Procedures*
* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
9
10
PROTECTION FROM CONTAMINATION
Cross -contamination
3-302.11(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-302.11(A)(2)
Raw Animal Foods Separated from Each
Other*
Contamination from the Environment
3-302.11(A)
Food Protection*
3-302.15
Washing Fruits and Vegetables
3.304.11
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing - Hot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization - temp., pH,
Concentration and Hardness*
4-601.11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*
4-702.11
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization - Hot Water and
Chemical*
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
Good Hygienic Practices
2-401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventing Contamination When Tasting*
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Employees*
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11
Handwashing Cleanser, Availability
6-301.12
Hand Drying Provision
BOARD OF HEALTH
Establishment Name:�Date: Uv Page: of Z
Item
No.
Code
Reference
C - Critical Item
R — Red Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
PLEASE PRINT CLEARLY
Date
Verified
-
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
inspection, to observe all conditions as described, and to
violations before the next ins p
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
your food permit.
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
Ll Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal 0 Other:
Violations Related to Foodborne IUness interventions and Risk
Factors (items 1.22) (Cont.)
PROTECTION FROM CHEMICALS
14
15
in
r
Food or Calor Additives
3-202.12
Additives*
3-302.1.4
Protection from Una roved Additives"
3-501A6(B)
590.004(F)
Poisonous or Toxic Substances
7-161.11
&lcntrfying Information - Original
Containers"
7-102.11
Common Narno - Working Containers"
7-201 11
1 Separation - Storage"
7-202.11
Restriction - Presence and Use*
7-202.12
Conditions of Use,
7-20311
7-204.11
7-204.12
7-204.14
'Toxic Containers - Prohibitions"
Sanitizers.Criteria- Chemicals*
Chemicals for Washin> Produce. Criteria*
Drying Agents_ Criteria*
7-205,11
Incidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria"
7206.1.2
Rodent Bait Stations*
7-206.13
Tracking Powder, Pest Control and
Monitorine"
r
* Denote, critical hent in the federal 1999 Food Code or 105 CtriR 590.000.
19
20
3-SOL'14(C)
Proper Cooking Temperatures for
3-501.15
PHFs
3-401.11A(l)(2)
Eggs- 155"F 15 Sec.
3-501A6(B)
590.004(F)
Eggs- Immediate- Service 145'F15sec*
3-401.1 1(A)(2)
Comminuted Fish. Meats & Game
3-501.16(A)
Puninals - 155`'':F 15 sec.
3-401.11(B)(1)(2)
Pork and Beef Roast - 130°F 121 ~nut"
3-401.11(A)(2)
Ratites, Injected Meats - 1.55'F 15
59Q.004(H)
sec, *
3-401.11(A)(3)
Poultry, Wild Game. Stuffed PHFs,
equirsmarts
Stuffing Containing Fish, Meat,
.009
Poultry or Ratites -165'F 15 sec,
3-401,1 t(C)(3)
Whole -muscle, Intact Beef Steaks
145'F "
3-401..12
Raw Animal Foods Cooked in a
Microwave 165°F"
3-401.11(A)(1)(b)
All Other PHFs - 145'F 15 sec.
Reheating for Hot Holding
3-403.11(A)&(D)
PFIFs 165'F 15 sec. *
3-403.11(B)
Microwave- 165' F 2 Minute Standing
Time*
3-4031l(C)
Commercially Processed RTE Food -
140'F°
3-4031 I (E)
Remaining Unsficed Portions of Beef
Roasts"`
Proper Cooling of PHFs
3-501,14(A)
Coaling Cooked PHFs from 140'F to
70'F Within 2 Hours and Froin 70'F
to 41"F/45'F Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made Flom Ambient
Temperature Ingredients to 41'F/45'F
Within 4 Hours*
* Denote, critical hent in the federal 1999 Food Code or 105 CtriR 590.000.
19
20
3-SOL'14(C)
PHFs Received of Tetnper<ttmes
According to Law Cooled to
4'1"F/45"F Within 4 Hours.
3-501.15
Coolie t Methods for PHFs
3-801.11(B)
PHF Hot and Cold Holding
3-501A6(B)
590.004(F)
Cold PlfFsMaintained atorbelow
41°145' Fa
3-501.16(1)
Hot PHFs Maintained at or above
140'F..*
3-501.16(A)
Roasts Held at or above 130°F. '0
'.. Physical Facility
Time as a Public Health Control
3-501.19
Timee as a Public Health Control*
59Q.004(H)
PariancoRecunzment
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801.11(A)
_
Unpastcurizzd Pre-packaged Juices and
Beveraees with Warning' Labels*
Animal Foods That are Raw. Undercooked or
3-801.11(B)
Use of Pasteurized Eg-s*
'', FC -2
3-801.1.1(D)
Raw of Partially Cooked Animas Food and
Raw Seed Sprouts Not Served. *
Pasteurized Eggs Substitute for Raw Shell
3-801.1.1(C)
Unopened Food Pucka >e Not Re -served.
