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PUMP N PANTRY - ESTABLISHMENTS // ' �Antf'� �o Pa(A1�k (bad RNIVERSAL® UNV-12110 MADE IN USA AA SUSTAINABLE MH.�GYQID If�IMATI�VE CDNIBlf10X® Co,tWiihor Sourcing P!)Sf M,rw.cfipmonm ary 41fICW I 4 Commonwealth of Massachusetts I* r City of Salem Board of Health Kimberley Driscoll I* 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Pump N' Pantry File Number:BHF-2004-000080 10 Paradise Road Salem MA 01970 LOCATED AT: 0010 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0074 Jan 1,2011 Dec 31,2011 $70.00 TOBACCO VENDOR BHP-2011-0075 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2011 A Board of Health f i This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 0,9 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4`FLOOR TEL. (978) 741-1800 KIM3ERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGtEENBAUM(@M1.EN1.CONI DAVID GREENBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD d"U�� n ESTABLISHME/'NT/- n NAME OF ESTABLISHMENT W /�f�N%�`r// TEL# 77k- 77 7- 7 7/ rI A-DDRFSSOFESTARLISNMENT �f �s hWLZ/i7 FPX# 79- 7Z444 57 MAILING ADDRESS(if different) 7 �� EMAIL- Business': Website: OWNER'S NAME TEL# 7f�/ •- Zi7�'i - 9/,e7- ADDRESS 06 W/� &7470 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) -7 / Q EMERGENCY RESPONSE PERSON /I/ Mdt)dL HOME TEL# / 9/- U / ��J 1'`.DAYS'OF-OPERATION_ ::;. =<-Monday i'' Tuesday Wednesday.,.'." ;Thursday . Is`i•;Fdday-r'- 1'' vSaturday,;..':;; .. :.Sunda_y'•'`° HOURS OF OPERATION Please write in time of day. i (For example l lam-11 pm) TYPE OF ESTABLISHMENT i/ FEE '(check oniv). RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$28 " more than 10,000sq.ft. 0 ------------------------------------------------------------------------------------------------------------------------------------------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ------------------------------------------------------------------------------------------------------------------------------------------------------------------ BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES/NURSING HOME------------------------------------------------------------------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO ALL NON-PROFIT(such as church kitchens) YES NO '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. t l477 Signature I ,� Date —10 Social Securit or Federal Identification Number Revised ionli 1 FOODAP201 Ladm Check#&Date I ri-��_ I I I1J I $ 2*0 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978) 745-0343 Name Date Type of Operation(sl Type of Inspection Cl)�/c "7 I El Food Service ❑ Routine Address ` // �/)/ `t RisK' ®'Retail We-inspection rGaYu i/F.�r.N Level ❑ Residential Kitchen Previous In a ion Telephone I ❑ Mobile Date: f.(cj C,.) c� ❑ Owner HACCP YM Temporary ElPre-operationL-r1tR. .__ I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) (7J I Time I El Bed&Breakfast ❑General Complaint In: !� fes. El HACCP Inspector p Gn� Iln EVA I Out: 4_ l Permit No. ❑Other Each violation chectlted Requires an explanation on the narrative page(s) and a citation of specific provisfon(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. LFOOD PROTECTION MANAGEMENT— `j ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ElEMPLOYEE HEALTH_ _ 9 13. Handwash Facilities- k PROTECTION FROM CHEMICALS' ❑ 2. Reporting of Diseases by Food Employee and PIC [:114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded _ __ ❑ 15.Toxic Chemicals LROM_APPROVED SOURCE -_� :___.�__- - - -) El 4. TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods )_j 4. Food and Water from Approved Source t _ )J ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating [:1 7. 18.Cooling 7. Conformance with Approved Procedures/HACCP Plans g PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices (CONSUMER ADVISORY_ ❑22. Posting of Consumer Advisories r Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(590.0so.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(591.101) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: ^y S 501n pecfFo m 14.A A) Inspector's Signature: Print: PIC's Signature: /��H��w AA Print: j/ •••"`CCC I Page of,7, Pages V rte.. Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT ( 8 Cross-contamination 3-302.11(A)(]) Raw Animal Foods Separated from I 590.003(A) Assignment of Responsibility* I Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* I I I Contamination from Raw Ingredients _ 12-103.11 Person in charge--duties I 3-302.1 I(A)i2) Raw Annual Foods Separated from Each Other" EMPLOYEE HEALTH Contamination from the Environment I 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by fncxt employees and 13-302 15 Washing Fruits and Vegetables f applicants* 13-304,11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person in ( I Contamination from the Consumer Charge* 590.003(G) Reporting by Person in Charge* I 13-306.14(A)(B) I Returned Food and Rted or C Food* Disposition of Adulterated or Contaminated 13 590.003(D) Exclusions and Restrictions* I I Food 590.003(E) Removal of Exclusions and Restrictions I 3-701,11 Discarding or Reconditioning Unsafe FOOD F ?OM APPROVED SOURCE I Food^ 141 Food and Water From Regulated Sources ( 19 Food Contact Surfaces 590.004(A-B) Compliance with Food law* ( 4-501.111 Manual Warewashing-Hot Water 13-201.12 Food in a Hermetically Scaled Container* I Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* I 4-501.112 Mechanical Warewashing-Het Water 3-202.13 Shell Eggs* I Sanitization Temperatures* 3-202 14 Eggs and Milk Products.Pasteurized' I 4-501.114 I Chemical Sanitization-temp.,pH, 13-202.16 Ice Made From Potable Drinking Water* I concentration and hardness. 15-101.11 Drinking Water from an Approved System* I 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* J 590.006(A) Bottled Drinking Water* I 14-602.1 1 Cleaning Frequency Equipment uenc of Food- 590.006(B) Water Meets Standards to 310 CNIR 22.0* I Sheldish and Fish From an Approved Source I Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Fool Contact Surfaces of Egttipment* Shellfish'' 14-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I Chemical* Sources* I to I Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority ( 2-301.11 I Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present' ( 12-301.12 I Cleaning Procedure* 1590.004(C) Wild Mushrooms* I 12-301.14 ( When to Wash* 3-201.17 Game Animals* I 111 Good Hygienic Practices 15 Receiving/Condition I 2-401.11 Eating,Drinking or Using Tobacco* 3-202,1[ PHFs Received at Proper Temperatures* I 12-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* I Mouth* 3-IOLI t Food Safe and Unadulterated* I 13-30L12 Preventing Contamination When Tasting* I 6 I TagslRecords:Shellstock ( 12 Prevention of Contamination from Hands 13-202.18 Shellstock Identification" ( 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" I Employees* TagslRecords:Fish Products I 113 Handwash Facilities 3-402.11 Parasite Destruction` I Conveniently Located and Accessible 13-402.12 Records.Creation and Retention* I 15-203.11 I Numbers and Capacities* 590.0041 J) Labeling of Ingredients' 15-204.11 I Location and Placement* 7 Conformance with Approved Procedures ( 5-205.11 ( Accessibility,Operation and Maintenance IHACCP Plans I I Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* I Devices 3-502.12 Reduced oxygen packaging,criteria* 16-301.11 I Handwashing Cleanser,Availability 18-103.12 Conformance with Approved Procedures* 16-301.12 Hand Drying Provision I *Denotes critical acm in the federal 1999 Feat Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: I,/JAA7 �J?6ell) Date: //L �� Page: ")L of 7 Rem Code C—CrNlcal Item DESCRIPTION OF VIOLATION/PL'AN OF CORRECTION Date No. Reference R—Red Rem verified {1 � PLEASE PRINT CLEARLY , t '`� - �l�,Gv C�r.J� \}y1 ✓ 4 C�Vlnn� r rn.�.. -I� 10� foA'. r ,t r 4a I I I I I / f Discussion With Person in Charge: d, I Corrective Action Required: I Cl No res a_ I have read this report, have had the opportunity to ask questions and agree to correct all oluntary Compliance LI Employee Restriction i A violations before the next inspection, to observe all conditions as described, and to Exclusion ;�( E d comply with all mandates of the Mass/Federal Food Code. I understand that Ll Re-inspection Scheduled ❑ Emergency suspension y noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �u�� ❑ Voluntary Disposal ❑ Other: � r 3-501.14(C) PHFa Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(items 1-22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS I 13-501.15 Cooling Methods for PHFs i 114 I Food or Color Additives { i 19 I ( PHF Hot and Cold Holding { 3-202.12 Additives* I 3-501.16(B) Cold PHFs Maintained at or below 3-302.14 Protection from Unapproved Additives* I 3-50L590.O6( H°t45°F* 115 Poisonous or Toxic Substances I 13-501.16(A) Ho[PHFs Maintained at or above 7-101.11 Identifying Information-Original f 140°F. Containers* I { 3-50L16(A) Roastc Heid at or above 130°F. 17-102.11 Common Name-Working Containers* I 120 I Time as a Public Health Control { 7-201.11 Separation-Storage* I 13-501.19 I Time as a Public Health Control* { { 7-202.11 Restriction-Presence and Use* I 1590.004(H) I Variance Requirement { 17-202.12 Conditions of Use* { REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 17-203.11 Toxic Containers-Prohibitions* I POPULATIONS(HSP) 17-204.11 Sanitizers.Criteria-Chemicals* I 17-204.12 Chemicals for Washing Produce.Criteria* { 21 3-801.11(A) Unpasteurized Pre-packaged Juices and { 7-204.14 Drying Agents.Criteria* { Beverages with Warning Labels* 3-80LII(B) Use of Pasteurized Eggs* 7-_05.11 Incidental Food Contact,Lubricants* I 7-206.11 Restricted Use Pesticides,Criteria 13-801.1!(D) I Raw or Partially Cooked Animal Food and i Raw Seed Sprours Not Served, 17-206.12 Rodent Bait Stations* I { 3-80I.l I(C) I Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for I Aminal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 Sea I Pathogens.*E" 1rnreror Eggs-Immediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) I Comminuted Fish.Meats&Game Ems* Animals-155°F If sec. { 3401.11(B)(1)(2) { Pork and Beef Roast-130°F 121 rein* I SPECIAL REQUIREMENTS 3401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3401.1I(A)(3) ( Poultry,Wild Game,Stuffed PM, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks I interventions and risk factors. Other 145°F* f 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a I practices should be debited under#29- Microwave 165°F* ` Special Requirements. 3-401.11(A)(1)(b) All Other PHPs- 145°F 15 see. 117 ( Reheating for Hot Holding ( VIOLATIONS R FLA TED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 15 sec.* I (Items 23-30) 3403.11(8) Microwave- 165°F 2 Minute Standing f Critical acrd non-critical violations,which do not relate to the Time* I foodborne illness interventions and risk factors listed above,can be 3.403.11(C) Commercially Processed RTE Food- f found in rhe following sections of the Food Code and 105 CMR 140°F* I 590.000. 3403.1 lkE) Remaining Unsliced Portions of Beef I i Item i Good Retail Practices FC 590.000 I Roasts* 1 23. Management and Personnel FC-2 .003 j 18 Proper Cooling of PRFs I f 24. Food and Food Protection FC-3 .004 _ _I 3-501.14(A) Cooling Cooked PHFs from 140°F ( 25. Equipment and Utensils FC-4 .005 ro 1 26. Water.Plumbinq and Waste i FC-5 .006 70°F Within 2 Hours and From 70°F 1 27. Physical Facility i FC-6 .007 to 41'F/45'F Within 4 Hours. * 1 26. Poisonous or Toxic Materials ! FC-7 1 .008 3-501.14(B) Cooling PHFs Made From Ambient + 29. I Special Requirements 1 .009 I Temperature Ingredients to 41°F/45°F 30 1 Other Within 4 Hours* 'Denotes critical item in the federal 1999 Fiord Code or 105 CMR 590.000. I i lassachusetts Department of Public Health Salem Board of Health120 Washington Street,4t" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT r' Tel. (978) 741-1800 Fax (978) 745-0343 Name rte/ / I 1 / Dae TyDe of OQeration(s), Tyne of Insoectlon V J (7 1J I �17 V (JCf_Il� I ❑ Food Service ® Routine Address ' j ��i�/ / Ri it t ft-Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ��- ' ❑ Mobile Date: Owner / ('GN�r j , y HACCP YM El Caterer ElPre-operation 7v / clU ❑ Suspect Illness Person in Charge(PIC) V / Time ❑ Bed&Breakfast ❑General Complaint inspector IcTSPI)I (Cr y I Ou Permit No. ❑Other r 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,-" ' 1 ❑ 12. Prevention of Contamination from Hands El 1_. PIC Assigned/Knowledgeabl / uties ElPLOYEE HEALTH 13. Handwash Facilities [EM - - I PROTECTION FROM CHEMICALS '" '� ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded [115.Toxic Chemicals LFOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source I TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling p PROTECTION FROM CONTAMINATION _ ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)' El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices CONSUMER ADVISORY - ! ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related CPitical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below T_ x by a Board of Health member or its agent constitutes an 23. Management and Personnel (PP2)(Ss0.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-a)(5s0.004)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION l vyS.S MSP n a,�e-u xe l/ ' ,� (10 o2.(0 m IInspector's Signature: / Print:` b15_;101 PIC's Signature: �� V Print:M d AA// L I Page (--- o&Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT �,8 Cross-contamination j 3-302.11(A)(]) Ra" Animal Foods Separated from 1 590.003(A). Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge" I Contamination from Raw ingredients � I 2-103.11 Person in charge -duties 13-302.1 I(A)l2) Raw Aintmd Foods Separated from Each Other' EMPLOYEE HEALTH I Contamination from the Environment I 2 590.003(C) Responsibility of the person in charge to 13-302.1 l(A) Food Protection" require reporting by food employees and 13-302.15nJ i Washing Fruits and Vegetables applicants* ( 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An * Applicant To Report To The Person In I Utensils I Contamination from the Consumer I Charge* 590.003(G) Reporting by Person in Charge" 13-306.l4(A)(B} Returned Food and Reseraced or C of Food* f Disposition of Adulterated or Contaminated 13 590.003(D) Exclusions and Restrictions* Food f 590.003(E) Removal of Exclusions and Restrictions 13-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 19 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.11 I Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* I 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114I Chemical Sanitization-temp.,pH, 3-202.16 I Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 I Drinking Water from an Approved System* I ( 4-001.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.0la 06(A) Bottled Drinking Water* ( 4-602.1 t Cleaning Frequency of Equipment 590.006(B) Water Water Meets Standards in 310 CMR 22.0" ( Contact Surfaces and Utensilsk Shellfish and Fish From an Approved Source 14-702.1 1 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Few Contact Surfaces of Equipment* Shellfish* ( 4-703.11 I Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I Chemical* Sources* I to I I Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 12-301.11 ( Clean Condition-Hands and Arms* 301.12 Cleaning 3-202.18 Shellstock Identification Present* 2- g Procedure* I 590.004(C) Wild Mushrooms* 2-301.14 I When to Wash* 3-201.17 Game Animals* I ]I I Good Hygienic Practices 5 Receiving/Condition 12401.11 I Eating,Drinking or Using Tobacco* I 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 I Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 I Preventing Contamination When Tasting* 6 I Tags/Records:Shelistock ( 112 I Prevention of Contamination from Hands 3-202.18 Shellstock Identification* I 1590.0041F,) Preventing Contamination from 3-203.12 Shellstock Identification Maintained"' I Employees* 1 Tags/Records: Fish Products 113 +I+ Handwash Facilities 3402.11 Parasite Destruction* I Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* I 15-203.11 Numbers and Capacities* 590.004(1) Labeling o1 ingredie tW I 5-204.11 Location and Placement* 7 Conformance with Approved Procedures ( 15-205.11 Accessibility,Operation and Maintenance /HACCP Plans I ( Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* ( Devices 3-502.12 Reduced oxygen packaging,criteria* Ili-301.1 l I Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* I 16-301.12 Hand Drying Provision *Denotes critical item in the fedend 1999 Food Code or t05 CMR 590.000. v CITY OF SALEM- BOARD OF HEALTH Establishment Name: LCJt�(? w-,Date: .'9/ r-r �o Paged of Item Code C- Iem Critical Item ° No. Reference R-Red RedN1 DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date _ (\ PLEASE PRINT CLEARLY 4 r 1,ns. — -�,�A�� )1J��r �-, h verified .� , �.�/ Iv - , �(-✓� f C-�xA��-+-S'in.f-iz�� ,Ui-��./4 ve o v e.., -�-,� rr(.�(lam ,n s. �),- r'�-„L,.�/ _ lGhknrr.4- 4), P/1��� /.j'b'l0 �_n .l• /1-A r�.I �Q `r ,. V 1 __41, m - e /OcWA OAC Penr-- n-n, ac— /-a �tc� n/ L01'7a- 1/n f� J r oe-ld eJ J'f- Kctc r,� r_mr(s 4-o —t7zLkt-:- C3c I - Sh , e tJI, ,,, s. rJ ,= - a�-'G40 6(40(V<,/ CRS/ A /r, rA ,ACJto f#CK JJ-I (10rt,( 5-1,9011jlctlllc-rcA�'� � _/ I J -v! !_ �19lYG MrS� G/.n� ✓J `JY/1u197 0�� n G /Q.cray. �_ KIiJ of L I�CtsY �o �n I Co CTnn,v -{ra I L,G, nAf f folu1 -'r?)All' t 4--1 _ Discussion With Person in Charge: / I Corrective Action Required: I LI No Yes I I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance El Employee Restriction/ violations before the next inspection, to,observe all conditions as described, and to Exclusion Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: y. 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors{items 7-22) (Cont.) 1 41'Fl45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 I Cooling Methods for PHFs 114 Food or Color Additives I I9 I PHF Hot and Cold Holding 3-501.16(Bl Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 1I 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 7-101.11 Identifying Information-Original J 140°F. Containers* 13501.16(A) RoastsHeld at or above l30°F. 17-102.11 Common Name-Working Containers* { 120 I Time as a Public Health Control 17-201.11 Separation-Storage* I 13-501.19 Time as a Public Health Control* { 7-202.11 Restriction-Presence and Use* I 1590,004(H) I Variance Requirement i 7-202.12 Conditions of Use* 1{ 17-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 17-204.11 Sanitiurs.Criteria-Chemicals* � 17-204.12 Chemicals for Washing Produce,Criteria* { ( 21 3-801.1)(A) Unpasteurized Pre-packaged Juices and { 7-204.14 Drying Agents,Criteria* Beverages with Warning Labels* 7-205.11 Incidental Foo Contact Lubricants* 3Use of Pasteurized -801.11(13) Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-S0I.t 1(D) Raw or Partially Cooked Animal Food and 17-206.12 Rodent Bait Smcions* I Raw Seed Sprouts Not Served. 7-206.13 Tracking Powders,Pest Control and ( 3-801.11(C) I Unopened Fuod Package Not Re-served. " I Monitoring* CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for,Consumption of 116 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PRFs Not Otherwise Processed to Eliminate 3-40i.IIA(1)(2) Eggs- 155 F 15 Sec. Pathogens'*0�11 1�1 Eggs-Immediate Service 145'F15sec, 3-302.13 *IPasteurized Eggs Substitute for Raw Shell 31101.11(A)(2) Comminuted Fish.Meats&Game Egfis Animals-155'F 15 sec. * { 3-401.11(13)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-J tis°F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401:11(A)(1)(6) All Other PHFs- 145°F 15 sec. ° 117 Reheating for Hot Holding VIOLAT70AIS R ELATED TO GOOD RETAIL PRACTICES 3403A I(A)&(D) PHFs 165-F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,canbe 3-403.11(0) Commercially Processed RTE Food- found in the fallowing sections of the Food Code mrd 105 CMR 1400F* 590.000. 3403.11(E) Remaining Unsticed Portions of Beef Item I Good Retail Practices FC 590.000I Roasts* i 23. Manaaernent and Personnel FC-2 .003 I 1$ Proper Cooling of PHFs i 24. Food and Food Protection FC-3 .004_ 1 3-501.14(A) Cooling Cooked PHFs from 140°F to 25. Equipment and Utensils FC-4 .005 26, 1 Water,Plumbing and Waste FC-5 .006 70'F Within 2 Hours and From 70'F 127. Physical Facility FC-6 .007 -' to 41°F/45'F RSthin 4 Hours. 1 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient + 29. I Special Requirements ,009 1 Temperature Ingredients to 41°Fl4.5°F 130. 1 Other ! I Within 4 Hours* ssr:«mwt-x a,. *Denotes critical nem in the federal 1999 Fwd Code or 105 CMR 590.000. CITY OF SALEM BOARD,.OF HEALTH _ bi Establishment Name: !/� An /1/ 1/�7Ny' i a' _ Date: B A /n Page: � of <N Item Cafe C-Critical Item / DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Verified PLEASE PRINT CLEARLY 1 - - �+ Gr�lar Lip �( n.(�✓ �a,�� 19M> reM�yc J I Qr . �� tk= � r,, , � y '' ii - - �} G;�JcI 4/ _ i Nn I I���• !I r i�i.,,lcrNa ,1 /4oTy I (o u,,.o ( .�,. l . r ck � I ��i(S cr F GCir/ln i/) C1 li, r 01tr+1/ /(r 16–A/ �{1�(Ot[� G�G��/� l�J f 7 �-- II' I UJ , !v �S -+A'% 6 �,a! - h �. r �l 100 n 1_�d %lerr.✓r,( lrl �cc Y-i" )�- �,�r✓�,� � b� i)��1--�n.,IvL o�G �:-,lU r� � ,,vlvN�- -�, Lo>�� -�ia•� i Ur)- S rf --1 ,71rw .l _ �nr l I (-o-c.IJ ,/n. / 3 /I�(Z /l. / A I f (-)7w ,� x9, f e,-t J �3n f} l�� 4 ,z)l I , I f ✓, � I /Ov.) 'CA /ZQ �—i r< u r(r3 C G o N/t mat j 0 r N Jai '�' '7 ccn K" . r, . lo.uv,.0( ,U D 1, I 1- - x ��n l 1`d ply .,�n, ► .�X ro u, �,I �\i1G35ic _1\ UAAa.) Oil 'Z 6OUDnO3 )62 c` I ).2,� n.Z.t�• Yc.L._ 1rc_Ct - � n L2_C�azC_„af. !!11ttiT"C1TY�I'��Ra.,.�f-41`" 4L-e14 1- 1a C a 14kl Discussion With Person in Charge: I Corrective Action Required: I ❑ No (JFYes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and toExclusion comply with all mandates of the Mass/Federal Food Code. I understand that Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ other: i , 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne 111nass Interventions and Risk According to Caw Cooled to Faetors(Items 1-22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 119 PHF Hot and Cold Holding 3-501.16(13) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 410/45'F* 3-302.14 Protection from Unapproved Additives* I 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 7-101.11 Identifying Information-Original 1400F. Containers* j 3-501.16(A) Roasts Held at or above 130'F. 1 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 3-501.19 Time as a Public Health Control* 7-202.11 1 7-201.11 Separation-Storage*Restriction-Presence and Use* 590.004(H) Variance Requirement� 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sattitizers.Criteria-Chemicals'* I yl 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning labels* 7-204.14 Drying Agents.Criteria' Use of Pasteurized Eggs* 7-205.L 1 Incidental Food Cantos,Lubricants* 3-801.11(8) 7-206.11 Restricted Use Pesticides,Criteria* 3-80111(D) I Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 1 7-206.12 Rodent Bait Stations* 1 3-801.11(C) ( Unopened Food Package Not Re-served. 17-206.13 Tracking Powders,Pest Control and I i Monitoring* CONSUMER ADVISORY 71MEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A{1}(2) Eggs- 155`F IS Sec. Pathogens.*Eft1l.arms Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game i Ems* Animals-155'F 15 sec.* 3401.11(E)(1)(2) Pork and Beef Roast- 130'F 121 nun* SPECIAL REQUIREMENTS 590.009(A)-(D) Violations of Section 590.009A 3401.11(A)(2) Ratites,Injected Meats-155`F LS ( )-(D)in sec. ' + catering,mobile food, temporary and 3-40LI I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, I debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks I interventions and risk factors. Other 145'F" 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked to aI practices should be debited under#29- Microwave 165`F* Special Requirements. 3401.11(A)(1)(b) All Other PHFs-145'F 15 see. 17 Reheating for Hot Holding VIOLATIONS R:LATER TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165-F 15 sec.* I (Items 23-230) 3-403.11(B) Microwave- 165'F 2 Minute Standing ( Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-40111(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* f 590.000. 3403.11(E) Remaining Unsliced Portions of Beef 1 Rem Good Retail re FC 590.000_ 1 Roasts" I i 23. Managemgnt and Personnel I FC-2 .003 I 18 Proper Cooling of PHFs f_ 24. _ Food and Food Protection I FC-3 .004 i 1 25. Eaulument and Utensils 1 FC-4 .005 y 3-501.14(A) Cooling Cooked PHFs from 140'F to j 26. I Water.Plumbinq and Waste I FC-5 .006 70'F Within 2 Hours and From 707 1 27, ( Phvsical Facilitv FC-6 .007 ! to 41'F145'F)&ithm 4 Hours. * 26. Poisonous or Toxic Materials FG-7 1 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. ( Special Reouirements 009 Temperature Ingredients to 41'F/45'F 30. 1 Other I Within 4 Hours* s:swnxa�. "Nnotes critical item in the federal 1999 Food Code a 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: J)j ,t.,n !J y Date: Q_ Pa g e: of Rem Cone - Item � Item R No. Reference R-Red Red Item ' DESCRIPTION OF VIOLATION/PLAN FICORRECTION Date f � PLEASE PRINVerified- T CLEARLY c I Ct. 11 t a-•� �-Allr rD N. coo .� r�r� 1 S4Y�.,..�A4.4� ..�. ..--f- 6?�• rQL/..y>°� l(.._l4� L � fi 1 I' I -�' �.� f1 I . -� G J� l� 1� I t=F• rn AJJ 4a! C'J3 G ` I � ✓ Cl,6/1 Se /+. Y r ((� f Pv1� to �Jq � -s r71/�, �l .-� �7 C7 Cl � /F.C. l )Sc I�, nld0l ,� � fti�� S err J ape (�Jl�' ' Mt�a' , �a/�. gym. ��1 � -Atra /10001, , /(> 'r2 fjjPjrPL �L� '� 3� , ("N (�- G-N- 5 dN V ec) 5(,.)G 14.)S—JR/ 7 r�,, r�o,'/ �/ r r�ar7�✓ _ Discussion With Person in Charge:\ Corrective Action Required: I ❑ No r''-yes it I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the n einspection, to observe all conditions as described, and to /' Exclusion ' Ise-inspection Scheduled CIEmergency Suspension comply with all,mandates of the Mass/Federal Food Code. I understand that l noncompliance may result,iri daily-fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food peemit. t 0 Voluntary Disposal ❑ Other: 3-501,14(C) I PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont.) 4t'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS I 3-501.15 ( Cooling Methods for PHFs 14 I Food or Color Additives I 119 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 3-302.14 Protection from 3-S0116(}A) Hot PHFs Maintained at or above Unapproved Additives* I 59 . °145°F* 115 Poisonous or Toxic Substances I ( lfi( H 140 7-101,11 Identifying Information-Original � 3-501.16(A) Roasts Heid at or above 130'F. Containers* 7-102.11 I Common Name-Working Containers* I20 Time as a Public Health Control 7-201.11 Separation-Storage* I 3-501.19 Time as a Public Health Control* 7-202.11 I Restriction-Presence and Use* I 1590.004(H) I Variance Requirement 17-202.12 Conditions of Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* I 7-204.11 I Sanitizers.Criteria-Chemicals* I POPULATIONS(HSP) 17-204.12 Chemicals for Washing Produce,Criteria* I ' 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and 17-204.14 I Irving Agents.Criteria* Beverages with Warning Labels* 3-801.11(B) Use of Pasteurized Eg,,rs* I 17-205.11 I ResInctricted Foal Contact ,urticant** I 13-801.11(D) Raw or Partially Cooked Animal Food and 17-206.11 Restricted Use Pesticides,Criteria I Raw Seed Sprouts Not Served. 17-206.12 Rodent Bait Stations* I 7-206.13 Tracking Powders,Pest Control and i 3-801.11(C) I Unopened Food Package Not Re-serval. " I Monitoring* CONSUMER ADVISORY TIMEITEMPEROTURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3401.11.0(1)(2) Eggs- 155°F 15 Sec. Pathogens.*e'"fDVBn' Eggs-Immediate Service 14501`15sec* 3-302.13 PasteurizedaEggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game Animals-155°F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 nun* I SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(A) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, ! residential kitchen operations should be Stuffing Containing Fish,Meat, ( debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a f practices should be debited under#29- Microwave 165°F* I Special Requirements, 3.401.11(A)(1)(6) All Other PHFs-145°F 15 sec. * I 117 Reheating for Hot Holding I VIOLATIONS R LA TED TO GOOD RETAIL PRACTICES 3403AI(A)&(1)) PHFs 165F 15 sec.* I (Items 23.30) 3-403.11(B) Microwave- 165'F 2 Minute Standing ( Critical and non-critical violations,which do not relole to the Time* foodborne illness interventions and risk factors listed above, can be 3.403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000, 3403.11(E) Remaining Unsliced Portions of Beef I Item I Good Retail Practices I ,FC 590.000 Ri a rts* ( i 23. I Management and Personnel f FC-2 ( .OM •I i 24. Food and Food Protection I FC-3 + .004 18 Proper Cooling of PHFs I I FC-4 1 .005 i 3-501.14(A) Cooling Cooked PHFs from 140°F to 125. EauirxneM and Utensils ( ) g 26. Water.Plumbina and Waste + FC-5 .006 1 70°F Within 2 Hours and From 70°F 127. Physical Facility FC-6 I .DO7 to 41°F/45'F Within 4 Hours. * ; 26. I Poisonous or Toxic Materials FC-7 ! .008 j 3-501.14(B) Cooling PHFs Made From Ambient . 129. Special Requirements = 1009 1 Temperature Ingredients to 4PF/450F ! 30. f Other i I i Within 4 Hours* c,ve:«„�iazax *Denotes critical item in the federal 1999 Foal Code or 105 CIvtR 590.000. CITY OF SALEM t BOARD OF HEALTH r Establishment Name:9u.M� ,✓ G����.n y Date: gl�'1 a Page: , of Rem Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Rem Verified , PLEASE PRINT CLEARLY rtFt � ��. l�-�l� 0717 A CO"A �` V! �"('n U�I.,�tMi�.✓I 'r �f/t>nn� 12�./�il r �S"7n / /n.l J.P� ;1//1�� o'�.-� r J. ...I � r „JJ J I - • - - I 3l 4th d< 0t-i -alamux d vSSkr : 3-501.14(0 PHFs Received at Temperatures Violations Related to Foodbome Illness interventions and Risk According to taw Cooled to ms I Factors(item f-22) (Cont.) 41°F/45°17 Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 1 Cooling Methods for PHFs 1 14 Food or Color Additives 1 19 1 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-302.14 Protection from Unapproved Additives* I 590.004(Fl 410/450 F* 1 15 Poisonous or Toxic Substances 1 3-501.16(A) Hot PRFs Maintained at or above 7-101.11 Identifying Information-Original I 140T. 3501.16(,0) 1 Roasts;Held at or above 13C Containers* °F. 1 7-102.11 Common Name-Working Containers* 1 20 1, 1 Time as a Public Health Control 7-201,11 Separation-Storage* 1 1 3-501.19 1 Time as a Public Health Control* 1 1 7-202A I Restriction-Presence and Use* 1 1 590.004(H) 1 Variance Requirement 1 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* 1 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1 7-204.11 Sanitizers.Criteria-Chemicals* 1 POPULATIONS(HSP) 1 7-204.12 Chemicals for Washing Produce,Criteria* ( 121 3-801,11(A) Unpasteurized Pre-packaged Juices and i 7-204.14 Drying Agents.Criteria* 1 Bevemees with Warning Labels* 1 7-205.11 Incidental Food Contact.Lubricants* ( 3-801.11(B) Use of Pasteurized Eggs* 1 7-206.11 Restricted Use Pesticides,Criteria* 1 ( 3-801.11(D) Raw or Partially Cooked Animal Food and 1 7-206.12 Rodent Bait Stations* ( Raw Seed Sprouts Not Served-3-801.11(0 Unopened Food Package Not Re-sensed. *` f Monitoring* CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 122 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for ( PHFs Not Otherwise Processed to Eliminate 3 Pathogens,'E"v. t 401.11,0(1)(2) Eggs- 1 IS Sec. 3- . asteurised ll Eggs- 30213 P Immediate Service 145°F15sec* � ( Eggs Substitute for Raw She 3.401.11(A)(2) Comminuted Fish.Meats&Game j Ems* Animals-155°F 15 secs* I SPECIAL REQUIREMENTS 1 3-401.118)(2)(2) 1 Pork and Beef Roast- 130°17 121 min* 1 3.401.11(,0)(2) Ratites,Injected Meats-155`17 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in I sec, * catering, mobile food, temporary and 3-401.11(A)(3) I Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F{ 590,009 violations relating to good retail 3-401.12 Raw Antral Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3.401.11(A)(1)(b) All Other PHPs-145°F 15 sec. 1 17 Reheating for Hot Holding VIOLA77ONS R LATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-303.11(0 Commercially Processed RTE Food- found in the following sections of the Food Cade and 105 CAIR 140°F* 590.000, 3403.11(E) Remaining Unsliced Portions of Beef I Hem ' Good Retail Practices 1 ,17C 590.000 1 Rests* 23. Management and Personnel i FC-2 .003 I 1 18 1 Proper Cooling of PHFs 124. Food and Food Protection I FC-3 .004 i 25. Equipment and Utensils I FC-4 ,005 ) 3-50 L I4(A) Cooling Cooked PHFs from 140°F to 126. 1 Water.Piumbinq and Waste FC-5 .006 I 70°F Within 2 Hours and From 70°F 1 27. Physical Facility FC-6 .007 I to 41°F/45°F Within 4 Hours. * 1 28. Poisonous or Toxic Materials FC-7 .008 ! 3-501,14(B) Cooling PHFs Made From Ambient ( 129. I Special Requirements I .009 I Temperature Ingredients to 41°17145°.F 1 30. I Other i Within 4 Hours* s.4W;mmhal4 z 6. 'Denotes critical item in the federal 1999 Fuad Code or 105 CMR 590.000. Nwv from Offire of '6atrin Citp Council *alrm, Ifl-I 01970 Ms. Janet Mancini, Acting Agent Salem Board of Health 120 Washington Street SALEM MA 01970-3523 *3 0,+73 FS 2 If I I I I I 10 1 1 11 1 111 111 1.111 11 11 If I I I I It I I I I If I I Is 11 1 1 1111 1 111 _ � , 1 �lil 1� i 1+( iil ii i �1 1 i ii� �i :i � S i illli( Citp of �&alrm, Aam5arbuatw Q �J cin , Office of the Citp Coundl 1 Citp joall COUNCILLORS-AT-LARGE PAUL C. PREVEY WARD COUNCILLORS PRESIDENT 2009 - 2009 THOMAS H. FUREY CHERYL A. LAPOINTE ROBERT K MCCARTHY JOAN B. LOVELY CITY CLERK MICHAEL SOSNOWSKI STEVEN A. PINTO JEAN M. PELLETIER ARTHUR C. SARGENT III JERRY L. RYAN MATTHEW A.VENO PAULC PREVEY JOSEPH A O'KEEFE, SR May 12, 2009 Ms. Janet Mancini, Acting Agent Salem Board of Health 120 Washington Street SALEM MA 01970-3523 RE; Second Compliant Trash Pump'N Pantry Store 10 Paradise Road SALEM MA(Ward 7) Dear Ms. Mancini: Several weeks ago I called your office about neighborhood concerns of discarded shelving against the side of this business. I noted this date the shelving is still there. Please have this matter investigated and take whatever action is required for the qusiness to comply with applicable city/health codes. espectfully, eph . O'Keefe r.� Councillor Ward 7 p/c Pump'N Pantry SALEM CITY HALL •93 WASHINGTON STREET •SALEM, MA 01970-3592 WWW.SALEM.COM Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 02/05/2010 ESTABLISHMENT NAME: Pump N' Pantry File Number:BHF-2004-000080 10 Paradise Road Salem MA 01970 LOCATED AT: 0010 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0350 Feb 1,2010 Dec 31,2010 $145.00 TOBACCO VENDOR BHP-2010-0351 Feb 1,2010 Dec 31,2010 $135.00 Total Fees: $280.00 PERMIT EXPIRES (December 31, 2010 l � 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 YL y CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH 120 WASHINGTON STREET,4m FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 NIAYOR DGREENBAUM&ALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT L NAME OF ESTABLISHMENT TEL# ADDRESS OF ESTABLISHMENT.�o Inc C qSc. S0.Q,t nn�A�r,7cFAX# MAILING ADDRESS(if different) EMAIL-Business': e Website: OWNER'S NAME i Q CA V\ TEL# q I A I-•tt1 — '1-19 -) ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# ISDAYS?QF„OPERT) k , TestlaY= a � -T�_ F ' ounalY itlaY:, rwnd HOURS OF OPERATION I j ! Please write in time of day. (For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check onlvJ RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. —= 280 more than 10,000sq.ft. 420 ------------------------------------------------------------------------------------------------------------------------------------------------------------------ RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------Y------•ES------id $'1'0'0'------ BED/BREAKFAST/ NO 0 CHILDCARE SERVICES/NURSING HOME 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 returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date ����(�dT/_ $ s CITY OF SALEM I, I BOARD OF HEALTH Establishment Name: 47^17 Date: 1 - Z -,J Page: I of I Item Code C-Critical Item DESCRIPTION OF VIOLATION!PLAN OF CORRECTION I Date l No. Reference R-Red Item Verified PLEASE PRINT CLEARLY rJ4a i 1 '. GGr�O b �iC(Jnil\�\ n OoPF1 i�1Y� S r nen. )AC'.-o bJl\ii� c I I LXn R-1;,2 VrC\ I ) I Q v, rr.%.ark lc \ Fnv 21 Ctl� c , ),fl I 1 I Discussion With Person in Charge: I Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ I violations before the next inspection, to observe all conditions as described, and to Exclusion I P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that i noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. /1 Ll Voluntary Disposal ❑ Other: I PHIii, Rel.,jwd Vitaistions Raistatel ta pi,,roborne furiess Int-riventions and RiqAt A'cvph fit,10 I-ill, coof.d to Factors(items 1-22,1 (Coot) 41 Walrill 4 Hours —Z 5 CtRioni,Nl"Ihod, for PHF�� PROTECTION FROM CHEMICALS PHF fl�and Cole,Htd;ng 14 Food or Color Additives ( 14 j S6(B) Cold PmF,Itinitrit,i"v'j at or w '�i-2()2,1 2 ! 4%(:eU t i V C. -X1J4 1 pr"'1w)"n""nil i ',-,50f I&A) Do 111f,,JNIkonlamedat or above IF Poi�onc-us or Toxic SubstanoLzi, WOT Nmf� Sett iin': it:a 0,1 ji Heid at or.ib(,ve i30'i�, Time as a Pulsic Health Central Sol; 1" Tiao,it,a vublic licalth mp,l w REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ic Olptanr'�Z!�- l'o 7.204.t! POPULATIONS(HSP) fi,�1 !1(,N) I 7-'_03.#2 Ono 5=xt'z �1 o61 1kc,Ci ' i ( R'lvrw�'es with 'Wernme j-"i'QK 7 W4 14 Cro".riit' j 1 I(Bi 7 1)5 11 jrii-ldmoal Rbltl conlact, IAto!;Can1i` I(D) R:iw or liato-Ah Ctof-d Animil Fkr-J-oA 7-20(1 1i llc'riwlc:. 7-206.f 2 Ri.dff[ Pj,! 'Slmiom Vv,,p�ned Rx�u Pachw� No! R? ,'Crvcd T'1�1 ini" z1f.tj CONSUMER ADVISORY TIM&TEMPERATURE CONTROLS 2. 3 W, I i Consultor Aftuaory Hinted "or �ansuta:ptu to of Riew, Undmlyllced o; Otherl,Jsc Llimmart. PHF-- 16 Proloar for 3 -101 11 Aft:( F',D, :5� F �5 5�,- Fg orlo'�Jm[t. '�,l"v:L EAS'1'#i'le( 1.401A if Ap ("Molipwi:d Fi,k 'A -t,&- fiJine SPECIAL REQUIREMENTS Plitt, slid b"�! ki'll't 'JU - 141 �Iuo I li'%lf iilit-oi��i M-g� - [55 P 1� 5=41)Mira!A)-f f)t Vidaziow,of Secticia 300.009(A)-;1)'It in catering. 111'Allic.f(xid. tcokporwle;ilrd 3,401AFA).�`r) poultr�' 11 il't"­ii""w.' sluleed 11 M". kitchen (vialons%hould lie Lmidcr flw it r,-bird tolox,Jlonw Ini'm 540.009 Violation';rclwirrl` to voxj r,lat, 40 1.12 Rl%z� :\uirwrl Kqik ill a }ori;rices hoiild 'x,,debited under #29 - sp(:clal Requirentolit, Ch!iei Nfk-- WT ic,, 17 Rchnatina for Not HoWns VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 1.403AUAWbi i'll iF, t o5,F (hents 23-30) 3- 1 ii b i Mmtma— C,iii wl rilif ni viol;d,pm do n); v,0if biudil".rne s,mfli s,mtonvwiil mkjoetorr li,wd con h: -403.f 1{C) urngmwailv flio:ei.icd RTFH"l I !riold to:he 'e"!ionk 'hl:Etivj Codc if"d II)i 11R ­ 7590,60 1 zlint, ut-ii-ii piqtoln.of Item Coact Retail practic's R�llm' 1 29 klarmgilm,�,t nod Personnvl FF FC 2 1 00, Ff�--xl and 1-ood Ptoirtclfori FC 3 i 004 18 1 Proper Coaling&RmFS .,Eq nent and WE�3ta F(, -4 u0A 3 501.14'Al C'viiiig GAIK�ift PH1." frlm' 1-4), 14, M Watii,ri!umbmrl,ind'Alaste FC-3 i 7WF Within and From 71r,I- 127 Ph'Sora!Fa6ity A 007 1 ti,41 T"'45 F'N:tl,in 4 Hou'-:, 2 6, potsortom of FC- 7W8 ---- ---- l.f(H) Coofin,',FHFs 1vU&FrFantArAmbient --,xy �40 oth.-� Within-t ikilsr` r d ' 0 M"n')A90A 11145f201)0 Commonwealth of Massachusetts Form 4--System Pumping Record Massachusetts System Pumping Record System Owner System Location Bursaw Oil Corp. Div of Alliance Energ Pumpn Pantry 36 Bast Industrial Road 10 Paradise Road Branford, CT, 06405 Salem, MA, u1970 (800)-899-8602 x (800)-899-8602 x Dan Type: Emergenc Routine ✓ Cesspool: No ✓ Yes Septic Tank: No = Yes7] Date of Pumping: a. 5 -02' Quantity Pumped: lir) Gallons System Pumped By: Wind River Environmental,LLC Permit#: Contents Transferred to: Contents Disposed at: Q.E.G.D. Salem, MA. Date: Pumper Signature: Condition of System/Other Comments i I 1 Dep Approved Form-12/07/95 JAN - B 2009 E,.:,�r'v:J OF HEALTH =_[:=I-�-`- ISI_ - I I_fTf 7+I. 1--- - -- - - - - - -I-. ._..I_ L. I. I --1it ��-- I i L w I i$ a�_L �+fh Y,Jr l i• !rr r �l_f 1__ _I. 1 I ig � ^s__ -I _ _ �_ -_ ?_Bi_ 4.!��t ' �, i _I .. ; i. i -L' _ I-_�-_t I I l � � f5✓I�� n I ��.rl' Ip . I .!_ _ I r --1 - ' I I I g - I- �' 49f I ' I i I � Y!--I•�—��„9E-�i i !,_a,E.—y i i at A,ix --JS i cin 'it -1- ! I I I I - I : 7, l I — I I • • � _ - ' I -I— — —I u � I - 1I - - n Commonwealth of Massachusetts s r City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 DATE PRINTED: 12/02/2008 ESTABLISHMENT NAME: Pump N' Pantry File Number:BHF-2004-000080 10 Paradise Road Salem MA 01970 LOCATED AT: 0010 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0003 Dec 3,2008 Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0004 Dec 3,2008 Dec 31,2009 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31,2009 i Board of Health a Page t CITY OF SALEM, MASSACHUSETTS ' BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIND3ERLEY DRISCOLL FAX(978)745-0343 MAYOR IDIONNEQSALEM.CONI JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ANI/ n A/ l'6 1-2 S0 TEL# 97?- -/Z/, ia7/12 ADDRESS OF ESTABLISHMENT //) �AP�1�%S/� �� f61�Gh FAX# MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAME r1Z-n.V /&5S.Ol / TEL# 7f'3/ -41715'— 9/A7 ADDRESS A' l X K///✓ A 92��i✓�p0/17 N OZ�/�/ STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# IDAYS OF,OPERATION:`" Monday - 1 =,Tuesday'' i Wednesday ' j ;`, Thursday: . i ' •Friday.': - j "-Saturday' 'I - Sunday HOURS OF OPERATION 1 Please write in time of day. 6 1110 (For examplellam-11 pm) TYPE OF ESTABLISHMENT FEE (check onlvJ RETAIL STORE ES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 .........................k ------------------------------_- AN -------- RESTAURT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES - 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 returns an��dy d all state taxes required under the law. /Yrs a6- a �J A'- /i/77 Signature Date L ' Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date fD ,) l I{-k 0 jQ Q $ , CITY OF SALEM BOARD OF HEALTH Name of Establishment: Pump-n-Pantry Address: 10 Paradise Road Owner(s): Dildar Hussain Phone: 978-744-9710 December 2, 2008 The owner of this proposed establishment presented plans for review in accordance with the State Sanitary Code. Owner must submit floor plan upon receipt. ITEMS FOR SALE All food items displayed and offered to the public must be from a source permitted as a Wholesaler from the Mass Department of Public Health. Jay Polep is the wholesaler. Pre made, pre packaged sandwiches will be sold at this location. There will be no food preparation at this establishment. FLOOR PLAN All surfaces must be intact, impervious and easily cleanable. All refrigeration units must have accurate internal thermometers. Refrigerated food must be held at 41 degrees Fahrenheit or lower, freezers at 0 degrees Fahrenheit or lower. A 3 bay sink will be used to wash, rinse and sanitize all coffee pots and utensils. The attic will not be used for any aspect of this business. EXPIRATION DATES All expiration dates on products must be clearly visible. Out dated items must be promptly removed from display. TRASH A dumpster will be used. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. Any changes in operation, such as meat or cheese slicing, must be approved by the Board of Health. Outside area of premises must be kept clean and sanitary. A pre-opening/o ng inspection will be conducted on Wednesday, December 3, 20Mat0 Iz-2- Da�d Greenbaum Date Sanitarian ,l � /i% yv1� l v- 2- Dildar Hussain Date Owner 0010 Paradise Road Pump N'Pantry City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-9710 Handwash Facilities FAIL Critical RED Owner: Comment:There are no paper towels in the restrooms. Provide disposable paper towels in the rest rooms at all times. Alliance Energy The mens room is missing soap. Provide soap at all times. PIC' I Violations Related to Good Retail Practices (Blue Items) Eddie Goncalves Food and Food Protection FAIL Critical BLUE Inspector: Comment:There are many price labels obscuring expirationlsell by dates. Do not obscure expiration/sell by dates with price labels. David Greenbaum Date Inspected:Correct By: The following items were removed outdated: 7/9/2008 1 -Gravy 4-Vanilla Nesquick Risk Level: 3-Pints 1%milk 6-Utz salsa and cheddar dip 1 -Tostitos salsa con queso dip Permit Number: 2-Tostitos creamy spinach dip BHP-2008-0093 Closely monitor all expiration dates. Status: Physical Facility FAIL Non-Critical BLUE SIGNED OFF Comment:The dumpster needs a thorough cleaning. Properly remove all hazardous waste, is. tires. #of Critical Violations: Special Requirements FAIL BLUE 2 Comment:Owner must forward 6 consecutive months of extermination invoices to the Board of Health. Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeOTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 09,2008 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 09,2008 ) Page 2 oft P5 2� kol. l k I 'o assac usetts Salem, Board-ofHe [Q,mbeidey Ddscoll:,��.�,- 120 Washington Street,4th Floor,, Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2007 ESTABLISHMENT NAME: Pump N' Pantry File Number:BHF-2004-000080 10 Paradise Road Salem MA 01970 LOCATED AT: 0010 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes RETAIL FOOD BHP-2007-0332 Jan 5,2007 Dec 31,2007 $100.00 TOBACCO VENDOR BHP-2007-0336 Jan 5,2007 Dec 31,2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES 'December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 7 of 11 CITY OF SALEM, MASSACHUSETTS BonftooEETRECEIVE® 120 WASHINGTQN STREET, 4T 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 JAN . 4 2007 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM �OARO OF HEALTH OF SALEM Mayor JOANNE SCOTT, MPH, RS, CH4 HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT POVhON ROO A�V TEL# ADDRESS OF ESTABLISHMENT © P0(X0L I se 00L4,,! ldI vo N FAX# MAILING ADDRESS (if different) t 1 101t EMAIL--Business': Owner's._= �,Afin/ QR �/tbaii•!'i�yi OWNER'S NAME Qwwia YETI TEL# ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# j DAYS OFOPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday _ Ij! HOURS Of OPERATION Please write In time of day. 6'ckv-,— t l P^ 66"Q~ Pru Avg - i 1 Pin+ I 1 Pw:d q+nt- I t P,,,,, 6 A,,,,,_ I I P,,,j 6&k� t i Pw lfor example Liam-010m) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE (YES NO less than 1000sq.ft. 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT ---- -NQ - -------- ---- ---- -- - ---- -- --- --l..e. -- --...--se -- _YES lss th- an 25 seats $100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES O $100 ------------ ------------- - ---- .............-------- --- .. -- ..... ..... ...... ... - ---_ -.................. ......-......... ADDITIONAL PERMITS MAKE(riot just serve) ICE CREAM, YOGURT, SOFT SERVE NO TOBACCO VENDOR YE O $5 ALL NON-PROFIT(such as church kitchens) YES NQ 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 retur nd paid all state taxes regwred under the law ( p, 02 --07 231 4? S 3 4-} Signature Date Social Security or Federal Identification Number - ------------- ----- ---- --- ----- -------------- ---- J - -.& ---------------- - --- --- ----- -- Revised 11113/08 FOODAP2007 adm Check#& Date f�9't� ^.,�, p'4i'. .,# .«y,•s:,..r�• 1r .4" .- r' x•> g1 T :sry-»:--.... P " v'.+`,.'>:e:..t: .«. ....;,�'«,i s...y':-U ��.'� ltr'Ki•�.mn 'P. �r' Commonwealth of lkaiiichusetts § ' City of Salem' Board of Health Idmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Pump N' Pantry File Number.BHF-2004-000080 10 Paradise Road - - Salem MA 01970 LOCATED AT: 0010 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0093 Jan 3,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2008-0121 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES (December 31,2008 Board of Health This Permit is not transferable and must be reissued upon change:of ownership or location.The permit must be posted in =_ a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 19 of 46 CITY OF SALEM, MASSACHUSEM BOARD OF HEALTH t ,t 120 WASHINGTON STREET,4' FLOOR TEL.(978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR ISCOTT a)SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT PUMP N PAN'r/R Y TEL# 179 �'/4 9?/0 ADDRESS OF ESTABLISHMENT 10 ?A)2AJ)iSF & SALEM A 0(9}oFAX# 977 910 MAILING ADDRESS(if different) �1 EMAIL-Business': A(-IAW9R @t' o-rmAI/_•(OM Website: OWNER'S NAME MOHAMMAD A KHALID TEL# 79I 6k0 S91� ADDRESS 2.6 Co2ES7- AVE SALA-M MR 6 (g310 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON A N SA N A SLAM HOME TEL# 97$ �4 21/S DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION u / Please vette in time of day. i60(W. -nVtM 6Ckvv - IIQwt 601w-- Ilpiy6Rw- ikptm. I GCkw-Ilfw 6Ctuw- IDPW 6oLW- IOP (For example Ilam-1lpm) TYPE OF ESTABLISHMENT FEE (check oniv) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - ------------------------- ---------- -------------------------------------------I- ­- RESTAURANT YES NO lesssthan 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 - -------------------YES------N-O ------------- ------...----------....-----------------------------------------$--100-..--.... BED/BREAKFAST/ CHILDCARE SERVICES - .-. . - --------------------------------------------. ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR 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 fled all state tax returns and paid all state taxes required under the law. -HLSi �' 01 /z-03 --0264 3/0 --H2- Signature gnature Date Social Security or Federal Identification Number ^^7-7-� _ ------------- Revised 4/24/07 FOODAP2008.adm Check#&Date ;40 1'7 �- 3-CD $ �'5 Page 1 of 1 Joanne Scott From: OKeefe Joseph Ctr 66 MSG/CEKV[Joseph.OKeefe.ctr@hanscom.af.mil] Sent: Tuesday, May 29, 2007 12:36 PM To: Joanne Scott Subject: 10 Paradise Road dumpster Joanne: Please have a sanitarian check the condition of the doors on the steel refuse collector dumpster at the Pump'N Pantry store/motor fuel facility at 10 Paradise Road C Vinnin Street(Vinnin Square). Constitutent alleges dumpster doors are not closed and birds pick at refuse open doors. R Joe O'Keefe, Councillor Ward 7 Joseph A. O'Keefe, P.E. 66 MSG/CEKV 72 Dow St. Hanscom AFB MA 01731-1910 Com, 781-377-4745 DSN 478-4745 Fax 781-377-8151 DSN 478-8151 vo. 5/29/2007 0010 Paradise Road Pump N'Pantry City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: I Violations Related to Good Retail Practices (Blue Items) 744-9710 Food and Food Protection FAIL BLUE Owner: Comment:The following items were taken off of the shelves due to outdates: Alliance Energy PIC: 11 Utz cheese dips 2 bags tostitos Asan Aslan, 2 Oscar mayer ham Inspector: 7 garlick farms milks John Gehain 3 tropicana orange juice 1 tropiicana apple juice Date Inspected:Correct By: 9 v8 splash mango 5/9/2007 1 v8 splash guava 8 Campbell tomato juice Risk Level: 3 dole orange juice 3 ritz chips 1 ritz cracker Permit Number: 3 sociables BHP-2007-0332 6 wheat thins Status: 3 vegetable crackers 4 chicken biskit SIGNED OFF 4 crunch n munch #of Critical Violations: 1 cheese nip 2 ritz chips 0 3 Fridays baked onion rings Time IN: Time OUT: 3 cup noodles 1 kraft deluxe macaroni cheese dinner Urgency Description(s): 1 kraft french dressing BLUE: Equipment and Utensils FAIL BLUE Violations Related to Good Comment: Kelvinator refrigerator not working. Company called to pick it up. Retail Practices (Critical violations must be corrected Shelves in walk in/reach in unit requires general cleaning. immediately or within 10 days)(Non-critical violations All shelves and food products in main part of store have accumulation of dust.Thoroughly clean all shelves and products. must be corrected immediately Physical Facility FAIL BLUE or within 90 days) Comment: Damaged ceiling file above front sink. Repair file 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. May 09,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: GENERAL COMMENTS: Violations Related to Foodborne Illness Interventions Owner to closely monitor all expiration dates on all foods. and Risk Factors (Require immediate corrective action) 1 � i v 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. May 09,2007 ) Page 2 of "�-�"� .'.°K.„il*' /�� i ��+ � 'f3M, ,.'"P"i. `.ie`V'_:4F'R Y - ,xi'}5r; � Ah kwe •4�e r. - �„ A-. tR'J`�s • ,1T . } S;a„ tt 'IW {��� X:PLSASE'REMIT�gYaIAENT O� •p'cr,' ;F> }. 11XT6,19Y�7B!4i}i�! �. .�, �.;r;, . .y_.,.. , k '� .�<, _ ."s,".'.. tits X;o roiP,rofessianais�' '' z(� L-_ }CURRENt 3Q DAYS 60QAY.... _4,, ,,t�,�j,L % �� a -� iR .DATe. 'DAY';:'t!,:iYPfi i:.- pA7E. rri.'�iTr^^;'� '�, p����••• % �+ I% - , .:nzp3 ssAfft4z'Mr�iYR:E; .3• .., ,.: . ..9 . p.;r,,s �•'4-`f:iln.'t:. J.., -AC�i.T. .+�±.*.r•.�:;:,i-�+,y.�,.�-�..�a��f�. , w _...e..Qt,7ryGy.— ,�-5�.,-�,1_ .L..—_.....�7._GI'iZ%rr'"'y'.. .'i^.. �... :i.•.. .,,: G1 .. .- ... GI_OEAL_. UEL.__..__._... - -_- _.__- cgNTggLFQR ',INTENSI.VE__.CCiN-ROL, F'.R_SERVICECHARGE.-�'..��A,`_0@ 141 RARAD:T SE._RD_ :_..z_ _ _ ._ ”-`• ' t' .cc .' v e-..<.: BER _.-.._- UNIT PRICE �'�MOUSEGLBD NUM �AtviOU _ `- 7$' 744•;-3710�� 08/116lj+5 , n TERNOO € ((ry MULTI DATE _DATE �� "' .. . PROTECTA . CHECK NO. PROTECTA LP . "RTU BAIT STA COMMENTS _ p MC _ ❑VISA ❑DISCOVER RAT GLUE BD I ;' SET UP OF SERVICE" lc:10 M �lJI;ES Pi'ZClLtSC"i... . ACCT# " -EXP DATE. SALES TAX i 1 �! /'i t/',�'` l('l/'✓' ti'i/3i/ �L.a C.O.o.U .. e 0 o TOTAL DUE ( `-"�C 1 n j 61 -4 TOTAL- _ .._. _ ._-__-. . _.-:.__.-._ _...._.._... . .TOTALAMOUNT PD �IvA ! 1 t a ADDITIONAL COMMENTS COMMERCIAL SANITATION REPORT Floors—Glean YES NO Counter Surfaces—Clean .... ... .. ..... .. .. 0", El. d, ❑ Drain Areas—Clean ........................ ❑ Rest Rooms—Clean ....... ......:.:':-. Dining Areas—Glean ..........::......`..;�.. 0 EJ ❑ ❑ Employee Areas—Clean . ..... ... .. ...,Y..'., ❑ ❑ Locker Areas—Clean ........ ............... Q-' r❑ RESIDENTIAL WARRANTY INFORMATION Storage Areas—Organized .. ... .. ... .. ... .. . -❑ DWELLING TYPE WARRANTY YES❑ NO❑ comments t Family ❑ 3 Family ❑ 30 Days D 60 Days L; 2 Family l J 6 Family ❑ 90 Days ❑ 6 Mos. ❑ REASON FOR NO WARRANTY -Partial service requested........... .................................................... ............LI -Poor sanitation............._..... . ............"......._......--........... ............... POST APPLICATION REQUIREMENTS ......� � ' �•� - � � 1 +Kitchen/bathroom cabinets not prepared...................... ..................... Ll THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE ..OUPIED AREAS MUST BE VACATED FOR HOURS -Closets/furniture not prepared... ........_................_... ...............-.._. ......❑ THOROUGHLY REOCCUPIED. DO NOT ALLOW ADULTS, CHILDREN,OR PETS ON -Rodent proofing needed............................................................... ........... (� TREATED SURFACES UNTIL DRY. -Other CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD 8 AGRICULTURE'S PESTICIDE I TIME I BUREAU CONSUMER SHEETS,WRITTEN STATEMENTS,POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2.7 DAYS PRIOR TO APPLICATION TIME-THE ABOVE SERVICE HAS BEEN SATISFACTORILY COMPLETED. INS s-t CUSTOMER SIGNATURE fl / . �' LIG# f r -H SIGNATURE TECH NO. S MEN 1 .,.. •.._. .. t . Cal,a ori ma - PfiGd tet 2 �S'i`e y - (78ItJ692-t/3� EXL2fiTilCkl9: r' IBOV-525 Cb25. 14 gip, n� }• t. y: ; ,y (54 }:$ 2=5$66 :' r K En ie ' ..`L�-i .'s 4m1Clyd;�:,. »x...,•t,..Y�:a�, 't "M� yr,Vr'yof '^.1".'�e('%Jra+,�'..)1,. ::..s I"3a a,zzy*err.L.7..'a",r•:�' Y¢ C,r•. 4.t4+6-.'.�" .rba. :f` tyOW Z586 �!� Y-hy, www'aiexterminators:com:k,:.§r: wL�.{"Js•=.,:.';i'`t'�v.7.�. h:.`i,.1+u(';:t,>','„x .l "'*ti 4t�d«tM�_�:k �i?:aW.n.P:�Sav}i @c4 T..r -h, V,.a � fi a•�( -v, :y'I i '9 .'fit''t '�v rte. M T•'�' T; to +,4 mer,tial,iindUttritkl'P:bst;Cdhtcol Servic>3A reement e V /(ppipp��,II�F,, f ,TI{U tv:qf.. .a v :,r,... 't',. Ii'✓n T'/ .��y�y �Hi' =•``M• t ro ks li° 1,w'''�•n* (fir'”" 1} IWYXN r 'ei ri, �' - r )�'R t � ,j ,.a +fl„•G A M F,, t,.,; F Dat t"ah `r• a f�� ' an��[ t�' 1” o,',,1, ^�'(5• s �;; f ,,:Ya;y.. e i a �vv,fi +' ," .•'r,CiUStORV9r .-\3' yr t,.fTj s.Yi t„yv v'�kry ^4'y :•'I,, a" ;,�,�y�.:S; ,e ..+"� . "7' ':V,. .., , y '.•TeE.,A"':s•r»'7_�__T-v'"'{r .__.S.ir/; iisp �' ��''� k'�hr:,Gr w^..+" �/�yy,AA t n � + aP:.},..n-., imi,.... ,,,.y.,; x . .f. .L i :' :.,. f - .I•�`jJ .:, g:';' Add ''�� „y .t C' �"Y C,..��• "� '„'. . ::7:'`�'f�:,. ,yt'3+i4!w�h: LM',.:.fab...,:1•di •F!f {e+F 'fi. ” „i' rha$s. e i1w'w• , .. 4"`k �,+rr.,b.�d^. {, �h(. , City; `.:St(�-l'+f'-.1•Vt'."1,*' 1 Siata r.> If- Z' Code n=,. icninformation and Location - f:•I• - •�>.., - GUtonl8f r J_ Tei H Mlip Cod- - It- City States - - - - - s Control:This agreement Is for the control of the following pauultiple Locations(see attachment) sts: { .)Roaches 'Ants. ' . setsMica 'Does not Include CAnts, Arita" ."Other, •_ , ;- -: - _ . _ - -'_^�,:-t: c'.�c;i';•• :,Does not include Termites,Wood Boring.insects or Flying Insects unless specifically mentioned: -.. AreatTha( ')interior { )exterior areas of the buildings)to be serviced Include the following: Special lnstructiops SeryEce ScbeduteE A=1 ExtermirtaTors will provEd= intensive service and will also provide - - I gularpest control services (c�$•1x month ( ) 2x month ( )weakly. ' Exterior RodentCantroL• ((( •))tx month (( .)) 2x month (( j)weakly. ' Exterior Insect Controh " 1x month' 2x month weekly. - Paymene In consideration aj th service provided by A-1 Exterminators,the customer agrees topay A-1 Extemunators,its successors or as- -signs the sum of$ �l � �, {} , l vdr�r each intensive service and$ for each regular service. lr"{" Payment Terms: ) Charge.Payment due u on receipt) ( ) Wr t of invoice. pp P )Total Annual Payment in Advance S less %discount$ $ for each intensiveserviee. $ for each regular service. S for eacbr.exterior rodent service. $ for eachexteriorinsect control service. Customer Obligation:The customer agrees to cooperate fully with A-1 Exterminators.Whenever conditions conducive to the breeding and harborage of pests covered by this contract are reported in writing by A-1 Exterminators to the customer,the customer shall take the necessary steps to correct such conditions. Pest Damage:The customer agrees that A-1 Exterminators is not responsible for any business disruption or damage caused by insects and/or rodents,on,or to the customer's premises or its contents,and the customer specifically releases A-Y Exterminators from liability for any such claims. Additional No Cost Service:A-1 Exterminators shall promptly provide additional service between regularly scheduled visits as it is deemed necessary by A-1 Exterminators. Services: Service is the inspection and/or application of pesticides for the control of the above mentioned pests. All services shall be performed in accordance with Federal and State requirements,and EPA and USDA standards. Materials: All materials used to control posts shall conform to Federal,State and local laws and regulations. A-1 Exterminators reserves the right to re-enter the customer's promises and remove any chemicals including rodent and insect baits upon termination of this agreement. Equipment and Products:The customer agrees to pay A-1 Exterminators for any equipment installed or placed on the customer's Property necessary for the control of the above mentioned posts. Insurance:Upon request,A-1 Exterminators will furnish to the customer a certificate of insurance showing coverage in effect. .. Terms of Contract: •This contract shall be effective for an original period of one year.Thereafter,this contract shall renew itself from month to month until terminated by either party upon thirty days written notice.Rate subject to periodic review and increase-by A-1 Exterminators after initial 12 month period. •The customer further agrees to additionally pay for any equipment or products ordered or installed on the customer's premises as determined to be necessary by A-1 Exterminators for the control of the above mentioned pests.Such items may include,but not be limited to the following:Bait Stations,Glue Traps,Multiple Ketch Traps,Fly Spray,etc. , A-1 emrnatorsACCs ted Rate .1'{. �.. p I � nnt, erne Pant Title By ;, Wrote Ofte COPY Yetlowsalas copy Pink-Cuslomer Copy _ Sign Name Massachusetts Department ofj PuYlic He I.th sale Int Board of Health ), w,- , w_ ` 120 Washington Street, 4' Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT - Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tyree of Ooeration(s) Type of Insoection / l)6 I ❑ Food Service ❑ Routine Address I lr' � Rist ( F& Retail ,.Re-inspection Level Residential Kitchen Previous Inspection Telephone 1 ` '' P �7 / (� El Mobile Date: 6(3P(a& Ownr HACCP YM El Temporary [I Pre-operation e -� El Caterer E3 Suspect Illness Person in C� �. ge(PIC) ' Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector _ 9� Permit No. ❑ Other Each violation ecked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Noncompliance with: Violations Related to Foodborne Illness Interventions and Risk 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 ' _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El_ a 13. Handwash Facilities EMPLOYEE HEALTH- "" .. . . , PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE " ❑ 4. Food and Water from Approved Source . TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods) ' , ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding , ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today;the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establish ment.operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28, Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other /� DATE OF RE-INSPECTION: S 5901nspectFomb-10 tloc o 0 0/--� Inspector's Signature: � / Print: 1 � ' n _ /t _!rte cam, n J/ PIC's Signature: // ��,� Print: '" �� £V�"R' I Page+of Pages Violations Related to Foodborne Illness ' Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT j 8 Crass-contamination 1 59O.003(A) Assignment of Responsibility' 3-302.1!(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* j Cooked and RTE Foods* j 2-103.11 Person in charge --duties j j I Contamination from Raw Ingredients 3-30111(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH I Other, 2 590.003(C) Responsibility of the person in charge to Contamination from the Envhonment j require reporting by food emplovecs and 3-30111(A) Food Protection, j applicants* ( 3302.15 Washut¢Fruits and Vegetables f 590.003(F) Responsibility Of A Food Employee Or An i 3-304.11....-; Food Contact with Equipment and Applicant To Report'ro The Person In Utensils* Charge, ( j Contamination from the Consumer j 590 003(G) I Reporting by Person in Charae* j 3-306.14(A)(B) j Returned Food and Recervice of Food* j 3 590.003(D) Exclusions and Restrictions* j Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions j ( Food 3-701,11 Discarding or Reconditioning Unsafe FOOD F ;OM APPROVED SOURCE Food* d Food and Water From Regulated Sources ( 9 Food Contact Surfaces j j 590.004(A-B) Compliance with Food Law* ( 4-501.111 Manual Warewash ng-Hot Water j 3-201.12 Food ma Hermetically Sealed Container* j Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* j 1-501.112 Mechanical Warewashing-Piot Water j 3-202.13 Shell Eggs* j ( Sanitization Temperatures* j 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 I Chemical Sanitization-temp., pH, j concentration and hardness. Ir3-2(12.16 Ice Made From Potable Drinking Water" _ j4601.1 t(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System" ( - j 590.006(A) Bottled Drinking Water* ( Utensils Clean" j 590.(k36(B) Water Meets Standards in 3 10 CMR 22.0* ( 4-601.1 t Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source j Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment, Shellfish' I 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I Chemical* Sources* j 10 Proper,Adequate Handwashing Game and Wild Mushrooms.Approved by ( Regulatory Authority 2-301.11 Clean Condition-Hands and As", 3-202.18 Shellsiock Identification Present* ( 2-301.12 Cleaning Procedure* j 590.004(C) Wild Mushrooms* j 2-301.14 When to Wash` j j 3-201.17 Game Animals" j j it Good Hygienic Practices j j g Receiving/Condition j 2-401,11 Eating.Drinking or Using Tobacco* � 3-202.11 PHFs Received at Proper Temperatures 2-401.12 Discharges From the Eyes,Nose and j 3-202.15 Package integrity" Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* j 6 Togs/Records:Shellstock j j 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification s j 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained, j Employees* Tags/Records:Fish Products j j 13 Handwash Facilities j j 3-402.11 Parasite Destruction* Conveniently Located and Accessible j 3-402.12 Records;Creation and Retention* j 5-203.11 j Numbers and Capacities` j 590.004(J) Labeling of Ingredients` 5-1-04.11 Location and Placement* j T Conformance with Approved Procedures 5-205.11 j Accessibility.Operation and Maintenance 1HACCP Plans ( Supplied with Soap and Hand Drying Devices 3502.11 Specialized Processing Methods* j ( 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced oxygen packaging,criteria* j I j 8-103.12 Conformance with Approved Procedures" j j 6301.12 Hand Drvinu Provision Denotes critical uern in the fe leial 1999 R"I Corte of 105 CMR 590-000. CITY OF SALEM 1 BOARD OF HEALTH Establishment Name: I/ An n _A HM Date: E/ r/V Page: Of 7 Rem Code C—Critical Item ' r DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date " No. Reference R—Red Item Verified 11 �� i PLEASE PRINT CLEARLY ! ' 124 'r-364 In I tl.A� Vfr.rnn� cJ� 15,4 jI J ,� ..; i A/1 ��'. J�/n..}'l•�T1w7✓� ���11A'n(Y /'I.gn �� I/T 71 l./"7 /�rlr I I � 1 � I � Y I I I ; I t, 7 E Discussion With Person in Charge: Corrective Action Required: I ❑ No I ( Yes 4. { I!have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion " violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension -cgmply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. \� 14V 0 Voluntary Disposal ❑ Other: 39GI.:4(-(-!) PHFs P.eceiroed at Temperatures Violations Related to Foodborne Illness mrarvenhnns and Risk A_cording to I as A Cnolcd lu Factors(items 1-2P) (Cont.) 4I'Fi45'F Within 4 Hums. ' PROTECTION FROM CHEMICALS � `-501.15 Conlin"Metbr ds for PHFs 14 Food or Color Additives ( 19 PHF Hot and Cold Holding 3-202.12 Additive,* 3-501.16(B) Cold PI-IF,, :intaiu. at(-ir below .• --� 3-302.14 Protection front 1`,tappet 590.00?;P) 41`I-i5'F";ed Addiirvec'' 1-501 16(A) ldnt Ph Fs Nlaintamed at or above YS Poisonous or Toxic Substances j 1�0�}•. 7-1171.11 Idenrit}vie lnh,rmation--Original 1 I s-5.;1 INA) Roasts Hila at or ahove I WE Container:." l 7-IO2 11 Common Nance-Working Container,," � ( 20 i Tame as a Public Health Control 7-30L11 Sepxuuion-Storae ( 3501.19 'bene as a Public'Health Control* ' ( 5`lJ1)C4iFit Variam,ekeyuircmcni f Restriction-PresLnce,rod t Ise' 7-202.12 Conduion:;of I!Ae' ! 203 11 'toie Container. - Piolhibmions'' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizcis,Criteria--C'hemicaly POP I,LATIONS(HSP) 21 3 `Il'I IIIA) Unpasteurized Pee-paekagcd.hriccs and 7-20;.12 ( Chemicals for Washinc Pruduze,Criteria' ( ! Beve;a;res with Warn,r•e t:ibeL; 7-204.14 Dru,n�,:'`u?uats.C;iteriu'' 3-RO!.: !tB) L'se:d Paaemizea Eger" 7-205,11 lucidrntalFo(wCbniart. Lubricitnt's* 13-80i,IIiD) iCavo-crPa!tiallgCcrkedAmmaiFood.md 7 2,06.1 i Restricted Use Pesticides Criteria" Raw Seed Sprouts hui Served. 1 7 20/},1 ) Pcxient Bait Stations- 3-801.111 CI Unoaened Food Pact,aee Nvt ke-sin'ed '" 7-206.13 Traddrig PmNders,Pest Control and Atoil;tor iTa, CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603 I I Comumcr Advisory Posted for Con umption of A,in:d F•rw.ds'lhtt are Rate.Undcr-ookrd or tfi Proper Cooking i'emperasures for Nnt i3thetwisc Processed to Eiunmatc PRFs 3-40LIIA(])(2) Eggs- 1557 IS Sec. Pathogen,-' ' Ergs-lm,nediate Service 1 5°F15aec, 1 3-302.11 Postelinzed Fags Subs.otute for Rax Shell 1-101.11(A)(2) CornimnutedFi,h, Meals&Game I Animals- Ii5'F 15 sec. ` 3-401.11B I l SPECIAL REQUIREMENTS C )l )(-) PurknndBeef.. r uast- 13J''F ,!2_7 min , o ?3-401.11(AY2) Ratite;, lnjeeed Meats 155"F IS 590.009! \)-(D; li4ucins of Sectionm 590.009!• .)-(D) in sec. catering, mobile food, temporary and 3-401.11(A)i"a) Poultry,Wild Game,Stuffed PHFs, I residential kitchen operations should be Stuffing Containing Fish, Meat, I debited under the ,appropriate;Sections Poullry or Ratites-165°F i i Set. " ! above;1 rc!ated to foodborne illness 1 3-401.11(C)(.3) Whole-muscle,Intact Beef Steaks ,ntervcntions and risk factors. Other 590.009 rinhatiors relating to gond retail 3-401.12 Raw Animal Foods Cooled in a I pracllccS should he debited under 1129 -- Micanmve 165'FSpecial Rerlitnerricntc 3-=101.11(•aI(1)(h) All OthciPHFs-- 1$�"F !5se( 1; Reheating for Hot Holding VIOLATIONS RELATED TC GOOD RETA(L PRACTICES 3-4()3.11(A')&(L)1 PHFs 16_i"F Li sci, ` (Items 23-30) 3-403.11(B) Nlicrowave- 165'F 2 Kit nine Standing Crilica!and non-(,41tvar vhd'raiv ny, orbith du irot rehire to the Time' fro;hurne.11hies;inter vennnn,e and risk fizc!ou:tined ahave. aan he 3-403.11(C) Connucrcialh Proccsaed R'rE Food- ,fwina in the follot,iug.vertimu,of the Fanrl rude alid 105 CMR wn'F* 5<0.000. _ 3-403.1 i(E) Remaining Umliced Portions of Beef I item Roasts* ---1 Gond Retail Practices FC .590.000 ( 23_1 Management and Per;nnnel FC--2 .003 13 Proper Cooling of PHFs ( 28 food and Foci Fuotecnon FG- 3 :DOA i 85. _rldpment and Uirns!is FC-a .005 3-501.N(A) Cooling Cookrd PHFs From 140°F m ( 26. Water.Plurnbinq and Waste FC-5 70"F Wohm 2 f lour:s and From 70'N 1 I 27. ?rim:,:al Facility FC--0 00?-- Lu 41"F(45'F Within.1 Hours. " ( 28. Poisonous or Toric loaterials FC-7 .008 __! 3-501.l-t(B) Cooling PHFs A9aoe From Ambient 29 Special Requirements 009 "Temperature Ingredients loth`F/15°F I ! 30. Oti!er -----� Within-4Hours� `,,,".- °'..,:16; J ' Denote,serosa,item in the itda.d 19x9 Fond Code nr 105 CNIR 590 000. >f Massachusetts Department of Public Health Salem Board of Health 126Washington Street,4t Floor Division of Fd'od ancrDrugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name r ]] Date // Tyne of Operation(s), Type of Insoection �J M. ) ) �ra/)7} �/ of�'o/<.1Sn ❑ Food Service [_1 Routine Address ' I / Risk ' m Retail Re-inspection d r Level ❑ Residential Kitchen revious inspection Telephone ii I C7/n ❑ Mobile Date: &1161p(; Owner k / 1/- 7/� ^ HACCP Y/N ❑ Temporary ❑ Pre-operation /`1 �l�I-F hr ad /�l G� f. ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast HGeneral ACCP Complaint In: �;c Inspector t t D0 QQ Out:,),) Permit No. ❑Other Each violation checked requires an explanation on the narrative pages) 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 - . ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties R- _ 13. Handwash Facilities 'EMPLOYEE HEALTH - , PROTECTION FROM CHEMICALS F-12. Reporting of Diseases by Food Employee and PIC [114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded . ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ,, , ... _ ,�- , ❑ 4. Food and Water from Approved Source ' TIMErrEMPERATURE CONTROLS(Potentlally Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling _ i PROTECTION FROM CONTAMINATION - - ' ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-4)(9590.090.0 044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the.food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 7. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 5001nsp UFO m 14 Ja n j J�74-;a 0 J�, / Inspector's Signature: `/ Print: PIC's Signature: // Print: 11 ' ' ' , Page pf<Pages l �-D v �� Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S I Cross-contamination I 590.003(A) Assignment ofResponstbdity* ( ;-302.1 t(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge` I ( Cooked and RTE Ftxwds* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Anirnal Foods Separated from Each EMPLOvEE HEALTH I I Other' 2 590.003(0) Responsibility of the person in charge to I I Contamination from the Environment require reporting by food employees and 13-302.1 I(A) ( Food Protection* applicants* 13-302.15 I Washing Fruits and Vegetables I 590 003(F) Responsibility Of A Food Employee Or An 3-304.11 j Food Contact with Equipment and Applicant To Report To The Person In Utensils* l Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge" I j 3-306.t 4(A)(B) I Returned Food and Rosen We of Food* 13 590.003(1)) ExclusionsaudRestrictions* ( Disposition of Adulterated or Contaminated 590.003(F.) Removal of Exclusions and Restrictions Food 3-70111 I Discarding of Reconditioning Unsafe FOOD FROM APPROVED SOURCE F(,d* d Food and Water From Regulated Sources I 19 Food Contact Surfaces 590.004(A-B) Compliance with Foch Law* ( 4-501.111 Manual Warewashmg-Hot Water 3-201.12 Food in a Hermetically Scaled Container* I Sanitization,Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.t 12 Mechanical Warewashing-Hot Water 13-202.13 Shell Eggs* I Sanitization Temperatures* 13-202.14 Eggs and Milk Product.Pasteurized* I 4-501.114 I Chemical Sanitization-temp.,pH, concentration and hardn 5401Water- 5401.11 ess. 'h .16 Ice Made From Potable Drinking Waterx I I 5-101.11 Drinking Water from an Approved System4-601.11(A) Equipment Food Contact Surfaces and * J 590.006(A) Bottled Drinking Watcr' I Utensils Clean* 590.0M(B) Water Meets Standards in 310 CMR 22.0* I 4-602.1 1 Cleaning Frequency of Equipment Food- Conmct Surfaces and Utensils* Shelflish and Fish From an Approved Source 4.702.1 i Frequency of Sanitization of Utensils and I3-201.14 Fish and Recreationally Caught Molluscan ( Food Contact Surfaces of Equipment* Sheilfish'l I 14-70311 ( Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I Chemical* Sources* I III ( Proper,Adequate Handwashing Game and Wird Mushrooms Approved by 2 RegulatoryAuthority --301.11 Clean Condition-Hands and Arps" 13-202.18 Shellstock Identification Present* ( 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms- ( 2-301.14 When to Wash* 13-201.17 ( Game Animals* 11I Good Hygienic Practices 5 I I Receiving/Condition I 2-401.11 i Eating.Drinking or Using Tobacco* 13-202.11 ( PHFs Received at Proper Temperatures* I 12-`107.12 I Discharges From the Eyes, Nose and 13-202.15 I Package Integrity- I Mouth* 3-101.11 I Food Safe and Unadulterated* I 3-301.12 Preventing Contamination Wlien Tasting" 16 I Tags/Records:Shellstock I ( 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 1590.004(F) Preventing Contamination from 3-203.12 Shellstock Identification Maintained'* Emplovees* Tags/Records:Fish Products I 113 I Handwash Facilities 3-40211 Parasite Destruction* I ConvenlenW Located and Accessible 13-402.12 Records,Creation and Retention* 15-303.11 I Numbers and Capacities* 590.004(7) Labeling of Ingredients' I 204.11 I Location and Placement* 205 - .11 Accessibility,ccessty, peraton and Maintenance 7 Conformance with Approved Procedures 5ibiliOperation I /HACCP Pians ( Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices ----- 3-502.12 Reduced oxygen packaging;crteria" 16-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures` I 16-301.12 Hand Drying Provision I *Denotes critical item in the tederal 1999 fond Cade ni 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH /� D Establishment Name: w.�t{� tJ�G(1 Date: 613a/J 4 Page: CP Item code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date ¢ No. Reference R—Red Item Verified ,E PLEASE P1y9.�1Nf CLEARLY �r`'/r Tf �f' /`T.1 / I ill Af�0 Il(.�n l/ (1 - r,- C+ l _J_ '�Q [ .) Iw '4 5 Ca(P J _ r2,rte(! r`e.C. )i-c d (C�w_ —lLJwJ� /a / )-) Iwnn�C vt L5� 1' '(ri� ..n / feGcJ.not� , �— n 11 Tl/'h/C. I cL, DC l o d I n 1. h Inn 11 I -- K !Dau,✓� 1 j I Discussion With Person in Charge: Corrective Action Required: ❑ No (� Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion vi014ations before the next ins P � Re-inspection Scheduled ❑ Emergency Suspension r comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of Embargo ❑ Emergency Closure `s your food permit. ❑ Voluntary Disposal ❑ Other: =-°.0+I Ian,i; Pt-iFs Rer;ztce,l.,:Tenrperrturee Violations Related to Foodborne Illness tntementions and Rtsk ,auurding to L:iw Crnled to Factors(stems 9.22) (Cont.) f)l-Fi45`t=WOon 4 Hours. ` PROTECT ION FROM CHEMICALS 3-5C:.i5 ':ootin*2 Methods for PIIFs 14 PHF Hot and Cold Holding 14 Food or Colo,Additives _ -50'.16Q3) CoL! PHF;Nl:rnt.aucr aI or ItJo s 3"2(1?,12 Additives* 5Ja.pi4&) 'tic 1_5°F" 3-30214 Protection imin l.nappnreed P.d:l;rive'" 3-501,16(Ait Hor PHFs Mwici�ned.:t or ahuv.: 15 ! Poisonous or 1 axle Substances i 71011.11 Identifying hiforn;;Ivon-O.iginal !40'F .16(.A) Roasts Fido at or aborc 130"F T 1 Contarnars" ( j 24 Time as a Public Health Control � 7"102.1 I Comrruon Nam: -11'n4inc Conr.:iners" 720 i.1) Separation-Stoutez" f 3-:101.'g ; T!:ne as It Nn-lir Heahh Control' 7-202.1 ! Rtstrietion -Piee.enee and Use' 590.W40 111 Va:iunce peq,vi Cement 7202.12 Conditions of tJsz' 7-203 11 Toxic Centaiuer,. - Prohib,nons+` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 I Saniti7cis.C'riieria-Chemicals' POPULATIONS(HSP) 7-'_'0,.12 i 01'1;emicala for N%ashme Produ,e,Criteria'' 121 ( 3 @111r A) llnp,sletarzed Pro-packaged Juice:and BeNemecs with V.arr:ne labels'. 72(-1.13 Drying.Ageals.C'nteria" ( I i(TI) Use.of Pasteurized Fapes" 7"205 11 Incidental Food Couuaet,I.ubrirant;^' %206 I t Restricted L'ee Pe<ticides. Crilcri r^` 1 3-k-1.i i(i)) Raw o; Partially C'o:r ed:;nmral Food and Raw Seed Sl-routs Not Served. ,t i"2(1P..1'2 Rodent Bait Station`` ( � 31.90;,11(0 unopened Fo xi Fackage Not Re-served. " 7-206 13 Tiarking Powdzr;,Pest Control and ( - -- Mon!torinn= CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advts-ry Pus.ted for Consmnption of lsnrrnal FrKids Th:a ae Raw. Undetcooked or - 16 ( Proper Cooking Temperatures for PHFs n,nt Othcnvisr Frnceeszd to Eliminate. ...,_ i i_ 301.i1A(I)(7) Eggs- 1.i5`F15 Sec.. ?-;011?.t3 Paste:msa;d F;ggs StdeLliU?e for Rut{v Shell Egos-%nmedirvc Service 145°Fl Ssec* 3-401.11(A)(2) Comminuted Fish, Meats&Chute Animals 3-401.11(13)(1)(2) PuAand BeefRoast- 130'F121ntrn* SPECIAL REQUIREMENTS 3-401.11(A)(2) Routes,Injected Meats- 15: 15 1)()9(A)-(0) Violations of Section 590.009(A)-(D) in sC1. r catering„ mobile forxi,temporary and 3"401 11IAi: Pouluy,Wild Game, huffed Plies, ,cadential l:tch�_n operations si-ould be Sml9ing Containing Fish, Meat, debited antler illiatppropriate sections Poultry or Ratites-165°F 15 sec. ' above if related to lroodborne i 3ness i4nl.l;(C)(3) Wbole-muscle, Intact Beef Steaks ! inlernentionsand'risk factors. 011ie- 145'F 50 0.009 g viola na-;:relating to good retail 3-401.12 Raw Animal Foods Cooked ;if a ( practices si,ould he dehited under N29-- Mictow;r:e 165°F'" Special Require,Icats. 3-401.11(A)(t)(h) Ai': Other PEIFt. - 1-}5"F 15 sec. 17 neheating for Hot Holding VIOLATIONS Flr1_ATED TO GOOD REElsIL PRAC:T!CES 3-403.11(A)&(D) PHPs, 165°F 15 sec. ^' (7letr_s 23-30) - 3-403.11(3) Miciowave- 165'F2-hone Standing Critical and run-rriticnb viulonm,), n nick do not relate to the Time" f'Odborn"dhieas integre:Hone and r,sk iu't,ry!ieled above, can he 3-403.11(C) Commer..tally Processed RTE Food- found in the following so.tionc o(:he Food Code and 105 C,LIR I YO'F" 590.000 _ 3-303.i1(F) RemainingUnshecdPortionsofBeef Ito.^ Good RetailAracllces i-C 590.000 Rovc;W I 23 Mananemerit and Perrcnne: FC-2 .003 Ig Proper Cooling of PHFs 24, Food and F=J Protect:Cn FC-3 ,003 3-- ! , o ,: 25. Equ.t:ment and Utensils PC-4 005 501 4(A) Coolin¢Cooked I HF.from Ido F o •28, Water, P:unit and Waste 5 .005 J '0'F�`rilhur 2 Flours and From".PF o P�_.;' ----- .------ _7 Physical, r,uty FC -r .007 to 4 FF/45'F Within;-Hours. " ! 28. Pwsonous or Tox,c Maierialr. PC,-7 ; .008 3-501.!•+(3) Cooling PHFs Made From.-'sari 29 Snerial Requremens .009 Temperature Ingredients t,,•1!°F/d5"F ( 30. Other --_� Wilhin4hlour>` Denotec.cluneal nem nr 110 Wleral 1909 Pm�d Cods or 105 CI\'IR:i916 000. ..y M 1 '1' Massachusetts Department; of )Pu.blic Health Salem Board of Health r , ! . 4 .q Y 120 Washington Street,4t"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tyof Ooeration(s) Tyge of Insoection _4vi (21.1(m'Q . I i e❑ Food Service �] Routine Address 1 �L' (� t ( Risk Retail ❑ Re-inspection Level Residential Kitchen Previous Inspection Telephone ry )1� ' j ❑ Mobile Date: N' l 1o5- Owner HACCP Y/N ElTemporary ElPre-operation O�CM(�fuC' M K nG ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint ln:inspector �� C D I Out: I-,) Permit No. ❑Other - Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. "FOOD PROTECTION MANAGEMENT ,• •� ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties - �13. Handwash Facilities EMPLOYEE HEALTH' •- ;, . , PROTECTION FROM CHEMICALS" ❑ 2. Reporting of Diseases by Food Employee and PIC - ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals r FOOD FROM APPROVED SOURCE' ❑ 4. Food and Water from Approved Source• `TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) . ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements 0 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans 18. Cooling 1'PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection e i, ❑ 20.Time As a Public Health Control • ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) f ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing E] 11, GoodHygienic Practices 'CONSUMER ADVISORY,;., ❑ 22. Posting of Consumer Advisories r Violations Related to Good Retail Practices i Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne llIllnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board Official Order for'Correction: Based on an inspection today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C .N 1 by a Board of Health member or its agent constitutes an 23. Management end Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations f ^' 24. Food and Food Protection (FC-3)(sso.00a) 25. Equipment and Utensils (FC-4)(5 0.004) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food X26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, Y ou y 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing .IL. 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE=INSPECTION: %,,S 59fnspe Fol 14tivc Inspector's Signature: 1 /� i Print:, PIC's Signature: V `. A/ Print: ^-,/r/oJ I Page-of Pages V Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT j 8 Cross-contamination . J 1 590.003(A) Assignment of Respon*ibility* I 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge" Cooked and RTE Foods* 2-103.11 Person in charge--duties Contamination from Raw Ingredients 3-302.11(A)(?) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003(C) I Responsibility of the person in charge to I j Contamination from the Environment require reporting by food employees and j 3.302.1 t(A) Food Protection" --- I applicants" 3-302.15 WashmL Fruits and Veeatables J 590.003(F) Responsibility 01'A Food Employee Or.An 3-304.1 i Food Contact with Equipment and Applicant To Report To The Person In Utensils* l Charge' ( Contamination from the Consumer J 590 003(6) Reporting by Person in Charge* j j 3-306.14(A)(B) ( Returned Food and Reservice of Food* J 3 590.003(D) Exclusions and Restrictions* I Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions j ( Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water Front Regulated Sources 9 Food Contact Surfaces .......,.,I 590,004(A-B) ( Compliance with Food Law* J 4-501,111 Manual Warewashing-Hot Water j 201.12 Food in a Hermetically Scaled Container* ( Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 1 4-501.112 Mechanical Warewashing-I-lot Water j 3-202.13 I ShellhggS* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized'" 1 4-501.114 I Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking WaterM concentration and hardness. j 5-101.11 Drinking Water from an Approved System" j 4-60 1A t(A) Equipment Food Contact Surfaces and 590.006(A) j Bottled Drinking Water* ( 4-602.11 Cleaning Clean' J 590.006(B) Water Meets Standards in 310 CMR 22.()* g Frequency of Equipment Food- Contact Surfaces and Utensils* Shei9ish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan ( Fain Contact Surfaces of Equipment* Shellfish'° i ^ "' T 03.11 Methods of Sanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed I ( Chemical"' Sources* 110 Proper,Adequate Handwashing J Game and Wild Mushrooms Approved by Regulatory Authority 12-301.11 Clean Condition-Hands and Arras* J j 3-202.18 Shellstock Identification Present* � 2-301 12 Cleaning Procedure* I 1590.004(0 Wild Mushrooms'" � ( -301.14 When to Wash* j 3-201.17, Game Animals* j it j Good Hygienic Practices j y ( Receiving/Condition 12401.11 Eating,Drinking or Using Tobacco* 3-202.1 t ( PHFs Received at Proper Temperatures* 12401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* � ( Mouth* 3-101.11 j Food Safe and Unadulterated* j i 3-301.12 Preventing Contamination When Tastingt'_j 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands -� j 3-20'_.18 Shellstock Identification * I 590.0(4(E) Preventing Containinationfrom 3-203.12 Shellstock Identification Maintained" Employees* Tags/Records;Fish Products j 113 I Handwash Facilities J j 3402.11 Parasite Destruction I j Conveniently Located and Accessible j 3-402.12 Records, Creation and Retention* j 5-203.t1 Numbers and Capacities* - 590.004(I) j Labeling of Ingredients` 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance I /HACCP Plans ( Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging;criteria" 6-301.11 Handwashing Cleanser,.4vailability - 8-103.12 I Conformance with Approved Procedures* j ( 6-301.12 Hand Drying Provision *Denotes critical Hent in the federal 1999 Food Code or 105 CNIR 590.000. F CITY OF SALEM I d - BOARD OF HEALTH s Establishment Name: /1 �r,�/1 Date:(�n� Page: 7�_ of Item Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No:, Reference R-Red Item Verified - . f PLEASE PRINT-CLEARLYff l Q ctoc l .�S, &r t_(7)ja.,n �.i��/ Llr2 C d S Irz- ✓I,)� r�./ ({ kA h- r---) Sfi,e- kPo A ot,5AA -,_ UP c)tq ' C�, /62"7 7�W,n�ti Aww' "SJ' ri(1p i /GrC(QQ 0." ,V ,-"A i r-C A I.)v�I cc,,) �2vr�T t�Prh C�tkl%/ /,130'..j( /I��e t��- 3,1 ? ter•/f, �/ f __ kr Q �l�n , �l1,r �Cs.✓t all 't i.✓ /� Ci f',? rY'b1 ,rt�....,vT�Y_ 07y Ui ''IV-0 � f-" G r✓�a a T � ( i 3 rr,T�/ ��(Jvion .• k ) nr -e I -v )Z C) I \CIVICMA r l rod hc/M 14, vt� zi— fCMr�Y!/ ( S1— l�r� Ar ZZ;4 a veer (~_-�Q , a, Jn /�_�� v P /k�.t�vr l -f C/ ?. r t ' 111 �r�unr. I1GJI s�/ l.,J• 1f.1 �J�-�e J 0-7 l�lJ�_ r 1 f¢M-)t/ud Ott A� . �?_ - - 1 ��F�= ill }(���,�J ('rrC�o.� r�r,vl trrn.,r'A r-vAat4-W- I `�c r�i 10 r< l lc �i2.). t — c s CtT� r� rc G J t<o co I( L7. r tJ✓I r O _ 11Z C..�i�(.t( -Tz Ilk) �'Jcr �,�I4- _ . eQ7 vc. !Ich(n /roc+-- c3� rf'n ` 2c$n„J;s ts92 ,L, � `f'`St)t. c t r _�I c -,-,o ► 1-i'C/ G n) Anr,� C'`AA/M(11 �it �4- Discussion With Person in Charge: r Corrective Action Required: I ❑ No �P Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to , Exclusion P ryR -ink spection Scheduled ❑ Emergency Suspension € corr!ply with all mandates of the Mass/Federal Food Code. I understand that `, noncompliance may result in daily fines of twenty-five dollars or son/revocation of ❑ Embargo ❑ Emergency Closure your food permit. /�] • ❑ Voluntary Disposal ❑ Other: 3-5; 1 14C P14F,Received Tc3ioe-ru`ares Violations Rotated to Foodborne Illness Interventions and Risk Accordant to Law Coo:ed 1 o Factors(items 1-22) (Cont.) , =1 F/45'FWttk:in4Hcus. 1 PROTECTION FROM CHEMICALS I 3 (;;.':5 C(xdm,-i:tioud.s or FHFs f j 19 PHF Hot and Cold Holding { { 14 Food or Color Additives 3.501 16B) Coli P111--s 3laint-,:ncd m or below 3-.1.02.12 Additaza'° � 590.001!F) 41`1,5'F., 302.14 Protection 'tom lmappnrved Additive;, 3-501 h�iA) 'lot PFF;Maintained at or above { y5 Poisonous or Topic Substances 40'F C .t ' 7-101.11 onLtpmc infonnanrnt-O:'i�$ial i ?. 5111.16(.A) Roasts Held at obo, 13(7°F. " { Container,' r a .c { { 7-102.1 i Cotruuun Narne- ��orkin:;Contanmrn'. 2Q Time as a P::bhc Health Control { 7-201.11 Seoa:atiou-$forase'; ( 3-50i.i9 TuneasaPublicHecithConttvl' - { 7 202.11 Restriction-Presencr and line` 590,00)4,H) V.:n arce Requir ment { 7-202.12 Conditions of Usol 7-203.11 Toxic Containci,--Rohthituat.0 REOUIREMEN'S FOR HiGHLY SUSCEPTIBLE 7 2114.11 Sanitizers,Criteria-Chemicals-'^ POPULATIONS(H$P) 7-104.L' Chemicals for Wsshm_Pro:':uce;Cnicri;," 121 3-5u L 11 1-3) L'npa:.teur izcd Pr:packaged huces and 7 204.14 Drying Acents.Criteria,- { 6ev;:.:ces wah Rmnine 1abetsM j 3 .11{H) Use of P.;ctemized Euce' { 7-205.11 Incidental Use Contaeaicict,Lubiterialt I3-801,1 1(D) Ra,; ur Partially Cooked Animal Frpvl and '7-206.11 Rcstrleted lis,-Peaiades.Criteria" Raw Sccrl Si)TolllR Not Sc.ad. " ',-20b.12 Rodent Ban etativas" 7-206.13 ')'racking Powders.Pe,t Control and { 3-801.11:('} Unopened Focal Pac'sage;Cut Re-served. " i 4kmioirin>;^ CCNSUMER ADVISORY TIMEITEMPER ITURE CONTROLS 22 3-603 t I Consumer A4%isor,;Pn.wd for Consumption of J6 Proper Cocking Tenipennures for Attinral Fetor,;1'l:at are Flaw. LTudercooked of PHFs i`4o'Ot!ier,vise Proceosed to Eliminate r Patho". * ee,•:5,=r.vx.. 3-401IIA(litG} Eggs- 15i'F15Sec. Eggs-hrnucdiate,,-twice {-'S`PlSsec* .11-302.13 Pasteurize,': Eggs Substitute fin'Roy,Shell 3-401.1 I(A)t,2) Comminuted Fish, Mcats&GatueEggs* Animals- 1541'F 15 sec. 'r 1 SPECIAL REQUIREMENTS � 3-401.it(B)(I)(2) PorkandBocfRoast- 130`1- 12; nunrj 5q;?/)09(:11-(D) ti'iolailonsotSecuon >90.0p9(A)-ill) in 3-401.11(A)(2) Ratite.;. Igjectca Meats-155'F 15 sec. * I entering. mobile food,to uportu2i and 3-401 11(1}137 Poultry,Wild Game, Stuffed PHFc, residential kitchen operations should be Stuffing Containing Fish, bleat, debzt.d undei the appropriate sections Poultry of Ratites-165'F 15 ccc. " above if related to fo idhorne ;!mess 3-401.1i(C)(3) NVMte-nmscle,IntactBectSteak, i me:veitions.vidrisk factor,. Other 145'P^` i i9t!,009 violations reia:ing to good mail It 3-401.12 Raw Aminal Foods Cooked in a praetic s should be.debited, ndei 1/29- Microwave 165'F'r Special Rega'srelnent,. 3-401.1 (A)(I n b) All Oiht:r PHFs- 145"F 15 sec. 17 Reheating for Hot Holding VIOLATKINS R.:LA TED TO GOOD RETAIL PRACTICES 3-403.11(A)&,(J)) PH Fs 165'F 15 sec. {)telrfS23-30} 3-403.11(b) Microwave- 165'172 Min rle Standing Critical and nun-critical viotwmn.,, which do r;ot,-elute to the Time' f o dborn�dlnes.;interremr my rend i isA fa(tors tis!td al ove. ,ca he 3-403.11(C) Comtncroally Pnaessed RTE Foot)- (wind in the follouo; .coition q%the Ft...el Code and I 05 CMR 140'14- 590.)00 I, _ 3-403.1 It Rrmvningliuslice,it'ui,ioncofBeef Item GoodHetatlfractitds FC 550.000 Roast:." 23 Managemert and Personnel FC-2 1 .003 13 { Proper Cooling of PHFs t 24. Food ar:d Food Prctecten K --3 ; .004 25 Egmpmaei and Utensils FC-4 1 AD 3-501,1,1(A) Cooling Cooked PHFs from 140`Fio ' 126. Water,dumbing and lniaste FG-5 006_ 70"17\4ithni 2 Hour3 and From 70"F ! 27 Physf.al Faci6N FC--6 007 u,4!`Fb95'F Within 4 Hou;s. 28 Poisonous or Tox:c Malenals .008 3-501 1416) Couling PHFs Made From.4mb,ent 29, SgCCIai RegUO-men's I-009 I Temperature Ingredientcr+ 41,�Pr45' 40''F I �-.-- _ _ - -- - - ----� Within 4 Hours* ! "".: Other Denatec crmh,al uem in in.,ledend 1004 Fn.xl Ct,&,lr 105 CMt2 590 660, j CITY OF SALEM BOARD OF HEALTH 4 Establishment Name: I/� ��1 {� ���n Date: Crl&/0/,. Page: �' of J Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY fzr�i�,/Z Cli h� c r.ln - a?1 - rtAa,-CJ &5d- 9j'_ u X,ACOC � c I es t i.1-1 �c�r�•�✓�e�e2s(.sr, 0T'11 l'a Move � � ��r J�. /t1G-v =_n O r Qha/n X05 FT J_ I,. C� njr u aNcw CX.� rwt acct / (an ( 1 OG fI A A-P�r1 c.. e�Jc,��. ��4/t.rI-�i..tl<�-C2.�. t�llt�l �- f P�1 Jr�cjr� "r� f l iii+ JCo 'fYV.4- ri n_l r!^ �/4�` f94&_ CSI ...,�C...�, '><�r..-Rr+rr v�►zi 16'ry-t a.�� 3�.F- ( o -j-� , oc. �,u�.y v� `� -�v�r�,� Ir�y a� iZ c IIG w rr Cir r / P,�rf V/ R ,�-3�. �V 1'44e f c��t J �7��t ter/•? CA"�t&A0,1et"?%Ce-f 11' n'j)<' / ver 1 r 1✓,A latci 5 cYN r moa%ae <'-( > W,1 , �rT7, �A .3-3❑' �1 /7k� 3c22tPl ct .Srn � c�A' c � Ffce GJJn�e2 ttn nJo� �7YIJL Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P '�Re-inspection Scheduled L3 Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five do1jars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. a ❑ Voluntary Disposal ❑ Other: _ V 5-S.,A 11;{; PHFs RcccnveJ a['Teml,;r-+ores - Violations Related to Foodborne lltness interventions and Risk A,o qr:i;m to t.nv Cucled D? Factors(items 1.22) (Cont.) 41'F4,`; F'Wi@-:in } Hour;. ' PROTECTION FROM CHEMICALS j 3-501.:1 Coo;ins Mrflicds for PHFS � L} 1 rood or Color Additives 19 PHF Hot and Cold Holding 3-5U!.16(B) Cold o'IPs Maintain--d al of below 3-202.12 Additives* ( 590.00417) 41",451 F' 3-302.14 !'axection firm 1 rmppro%ed Additive, 3-501 lfli A) ;-{ot PHFs tilaint;dneei at 15 Poisonous or Toric Substances ; 7r above 7-101.11 klentifivtc Irformab:,n--Original - z `.Cl.t6(3) Roasts flela nt or above 130°F. ' Coutniners* 1 ! 7-102.11 ,'onanon Nam- -WN,diitg Containers' 1 L0 I Time as a Public Health Castro! 7-201.,! R.:paratiou-Stuff age' ( j 3-507.19 Time as x Put,lic Health Control" 7-202.!1 Rcstti,tion-Ptewencemid Use, = .t;fi•ifHi VarianceRaouircnient 72.0:.12 CnndrtioiS of L'seT 7-303 11 Toxic Container,-- hi , " REOU!REMENTS FOR HIGHLY SUSCEPTIBLE 7-IOJ.t1 Sau:vers,Criteria-Che:ui�ak POPULATIONS(HSP) 7 .'04 12 Chewlcals for�y'ashn?c 1'r sfteC , c rn•rn:+" 21 3-8tH.!i(A) Lnpasteur:red Fre-packaged h:icee and 7-204.14 Drying I Severiges with W'drnina iarbeis^ 7 g Aectats,t:r:rr:a"' ;-801.!1(L) Ut,z of T'stearmd 1 7-%05.11 incidental Fotd Con6as.Lubricams" ( 3-801.711 )) Raw zn Pzrtiailp%arke�i 3ninaal Food and 17-206.1 l Restn�ted Use Pesticides.Criteria" 7-206.12 Ra'ent Bn:i Stauors` i l lCj Unopened Seed Sprouts Not Screed. 7-206.13 Tracking Powriers,Pest Conlroi and i ( 3-80L opened Penna Pnekattc Not Praerved Monnorin:;" CONSUMER ADVISORY Tl4AktTEd1PER4TURE CONTROLS 22 1 3-e03,i i Consumer Advisorp Posted fur Con<u aption of ' Aw"al F'oods'llidt me Raw.Ur:dercookt0 or i lti Proper Cooking Temperatures for T:a Odaerv;n.e Processed toEliminate PHFs e& Pr cense 1-,l Pat 4. _ OL11A(!J(2) Eggs- 155'PISSec. -30 .7 3 PAsteurized Fees substitute faw Shell L-;?s- lum:ediate Service 1•i5"F15scc : _ or R Eggs" 3--101.1 I(A)(2) Comminuted Fish,Meat,&Game I . Animals- Ii5'F 1S nee. 'k SPECIAL REQUIREi4"<EN?3 3-401.1 FB),i)(2) Pork and Beef Roast l it)°F 121 n n"' 3-401 11(A)(2) Routes,Injected Meats- 155`F 15 Sy0004(A)-(D) Violations of Section 590.0(19(A -(D)in sic.r I catering. mobile fora!, temporary and -•101.11(A)(3) Poultiv, Wi'.d Game,Slufled PHFs; [estdenGal l.ifchzn operations rJxndd he Shilling Containing Fish, Meat, debited undo:the appropriate sections PonlCty or Ratite,-165°F 15;ee. ' I above if related to foodborc i0ness 3-101.11;00) Whole-nnlecle,Intact Beef Steaks interk�n ions and tisk factors. Other 145'9 ( 590.004 t:olations relating to good retail 3-401.11 P,mv Anima!Foud:.C(ioked in a practnrs should be debited under 4`24- Mit rowave 165`F* _ Sneci:ci ltequuernaGts. 3=4011ItAalyb) All OthcrPHrs-- 14S"F 15 sec. * 17 Reheating tot Hct Holding ( VIOLATIONS R. LATED TO GOOD RETAIL FRACTICES 40?.11(3)&(I)) PHFs 165'F 15 se_ ;` (lte[ns 23-30) - 3-103.11(6) Microwave- 165' F 2 Minute Standing C,lural and non critical tiu!rrtioni, whcch;!o Im ,elute to the Tin?e" jun,lharne illite^c inte•rveattone and r'sk,)[mors listed above, can be I-403.1 4C)iC) Conmaercmlly Processed 1T'1-E Food- knmd;r,thejlllinndng.icuinn.c nl'dte Food Cede and Itis C.NR i 10'F" 590,00o. i ?-430;3.1':([.) Renia:mng Unzlice,f Portionsof licef ( ( Item Good Retail Practice.^, FC 590,001)---� Ruastc* b'3. M2naaercent and Per onne! FC-2 .001 -1 !$ ; n >Proper Ccoling of PHFs ?_4. Foot and Pool?:u!ectloC- 3 .J- C4 25. Equipment and i1t^nsas FC -4 005 ! 3-501 11(A) Cooling Cooked PFIFs from 110°P to > u! , n ,,u -- --1 • 4/ater urnbinc[a::.,4l� t2 FC--S .CUE 6 70"F t4'nInm 2lloere and From TPF 27. Phgsi.oal FaciNy -6 1 007 j t:;4 i`Ph5"F WilliIa d Home. ' 28, r oisonous or Toric Materip;s =C-7 1 .008 3-501 14(6: Cuobng Pf IFI.Made From Ambient 29 Soecid Rectu:remerls Tcmpeian[felneredientstodl`F/di'F L30. Other - ---- �-'-- Within 4Hours vnEl,iI;,,I Fenole;Tlncal ile,If,the f97rt'al 1019 Food Code or 105 CMR t90 01ln. CITY OF SALEM BOARD OF HEALTH Establishment Name: AA (7 AJ P� Date:_ G/C_[a G Page: - 4_ of cL 'F Item Code C-Critical item 1 DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified I PLEASE PRINT CLEARLY '� �� : �21�/.C� r��C✓,U�� n`�� �h-„Jvt c� �MIh�4 ��.rS� ( .r��i/ !: � T/t'I-�_ f_(7 15jzPrm�rt � I t I ,t � I I I 1 I I � I 1 1 1 I I Discussion With Person in Charge: Corrective Action Required: ❑ No es I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ r inspection, to observe all conditions as described, and to Emersion violations before the next ins P �Re-inspection Scheduled ❑ Emergency Suspension cor3ply with all mandates of the Mass/Federal Food Code. I understand that / noncompliance may result in daily fines of twenty-five doll rs or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �/��� ❑ Voluntary Disposal ❑ Other: '�r PHFs Retched at T•enrpccmir's Vir,7ations Related to Foodborne 18ness hrterveotiors and Risk ACcoolint=.to Uv, Cooled to r Factors(items 1.22) (Cont.) 41^F/45 F`,'rSthin 4 Hours. " PROTECTION FROM CMENiiCAI-.'v+ i 9-70',i5 Conlmg Methods for PHFc: j 19 PHF Hot and Cold Holding 14 ( Food or Color Additives3-501.16r t C::Id PI IF, Vhlintainud at of belao; j 3 202.12 Additives'" 590 004(_) 41`/45'F, 3 302.14 Protection)'rook Unaoprored Audi!ive;: ( Hot PI-IF,Mao ntameato, ovr d r ubI 15 Poisonous or Toxic Substances ( 1 1404-. Conwiner;>' ' 7-l0i.il IC!enelofovnation--Original 3-501 i5(A) Ruas!s Held at of above 130°F. '" mine ; 20 Time as a Public ltealttr Control 7-102.11 Common)Qante-l��urkme Cbnuuners` 7-201.11 Selr:,rstinn-Stu;ago:=` 1-501.1'9 Time as a Public Health Control'" 7-202.11 Restriction-Presence acid tis.'- 590"C'dl Hi Kati:mec Requirement 7-202.12 Conditions ot 7?U3 1l Toxic onturer,,-Prohibitions' REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitireu;,Cricerta,-Cheiioeals POPULATIONS(HSP; 1770,1.12 Chemicals Ior 4L'nshu,c Produce,Cuteno" 21 13-$UL! !(A) Lapis:eorii:ed Pre packaged luice:and Gere aces wah Waning Labels" _ 7-204.14 Dnmg rents.Criteria' 3-801 11(P) Use of Pasteurized Egg.,-" 7-205.11 incidental Food Contact,Lubricant.;" 13_$01,{1{17} Raw et Paaialiy Curkrd Animal FcxKl:,lad 7-206.1! Restricted Use Fe,tirales.Catena" Raw Seed SPinms No. Served. 7-206.12 R{xicnt Rao Senior.;" ! 3-801.11fC) Unopened Food Package Not Re-served. " 7-206.13 Trac-km,Po"":;erc,Pest CcmOvl and Ltonitorine; CONSUMER ADVISORY 22 ' ? 603 1 1 CO ;timer Advisory Posted for Consumption of TIMEtTEMPER9TURE CONTROLS j Anunal •r,+ids thin:vc Raw, t'ndcr:ovked of 16 Proper Cooking Temperatures for PHFs N:t ,metuise Processed to Eliminate 3--tOLIIA,!;(2) -vg4, ISo.FISSee. PL"o:T,m E!,gs-I Immediate Sen0ce 145`F!:isecr ( 3-502. IS Pasteunzcd E�,�S Subuitute for Raw Sheh 3-401.1 J(A)(2) Comminuted ted Fish,Meat,:4.Name I Animals- 155'- !5 see. 3-401.1 1(L31(I J(?) Pork and Beef Roast- I'O'F 121 min" SPECIAL REQUIREMENTS 5 r 40.009(A (C! Violations ats o. 59 , ,r 2 ) o c Scusoa . .( .Ot)9(A)-(U) in 3-401.11,A)f ) Ratites; Injected i4lcate.- 155'F IS et. catering, mobile Food,temporary and 3-<I01.1 U,:1u's) Y�ndtry, Wild Game,Stuttai PHFs, !'e,rd'Untial kitchen operations should be Stu@uta Cont mvng Fish,Paaal, debited under the appropriate seed.,rns Poultp,or Runes-165'F 15 sec. * above i=related to foodborne illness 3-401 1 I(C(3) Xhole-nnuxle,Intact ;cef Steaks j inrcrvent;ons and risk factors. Other 145-6 540.(709 violations(elating to x,od retail 3-101 12 Raw Animal Foods Cooked in a ptact,ces should be debited trader #29-- Miclowaoe165CF ! SpecialRequir:utents. 3-40!.l t(A)(l ab) All Other PHFs- 1.45'F 15 see. � 17 Reheating for Hot Holding V'IOLATION'S R.:LATED TO GOOD RETAIL PRACTICES 3-4011!(A)R;(D) 111-IFs I65'F15s,c. (I terms 23-30) � 3-403.11(b) Microwave- 165'1,2 Monne Standing (,riga,!r_r.,l nun-rr!ricn!vinr'ron,a, wflieh:4;urt re!a!e to th" i file" ,(oodbome diners nrterveraiur.,s and r'jo !actors listed,&ovr, can be 3-403.!I(C) Commercially Puxessed RTE Food- fouard in the tol6nving.s-,rrliuns n(the Foo.4 Code and 105 CNR 140"F" 500.000. 3-403.1 i(Ei Rentaininr Unshred Portions of Ree( ! Item Grod Retail Practices FC ! 50.000 1 Roasts' j 20. itfiarr7grmant and Personnel FC--2 003 Ig Proper Cooling of PHFs 25 Food and Food Protection FC-3 ,004 3-50114a C'ool.n_ 25. __ EUulnmcnt and Utunsus FC-, 005 ( ) Cooked PH Fs from 140CF to i ' 25. W,:cr.Plumu!no nd)Haste FC�-5 � 006 _ 70"F Within 2I-four.;and From 70"F j 27. Fh,,s.cal Fae;litV FC--6 007 f to 41'F/45"F Within 4 Hows.I _- j 26. Poisenuus or-mac Pdatov Ws F..,r / .008 ?-SUI.I<I(G) C;n,ing PP[Fs A1ade From Ambient I ' 29. specaal Reou,rements .009 Temperature :netedier to41�17115`F i0. Other ,; I Within 4 Hours {.ren.we crrucal r!em to tLr Rde,al 19-i9 R-oa Code or 105 CP11;5901100. Jul 26 06 02: 19p sunny 19767449710 P. 1 Ak z 3-Aly-0-T . Al {L.JBI Prminat�rs �NV�1�.E PLEASE REMIT PAYMENT TO: las RD REEi,LYNN,MA o1882.469i {Y Y 1s P.O.Box 310 Lynn,MA 05903-0310 0 781-592-7731 I-8118$254825 FAx't81392-7641 Past and Termite Control Professionals CURRENT 30 DRYS sD GAYS so DAYS ( Ri DATE DAY TYPE DATE ACUT.NO ¢ONTROL FOl3 - .. SERVICE CHARGE . ..- NUMBER UNIT PRICE AMOUNT ^ - MOUSE GL BD — - -^' - MULTI CT TRAP ^, DATE PROTECTA _ CHECK NO - - PROTECTA LP RTU BAIT STA _ COMMENTS 0 MC ❑VISA ❑DISCOVER RAT GLUE BU ACCT.If _ - EXP DATE SALES TAX C.D.D.❑ CHG 0 N/C❑ TOTAL DUE 1 TOTAL AM,OUN7 PD - W� ROW ADDITIONALCOMMENTS COMMERCIAL SANITATION REPORT Floors—Clean ............YES NO Counter Surfaces—Clean ................... Q ❑ Drain Areas—Clean ............... I...... Q - ❑ Rest ROOMS—Clean .................:....... Dining Areas—Clean ... ............ ❑ ❑ Employee Areas—Clean .......:........... . ❑ ❑ Looker Areas—Clean ..............:... ..... ❑ C RESIDENTIAL WARRANTY INFORMATION Storage Areas—Organized .................. Cl- ❑ - DWELLING TYPE WARRANTY YES❑ NO❑ Comments 1 Family . 17] 3 Family E: 30 Days C 60 Days Q 2 Family Cl 6 Family Ci 90 chars 0 6 Mos. ❑ ` 'REASON FOR NO WARRANTY -Partial service requested....... ....................................................................Ll Poorsarutation_..._..__......_......_..............._........_...._............_........._.... POST APPLICATION REQUIREMENTS • � � -Kitchen/bathroom cabinets not prepared..........._............................... OCCUPIED AREAS MUST BE VACATED FOR _ HOURS. -Closets/furniture not prepared................................... THOROUGHLY DO TREATED AREAS BEFORE THEY ARE ""•"""...""""""" TREATED DO NOT ALLOW ADULTS,CHILDREN,OR PETS ON -Rodent proofing needed........................................................................... � TREATED SURFACES UNTIL DRY. •OtFlar- CONTRACTINGENfITIESHAVERECENEDALLMASSACHUSETTSDEPARTMENTOFFOOD&AGRICULTURE'S PESTICIDE TIMEM BUAEAV CONSUMER SHkrTS,WRITTEN STATEMENTS,POSTINGNOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 DAYS PRIOR TO APPLICATION TIME.THE ABOVE SERVICE HAS BEEN SATISFACTORILY COMPLETED, wso-t CUSTOMER SIGNATURE - LIC.If I TECH SIGNATURE I TECH ND. I SEE REVERSE SIDE FOR PERTINENT INFORMATION White—01668 Copy Canary—CUSIDr*r Copy Pink—Remittance Copy umam�s♦�� Jul 26 06 02: 19P sunny 19787449710 Al 1Axd€,,TiinattO(&wo1so24�7 INVOICE PLEASE REMIT PAYMENT TO: RO.Box 310 Lynn,MA 01903-031D W 711.542-2731 1.810-525.4125 FAX 781-502-7641 - CURRENT ! 30 DAYS 68 DAYS 9D DAYS Pest and Termite Control Professionals - HT DATE MY ".PE DAM . CONTROL FOR - ., - - � S£RVtCE CHARGE - NUMBER UNITPRICE AMOUNT .. MOUSE GL BD MULTI-CT TRAP DATF - PROTECTA _ CHECK NO, l y -1 PR07ECTA LP _— COMMENTS RTU BAIT STA _ Cl MC 0 VISA 0 DISCOVER RAT GLUE BD ACCT,k EXP DATE _ _ SALES.TAX C.00 C CIS❑ we❑ TOTAL DUE TOTAL AMOUNT PD Ii 10 111 11 ADDITIONAL COMMENTS COMMERCIAL SAFBTATION REPORT FMors—Clean YES NO Counter Surfaces—Clean ... ............... ❑ ❑ Drain Areas—Clean ...................._ , J r, Rest Rooms—Clean ......................... ❑_. ❑ Dining Areas—Clean .............,...:..:.. ❑ I-, Employee Areas—Clean ... ............... .. ❑ 0 Looker Areas—Clean ............ ..... ..... ❑, ❑ Storage Areas—Organized RESIDENTIAL WARRANTY INFORMATION ................. 17)- ❑ Comments DWELLING TYPE WARRANTY YES C7 NO❑ T Family ❑ 3 Family ❑ 30 Days ❑ 60 Days C! 2 Family O B Famay ❑ 90 Days G 6MM Ct REASON FOR NO WARRANTY -Partial service requested......_............................_................_._......... ..._..Q POST APPLICATION REQUIREMENTS •Poor sanitation_................_................................_.......,,........,...................,p OCCUPIED AREAS MUST$E VACATED FOR_,._.HOURS. -Kitchen/bathroom Cabinets not prepared.,...__........................ __........_ � THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE •Cfosets/fumiture not prepared........_..._.....-..............................................('7 REOCCUPIED,DO NOT ALLOW ADULTS,CHILDREN.OR PETS ON -Rodent proofing needed.........,._-....,.............-................,._........._..............D 'TREATED SURFACES UNTIL DRY. -Other CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD&AGRICULTURE'S PESTICIDE T^IMEI�I-� „ BUREAU CONSUMER SHEETS,WRITTEN STATEMENTS,POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7Ns 1 / `I DAYS PRIOR TO APPLICAMONTIME THE ABOVE SERVICE HAS SEEMSATISFACTORILY COMPLETED. i 1 ` / CUSTOMER SIGNATURE _ __ i Y LIC 4 j TECH SIGNATURE a SITE - SEE REVERSE SIDE FOR PERTINENT INFORMATION Whito—Office Copy Canary—Customer Copy Pink—Remittance Copy Jul 21 06 10: 30a sunn9 19787449710 p• 1 R- AN [1L`".'1sG iS Jl � Opys OT f7Dl1h 6—OCGElfldbts Opt Ow dos Cuncl� �Pt 2t:t� 7�r X40 59 �� U=vtnLI - �al� �1�. CS'lc� V1Q} r 0. t �ftiC- t1�YtS� Tcr, �lav r ern ✓vv�irla �cr , { l ,a$ ti � Ilan �'SjhtrYst ;y65 had 5)rwyLQ un CQs� wee; Uric l� �(u4 e UUV1�l,,A' cty4uc4d o---Vf,6YL ,414qjo� j� Oe Jul 21 06 10: 31a sunny 19707449710 P. 3 A (781)lQ Gorporata Headquarters Cape Cod 183 Shepard Street 72 Main Street Lynn,MA 01902 Suite 7 592-2731 W.Harwich,MA 02671 X1.1 Exterminators 800525.4825 (508)432.5866 Fax(781)592-7641 800-499-5866 www.alexterminators.com {{Commercial, Industrial Post-Control.Service Agreement. 6, t RXt t ,at? Date: Customer � Tel. Addr— iO 3"t;i!/LG2 CZ,t.A9. 2 City `s o-1"'e- state Zip Code Service Informadon and Location Customer lel.a Addra<v C111 State_ Zip Cod- Multiple Locations(see attachment) Control•This agreement is for the control of the following posts: ( }Roaches ( y'Ams ( }Rats ( )Mice i )"Other 'Does not include Carpenter Ants,Pharoah Ants. "Does not include Termites,Wood Boring bisects or Flying Insects unless specifically mentioned. Area:The( )interior ( )exterior areas of the buildings)to beserviced include the following: Special Instructions: Service Schedule:A-1 Exterminators will providr Intensive service and-will also provide Regular pest control services 1 x month ( } 2x month }weekly. Exterior Rodent Control: )1x month )j 2x month (( )weekly. Exterior insect Control: ( )txerwngr ) 2x month-(- }weekly. Payment:In consideration of Nq service provided by AA Exterminators,the customer aggroes to pay A-1 Exterminators,its successors or as- signs the stast of 3 Ips '-•tot each intensive service and S. for each regutarservice. . Payment Torms:(( ))COD ( )Charge.Payment due upon receipt of invoice. ( )Total Annual Payment in Advance S less- %discount S S --for each intensive service. s=ror each regular service. s _tor each exterior rodent ser+ke- S for each exterior insect control scmice. Customer Obligation:The customer agrees to cooperate fully with A-1 Exterminators.Whenever bondibdns conducive to the breeding and harborage of pests covered by this contract are repottedin writing by A-I-Extemrinators to the customer,the customer shall take the - necessary steps to correct such conditions. Pest Damage:The customer agrees that A•1 Exterminators is not responsible for any business disruption or damage caused by Insects wx for rodants.on,or to the casiomer's premises or its contents,antl the customer specifically releases A-1 Exterminators from liability for any Such claims. Additional No Cost Service:A-1 Exterminators shag pro"provide additional service between regularly scheduled visits as it is deemed necessary by A-1 Exterminators. Services- Service is the inspection armor appiloabonof pesticides for thscortrot ottha above mentioned pests. All services shall be performed in accordance with Federal and State requirements,and EPA and USDA standards. Materials: All materials used to control pests shag conform to Federal,State and local laws and regulations. A-1 Extemtinators reserves the right to re-enter the customar's premises and remove any chemicals including rodent and insect baits upon termination of this agreement- Equipment and Products:The customer agrees to pay A-1 Exterminators for any equipment hnstalledi r placed on the customer's property necessary for the control of the above mentioned pests. Insurance:Upon request.A-t Exterminators will furnish to the customer a cer ificale of insurance showing coverage in effect. Terms of Contract •This contract shall be effective for an original period of one year.Thereater,this contract shall renew itself from month to month until terminated by either party upon thirty days written notice.Rate subject to periodic review and imcreasa by A-1 Exterminators- after initial 12 month period. •The cLoomer further agrees to addibors*pay for any equ ipmeacir productss ordered or installedon the customer's premises as determibed to be necessary by A-f Exterminators for the control of the above mentioned pests.Such items may Include,but not be limited to the following:Bait Stations,Glue Traps,Multiple Ketch Traps.Fly Spray,etc. A-t ennina(torrss_ Accepted Date ay ;t.?]Lc4 -7itr �/n(t r PrYn Nnme Prnl roe Title `1 K.`+'- RY _ - wh of Ce.0any Yeah.-sabs Copy Phk-COstorr.Cecil Name t - 'fr Commonwealth of Massachusetts s ; 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: Pump N' Pantry File NumberBHF-2004-0080 10 Paradise Road Salem MA 01970 LOCATED AT: 0010 PARADISE ROAD SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1Notes RETAIL FOOD BHP-2008-0181 Jan 3,2006 Dec 31,2006 $100.00 TOBACCO VENDOR BHP-2006-0182 Jan 3,2006 Dec 31,2006 $50.00 Total Fees: $150.00 PERMIT EXPIRES IDecember3l, 2006 Board ol'Health �� �•a�_' This Permit is not transferable and must be reissued upon change of ownership or location.The permit most be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonatious,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 5 at 10 I CITY OF SALEM, MASSACHUSETTS m BOARDOF HEALTH �I V Ll 1ZO WASHINGTON STREET, 4TH FLOOR If If a SALEM, MA 01970 TEL. 978-741-1800 DEC 2 8 2005 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR WW W.SALEM.COM CITY OF$ALEM JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH AGENT HEALTH 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT be A PUMP N PAIV'tRV TEL# 978'- 7�� '71° ADDRESS OF ESTABLISHMENT 10 PAPAW56 eoAD SAl6'M MA 0 t 4�0 MAILING ADDRESS (if different) OWNER'SNAME VInViAMMAD A KMALtD�1 TEL#7916 -4 4001 ADDRESS 1�2_�5 9m1A z S Taff[ CITY L,/m_4 6-� �"l , STATE V14 ZIP 2Z03 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 1JA Q A2 KVI61V HOME TEL#97g 31`S 2001 HOURS OF OPERATION: Mon6F -8 ue6nre_+ted6AvY Np huri�RM�N ,Sat AX-11 un.dAv-lly,N TYPE OF ESTABLISHMEUT FEE (check onlvl `RETAIL,STORE} YES NOless than 1000sq.ft. =$ 50 LJ(„� more than 10,000sq.ft. =$250 ----- ------ .. .._............... ............................l.ess.. ..t. _ha...-n-..2..5 s'ea" t-...... $11"60,-----..._.....- RESTAURANT YES NO s 0 25-99 seats =$150 more than 99 seats =$200 ......... ...... -----------•--.....------•-----...-----_-----...----...---------.-...----•-------...$11. - ..------------... BED/BREAKFAST YES NO 00-. --......-----•................_....-----•-----••----.....--.............--.... ...--..._......... ............_..-----------------------.... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT SOFT/�E� RVE YES NO $5 DO TOBACCO VENR} ! "OCQ 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. 1.2 of 2-31 4-' 834-7 Signature' Date Social Security or Federal Identification Number ------------------------------------------------------------ - ----------------�--r------------------------------ -------- Revised 11/03105 FOODAP2.adm Check#&Date 1 CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH nom° 120 WASHINGTON STREET, 4TH FLOOR �. SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Pump N' Pantry Address of Establishment: 10 Paradise Road Owner's Name: Mohammad A Khalid Restrictions: Application Date: 9/12/05 Permit for Food Establishment 319-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 68-05 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 +p, CITY OF SALEM, MASSACHUSETTS �« 7L BOARD OF HEALTH { 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �1�'o✓n P M ' Pa✓n -t`-w4 TEL# 781 6140 S9/7 ADDRESS OF ESTABLISHMENT 10 PARAO) SC ROi S AL,l MAq �o MAILING ADDRESS (if different) OWNER'S NAME MpH AMMA IN A KHA,�,_/D TEL# 7�D3 X262258 ADDRESS IV.4S RARIVAgA5 TeAIL CITY 2abReL"-xc STATE_ VA ZIP 2,Z.t9 3 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) *#(Nall Rs6- 7 64x591 EMERGENCY RESPONSE PERSON kkft! HOME TEL#93g 3!_t� HOURS OF OPERATION: Mon.—Tue.—Wed.--Thu.--Fri.—Sat.—Sun.-- TYPE on. Tue. Wed. Thu. Fri. Sat. Sun.TYPE OF ESTABLISH FEE check only RETAIL STORE Ly�S NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. E11Z more than 10,000sq.ft. =$250 RESTAURANT YES NO 31 q- Il'than25 2seats =$100 5-99 seats $ 0 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS 4 15-V MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE ,DY-ES��, NO $5 TOBACCO VENDOR T< NO 50" ALL NON-PROFIT(such as church kitchens) (k'll 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. 23l- y�- 83Sr7 Signature /'7�z ' .rl Date Jul,s Social Security or Federal Identification Number ---------------=---------------------------------------------------------------------------- --------------------------------- Revised 11/03/03 FOODAP2.adm Check#& Date---/a-' �• 3-�0, Ise 111111 Milllllll_ 0010 Paradise Road Pump N' Pantry City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ TelephoneItem Status Violation Critical Urgency Nature of problem or correction 744-9710 Non-compliance with: Not Done Owner: Anti-Choking N/A ❑ Alliance Energy Tobacco PASS ❑ PIC. ' i' Asan ASlam FOOD PROTECTION MANAGEMENT Not Done AS Inspector: As: PIC Assigned/Knowledgeable/Duties PASS ❑d RED David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected' Correct By: _, Reporting of Diseases by Food Employee and PIC PASS RED 8/29/2005 Personnel with Infections Restricted/Excluded PASSd❑ RED Risk Level: FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS ❑ RED BHP-2005-0073 Receiving/Condition PASSd❑ RED Status: Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED OFF #of Critical Violations' Conformance with Approved Procedures/HACCP PASS RED Plans PROTECTION FROM CONTAMINATION Not Done Time IN: Time OUT: Separation/Segregation/Protection PASS 0 RED Notes: Food Contact Surfaces Cleaning and Sanitizing PASS ❑Q RED 258 Proper Adequate Handwashing PASS ❑d RED Urgency Description(s), Good Hygienic Practices PASS ❑d RED BLUE: Prevention of Contamination from Hands PASS ❑d RED Violations Related to Good Retail Practices (Critical Handwash Facilities PASS ❑Q RED NOTE: Make sure that all handwash sinks violations must be corrected are stocked with soap and disposable immediately or within 10 paper towels at all times. days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 29,2005 ) Page I ora 0010 Paradise Road Pump N' Pantry must be corrected immediately PROTECTION FROM CHEMICALS Not Done Or within 90 days) Approved Food or Color Additives PASS ❑d RED RED' Violations Related to Toxic Chemicals PASS RED Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures N/A ❑ RED immediate corrective action) Reheating N/A ❑d RED Cooling N/A ❑J RED Hot and Cold Holding PASS ❑J RED Time As a Public Health Control N/A RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP N/A RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A 0 RED GeOTMS®2005 Des Laurlers Municipal Solutions, Inc. ( Rev. Aug 29,2005 ) Page 2 of 0010 Paradise Road Pump N' Pantry Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE 32 items found outdated. Owner must closely monitor all expiration/sell by dates. Some price labels covering expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels Equipment and Utensils FAIL Non-Critical ❑ BLUE Microwave has an accumulation of food spills and splatter Thoroughly clean microwave the walk in Floor needs a thorough cleaning including under all racks Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non-Critical ❑ BLUE The sink at the coffee counter needs barriers on the sides to prevent splashing on the coffe and supplies. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE Owner is not currently using the hot dog warmer. Owner will remove the warmer j and will notify the Board of Health if and when he begins using the warmer A Certified Food Manager must be employed full time at that time. Owner is considering moving a 2 bay sink from the counter area to the back room. Owner must present plans to the Health j Agent prior to making any changes in equipment or the layout of the store GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 29,2005 ) Page 3 of 3 a Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name �2 Date Tyrie of Ooeration(s) Type of Insoection C!/I1-l"o 2 1 u -1 -�_( V I ❑�P6od Service ❑ Routine Address ,�" o9� /D� Risk ® Retail ElRe-inspection la /`/4adXL5e /Tv Level ❑ Residential Kitchen Previous Inspection Telephone �M ryy�, 9171d y/11 El Mobile Date: S'/G-O 3 Owner HACCP Y/N ❑ Temporary El Pre-operation 0Z-e'/t7Z,y,C,< 61tleeG 4-/ I ❑ Caterer ©Suspect Illness342-oN Person in Charge(PIC) 1l✓I� (� Time ElBed& Breakfast El General Complaint I [_1 HACCP Inspector p l O Permit No. ElO herr 6R�'1.3�w1` v YY.�u,�la�r I out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH "" - UAIS. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 10. Proper Adequate Handwashing L]21. Food and Food Preparation for HSP � ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions G immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, signed below, when c x P 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590 007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: /3r0� S 590/nSpECtFOmi6-1400c So ector' Si gnat Print: Pi.avti'`r1g 211 ._-- r 7l 7Yl�ua u Z pfC's Signature: /,'u /�/ j Print: �/P�7� ,��� /y� "� Page of Pages Violations Related to Foodborne illness interventions and Risk Factors(Items 1-221 PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT Cross-contanuhation 1 590.00NAs As�ignmeut of Resigns:iraitN" 3-3u2.1 UAia l a Rau• Animal Fools Separated from 59U.003(B) Dwnonctrat:on of I(noA ledgO I ( Cookcd and RTE Fol)ds' Peron in charre-dude, Contamination from Raw fharedients 3(72.11 tAp I &av,Animal Food? Separated i om Each EMPLOYEE HEALTH Othcrr ? ;917.003(1) Responsibility of[hc nelson in chaige it:, I -ortaminario,from the Em:rerrnent require reporting by food employee:;and13-302.11(o,l Food Prosection` I applicams* ( j 3302.15 Wa fv:iF Friii;and Vegetables 590.003(F) Responsibility Of A Food Employee 1), An ;-304.1 I Food Contact with Equipment and Apjltealu'Ils Report To The Person in IJtensds' Clsame* I ( Coritatmhatipn from the Consumer 590 Ofi((3) Reporting by Person in C'h.iree" I ( 3-306.14iel)iB a I P.ehtraed Vinod_mit 12.'sC'v+s c"Food" 3I590.003(Di Exclusions and Restrictions* i I GtsposnsonofAdAvramdorContam;harea 590.O03(E) Removal of Exclusion,and Resiricnonr Food 3 7()! 11 Discarding or Recoiid,homng Unsafe FOOD FROM APPROVED SOURCE Food* 14 Food and'✓Va'cr From Regulated Sources ( 4 Food Contact Surfaces S�+C!ON(A-B) Compliatue with Food Law': I d-5111.111 M.emal W`a,.cw:e1.;!it;. Hot Water 201.1" Food in i Hermetically Sealed Contamcr' Smuifivation"-eniperatu:n,'. 3-201.13 Fluid Milk and Moll 4Piodacts' j i 4 '01.112 :vltchauical`,1'arewauhmg-Hot Nater 3-202.13 'Shelf L_Rs* S:mit'zntion Temperature<' 3=202 14 Eggs and Mill:Products.Pasteurized" I + .,JI.I 14 Clwhimtr rml Saniti.:aaon- nip.,pH, s a,ncentretsai and ha.dnees. ' J 3-202.16 Ice Made Frou:Polahle Drinkine Water- 11401 11(A) Equipmas;t ft.)d Contact Surfaces and 5-IUI.I I Drmkmc Wamutt ,rosn Approved Systrm" ( .. 490.006(A) I Bottled Drtnkins W wcrT I litene::s Cle:ut" V!,")111 Cleaning Frequency of Equipment Food- 591},0tib(B) Water bleeG Standards in 3!0 CR4R 22.0"' ,. ,-ontaci Surfaces mid Utensil." Shellfish and Fish From an Approved Source ( ^,._702.11 Frequzncy of S.:niiizani»1 of Utensils and 3-2()1.14 Fish and Recreationally taught Molluscan Lkuul MCo;:(act Surfaces of Equipment* 3-201.15 MoloUnislr' I 03 11 Methods of Saniti;%tion --Hot Nater and luscan Shr0{isb item:MSSP Listed ChenucaP' Sourced* j iiD ( _ Proper,Adequate Handwashing Game anWild d Mushrooms Approved by Regulatory Authority -;p1.l 1 Clean Conditionulition-Harda and Ar!!is" j I 202 IS Sheilmok Identification Present* ( ( 2--101.]2 Cleanin_Pro.xdme:1 .ix),)fA(C) Xild Mushrooms` I ( 2-;01.14 When to W'as!,° 3-271.1' Garue Animals* I LI ( food Hyt712nic Practices t g 1 Receiving/Condition ( 2401.11I Eating,Drinking or Using Tobacco* 3-202.1 ! PIIFs Received at Prover Tenipc roves' 2-401-12 Discha-gc;Front the Eyes. Nese mid 3.202 15 Pucka,,e fnt ;rity` Aloud, 3-IoLI1 I Fail Safe aid Unudullwated* ! 3-301.i2Fre,entinq Contamination When'f asting* 6 TagsJP.ecords:Shelfsiock I 12 DrevuritEcgi of Contamination from Hands j 3-202.16 Sheilstock ldentificarion 590.001(E) Presenting C!ntamination from 3-203.1" ShelLtockidcnliflcationMaimahied* Eiupiolee`' Handwash Faciiiiies lags/Records: Fish Product; Located and Accessible :?-}C2.:f Varausie Dcstrnction" Conve I j 1402 !2 Records.Creation and Rrteniuoni- ( :�2(13 11 Numhers and Capacities-5%O04(j) Labeling of Ingredients' 5-214.11 I L.ocadon and Placement' 7 Conformance with Approved Procedures 15-205.11 A:.cess;bility.Operatwn amd Alaintenance Supplied with Soap and Hand Drying I /HACCP Pians ! 7pvices 3-502.11 Specialized Pror;ssin^ Metlnids' ! ' n 6-30`.11 Hand,yashi::gClcans.r. Availability -103.112, 1- Reduced oxygen Packaging,cnaena'r I 6-301.12 j Hanel Dryins Provision I k1-103.1;: Confonnance with Approvedt roce..a nres" � .. Denotes cuamai acm H the:cd-2m 1999 Paod Code m 105jos a ou0. CITY OF SALEM BOARD OF HEALTH Establishment Name: 9 el,o Date: Lj J6 /,ILK Page: 02 of 2 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY SII / GTv.i�irve Kr�ni� ��cl /NSPer7'le77 li/pd /-,�e G�Gieui/ti v; !ea/uiX117,e NPPCIs U,C/i 6d �/rruPAy¢_ 7;6Ae4',G' / ll/ Sd�rr�� fRr�Lee .�ii�,P,ws�vaf' G�aAJ'-,vP��s L'et/e-,F ✓�"� y 4-- ?- 2 q 2q C, /D fob � �3�/ ��' �(sy°F/wi.vrd� 601),Ieoi/erZ?w /4fo�°Fd.P 4Bdde- r1� I Z Lf — A!h`r�Or/�Gt�`�'i ZA,0 cs ci*,.,t, r3�iFl°cSia r/ -(�tl7dt'S?*PohoiJ -Mmacle I&h/�0 27 —B?(5.�DrVAe �oSYSPFiak lyeedc �3.vPPb-1nGiLG /,t/ W;�b a-/- 7/J2PS/f'14 / � (ii274141,e_A1 il� / /riPM1 !Y lbaST J��rX vP X/ 'P ' / a/ VIS[/jLc l eeo . I ✓ ti9 / S/.7M1 �2/.ti9 Discussion With Person in Charge: Corrective Action Required: I ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P :3 Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty'five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit.' n /� l �J�`✓ EA /X �G/� � 0 Voluntary Disposal 11 Other: i 4 1(i') PLIFsReemed itTa7.peratur:s i Violations Related to Foodborne Niness lntervamions and Risk According h)I.a.v Cl)oled,u Factors(items 1.22) (Cont.) =41`D4S F'.Vrtfvn 4 Hoot; 'r PROTECTION FROM CHEMICALS ! 3-5i)i15 Ccoint,Nlethod;!or PUFF f 14 ( Food or Color Additives 19 PHI-Itot and Co'!t Ho!dtng 3-501.1;1131 Cold PHF, .1lruwamed at of below 3-20211 Addil:ccs^ °-9U.004(F1F- 3-102.14 Pauteclinn nom U itnoproced Add;uves" ! � Sql ICi1.A) Hot MIF~ t ' 1 - Maintained at or ahot•e 15 Poisonous or Toxic Substances 1,10'F.1(i'F .e 7-101.11 ident&orutlnfonnation-Oriaina! - ) Con!aimars" i-50!.!6(.1) Rcaasts Held at or above 130`F , Cn;t amers' -)o ime as a Public Health Control 7-102,11 C•ornmon Nance--t4t,xkmp t ' 1 1 7-'(11.11 Separation-StoutFe1' 3-501.17 Time a:.a Rbfic I-Ieatth('on+roN' I7-202.11 Restricnuo- PresenceandUsek I 041H? VariauzeRequirement 7-202.12 Condition,of Use" 7 '0311 ToxicC:,nteiuers-:'rohibitious' ' REG'UIREMENTSFOAHIGHLYSUSCEPTIBLE 1-204.11 Sanitizers.Criteria-Cneri cols^ I POPULATIONS(HSP) 7-201,1'1 Chemicah,I1: ,(_ r Nash( Prrdnec.Criteria" 111 3-801.t1!A) Unpastetu,cedPre-package Juicasand f I u,verages with 1Varnine I.,bels^ 7-204.14 Diving,er al Foo.Criteria' ! 3-801.1 BB• Use of Pasteurized tieq:;' ]-205.1 t Incidental Food Contact ;nhr)cants^ .,-g 1 ,Cooked - 7 206 11 Restricted list festiudes. C7!te,c:" - i � � Ul,i I(l)l Raw of PartisLl ,.00ker.Anintai Feud and R.rr.+Seed it7rauts \'ot Sa',ecl 7-206~.12 Rodent Batt Stations" 1 i 3-rul.I I(C) ( Unr;pened Fa xi Package Not Re-served. 7-206.13 Trachm2Powd:r,.PzstControl and - Nionito%,,° CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consarn.t Ad,isoiy PoAed for C'otsumptiun of : Animal Fotxl,.''hat.un Paw.Undetcookcd or _ Lt; Proper Cooking Temperatures>ar PHFs Not Oth.,rwise Pr.+ers:xd to Eliminate a--101.11.4(11(2) Eggs- 155'F 15 See Pathu;;ens.� - c•. 3-3(}2.13 Pa,teuriled Egg>Substitute R)r Raw,Shell L,z_s-humediatc:.,c-rvite 145"F15s.c 3-46,1.11(A)(2) Comminuted Fish. Meats r& Game I BFFs 1,t;k and 155°F 15:,st- ! '= SPECIAL RF-.QUIREMENTS 3-401.11(B 1(1)(,'2) Pork and Beef Roast- !3t)`'F 121 ,tin* ; 3-401.11(A)(2) Ratites. lnjecledNkat~-- 155°F 15 S u.009(A)-tDi Violations of Section 590.009(A)-(ll) in at cering. mobile food,temportu i and se" -101.1 HA)(31) Foultrv,Wild Came, Stuffed PHFs, ros;&ntial kitchen operations should be Stuifine Conetining Fish, Meat, debited under the appropriate Sections Poulity or Ratites-l5s T 15 wc. above if related to fi;CdhOrnC i ihtCSS 3-401.i i(C)(3) w'holP-ItniSCle.Intact Beet Steaks interventions and tisk factors. Other IaYI: : I +90.009 violations relating to goad retail 3-401.12 Raw- -4ninni!Bxtds Cooked in a I practices siould be debited under 929- Micruwave 165"F." Spe.xd R.'quiternents, 3401,11(A)(1)(h) AllOthe:PH Fs- 145"F 15 see i 7 Reheating for Hot Holding VIOLATIONS R. LAT ED TO GOOD RETAIL PRACTICES 3-403.11(A)'&(U) PHFs 165'F 15 sec. (Iteals 23-30) i-403.11(B) Microwavc- 165` F 2 Minute Standing C,it,,al and non-critical vtointr ms, which do not relate to th,, ''rine' I loodberne illnesv inteirentiuns and risk 1.1.urrs listed above, can be 3--::03.11(0) Commercially Pioce,sed RTE Food- I bond in :Fie jai G..ing sections of the Food Codand 105('PAR I40'F" I 59n.0u6. 3-:63.!1(!?) Rcntainine Unsi,.ed Por ons of rood item tinod i?etait Fracfires FL' 1590.000 R,asts' ! 23. tdanagernert and Personnel FC-2 1 .003 18 Proper Cooling of PHFs ( 24 Food and Favi Protxiioo FC- 3j ,004 25. Ecuioment and Utonsiis FC-4 005 3-501.14(A) Cooling Cooked PHFs from Ido"F to 26. Wafer,Pitinibir,-and Waste FC- .5 I .00b 70'F with:it 2 thin ra and From 70`F 2). Phvsica:Facility FC--6 007 j to 41•'F145`F within 4 Hutu s. W 1 28. Poisonous or 1 oxic Materials FC--7 .003_-- 3-5(11. 1U:) Cwfing PHFs Made Frew Ambient ! 29. Slowiai Renuiro:rnents 009 i Ttmpei,uurehtg.cdicntslolP'F/45`F 1 30 Other Within d 1lourc': - Den ow,,cnncal„epi it,!hr Inderal 1999 Fo,:d i\.dc or 105,CMI: 500W(). Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Typg of Ooeration(1 Tyne of Inspection d P� P,L� U�/,�-L7�Jrn pod Service 21)Routine Address i l� Risk etail []'Re-inspection m " '" AY100� Level esidential Kitchen Previous Inspection Telephone lay 91 ❑ Mobile Date:�_�_til Owner HACCP Y/N [j Temporary El Pr -operation?? /��Li/1irLn X n/P,p a y I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint /Kjil" -'I NI If_ ftr' G In: ❑ HACCP Inspector P 1/4/w 41, Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives El 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE E3 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): 0 of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofc Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Print: PIC's Signaf)e I PrintM n n r, F iM I r 1� i 1 Pagel of -Pages r"Rr I t 1. -r'rT -yr Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM, CONTAMINATION FOOD PRO FECTiONMANAGEMENT J S 1 Cross ontan:draton 1 5C)0003(A) ( Assignment Of Repo;.sibility- 3-301II(AI,:) Raw Animal Fords Separaicdfrom -- --- 590.003(61 Demonitration of Knowledge j (:inked and RTP Foods* 2-103.1 1 I Person in chane-clutie:; ( j Contamination from Ra,r,Ingredients 3-30211(A)(2) Raw Auimml Fotx1;.Separated trout Fach EMPLOYEE HEALTH I I Other= 12 1590.003((') Responsibility of the person m che:ge to J Cor:tavrhJion frim this-Environment J :'eciuire rcemmote by fond euq,!oye sand 3-302.1!(A) Food Protraction' I I I anpficrmv. 1 3 302.!5 lNa-hin>Fruits and Vegetables 590 o03(F) Responsibility Of A Food Employee Or An 1 1_104.1 i Fonb Crmhtct•.'vi t; Egai;mcnr ^nil Applicant'fo ReportTo The Person If, Utensils" I '• Charre"% ( Contatmha*ion from the Gonsumrr J 590.003(G) Reporting by Person in Charge" j 3-305 I ti Al;ti) J Retumeu Food and Resreice 131 5940030) Exclusions and Rer,Mchom J I Ctospositon of Ada'terated or Co taranated J 590.(A)3(Ii) Removal of ixclusu,ns and Restricti,ms j Food i.70L.i ! Disoanling of kcrrndidonmg U;isat, FOOD F IOM APPROVED SOURCE ,wd- 41 Food and tVarer From Regulated Sources ( J 't Food Contact Surfaces j 51 0.004;A-B) Comp')ance with Fuad Ia,,v* j 4-:i07 HI Almond Wmewashing-Hut Water j ' Sani tizat:un Tenn'Wres" - -- - 3 2 m 01 12 Food in a Heretically Sealed Cummer" 3-201.1Fluid Milk nod Milk Products1 5tsl.I vi,s .:hooal`,3'arewashtn F.ot l'<4ite, 3 ' j j . 3-202.13 Shell Egg * j i S.:mt:iation Temperaiure" I 3-202 14 Hg's and Mill:Product.,.Pasteurized'^ I ' .l 14 I Chemical Sanitizatwr:temp.,pt-1. --xncc.ntr ?u,u and hardness. .` J 3202.16 Tee Made Prom Potable Drinkine,}Vater' j ( 4_{;01.1 I(A) Equipnteni FaO Cuutad Surfaces and 5-101 11 Drmkme Water f-ora an Approved Sy;trn)' Utensils Clean'" 590.006(A) Bottled Drmki ng Water" I .1-502'.1; Cle.ming Frequency of Eouiitnient tiled- , J 590.Ou6(B) Water Meets Standaruc in JIf CMR 22.0* I ! Shellfish and Fish From an Approved Sourre ) ( Contact Snnnccsand Utem;ilss _ _9el F-equeney of Sanitization of Utensils and ' .:20!.i4 Sha..^.d Itccrcati:many Cat'ght Molhtsexn Fold Contact SnrlaeCn of Equ pultnf' •4ho11?ish' 4-703.1 I Methous of Sanitiziihon-Hot Water and 3-201.15 Motfusra r Shellfish frorn NSSP L;stcd i Chemical` Sources* 1 lit s i Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2.3p1.1 1 Clean _o,i,n on-Hands and amc ' Repula+cry Aulhori(v 3 202.13 Shellstock Identification Present' j ( 2-3`A.12 Cleanins Prr:edit-0 ( 590.004((') Wild D4ushrmns' j ( 2-101.14 When to brash" J 3-201 17 Game Animak* J 111 1 Goad Hygienic Praciires J � 2-40 i.?I hobo;?•Drinking or Urine Tubaao" 1{ ( Receiving/Condition J � ! 3.202.11 Pi IFs Received at Proper T.n:perat:res` 3-.11?L 12 Discharge Fr,,m tre Eyes, tins: and I J 3-202 i5 Package Inmsity" I Mourh4 3-IoLl1 Food Safe and L naduhcrated"' 3-30L12 Pre,-catm,Cordrtnination W".icn'Pa:rine* J {� TarlaJRecurds:Sheila#cck ( 112 J Prevention of Con?amination from Hands J 13-202.1 s Shellstoek identification" I ! 590.00='.P; 1?rsenting Conhumnsituu from J bmpl'oec"* 3-203.:2 ShellsL:ck ldentif'cation Mainlaincd" ( j 13 I Handwash Fac!ihies J3-=102.11 par a aFish Products f Ccnveniem';y t orated and Acccssfb:tt parasite [c Dest�uction" J 1 J 3-402 12 Records.Creation and Retention J 15-203.'1 Numbers anti(7apat.111, * 5-204.11 i,ocatiun and plat•:trent"` j 590.004ti) Labeling of Ingredients' j ,- i 7 Conformance with Approved Procedures J t i_".t t Accessibiln-,0ozation and Iblaintenance J 1 /HACCP Pians Supp,ferl with Soap and Hand Dryn!c Da'ricGs J 3-51)'? It Specialized Processmy,Mttliotls* j 3-502.12 Reduced oxwgen packaging,criteria` j 6-3U!.i 1 I lard washing Cleanser. Availability 8-!Ori.12 C'orfomtance with Approved Procedures' j j 6-3012 Han('Dryh>',Pi cvisu,;: 'Denoies rmiaJ nem in the fedc).J 191:,)FiH)d Gx!e of U)'(•1172 7"•tib)0, CITY OF SALEM BOARD OF HEALTH Establishment Name: /iiD71D 9 � r7� / Date: q-13-1) Page: 0- of oL Item Code C—Critical Item t DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item PLEASE PRINT CLEARLY Verified X�11,4rtie s,'-ieN "Te/r', lyna'_d l IV e- -4VA, N9 1)o 7` _n,-Ja. as AV r 7� '�7JifiirrT/� . �e°i�, r '1L Yts7n i�r/ /i f- %Cl0 °� ✓ �w.0 y 7L O 1,1ek- / Yf fJ OF �JY�ale V/n�iv / g-r.r /�i le � /ii/ / /Ns/21- 7' I � 1 . I � I � I 1 ,I . Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fins o�ty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 4� a L,(.�( .l'�t nD Q /— ❑ Voluntary Disposal ❑ Other: I i - - PriFs Deceived.!i 'Pemncr.unres Violations Related to Foodborne Plress Interv>ntions and Risk Aceirding to L,iw Cr,,iled to Factors(items 1.22) (Cont.) 41'-F/45'F Within 4 Hours. " PROTECTION FROM CHEMICALS ( 3-SOi I5 Comm;Methods fo-l'_HFs 19 PHF Hot and Colo Holding 13 Food or Color AddlOves 3.501.10M Cn,, Maintain-d- 3 02.12 Additives x 7 'i FHFs Maintau:u at or bzlaw j 59(1.004(F) 41'145` F'- 1302 la Protection from Unappnned Additive;ti ( ,-jt)1.IrYA: Hot PI-117i,Ptamnuned at orabove la Poisonous or Toxic Substances j an°F. r 7-I0i.I t IdenUtyn n; !ninrinatiun-Original i-5(;l 16(h) ;,oasts Held at or above 130°F. Containers- 20 Time as a Public Health Controi 7-102.11 Common Name - Workin;;Containers 7=20I.I I Scpara[ion Stnrxce' 1 3-561 :9 Time as a Puble,Health Conu'o:" -- 7-202 11 Restriction--Prsence and U.e* 1 590.004(FD V.i t:rce Re9mrewcut i 7-202.12 C„ndiiions,(if Use' !, 7 203.11 In is Container,'-Prohibi:ions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP' 7-204.11 Sadi:dzers.Crite•ut-Chcmic:dsT ' 7-204.12 Chemicals for Washin Pri�fuce,Cri:eria' Zt ?-SOL I;rAj Bevej gee withied Warning fed.-,ls sand 7-204.11 Diving Aeents.Cntena'" ( Berei aces with tVantin?t Labels' 7-205.11 1icidem al Focd Cunract, Luhncsntrt* 3-80i.]l(BI ilse,,f Pasteurized Ee^_sA r I J-SOF 11(D) kac+orP:aiiallyCa,kec( AnimalPixxland 7-_06 I 1 Ke::4ticted Use PesticxLa.Criteria Raw See.]Sprouts Net Served. 7-206 12 Rodent IlanS1ations^ 1 -2, . Ur.�-: ''sekareNot Re-senrrl. ' 1--?06 13 T'rackinL! Powdrra,^est Control and 20111(7)( - pend Fcxx1 t louitorin x CONSUMER ADVISORY TIMEIPEMPERATURE CONTROLS 12 3-603.!1 Ccneumer Aefi,isorn Posted for Consumption of Animal Foods T1:.0 arc Raw- Undercooked or lfi Propel Cooking Temperatures far PHFs Not Otherwise Prucesscd to Eliminate I 3-101.1]tit U(2) Eggs- 155'F 15 Sec. Pathogens.'- I.45`•PlSsec" x02.13 Pastd Fggir Substinae for Raw Shell EgLs-hnmetiiateSzrvice � eurize �' 3-401.11(A)(2) Comminuted Fish, Meats&Come Erps'" Animals- 155`F 15 sec. 1 3-401.11(F;)(1)(2) Pork and Brei Roast 130"F 121 min'" SPECIAL REQUIREMENTS 59u o(,9(A)-(D) Viclalions of Section 590.00','(A -(D)in 13-4(il.11(.A)(2) Ratitrs. InectudMeats-155'FIS � ) sec. 'r C^rerin,, mobile food. :emporarg anti 3-401.11(AU 3) Poultry. Wild G.,me,Stuffed PHFs, resicicahai kitchen ope;a0uns choald he Sioffinc Contalron=Fish,Meat, deLt!ed under the appropriate sections Poultry or Ratites-lbs-P 15 sac. ry above if related to foudborne illness 3-101.1107;(3) Wh,lh-muscle, Infect Bmf Steaks interventions and risk factors Other 1450P' 59(:,0;)4 violations relaiinr io good retail 3-401.12 Raw Animal Foods Cooked in a practi_es should be debited under 1t29- Micmtcave 165"F* Special Requirement::. 3401A1(A)(1)(bf All Other PHFs- 145`Fl5sec. ' 17 Reheating for Hot Holding VIOLATIONS RLLATEATO GOOD RETAIL PRACTICES 3403.11(A)Nc'D) PHFs 165`F iii sec. ^' � (Items 23-30) 3-403.111 B) Microwave 165°F2 Minun•Standing I Gritir:,(accd eon-rriti<n%sir,&a:one, n'Incla do not relate in rt,� Tina-" ,foodborne illness ince v,,, nuns pad ri.rk;4rcia's Curd above 'aa be L403.11(C) Commarcially Pio�e6sed tZ rE Food- ,Toned an the fsH�,,:mg s✓rrinnr.q;;h.^J''oo<t Code nn,1 1 its CMR 140`F" I 540./000. 3-10 3 1 It E) Remaining Unsliced Portions of Beef i ttem Good Retzii Practices FC 500.0oo Rias!'* I 23. h4anagement and•rersonnei I-C-2 .003 ! Proper Cooling of PHFs 24. Food and Fuad Protection FC-3 004 IR _.-_ _. _ ' �_25. Equipr:ont cnd Utensils FU-4 .005 3-501.14(A) Cooling Cooked' Pt[Fs (coat 140'F to 2R---- Water,Piumbinn and Waste FC- 5 .006 _--- 70'F Within 2 1fours and Prow 70"F 27, Phtr,ical Facility FC-6 007 to 41"F/45`Y Within 4 Houc.. "' i 28 Poisonous or Toxic Materials . C -7 ; .008 J 3-501.i4(F) Cooling PlIFs Made Frotu Ambient I-29, -Stas-tai Repuireauents .00S Temperature lncrcdierfN is 41"F/45-F 30. 0her Within 411:yar,!' Deno7e>ennead dem In rederal 19Qq Fund('ods or 105 r'pt}t 590 0'10. ' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Pump N' Pantry Address of Establishment: 10 Paradise Road Owner's Name: Alliance Energy Restrictions: Application Date: 11/18/04 Permit for Food Establishment 29-05 Frozen Desserts/ice Cream Permit for the Sale of Tobacco Products 007-05 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. 41-01w� '14� HEALTH AGENT CITY OF SALEM, MASSACHUSETTS a BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-74 1-1800 FAX 978-745-0343 STANLEY USOVIC2, JR. JOANNE SCOTT. MPH. RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Pump 'N Pantry TEL#(978) 744-9710 ADDRESS OF ESTABLISHMENT 10 Paradise Road, Salem Ma 01930 MAILING ADDRESS(if different) OWNER'S NAME Alliance Energy Corporation TEL 4781) 674-7780 ADDRESS 57 Bedford Street, Suite 101A CITY _ tanton STATE_ rJiQq_ ZIP UL4LU-4o5�1 CERTIFIED FOOD MANAGER'S NAME(S) _�lle�t__CERTIFICATE#(s)AD.O O.O45368 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Edward Davis HOME TEL#(978) 777-2898 HOURS OF OPERATION: Mor.��1�1=V ' , _ =t_t 7 d6Eky TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO �9— less than 1000sq.ft. =S 50 / 1000.10,000sq.ft. =$100✓ more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =5100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO 5100 ADDITIONAL PERMITS MAKE(not just serve)ICE CREAM,YOGURT,SOFT SERVE ES NO $5 TOBACCO VENDOR dQ `/_ osYES 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 Chaptr 62C, Section 49A, I certify under the pains and penalties of perjury that I,to my be t-know) d I' f,have filed all tate tax returns and paid all state taxes required under the law. /��� a�is/oy 0.4_1137--41R Signature Dale Social Security or Federal Identification Number ---—--------—-----------------—---—----—-------------------"--T.�/--- ------- - Revised 11/03/03 FOODAP2.adm Check#8 Date 6a -- 9 ] Q �/� CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH x 91 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 j TEL. 978.741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO t�r MAYOR HEALTH AGENT t�, ✓ April 12,2004 Global Pump&Pantry 10 Paradise Road Salem,MA 01970 Dear Owner, On March 29,2004 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old male purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Global Pump&Pantry is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco,snuff,or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of ONE hundred dollars(5100)for the FIRST offense. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4`h floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders,and other documentary information in the possession of this Board,and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, 900anne,Scott Health Agent JS/bas Cc: North Shore Tobacco Control Program Christina Harrington,Board of Health Chairman •I I� N2 2181 a 8 I City of Salem - Board of Health Violation Notice - Tobacco Sale to Minors This notice is to inform you that during a tobacco sales compliance check,your establishment violated the Salem Board of Health regulation#24 prohibiting the sale of tobacco products to persons under 18 years of age. 610. CO Pum , n PC-,-i--- Name of establishment Address 3PWoy S` t3 17 Nl Date of sale Time of sale Minor's age/gender Minor's ID# Adult supervisors Narrative report of incident and description of seller by adult supervisor who will testify at the Salem Board of Health meeting including a description of the seller I affirm,under the pains and penalties of perjury, that the above report is true to the best of my knowledge and belief. -lYl C &ory� ' Adult supervisor(Signature) Adult supervisor (Print name) mot y, VENDOR STATEM T: I acknowledge I received this Violation Notice on c3���/ -1H at�Alvnd I am being given a carbon copy of this notice I also acknowledge that I have been told that a letter regarding Board of Health follow-up to this violation will be mailed to me at the above address. X��alr.,� Otvn$/Iv�naget/Cle (S�gnoture) 40er v eager/Clerk(Print name) If vendor refuses this Notice or if Adult Supervisor feels unsafe in delivering it, an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information, contact the North Shore Tobacco Control Program at 978/741-5646. Board of Health-white/NSTCP-yellow/Establishment-pink 1` XO OXCWAEMf AT A SMALL AMGIE N SFE 7XIS SECUai121 _1� t NalN.ms NNaA®Ii NAS AN WI,,It(N��a1 MA1FXYW PMM®WAW@M4NR i=\ vto ova sT000 Dal¢96633 PAY * ***100.00 TO THE ORD///E'''��IRO�SNF��—,l 1 .S 1SIG , EEr 49" . 'a�� '. .r . -CIN ISTAIE ZIP iia S S S000i1M is 10 2 1004001: 68000040009 38 3,11 _ _ . i y' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH ¢ 120 WASHINGTON STREET,4TH FLOOR SALEM, MA O 1970 TEL. 978.741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Pump N' Pantry Address of Establishment: 10 Paradise Road Owner's Name: Alliance Energy Restrictions: Application Date: 12/15/2003 Permit for Food Establishment 194-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 44-04 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 Cade, 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 J q.p CITY OF SALEM, MASSACHUSETTS -xy BOARD OF HEALTH 180 WASHINGTON STREET. 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Pump IN Pantry TEL#(978) 744-9710 ADDRESS OF ESTABLISHMENT 10 Paradise Road, Salem Ma 01930 MAILING ADDRESS(if different) OWNER'S NAME Alliance Energy Corporation TEL 4781) 674-7780 ADDRESS 57 Bedford Street, Suite 101A CITY AIGPE�t0� .� STATE 8 CERTI LICA E s)AD.QO,9��J5368 CERTIFIED FOOD MANAG S NAME(S) ]S((aj'�[_��jj ,_ (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Edward Davis HOME TEL# 978 777-2898 HOURS OF OPERATION:Mon.g a a —Ag ru d nig htat. ? days TYPE OF ESTABLISHMF�tT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$50v '0 1000-10,000sgA =$100✓ more than 10,000sq.ft. =$260 RESTAURANT YES NO less than 26 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 ES NO $5 TOBACCO VENDOR c (/-0`� 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 1,to my best knows a lief,have filed all state tax atoms and paid all state taxes required under the law. �. /a f 04-1137.410, Signature Date Social Security or Federal Identification Number Revised 11103/03 FOODAP2.adm_ -Checka a Date IV�i a� 10 n!- J'-1,4 r,4-ice-e-3 ___ a CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET. 4TH FLOOR SALEM, MA 01970 TEL 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR JOANNE SCOTT. MPH. RS. CHO MAYOR HEALI'FH 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 : Alliance Energy/Bursaw Oil Corp. Name of Establishment : Pump N' Pantry Address of Establishment : 10 Paradise Road Type of Establishment : RETAIL FOOD Application Date : 12/11/2002 Restrictions : Permit for Food Establishment 80-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 19-03 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 14 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WAS14INGION S'I'RLET. 4TH FLOOR DEC 112002 SALE bM, MA 01970 - TEL. 978-741-IeOU (eri "}� M }a FAi. 978-748-0343 ;{ ALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS. CHO BOARD �� MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Pump 'N Pantry TEL# (9781744-9710 ADDRESS OF ESTABLISHMENT 10 Paradise Road, Salem, MA_ 01970 MAILING ADDRESS(if different) OWNER'S NAME Alliance Energy/Bursaw Oil Corporation TEL# (781)674-7780 ADDRESS 57 Bedford Street, Suite 101A CITY Lexinaton STATE_ MA _ ZIP 0220.4550 CERTIFIED FOOD MANAGER'S NAME(S) Mary Millett .GAERTIFICATE#(s)XS 3�0'r (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Edward Ed�waard DDaviS HOMETEL#(978)777-2898 HOURS OF OPERATION: Pn.a 7 e_Wed ii d n ip~ 7 qul'n y� TYPE OF ESTABLISH — FEE check only l RETAIL STORE YE5 NO D3 less than 1000sq.ft. =$50 06 1000-10,000sq.ft. =3100 rAl� (/X 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 S100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVEVSIN t $5 TOBACCOVENDOR / $50 ALL NON-PROFIT(such as church kitchens) $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 NIGL Chapter 62C, Section 49A, i certify under the pains and penalties of perjury that 1,to my best knowledge a d be have filed all stet tp x returns and paid all state taxes required under the law. — lls �/oL 04-113.7-410 ,,,'Si nature` Date Social Security or Federal Identification Number Revised 11/25/02 FOODAP2.8dm Chedt#&Date/n '>/7:3/i7//- / 02 ii-a�- ._... .. . . a».. _. .......�. .. .-. -..., ..- .�.,J-.R.-.+.. rr...�x�+CY'vw W�M"'-sV+n.y..-ye,.�nMMy1M.r ..�....._r-v+y.�.. u.s� w.- �-. -r. ..-....v-✓-aj THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 07970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date TV"^f nnPwtinn(s). Type of Inspection ©�",;� /7/ sy s16 A7 El Food Service eRoutine Address Risk RrRetail ❑ Re-inspection /O Pg rav!_rz /?na ,l Level ❑ Residential Kitchen Previous Inspection Telephone El Mobile Date: Owner / HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person In Charge(11I(°) - Time ❑ Bed 8 Breakfast ❑ General Complaint Inspector In: [I HACCP ���` �4.�.4G�.✓ Out: Ary Permit No. X -p? ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures El 5. Receiving/Condition ❑ 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction:. Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below c N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Print: PIC's Signature: ' r Print: Page/of?Pages FORM 734A HOBBSfi WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw AnimahFoods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* I Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-30111(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces 4 I Food and Water From Regulated Sources 4-501.1 I 1 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Contamer* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipmem* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing ' Regulatory Authority _ 01.1 I Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 I Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and l3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.0040) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 I Conformance with Approved Procedures HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: / I&I'" iv' /Ja, rrc., Date: �;__16 A T Page: of ? Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Items Verified PLEASE PRINT CLEARLY �\� d '�A:K-� �rgc.0 -,',.. L/,o� 5�,..c S'o wi /�_ i✓.�ra f s� S'�? S`�c— � ) /� S, /C srri A eoo vae� �a fdo, Seo F 1-76, �J� fu 7 T9a 13 / 2 / /S>. Ewa., NecQ .✓ C �¢ 1gLk G �A, c, fCcrt I I I I I I I I I I � I I n I ©.e. .•T CL473vR e r Q/F. O I I Discussion With Person in Charge: Corrective Action Required: I ❑ No I o.- fifes I have read this report, have had the opportunity to ask questions and agree to correct all Q' Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/ revocation revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0��� 1/1 L _71 y iL�t � [ —A' /(,C > o Voluntary Disposal 0 Other: 1(("1 PHFs f(,ceivvJ at'I*,-11:1.-rA0;-S Viotnticne;Rolafed to Foodborne libiess 67tervertfo,?i;and Risk A-or-!;n�!o Law(":"I-d to Factors(items l-?Z) (Cont) ,z Cuoi:::�,Methods for PI-IF; PROTECTION FROM CHEMICALS it) PHF HM and Cold Holding 14 Facie or Color Additives i-501 il',0i; orbulow, 3-202,i2 Aidditi%,Q,,' 1-302.!J Poa�cfion from throppniveJ Additnc-,� t5 ?.SOI Ir(A) Hot PI 0sMairn-u,�ncG' aoi above Poisonous or Toxic Substances 140,i= 7-101.11 Identifing Inkorro,tion-Or;;illal 3-5?j 1.16(Al, Roasts Held at at alnoc 1101" Containers" 0'.11 CuinnainNnine -WorkingCornainel"* Time as a F�Vbtic Health Control 2 5(,'3- 1,19 Time as a 1`4.J;,, HealthCon!roP' 7-201 It Sefairfl;on-5aolau` 59'0'.00,�(H) Vailala-�Koau�;cur�nt 7-202.11 Restriction--Prest-rice-awl Use* 7-202.12 Condilions of User -11'-2103 11 'Inxic Containcrs-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sarrizers.cf1teria -Clwlllic,110 POPULATIONS(HSP) 7-204 1-, Chcnfica`s hat Washing P!-ttluce.Cr;!?fiu' 1 21 4-801.1 (A) lhipavcuri'icd PrC-Dackagod JuiQts and 7-20-1.14 Dlviri�Agcnt".Criteria" I Bcvarjees wish Warnita, Labvo,:" 3-80i.I (B� ll!e of P-stevrizej fai:, 7-205 11 hicnientat Food Contact. Lttbijcarrts 3-liM i(D) 1 Raw,or Partitill-Cooked Amoral JI all 7-205.11 Reqrictcd Use Pcqt,ides. Oilena� Se"d SprClas Nu! S,I ved. 7-205.12 Rodent Bait Stations 3-801A 1 tQ Urarpned Food Pin!Ujec N..t Re-set'ed 7-206.13 '1 rackilw R ivders, Pest Control and Munilcline, CONSUMER ADVISORY TIME[TEMPERATURE CONTROLS 22 3-603.11 Consume[ Ad,iF(Ty Posted for C011valIllption 0 Animal Food;That are Raw, Undercooked or 16 Proper Cooking Temperatures for I Not Otherv.-ite lsrfwesged to blinnin"ac PHFs 3401.1 IA(I iQ) Ec,s- 155 F 15 Sec Fg,s-lmnrc.fiaac Service 145'Fl 5i,ccl 3-302.11 P-,acui`izcd Eggs Submitute for Raw Shei I 3-401 11(A)(2) C(jnonrniaed Fish. Mc,nts&Gatiru 155'F 15 sec. - 3-40I.Il;Bql)(2) Pork and Beef Roast 130 F 121 rinin SPECIAL REWRENIENTS 1 40 1.11J A (2) Rah cs,brijected Meat,- 155,7 15 590.008,A)-(D) Vicljq;ons of Sect;(,[, in sec. ca:erir.g, mob!1c tood. bernporitry and ;-401.1 I(A)r2) Poultry,'Wild(J1.1111C.Staffed PHI-s, tdichen opeiall"'Its should bc Stuffin-Contanualp Fiso Meat debited under the appropciah: sections Poultry or Ratites-1 6SF !'i,ec, e.h0VC If related to ;ooclhoi riv illness WI- muscle,-muscle, Intact Beef Steaks ';4)1.11(0)(;) iJdeTVCKL10n.s ani,€ risk factors. Oiliot 145*-F i 590.0100 violations relati tit It) ,rod ir, ail Raw Animal Foods Cooked in a practices,riuld be dcNied under#29- K'I owave 1 h,-T * Special Requirenicn;. '1-401.1 I(A;(Otb) A[I Other PHFs - 145'F IS see, 17 Reheating for Hat Hording 'AJOLATIONS R-1 ATED TO GOOD RETAIL PRACTICES s-+103.1 l(A)&(D) PHF,, 165'F 15 sec. " (items 23-301) -1-4()',.11(13) €s4iCR)WdVe- 105' F2 .10natic Slaralin'g, Cruiud and not criorid vi,lalions, hicli da rwt relate to the Time"` )aodb,,;ne:!b:en tm ei%cutiony and ri,k,locroi s lisled abotv, can be 3-4{13.1 I(C) Commercially Processed R-1 E F-od- 101111d bf the j`o;V,;wb,e see ti I oen eJ the food G;de and 105 CITH 14017- 590.000. 3-403.11(E) Remaining UrAiceLl Purl ions of Beef Item I Good Retail A--ctices; FC 590.000 Ro.ist.o 22. Vlanacennent and Pcrron-,sl FC I�01 S 18 Proper Cooling of PHF, I 24. f cal and Fond Protection Fr,-6 .004 25. EI'lipment and ulellsi:s FC-4 0105 3-50;.14(A) Cooling Cooked PHFs from 140'7 t;� 26. 1 vViaet, Flurnbinq and Waste FC--5 'OU6 70TWohn-i I Hours and Front'IXT 27 Ph0,^al PsOltv FC-5 007 io,l l'F/4.S'F Within 4 Hours. I 128 Pasonous cr I ox;c filaiciriais FC- 7 .008 3-50L 1 11(B I Cooline PHF's Made Fivin Aniti:,iii 1 29. Spe;rnl Requirements .009 Temperature hipre6:cnis to 41"F145'F I 30 other Within 4 fnuri:' l')99Fo,dC,de oi 105 UM 590.000. ( IMPORTANT MESSAGE ) FOR _ _��_ +Y• V DATE /T�IME OF PHONF / AREA CODE NUMBER EXTENSION_ O FAX O MOBP F AREA CODE NUMBER TIME TO CALL TELEPHONED I PLEASE CALL CAME TO SEE YOU , WILL CALL AGAIN WANTS TO SEE YOU I RUSH RETURNED YOUR CALL I WILL FAX TO YOU MESSAGE ck �7GNED mFORM 4009 MADE IN U.S.A NOTES CITY OF SALEM BOARD OF HEALTH `Establishment Name: Z AvA 10 7,15�2 wi Date:_ --?//.2 / Sl Page: of Item Code C-Critical Item ' DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date }. No. Reference R-Red Item Verified PLEASE PRINT CLEARLY I / 7i9 //l La✓C�iih/_ �r�i��� /� P� ✓✓�i/�2 h��.,. /id' s/ 2 / ' G1 t,,12u.h///J/�/JPv d _�i�iJ//17/J/� P I I I I I I I I I I I I I I I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes F I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure -w your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PHFs Received at'remperitures Violations Related to Foodborne Illness Intervention-,and Risk According!o I'sw Cooled to Factors(Items 1-22) (Cont.) 41-Fi45T Whhin 4 Hnuis. 3-501.15 COD!blit: Methods f.-.r PHEs PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding 14 Food or Color Additives 3-501.16'B` Cold PHFs Maihi-inw' 41 or below 3-202.12 Additives" 41'/45"F" 3-302.14 Protection front Unapinovcd Addifiws* Hot PHFs Maintaic-I at of above 15 Poisonous or Toxic Substances1(-,(.A, 14(Y'F. 7-101.11 Identifynitt Information-Original Containen,' ' 561.loiA) Roaso,Held at ,,j aboc, 130'F 7-102.11 Common Name Working Containers"' 20 Time as a Public Health Control 7-20 1.J I Separation-Stoi age' 19 Tone as a Public, I lealth ConlroP' 7 202.1 1 Rcstriction-Presence and Use'" 590.004(li) Vartanc. Reclub.-t-a-mrt 7-202.12 Condhtions of Use, 7 203,1 1 Toxic Container-,-Pri:hi bit ioris, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sjnitizers.Criteria--Chemical:,' POPULATIONS(HSP) 7-204.12 C[i for Washing Produce,C)in-ria` 21 3-x6 11(A) I'ripa�rcurized Pru p:ickazed Juices and Beverages with Wainin,'Labels"7-204.14 !hying Agents,Criteria 7-205.11_ Incidc intal Food C011taLt. I-A&I WUHtS* 3 11(B) Use(,I Pa.siteudzed L.-s, 3-S011 il(D) Ra%t r,; Paraall%'CuokcdAnianai Fwl and 7-206.11 Restrictive' Use Pe�aicides,Croet ia'l' I Ra" Seed Spiouls Not Served. 7-206.12 i Rodent Bait SLationsl 3-50;.1 I(C) ( UTIOPCIlLd Food Package Not Re-served. 7-206.13 Tracking powders, Pest Control ;aid Mointoriniv CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Ad,isoq Posted for Consumption of Proper Cooking Temperatures for I Atonal Foods 11u11 ire Raw. Undercooked ur PHFs Not Othevwke Processed to Elirriwaie 3-40 1.11 A(l)(2) Eggs- 155,-F 15 Sec. Immediate Scivue 145-FlSsecl 3-302.1? Poaeurized Eggs Substitute for Raw Shelf 3-401.1 I(A)(2) Comminuted Fish.Meats&Game 11g9s' SPECIAL REQUIREMENTS 3-40 1.11(B)(1)(2) Pork and Beef Roast- 130'F 10'F 121 min" 3-401.1 liA)(2) Ratites,Injected Meats- i 55'F 15 :i90 Cl()9(A)-(D) Violations of Section 590,009(A)-0))in see. catering, mob=ile food, temporary And 3-401.11(A)(3) Poultry,Wild Garrie.SLUffed PHFs" residential kitchen operations should be Stuffing Containing Fish, Meat, debited undict-the appropriate sections Poultry or Ratites-165"F 15 sec. above if related to foodborne il[tiess 3-401 11(00t Whole-muscle, intact Beef Steaks interventions and risk factors. OL1101 145-F A i 590.009 violations relating it) good retail 3-401.12 Rav,Animal Foods Cooked in a practices should he debited under 1/29- 1%4ictriwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs - 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS R.LATED TO GOOD RETAIL PRACTICES 3.403.1 I(AWD i PlIFs 165'F 15 sec. ': (items 2.1-30) 3-403.11(8) Microwave- 165'F 2Mnotte Standing Critical and non critical violations, which do no!reline to the liwdbo,-ne ooer,eini ms and t i+1, "Joclors!rated above, can be 3 403 11(C) Commercially-Processed RTF Food- i .1nund in dwjollowi,?k se(tw,o q1 the Food Code and 10.5 CJJR 14W Ft 590.000. 3-403 11(h) Remaining Uns'liced Portions of Beef I Item Good Retail Practices FC 1 W Personnel FO - 2 .003 Roasts* 23. , ratiernent and Peu.D, 24. 1 Foori and Fuffl Protection FC-3 C-04 18 Proper Cooling of PHFs 25, EQuionient and Utensils FC-4 _005 26. Water,Pla.mbwQ and Waste FC -5 006 3-501A,I(A) Cooling Cooked PHFs from 140'F to 70T Within 2 Hours and From 7WF 127. Physical Facility 1 FC-6 007 to 41-F/45"F Within 4 Hours. ` . 28. Poisonou-;or Toxic Material& FC-7 008 3-501.14(6) Cuolinit PHFs Made Fiorn.Arabient 29 Special Reciluiremcrits; 009 Temperature lnlgjodicm<it)41'F/45"F 30. Other Within 4 Hours, Dmote;trib=al i roni in the fedora] 14v9 Few Cooc�.i I(5 C..',l R"AM.6f 10 �curmrr CITY OF SALEM, MASSACHUSETTS , r �vg Idy BOARD OF HEALTH b 120 WASHINGTON STREET, 4TH FLOOR a, SALEM, MA 01970 TEL. 978-741-1800 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 : Bursaw Oil Corp. Name of Establishment : Pump N' Pantry Address of Establishment : 10 Paradise Road Type of Establishment : RETAIL FOOD Application Date: 12/05/2001 Restrictions: Permit for Food Establishment 165-02 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 43-02 These Permits Expire December 31, 2002 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. q"HEALTH"A'GENT CITY OF SALEM, MASSACHUSETTS +� BOARD OF HEALTH ° 320 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 RD TEL. 978-741 1iV7/ FAX 978-745-03430343 STANLEY Uspvicz, JR. JOANNE SCOTT, MPH, RS, CHO DEL 5 :n(il MAYOR HEALTH AGENT CITY OF SALEM HEALTH DEPT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT PL)MP N PA„rm Y� STEL#_(q78)'1JjAI-9 L} ,s `I I ADDRESS OF ESTABLISHMENT 16 NZAme RJ ROAD AI-.E.M MA 6 tg`1n A MAILING ADDRESS (if different) 1 C EI Sr f•n d,�p� (�N VER$ I rAn A CS 1923 o NAME r3LLasaw Oil- CoRPnP.A,- 1f7I`] TEL# �47$�(�l(n ADDRESS 21 CkiC-k' f£7r CITYAC A NVISm S STATE_&A ZIP 0� _ CERTIFIED FOOD MANAGER'S NAME(S) NIA CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON TosEPH AtwnRD HOME TEL#jjg8)3(,6- 1030 DAYS/HOURS OF OPERATION: Man._Tue._VJed.—Thu._Fri._,_,_Sat._Sun._ TYPE OF ESTABLISHMENT ` F5k check only RETAIL STORE ES NO /� O RESTAURANT Y S NO $40 BED& BREAKFAST YES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE aES NO TOBACCO VENDOR NO (jamNO CHARGE FOR NON-PROh as church kitchens)PLEASE INCLUDE COPY OF TAX EXEMPTFORM Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State 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. L, '/P- 1;?-J4 -01 Oq- 11311-11 ) `Sign ure Date Social Security or Federal Identification number Revised 11/1/01 foodap2.adm Check#&Date 0 32,K:5-,3 S�51,!L4;.3 -��.-- s�,^„�-•ti..^-+.,."'+�v-+4rPrw-fN'4*r°A'r.A..rerae:�^n^r-+.,�'wi°�-.a +�w�+.Ys,M1 ...:......................,. .,...,....,., THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM BOARD OF HEALTH Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name /,,,^ /� Date Type of Onerationrga Tvne of Inspection AV6d / //i ��/� �� ��/�/� Food Service �] Routine Address /� ( Risk Retail ❑ Re-inspection Level El Residential Kitchen Previous Inspection Telephone q'2� ^7,/�/ _ 2/D ❑ Mobile Date: Owner /// /T ` / C HACCP Y/N ❑ Temporary ❑ Pre-operation A"//-"'.9 C,_� 0 r / I ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) Time L1 Bed& Breakfast El General Complaint m ,/ /^ / In: ❑ HACCP Inspector e- `v/ j ( /4:f�f Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red ItemsI Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties 13, Handwash Facilities EMPLOYEE HEALTH �K., TECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source E:116. Cooking Temperatures ❑ 5. Receiving/Condition - El6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ElEl 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR o Health. 590.000/Federal Food Code.This report, when signed below c N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Pring-'!, '4-l/t 1 Nr- PIC's Sign`atlure A t Il/)?'.P)( fI Print: I Page,of�Pages ( f FORM 734A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION %+ 8 Cross-contamination _J FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 1590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.1 l(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD F IOM APPROVED SOURCE 9 Food Contact Surfaces 4 I Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H, 3-202.14 Eggs and Milk Products,Pasteurized* P gg � Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* IJ 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* JI 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 111 Good Hygienic Practices 2-401.11 3-201.17 Game Animals* Eating, Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes.Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301 12 Preventing Contamination When Tasting- 3-101.11 Food Safe and Unadulterated* 6 Tags/Records: Shellstock 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* Tags/Records:Fish Products 13 ndwash Facilities Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 16-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM L BOARD OF HEALTH / ' T A/y / � �� Date: ��! Z Page: of Establishment Name: 9 Item Code C—Critical Item ' DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R—Red Item PLEASE PRINT CLEARLY Verified Z' I P. tI f Discussion With Person in Charge:t g Corrective Action Required: I ❑ No L)Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to comply Exclusion 1 with all mandates of the Mass/Federal Food Code. I understand that noncompliance may LI Re-inspection Scheduled LI Emergency Suspension r result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other , t FORM 7346 HOBBS & WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41°F/45°F Within 4 Hours.* PROTECTION FRO d CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* 20 1+ Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw.Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Effective 11112001 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(8)(1)(2) Pork and Beef Roast- 130°F 121 Min.*I catering, mobile food,temporary and 3-401.1l(A)(2) Ratites,Injected Meats- 155°F 15 Sec.*I residential kitchen operations should be 3-401.1 l(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165'F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23.30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41°F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1499 Food Code or 105 CMR 590.000. s - 1 .«,♦•�.. •y,.-r.-r,......+'4...�h-..y;R.✓�:>"vi.r'a.�•k..Nre•N1a^w.:£i'T:.:..3..+rMf"v.ww•)'f'r-.�N.,v F.+✓'--+'+..w"'n•+.wpr-.. .. Xs+..rlyy..e-y.....-r-.�.N-e....^,r�..�_._ I THE COMMONWEALTH OF MASSACHUSETTS ' CITY. OF SALEM BOAR6 OF HEALTH Address: 120 Washington Street,4th Floor ' Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name / Date T f r i n 7yog of InsoectjQn �u✓h� �`��� yr� 3'/ry �, Food Service [Routine Address- /Ol'/G��P -�D�Q/ Risk El Retail ElRe-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ,yyy /5;J7 ❑ Mobile Date: Owner ��jj HACCP Y/N El Temporary ❑ Pre-operation /s% l .4-e/4tJ ❑ caterer ❑ Suspect Illness Person In Charge(PIC) �J Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector rT'.,ire 'O/u2 Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items), Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating ❑ El 7. Conformance with Approved Procedures/ HACCP Plans 18. Cooling 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing El❑ 10. Proper Adequate Handwashing 21• Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR o Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590 007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other /J//J DATE OF RE-INSPECTION: Inspector's Signature: !%� I Prink PIC's Signature: �� Print: Page otzPages FORM 734A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-co€tamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 1590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 13-306.14(A)(B)I Retumed Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces 4 I Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water II 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved Svstem* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301 11 Clean Condition-Hands and Arms* Regulatory Authority 3.202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 5 I Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 11 2-401.12 Discharges From the Eyes, Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 1 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 16 1 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 113 I Handwash Facilities I Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 I Conformance with Approved Procedures /HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM i S BOARD OF HEALTH ,F Establishment Name: ���''�/� J �/ Date: 1-7 Page: ^Z of t Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R-Red ItemVerified PLEASE PRINT CLEARLY l p�C a 7 /t�// _ �fJl/�'�//i/ir/ �hP/rf7>(/11JnC 6f✓ /si / ( 'df�/�/ _/irii.f yl../i_�/i/7r I �� I ' /I/i✓/hfl���/�/h � ��/i//'»/LhYl.fr!/ /r>4//1t ii�� ///Ji^�t - ' i ^/ 'ilrrr�.��f" ��/Ji/lPr>,1s-ii /�.-, ilk 1_/•ICJ .�/. �/7�_ /7s�iii�/s//Pi' g /lK P>Jl>./l�l (�or rrJ9//1?' /Jx�//if1�✓ h�-ii�Jif/ T'/v /'��1�� �, 6 F Jrh�J,n�i .O(r / fvs l��ri✓J:>>( /! vb�y>J%f f/si /�J/J j/i row k � I � r` Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to comply Exclusion ❑ Re-inspection Scheduled LI Emergency Suspension 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. ❑ Embargo ❑ Emergency Closure 5 i ❑ Voluntary Disposal ❑ Other C FORM 7348 HOBBS &WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41*F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F* Containers* 13-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* ' 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 13-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* 1 Beverages with Warning Labels* 11 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEITEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Enectim 11112001 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145*F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 Min.*I catering, mobile food,temporary and 3-401.1l(A)(2) Ratites,Injected Meats- 155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70*F 27. Physical Facility FC-6 .007 to 41°F/45*F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. a, ...,. yi. .. .,,,,,.r.:i.,c.'++t.•.('ir,'v�!°i bt� ;�Q 6'6tN<r.Y-NYx^'. :r h�"' ..;.�a�j,c-'v-��di�.R6iR9Y'T.T.t.!'W6 ,"�,TF�M�7'f���b ..,{'� If y �d Massachusetts Department of Public Health 120SalW Boardashington of SSHealth 120 Wtreet,41h Floor Division of Food and Drugs ° Salem, MA- 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT { Tel. (978) 741-1800 Fax (978) 745-0343 Name l I 1 Date Tyge of Ooeration(sl Type of Insoection Jm o (v �S-,/Kt 1 1^�� til D�q Z I ❑ Food Service Q Routine Address (l7 "IJGR7 c' f�Ju�/ Risk ®'Retail AF Re-inspection, ; (' Level ❑ Residential Kitchen Previous Inspection Telephone (�, h 7 +J ❑ Mobile Date: D /,) ✓y Ownerffl 9977SS II HACCP YIN El Temporary ElPre-operation /I r!C , I<lG, l I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP inspector h�a�v, I Outs, .(7 Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. - FOOD PROTECTION MANAGEMENT. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ., . PROTECTION FROM CHEMICALS ' ❑ 2. Reporting of Diseases by Food Employee and PIC El ' 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded E] 15.Toxic Chemicals -FOOD FROM APPROVED SOURCE`. .. ....� : TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION_ ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection El 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(MSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing 'CONSUMER ADVISORY " ElEl11. Good Hygienic Practices 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. I 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 2Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 244. Food and Food Protection (FC-s)(sso.004)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 5901n IFom 14 em Inspector's Signature: > ) PIC's Signature: ��j/,�- Print: r�� /,z Page_,���^� I Page,oryrr_ages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT ( 8 1 Cross-contamination j I 590.003(A) Assignment of Responsibility* j 3-30111(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* i Cooked and RTE Fouds* j 2-103.11 Person in charge-duties ( Contamination from Raty Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLO"EE HEALTH I Other, 2 590.003(0) Responsibility of the person in charge to Confammation from the Environment require reporting by food employees and j 3-302.11(A) Foal Protection" j applicants" ( +-302.15 _ _ Washing Fruits and Vegetables - 590.003(F) Responsibility Of A Food Empluyee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils-* Charge* j Contamination from the Consumer j j 590.003(G) Reporting by Person in Charge" 3-306.14(A)(B) j Returned Food and Rescrvice of Fixed* j 131 19O.003(D) Exclusions andRcstrictions* j I-- I Disposition ctAdulterated orContaminated j 590.003(() Removal of Exclusions and Restriciions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Ftxd* J 4 Food and Water From Regulated Sources ' j 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* j 1-501-111 Manual Warewashutg-HotWater j 3-201.12 Food inn Hermetically Sealed Container' j Sanitization Temperatures' 1 j 3-201.13 Fluid Milk and Milk Products* j ( 4-501.112 Mechanical Warewashim;-Hot Water j 3-1102.13 Shell Eggs* j Sanitization Temperatures* j 3-202.14 j Eggs and Milk Products.Pasteurized` j ( 4-501.114 Chemical Sanitii•ttion-temp.,pH, j 3-202.16 j Ice Made Froin Potable Drinking Water* j concentration and hardness. '" 4-601.11(A) Equipment Fad Contact Surfaces and 5-101.11 Drinking Water from an Approved System" ( Utensils Clean' 1 j 590.006(A)• Bottled Drinking Water* j 4-602.1 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0" ! j Shelifish and Fish From an Approved Source j Contact Surfaces and Utensils* J 4-701.1 l Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-70?.l I Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed j Chemical^ rn Sources* j to I Proper.Adequate Handwashing Regulatory Authority j Game and Wild Mushrooms Approved h}. 2-301.1 i Clean Condition--Hands and Arens* j 'ority ty 3-202.18 Shellstock Identification Present" ; j 2-301.12 Cleaning Procedure* j 590.004(C) Wild Mushrooms` j 2-101.14 When to Wash* j j 3-201.17 Gamc Animals* j ]I Good Hygienic Practices j 5 j Receiving/Condition 2-401.11 Eating.Drinking or Using Tobacco* j 3-202.11 j PHFs Received at Proper Teniperalures* j 24101 12 I Discharges Prom the Eyes, Nose and 3-202 15 j Package hnegrity* j Mouth* 1-101.11 Food Safe and Unadulterated* 3-30 L.12 Preventing Contamination When Tasting" j j 6 Tags/Records:Sheiistock 112 Prevention of Contamination from Hands j 3-202.18 Shellstuck Identification1 j 590.0W(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* j Empin}ecs* l Tags/Records:Fish Products j j Handwash Facilities 13 - j Conveniently Located and Accessible 3-402.11 Parasitc Destrction' j 3-402.12 Records.Creation and Retention' j j 5 203.i 1 j Numbers and Capacities* 59(10040) Labeling of Ingredients' j 5-204.11 j Location and Placement* j T Conformance with Approved Procedures 15-205.11 Accessibility.Operation and Maintenance j /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices j 3-502.12 Reduced oxygen parka)6m;.criteria" j 0-301.11 I Handwashing Cleanser,Availability j 8-103.12 Conformance with Approved Procedures" j 6-301.12 Hand Drying Provivon j 'Denotes critical rem in the Federal 1999 Fuel Cede or Ii j CMR 590.000. CITY OF SALEM / BOARD OF HEALTH Establishment Name: f/Ji to 1./ /fns N Date: d_f/ cflf)� Page: �— of Item Code C-Critical Item, j DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference' R—Red ItemVerified I r - . ' PLEASE PRINT CLEARLY / I 1 I 1 i I - i 1 I I I I I 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ E cEmployee lo a Restriction violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that / noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure / your food permit. / ❑ Voluntary Disposal ❑ Other: 1 i ',:Ot 1j,, ;' f'lff,�Rea•iycd?t TentNtrabees VictiaFicins Rotated to Foodborne fitness 1nlarveniiuna and Risk -NE-vording,to Law Cltoid to Factors(Ellerns 1-22) (Cont) I '144YF Wjt6n-1 flows fEor PTIR PROTECTION FROM CHEMICALS 140 F Hot and Gold Holding 14 Foad or Color Additives NIVilit'l;rEed at of b,41,w 1-302,14 Ptmccj;,rn from Uiia,,flruve.d -kddoi,,>s' A,i PHI-.islaelifawej at orabove 35 Poisonous or Toxic Substances !40T, �t ;f,fA! Qw,i,�ia Held at i `WP 101.11 Welaityuo,'hrtft,lul�llioa- 011,,�'IVNIV colajoe,- T�mne as�Public Health Control 1 7 102,11 Common-Nam, Wk=rkine Com,on-n." ulwk- sloraitc" 7-202,11 R,�,tiictioa Fr,,scitco End Ucit` V�Iiance XwDEcolclif 7-10'.12 of USQ, REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2w [I Toxic Coataim; -Nollibil'om POPULATIONS(HSP) 7.204.11 Sanit;?er:;.Ontert?-clictoic:'k 7-?f)-3.1 2 cilclakak for W,v hit,., l%odqce Cli,ezia, It EAMAI(A'� Uapa:ic•irmen Pce.pa,-i:agitd loices and i1c,"f,mes vith V%andlip Lab,,W 7-M4 1.4 DE-ving Aavul�.FrIlVila' 1-20,5,11 IncidVrail F,t)(I Contact,I ant icaw v u,c of 7-206,11 kc,imc:cd U&v 11�,iic,� If iltil,It Criteim' 1 ita�� ,r Paoialj,, G`(tk-d ARiMi FiXKI 11A I Rw, St t-d Spr,,ai.ly)l Ser voi. I i 7-40.12 RkAVIa bmi i.1;'f C i I rooeiwd F,.,l Paii:s.t: Not R, 1-W 13 Twckinti N,tdVr:. UviltiO and lionlioriTi". CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 2z I I Cc'u'umf qm,VT Nal'isers po;;t,d f'a Cm-molition Of i 16 Proper Cooking loi =,A Olhtm;se ;4j Hill PHRI, 40 1 11 A(I i(-*) 111a, "i'E'F I J"'o% —o .11 M Tc,nr,a Ec�z Siibawui,- to Raw Shell 3.40!.11(A)f l) coiruldflwcd Ftnii, Mt.,oD&t1sinc 3 Aoitwtl,- t:=sec. SPECIAL REOUIRE&IENTS 4(11 11(B)(I jQ) Polk and flt'd Ktxtm 1 ,f)"F Ql rairit i9,0 0-14iA:-El), oi'Secbi ,n 5-W tX,9iAj f D) in klgite>,I,,j(-c-,W NIV st,, 155 F 15 1 ;lik-bil"teilj,temp;;rai t and 1 40!-11 A ECY, reSideqlilal kitviv:n opo--ttions 4 bould be Fis'll. d,+wce vilticr file appoprl ma's cekl-1011ti I-'ofjlo V(,I !conic;: 165`11 -buV(-,if I elaik"i 1�)to.,dbktrne (!lnes* 3-401.11 ECK,) 9Vh,)!e-muwlEt. hvim 11, J S1,jtk, Otber roalirli' !o"oExi faith .;',1i.1_2 Raw NaErrial Fc,sJ,Cixlk.d in a t jwecuc�, hoii!d rte dehited under#29 - lf)51 I Al' kXh--1 ilff - 115'F 15�cc I 17 Reheating tar Hat Holding VIOLA TiONS RELATED TO GOOD RETAIL PRACTICES ItA}&-fW I .0 lilemi; 23-36! A-iw.l uii) 165°F 2 MEow,-S!JcAiilr Wt iih do no; ,irate v)litc. Tlrky?l rnt i!l,^yt cwi vew.,wwid rt:A /o,o,rs 1:,ted ahtwr, (an bf 3--403,1 (,njjar- 'JaIJV jljlt>re�jod Wit-JIKO E'ood Cod-"wd 100 CUR 140 F' I Rom cr,04 ReWU practices 1 FC 590,WO -463A 1(F.) Remalmu", Uo�hcoi PEq pit as of licci 1 Aw< -ii I!I n,4 Ptii>Ctt;rQl PC' -2 om ER Proper Cooling Ell PHFs 'ind rkA 120 i ,vid ut"al-,q '-501,14(A) Ctslim,-C�K)Kcd PliFs frim 14(PF it, 'Ntu pl:'m 2F, a W Et4!e I F , 00b - - ;il,F Within 2 fTour:;wid From 79,F WFa:01 IN 3 .007 41'F(45 F\Vifl:m 4 How,!, PV_,_-101s >, T:Ixtc M-i,oka!� FC -7 60f,-1 it)[A 4 c4ictllw,Pilh,NiicJt, Fl.tni '00zl Within mEh' NN9 Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4t"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name A II ' Dat ' Tvpe of Operation(s) Type of InsDection . (f�f) !\l � r (0, r(Cx ❑ Food Service Routine Address /lam 1/inAi A'� � ' Ri4k Retail ❑ Re-inspection 1� Y Level Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: ?1Ll . c.� 1 n OwnerHACCP YM C1Temporary ElPre-operation /) 4',) S 5'. A ❑ Caterer [I Suspect Illness Person in Charge(PIC `' Time - c/ ❑ Bed&Breakfast HGeneral ACCP Complaint In: 0�, l ) Inspector Out:r-21 e, Permit No. ❑Other Each violation checked r€quire/S an expia`nation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors 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"'", ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTW' �_ PROTECTION FROM CHEMICALS ' ❑ 2. Reporting of Diseases by Food Employee and PIC - - ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El15.Toxic Chemicals FOOD FROM APPROVED SOURCE `"'" ,';' M 7 ❑ 4. Food and Water from Approved Source : TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 1 B. Cooling PROTECTION FROM CONTAMINATION "`V µ' ' ' L" ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C 'N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FG2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-9)(9590.090.0 044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you X27.Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S ssm V. (Foowia eoo Inspector's Signature: Print: .�� 7) , PIC's Signature: ( / � � Print: �n q �� PageL of-?Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Hems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT ( 8 Cross-contamination j I 590.003(A) j Assignment of Responsibility" _ j 3-30111(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* j Cooked and RTE Foods* 2-103.11 Person in charge -duties j j Contamination from Raw ingtixlbnts j 3-"502.1 I(A)(2) Am mal Amal Foods Separated from Each EMPLOYEE HEALTH I Other* 2 .590LW(C) Responsibility of the Person in charge to j Contamination from the Environment j require reporting by to, employees and j 3-302.11(A) Food Protection* ---- applicants* ( 3-302.15 Washine Fruits and Vegetables J 590.003(F) Responsibility Res Of A Foul Em Or An 3-304.11 t y Employee? ( Fual Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* ( Contamination from the Consumer j 590 003(G) Reporting by Person in Charge* 3-306.14(A)(R) j Returned Food and Reservice of Food* j 31 590.003(D) Exclusions andRcstricnons* ( I Disposition of Adulterated or Contaminated j 590.003(1-:) Removal,4'Exclusions and Restrictiims ( Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food'_ 4 Food and Water From Regulated Sources j j 9 Food Contact Surfaces j 590.004(A-B) Compliance with Food Law* j 4-501.111 Manual Warewashing-Hot Rater j 3-201.12 Food in a Hermetically Scaled Container* Sanitization Temperatures` - j 3 20 1.13 Fluid Milk and Milk Product:.* 4-50..113 Mechanical Warewashing-Hot Water j 3-202.13 Shell F,'ggs* Sanitization Temperatures* j p• j 3-202.14 Eggs and Milk Products.Pasteurized* ( 4-501.114 Chemical Sanitiiation-temp., pH, j 3-202.16 Ice Made From Potable Drinking Water- concentration and hardness. * l j 5-105.1 I Drinking Water from an Approved System- ( 14-601'I t(A) Equipment Foal Contact Surfaces and 590.006(A) Bottled Drinking Watcr' j i Utensils Clear- 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.11* j Contact Surfaces and Utensils* l Shellfish and Fish From an Approved Source ( ( 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Fool Contact Surfaces of Equipment* Shellfish* 4-7031A 1 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I Chemical* Sources* to ( Proper,Adequate Handwashing j Gagne and Wild Mushrooms Approvea by I 2-301,11 Clean Condition-Hands and Arms* Regulatory Authority j 3-202.15 j Shellstock Identification Present* 22-.301.14 When to Wish*12 Cleaning Procedure* i ( 590.004(0) Wtid Mushrooms' j I j 3-201.17 I Game Animals* j j 11 j Good Hygienic Practices j 5 j Receiving/Condition j j 2401.11 ( Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* j ' m 401.12 Discharges Frothe Eyes, Nose and 3-202.15 Package Integrity* j I u ( Mouth' 3-101.11 Feud Safe and Unadulterated'* j 3-301.12 j Preventing Contamination When T_astin2* j j 6 Tags/Records:Shellstock j 12 ( Prevention of Contamination from Hands 3-202.15 Shellstock Identification* j 590.004(E) Preventing Contamination from j 3-203.12 Shellstock Identilication Maintained" j Eniployecs* j Tags/Records:Fish Products j j 13 Handwash Facilities 3-402.11 Parasite Destruction' j Conveniently Located and Accessible j j 3-402.12 ( Records.CYeation and Retention* j j 5 203.11 Numbers and Capacities* j 590.004(7) jLabeling of Ingredients' 5-204.11 Location and Placementl' 7 Conformance with Approved Procedures j 5-345.11 Auessibility, Operation:md Maintenance j I /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* I Devices � 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability j I j 5-103.12 Conformance with Approved Procedures' j 6-301.12 Hand Drying Provision Denole•:critical item in the Weral 1999 Fmd Code or 105 CN1R 590.000. v CITY OF SALEM `� \ BOARD OF HEALTH Establishment Name: P, N Date: O Page of Item Code C-Critical Item / DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date ¢ No. Reference R-Red Item .Verified qF PLEASE PRINT CLEARLY Ver - I(, ,Z� O-Ad4 �o�. I -•.� / �� lilulA/�uoY� GJCA In Ede--;ti., S-4pj`.trY., 4(,Jr__0 --,/1 I— n !P f_n(,,0A -, n A) o eoh 4)x-4 �...J. Fc4, ( 0„ - r (i A __L- A)00r. J114 A p,n _1 - -4-!. D1/./. Gr^/.. On ,/I 1 1-,p� A/ 7 fJ 1.i /1.� AJ 6 r Vl /H P 1A 10.10 .� (Y1) �A .�' 1 �i f - I.%Ax Iii 1 I UC(_rA MA-m-4 I )tck er✓ 5ccr/_ ,a a ��z oZ 3 r�_ l ^1�•cn_`IL__Al C7LOje lj I �f fir} 4 Cy Z.Lk ,2_ n r. _�ri4+ r Ht'�iS(A) Snrre� O,�i� C7� �-�'Y7 sS Z �� i /t It Aw sAA 5W(2Gfi AJ _ 1 re, 9� 0i?- cJ ,G Ca-�,' IF r7 %7" ri Mce 71 � 7'3 s_1, u. to n Ct. I , _79-!T� �)+3 /1O i ,fir f/ F r- i Al f c 00G✓aM.vt"A n 1— A),90r a tl c Discussion With Person in Charge: Corrective Action Required: No I rdrFes I have read this report, have had the opportunity to ask questions and agree to correct all ° Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to \ / Exclusion p � Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or spension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: 3-501 )4(t:i PHFS Reuived at Temperatures Violations Related to Foodborne Illness Interventions and R/sk According to Law Cowled to Factors(/left 1-22) (Cont) ( 41°P/45`F Widiin 4 How's. PROTECTION FROM CHEMICALS 3-501A5 Cooling Methods for I'HFs 14 Food or Color Additives I 1 19 PHF Hot and&Ofd Holding s ,- - ( 3SU?.i6(li) Cold PHF.?vtanu.rinetl at ix bedrtw 3-202.12 Additive,'" S90(IiWF; 416/45`1 F* 3-302.14 I Notection front L`nannru.ell Addttivev' I 13_ir S I Poisonous or Toxic Substances _ )1.?fi;:\j ve '. Idc:nB frin�` lnft•a maroon -Un�in,d Ida'P. ' IMA/ -Sul,H*4;J Ru.+,G.Ht III at or.dtotc I3{1'F, v I t untul.ar' Time as a Public Hearth Conlrof - — Hot PHFc Maintained at or abo 7 072.11 I Crrmnon \amt° - R'•n'ki*tci„n::nn:rr"-^ - --} _---- ---- I __----.-_. _._.- -_ .. 'ii� i., � ?im•s a Public(?ealth Control' I i-?(}lJl ArPy,.tuoa�$tuta e^ - - .202.11 I t!ce'tn,.non -Ytrv-ncc rutd t �S" r,tn r',' nirrrtxnt i7-202.12 I C,tndttwrr•ufltre° --`- --� . __._... -- �_..-- j 1-203 11 1 tic CIJI'Ia]nC'tf -Prolt;b"o'll,. HcGtLiEREMEt 3"S FOR HIGHLY SUSCEPTIBLE 7-204.11 I Sanit'vrt.,Crtl(ri;, -Chotnic:d" -� POPUkATfONS tHS=1_- — 7-204,12 ( C'hanucak f„t tt:rhing V •iu':e- C,iter,,t* I !I •-li t_,NA) I lial t-,tcwi,_cd i rc-pa .:agai Jtneec atd^ . „ '----- t..— itct.':;_ca•,villa 1t artnn4 l.rbals' x_04.1 t Urula :lrcutt.Can•ru:'" r 205.11 _ _ hx,id:ntai I;xxl Contact. lab)t.,;ilr S e. , f. . l t :U6.?'• �v 1 .,. Vit.., ;t,..nt. \ 'r Sesv : _ — .. - '- _; � '� �� .ter Psc.,2•LC Sa+. 1?:-94t'C% � i TOWE,'TEMPFRATURE CONPROLH n. n.t,l'li i .'1S' ,r 'r',):t 1, s;f't, ;ntt,• n,., rt+ ilei.a't ib:;,, ' ;tr i ! Pruner Cookino Tzmnct aiu:rs'at i t et=: ,i�F;' .,.;h•.t.::.,,-f'r CCa.o$s�,c�i F i i._ r P">•. Intm:'UE:14• 'rr. '0' tis"1.:?o-rj_J .• •. .' ,. i -;•'l.'•;:1!t i c.lvr':'ata`..:tri:n t1 c:'. !. ::,:,:_ •.._ .' _ _ . _ .. . . .. . __.. t , , ! il. "S3k ij't, 1 !'cA r.(! Ii i'i iL•..: ( ._ .. _ _r .- ._..1.. _. . ._. _tY€=5 _ _ ___ —. _-_ __ .. , J;it i.r?' � i 6)tti, In:'t'..t. ilt�d(, i .�4: i% y `t .. , .. ... :.':€iY}+ ;^t?i t&••):.'i�(j t} : . 0IIth:'H,'„ a!K t.. . I P eo, t' d ' c, . n 1 vh,{'ri.:... .,:':r ! jft :..ruC'nn!•J: ...,F•i: �:..,., . ...,'ice .`"i:' i9ti at.l" 'trij,t'Y, i;1:ig 4cnP3tt.^..7 t:1' i ;-.iilS.l it:1}R,i.n t li�P` th tl-��i; .r I tlt'>ttu G*-ue, 103.11(R I \,I,, :!+t- Irl'l Z 1;r.,c 'Swtr.ltn, ;r L:n^ a.dt:, roc , ,. ,r r�,'t,..:':: :ar,' < t,)t r•,,-�P�trtf c"„s, :vtL- i it 1 ( Con,1e,I't,0% I'st.. ,' `?'1! 1, ;! i ,.ur,:St 'r.t •' •„ ,ti, :, :I„ P"Al<b.0 a,.J l"5 t�i1H t „ t-0%�.. ( E;fi? li:n::uor;r,Lt%.fr n.; f.•:ucn„i?,:t., 1 Ite.n _ ^rr.; t,3>ta„ Practices _ _-_Pc; 59:7 D?it _� I !i„aao• ! <<^3 _::ia:;3y,;,,..- d P�t,: nr.t .- _- '-I8 j Proper Cooiinq of PHss j . '.; {-",_'}' "a._Mo_I`rcx-rot» �Ff. 10�. _- ___ ',A) Ctr•ii(w G+)F•d Pti(=c i,oto' ? 4"V L; 1 r?� �."_ .r__CI _ _ __..,- - _ It _ r•X:: i k ':t nbm ' (`t df..d`c I ?r •n ' }., :-.-,i r _ _ • .tT � f_ - .,;� r - -- i A.,, ` bbl.id,lid Plil': Mair Fn .0 r i ' 'f,:mp:taiurr Lt;red:at,;< •.. ? �i�..1i�F � - . '\"Tait a 1-1,Air, f CITY OF SALEM t � - BOARD OF HEALTH 1�t Establishment Name: IL.A (l �� I , n_r�� Date: /__11,(6 q Pager of Item Code C-Critical Item f DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified i' ,j _ PLEASE PRINT CLEARLY b-7 rl G ,]d 1 1 AA '\�— V/Y--P i 0 -e A 6" 1 (7. e*p Sr 1 . _T,i/AJ r 64-- _ t I 4 r ( J I/7�15s 1 7 ^�-)QJ r �I.t moi. , JAA, � J i [Jr..k� o ,c , PQr� r-Y '( AJ, _,. t G o It /YX- )-I 4,,— _ ate_ _J� L 4�—n . Af XL L N 'J 9 — -i,L/-A J /YrL L) a,u I ClIteP,r, CC/lc �( '��, Ja J1+ n _�n ► i c—n c It' V —re lP J")t.Pl t rA AO. � ,X Iit� ,nf I U n. f cP n, i A kP t 4 2 jl ) 1, �� � I i X - ItT V - - Discussion With Person in Charge: Corrective Action Required: I ❑ No IAB—yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p Q�e-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollar r suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. c�� c —� I C---- ❑ Voluntary Disposal ❑ Other: J f 3-511.14((;) PHFI,Re.•ctved at Temperatures Violations Related to Foodborne Illness Interventions and Risk l urdi ng to La-v, Cooled to Factors#tehM 1-22) (Cont.) 41'F/45`'17 Within 4 Hours. # _ ( 5(11.15 ( Cuulino Methods for PHFs PROTECTION FROM CHEMICALS ( 14 I PHF Hot and Cold Holding ( 14 ( Food % Color Additives I 9-50'.16(R} Cold PHFs Maintained at or betmv :t-202.12 � ,ldclilivcs'z 5�3li01F1{[�1 t<. 3-302,14 Protection from Unapproved Additive;" - 41%4., F` ( 15 Poisonous or Toxic Substances i 3-50i,ib;.�'i lint PHI,Maintained atorabuve 101.11 Identifying tnftam;d:on -Ongina! 140'f= ` 1 i ?6ui.16(At - i Runt+Htld:uu; above 130'F a Container>` I _-- r- -- - -- - - — i 7 10-1 11 ` C ctnmtat Nam; -- R.'rk k,,t', ❑;;,;r:." Lz{1 ss Time as a Public Health Control ?-iry i': Pin.,' aw a Public ilralth C'nnre_#I' ( 7-701.11 ( Japat arson- Stt r,aR.:` .__ i cgCt'i_C-t!Hi t 1'.., ira'1;e tfitetF;eni I ??(}2.71 I1:eat:i:9lnn -Pr:'pxptc,ln,I 202.1 �u('.etdliltN:v'+f C.:;- —_.--_ ___ I °17.3 1: i To>it Cuniamtt- -Pnd ht:it:tr\' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ------- ( POPULATIONS(HSP) i HSP'_Od.11 Snm:vet�<'nicrut -C'herruc>k' 21 i.l NA, 1 Vnp;:;tcunmd Pre-padltnrec;and }t,l_ ( i'ixjnioaL 1 ,n w'a\hnya t7rnlvr: t;tirrt:a` i k '7 k)41,4 - Narinvg 1�ttai.:' Unm;;Aveno.Crimia' Pa'tdan,ed )5 i' i Ltcid:ntal f:+x!Cuntat'. L:bc,:an?s or}aua,'.ta,,i::i Aniatal Ft>:r7 ar,m : t r • 1 7-?tlf.i! i {<c-ii t;:r,i l'u Pr,,.it.,ti'• (lnrra j ! _ N,00w ---_ .... ADViSGRY Tl(LSERE(rPER&Ts.ffiE CONTROLS LS :,' t i i ! •+;.;:, :,:c Ac; a:::\ Fi.ta;'hN is tit'c•tnea i le Pruptt Caakmg Tentpet atoms fir i - 3 ! PHF; ! er.--;----•, -- ; I-,..,.. Vic, r : ( .s.. S13e17 t ; ! 7 f �- ,•39 - , 1'. Ir5 :t„r.r „, 7 :a�r.»z :r::a7.. f;�t•tt.te: + .;oar ,u:d j . 7(t Ar , i �{,.a;-:�-. \raid t�u•: . ;,:et�t;; :`i,t ; ( f :.,:. a S,i is i,t-t; nlr,:,.tikx„ :{1::�lcl '.. I r•:�aa tr 'iS:'tl Fr: F:pL. 1,1c..- t.-';-u:: : iII rilc'i If iC 91`!`rt't`I_.. . u:Uvih ! ':L, is C. � .c :• .... ;...\. � . . . ' t., O. reJat:,i919, .x.:; 1'`p i,'r. : :rr ��f..3^,e•_.�v t: ;.,? �:... ,. .. ;(ii1 li4i,n.:;l.t- !l ` - 'tl ltil Ind:;T;, iu, i..9 :h,1 r, . , ,, .. ra it t � (•ty, i i�f'r t��,tr,• 'taay i+tta:. ,i :?-1 2,,x: rtt3:: �tt t?,r •,rt 'n. {rn,a t.1r.t,:, 1 4, ll'r from Gera Rera I P-art; F"C 590.000 i ^-al•i i!:;7D ts, 7,u.liC:'U PtCitt^.K C „17; S'i _ - 2'. � taoaq,am _t a:d?cr:4rn-c, FC 60.; i IK 1 Proper Cooling of PHFs -` _- 'nd-_ —._ rat__ !:p { - -_ Irt ;-, 5( 7 L ( P}(r f,.m1,!0 1it I - . , tvnhtn 2 Hl,ur .,ml Fenn /:i'i Y: P-rK Fa'w _ _ —__ a 1, h 4l tlan-. H,vr — —j £S i S'as,::ga;; _ . h-". 00(: _ FmAirkt.ut �tit' '4l :c:idLC hidit'tirClS:•tit I,�ii '11•i S•i: -t� + -.lit': It;• `t_ithilt I7.0.n ___-__ ___ ,. ...• 1,::no.d,.nl,c.rl,.en:a,d,... i... .: r.. . :. ..., jt:\4 ♦i•-\.�.,,.f. ' r .. w p,r+ _ "Ca a'1` ;d"F /•.�:Q.S'4.'I" ;4s., I .. .. . .: ,.. I ..F.•.-. . :. �����T'�.: `;`-1. ,:� _ f,F91� Nay<° • v vY; ...,. ..r,,.r.. � '+;. 79.•• . .•Sri :f.'��p lir-.>::�..r.i x�47T O CATE-11 le r � TA.Y Ir : � i ! DAT8�1 , r We pA ` ME ..t I01 CUTS_ T-�1�'�!f[= IIN alT i Prl�'�^`l:•'S IW OUT m 13RIEO.,C3I-TWE ❑Ru [,]cow. ❑IRDOOR 13OUTDOOR (3RED, p I-TIME ❑Ru ❑COLD& 13WDOOR [IOUTDOOR ❑RIO.— 1-10 13REE. ❑CONK ❑INDOOR ❑OUTDOOR El MOPE AOp w 1./ 4-'iti,.,..,. 1 • Si _. l�.,yg . _ J 1'a!'l:i/-`• i}t Y�.li 1 {'�i ;{��1s";'F6 .•._f>, j;:1`l r CRY,BTATC,LP _V +�, l PNON6 ' CRT,BTATF,IW r. tS _r V»gNF - CT'.BTATYREW`'R :. , Y"+ pmm' li I' fiA i '-`Tib ' ❑ IMPEMN v" t..!°.: _ •tj NISHMN I 6 tv%'--•Y..')- ❑ INBPECnoN ?,•,N:,''.'- c.; ❑ TREAThIENT t i^ TREATMENT '.„ ; f ❑ TREATMIUJT �s I '(] �,2.rj ..l a-3 :T•T"' I ..sir ❑ iii"i'cr'r1 ❑ j'F P•r't. t ft: Y ❑ I .1 I'+- ! 1 .ra AI t CA r ,lWftl �Bv T L,dEVIdlii'l ld,.ch.ltil i i!Ii:Ill:16Vdd4�'A it Id'J11,4,1115 414 I ' r ij�i ftf:^,l �^:/� 4 �. � / .. �"!1-'s i',� r•.. o .4.. � 1 tl - t �i , c I '' ,861yKE0'BY'; UC NO.i.:. +"' •..-.� l•96AVICFO LIC.N0._ - .'.>•r .,,•�. �{ SFHACmBII UC N0. . �,,fi i ITOTAL - _3.... r.,;..:. ,! t I J ?t; TOTAL _ s ;- i( .J,i- , I TOTAL LTttBTCA1El} WWINAE CU9f0YF(I6IGNATYgE ��- J ^ GUBr0YF1�U+TJAP r - SERVICE REPORT ` -9 j. SERVICE REPORT ;;; SERVICE REPORT 2• pW.u�.v.ue...:.....v..w',u+,«ueee..r:.,x..n�:'urnue.:r�s..e.waa,s i..ut:.-...ai�,aWu_A....•. -- =,�.m),.it.rrtl.a tu,em.tiuu.e.- m c cu CL H 1dOd38 33UId3S - are L,l'/(i1'ti I-As 'nrne , r, :. aenarn'mgbprnirv». r�r1g1 . . e u, E' IN OIIT T•r t'_. 1Y101 ,. 1• q oI ❑REO._O 1 TIME Q Rim ❑C011�R. ❑INDOOR ❑OUTDOOR 'r l.•.::;-�: .�' "ON "' e o9oVtla r' V FiJ'i I IN OUT .i' '❑RIO.p 1•nm D Ru. ❑ii lig ❑mm ❑MWOR CD N,OPE89 r/ i c � ' 1., I 07 cm.9rnrB.Sv t I rwNB All A1111,11WAII.IJOU hillIldIIRI:.IIsI:. 1 j ❑ IN9PEQNNi ;'i�. S+'• !.'. .� I 1 1 . I mum C INBPEcnON ❑ TREATPdGNT ❑ TWAn%NT Y'< c.'-1 c`.`1'' 1u19sd1rll�Itli!I:Idl�illbVdl1116:{��su'eu LA J A!1: W6,1l4 AN r r. f j ,. - I r, r .,.,..-,,•s NDu03d m ❑ 11✓I!!ll@;.o1�ii�lldsil:i4liuulYllil'IWpIL�9uY��lll!I�g1i,J�l liliSh:,il o,1L {} j r I., I r^, j+ . ... HOOMM❑ WOOM❑ VW06❑ '8311❑ 3PN1-1❑ '0311❑ s_ .-. s: .,. •,:;'.�c ..i , . ...BEFIT Bv' uc.No: an 'TOYA'C'� ;y' :.» flu (1 yTOTAIj�t, -CU9iOMERCIG TURl •,. 31'nlI '` t iL. ,rr9eV0. ./r_: +: NBTOMkn�.pN1114rNe .....- C3 SERVICE REPORT - SERVICE REPORT a{ c 7 May 21 12 06: 09p YFQOOB 19787449710 P. 1 AV) . ck C May 21 12 06: 10p YAQOOH 19787449710 p. 1 i r DATE _ TIME TJME OUT -- DATE IN OUT _ = IIN ❑ REG. ❑ I•TIME ❑RES. ❑COMM. ❑ INDOOR ❑OUTDOOR ❑REG; ❑ I-TIME ❑RES-G COMM, ❑INDOOR ❑OUTDOOR NAME NAME'_.. ADDRESS ADDRESS CrrY,STATE,ZIP PHONEI PHONE CITY,STATE,ZIP HE�IX(cE@fEEBFA�iG1 fitEP �� - �� �G �:' 71 INSPECTION _ _ G'INSPECTION ❑ TREATMENT - ❑ TREATMENT El ❑ II�yp�� I .h 111 III k Il..u.l.l(e Ln nnl Id1l94huulu�I,�uue�hal�Imusdllhu IllIIwII,6kdGlalhllllli. I — , I I �I SERVICED BY SERVICED BY (LIC NO, (TOTAL - -. ; ,I TOTAL __ --- CUSTOMER SIGNATURE OUSTOMER SIGNATURE SERVICE REPORT SERVICE REPORT S. May 21 12 06: 12p YAQ00B 19787449710 p, l pATE,' TINE ._. . ..- IN OUT ❑REE. ❑t-TIME ❑RES.. a COMM. G INDOOR a OUTDOOR NAME.- AOOREES CITY,STATE,ZIP PHONE ❑ INSPECTION ❑ TREATMENT �cra:.uw,Erdw�,.��sl�'. �,ilit�y �II� EuediumeLL,u1W1 SEPVlCE09Y JC.NC _ jTOTAL -. 1 CUSTOMER SipNATUHE SERVICE REPORT h Massachusetts Department of Public Health j (' Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name / Datd7 Tyke of Ooerationfsl T pe of Insoectlon ✓�}��✓ /G/1 /Ib�i I ❑ Food Service Routine Address 11 i // Risk 1 [�Retail ❑ Re-inspection 7 I�G�G I 1 e �r f Level ❑ Residential Kitchen Previous Inspection Telephone ❑ G Mobile Date: Owner ' ) � S HACCP Y/N ❑ Temporary E3Pre-operation r r� ry ❑ Catr El Suspect Illness Person in Charge(PIC) Time ❑ Bed ere8 Breakfast ❑General Complaint Inspector I Out: ('l I Permit No. 4;*} ❑Other Each violation cKecked 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. i CFOOD PROTECTION MANAGEMENT I [:112. Prevention of Contamination from Hands E] 1. PIC Assigned/Knowledgeable%Duties ❑ 13. Handwash Facilities [EMPLOYEE HEALTH I - - - - �PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals L �_ �. FOOD FROM APPROVED SOURCE� TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods); El 4. Food and Water from Approved Source ( ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating E] 7. Conformance with Approved Procedures/HACCP Plans El 18.Cooling PROTECTION FROM CONTAMINATION '' I{ ❑ 19. Hot and Cold Holding 0 B. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR HIGHLY SUSCEPTIBLE_POPULATIONS(HSP) i * ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑;11.Good Hygienic Practices tCONSUMER ADVISORY d El 22. Posting of Consumer Advisories Violations Related to Good Retail PracticesNumber of Violated Provisions Related / Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR I of Health. 590.000/federal Food Code. This report,when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(sso.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-4)(590.0054))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-4)(990.009) the food establishment permit and cessation of food '26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. _ 30. Other DATE OF RE-INSPECTION: S 5WOVT Gm 14 Coc n I j-' / _ / I e Inspectors Signature: Print: f � xall`l u.1�0 LL I'PIC's Signature: Print: g h, --�, I Pagel ot(Pages d - , I TTTTTT . . Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1 I Raw Animal Foods Separated from I � Cooked and RTE Funds* 590.003(B) 'Demonstration of knowledge" ( Contamination from Raw Ingredients 2-103.11 Person in charge-duties 13-302.11(A)(2) Raw AnincilMFoods Separated from Each EMPLOYEE HEALTH Other*,.t { Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 13-302.11(A) Food Protection* „ I require reporting by food employees and 13-302 15 Washing Fruits and Vegetables applicants* J 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils - I { Contamination from the Consumer { Chirac* 13-306.(4(A)(B) I Returned Food and Rescrvice of Food* 590.003(G) Reporting by Person in Charge' ( � Disposition of Adulterated or Contaminated 13 ( 590.003(D) Exclusions and Restrictions' I I Food J 590.003(E) I Remo%a]of Exclusions and Restrictions I 13-701.11 Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 1 4 Food and Water From Regulated Sources I 19 Food Contact Surfaces i 590.004(A-B) Compliance with Food Law" { "_ 4-501.111 Manual Warewashing-Hot Water { 3-201.12 Food in a Hermetically Sealed Container* I Sanitization Temperatures* J 3-20 1.13 ( Fluid Milk and Milk Products* { 14-501.112 Mechanical Warewashing-Hot Water 13-202.13 Shell Eggs* I Sanitization Temperatures* 3-202 14 Eggs and Milk Products,Pasteurized* I 14-501.114 Chetnical Sanitization-temp.,pH, 13-202.16 fee Made From Potable Drinking,Water^ concentration and hardness. 5-101.f I Drinking Water from an Approved System' { 14-601.11(A) Equipment Food Contact Surfaces and Utensils Clean" 590.006(A) Bottled Drinking Rater* I 4-602.11 ( Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* I Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source ( 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* { ShelIfish" ( 14-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed ( Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 12-301.11 Clean Condition-Hands and Antis* 3-202.18 Shellstck Identification Present° I 12-301.12 Cleaning Procedure* 590.004(C) Wild MushrootnsA 12-301.14 When to Wash* { 3-201.17 Game Animals* I I l l I Good Hygienic Practices { 5 Receiving/Condition ( 12401.11 Eating,Drinking or Using Tobacco* { 3-202.11 PHFs Received at Proper Temperatures* 12-101,12 ( Discharges From the Eyes,Nose and 3-202.15 I Package Integrity* , Mouth* 3-101.11 Foaf Safe and Unadulterated* { i 3-301.12 { Preventing Contamination When Tasting* { 6 Tags/Records:Shelistock 112 { Prevention of Contamination from Hands 3-202.18 Shellstock Identification* I 590.0(A(E) I Preventing Contamination from 13-203.12 Shellshxk Identification Maintained- { Employees* Tags/Records:Fish Products I „ 113 Nandwash Facilities 1 3-402.11 Parasite Destruction* Conveniently Located and Accessible {I - - 13-402.12 Records.Creation and Retenhon* I 15-203.11 Numbers and Capacities* { 590.004(1) Labeling of Ingredients' I 15-204.11 Location and Placement* 15-205.It Accessibility,Operation and Maintenance 9 Conformance with Approved Procedures � Y /HACCP Pians ( Supplied with Soap and Hand Drying Devices 3-502.11 'Specialized Processing Methods*Methods* 3-502.12 -{ Reduced oxygen packaging,criteria"` { 16-301.11 Handwashing Cleanser,Availability 18-103.12 I Conformance with Approved Procedures* I 16-301.12 Hand Drying Provision 'Denotes critical item in the federal 1999 food Cate or 105 C:'N R 5','0.000. • « } j _ _ `. .�.�- mow., y w CITY OF SALEM BOARD OF HEALTH Y Establishment Name: �� � !J 1'4>,t � n Date: Page 6:2 of nem Code w C-Critical Hein / DESCRIPTION OF VIOLATION!PLAN bF CORRECTION - No. Reference R-Red Hem _ Vedfled I Jj / ,/r, r f PLEASE PRINT CLEARLY Gt. .1. P I7 ,'y ", ��', �. iL1 JU-Al/� I rl'l f�n.,r•� ,. v I N - .� NJ- cY� Aaq�N ,A/ C 1, /.1(r fllr,r.P 1^ 11111 \ r�ltror5 ��� �� AJe- r y�l r r-�IC,YC 1H. 1 'fryCnc�� I•�o �I �� ��-- c�'h '7 tr,s.J� ,p�,�Tf+sTFi�.f-� .IMrL"3-, (_� I ..����/, '' Iv , `� n__a_, I_( . -•�' r �fo�_�,.o.✓ [�12�r—'rlkrr��17.17��, 1=c tis7t-� let i �i-. i3� )7 _ � . {: _) ,.,yt0�1Z ! Pr,J�ot� t12 n��, /Ukl•trra/ Imp L ( rQ/.1 AOt1 13 J..) y /' n AA LAP; e � 27 i 1- !�s-r�' rte-, OY- C7 ' (-3 - -- !411, 027 ! 9/1�2.�� lr�L! A�on�if � Gvin� '�r+w�nr`nA /,.12 �.I✓� 1- qr ,I� - " ay,r.;. -jny urM - � Al,an 1t::02j.ur Discussion With Person in Charge: Corrective Re No No a I'have read this report, have had the opportunity to ask questions and agree to correct all , Voluntary Compliance I ❑ Employee R friction violations before the next inspection, to observe all conditions as described, and o Exclusion r `❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Feder-al Food Code. I understand that noncompliance may result in daily fines of tvtler>\y-five dollars or suspension/revodation of p Embargo ❑ Emergency Closure c your food permit. 4• �s y ►' tl ❑ Voluntary6sptosal ❑ Other'. x ( Violations Related to Foodborne Illness Interventions and Risk 3-501,14(C) PHFs Received at TemperaturesAccording to Law Cooled to Factors(hens 1-22) (Cont.) 41°F/45"F Within 4 Hours. PROTECTION FROM CHEMICALS 3-5Ol.15 Cooling Methods for PRFs I 19PHF Hot and Cold Holding 14 I Food or Color Additives 3-50IA6(B) Cold PHFs Maintained at or below 3-202.12 Additives* 3-302.14 I Protection from Unapproved Additives* 5�' ( 4i°/45°F* 3-50116(( 15 I Poisonous or Toxic Substances . 0) Hot PRFs Maintained at or above I40'F. 7-101.11 Identifying Information-(Original I 3-501.16(A) Roasm Held at or above 130°F. Containers* I 20 17-102.11 Common Name-Working Containersx Time as a Public Health Control 7-201.11 Separation-Storage" 3-501.19 Time as a Public Health Contra!* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _ 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 + Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* I Beverages with Warning Labels* 7-205.11 incidental Food Contact,Lubricants* 3-801.11(B) 1 Use of Pasteurized Eggs- 7-206.11 11(D) I Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* 4 Raw Seed Sprouts Not Served, 7-206.12 Rodent Bait Smrioas# 3-801.11(C) I Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and ( 1 Monitoring* CONSUMER ADVISORY TIMElTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Ani mal Foods That are Raw,Undercooked or PRFs I Not Otherwise Processed to Eliminate 3401.110(1)(2) Eggs- 155`F IS Sec. � ` Patboxens.*""rnrmrr Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Gama Ems* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(B)O Poria and Beef Roast-130°F 121 mint* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3401.11(0)(2) Ratites,Injected Meats-155`F 15 I catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks i interventions and risk factors. Other 145°F" I 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a I practices should be debited under#29- Microwave 165'F* ` Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. * � 17 Reheating for Hot Holding VIOLATIONS R-LATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec.* I (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing ( Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can be 3-403.11(0) Commercially Processed RTE Food- ( found in the follaning sections of the Fond Cade mrd 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef ( Item Good Retail Practices I FC 590.000 I Roasts" 1 23. Management and Personnel FC-2 .003 .I 18 Proper Cooling of PRFs I i 24. Food and Food Protection I FC-3 .004 _ _ 1 3-501.14(A) Cooling Cooked PHFs from 1 26.140°F to 25. I WatEquer.neni and Utensils i FC-4 .005 i f f W atsr.Plumbing and Waste FC-5 .006 I 70'F Within 2 Hours and From 70`P 27. Phvsicai Facility FC-6 C .007 I to 41°F/45'F Within 4 Hours. * 26. 1 Poisonous or Toxic Materials FC-7 I .008 3-501.14(B) Cooling PHFs Made From Ambient ( 29. . 1 Special Requirements I I .003 Temperature Ingredients to 4l°F/45'F 1 30. I Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code a'105 CMR 590.OM. CITY OF-SALEM / , } BOARD;OF HEALTH a Establishment Name: ! �A� /1 0- 7GA,g411 1 Date: 6 [la-- Page: 7 of Item Code I c-Critical}tem No. Reference R-Red Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION I Date i ' verified / �"� PLEASE PRINT CLEARLY 2 t~n�u R n 4, I 4A,-e_i- 6 , ' s Wr-o— rl.c I Cis t;.Wv / (AJ Wa(V (n �,�a��� 1 l.lcjhct CVII to (A ( (/_, n IL�7­6gdi(ld 1 140,^1? ,11KL I I 1 1 Kr Cern ,int >ya -� t 7TL 1 t �v v 1,L 1\-J-/ t 3t A/14 a i3 TnG' t-YP/t 71n /t �i.V_ o N the I�PST-r �- J AIS M/42 t 1-) I�(�r51� •� A DiDi ucsssion With Person in Charge: -� ' Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all \O luntary Compliance ❑ Employee Kesnction/ violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal Food Code. I under land that ❑ Re-inspection Scheduled L] Emergency Suspension ]. noncompliance may result in daily fines of twenty-fiver\ollars or styus J nsion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: a 3-50I.145C) PHFS Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk, I According to Law Cooled to Factors(Nems 1-22) (Cont.) 41°F/45`F Wiring Hours. PROTECTION FROM CHEMICALS { 3-501.15 { Cooling Methods for PHFS { 1 { 119 { PHF Hot and Cold Holding 4 Food or Color Additives 3-501.16(B) Cold P.IIFs Maintained at or below 3-202.12 Additives* 590(I04(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* ( 3-501.16(A) Hot PRFs Maintained at or above { 15 Poisonous or Toxic Substances 1140°F.* 7-101.11 Identifying Information-Original 3-501.16(A} Containers* { I Roasts Held at or above 130°F. * { 17-102.11 Common Name-Working Containers* { 120 I Time as a Public Health Control { { 7-201-11 Separation-Storage* { I-3-501.19 I Time as a Public Health Control* { 7-202.11 Restriction-Presence and Use* 1590.004(3) { Variance Requirement { 7-202.12 Conditions of Use* 1 { 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 17-204.11 Sanitizers,Criteria-Chemicals* 1 POPULATIONS(HSP) i 7-204.12 Chemicals for!'dashing Produce,Criteria* { � 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and { 7-204.14 Drying Agents.Criteria* 1 Beverages with Warning Labels* Use of Pasteurized Eggs* 7-205.11 incidental Food Contact,Lubricants* 1 3-801.11(D) Raw or PartiallyCooked Animal Food and 7-106.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served * 7-206.12 Rodent Bait Stations* { 1-801-1](C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY . TIME/TEMPERATIIRE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for I Animal Foods That are Raw.Underecoked or PHFS Not Otherwise Processed to Eliminate 3-401.1IA(1)(2) Eggs- 155°F 15 Sec. Pathogens.*E'h""'t Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&(Lame + Eggs* Animals-155°F 15 sec.* { 3-401.11(B)(1)(2) Pork and Beef Roast- 230°F 121 ruin* I SPECIAL REQUIREMENTS 590009(A)-(D) Violations of Section 590.009 A 3-401.11(A)(2) Ratites, . tes,Injected Meats-155`F 15 I catering,mobile food, temporary and to 3-401.1 f(A)(3) Poultry,Wild Game,Stuffed PHFS, residential kitchen operations should be Staffing Containing Fist,Meat, debited under the appropriate sections Poultry or Ratites-I65°F 15 sec.* I above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks i interventions and risk factors. Other 145°F* I 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a ( practices should be debited under#29- Microwave 165`F* Special Requirements. 3401.11(A)(1)(6) All Other PHFS-145°F 15 sec. 117 Reheating for Hot Holding { VIOLATIONS R LA TED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFS 165°F 15 sec. * { (Items 23.30) 3-401.11(B) Microwave- 16.5°F 2 Minute Standing � Critical and non-critiral violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- ' found in the following sections of the Food Code and 105 CMR l 1403F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef I Hem I Good Retail Practices 1 .FC 590.000_ 1 Roasts4' i 23. 1 Management and Personnel 1 FC-2 I .003 i 18 { Proper Cooling of PHFS i 24. FoodandFood Protection FC-3 .004 j 3-501.14(0) Cooling Cooked PHFS from 140°F to 1 25. Equipment and Utensils 1 FC-4 .005 1 26. Water,Piumbinq and Waste f FC-5 006 I 70°F Within 2 Hours and From 7WF 127. Phvsical Facility " FC-6 .007 ! to 41°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 1 .008 3-501.14(B) Cooling PHFS Made From Ambient I 129. Special Requirements I .009 I Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours" 'Denotes critical item in the federal 1999 Foal Code or 105 CMR 596.5)00. 4 4 t - CITY QF- SALEM P l BOARD`lF,HEALTH �/'" Establishment Name: I' ?A'A"� �., °- Dafe: i �a Page: -f�� of ' �em Code C—Crtticai Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red item II n Verlfled PLEASE PRINT CLEARLY i � a� alcl �afr( dlr ;/U1P�St t-� J .� ct�, f�4a �� r¢rtlnw� 41 �crr-� Nlr�cc< ,.�nl +C'1�e Ic( ��--crz/3 (�iftrPJ l�sr, wl�. �,_,a b, i.z �cy%� a�►� I I�E✓A,!10A (,t-�.�fa �. � �,- _ont ( �.eH.re c _ ,3sfr�3� �f�r.�T�"�,;.r� QL3 (OAk- , (4 JC? If ,:jy 24 cG�a a ami A I - P*(10 v i ,A4)01 .5.� Ir„ Let), f=ate o s CC'M a*/ i f�� �:> a� t I [N oiler+ ' V_.e_0r3, , ' AM;r* a--D la. - ^,Ary ara , v1s I - IJR�d�(/�l{.� �_I ��t� i--�..���-1 -rll� � r (( l�►v�el �-13,� tr3 ,�2 ,.�-�, a i - ,Sfolaly �-Q-1 Go fG41,r,e1 20NfIfJs14?4, 1 7-M. (z- -a—� " I _ 'x 4—s ieta�o �DV,C�s , 'I�l�n, ch �(••xo 6r� C0 f ef.�.aro/ I \ I J�f3Nc o I old C(�k ns 41 w►c Snk cVu G-t-i7i4Ksa y I-C Af JA,rd c� ,� 01 12t �v p(AAT1s S-�:f t /!R(t1� t�I5 f in ��n, i rte,. , 3Ps i i31 o ate. t I I'•'SJ I r - �c. i, s� f Discussion With Person in Charge S1,M TA4 r p(41� L,n, i-'� 4 t, { C'orrective Action Requirerd: No � s I have read this report, have had the opportunity to ask questions and agree to correct all -� luntary Compliance ❑ Employee Res rt iction violations before the next inspection, to observe all condition's as described, and to l Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-five dol ar s son/revocation of ❑ Embargo ❑ Emergency Closure your food permit. _ ❑ Voluntary Disposal ❑ Other: 3-50114(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to law Cooled to Factors(Nems(-22) (Cont.) 41'F/45°F Withia 4 Hours. PROTECTION FROM CHEMICI 3-501.15 Cooling Methods for PHFs ALS l 114 Food or Color Additives I 119 I PHF Hot and Cold Holding 3-202,12 Additives* j 3-501.16(131 Cold PHFs Maintained at or below 5m(104(F) 41'/45°F* 3-302.14 Protection from Unapproved Additives' 1 � 3-501116(A)15 Poisonous or Toxic Substances Hot PHFs Maintained at or above j I140°F 7-101.11 Identifying Information-Original ( j 3-501.16(A) Roasts Held at or above 130°F. Containers* j 20 Time as a Public Health Control 7-102.11 Common Name-Working Containers* I { 7-201.11 Separation-Storage* I j 3-501.19 Time as a Public Health Control'' 59p.044(H) Variance Requirement Restriction-Presence and Use* I 1 7-202.12 Conditions of Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE j 7-203.11 Toxic Containers-Prohibitions"` I 17-204.11 Sanitizers.Criteria-Chermicals* I POPULATIONS(HSP) 7-204.t.. Chemicals for Washing Produce;Criteria* I 121 13-801.11(A) ( Unpasteurized Pre-packaged Juices and ' 1 7-204.14 Drying Agents.Criteria* j Beverages with Waminr Labels* j 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Foal Contact,Lubricants* I 1 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides.Criteria* i Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* ( 3-801.11(C) Unopened Food Package Not Re=served. " I 7-106.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for ( Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.*&`"r 3-001.1 lA(I)(2) Eggs- 155'F 15 Sec, 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs-Immediate Service 145'F15sec* 3.401.11(A)(2) I Comminuted Fish.Meats&Game ! Ems* Animals-155°F 15 sec. * I SPECIAL REQUIREMENTS j 3-401.11(B)(1)(2) j Pork and Beef Roast- 130'F 121 min* i 3-401.11(A)(2) I Retires,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, ' debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* ' above if related to foodborne illness 3-401.11(C)(3) ( Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 ( Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3401.11(A)(1)(b) j All Other PHFs-145'F 15 sec. j 17 ' Reheating for Hot Holding I VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES { 3-403A I(A)&(D) j PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the ' Time* . foodborne illness interventions and risk fdcrors.listed above,can be 3403.11(C) ' Commercial ly Processed RTE Food- found in the follawing sections of the Food Cade and 105 CMR 140°F* 590.0110. ' 3-403.11(E) I Remaining Unsliced Portions of Beef 1 Nem I Good Retail Practices FC 590.0.00 _ I Roasts" 1 23. + Management and Personnel FC-2 .003 .I 18 1 { Proper Cooling of PHFs I 1 24. ` Food and Food Protection FC-3 .004 i { 25. Equipment and Utensils FC-4 '005 3-501.14(A) I Cooling Cooked PHFs from 140°F to 1 26. I Water.Plumbinq and Waste FC-5 .006 I 7q°F Within 2 Homs and From 70'F 1 27. I Physical Facility FC-6 1 .007 to 41°F/45'F Within 4 Hours. * 28. i Poisonous or Toxic Materials FC=7 1 .008 i 3-501.14(B) Cooling PHFs Made From Ambient ' 23. ( Special Requirements l 1 mg I Temperature Ingredients to 41°F/45°F l 30. Other I I Within 4 Hours* "thnotes critical treat in the federal 1999 Food Cale or 105 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"' Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. IName ' I Dae ' Type of Operation(s) Type of inspection 'P. N I/a A M (p L I t El Food Service ❑Routine Address _ Ri k / Z.4tetail We-inspection Level ❑ Residential Kitchen Previous I ion Owner HACCP YM Telephone El Mobile Date: q�pe G `i` I o r r El Temporary ❑ Pre-op ra n//n I ��� `r �...�i6�,� ❑ Caterer El Suspect Illness Person-in-Charge(PIC) Time ❑ Bed 8 Breakfast ❑❑ General HACCP Complaint ^ In: Inspector .I_ ��C}� 9- Ou �(O Permit No. ❑ Other �Sn Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Norrcompilance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking 590.009(E) Items) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ Y P t q Allergen Awareness 590.009G) ❑ corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities 'EMPLOYEE HEALTH - PROTECTION FROWCHEMICALS, ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE 171 4. Food and Water from Approved Source TIMErrEMPERATURE-CONTROLS(P.otentialty,Hazaidous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑ 20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPuLATiONS(HSP) ❑21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMERADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-zXsso.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3X590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you _ 27. Physical Facility (FC-6X590 007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s.�er aucx Inspector's Signature: Print: A 1 PICS Signature: I Print ' Page of�Pages i- 111 '�. F"" tis.��' -+-;..,r. .r ;� �......s , . '_-.. -_ • ..ry„Yn.. ,v� �`., ,.t_. . Violations Related to Foodborne fitness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18 ( Raw Animal F00dn _ _ I 3-302.11(A)0) Raw Anima!Foods Separated Dorm I 1590.O03(A) Assiyunent of Responsihihty* I ( Cooked and RTE Fu+nls* i 590.003{$) Deutor stration of Knowledge" I I I Contamination from Raw ingredients f 2.103.11 1 Person in charge.-Unties ( 3-302.11(A112) I Raw Annual F(x)&Separated from Each EMPLOYEE HEALTH E Gthcr' I Contamination from the Environment 3-30 2 590.IH)31C1 Responsibility of the person in charge to 2.1 l(A) Food Protection" ` require reporting b }-3{), y fund eatployces and 1 - - - --- --- i I 2 t5 Washing Fruits and Vegetable",( 3-304.11 Focxl Contact with Equipment and 59Q003(F) Respon ibilrt% Of A F(xA Employee Or An � ! Utensils" Applicant To ReportTn The Person In I Contamination from the Consumer j 590.003(G) Reporting by Person in Chart e* I ''306.14(A)(B) Returned Food and Rvrervice of Food* f f Disposition of Adulterated or Contaminated 13 590.003(D) Exclusions and Restrictions* Food 590,603(F) Removal of Fxclusions and Restrictions I 3-701.11 Discarding(x Reconditioning Unsafe f FOOD FROM APPROVED SOURCE Fa)J* 4 I I Food and Water From Regutafed Sources 19 I Food Contact Surfaces II 540.004(-A-B) Il Compliance with Food lain* j 4-5Ql.l l t Manual Warewinhing-Hot Water 3-201.12 I RKA in a Hermetically Settled Container* I Sanitization'remperatures* 13-201.13 Fluid Milk and Milk Products* I I <t-501.112 Mechanical Warewashinr Hct Water 3-202.13 Shelf Pus* 4 I SanitizalionTemveraturel* I 4-501.114 Chemical Sanitization-tem PH, j 13-202.14 Diggs and Yolk Products.Pasteurized" I P,I 13-202.16 I ice Made From Potable Drinking Water* I concentration turd hardness_�� _ 5-101.11 Drinking Water from an Approved System" I 4-60 1,11(A) Equipment Food Contact Surfaces and 590.(H)6(A) Bottled Drinking Water' ( Utensils Clean"' 590.I4(A) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Foud- Shellfish and Fish From an Approved Source f _ - Coalaa Surface,and U,cnsils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and liecreatioually Caught Molluscan I Food Contact Snrtacvs of r E ument* ! Shethish* 4-701,11 Methods of Sanitization--}lot Water and 3-201.15 Molluscan Shellfish from NSSP listed ( Chemical* Sources* I t0 I Proper,Adequate Handwashing Game and Wild Mushrooms Approved by i Reguiiatory Authority --301.11 Clean Condition-Hands and Aruts^' 3-202.18 Shellstock ldentificat+on Present* ! 12-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* I 2-1()1.14 When to Wash* 13-201.17 Game Animals* i i1 Good Hygienic Practices _- --- I 15 ReceivinglCondiflon ( 2401.11 Eating,D ink'inb or Using Tobacco* - f 3.202.11 PH Fs Received at Proper Tentperan+res* ) 2403.12 Discharges From the Eyes,Nose and 13.202.15 Package hnesrsity* I Mouth* 13.101.11 Fond Safe and Unadulterated* I 3-301.12 Preventing,Contamination When Tastinga' 61 Tags/Records:Shelistock 1 112 Prevention of Contamination from Hands 3-202.13 Shelistok Identification* j 590.004(E) Preventing Contamination fruni 3-203.12 Shellstock lidentilicatiun Maintained* j Employees* TagaiAecords:Fish Products I I fl3 Handwash Facilities 3-402 11 I Parasite Destruction* I Conveniently Located andAccesslbfe ) c 3402.12 Records.Creation and Retention* I ( 5-203.11 I Numbers and Capacities* 590.003(J) Labeling of Ingredients* I 15-204.11 I Location an([Placement* 7 Conformance with Approved Procedures 15-205.11 ( AccMsibility,Operation and Maintenance f IHACCP Plans1 I Supolled with Soap and Hand Drying 3-502.11 Speciatiaed Processina Methods* I Da Vices 13-502.12 I Reduced oxygen packagine,criteria* I 16-301.11 Handwashing Cleanser,Availability 4 Approved Conformance with H-103.12 A 16--141'1L � Hand Drying Provision I I I Pp d Procedures"' I i ffenotec critiw}imnt in the fcrle+al 19ny P+,wul fmle w t1t5�-RiR SnU,(NH3. CITY, OF SALEM BOARD OF HEALTH Establishment Name: 9 Q_N / Date: Pager of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R Red Rem Verified PLEASE Pq NT CLEARLY - ra h� �A) r)r�-�AQI -j:Z5 rr�. GLCe MSIS, -- . 1444= -U rveB d .Sh ie t 1 irk V Y 4� UQ I./Q(T, 1�[�Ic A / ViGch -cry r)P-4e-27„ FVkkk) 10a - ^�r—� > \ A l BTU f. (1C� r . I n (( i I (�,• � — mr,te —i A 30 hy�!s1�� I � 1 I I I - I Discussion With Person in Charge: �Corrective Action Required: I ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all y/ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to (\ P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Fo Code. In erstand that noncompliance may result in daily fines of twenty iv dollars or uspension/revocation of o Embargo ❑ Emergency Closure your food permit. _ ❑ Voluntary Disposal ❑ Other: 3-i01.14(C) PRFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41°F145°F Within 4 Hours. PROTECTION FROM CHEMICALS ( 3-501.15 Cooling Methods for PHFs 14 ( Food or Color Additives { ( 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below I3-202.12 Additives* j 590.004(5) 41°145°F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A! Har PRFs Maintained at or above j Y5 Poisonous or Toxic Substances ( - 140` * 7-101.11 Identifying Information-Original ( 3-501.16(A) Roasts Held at or above 130°F. Containers* 1 1 17-103.11 Common Name-Working Conminers* j 20 Time as a Public Health Control { 7-201.11 Seaaration-Storage" j ( 3-501.19 Time as a Public Health Control* ( 7-202.11 Restriction-Presence and Use* j ( 590.004(H) Variance Requirement { ( 7-202.12 Conditions of Use* i REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ( 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) ( 7-204.11 Sanitizers.Criteria-Chemicals* j 213-801.11(.4) Unpasteurized Pre-packaged Juices and ( 7-204.12 Chemicals for Washing Produce,Criteria* i ( Severes with Waming Labels* i 7-204.14 Drying Agents.Criteria* 1So 7-205.1 I Incidental Food Contac.Lubricants* 13-801.11(B) Use of Pasteurized Eg,°s* 7-206.11 Restricted Use Pesticides,Criteria* { 3-801.11(D) I Raw or Partially Cooked Animal Food and 7-206.t 2 Rodent gait Stations* 1 Raw Seed Sprouts Not Served.* j 7-206.13 Tracking Powders,Pest Control and ( 3-80l.i l(C) Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for � Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.'Elk`"` 3-401.IIA(1)(2) Eggs- 155°F 15 Sec, Eggs-Immediate Service 1.15°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 4 Eges* 3-401.11(A)(2) Comminuted Fish.Meats&Game I Animals-155°F 15 sec.* I SPECIAL REQUIREMENTS 3.401.11(B)(I)(2) Pork and Beef Roast- 130°5121 min* j 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.0590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, ! residential kitchen operations should be Stuffing Containing Fiish,Meat, I debited under the appropriate sections Poultry or Ratites-165°F 15 sec. *' above if related to foodborne illness 3-401.11(0)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other _ 1450F v 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Micmwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec.* j ( 17 Reheating for tot Holding j VIOLATIONS R-LA TED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 1650 F 2 Minute Standing CrUical,wid non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403A I(C) Commercially Processed RTE Food- found in the following sections of the Food Code wid 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Umliced Portions of Beef 1 Rem i Good Retail Practices FC 590,000 I Roasts* I 1 23. 1 Management and Personnel FC-2 .W3 I ( 18 Proper Cooling of PHFs j 1 24. Food and Food Protection FC-3 .004 I 1 25. ! Equipment and Utensils FC-4 .605 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. 1 Water.Plumbum and Waste FC-5 .006 k 70*F Within 2 Hours and Front 71) F ( 27. Phvsicai Facility FG-6 .007 i to 41°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials ` FC-7 om 3-501.14(B) Cooling PHFs Made From Ambient 129, 1 �et�Requirements .009 Temperature Ingredients to 41°1`145°F Within 4 Hours* *Denotes critical item in the iedersl 1999 Food Code or 105 CMR 590.0(X). Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax (978) 745-0343 City/Town of Address: FOOD EST LISHMENT INSPECTION REPORT Tel. NameI / Date Type of Operation TT fInspection Is)Ar) N ✓ ( El FoodService Routine Address kt 1 ( Risl4 Retail ❑ Re-inspection I � �G�I iLYM- Level Residential Kitchen Previous In pe ion Telephone ❑ Mobile Date: �p �uu 4 (r7 5 (" 13 ❑ Temporary ❑Pre-op ra o Owner , ` IA ` �I J SSQ t J HACCP YIN ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time ❑ Bed 8 Breakfast ❑General Complaint � In: ElHACCP Inspector OSvii{�I�'nc� Oufi/6}O Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compiianee with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ q Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. FDOD.PROTECTION MANAGEMENT_,- - _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties . EMPLOYEE-HEALTH ` `- - ' ❑ 13. Handwash Facilities ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROWCHEMICALS ❑ 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded _ ,__ _ _ ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ATU -- `TIMEITEMPERRE CONTROLS(Petentlally Ha:atdousfoods)- I ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION- __ �; ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ,REQUIREMENTS FOR,HIGHLYSU$CEPTISLE'POPULATIONS'(H$P).'A El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.0 order of the Board of Health. Failure to correct violations 4. Food and Food Protection (Fc-4X590 0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-aX59o.o05) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-SX590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address .. 29. Special Requirements (590.009) within 10 days of receipt of this o er. 30. Other DATE OF RE INSPECTION: o-�aex � (� Inspector's Signature: PICS Signature: N Print: s ���''V/.� �m II Pag�-of-QPages ..��r.....r`...�r`.+-r--Vw.-.Y..�•r'-.��.'�.I��-+car'�Trvn.I'1-�.i.l.'^r•^��"'�eVrw.T'ti�' ---rte.-�w.1�yti. ,fr � Aq sa'9Y���.�..rr�_.�i Violations Related to Foodborrie Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* lil 590.003(B) Demonstration of Knowledge* ( Contamination from Raw Ingredients 2-103.11 1 Person in charge-duties 3-302A I(.A)(2) Raw Animtl Foods Separated from Each EMPLO"EE HEALTHOther* J Contamination from the Environment J 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* J require reporting by food employees and 3-302A.5 Washing Fruits and Vegetables J applicants* 304.11 i Food Contact with Equipment and 590.003(F) Responsibility Of A Foud Employee Or An I utensils* Applicant To Report To The Person in Contamination from the Consumer Charge* 4-306.14(A)(B) Returned Food and Rescrvice of Food* i 590 003(G) Reporting by Person in Charge` Disposition ' ion of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food� 590.003(E) Removal of Exclusion and Restrictions 13.701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 141 Food and Water From Regulated Sources 9 Food Contact Surfaces j 590.004iA-B) Compliance with Food law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 F(x)d in a Hermetically Scaled Container* ( Sanitization Temperatures* .� 3-201.13 Fluid Milk and Milk Products* ( 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 14-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Tce Made From Potable Drinking Water* concentration and hardness. 4-601 11(A) I Equipment Food Contact Surfaces and I J 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.()n6(A) Bonled Drinking Water' 4-602.11 CleaningFrequency of Equipment Food- I590.006(B) Water Meets Standards in 310 CMR^_2.0* ( I Contact Surfaces and Utensils* Shotf(ish and Fish From an Approved Sourre _ I .f_702.11 I Frequency of Sanitization of Utensils and 3-201.14 Fish and Rerrewianaiiy Caught Moliuscsn Foal Contact Surfaces of Equipment* ShelL'ish' I 4-703.11 Methods of Sanitization-Har Water and 3-201.15 Molluscan Shellfish Eom NSSP Listed ! I ( Chemical* Sounes* --__I J 10 Proper,Adequate Handwashing Game and Wld A.4ushrooms Approved by Ragutatory Authority 2-3 01.11 1 Clean Condition-Hands and Arms* J 3-202.18 Sheilstock identification Present' 2-301.12 Cleaning Procedure* 590.004(C) I Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 111 Good Hygienic Practices 5 ( ReceivingrCondition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Teroperamres* 2401.12 Discharges From the Eyes,Nose and 3-202.15 Package lmeysity* I I Mouth* 3-H)i.11 J Pool Safe and Unadulterated * 13-301.12 Preventing Contamination When Tasting* J 6 TagsMecords:Shellstock 112 I Prevention of Contamination from Hands J 3-202.18 Shellstock Identification* 1590.064(E) I Preventing Contamination from 13-203.t2 Shellstock Identification Maintained* Employees* Tags/Records;Fish Products i 113 I Handwash Facilities 13-402.1 t Parasite Destruction' i I I Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 I Numbers and Capacities* 590.004(.0 Labeling of Ingredients' 15-204.11 Location and Placement* Conformance 5-205.11 Accessibili .Operation and Maintenance ' I I HACCP Plans vrith Approved Procedures ( I Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices J 3-502.12 Reduced oxygen packaging,criteria* 16-301. l Handwashing Cleanser,Availability 18-103.12 Conformance with Approved Procedures* 16-301.1 1 2 Hand Drying Provision :Denotes critical lien in the federal 1999 Food Code or 105 CMR 5()0.000. CITY OF SALEM I BOARD OF HEALTH Establishment Name: 9_1 A I w) �Gv1I1Y y Date: )L./ Page: ) of,tn Item Code C-Critical Item r / DESCRIPTION OF VIOLATION/PLAN OF 6ORRECTION Date NO. Reference R-Red Hem '/�1 ,,, L. rL PRINT Verified Ixs tll��. Il / ! It� 'IJW(110 C� c71 SE nAAU^ ly 1/i �Irr� n�1 OA IYI r? ^ VA rd h6 A(P- 4'!�—�2T --aC' fn �N. i . /' II ./1cD-rrTt _N_'0 VI S,iJl(/�l L[ La_ per, nOle-d ci✓ l6-)/IL�_l4_// ll(ACA-r/-1 QA J S n1K r J ) Z 117 I �� �Jsa 1t ✓ Tl�reor,�i_ �1c �1� (Lc�tr,� clowod( 3q- ) 1Inre u�ss, ,,r ����evri✓� sh�eto�, . �r 4_ Rr M o-t f . I.c Inc ,7.; n jfw I r cru- th;7 33& 26qZ—xx, 3 00A10A 0,o '�_v'0 ?3 13 T�6-,Y3/4 04-6,M &11i'� -le,tan_1 AL' 5'0cL« r i` or>L irTU-) ew. r.w ay ria- ► ( i Z_r_ I(-E 184 I Cyr-, �,a3 114 ' I / 1tn� �.hD I <D � (h2�tn �7✓i ►�avec; 1 �1M. r4 1rf V�ic�c Discussion With Person in Charge: orreetive Action Required: I ❑ No ( Yes I have read this report, have had the opportunity to ask questions and agree to correct all V untary Compliance ❑ EmployeRestriction/ violations before the next ins ection, to observe all co-Witions as ribed, and to Exclusion P Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food C e. I unde sta d that noncompliance may result in daily fines of twenty-five i Ilars ors sp nsion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: 3-501.14(C) PHR Received at Temperatures Violations Related to Foodborne ttinesst interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont) 41°F/45`F Within 4 Hours. ' PROTECTION FROM CHEMICALS I 3-501.15 Cooling Method for PHFs { { 19 PHF Hot and Cold Holding 14 { Food or Color Additives { { { 3-50L16(B) Cold PI1Fs Maintained at or below 3-202.12 { Additives* i 590.004M 4101450 F* 3-302.14 Protection from Unapproved Additives* 3-50 1.16(A) Hot PRFs Maintained at or above is Poisonous or Toxic Substances I140°F * 7-101.11 Identifying Information-Original 13-501.26(A) Roasts Heid at or above t30°F Containers* " { I ( { { 7-103.11 Common Name-Working Containers* 20 Time as a Public Health Control 7?01.11 Separation { 3-501.19 Time as a Public Health Control* { { { 7-202.11 Restriction-Presence and Use* i 590.004(H) Variance Requirement t 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE { 7-203.11 Toxic Containers-Prohibitions* I POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals* { 21 3-801.11(.4) Unpasteurized Pre-packaged Juices and { 7-204.12 Chemicals for Washing Produce,Criteria° { .Beveroecs with Warning Labels* { 7-204.14 Drying Agents.Criteria* l "3-801.11(B) Use of Pasteurized Eggs* I 7-205.11 incidental Food Contact,Lubricants* { 3-801.11(D) Raw or Partially Cooked Animal Food and i 7-206.11 Restricted Use Pesticides.Criteria* { Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Sta[iom* 1 { 3-801.11(C) Unopened Food Package Not Re-served, 7-206.13 Tracking Powders,Pest Control and " MomtunnO CONSUMER ADVISORY TiMEti EMPERATURE CONTROLS 22 3-603.i l Consumer Advisory Posted for Consumption of ' 16 I Proper Cooking Temperatures for I Animal Foods That are Raw,Undercooked or PHFs I Not Otherwise Processed to Eliminate } 'Ytecum ih2rlOi 3-401.I1A(I)(2) Eggs- 155"F 15 Sec. Pathogens.' Eggs-Immediate Service 145°F15sec* 3-302.13 � Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-755°F 15 sec. * SPECIAL REQUIREMENTS { 3.401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 nun* 3401.I1(A)(2) Ratites,Injected Meats-155°F 15 590.009(A}{D) Violations of Section 590.009(A)-(D)ernporry and in sec. * catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fisl[,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 1 3-401.12 Raw Animal Foods Corked in a practices should be debited tinder#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-1, 17 Reheating for Hot Holding { VIOLATIONS R-LATEO TO GOOD RETAIL PRACTICES 3-403,11(A)&(D) PHFs 165°F 15 sec.* (Items 23-34) 3-403.11(B) Microwave- 1650 F 2 Minute StandingI Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3.403.11(C) Commercially Processed RTE Foal- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef 1 Rete i Good Retail practices .FC 59D.000 Roasts* 1 23. 1 Management and Personnel I FC-2 .003 i { 1g Proper Cooling of PRFs 1 24. Food and Food Protection FC-3 .004 i 25. Equipment and Utensiis FC-4 005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Wept,Plumbinpand Waste" i FC-5 .006 70°F Within 2 Hours and Front 70 F127. Physical Facility FC-6 .007 to 410F145°F Within 4 Hours. * 128. Poisonous or Toxic Materials FC-7 .om 3-501.14fB) Cooling PHFs Made From Ambient 129. Special Requirements .009 i Temperature Ingredients to 41`3!45°F 1 30. Other I Within 4 Hours* "Deeotc,critical lien in the federal 1999 Fend Cc&or 103 CMR 590.(100. CITY OF SALEM , II BOARD OF HEALTH Establishment Name: �1 t� N �A N�/ Date: J /y Page: 7 of4_� Rem Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION - Date NO. Reference R-Red Rem Verified 1 PLEASE PRINT CLEARLY �1 4_JZG cc ,. Irnf.l S" :kJ . 1 I D�- >` svl- (i J U Aor- baa Aai�-, i,-1 c�l� vn, n,c.S�LL '40fi�" z Y�T d�� l4h� 4—V3 - .� c�S A94 cz cA, .r- 1-ox ,,w q44- a1`1 ( Y OkAr 0'\ '(33 Wf Cif-R1,4 iov- c-Y6 In du kN AV—13 I � K7/��1�12A, -z� .�rn} I 1V0A Pr1ec MILV Sh.10 tl -��vTV 11 �--W ���M4Va:TIL( r GQ2b W 1— t�V ilt `. S�C.uo _ I I c�'1—ell cl 7 46�3Y uAV tviu I I in cue R t l K (k) oin OZ C r=vrl ride 16 i y y f,.b I•i/ I W6 1-70 Oa ,L K Rik t ie�: 'w' t r r n a ir'( 1(1 rL1 a A 0 A^) GLQG/)i Af_,5�-7v4 C'h vt Discussion With Person in Charge: Corr�Action Required: I o No I� Yes Tn.� K•�� 2es.d.Le �O I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Codg. I understand that noncompliance may result in daily fines of twenty-five do rs or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: - 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors{Items 1-22) (Cont.) 41'F/45`F Within 4 Hours. PROTECTION FROM CHEMICALS I 3-501.15 Cooling Methods for PHFs I 114 O Food or Gator Additives I 119 PHF Hot and Cold Holding 3-50L16(B) Cold PIFs Maintained at or below I3-202.12 Additives* 590.004(17) 410/450 F* 3-302.14 Protection from Unapproved Additives* ( 3-501.16(Al Hot PRFs Maintained at or above 115 Poisonous or Toxic Substances 140°F. * 7-101.11 Identifying Information-Original 3-501.16(.9) Roasts Held at or above 130'F. * I Containers* ( 20 rime as a Public Health Control 7-102.11 Common Name-Working Containers* j 7-201.11 Separation-Storage` 3-501.19 Time as a Public Health Cenral* 7-202.11 Restriction-Presence and Use' i 590.004(H) Variance Requirement I 17-202.12 Conditions of Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* 1 POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals° 7-204.12 Chemicals for Washing Produce,Criteria* I 121 3-801.11(.9] BevUnperages wit Pre-packaged Juices and I Beverages with Warning Labels* 7-204.14 Drving Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental FooUse Contact, .urticants* � � 3-801.11(D) Raw or Partially Cooked Animal Foal and i 7-206.11 -Restricted Use Pesticides,Criteria* I Raw Seed Sprouts Not Served.* ` j 7-206.12 itodcut Bait Stations* j 3-801.1)(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and t Monitoring* CONSUMER ADVISORY TIMEti EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 26 Proper Cooldng Temperatures for Animal Foods That are Raw,Undercooked.or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155`17 IS Sea 1 Pathogens.*`r""'°"n wl Eggs-Immediate Service 145'FiSsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155'F 15 sec. * SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* j 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590,009(A)-(D) Violations of Section 590.0(}9(0)-(D)in sec.* catering, mobile food,temporary and 340LI4(A)(3) Poultry,Wild Game,Stuffed PHPs. residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sce.* I above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F" 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Corked in a practices should be debited under#29- Microwave 165°F a Special Requirements. y 3-401.1 I(A)(1)(6) All Other PHFs-145'F 15 sec. 17 i Reheating for Hot Holding VIOLATIONS R FLA TED TO GOOD RETAIL PR4C77CES 3A03.11(A)&(D) PHFs 165°F 15 sec.* I (Items 23.30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Tine* foodborne Illness interventions and nisi factors listed above, can be 3-403A I(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Porcinns of Beef % Item I Good Retail Practices FC 590.000 1 Roasts* 23. I Management and Personnel i FC-2 .tML9005 I 24. Foal and Food Protection FC-3 .004 25. Egvipnrent and Utensils FC-4 1S Proper Cooling of PHFs _ 1 , 3-50L14(A) Cooling Cooked PHFs from 140'F to 26. . Water,Plumbinoand Waste 1 F0-5 .006 I 70*F Within 2 Hours and From 70'F 27. Phvsical Fackut FC-6 1 .007 I to 41°F/45'17 Within 4 Hours. * 1 211. Poisonous or Toxic Materials ' FC-7 00a i 3-501.14(B) Cooling PHFs Made From Ambient 1 29. Special Requirements .009 i Temperature Ingredients to 4I'P/45'F 30" 1 Other I I Within 4 Hours* "Nnotcs critical hem in the federal 1999 Fuad Code or 105 CN4R 590.000. CITY OF SALEM I - BOARD OF HEALTH Establishment Name: )An A1 �l<UT/!.1 Date:' Page: `/ of Rem Code C-Critical Item / DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item verified / PL ASE PRINT CL RLY 3 f- c e c. -i ip r1p < c � s Aip _ s ef _GA) , x s ( d), ,n /w -ref / I fm �r1 r�� 17��In f �rz2ccw I^r�s�r.,{{ l6 c7� on,(`F) a-+�JSL ' � ✓ Q t M4,n Do/K / 13V a�,Y(r� ';to (-4 t( y-.l.lNpirz � d�Atz; --d c r �lS > n5 a3 1-- J ds 1 (0 � l ,.s nc1� '3 C7 a::L u r I _ Cam �+e( t ��I�►- --`���-I�� �- ,-r,; � (��tot4.�1 , i�s1.�(� '�n��e. l--�ho a�u� rWy� Inr�(,7te �/ 3 ��� n?/Z � trt t3 i,r a4 qec o� r I Cry ( 1 ou 0, a cl(,SSlc 2 ss ar7 .2[;-RowC)Ve4_�n t r-i�vl 6 11 i_ec 04 A2�jl; v tats yr 17/�SS, Iry200 r)cNa✓o. 13 Discussion With Person in Charge: Corrective Action Required: C ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance LI Employee RI estriction inspection, to observe a -onditions as described, and to C Exclusion violations before the next ins P CY Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Fo clCode. I unde tand that iC noncompliance may result in daily fines of twenty fi"e dollars or pension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne illness interventions and Risk According to Law Cooled to Factors{items 1-221 (Cont.) 41°F/45`F Within 4 Hours. " PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs I 14 FoodAdditives* iv Gator Additives { 119 PHP 1*4 and Cold Hoidinq I 3-502.16(B) Cold PHFs Maintained at or below { 3-2U2.12 Add t vas° 590.004(F) 4101450 F* 3-302-14 Protection from Unapproved Additives* i 3-501.16(A) Hot PHFs Maintained at or above { 15 + Poisonous or Toxic Substances I 140°F. * 7-101.11 Identifying Information-Original 1 3-501A(i(.A) { Roasts Held at or above 130°F. * { Containers* II { 20 { Time as a Public Health Control 7-102.11 Common Name-Working Containers'' { ( 3-501.19 Variance Requirement Time ac a Public Health Control" 7-201.11 Separation-Storage4' 590.U04( { { 7-202.11 Restriction-Presence and Use* { 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE { 7-203.11 Toxic Containers-Prohibitions* t POPULATIONS(HSP) i 7204.11 Sanitizers.Criteria-Chemicals* { 21 3-801.11(.4) Un astevrized Pre-packaged Juices and 7-204.t3 Chemicals for Washing Produce,Criteria* 21 with Wanting Labels" { 7-204.14 Drying Agents.Criteria* 3-801.11(B) i Use of Pasteurized Eggs* { { 7-205.11 Incidental POW Contact.Lubricants* j 13-801.11(D) � Raw or Partially Cooked Animal Food and { 7-206.I t Restricted Use Pesticides,Criteria* t Raw Seed Sprott Not Served.° 7-206.12 Rodent Bait Stations* � { 3-801,11(C) Unopened Food Package Not Re-served. * � - 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TiME7TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods Thatare Raw.Undercooked or 16 Proper Goole ng Temperatures for PHFs Not Otherwise Processed to Eliminate PaLhogeDs* 3-401.I1A(1)(2) Eggs- )55°F 15 Sec. Eggs-immediate Service 145°FISsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec.* SPECIAL REQUIREMENTS { 3.401.I1(B)(I)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 catering,mobile food,temporary and 3-400.1 t(A)(3) Poultry-,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish Meat, debited under the appropriate sections Poultry or Ratites-165°F i 5 sec. ' above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foals Cooked in a practices should be debited trader##29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sea { 17 1 Reheating for Hot Holding 1 VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3-403.11(A)&(D) PHFs 165°F 15 sec.* (Items 23.30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* I foodborrte illness interventions and riskfactors listed above, can be 3-403AI(C) Commercially Processed RTE Food- i found in the following sections of the Food Code wrd 105 CMR 140°F* i 590.000. 3-103 11(E) Remaining Unsticed Porti ms of Beefite ! i m I Goad Retail Practices FC 590.000 i Roasts* ( 23. ! Management and Personnel 1 FC-2 003 I { IS Proper Cooling of PHFs 24. 1 Foal and Food Protection FC-3 .004 f 25. j Equipment and I tertsfls FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26, Water,Piumbinq and Waste i FC-5 5 I .006 f 70°F Within 2 Hours and From 70°F 27. Physical Facility ! FC-6 d .007 ! to 41°F/45'F Within 4 Hours. * 128. � Poisonous or Toxic Materials ! FC-7 I .008 i 3-501.14(B) Cooling PHFs Made From Ambient129. Special Requirements .009 I Temperature Ingredients to 41°F/45°F Z ( Other Within 4 Hours' Iknotes critical haul in the federal 1999 Fuad Cade or 105 CN4R 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 1//Mn /V /G Date: J �X//y Page: S— of t` , Rem Code C-Critical Item DESCRIPTION OF VIOLATION/F$LAN OF CORRECTION Date No. Reference R—Red Rem Verified PLEASE �PRINT CLEEARLY (-0 y' a�CC7CJ o�fl r — IC� sv's r t t.P,4 l5' d R V_r 0-t-On, , r zr),A d �� �R f9 3 t-3 cM ro Rs� _573-6-2-- city 1 11AFrcJ PIC-57-4 -57/XAA1 1 (h /., nit=-C) r &C=4 ,A('�p Rn a-�7ryT a/>° ct t�Y lL(LJ cK C 1r.L�g ,(/'lla ( f�3�� yAL,/�y1� riTi� g/,>/%�✓02 Q t(.+ a> I>), �[l ^ / ti , / c SGS c 4er' Q,.v5:, 1 0 /a�F e� IV r�c.rv2LU/' - �vr TJX., >•/ u o c ?cr�.� u. err 1 I tj a7 r)z ,ano f19s7,�, 4�� —a /T ,13 b"i c2/ `l r I Discussion With Person in Charge. Corrective Actlon Requio d: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ luntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe al onditiohs as d cribed, and to Exclusion P Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Fo d ode. I unde t nd that noncompliance may result in daily fines of t ty ive dollars or s ension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal 0 Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne illness interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont) I 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coming Methods for PHFs ' 19 PHF Not and Cold Holding 14 Food or Gator Additives 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 410145°F* 3-302.14 Protection from Unapproved Addiuves* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substance 140°F 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F Containers" ' Time as a Public Health Contra! 7-10'_'.11 Common Name-Working Containers* 3-501.19 Time as a Public Health Control* 7207.11 Separation-Storage* 4 7-202.11 Restriction-Presence and Use:'" 590.004(H) VarianceRegturement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) f 7-204.11 Sannizers.Criteria-Chemicals° 21 3-80L11(.A) UnpasteutizedPre-packagedJuices and 7-204.12 Chemicals for Washing Produce,Criteria* Eeveneur with Pre-packaged a labels* j 7-204.14 Drying Agents.Criteria* 3_801.11tB) Use rs Pasteurized Warning 7-205.11 Incidental Food Contact,Lubricants* 1 3-801.11(D) Raw or Partially Cooked Animal Food and i 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* ` 7-206.12 Rodent Bait Stations* ( 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEiI EMPERATURE CONTROLS 22 3-603.I1 Consumer Advisory Posted for Consumption of 1Animal Foods That am Raw.Undercooked or 16 Proper Cooking Temperatures for ` PHFs Not Otherwise Processed to Eliminate Pathogens.*Ems"°" 3-401.11A(I)(2) Eggs- 155`F 15 Sec. Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&(tame Eggs* Animal's-155°F 1.5 sec.* SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 sec.* catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, ( debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.001 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Micruwave 165°F* .Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sea 117 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 15 sec.* (Reiss 23.30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Tithe' foodborne illness interventions and risk factors listed above, can be 3-403A I(C) Commercially Processed RTE Food- found in the follnwing sections of the Food Code and, 105 CMR 1400F* 590.000, 3403.11(E) Remaining Unstioed Portions of Beef % Item i Good Retail Practices FC 590.000 1 Roasts* 123. 1 Manauement and Personnel j FC-2 .003 1 18 Proper Cooling of PHFs 1 24. Food and Food Protection FC-3 ( .004 i 1 25. 1 Eguioment and Utensils FC-4 005 i 3-501.14(A) Cooling Cooked PHFs from 140°F to 1 26. 1 Water,Plumbirm and waste i FC-5 006 1 70°F Within 2 Hours and From 70°F 27, Physical Facility . FG-6 .007 1 to 41°FASOF Within 4 Hours. * 28. I Poisonous or Toxic Materials FC=7 I o08 I 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements It1 .009 i Temperaturc'Ingredients to 41`F/45°F i 30. 1 Other Within 4 Hours* *D2notes..•dticai hent in the federal 1999 Fwd Code of 105 CNAR 590.000. ' CITY OF SALEM n BOARD OF HEALTH Establishment Name: �Ja f� AJ I✓�3.J�j Dater /�J Page: /A of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OFfCORRECTION 'Date. No. Reference R—Red Item Verified PLEASE PRINT CLEARLY C",`f '< <)t (�.fd- Ian ago urn /� ✓u�ta.� 11 ��, - i/ y r2l 47J 1c, o ty 7 • , y rl-e(7 IU � nti✓IZ rt ikC /3 n� '))f%A L7 IV I Il a,iA /e :19--rmf I aora S11,U ,%z A., i1-4A P&C& fV-4 s 4Lk,0 .Herz PL6 av rL.. T13/ ,j JJ z� 7 my �r- - 17aoII CIa:�AIe ISI V OA JkW,Ac, a Cmss �D� j fK �- i� 'JA I r F �� � I u. (V--t n C- J:) 1 b-C QJQ�P-l_ l5 /V OAJ �'_r d CC'IlA�irX/ t n tN✓/'fdl\C 'M'4vW' (L— Iall (S A4(s5, Y-. C1�11Y C 'l�I haze (P6 1/15AV/0"/ I Discussion With Person in Charge: I - Corrective Action Required: I ❑ No IOL Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee R{eessttrriction/ inspection, to observe all conditions as described, and to r / Exclusion violations before the next ins P � Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I nderstand at noncompliance may result in daily fines of twenty-five dollar r suspen i n/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PRFs Received at Temperatures '1 Ylotatlons Related to Foodborne Rinesstntementions arta Risk - According to Law Cooled to Factors{Items 1-22) (Cant.) 41T145°F Within 4 Hours.* S PROTECTION FROM CHEMICALS I 3-501.15 Cooling Methods for PHFs A { 14 1Color { 19 PHF Hot and Cold Holding Food or AAdditives 3-501.16(13) Cold PHFs Maintained at or below 3-202.12 Additives* { 590.004(F) 41°145°F* 3-302.14 Protection from UnaPRroved.Additives" j , 501,16(A) Hot PIFs Maintained at or above { 15 Poisonous or Toxic Substances I 140 r 7-10111 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* 20 Time as a Public Health Control { 7-102.11 Compton Name-Working Containers* I 4 3-501.19 Time as a Public Health Contnrl*7-201.t 1 Separation-Storage* I t 7-202.11 .Restriction-Presence and Use* { 190.004(H) I VarianceRetmirement { 17-202.I2 Conditions of Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE { 7-203.11 i Toxic Comainer;-Prohibitions* { POPULATIONS(HSP) 17-204.11 f Samtizers.Criteria-Chemicals* { 21 t-801.1](A) Unpasteurized Pre-packaged Juices and 7-204,12 { Chemicals for Washing Produce.Criteria* 1 Beveraleswith WarttingLabels* � 7-204.14 � Drying Agents.Criteria* l 3-80L I I(B) Use of Pasteurized Eggs* I { 7-205.11 Incidental Food Contact.Lubricants* I j 3-801.11(D) Raw or Partially Cooked Animal Food and 17-206.11 I Restricted Use Pesticides,Criteria' I Rax,Seed Sprouts Not Served. 7-2D6.12 Rodent Bait Stations* 1 { 3-801.11(C) ! U nopened Food Package Nut RL-served. " { i 7-206A3 Tracking Powders,Pest Control and f Monitoring* CONSUMER ADVISORY CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumpttim of TIME7fEMPERATURE CTemperatures far Anima]Foods That are Raw,Undercooked or 16 Proper C oldngONTR PHFs Not Otherwise Processed to Eliminate Pathogens.*Efx,+ rnrmet 340i.IIA(1)(2) Eggs- 155`F 15 Sec. 3-3D2.13 Pasteurized Eggs Substitute for Raw Shell Eggs-immediate Service 145°F15se:* Ems* 3-401.11{A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec. * SPECIAL REQUIREMENTS 3401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 min* 3-40111(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 540.049(A)-(D) n sec.s catering, mobile food,temporary and 3-40)-1I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be { Stuffing Containing Fish,Meeat. debited under the appropriate sections Poultry or Ratites-]65'F 15 sec, * above if related to foodborne illness 3-101.11(C)(3) Whole-muscle,hand Beef Steals ( interventions and risk factors. Other 145°F* ( 590.049 violations relating to good retail 3-401.12 Raw Animal Fouls Cooked in a practices should be debited under 9129- Microwave 165°F* Special Requirements. i 401.11{A}(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hof Holding { VIOLATIONS RCLATED TO GOOD RETAIL PRAC77CES 3-403.1 I(A)&(D) PHFs 1657 l5 sec. * { (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing I Critical and non-critical violations, which do not relote to the - Time* I foodborne illness interventions and risk,factors listed above, can be 3-103.11(C) Commercially Processed RTE Food- faund in the jolloning sections of the Food Cade and 105 CMR { 140"F* 590.000. r 3-403.11(E) Remaining Unsliced Portions of Beef i Item I Good Retail Practices IFC 53AAd0 - !!! Rests* i 23. 1 Marenament and Personnel FC-2 5003 18 ! Proper Cooling of PHFs { ! 24. 1 Food and Food Protection FC-3 .004 25. ( Equipment and Utensils ' FC-4 E .005 j 3501.14(A) Cooling Cooked PHrs from 140`F to 1 2,. I Water.Plumbinct and Waste I FC-5 i .006 70'F Within 2 Hours and From 70`F 1 27. Physical Fad[tV FC-6 .W7 to 41`F/45'F Within 4 Hours. * i 28. Poisonous or Toxic Materials ' FC-7 .008 3-501.14($) Cooling PHFs Made From Ambient 129. I Special Renuirements .009 1 Temperature Ingredients to 41'F45°F i Other - ! Within 4 Hours* _ } 'D aorms co ieat=rn in the L-dea] 1999 Fool Cate w'105 CaiR 590.000. )