CONSUMER ADVISORY
22 3-603.11
Consumer Advisory Posted for Consumption of
'.. FC
Animal Foods That are Raw. Undercooked or
j.. 23,
Not Otherwise Processed to Eliminate
'', FC -2
Pathogens.* ""'`goo,
3-302.13
Pasteurized Eggs Substitute for Raw Shell
.004
005
006 J
27.
A) -(D) I Violations of Section 590.009(A) -(I)) in
catering, mobile 1'aod, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors-. Other
590.009 violations relating to good retail
practices should be dabited under #d29 -
Special Requirements.
VIOLATIONS
(Items 23-30)
Critical and ~ton -critical violations, which do not relate to the
foodborne illness interventions and risk {actors listed above, can be
,/hand in the following sections of the Food Code and 105 CMR
590.000.
Item
Good Retail Practices
'.. FC
590.000 i
j.. 23,
IF_Managemeni and Personnel
'', FC -2
.003
24 Food and _Food Protection
25 ----- 1 E ui ment and Utensils _ - _.
�p
26. Water. Plumbin and Waste
FC - 3
- i,_FC 4
FC -5
.004
005
006 J
27.
'.. Physical Facility
'.. FC -6
.007
1_28
Poisonous or Toxic Materials
FC -7
.008
equirsmarts
_
.009
a,..d,n.,.,,JrpH�.`«"+ti,,,::�u�,,,,,,,.+..i:2R�.�`ib-+.�"w�a�"aFTRY"Ytp+ ,,.,:..r•.,-.v+'..i-t �.�Mt^^"„*+-y,,.,,-'w, :.. ,
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
a 6 C_/
❑ 17.
Reheating
Date
? // 63
Type of Oloeration(s)
Food Service
Retail
L1 Residential Kitchen
Ll Mobile
El Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
Type of Inspection
❑ Routine
ElRe-inspection
Previous Inspection
Date:
ElPre-operation
❑ Suspect Illness
❑ General Complaint
❑ HACCP
ElOther
Address / - - 's -a -
(�j
Level /a n
j'(//
Telephone
(O- lO
Owner / Jr7�a✓ 7 /� `
HACCP YIN
Person In Charge (PIC)/
Time
In:
Out:
Inspector
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
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted / Excluded
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source
❑ 5. Receiving / Condition
❑ 6. Tags / Records / Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures / HACCP Plans
PROTECTION FROM CONTAMINATION
❑ 8. Separation / Segregation / Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices (Blue
Items) Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Non-critical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C N
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protection (FC -3)(590.004)
25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
27. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.008)
29. Special Requirements (590.009)
30. Other
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16.
Cooking Temperatures
❑ 17.
Reheating
❑ 18.
Cooling
❑ 19.
Hot and Cold Holding
❑ 20.
Time as a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions
and Risk Factors (Red Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/1'ederal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE -INSPECTION:
Inspector's Signature:
Print: l i 1/
`v 'I
1 / L / x _.
PIC's Signature:
Print: `` ,, `�
at,��i
Page / of C'7
-_Pages
FORM 734A HOBBS & WARREN -BOSTON
Violations Related to Foodborne Illness
Interventions and Risk Factors (Red Items 1-22)
FOOD PROTECTION MANAGEMENT
1P. 590.003(A) Assignment of Responsibility*
590.003(B) Demonstration of Knowledge*
2-103.11 Person in Charge - Duties
EMPLOYEE HEALTH
2•:
590.003(C)
Responsibility of the Person in Charge to
Compliance with Food Law*
3-201.12
require reporting by Food Employees and
'
Fluid Milk and Milk Products*
Applicants*
Shell Eggs*
590.003(F)
Responsibility of a Food Employee or an
3-202.16
Ice Made from Potable Drinking Water*
Applicant to Report to the Person in
Drinking Water from an Approved System*
590.006(A)
Charge*
590.006(B)
590.003(G)
Reporting by Person in Charge*
3i'
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
4,,
5
6;
FOOD FROM APPROVED SOURCE
• Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
8
9:
all
PROTECTION FROM CONTAMINATION
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Food in a Hermetically Sealed Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.14
Eggs and Milk Products, Pasteurized*
3-202.16
Ice Made from Potable Drinking Water*
5-101.11
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0*
Shellfish and Fish From an Approved Source
3.201.14
Fish and Recreationally caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
4-501.111
Game and Wild Mushrooms Approved by
Regulatory Authority
3.202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
4-602.11
Receiving/Condition
3-202.11
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated*
2-301.11
Tags/Records: Shellstock
3-202.18
Shellstock Identification*
3-203.12
Shellstock Identification Maintained*
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(7)
Labeling of Ingredients*
Conformance with Approved Procedures
/HACCP Plans
3-502.11
Specialized Processing Methods*
3-502.12
Reduced Oxygen Packaging, Criteria*
8-103.12
Conformance with Approved Procedures*
• Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
8
9:
all
PROTECTION FROM CONTAMINATION
Cross -contamination
3-302.11(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-302.11(A)(2)
Raw Animal Foods Separated from Each
Other*
Contamination from the Environment
3-302.11(A)
Food Protection*
3-302.15
Washing Fruits and Vegetables
3.304.11
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing - Hot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization - temp., pH,
Concentration and Hardness*
4-601.11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*
4-702.11
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization - Hot Water and
Chemical*
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
Good Hygienic Practices
2-401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventing Contamination When Tasting*
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Employees*
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.1 I
Handwashing Cleanser, Availability
6-301.12
Hand Drying Provision
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: , JiZo-�_ c/S Di -fl- Date: / �� ��� Page:_ of f
Item
No.
Code
References
C - Critical Item
R - Red item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
- -
-- PLEASE PRINT CLEARLY ---
Date
Verified
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
violations before the next inspection, to observe all conditions as described, and to
P
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
your food permit.
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
EI Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal 0 Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors (items 1-22) (Cant.)
lti
Food or Color Additives
3-202.12
3-302.14
Additives*
Protection from Unapinroved Additives's
Poisonous or Toxic Substances
7-101.11
Identifying Information - Original
Contamers'K
7-102.11
7-201.1.1
7-20111
Common Natne - Working Containers''
Se _ arahon - Stora e"` __
Restriction - Presence and Ilse*
7-202.12
Conditions of Usc*
7-203.1 1
Toxic Containers - Prohibitions*
7-204.11
Sanitizers. Criteria -Chemicals^
7-204.12
Chemicals for Washing Produce.Criteria*
7-204.14
7-205.11
Diving A zits. Criteria'*
Incidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria*
7-206.12
Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Mori tonne*
lti
PHFs Received at Temperatures
Proper Cooking Temperatures for
According to Law Cooled to
PHFs
3-501.15
3-401.1IA(1)(2)
Eggs- 155'F 15 Sec
PHF Hot and Cold Holding
3-501.16(B)
&a�.s- Immediate Service 145'Fl.5sec*
590.004(1
3-401.1(A)(2)
Comminuted Fish. ,Meats & Game
Hot PRFs Maintained at or aboee
.Animals - 155"T 15 sec. *
;-501.16(A)
3-401.11(13)(1)(2)
Pork and Beef Roast - 1.30'F 12l min*
Time as a Public Health Control
3-401.11(A)(2)
Ratites, Injected Meats - 1.55'F 15
590.004(4)
Val" lance Ra Uit'ernellt
sec. 'r
3-401.11(A)(3)
Poultry, Wild Game. Staffed PHFs,
Stuffing Containing Fish, Meat,
Poultry or Ratites -165°F 15 sec.
3-401.1 i(C)(3)
Whole -muscle. Intact Beef Steaks
145'F *
3-401.12
Raw Animal Foods Cooked in a
Microwave 165'F *
3-401.11(A)(I)(b)
All Other PHFs - 145'F 15 see.
I7
Reheating for Hot Holding
3-403.11(A)&(D)
PHFs 165`F 15 sec. *
3-403.11($)
Microwave- 165' F 2 Minute Standing
Time`
3-401.1.1(C)
Commercially Processed RTE Food -
140-F*
3-403.1 I(E)
Remaining Unsliced Portions of Beef
Roasts*
Ig
Proper Cooling of PHFs
3-501.14(A)
Cooling Cooked PHFs from 140'F to
70'F Within 2 Hours and From 70'F
to 41'F/45°F Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41'F/45'F
Within 4 Hours*
x Denotes critical firm in the tederal 1999 Food Code or I0S CMR 590.000.
4
3-501.14(C)
PHFs Received at Temperatures
Consumer Arlvisory Posted for Consumption of
According to Law Cooled to
41'F/45'F Within 4 Hours,
3-501.15
Cooling Methods for PHFs
19
PHF Hot and Cold Holding
3-501.16(B)
Cold PHFs Maintained at or below
590.004(1
41'/45° F*
3-501_ 16(A)
Hot PRFs Maintained at or aboee
14WIz *
;-501.16(A)
Roasts Held at or above 130'F.
20
Time as a Public Health Control
3-501.19
Time as a Public Health (ontroPs
590.004(4)
Val" lance Ra Uit'ernellt
21
3-&)1.11(A) Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
Consumer Arlvisory Posted for Consumption of
3-901.11(B) Use of Pasteurized &*as*
3-801.11(D) Raw or Partially Cooked Animal Food and
Raw Seed S iotas Not Served. *
3-801.11(C) Uno. erred Foorl Package Not Re -serval.
CONSUMER ADVISORY
22
3-603.11
Consumer Arlvisory Posted for Consumption of
.Animal Foods'I'Itat are Raw, Undorcmoked or
Not Otherwise Processed to Eliminate
Padrogens.* `_,:vzoo.-
3-302.13
Pasteurized Eggs Substitute for Raw Shell
k?ooS'
SPECIAL REQUIREMENTS
590.009(A) -(l)) Violations of'Section.590.009(A)-(D)in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above ifrelated to foodborne illness
interventions and risk factors, Other
590.009 violations relating to good retail
practices should be debited under ##29 -
Special Requirements.
VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
(Items 23-30)
Critical and non-critical violations, which of, not relate to the
Jbodaorne illness interventions and risk factors listed above, can be
found in the following sectian.r of the Food Code gad 105 CD11?
590.000.
s „ . d::,: