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' CITY OF SALEM, MASSACHUSETTS H , BOARD OP 120 WAS]HNUI'ON S'11tUltT,41"FLOOR KIMBERLEY DRISCOLL Tea..(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/REFIS,CI-10,CP-FS MAYOR Immdln@salem.com I HEALTH AGENIT - Food Establishment Permit Application (Application.must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 154 g- 1�' ,, vp 2) Establishment Address �O- 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: g 5) Applicant Name&Title: 6) Applicant Address: , 4A VJ J"�,e-N Ge' A # 7) Applicant Telephone No: $ `� �Q �l 24 Hour Emergency No: Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation An individual 903A Akr,9 � A partnership Other legal entity 12 Person Directly Res onsibleeFor Daily Operations Owner, Person in Charge,Supervisor,Manager,etc. Name&Title: 49p, I✓k JJ R k'5- Address: 64 ILAW C 0- 5" M;29 Telephone No: fJ 3 of r7(� 04 Fax: Email: Emergency Telephone No: $ Q 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: ry Fax: Email: cb- Check#: /��` Date: /�'" 1 �7 — �� Amount: U v �` Food Establishment Information 14) Walor Source: 15) Sewage Disposal: WEP Pu6Iic Water Supply No: (if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person In Charge Certified in Food Protection Management: Required as of 101112001 In accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑Caterer Permanent Structure ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length OF Permit: Breakfast Establishments RETAIL STORE......................•••-------------.............RESTAURANT Establishments Annual (check one) ❑ Less than 1000sq.ft. $70 ❑Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑Residential Kitchens $140 ❑More than 10,000sq.ft. $420 121'255-99 seats $280 ❑More than 99 seats $420 Temporary/DatesMme: - - -------- ❑ Bed&BreakfastiChildcare Seryices-Nursing Home $100 ADDITIONAL PERMITS ----------------------------------------•--------------------------------------------------------------- ❑MAKE ICE CREAM,YOGURTISOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT` $25 *Including, church kitchens, state funded childcare 6 private club 23) Food Operations: Definitions: PHF-potentially hazardous food(dmeRemperaturecontrols requireci) Non-PHFs-non-potentially hazardous food(no timeltempereture controls required) (check all that apply): RTE-ready-to-eat foods Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum PackaginglCook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Nor-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been Instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: K024— IIA � nfAnlD-Uf i Pursuant to MGL Ch.62C,sec.49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required ;under law. 25) Social Security Number or Federal ID: 7 �_o �u 26) Signature of Individual or Corporate Name: Massachusetts tDe artment of Public H Salem Board of Health Department Health 120 Washington Street,4"Floor Division cif Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978 5 0343 City/Town of Address: FOOD ESTABLISHMENT INAPECTION REPORT Tel. NameDa Type of Operation(s) Type of inspection ( Food Service Routine .Address ,J r k � Retail e-inspection O Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-operation n.6,1, ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time / ❑ Bed 8 Breakfast El General Complaint In:�;S ElHACCP Inspector 0ut: Permit No. ❑.Other Each violation checkbd requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD PROTECTION MANAGEMENT _ - _ _ ,. [112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC I PROTECTION FROM'CHEMICALS ' El 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded --- - -._._ _ L. ❑ 15. Toxic Chemicals _FOOD FROM APPROVED SOURCE,,,._ ❑ 4. Food and Water from Approved Source _ ;TN7EfTEMPERATURE"CONTROLS(Potentlalty Hazardous Foods) ❑ 5. Receiving/Condition ❑16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION- _- - _«- 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing !REQUIREMENTS FOR.HIGHLYSUSCEPTIBLE-PO_li IONS' :(HSP El 10. Proper Adequate Handwashing )` El 21.Food and Food Preparation for HSP _ El 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 `J immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590-000/federal Food Code.This report,when signed below C Nby a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3X590.004) 0044)) cited in this report may result in suspension or revocation of 5. Equipment and Utensils (FC-aXsso.00s) the food establishment permit and oessation of food 26. Water, Plumbing and Waste (FC-5X590.006) 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-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. 0.Other DATE OF RE-INSPECTION: -L"3 -r.d ' Inspector's Signa Print: PICS Signature: Print: Page of,)Pages �.,�t.�.^F-�wv}�r'r�.rnrfti...l � rr.Y•^S_.1 /`. _. ... -. rY r}\ iv. Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Crass-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)fL) Raw Animal Foods Separated from i 1 590.003(A) Assignment,ofReg2risibill[ * Cooked and RTE Foods* 590.003(8) Demonstration of Knowledge* Contamination from Raw Ingredients 2-Ln3 11 Person in Charge-duties 3-342.11(A)(2) Raw Animal Foals Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 59fI003(C) Responsibility of the person in charge to 3-301.11(A) Food Protection* require reporting by foal employees and 3-302.15 Washing Fruits and Vegetables a licants* 3-304.11 Foal Contact with Equipment and 590.063(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report"re,The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Ford" 590.003(Cr) Re t o by Person in Chartz_e" 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 Fund* FOOD FROM APPROVED SOURCE 4 Foodand Water From Regulated Sources 9 Food Contact Surfaces 59R()44(A-8} Com rti:nce with Fail Law'k 4-501.111 Manual Warewashing-Hot Water 3-201,12 Food in a Hermetically Sutler#Container" Sanitization WarewashingTemperature * 320'1.'13 Fluid Milk and Milk'Prod ucts" 4-501.112 Mechanical Temperatures* Water S:utitization Temperatures* 3-202,13 Shell Eons* 4-501.t W Chemical.Sanitization-to H, 3-202.14 F,+s and Milk Products.Pasteurized* �"P concentration and hardness.'" 3-202.16 lee Made From Potable Drinking Water* 4-601..11(A) Equipment Food Contact Surfaces and 5-101.'11 DrinkingWater from an A roved System- Utensils Clean* 590.006(A) Bottled Drinking Water 4-602.1.1 Cleaning Frequency of Equipment Food- 590.0m(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shefflish and Fish From an Approved Source r7O3 Frequency of Sanitization of Utensils and 3-241.14- Fish and Recrealianally Caught Molluscan Fad Contact Surfaces of ui ment* Shellfish* 1 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish f-om NSSF fisted Chemical* Sources* to Proper;Adequate HandwashIng Game and Wild Mushrooms Approved ay 2-301.1.t Clean Condition-Hands and Arms* Regulatool Authority 3-202.1.8 Shellstock Idemification Present'+ 2-30132 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals" t2 Good Hygianio Practices Recelving/Conditton 2-441.31. Eating,Drinkingor UsingTobacco* 3-202.11 PIIFs Received at Proper Temperatures* 2-401.1.2 Discharges.From the Eyes,Nose and Package ante it'* Month* 3-202.15 3-102.11 Food Safe and Unadulterated* 3-301.12 PreventingContamination When Tasting* 6 TagsfRecards:Shelistock 12 Prevention of Contamination from Hands 3-242.18 Shellstack ids:Shelllstoentification* 590.004(E) Preventing Contamination from Empl - 3-203.12 Shellstock Identification Maintained* Handwash es TagstRecords;"Fsh Products 13 Conveniently Located and Accessible 3-402.11 Parasite DestruQ600 5-203.11 Numbers and Capacities* 3-402.12 Records.Creation and Retentiun* 5-204 l 1 Location and Placement* 590.404(1) Labeling of Ingredients' - Conformance with Approved Procedures 5-205.I1 Accessibility, ration and Maintenance Confor ConferPlans Supplied with Soap and Hand Drying Devices" 3-502.11. Specialized Pro:essin Methods* 6-301.11 Handwashing Cleanser„Availabilit 3-502.12 Reduced oxygen Eackaging,criteria* - 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* 'Denotes eritirrl heat in-the"federal 19"ro,)d Co&ur 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: t Date: Pager_ of Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEA EP INT CLEARLY u 04 JL 0 -1-_dn *V?1 NZ IL S DkA V, r ePD 2 c' 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 Resitriction 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 tenty- ' e dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: 41 i 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to 1 Factors Memo 1-27) (Cont.) _41'F/45'F Within 4 Hours. 3-501..15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding 14 Food or Color Additives - 3-501'16(13) Cold PRFs Maintained at or below ' 3-202.12 T Additives* 590.004(F) 410/450 F* 1 3-302.14 Protection from Un roved Addhives'i 3-501.16{A} Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. 7-101.11 Identifying Information-Original 3.501.16(A) Roasts Held at or above 130'F. yContainers* " 7-102.11. Common Name-Working Conminers* 20 Time as a Public Health Control 7-201.11 Separation-StoraF*. 3-501,19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use" - 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203-11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP - 7-204.12 Chemicals for Washin Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Laihricants* 3-801.11(B Use of Pastemizetl Begs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served* 7-306.12 Rodent Bait Stations* 3-801.11(C) Unopened Food ParkaNut Ro-served. 7-206.13 Tracking Powders, Pest Control and _ siring* CONSUMER ADVISORY TIMER EMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 340i.IlA(1)(2) Eggs- t55°F 15 Sec. patiogens.,owlM Imran 1 E -Immediate Service 145°Fl5sec* 3-302.13" Pasteurized Eggs Substitute far Raw Shell E 3401.11(A)(2) � Comminuted Fish.Meats&Game 'j Animal's-155'F 15 sec.* SPECIAL REQUIREMENTS 3.401.11(8)(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 see.* catering,.mobile rood,temporary and 3401.1.t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited utider 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 j 1450F°' 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401.1 I(A)(1)(b) All Other PHFs-145°F 15 sec. 19 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165"F 15 sec. * (Items 23-30) 3-403.11(B) Microwave 1650 F 2 Minute Standing Critical..mrd non-critical violations,which do not relate to the Time* i foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections,of the Food Code and 105 CMR 1400F* 590.000. 3403.11(E) - Remaining Unsliced Portions of Beef Itarn I Good Retail Practices ,,FC 590.000 ' Roasts" 23_ 1 Management and Personnel FC-2 .003 " 18 Proper Cooling of PHFs 124." 7 Foal and Food Protection FC-3 .004j 25. Equipment and Utensils _! FC-4 .005 3-501.14(A) Cooling Choked PHFs from 140'F to 26, Water.Plumbing and WasteIFC-5 .006 1 ? 70'F Within 2 Hours and From 70°F 27. Ph ical 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. Serial Requirements .009 FTemperature Ingredients to 41'F/45°F 30 1 Other _ Within 4 Hours* . ssvnro,n sw.zM- *Denotes crifical hem in the federal 1999 Fwd Cale w 105 CMR 590.000, Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4a' Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT IN CTION REPORT Tel. Name Date Type of Opetation(slypa of inspection ! ® Food Service Routine Address S R k [� Retail Re-inspection Telephone Level ❑ Residential Kitchen Previous nspVion ❑ Mobile Date: tdra/� Owner HACCP YIN ❑ Temporary [IPre- paon ❑ Caterer ❑Suspect Illness Person-in barge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ElHACCP Inspector 070 Out�L ` I Permit No. ❑.Other Each violation checkfad requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors-(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.909(F) ❑, corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) El FOOD PROTECTION MANAGEMENT' _. _ _ _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH - - ❑ 13. Handwash Facilities r _ _- -- 1 jPROTECTlQkFRONI'CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC E] 14.Approved Food or Color Additives EI3. Personnel with Infections Restricted/Excluded _ El 15. Toxic Chemicals F000'F.ROM APPROVED SOURCE _ - 71MErrkmPERATURE GONTROLs(Potentlalty Hazardous Foods) 0 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 HIGHLYSUSCEPTIBLE-POPULATIONS:(NSP). ; F] 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP _ RAD4lSORY , ' - . - .•--- ._ , E] 11. Good Hygienic Practices CONSUME _. - - - - -- - ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.0 order of the Board of Health. Failure to correct violations 4. Food and Food Protection (FC-3X590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-axsso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5X590;006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6X590.007) have a tight 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 9rder. 30. Other DATE OF RE-INSPECTION: Inspector's Signature• Print: PICS Signature: i Print t 2%1 PageoPages .r- ) '+.✓«n...n+4 ryre•<-W.4..s'4+y'^+1,.-'-�`. .ti•;.r+'�-...-..--.••�.r'f"^'+,*"'.t^'rt"'"^"-':^,r . Violations Related to Foodbonte Illness interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION g 1Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assig ment of Responsibility* Cooked and RTE Foods* 590.003 B) Demonstration of Knowled e* Contamination from Raw Ingredients 2-103.11 Person in char e-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.(Hl3(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reputing by foot!employees and 3-3ff215 Washm Fruits and Vegetables a licants* 3.304.11 Food Contact with Equipment and 590,003(F) Responsibility Of A Food Employee Or An Utensils* _ Applicant To Report To The Person In Contamination from the Consumer Char * 3-306.14(A}(B Returned Food and Reservice of Food* 590.003 G' Re n b Person in Charee* Disposition of Adulterated or Contaminated 3 ,59(),003(D) Exclusions and Restrictions* Food 590.003{E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditi mine Unsafe Food* FOOD FROM APPROVED SOURCE 4 I=P" water From Regulated Sources - 9 Food Contact Surfaces 590.004(Atce withFaxllaw* 4-501_11t Ivianual Warswaslsing-Hot Water -----^----��- SanitizationTe raiures" 3.201,12a Hermcticall •Sealed Container* 4-501 1 l2 Mechanical Warewasbin Hot Water 3.201.13lk and Milk Pro ucts* SSanitization Tem eratures* 3-202.13ns* 4-501.I14. Chemical Sanitization-to H, 3-202.t4I Milk Pi ducts.Pasteurized" 'pconcentration and hardness. eeMade From Ptaable Drinking Water* 4.601 i l(A7 Bcluipment Fa Contact Surfaces and 5-101..11 DrinkingWater from an Approved System* Utensils Clean* 590.0O6(A) Bottled Drinking Water{ 4-602.1.1 Cleaning Frequency of Equipment Foiod- 590.006(B) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and Utensils" Shelhish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and - 3-201.14 Fish and Reereation:i0y Cauphf Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from'SSF Last€d Chemical* Sources* 14 Proper;Adequate HandwashIng Game and Wi!d ARushrooms Approved by 2-301.1.1 ean Condition-Hands and Aims* Re ulato Authorit _ 3-202.1.8 SheiNtockldentificationpresc.nt' 2-301.12::::::f aanin Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices RscslvingrCondition 21401.11 Eating,Drinkingor UsingTobacco* 2A)L 12 Discharges.From the Eyes,Nose and 3-202.1 f PHFs Received at Pro r Tem ranues* B Mouth* 3-202.15 Package lnm it 3..!(ii..'1 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*. 6 -TagslRecords:ahelistock l2 Prevention of Contamination from Hands 3-202.1$ Sheilstwk Identification* 590.004(E) Preventing Contamination from Employees* 3-203.12 Shellstock identification Maintained* 13 Handwash Facilities TagsJHecards:Fish Products ConvenienttyLocated 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* Conformance with Approved Procedures 5-205.11 Accessibility, ration and Maintenance Confori Supplied with Soap and Hand Drying /ACC/HACCP Plans Devices 3-502.11 Specialized Processing Methods" 6-301. 3-502.12 Reduced os en packaging,criteria* - 11 HandwashCleanser,.Availabilit 8-103.!2 Conformance with Approved Procedures` b 30L.1.2 Head Drying'Provision '*limotes craicai iisat intim federal 1499 Food Code u 1135 CMR 5WCO). I ^ �.�A IA MWA FIN RIM=ice �: . � �=�•'�� O i 4 - 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne 01ness.Interventions and Risk According to law Cooled to Factors(items 1-22) (Cant.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolin Methods for PRFs t, 1g PHF Not and Cold Holding { 14 - Food or Color Additives 3-202.12 Additives* 3-501.16(6) Cold4101 PHF*Maintained at x below 3-302.14 Protection from Unapproved Additives* 590.0016( 41 145 F 15 Poisonous or Toxic Substances . 3-501.16(X) Hot PHFs Maintained at or above 140°F. 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F. Containers* 20 7-102.11. Common Name-Working Containers* Time as a Public Health Cartrol ' 7-201.11 S aralion-Stora e* 3-501,19 Time as a Public Health Control* 7-202.11- ,Restriction-PresenceandUse* - 590.004(H) Varianceuirement p 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEFnSLE 7-20111 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* '' 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.1)(A) Unpasteurized Pte-packaged Juices and 7-204.14 cots.Criteria* Beverages with Waning Labels* 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 S tt Not Served, 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 'r 7-206.13 Tracking Powders,Pest Control and 1 Monitoring* CONSUMER ADVISORY TiME(1EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooidng Temperatures for Animal Foods That are Raw,Undercooked or Z PNot Otherwise Processed to Eliminate *EXecava fn2IX!r t' 3-401.I1A(1)(2) Eggs- 155F15 Sec. Patho'ens. ' ° 3-302.13. Pasteurized Eggs Substitute for Raw Shell Eggs-Immediate Service 145 F15sec, Eggs* 3.401.1I(A)(2) Comminuted Fish.Meats&Game i Animals-155'F 15 see. y SPECIAL REQUIREMENTS 3-401.11(11)(1)(2) Pork and Beef Roast- 130'F 121 min* j 3-401A I(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-{D}in i sec. * catering,mobile food,temporary and 3-401.11(X)(3) Poultry,Wild Game,Stuffed PRFs, residential kitchen operations should be Stuffing Containing Fish,Meat. debited under the appropriate sections ,k Poultry or Ratites-l65'F 15 sec. * above if related to foodborne illness ( 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other i 145T* 590.009 violations relating to g-ow retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited trader#29- Microwave 165°F* Special Requirements. 3-40'1:1I(A)(1)(b) All Other Plus- 145°F 15 sec.' s17 Reheating for Not Holding VIOLA770AIS RELATED TO GOOD RETAIL PRAC77CES 3403.41(A)&(D) PHFs 16ST 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* joodbome illness interventions and risk,factors listed above, can be `. 3-401,11(C) Connnerctally Processed RTE Food- found in the following sections of the Food Codc and 105 CMR 140°F* 590.000. 3-403.1 l(E) Remaining Unsiiced Portions of Beef rte+ 1 Good Retail Practices I FC 590.0m i i i 23. 1 Management and Personnel FC-2 .003 i 18 Proper Coaling of PHFa 24. 1Food and Food Protection FC-3 .004Roasts ! 25. Equipment and Utensils _I FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140`F to Water.Plumbing and Waste FC-5 .008 70'F Within 2 Hours and From 70'F 27. Physical Facility FC-6 �7--- to 41OF145OF Within 4 Hours. 28, Poisonous or Toxic Materials FC-7 .008 ' 3-501.14(6) Cooling PRFs Made From Ambient 29. Special Requirements ) .009 Temperature lagredieno to 41'F145'F 30• 1 Other Within 4 Hours* s<mt.,muc_ i *Dentes critical iwm in the Lederai 1999 Fr AJ Cmie of 105 C-MR 590.000. ) . . II. Jy • .l taw L . 1 /V •. . - • . . - INT AP rfJtTM 11 1 MI --� vAWAIIIII ��L- ..l• .ytDur food permit. / MIN NO M FETAFER ssion With Person in Charge: �,ii-ter` . .. • r t 3-501.140 PHFs Received at Temperatures - Viodaitons Related to Foodborne fitness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 410FAFF Withia 4 Hours." l 3-501,15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding 14 Food or Color Additives 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives*_ 590.004(F) 4101450 F* r 3-302.14 Protection from Una roved additives* 3-50L16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances '( 140 , 7-101,11 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. CoName-Working Containers* Common - 1 7?01.11 Separation-St +' 3-501.19 Time as a Public Health Control' 7-202.11 ,Restriction-Presenceand Use* F-590,004(H) Variance Requirement II) 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 'i 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beveraces with Warning Labels* 7-204,14 Drying Agents.Criteria* 3-801.11.fB) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 7-206,11 Restricted Use Pesticides;Criteria= 3-801..11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. ,-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Packs Not Rc-served. 7-206.13 Tracking Powders,Pest Control and 1 Momtorin * CONSUMER ADVISORY x TIMEt6EMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of i 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or I Not Otherwise-Prmeessedto Eliminate I PHFs Pathv Tom"�..BI ! '3-401.11A(1)(2) Eggs- 155°F 15 Sec. E immediate Service 145`F15sec* 3-302.13. Pasteuri�d Eggs Substitute for Raw Shell E 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec. 340111(B)(1)121 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 ftxxl,temporary and 3401.1 VA)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections 1 Poul or Ratites-165017 15 sec, * above if related to foodborne illness 3-401.11(CH3) Whole-muscle,lmad Beef Steaks interventions and risk factors. Other ! 1450F* 590.009 violations relating to good retail `i 3-401.12 Raw Animal Foods;Cooked in a practices should be debited under#29- k Microwave 165'F' Special Requirements. 7 3-40LII(A)(1)(b) All Other PHFs- 145°F 15 sec.* 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165°F 15 see.* (Items 23-30) 3403.11(B) Microwave-'165'F 2 Minute Standing Critical,and non-critical violations, which do not relate to the Time* foodborne illness interventions and riskfactors listed above, can be 3-403.11(0 Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3403.1l(E) Remaining Unsliced Purdons of Beef Nem I Good Retail PractIces FC 590.000 Roasts" 23. 1 Management and Persorsnel Is Proper Cooling of PHFs 24.Food and Food Protection ! FC-3 ON 25. Equipment and Utensils I FC-4 .005 j 1 - 3-501.14(A) Cooling Cooked PHFs from 1401F to 26. Water,Plumbing and Waste ' FC-5 .006 1 70'F Within 2 Hours and From 70'F 27. Physical Facility 1 FC-6 .007 t to 41`F/45'F Within 4 Hours. * 1 28._ Poisonous or Toxic Materials 1 FC 7 .008 l 3-501.14(B) Cooling PHFs Made From Ambient 29. Special R uiremems .009 t' Temperature Ingredients to 41 0171450F + 30 Other It Within 4 Hours" srv9ns,msn:-,•�:_ 1 Denotes crifical item in the federal 1999 Fatd Cade w 105 CMR 590.000. i `Commonwealth of Massachusetts' " City of Salem Board of Health Klmbefley Dnscoif' u 120 Washington Street,4th Floor mayoi ` g, 4 �SABEM;MA 01970 z t! 4 s x � Food/Retail Establishment Permit, y . DATE PRINTED: '12/19/2012 . 3 - ESTABLISHMENT NAME; Ana Miguel Restaurant File Number:BHF-2004-000107a .y = 101 Lafayette Street ` Salem - MA 01970." �. . � LOCATED AT: -0401 LAFAYETTE STREET< = _ a. SALEM,MA 01970 , s an nc Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE =BHP-2013-0253 a.11 'Jan,1,2013 Dec 31,2013 `^ -4'$280.00 '-ESTABLISH'MENT' Total Fees:0. . . $280.00 v$ 2. t I Al - PERMIT EXPIRES , December 31,,2013. zJ Y £ N ABoard of Health , t �« — This Permit is not transferable and must be reissued upon change'of ownership or location.The permit must be posted 'A in a prominent locatiop i the Estabhshment." In accordance with the State Sanitary Code,:beofre any revonations,improvements,of equipment changes are made,` all plans for such must be submitted to and approved by the Salem Board of.Health. a` pagewq " a CITY of SALEM, MASSACHUSETTS »>icxeatrn BOARD of HE,J,n-r ,... .am,.. ., 120 WAS]IINGTON SIREET,4111 FLOOR KIMBERLEY DRISCOLL Ti;L.(978)741-1800 FAx(978)745-0343 LARRY RAMDIN,RS/RT [IS,(1410,CP-FS MA-17OR lxamdii asalcm.com Hu,A1;I'4TAGUNT Food Establishment Permit Application (Application �ymust be submitted at least 30 days before the planned opening date) 1) Establishment Name: A,,1/+ v,t,I/ 6,ve(// 2) Establishment Address: Gam. �dL�S - 'fit. l - 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: _ Z 5) Applicant Name&Title:, gdr5sf G 6) Applicant Address: �' O/l d 7) Applicant Telephone No: l D 0 24 Hour Emergency No:f78 )33 -!l/Cr mail: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation./ An individual < mr7 A partnership Other legal entity 12 Person Directly Responsible For Daily Operations(Owner, Person in Charge,Supervisor,Manager, etc. Name&Title: Address: n! JC o S✓�l' - r(✓� Telephone No: a D Fax: 7111-:Z-70 Email: Emergency Telephone No: 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: Date: 7 c� Amount: Food Establishment information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑ Caterer Permanent Structure ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile 0 Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: „_____..---Breakfast Establishments------------------------ (check one) RETAIL STORE RESTAURANT Annual 17 Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑ More than I0.000sa-ft. $420 IZ 25799 seats. $280 0 More than 99 seats $420 Temporary/Dates/Time: -- --- ------------------------------------------------------------ ❑ Bed &BreakfasUChildcare Services/Nursing Home $100 --------- --------------------------------------- ----------------------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 11 ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare&private clubs 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no timeltemperature controls required) check all that apply): RTE-ready-to-eat foods(Ex.sandwiches,salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code , 24) Signature of Applicant: � S o a Pursuant to MGL Ch.62C, sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 5 26) Signature of Individual or Corporate Name: Commonwealth of Massachusetts • e City of Salem Board of Health Kimberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2011 ESTABLISHMENT NAME: Ana Miguel Restaurant File Number:BHF-2004-000107 101 Lafayette Street Salem MA 01970 LOCATED AT: 0101 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2012-0240 Jan 1,2012 Dec 31,2012 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES IDecember 31,2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pago 1 i . . � CITY OF SALEM, MASSACHUSEI"I'S BOARD OF HE.NLTH 120 WASHINGTON STREET,4... FLOOR Te:[.. (978) 741-1800 K L%1BElu.1-'.Y DRISCOLL FAX(978) 745-0343 MAYOR h aindinLaJsalcm.com LARRY RANIDIN,RS/RE[IS,(11 10,CP-FS I-IIi. ixiI Ac IiN'I' 201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ,4 A11,1,W TEL ADDRESS OF ESTABLISHMENT 4dL14e3 /� /f 3 r FAX# (Q �) /�3 MAILING ADDRESS(if different) EMAIL-Business`. Website: OWNER'S NAME Mg�j!Z. r✓k� eZ TEL# ADDRESS 6�� .t�N ee- 5& 5✓f//S� 44 4� STREET �/ CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) 4 90< nJ Ri,lt5 CERTIFICATE#(S) .20 90�24/ (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYSOFOPERATION = Monday :.1 Tuesd Wednesda 1 Thursday; `z - Friday',-1 Sabwia—y Sunda HOURS OF OPERATION Please write in time of day - ' (For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 _ - --------------------- - ------------------------- ------------------------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) <-25-WSLraTs =$280 m tan seats =$420 BED/BREAKFAST/ --------- 146 YES NO-- ------------------------------------ - - - $100 CHILDCARE SERVICES/NURSING HOME -- ------------------------ ------------- - ------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES 0 $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 cen'dy under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax retuws-ard paid all state taxes required under a law. Signature Date Social Security or Federal Identification Number Updated 523/11 FOODAP201 Ladm Check#&Date f 1 Massachusetts Department of Public'Heaith Salem Board of Health i. ° 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 / D TXoe of O eration s Type of Inspection Q-Lpod Service ❑ Routine Address - / Risk Retail e- inspection Level ❑ Residential Kitchen revious In pection Telephone �/ 7 . ❑ Mobile Date: �� y Owner ( HACCP Y/N ❑ Temporary ❑ Pre= er3t(cui ,mac 1-fP�,�w ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint / "u In:y,/ ❑ HACCP Inspector / puC: ' - 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. __-__ - ---- - ,.�� FO D PROTECTION MANAGEMENT �___ . ___ 6 ❑ 12. Prevention of Contamination from Hands 1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities -�n. EMPLOYEE HEALTH. --..__�� --..__.�_____ - PR ___..�.__ _- -_-_4.�..v...4 _... OTECTION FROM CHEMICALS _ El 2. Reporting of Diseases by Food Employee and PIC _ . El3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives na_, e.. -__ - „�. -®_�� , ❑ 15 Toxic Chemicals -0666--FROM APPROVED SOURCE : - ,�„�� ®,..,�, � EMPE rtTIMERATURE NT _CO ( _ ROLS Potentially Hazardous Fooda). f El 4. Food and Water from Approved Source _ !_ __ _-. ._. ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling 1 PROTECTION FROM CONTAMINATION 1 ❑ 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 E] 10. Proper Adequate Handwashing _ ❑22. ERA of Consumer Advisories ❑ 11. Good Hygienic Practices rCONSUMER ADVISORY- Posting s Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-5)(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 SXIna IFom 14. oo Inspector's Signature: Print: - / Ic PIC's Signature: f, 'J' � Print:f `,.] �.%�,� `� PageNf�Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION_ 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(]) Raw Animal Foods Separated from 1 590.003(A) Assignment of Res onsibili[ * Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in charge-duties 3-302A I(A)(2) Raw Animal Foals Separated from Each Other" EMPLOYEE HEALTH Contamination from the Environment 2 590.003(,C) Responsibility of the person in charge to 3-302.11(A) Food protection* require reporting by food employees and 3302.15 Washing Fruit's and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 590.(103(G) Reporting by Person in Chare* 3-306.14(A)(B) Returned Food and Reservice of Food'* 131 590.003(D) Exclusions and Restrictions* FodsdionofAdulterated orContaminated 590.003(F,) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD_ FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem eratmeO 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell!j s* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-50 L 114 Chemical Sanitization-temp.,pH, - 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5401.11 Drinking Water from an Approved System* 4-601.,11(A) Equipment Food Contact Surfaces and 590.006(A,) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.57__ 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Fend Contact Surfaces of Equipment* Shellfish* 4-703.11 - 3-201.15 Molluscan Shellfish from NSSP Listed Methods of Sanitization-Hot Water andChemical* Sources* ip Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authodt 2-301.11 Clean Condition-Elands and Arms* 3-202.18 Shellstock Identification Present* 2-301..12 .-Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* 11 Good Hygienic Practices 5 ReceivingfCondition 2-401..11 Eating,Drinking or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2401.12 . Discharges From the Eyes,Nose and 3-202.15 Package Irate it Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification''` 590.004(E) Preventing Contamination.from , 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11. Parasite Destruction* Conveniently Located and Accessible 3-402.1.2 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.1.1. Location and Placement* Conformance with Approved Procedures 5-205.11 -Accessibility.Operation and Maintenance /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,Availability 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: l Date: k/ 1 Page:_ of,;:—)-- Item Code c-Critical item f DESCRIPTION OF VIOLATION%PLAN OF CORRECTION Date. No. Reference R-Red Item Verified PLEASE PRINT CLEARLY E C-F I 'U✓A4 CIJA_ le�Nr fa 5;,/1 r� < ` Urh S - �_ 1�r c ' 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/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension cf)mply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five-dollars of suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. - P - r T_ Other: ❑ Voluntary Disposal Ll 3-501.14(0 PHFs Received at Temperatures Violations Related to Foodborne illness interventions and Risk According to Law Cooled to Factors Mems 1-22) (Cont-) 41.'Fi45°F Withia 4 Hours. PROTECTION FROM CHEMICALS 3-50!.15 Cooling Methods for PFIFs 14 Food or Color Additives 19 PHF Not and Card Holding 3-501.16(B) Cold Pl-IFs Maintained at or below 3-202.12 Additives* 590.004{F) 41°145°F* 3-302.14 Protection from Una roved Additives* 3-501.4(F) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 1400F. * 7-101.11 Identifying Information-Original 3.501.16(A) Roasts Held at or above, 130'F. Containers* Time as a Public Health Control 7-102.11, Common Name-Working Containers* 20 F 3-501.19 Time as a ublic Health Control* 7?01.L 1 Sion-Sto * 7-202.11 ,Restriction-Presenceand-Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801-I.1(A) Unpasteurized Pte-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* :Bevrntees with Warning Labels* 7-204.14 Drying Agents.Criteria' 3-80LII(B) Use of Pasteuriml Eggs* - 7-205.11 incidental Food Contact,Lubricants* 3-801.A 1(D) flaw or Partially Cooked Anima)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 Monitarin * CONSUMER ADVISORY - TIMEfi EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pouted for Consumption of Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs Pat6o�ens*e"°""<on�'r 3-401.11A(1)(2) Eggs- 155'F 15 Sec Eggs-Immediate Service 145'Fl5sec* 3-302.13, Pasteurized Eggs Substitute for Raw Shell O * 3-401.1 I(A)(2) Comminuted Fish.Meats&Game U Animals-155'F 15 sec.* SPECIAL REQUIREMENTS 3401JI(B)(1)(2) Pork and Beef Roast- 13WF 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 Poul or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.049 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited trader#29- Microwave 165'F* Special Requirements. 3401AI(A)(1)(b) All Other PHFs- 145'F 15 sec,+ 17 Reheating for Hot Holding 111101 ATIONS RELATED TO GOOD RETAIL PRACTICES 3403.1 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:elate to the Time* foodborne illness inten entions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 140°F* 590.000. 3-403A I(E) Remaining Unsliced Pardons of Beef - t Rem 1 Good Retail Practices I FC �.590.000 Roasts* 23i_Management and Personnel FC-2 .003 24.' i Food and Food Protection ( FC-3 004 j 18 Proper Coating of PHFs �� 25. � Equipment and Utensils _! FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140`F to 1 26, 1 Water.Plumbing and Waste i FC-5 .006 70'F Within 2 Hours and From 70'F 27. 1 Physical Facilityi FC-6 .007 to 41`F/45°F Within 4 Hours.* i 28_ 1 Poisonous or Toxic Materials ' FC 7 .008 3-501.14(6) Cooling PHFs Made From Ambient X29. I Special Requirements .009 Temperature Ingredients to 41'F/45'F 30. 1 Other Within 4 Hours* swnr,ma-.tea.�_ "Drnotea CriiiCal item in rhe federal 1999 Food Cale ox 105 CMR 590.000. p ) � I ( 4 Salem Board of Health Massachusetts Department of Pubjl4 Health 120 Washington Street,4t6 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978) 745-0343 Name Da T e of O orations T e f Ins tion // Food Service Routine Address I �( I03 / S Risk Retail Re-inspection Y� Level ❑ Residential Kitchen Previous Inspection Telephone 6 El Mobile Date: OwnerHACCP YM ❑ Temporary ElPre-operation n( ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) A 11 Time ❑ Bed&Breakfast ❑General Complaint Inspector In: 3j Permit No. ❑ HACCP Out: El 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. 0_D D PROTECTION MANAGEMENT xr, ❑ 12. Prevention of Contamination from Hands 1. PIC Assigned/Knowledgeable/Duties __ _ ❑ t3. Handwash Facilities EMPLOYEE HEALTH'_ - PROTECTION FROM CHEMICALS ❑ 2 Reporting of Diseases by Food Employee and PIC ❑ Approved Food or Color Additives ❑ 3 Personnel with Infections Restricted/Excluded 6- __ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE . =.=�a ❑ 4. Food and Water from Approved ITIMEn-EMPERATURE 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. r. :- ❑ 19. Hot and Cold Holding �❑ S. 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 El 21. Food and Food Preparation for HSP ❑ ` ❑ 11. Good Hygienic Practices CONSUMER ADVISORY : ❑22. Posting of Consumer Advisories n Violations Related to Good Retail Practices Number of Violated d Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions 11, immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below C x "` by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.00 3) 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 5. 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 6. 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:ssools�reciFn ms,a.aoc !`'J �/ x,l �� //� „e Inspector's Signature: , Print: ) ' PIC's Signature: Print: Page of Pages I Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590A03(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(0) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 1 Washing Fruit's and Vegetables applicants* 3-3(4.11. Food Contact with Equipment and 590.003(F) Responsibility OPA Fail Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Char * 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charm* 3 590.003(D) Exclusions and Restrictions* DispositionofAdutteratedorContaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fund* 4 Food and Water From Regulated Sources FT Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501_I11. '.Manual Warewashing-Hot Water 3-201.12 Foorl in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eg s* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 lee Made From Potable Drinking Water* concentration and hardness. * 4-110 L 11(A) Equipment Food Contact Surfaces and 5=101.1.1 DrinkingWater fmm an Approved S stem* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 CleaningFrequency of Equipment-ment Food-- 590.006(B) Water Meets Standards in 31.0 CMR 22.0* q y p Contact Surfaces and Utensils* Snelbish and Fish Froman Approved Source 4-702.11 Frequency of Sanitization of Utensils and - 3-201.14 Fish and Recreationally Caught Molluscan Fort 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 Regulatory Authorit Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Rul 3-202.18 Shellstock Identification Present* 2-301.12 .-Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2401.11. Eatin ,Drinkin or Usin Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package htte it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-30L12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590k 4(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em 10 ms* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(1) Labeling o1 Ingredients' 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,O eration and Maintenance (HACCPPlans Supplied with Soap and Hand Drying 3-502.11 S m1ahzed Processin Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* b-301.1.2 qand Drying Provision '*Denotas critical item in t'he federal 1999 Food Code or 105 CMR 590.000. a CITY OF SALEM BOARD OF HEALTH Establishment Name: /a �S i Date: 4Z4 r,Z�- Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I .UOV l l- r N � 6� JL41,1A ss W, r�Is =sir /V-) C (-- / - 4-- 1J 17 rN t av 7 Kl� I/ _ // Discussion With Person in Charge: Corrective Action Required: ❑ No es I have read this report, have had the opportunit yto ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ ! Exclusion violations before the next inspection, to observe all conditions as described, and t0 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. - 0 Voluntary Disposal ❑ Other: 3-501.14(0) PHR Received at Temperatures - Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Nems 1-22) (Cont.) 41'F/45'F Within 4 Hours. * PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PIJFs Maintained at or below .10 41 p 3-302.14 Protection from Un roved Additives* 3-501 t45°F - 3-501.16(A) Hot PHFs Maintained at or above le Poisonous or Toxic Substances 140°F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Heid at or above 1300F. Containers* 20 Time as a Public Health Control 7-102.11. Common Name-WorkingContainers* 7-201.11 Separation-Storage* .3-501.19 Time as a Public Health Cantrell 7-202.11 .Restfiction-PresenceandUse* )90.004(H) I Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2041. Sanitizers.Criteria-Chemicals* � POPULATIONS HSP .7 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-ROl.1I(A) Unpasteurized Pre-packaged el ices and 7-204.14 in guts.Criteria" :Bev'cratres with Warning Labels* 3-801.11(13) Use of PasteurimlB * 7-205.11 IncResdental edFood Pestnm ticides;Criteria* 3-801..11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served. ,-206.12 Rodent Bait Stations* 3-801-II(C) Unopened Food Package Not Rev-served. 7-206.73 Tracking Powder,Pest Control and Monitorin * CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 1.6 Proper Cooking Temperatures tar Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3401.1IA(1)(2) Eggs- 155°F 15 Sec. Patbo*ens.*El'v"• t Eggs-Immediate Service 145°F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-441 A I(A)(2) Comminuted Fish.Meats&Game E * Animals-155°F 15 sec. 3.401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 mfr* SPECIAL REQUIREMENTS of NTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violationsns of Section 590.009(A)-@)in see.* catering,.mobile ford,temporary and 3.401.1.1(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3=01.11(C)(3) Whole-muscle,intact Beef Steaks interwritions and risk factors. Other 145°F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requireinents. 3401:11(A)(1')(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1 I(A)&(D) PRFs 165'T 15 see. * (Items 23-30) 3-403.11(B) Microwave-'165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Tmre* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Foal- found in the follondng sections of the Food Code and 105 CMR 1400P 59aOOO. 3-4032.11(E) Remaining Unsliced Portions of Beef 1 )tem ! Good Retail Practices , FC 590.000 Roasts* 23 _1 Management and Personnel FG-2 .003 1 18 PropFc Proper Cooling of PHFs ! 24. al and Food Protection FC-3 .004 25. f Equipment and Utensils _ I FC-4 .005 1 3-501.14(A) Cooling Cooked PHFs from 140`F to 26. Water.Plumbina and Waste M ^! FC-5 .006 70°F Within 2 Hours and From 70°F 27. PhVsical Faciti FC-8 ! .007 to 4I'F/45'F Within 4 Hours.° j 26_ Pasonous or Toxic Materials FC-7 .008 3-501.14(6) Cooling PHFs Made From Ambient 29. Special R uirsmonis .009 Temperature Ingredients to 41°F/45' L30. i Oma -- Within 4 Hours* s' ':irvdmif"y: Denotes rriticat ium in the b^^decal 1999 Foul Cmie or 105 CMR 590.0(!0. CITY OF SALEM � � BOARD OF HEALTH Establishment Name:A'A- t(UP� � Date: y l Pager of Item Code C-Critical ItemDESCRIPTION OF VIOLATION/PLAN OF CORRECTION • '" D�- No.' Reference R-Red Itam / Verified PLEASE PRINT CLEARLY 12C a Rr Q _ �✓ rJ �_ _ n OQ (—t C es JC47ve 4v , - o, n r n O L)jf- fq-LV s nJ cit' sn I nJ r rt-U �car c .�t &L c 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 El Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars-or suspension/revocation of Embargo ❑ Emergency Closure yoyr food permit. — .� 0 Voluntary Disposal ❑ Other: 3-501.14(0) PRFs Received at Temperatures Violations Related to Foodborne Illness.Intemennons and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'Fl45°F Within 4 Hous. PROTECTION FROM CHEMICALS3-501.15 Coolintz Methods for PHFs 14 Food or Color Additives - 19 PHF Hot and Coid Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives*' 590.004(M 4101450 Ft- 3-302.14 * 3-342.14 Protection from Unapproved Adlitives 3-50L16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances - $ 140`F. 7-101,11 identifying Information-Original 3501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11. Common Name-WorkingContainers* 20 Time as a Public Health Control 7-201.11 Separation-Storage 4, 3-501,19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* 590.004(H) V ariancn Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitize".Criteria-Chemicals 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(A) Unpasteurized Warning Laged els* and .Beveraees with Warning Labels* 7-204.14 Drying Agents.Criteria" 3-801.l l(B) Use of Pasteurized B * 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 No Re-served, '- 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY 7or TiMEIFEMPERATURE CONTROLS 22 3-603.I1 ConsumerAdvistmr Posted fo Consump16 Proper Cooking Temperaturos for Animal Foods That are Raw.Undercook Prop Not Othenx*e Processed to Eliminate HFs 3401.IIA(l)(2) Eggs- 155'F 15 Sec. Pati o '* rm� Eggs-Immediate Service 145'Fi5sec* 3-302.13. Pasteuri.wd Eggs Substitute 11 for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155'F 15 sec. * SPECIAL REQUIREMENTS 3.401AI(B)(1)(2) Port:and Beef Roast- 130'F 121 min* 3-401.1I(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(I1) caterinViolatg, of Section 59mporan,and in sec.* cater ng,,mobile Card,tetttpnran and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 see. * 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 tinder#29- Microwave 165°F* Special Requirements. 34 IJI(A)(1)(b) Ail Other PHFs- 145°F 15 sec.' 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-103.4I(A)&(B) PHFs 165"F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk{actors lasted above, can be 3-A03.11(C) Commercially Processed RTE Food- found in the fallowing sectionsofthe Food Code and 105 CUR _ 140°F* 590.000. 3-4012.11(E) Remaining Unsliced Portions of Beef Hem { Good Retail Practices FC ! 590.0U0 Roasts* 23,_ 1 Management and PersonnelFC-2 18 Proper Cooling of PHFs 24. Food and Food Protection I FC-3 25. Equipment and Utensils _ 1 FC-4 1 .W5 3-501.14(A) Cooling Cooked PHFs from 140`F to 26, 1 Water.PlumbiN and Waste v-^1 FC-5 1 .006 70'F Within 2 Hours and From 70°F 27. 1 Physical Facility FC-6 .007 to 41'F/45'F Within 4 Hours. • I 1 28._' Poisonous or Toxic Materials �' FC-7 .048 ' 3-501.14(6) Cooling PHFs Made From:Ambient ~29. Special R uiremems 009 1 ' Temperature Ingredients to 41 01`45°F 30. Other --i- - Within 4 Hours* s:sonr�, *Denotes critical ia`m in the£^.deal W99 Focd Cale or 105(:MR 590.000. 1 Masscichusetts.Deliartment 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 D T of 0 eration s T f Inspection /41" ood Service Routine Address I- isk Retail I ❑ Re-inspection Level El Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner . HACCP Y/N E Caterer El ❑ Pre-operation ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint [I HACCP Inspector D Ou3 0�. 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 MANAGEMEWTIMF ' x= =tsl : . ❑ 12. Prevention of Contamination from Hands I]1 PIC Assigned/Knowledgeable/Duties -' ❑ 13. Handwash Facilities rEMPLOYEE HEALTH�r...,.�, ,,� ,,.:,;_ ry PROTECTION FROMCHEMICALS & 77 ;�7"" 5� ❑ 2. Reporting of Diseases by Food Employee and PIC "" "� El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded _ ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE � - •. .a „:;�;. '.:.. -,„. ,� ❑ 4. Food and Water from Approved Source 71ME/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 ;. .. :A ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control _ _ �- � ElGl1I 9. Food Contact Surfaces Cleaning and Sanitizing [REREMEHTS FOR HIGHLY SUSCEPTIBLE POPULATIONS-(HSP)I ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices � CONSUMER.ADVISORY..- . ❑22. Posting of Consumer Advisories \ ,a Lt 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 of Health. today, the items checked indicate violations of 105 CMR c ,N, 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (Fc-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc-4)(550.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Vater,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'Wfnspe Fw 14.Erc Inspector's Signature: Print: PIC's Signature: Print: ®� ✓ Page of Pages r. r Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION $ Crass-contamination FOOD PROTECTION MANAGEMENT 3-302.11(.0)(1) Raw Animal Foods Separated from 1 590.003(.0) Assignment of Rcsponsibilit Choked 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 Anitmil 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 1 Washing Fruits and Vegetables applicants* 3-304.11 Ford Contact with Equipment and 590.003(f) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) .Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* 3 590.003( Food 0) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law*V 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed 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* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.1.6 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.'11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* * Contact Surfaces and Utensils*4-602.11 Cleaning Frequency of Equipment Food 590.006(B) Water Meets Standards in 310 CMR 22.0 Sheldish 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 Re qMato ry AuIhorH 2-301.1.t Clean Condition-Hands and Aims* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004 C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package htte i[ * Mouth* 3-10LI I Food Safe and Unadulterated r 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-20'2.18 Shellstxk Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located end Accessible 3402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 HandwashmE Cleanser, Availability 8-103.12 Conformance with A roved Procedures* 6-301_1.2 HandD 'n Provision 'Denote critical item in the federal 1999 Fond Code or 105 CMR 590.000. CITY OF SALEM F BOARD OF HEALTH Establishment Name: U, Date: Pager of /? Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date` No. Reference R-Red Item Verified /1 PLEASE PRINT CLEARLY J 1 ll ) Ilc y ) r�lo�ry Qg (r,AJ/)/ �srtur =�� 1 r - zrJ IU � _ � .. _ _ _ r r� Fe'lo -ivr(: -1 0OcIr(I e sr �P( -�. , - ;S Qg cvfo� , �P S; iAJ fin 12 O /1 r l'1l f r !' A (4////1 g7 /'r r a o ate- .J Sn"3 i J J CCJ Cr-A r'c', i,/14, �. . n � .y 44 I)( awf 6 \/,04 r(c A. `x V C4r> c-IJI,r'(O \ -7- Shc(( ! [V r t yrrtiAyiI rr s A s)- - ,J1-_anc , '7 4jrA ' ✓ h �• Li-7 Discussion With Person in Charge: Corrective Action Required: ❑ No t7, Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P � Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the MasslFederal�Food Code. I understand that V noncompliance may result in daily fines of twenty_tiveldollars_or-suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ----'— `>,.-(r�7 ❑ Voluntary Disposal ❑ Other: ------------- \t 3-501.14(0 PHFs Received at Temperatures Violations Rotated to Foodborne fliness f iter�endons and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'171457 Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501,15 Coolie_Methods for PRFs 14 Food or Color Additives 19 PHF Scot and Cold Holding 590.004(F)16(8 3-202.12 Addilivee 3-Sg1,.i6{B} Cold P1lFs Maintained at or below � 41°145°F* 3-302.14_ Protection from Unapproved Additives* 3-50L16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances " i40cF. 7-101,11 identifyingInfor[nation-Original 3-501.16(A) Roasts Held at or above 1300F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora * 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-PresenceandUse" 590.004(H) Variance Re uiremtm 7-202.12 Conditions of Use" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204,11. Sanitize".Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.1](,A) Unpasteurized Pre-packaged Iuices and Beverages with Warning labels* 7-204.14 n eats.Criteria" 3-801.11(B Use of Pasteurized fig 7-205.11 incidental Food Contact,,urticants* 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 Ford Package Not Re-served. ' 7-206.13 Tracking Powders,Pest Control and Monitoring* - CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted fur Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or Not Otherwise-Processed to Eliminate PHFs E*`1/"" 3-401.11A(1)(2) Eggs- 155F 15 Sec. Petro ons.* E -Immediate Service 1450F15sec• 3302.13Pasteu . rid Eggs Substitute far Raw Shell 3j401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155°F 15 see. " SPECIAL REQUIREMENTS 31401,11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.Og9(A)-(D) Violations of Section 590.649(.1)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155`F 15 sea * 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 145OF* 590.009 violations relating to good retail 3-401.12 Raw Animal Fax1s Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401JI(,A)(I)(b) All Other PHFs- 145`F 15 sec. 17 Reheating for Not Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-103.11(A)&(D) PIIFs 165F 15 see. * (Items 23-30) 3-403.11(B) Microwave--165`F 2 Minute Standing Critical.and non-critical violations,which do not relate to the Tiazr* foodborne illness intenentions and risk,factars listed above, can be 3403.11(C) Commercially Processed RTE Food- found iia the following sections of the Food Code mrd 105 CMR 140°F* 590.00). 3-403.11(E) Remaining Unsliced Portions of Beef - /loin ! Good Retail Practices I FC 590.000 Roasts'` 23. I Management and Personnel ! FC-2 .003 y 18 Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004 25. E� quipment and Utensils FC-4 .003 3-501.14(A) Cooling Cooked PRFs from 140°F to water.Plumbin }and waste FC-5 .006 i 70`F Within 2 Hours and From 70'F 27. Physical FacilityFC-6 .007 to 41°F/45'F Within 4 Hours.* f 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(.8) Calling PHFs Made From Ambient 29. Special Requirements --- Temperature Ingredients to 41°F/45°F 30. i Other Within 4 Hours* Denotes critical item in the federal 1999 Fuel Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: &6JA. LSP f Date: �'' Page: 3 0P Item code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified h i PLEASE PRINT CLEARL'V 11 <l� A) /P A J 9 26 , r , + jLo n ' A .t2!nz S�nY I/� D r , , Discussion With Person in Charge: corrective Action Required: ❑ No JAIYes 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 t�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 t❑ Embargo ❑ Emergency Closure your food permit. ��', 0 Voluntary Disposal ❑ Other. s 3-501,t4(C) PHFs Reccived at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(Items-r-22) (Cont.) 41'F145'FWithia4Htxas. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PRFs 14 - Food or Color Additives 19 PHF Not and Cold Holding 3-202.12 Additives*' 3-501..16(B) CodIds°Fd PHF#Maintained at or below 3-302.14_-- Protection .... _.. 590.004(F) 41 Protecc tion from Unapproved Additives* 3-50L16(A) - Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 140`F. 7-101,11 identifying Information-Original 3.501.16(A) Roasts Held at or above 130'F. * Containers* 7-102.11. Common Name-WorkingContainers* 20 Time as a Public Health Control 3-501;19 Varie as a Public Health Central* 7-201.11 Separation-St * 7-202.11 .Restriction-Presence and Use* - 590.004(H) Variance Re uirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 'Toxic Containers-Prohibitions* POPULATIONS NSP 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.1.2 Chemicals for Washing Produce,Criteria* 21 3-801.1.1(A) Unpasteurized Pte-packaged Juices and Bevera*es with Warning labels* 7-204.14n eels.Criteria' 3$01.11(6) 'Use of Pasteurized B 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(0) 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 EyLaE Not Re-served. K 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of TIMElTEMPERATURE C 16 Proper C ONTRolting Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise-Processed to Eliminate 3401.IIA(1)(2) Eggs- 155°F 15 Sec. PCO '* E gs-immediate Service 145'FISsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell * 3-401.11(A)(2) � ComminutedFish.Fish.Meats&Game _ Animal's-155'F 15 sec.* SPECIAL REQUIREMENTS 3401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* 3-401.11(A)(2) Retires,Injected Meats-155`F IS 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. *, catering,,mobile food,temporary and 31401.1 i(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-I tis°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 t' 590.009 violations relating to good retail 3-401.12 Raw Animal Faxls Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLA770NS RELATED TO GOOD RETAIL PRACTICES 3403:4 r(A)&(D) PHFs 165-F 15 sec. * (Items 23-30) 3-403.11(9) Microwave-165`F 2 Minute Standing Critical,mrd non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed adore, can be 3403.11(0 Commercially Processed RTE Food- found in the following sections-of the Food Code and 105 CMR 1400F* 590.000. 3403.11(E) Remaining thisliced Portions of Beef 1 kern 1 Good Retail Practices I FC 690.000 'Roasts" L29__-rI�Management and Personnel I FC-2 .003 18 Proper Coding of PHFs 1 24. r00d and Food Protection FC--3 . .004 ' 25. 1 Equipment and Utensils _ 1 FC-4 .005 3-501.14(A) Carling Cooked PHFs from 140`F to 26, Water.Plumbing and Waste i FC-5 .006 70°F Within 2 Hours and From 70°F 27. Physical FacilityFC-n .007 to 41'F/45'F Within 4 Haws. * 28. Poisonous a Toxic Materials FC-7 .008 ' 3-501.14(8) Cooling PHFs Made From Ambient 29. S sola!R uirements Temperature ingredients to 41'F/456F 30 i Other Within 4 Routs* "Denotes critical i"i in the federal 1999 Foal Cale w 105 CMR 590.000. Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Ana Miguel Restaurant File Number:BHF-2004-000107 101 Lafayette Street Salem MA 01970 LOCATED AT: 0101 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0232 Jan 1,2011 Dec 31,2011 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES IDecember 31, 2011 Board of Health a�� 49 This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIN113ERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGRHLM4AUNI&ALLM.COM DAVID GREENBAuM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT G(Ar✓� /"(//tl �cZ5� ,�SZ��2 /JCJEL# �7�/�2��/E ADDRESS OF ESTABLISHMENT"ed 1---1//� FAX# MAILING ADDRESS(if different) �� C✓a /r�ffl�� 5 �r 1— zza - —1!21-Z;E29 EMAIL- Business': Website: OWNER'S NAME 4155- 0, TEL# ADDRESS_ STREET /J CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) F4 P,&+c CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYSAFOP,ERATION Monday k •;, Tuesday';: Wednesday, ;..7hursday Plida"y',, , I .•'Saturday, , Suri p } e.-r HOURS OF OPERATION j Please write in time of day. For example 11 am-11 pm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ----------------7 RESTAURANTES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$ 25-99 seats =$280 more than 99 seats =$420 --------------------------------------------------------------------------------------------------------------------------------------------------------100----- BED/BREAKFAST! YES NO $100 CHILDCARESERVICES/IJURSING HOM-------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $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 slate tax retuand paid all state taxes r 'ed under the law... Signature Date Sociaf Security orrede}al Identification Number -----------'—--------------------- — -----------------p�--------------- Revised I onli 1 FOODAP201 Ladm Check#&Date N Commonwealth of Massachusetts ° City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 I I ESTABLISHMENT NAME: Ana Miguel Restaurant File Number:BHF-2004-000107 101 Lafayette Street Salem MA 01970 LOCATED AT: 0101 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0051 Jan 4,2010 Dec 31,2010 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31, 2010 i fi 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 I 4 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH x 120 WASHINGTON STREET,4m FLOOR TEL. (978) 741-1800 KIMBERL.EY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUM&ALEM.CONI DAVID GREENBAUAf, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT A,✓fir //�J,�� , i�' /,1J0_ TEL# ADDRESS OF ESTABLISHMENT �I— �✓ tfl'%�/ FAX# MAILING ADDRESS(if different) 1/�'�C�r %��Gz� 7F /rs tf. z( Q G' � EMAIL-Business': Website: OWNER'S NAME KC, �.Ua, ,;fie Ti —TEL# ADDRESS 61 b ra ve. �5' -5 — �j /0" 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# 04YS QE OPERAT•.ION Monday Tl esday;;. Wellnesd� rThursday ` ? Fnda i Saturday Sunday HOURS OF OPERATION ! Please write in time of day. For example 11am-11 m ! TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ----------- -----------------•------------------------------------------------------------------------- RESTAURANT ES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$21k--/, 25-99 seats =$280 more than 99 seats =$420 --------------------Y-------ES---------------------------------------------------------------- ----------------------------$---10-------- BED/BREAKFAST/ NO 0 CHILDCARE SERVICESMURSING HOME - - - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $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 ret and paid all state taxes required u r the law. 7 c/ Signature Date Social Security or Federal Identification Number. Revised 424/07 FOODAP2008.adm Check#&Date.. % r $�` { Commonwealth of Massachusetts e City of Salem Board of Health tGmbetiey Oriscati 120 Washington Street,4th Floor Mayor I SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: Ana Miguel Restaurant File Number:BHF•2004-MI07 101 Lafayette Street Salem MA 01970 LOCATED AT: 0101 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0220 Dec 23,2008 Dec 31,2009 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31,2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS ' BOARD OF HEALTH 120 WASHINGTON STREET,4`FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR IDIONNE&.AI. M COM JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT� 624 /.sl, TEL#�10L-A11 /LG� ADDRESS OF ESTABLISHMENT /l� � ��/� 5 FAX# MAILING ADDRESS(if different) EMAIL- Business': Website: OWNER'S NAME 9-0aWC.j-;)at )'t2gZ TEL# ADDRESS >0 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) dx->k 14—.j �7 i.4� CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared EMERGENCY RESPONSE PERSON jjZ -IA .f/�>s: HOME TEL# '� Y> DAYS OFOPERATION I '.Mond Tuesda Wednesda � s?`.;,Thursda Frida Saturday, Sunda HOURS OF OPERATION d / Please write in time of day. I l I t 'd 1!� I '✓ ' ` (` ' If A--( (For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 ------------------------------------------------ - NO le -- n-----2-5 s--s-ea-- t----------------=-$140- --- ----- RESTAURANT ES s (Outdoor Stationary Food Cart$210 25-99 seats =$280 more than 99 seats =$420 BEDiBREAKFASTi i ES NO $100 CHILDCARESERVICES --------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (notjust 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 fled all state tax ret nd paid ail st a taxes required er the law. Signature Date Social Security or Federal Identification Number ------------------------------------------------- Revised 4/24/07 FOODAP2008.adm Check#&Date 3-in )i7__ �i $ ,�p & f My Filp Edits .Tools Help , , ( _ A a � �_; •,r �'{eat/T�peeBill Ko �- �Lustomer account mforrnatlon }� Hutory i �2008i{PPRm k ^ .' 729 � 7 -: 45778 ANA MIGUELRESTAURANT Detail } r ' _ : i. I 101 LAFAYETTE STREET Ong Bill E°j f. SALEM MA 01970 E ¢ . Apply Pmt i , Quick Scan IOSpecial ConrLhons/Notes --- r PaicellD, Specific Bill E Prop ID 502549 _ w � - ` Prop Loc 1101 CAFAYETTE STREET ,t Effective Date C:6 E77 Utility ACO .. . tx Customer Parcel ; -.Int Int-Do Baled Abt/Adl Pmt/Crd n Interest ��. .� Unpaid bat 08/02/07 {. 515 too 00 , ,, a 4 105r s 2of. E Name -17/02/07, ' ' 5148FIBO r ^ 02rodro8 5 36 ; 00 6.071 ,. ., Misc Receipt , � . 05/02/08 53 �� 588k § ' View-Rev @ Eees/Pen �'t 00 : 500 k 06 00 5.0 lei Validator € Totals ' G . 2100 500 , .:,00 ~;x. 3E? It— V 5 Billing Dates 1 NolestAlerts _- 1)66 01/15/2009, r 2915 ? Bill AudR Per Diem JAN 1 Owner RASA HERNAND4.EZ �, Int Paid s: 00' r " Reprint I #' DBA.BRISAS DEL CAME—, Preferences 4i (.'View poor unpaid bills . .:. .yt{w,. §. A.:e.,.:... 3, _ 3 'L� a ^ •Pxr% F„. k i 9 .5r 14 20C��J l 71 1 [ ' vt tIe=1" s\'r N � S f L f IDisplay transaction history For the current bill My ,Fife':,'Edit'Tools'HelpEtE, YeadT}gaBtl'No r — --- *- E Customers vunt inforra:iun t History `. 2009j PPR-_ 42ul i _ 457'78) ANA MIGUEL RESTAURANT Detail 101 LAFAYETTE STREET.. SALEM,MA °z 01970 ' Drig Bal • I . E � hA f 3 Apply Pmt 1 .s �-Property information Quick Scan E --- I.Parcel ID• : s € ?E Specific Bill ! I" Prop ID "If502549 � ; E } ,"l` '�':• '"`" _ s °Prop Lac •'T101 LAFAYEYTE STREET :"s; E °'` r Effective Date — Utility acs + CustmerI [ Parcel r ;Inl Dt t,Billed Abt/Ad1 tPmtJCrd Inter0F, Unpaid bal •, -'; " c 06/64/09 3. 3 OD } O0 5 7Z! F i h Name . t-11 /04/08 h` .5.38 3 _ UOl g ' IrO22103/09i '.. B2B Misc Receipt .......,m.� a ° 405104!09 �. ; B27jt .00 ` 3 00 s DOE : 627 View Rev a 1•,FeesJPen i 00 00 � 00 1:7 77,1 t 00: ` -E res". E E : r tI TETotals Validator ....2331 3......... 00� a Ess 110 49 _ 23.8 3 - r t t ' - •, 30, I. r a � Billing Dates , ; NotesJAletta 7 --._Due 01!15/2009 Bill Audit + + 3": JAN 1 Owriei ANA MIGUELRESTAURAN Int Paid 00. Repent E} 4 DBA.BRISAS DEL CARIBE "` „ , � mE•s sari • "°' r , E E Preferences r.,; Lr3Viewpnor unpaid bills '� E L Y �'` DBG BILL HDR y' E4 r, � A, . 11 ` J z °c i° � ►I ttrel� s, S JAN 1 4 1t12, I c 1 r i E t E E E Display transection history For the`&rent bill i , CITY OF SALEM PERSONAL PROPERTY TAX P.O. BOX 203 MA-037-PP-2006-00-754 MILFORD, MA 01757 O1VDl7 1 ROSA HERNANDEZ 101 LAFAYETTE STREET SALEM, MA 01970-0000 :,��\'cif TAXPAYER'S COPY The Commonwealth of Massachusetts DO NOT MAIL CASH FISCAL YEAR 2006 MAIL PAYMENT TO: COLLECTOR OF TAXES CITY OF SALEM DATE OF ISSUE FDR FURTHER P.O.BOX 203 NUMBER INFORM VRON BONNIE CELI MILFORD,MA 01757 07/01/2005 754 RECARD[NO THS NOTICE,INQU1REOF BOARD OF ASSESSORS VALUATION STATE CLASS TAX 980 501 101 LAFAYETTE STREET 20.90 DUESUMECCTTO PENALTIES OF INTEREST, CALCULATED RATE NOTICE OF PERSONAL PROPERTY TAX FOR THE FISCAL YEAR 2006 ABATEMENT DEEM,IND CHARGESREST AND $21.33 per$1000 DUE AND PAYABLE IN FULL WITHIN 30 DAYS OF ISSUE ON ANYUNPAID BALANCE UNTIL THE DATE OF PAYME MA-037-PP-2006-00-754 NOTICE 12.00 DEMAND 5.00 RATE OF I4%AN ANNUAL 01/1412009 ROSA IIERNANDEZ RM APPROVED 101 LAFAYETSTREET SERVICE 0.00 WARRANT 10.00 Bne TE oexARTMENTOF REVENUE. SALEM, MA 01970-0000 OTHER INTEREST 9.3 PAID TOTAL DUE 5 .29 MA-037-PP-2006-00-754 Invoice Transaction Le 01/14/2009 07/01/2005 001:ORIGINAL TAX 20.90 07/01/2005 MAILED INVOICE 05/15/2006 MAILED DEMAND 5.00 JAN 4 N'12J 02/27/2008 SIMPLE INTEREST 6.67 03/14/2008 MAILED WARRANT 10.00 1) 03/14/2008 MAILED FIRST 12.00 01/01/2009 AUTOMATIC INTEREST 2.72 V [My File• lEtlit Toots .HEIp ��-** g� �m "' : 16° �; i''^ �'^ � ��$.� r"ii� ��„ � If_'� � �M � � ® � Yri' C�it T• � _ _,, c teadT;pelBdl N❑ — '� '�-Lu tomer ac Hunt m(orma!ioh :ri 2008� PP•R': 729 ' r : 45776” History r _ ,} T, • k a ANAMIGUEL RESTAURANT DetailLAFAYETTE STREET SALEM MA 01970 it° Drig Bio Apply Pmt f �,um _ 't i."�•ProPerkv informa4on ." Quick Scan 3 I d "R Special Conddions/Notes A4 ParcellD . . .. , ..', ., , Specific Bill Prop ID 502549 x i, I" k, Prop Loc -lO1 tAFAYETTE STREET '� ; ,t Effective Date I E.---.-T----»--- _ .. J, y { { Utility Acctt - "� ➢ "r S r: r r t .. �.. pa i Parcel :Int ig, Interest 'Unpaidba Tll1 Name 11/02/07 514 �. 00 - j `S 87 .3 6011 % A _ Mise Receipt i 02/04/08 .E';,i _ 536 " ; 00 : 00 71�t fi r . to- € , Fe"e View Rev slPeni� , 00 500 - s 0 00� r 5 _ . w` Validator t Totals 21 00 ( 5 00 316 << Billing Dates _ NptastAlevtsb-- 'x, Due 61,115/2009 2916' I i,, : ,. G r : ,per Diem Bill Audit TAN 1'0vwner RQSAHERNANDEZ - p t Int Paid 00. f Reprint r # i . . f. ., r € 1 DBABRISASDEL CARIBE Preferences 9 View prior unpaid bills Q' -t a DBG BILL HDR l Ali nlwl AID E . a i ,JAS it I T T, Tl R t. IT E g £ ITT- iT r »a ;Display transaction history For the current bill..'_ .t., s1, tin My File' '.Edit Toots Help 77 ..-. Yaar1T peJBillNo -- Customer account inCorrro�tidn History i'; 2009 R42b5778 — . ANA MIGUEL RESTAURANT Detail }'- i 101 IAFAYETTE STREET' I Orig Bill E E E SALEM,MA'01970'� Apply Pmt T ,f PropSrty+nformahon -•i a t Quick Scan - . r . i , Special'Condibons/Nates ` ? '.Parcel ID _ � 4 P t t ;lr Specific Bill . .`.Prop ID 502549 p o , F'to Loc i10TLAFAYET TE STREET ;z, ...' Effective Date r a € ""�' •i i3 UtilityAcct { , e t Parcel . �'-,Int Dt ?Billed AbdAdt ..PWCrd Interest Unpaidbal "fes: " t .08104108 ` 38J �— 00 ,�- 00 _34'j LivName t ;11104106 00 .00a I, . Misc Receipt [ + - 0210.3109 3,. 628 00 008 i" t ,., 05/04109 , `. X627 y .1 00 :00 627, View Rev t.F FeeslPan . - 00 00� p 00 00 � 00;3 Validator ..Totals •.rw3 `.23.31 1 00 2380'. Billing Dates a ; ,,..NotestAlerttl �^; Due01/1512009 ,` r175 Jl Bill Audit t ' s WY e4e� Per Diem v �0 ` JAN 1 Owner ANA MIGUEL RESTAURAN ? Int Paid003 pi .. x.. .... Re not I DBA'BRISAS DEL CARIBE Pretarences r r s1120,View prior unpaid bills , 4 Al ,f DBGBILL HDR 3 e` ' e E� I= x }}p JAN V41( t y } e: r ' g ,r YDisplay transaction history for the current bill.. CITY OF SALEM PERSONAL PROPERTY TAX P.O. BOX 203 MA-037-PP-2006-00-754 MILFORD, MA 01757 A. f ,ill ROSA HERNANDEZ 101 LAFAYETTE STREET SALEM, MA 01970-0000 �G►I1NE 0 - ., TAXPAYER'S COPY The Commonwealth of Massachusetts c DO NOT MAIL CASH FISCAL YEAR 2006 MAIL PAYMENT TO: CITY OF SALEM FOR FURTHER COLLECTOR OF TAXES P.O_BOX 203 DATE OF ISSUE NUMBER INFORMATION BONNIE CELI MILFORD,MA01757 07/01/2005 754 REGARDINGTHIS NOTICE,INQUIRE OF BOARD OF ASSESSORS VALUATION STATE CLASS TAX IN 980 501 101 LAFAYETTE STREET 20.90 IFNOTPAIDT DUE I'TO PENALTIESLTTES OF INTEREST, NOTICE OF PERSONAL PROPERTY TAX FOR THE FISCAL YEAR 2006 ABATEMENT DEMAND CHARGES AND CALCULATED RATE FEES,INTEREST ACCRUES $21.33 per$1000 DUE AND PAYABLE IN FULL WITHIN 30 DAYS OF ISSUE ON ANYUNPAIDBAIANCE UNTIL THE DATE OF MA-037-PP-2006-00-754 NOTICE 12.00 DEMAND 5,Q0 RATE OMn oAN ANNUAL 01/14/2009 ROSA HERNANDEZ ROVED 101 LAFAYETTE STREET SERVICE 0.00 WARRANT 10.00 THIS FORM B THEDEPARTMENTOF REVENUE, SALEM, MA 01970-0000 OTHER INTEREST 9.3 PAID TOTAL DUE MA-037-PP-2006-00-754 Invoice Transaction Le 01/14/2009 07/01/2005 001:ORIGINAL TAX 20.90 07/01/2005 MAILED INVOICE 05/15/2006 MAILED DEMAND 5.00 IAN A, �0�9 02/27/2008 SIMPLE INTEREST 6.67 JH 03/14/2008 MAILED WARRANT 10.00 - 03/14/2008 MAILED FIRST 12.00 01/01/2009 AUTOMATIC INTEREST 2.72 ' L ` `.r"'•`-�. _,.+� :t.::.,�,.,,i,,;.!}yr-.*(v.,,,ni„aF+r*R��1'4+...fdt�ra,�'.,,.".�w-�,"r�� - , r-'m.-.,.. wwrn+/l-i+',(x+. ....,t �'�M-�R. t...,e%�'n,.,.J!'`°".'*r�.-�s*.CS"'s*i. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date Tvoe of Ooeration(s) T e of inspection ftq) , _.l ( 1.i4„d l-a. - .r i) Co,, 7"'(')'v 5 "K Food Service Routine Address t r�l �a P A n Risk ❑ Retail Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone �. a4 ❑ Mobile Date: El Temporary E] Pre-operationOwner J \ HACCP WIN ❑ Caterer ❑ Suspect Illness r�s�, C °Pi1�llcz.t p Z-.- Person in Charge(PIC) ISA Time ElBed&Breakfast ElGeneral Complaint Mtein. PT-e S In: 1:6)0 ❑ HACCP Inspector P Out:. tmi Permit No. ❑Other Each violation checked requires an-explahation on the narrative page(g) 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. r FOOD PROTECTION MANAGEMENT ;,� .,�,,.. w.�r. m. . -� t ❑ 12. Prevention of Contamination from Hands 1 PIC Assigned/Knowledgeable/Duties C'EMPLOYEE HEALTH � � � � El 13. Handwash Facilities ..�_ �.„ „a .»«�...�,.az a rPROTECTIONFROM CHEMICALS x ❑ 2. Reporting of Diseases by Food Employee and PIC �al» ro ��.»im. _.•�. �w o,�-- ❑ 3. Personnel with Infections Restricted/Excluded ❑ 14. Approved FoodorColor Additives p El 15.Toxic Chemicals �.FOOD FROM APPROVED SOURCE ,. .,„... . E] 4. Food and Water from Approved Source i JIME&EMPERATURE CONTROLS(Poten(lally fiazardaua Foods)�,4 '. ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating 1. ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling FPROTECTION FROM CONTAMINATJONF a9 r °" ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection �® ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing - REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)'-I El21. Food and Food Preparation for HSP/ t El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices it-CONSUMER ADV ISORY€ „a. ;;„'"„1mr,`"� 'aa`i"f,,,� '.°,� h � r) ❑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 ' by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27'. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 5:5901nspectFomS-14.tloc V Inspector's Signature: y Print: t / PIC's Signature: , Print: _ Pagel of ages ' i r . �. - 1 5 Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT_ 8 Cross-contamination 1 596.003(A) Assignment of Responsibility* 3-302.11(A)(]) 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 Raw Animal Foods Separated from Each 3-302.1.1(A)(2) EMPLOYEE HEALTH _ Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by foal employees and 3-302.11(A) Food Protection` applicants* 3-302.1.5 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Fax]Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(13) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Ha Water 3-201.12 Fund in a Hermetically Seated Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures- 3-202.14 em eratures*3-202.14 F,g s and Milk Products.Pasteurized* 4-501.11.4 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water" concentration and hardness. * 5-101.11 Drinking Water from an Approved System* 4-601_Il(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Fnnd- ShelHlsh and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-20.1.14 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* 1g Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatoty Authority2-301.11 Clean Condition-Hands and Arms` 3-202.18 Shellstcck Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* LL Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges,From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin ,. Togs/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em plo gees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.71 Parasite Destruction* Conveniently Located and Accessible - 3-402.12 Records,Creation and Retention* 5-203.11. Numbers and Capacities* 590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement* � Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans - Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-5102.1.2 Reduced ox en acka 'ng.criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand D 'n Provision "Denotes critical item in the federal 1999 fax]Cate or 105 CMR 590.000. CITY OF SALEM r, BOARD OF HEALTH Establishment Name J''N+ .<n rr.,A Date: —() Page of a item -, Code C-Critical Item, yq -a DESCRIPTION OFVIOLATION/PLAN OF CORRECTION' 3 r„ Date '- Reference R-Red Item Verified'; PLEASE PRINT CLEARLY . - IC I 01 L4 /' - u-Ik" WW � - 0J2+ — l PA 104 A OP ll "A,��)r/� — nn� Al 11 - V 1 /Ci� n U. AX �-Va.��/A. X C-.�(�, 4 5 1!�_p l aJ1 Vlr1 t-AI i (7i � \ "J./J/'.� �Z�� t ( nn Alln_ .�\ 1 �_'\ /X /sX_ c_ a0 'n n,1 A , l . nn A til w.n . C\PA r;^"'AA o 1 f.P P�, �P V in,a')ko 177C�� A o ,-_v A `t'�n P I _P . n,\. .,, , +n Q-0-0AA . /� 1�Cil�vi! � PL -47J0--nn v ,II.,_, `�\�'1�� 1 N`�-C?A �S-'-11 A�A,t rJ- iC�,'��. 1x h LAA\P,i J J r n m �,r-t t� IIC...'y /&_-PTil C-'lA .( n e�n ['_Rco \_n,1 <..,-?% ' l�) I (4 rfft __)on-"nnI.ti,_., (70 ;I.CL�ti01 ,� ,�.�/L' ��M AL ;2/I rKL(-'At , 7 ri P1 „ .. , i Discussion With Person in Charge: Corrective Action Required: ❑ No o�-Yers i i _', t erncvJ P/� Z t t� �2_1/ I - f 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 13 Re-inspection Scheduled ❑ Emergency Suspension i 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. t ❑ Voluntary Disposal ❑ Other: i Pl4k,—Rw�ivej a*tfe-flri;�T-amris— Violations Relatod to Foodborne illness Interventions and Risk Cooled to Factors(Items I-22) {Cont, 4 1�F/45"+Within 4 Houm PROTECTION FROM CHEMICALS 3-501,15 CCK)fi0-,MeBr;J&for VHFF 19 -FHF Hot-and Cold Hot—ding F14 or Color Additives (bbd PHF.,Mvmtinti at orTeitwv i 3-202,12 AKE,7o,- 59(7'000 (F) 41°/45" F* 3-302.14 --- 3-50 i,Bit A) Her PIR's Maintained at or above 1-5 Poisonous or Toxic Substances 14()'F, * 3-501,16(A) Rests Held at or above idenfit�wg 1"to)rmilion - origmal, 20 conwjners� Time as a Public Health Control 7-102,11 ComraonNawc- Vvork;ng('oautm,�rs* 3-50!.19 Time,as a Public Health Control" 7-2())2-11 [.] �2ararion-Ste' 90.0044) Varianee Reni atorct!) R�))2 1�IRC��iTicilon -prostAce md U�C* 7-2f-1.12 conditions of Use* 7-20111 Toxic Cwlamcqs-Prohibi*iolls'o REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS 7-204.11 I Saniliztts'criierio--cheiniols* — 7-204.12 --- 3-1, 1.I 1(A) Utip e,acurized Pre-pachaged Juices and Chemicals for WashieE V x1mr.,0heiral Fi14 Dates Beverages with 7 2- LA _ tg ��a—lln Ili - _LjLe0fPa1te11ri7C�iE. ". �-205,11 cis-*_ 3-801.11(D) Raw or Partially Cooked Animal RxT,71d qT-O&T) Resti ruled Use Pe he Cntcria� -- Raw Sc.d Sl Lrok"111A Set 7-20602 4 1"weat Bla Sutoore,- 3-9(i1AVC) �Noilte-sQrved, 66—,3 Tracking PoNdr(i�Pe,"Control and Nlonit CONSUMER ADVISORY 3-003 11 Ponied fort (mmunpurm of TIME(TEMPERATURE CONTROLS I Aninud Fcxxis'lfat are Raw.Undera okcd or 16 Proper Cooking Temperatures for PHFs \lot Otherwise Pt<A-<,%sed to 141irninau, IA(l)(2) Fcp, 17.) 15 Sec 3-301.j 3 1 1`1143teurized F.ggs Substitute for RAw Sh� -T,ir)LI I(A)t27 connninwed Fish-'%Ieaes&G"11110 AnhuaLi 155"F1 sec, ' --- t Roast - 13W,F U I min* 77'3 40 1.11(13)(i)(2) ilok i;,d Bce SPECIAL REQUIREMENTS 7� zl --Rafire�, lnjeocd M�ats - 155 F 15 590 009(A)-(D) Violations of Section 500.009(A)4D)in sot. catering. mobile food, tempora, and 3 lAI(A)(3) [IOU]rr),wtid C arae,Stuffed f1k7Fs, remdeiWal kitchen opciations should be So4mg Cowanani FishMeat, debited under the appropriate sections _joultryor Rants, 165`T 15 sec. above if related to fcxxiborne i liness 3=+61,11(C)(3) whole-Inusele, Intact Beef Steaks interventions and risk factors, Other 590.W9 violations relatmo to wood mail 3-401.12 Row Aaa�l�,oI,(,,,keTd111 a piactices should be debited under #29 - — Micl owave 165 F_ * — Special Requirements., 3-401A 1(A)(1)(b) M1 Other PI-11's-- 1451 15 iec 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403A I(A)&(L)) Pi-ll-.c 1651-- 15 1 -- (Items 23-30) -74(7)31,1(B) Microwave- 165"r).Nlinute. Standing Critical and non-crilhol violedions, w1rich do not relate in lite Time" wnbr 3-403.I I(C) Commercially Processed RTE foil - found in then following sections of the Food Code and P6(Aim 140+* I 3403,11(F) Reinamin, Umliced Portions of Beef Item I Good Retail Practices 690,000 Management and Personnel 1 FC Proper Cooling of PHFs 2A Fchd nd Fcxd ProlactWnFC 004 FC 4 17(76 3-501.14(A) ("".4 ing C(X)ki"d Pffi-s form 140°4't° - J.Egiip'21 -------- 26. Water, __ Plumbing arid VLjsra FC - i 70OF Within 2 Hours an([From 7TT Pha6iral FacilitV FC-0 to T/45'F A"ithin 4 Heim, Fc- "-008 t. ng PHF�Made Front Ambient 009 T T empeorwee lagre&-mts lo 410F/45'14 30, Other C CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code I c-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION,,, Date „ Verified . _ =a: _� < =, 1 NO. Reference 'R—Red Item ,� yy, i ,�1�R y PLEASE PRINT CLEARLY a -SCA C? 1 ) CYA5 C l U Se ._ -lam ^ l� ) 1 C l J� Discussion With Person in Charge: Corrective Action Required: TO No a Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 14(C) PHFs Reo6vedat'l-emperatures; Violations Related to Foodborne fitness Interventions and Risk According to Lain Cooled to Factors(!tents 1-22) (Cont) 41'F/45'P Within 4 Hows, PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs L14 Food or Color Additives 19 PHF Hot and Cold Holding Maintained at or b,�Iiw 3 501�16(B) Cold P141'ei 3-202,12 1 Additive,* 590,09(F) 41`145`F' 3-302J4 Protection firisrolln 3_$41.16(A)—A) flot PHFs Maintained ,it or above 1-5 *— Poisonous or Toxic Substances 140'F. 1 7 101AIIdentifying lith)i niation--Original — 1 kw�ts Heldat- ,7 3-501�16(A) or illow 130-1, L20 Time as a Public Health Control e Worli,irre Containers* -T -Ti-oi-,I Common Narn PublicI health Control'� 7-20 t.I I anon-Stol a3-%1.19 as a Public lee* 490,00,41-1) Variance R 7-202.11 Restriction-Presence said Lie* nn�ellt —1 7-202 12 CondiTionTot Us,* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7203.11 Toxic ConlairleiProllibinow"l POPULATIONSHSP) 7-204,I1— Sannveis,Critsiti -Cheoricals* 1.t I(A) Unpasteurized Pre-packaged Juices and 7-1-04.12 Chemicals for Washir)l, , , , ite[i21 3-80 'le Beverazes, with Warnil 7204-14 3.861.1103) U�w of pa"te 7-20,9A incidental F(lod Contact.lmbficantsl`� —1 of Paq1e"rlELE1191—.-- 3-bOl.I I(D) Kaw or Pailialtv Cooked Avierml Food and 7.205. I R,,melo-d Use,Peticide�.Critena" Raw Seed SPtouta hot Served 7-206.12 I Roilew fllh Statiom, 7 006 11 Tracking Powdom Pest ontrol and 3-X0 1:1 J(C) CONSUMER ADVISORY 22 3 03.11 Consumer Advisory Poswd for Cowimni: ..n of TIMEITEMPERATURE CONTROLS Animal F�x*That are Raw. Undercooked o Proper Cooking Temperatures for PHFs Not Otherwise firmessed to j][minate, 3-401.!15(1)(2) Fgpp- 15i'F 15 Svc. Figs-hmnech«x-Servicc 14.5,F15sec, 3-30 z 13 Pasteurized Egg.;substitute for Raw Shell 71�4()f:Tl(A) Comminuted Fi<k Meiiui&Game AnjuiaLs 155"Fl5sec. :' SPECIAL REQUIREMENTS 3-401.11(13)(11(21 PoiP and Beef Roast -130 t 121 jiii0 3-411)1-1 l(A)(2) RafilcN, iniected %Uals - 155 F 15 590,009(A)-(D) Violations of Section 590.009(A)-(D)TR7 Sec. * cateringmobile food, temporary and 3 TH(A)(3) Poultry,Wild Garne, Stuffed PRFs, reside iwal Kitchen operations should be Containno, Fish, Meal, debited ander the appropriate sections Poultry or 16thes-165"F 15 sec. abulle if refilled to tel)(lbol-ne I llness -7401 11(C)QWhole-ttiowle. Intact BeafSwaks interventions and risk factors. Other 1451, 590.009 violations relaLing,to good retail 3-401.12 Raw Anoyul Foo(k(ookcil III a practices should be debited under#29 Miclowave 165,14 * Special Requirements. 3-401,11(A)(1)(t)) All Other lllif`>-- 145'F 15 sec, Lt7 Reheating for Hot Holding VIOLATIONS RELATED To GOOD RETAIL PRACTICES 3-if)3�IRAT&(D) PHF, 165'115 se,,* (Items 23-30) 3-403.11(B) Microwave- 165'F2 Mimae Standing Critical wid nun-critical violnfiuns. which do riot relare to Pie Tiale" foodborne Illness interventions crud risAitictors lisnld abawwn be 3-463__.11(0) CornmertailN Pfivessed RTE Kod- found in Ilief6lionoiR sections of the Food Code and 105 CMR 140'F* J90,000. r item7-40311(F) Remainin", Beef Management nq Personnel -_-1 00l, Roas 'l —+t.11' --- Proper Cooling at PHFs Food Food Protection FC 3 -70�4 18 2---7 Equipple'i trrlt(�Lens -7�O 1 14(A) Cuol deg Cooked PHFs from 14(J'F to -------------- Waste -------- 61 "112bin arid 5 um 70"l;Within 2 lfour<and From 10"1' 27, FC-6 '007 Lo41'1^/45cF'kitliin4Heirs. * 2ti. Poisonous or Toxic Materials TAmbient 5 1.14(B) Cooling PHFs Made From 29 _Sp2ciaJ_5±qqrrernffjtg ...... 009 F Other Temperature Ingredients it,411-/45'' ---,30- Within 4 lhlurs' Den"tes'nuchl item in the tr ICcni 19)9 Foml(We or 105 CNIR 591)NX), ''�.,r r 1 -�:��, <. '��+,r► 'i+vrti. v,r'4tt+`t.':tt dYt�.b;,/rt�,::.'�..wJ�..T ..t.. , .,'C,,;..{�+iki`R.Y, 1,.! 1T1. .J d..p..x!'11 "noe" ., . • �e Massaausetts Department of Public Health Salem Board of Health 120 Sal Division of Fooii and Drugs Washington Street,4" Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name / Date Tvoe of 0 eration(s) Tvoe of Inspection nGf t I e rc✓1. 0 ® Food Service 0 Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP YM Caterer ElPre-operation „ El El ElSuspect Illness �,� Person in Charge(PIC) Time ElBed&Breakfast El General Complaint AJ In: la a9 E] HACCP Inspector Out; _ Permit No. ElOther Each violation checked reciluires 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. F60D PROTECTION MANAGEMENT'�M4rr .�,j.„ :. - x t��„a, „,y,�;' ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties r L e ce �� ❑ 13 Handwash Facilities ,'EMPLOYEE HEALTH, ...., , z®y P,;3� F.�,.}.,�) 'ILLH t t'AROTECTION CHEMICALS t .""FROM CN " €!' i �- ° 1 "'r r r s � 5z 9t'A�a ❑ 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 S0URCE,�w s5� 3 ,,=3 rt'.w �TIME&EMPERATORE CONTROL§(RotemlalliAe`ardous Foods) r� ❑ 4. Food and Water from Approved Source jI ❑ 5. Receiving/Condition [-116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating F❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling PROTECTION FROM CONTAMINATION a s " 6"� -�: ❑ 19• Hot and Cold Holding ` �°"°a��W '9s:PW W,4. 1 Ww.�" ❑20.Time As a Public Health Control ❑ 8. Separation/Segregation/Protection to ❑ 9. Food Contact Surfaces Cleaning and Sanitizing j-REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP),) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER AUu1SORv ;� �is 4; ,gym? -w;`�� .94�' ❑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 LC2 INC, by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) 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: f� h h(2, J� ' V d sssom:aa=rro�-ia.emr . .._ _ i 1 Inspector's Signature:�J Print: PIC's Signature: Print: A D Z 1,41 -) Page of-3 Pages 1 Violations Related to Foodborne Illness ' Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination , 1 590.003(A) Assignment of Responsibility* 3-302.1](A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cc oked and RTE Foods-* 2-103.11 Person in charge--dutiesContamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foals Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) - Food Protection* a plicants* 3-302.15 Washin Fruits and Ve stables 590.003(F) Respomfiibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(B) Removal of Exclusions and Re frictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources FT Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization rem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-I-lot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.11.4 Chemical Sanitization-temp., pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. '" 5-101..1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590A06(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.01` 4-602.11 Cleaning Frequency of Equipment Food- She!(1lsh and Fish From an Approved Source Contact Surface and Utensils" 4-702.1 1 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Ccnttact 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 Regulatory Authorityand Re mMushrooms Approved by 2-'301.1 1 Clean Condition-Hands and Arms* R 3-202.18 Shellstock identification Present* 2-301_12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* Fit Good Hygienic Practices g Receiving/Condition 2401.11 Eating,DrinkinE or Usina Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Package Ince it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 TagslRecords:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.0(4(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction'" Conveniently Located and Accessible 5-203.11 Numbers and Capacities- 590.004(J) a acities- - 3-402.4( LabellingRecords,Creation and Retention* 5-2(4.1.1 I-mation and Placement* 590.004(7) Labeling of Ingredients' 'J Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance /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 Hindwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision I)enoeec critical item in the feder�d 1999 foal Cale or 105 CMR 590.0(10. CITY OF SALEM 11 � ll BOARD OF HEALTH Establishment Name: 1 ' 1 1 /�u� r Date: ( I I C) I J Page:__ � of ff �..�,,. :,� ,. ,a.,.t„ w .. ,- ! if„'.^ :'i •Date item code C-Critical item _ r DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION -No. Reference R-Red Item as ,`" A ` - '� ` - Verified s " PLEASE PRINT CLEARLY l + - �� I t c 5 S— -tap( LI . (1�r ab Q C a A) Ik �/1 _ t A , �� fJ l r'.M-kn/, / rP f 12W 1`i 1SUI 1r1< Oo _ ho- C/t � r I ( O tP /) SZsrYn _7 L/ (AZ !d�7 � (.I✓1 1JGLS s r r.nr, /J �_tr r/i/l , lPAA,e-,\1Q 01) r eCC,>5CA, I N.� / �r/uJ r� Get .I ► Gt A)�. 7i j i t Discussion With Person in Charge: Corrective Action Required: o No ❑ Yes j I have read this report, have had the opportunity to ask questions and agree to correct all U Voluntary Compliance ❑ Employee Rdstriction f inspection, to observe all conditions as described, and to Exclusion violations before the next ins P �! Re inspection Scheduled ❑ Emergency Suspension t comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five`dollarss or suspension/revocation'of ❑ Embargo ❑ Emergency Closure your• food permit. � �/' ❑ Voluntary Disposal 0 Other: 1,74(�) Plif"s Reeeiwd nt Temperatures Violations Related to Foodborne fitness Interventions and Risk Accordi ag to haw Cooled to Factors(Items 1-22) (Cont) I 4I'F145 Within 4 Homs. 1501.15 CoOnn,Methods for PffFs PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding 1=4 Food or Color Additives 3 5016(B) Cold PHFs Maintained at or below 3-262.12 Additivcs* 590,004F, 41 /45`F* 3-3{)2.14 Protection front Addiiiw,' Poisonous or Toxic Substances 3-501,16(A) Bnt 111F; Mawtnined at orabove 1,10'F ;-I-- identifyinfiltdiennation -Orl"inal 01 11 Time field at or above 130'F. Containers* T� a- 20 Time as a Public Health Control I 102.1 I Common Name - or iout- — 3-iOIAO Tune as a Public.Health Controll 7-20t.11 -L'2aradon-Storage" I -- F-72�)1 -211 Res�ricRestriction-Presence and Usc* 990'fo1 --Ssuremeat 7 202.12 Conditions of UW REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203,11 loxic Containet, Pr7hi;uionslc POPULATIONS(HSP) 7 1-204.11 Sannizers,Criteria-Chemicals� 7-204.12 Chemicals for Washinv Produce,Criteria'. 21 3-801.11(A) Unpiqteurizcd PrePackagedJuices and7-1104,14 Di pIT A iteria- Bevetuees with Warms 1 :5-80 L 11(1h) UsQ of Pwtculiej f"Lirs- 7-205,11 Incidental Fxyl Contact,Lubricants — =,-�� 3-801 TF(D) m or PamaiJy Cook-(] Animal Ford and 7-206AI Restricted Uw Peticides,Critetia* IServed 1 7-206.1� R�5ent Bait Station�* ---- SLIT2TI, No�- 206 11 Cracking Powturi,P,-&L Conn of and Mortilorin-4 CONSUMER ADVISORY 22 3-603.1 11 ('011sumor"'Vixisory flosled for Consumption of TIMIETEMPERATURE CONTROLS Anitwd F,NxJs If un in!Raw. Undercooked vi 16 Proper Cooking Temperatures for PHFs Not Othom 1st Pr(g!essod to bliounaze -4 1. 1 A(l)(2) Egg., 15,5'F 15 Soc. 301 1:r in,"weunied Fgg::Substinav foi Raw Shelf 3-401,I I(A)(4) comminuled Fish,Meats&claine Animals - 157'F 15 se(:. " SPECIAL REOUIREMENTS 3-10LJ l(B)(1)(2) Pork and t eel RoiiW- I5) k 127 Dun* -- Ratite~, Injected Meats-- 155 F 15 510("'ll 1'"7 Viol ioknoni�of'Section 59f590.009(4)-(D)9(A)-(D)in sec. catering. rnobilc triod,tentpurary and - 4 1 11(A)0,j Poultry,Wtbd Game, Smiled PRFs, residential kitchen operations should be. Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or katites-i 65"T 15 vec. above if related to ftlodtiortn: Marva Intact Beef Sleaks irocivvntions, and risk factorg, Otbff 145OF c. 590.009 violations relating- to,,,(xxi retail 7-401.12 Raw Annual Foods Calked in a pia trees should 1--c debited under#29 - Microwave 165'F* --- Special Rexjuiremants. 3-401 A f(Ar(l)(b) All Other PHFs- 145'F 15 sec. try Reheating for Hot Holding —VIOLA TIONS RELATED TO GOOD RETAIL PRACTICES 3-103.11(A)k(I)l- 1`141-1 1659' 15 sec. I -- (Items 23-30) 3-403.11(13) -Microwave- 165°F 2 Minnie Standing Cihowl mrd non-c rilh:al whjih do not reiane to the I Time, f(wriborne illness imerventiony rind rokja<iors listed wwve, (on be 3-403.1I(C) CornmexciallY Procesied RTE Food- found in the loffimiog secooto o.1 Me Food Code and 105 CAIR 4L) F^ 590'000. ---- 3-403,11(E) Remainin- Undited Portions of 11cef fC 590X00 Roast,* ?3, Management and Personnel 24 1 Food and Food Prolff�hkri__...... i FC:- 3 .00 18 Proper Cooling of PHFs --T - utensils E�oipW,;.7nianci-- FC--4 '005 __f sils tT�E4(A) C"�,liiigC(x)kcdPFIFsfiom ]40-Ft.I 28 Water,Plumbn iE Tc- -06-6 F Within 4 Hoar�. 27, 70'F g ithin 2 flours and From 7017 FC-6 i I i, - �-FF to 4 soMatenal� O --7 84(B) CooliPFffis Made From Ambient, -2� §Peelal Requirements ---------- 5—01 1 Temperature lnf;rediraas to 41'F/45;IF Ni Lhin4 flw* . CITY OF SALEM BOARD RD Of�F HEALTH nateEstablishment Name: �)Izef\ : r1( Page: of 'Item x °. ' .Critical Item A7.1 �" Dater Code C= - DESCRIPTION OF,VIOL`ATION7 PLAN OF CORRECTION ra Z" No Reference R—`Red Item - = Verified PLEASE PRINT CLEARLY • ��- h � , �— l o. flier a r )Al ' l�L,/1a r F Iv _ �fJ rir I ' f V ttt62 mr e tSr , alb s � 0— .Y.\ rns,7 rs :,Q ')j rciNed ore r � =Zi (Uf I/' � - f f!. F--} Ionrn n� Discussion With Person in Charge: Corrective Action Required: ❑n No�- ❑ Yes "_ f I have read this report, have had the opportunity to ask questions and agree to correct all L.) Voluntary Compliance Ll Employe Restriction / Exclusion ,I violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension t comply with all mandates of the Mass/Federal Food Code. I understand that snoncompliance may result in daily fines of twenty 1five-dollars or suspensionLrevocation of ❑ Embargo ❑ Emergency Closure your, food permit. / i ❑ Voluntary Disposal ❑ Other: L 1 Violations Related to Foodborne Iffness Interventions and Risk According to IACooled to Factors(items 1-22) (Cont) 4 Within 4 HouF, Cooling=Methodsfor PIJF� PROTECTION FROM CHEMICALS 3-501.7 5 1 Food or Color Additives F19 PHF Hot and Cold Holding Adclaivc,"� 3-501,16(13l Cold below Maintained at or belo 590.(i1-iff, 41`145"i 3-302,14 Protection from Unapproved Additives* 3..50) 1 fir A) Hot PIfFs Maintained at or above Poisonous or Toxic Substances 14617. 101.11 Identifying Information--Original 3-501,16(A) i Roasts Hold at or above 130'7, Containers* Time as a Public Health Control 7-102,11 Corartion j�Laftie, -�k ork in, EK —-7 ---- as a Iluidw iTlealth Control- 7-201.11 -Se 3 Cl V) 7-20111 It-c.�tiction-Presince.and Use -�90(04 1�) -Variimcc RSqtt�tnera 7-202.12 Concfiiiorcs of Use -7-20",11 Toxic Container,-Probibitions4c REOWREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanni7en,Crileria-Chemicals* POPULATIONS(HSP) 3-801.1 1(Ai Unpasicurized Pe-paclaged Juices and 7-204-12 (Theiricals for ce,Clitelie !VLI -- 7204A Critcrial� -- Beverw"ec with Warni 3-80 1.11(B) 11'seofPa�teuriz�d Eggs� -205.11 Inciticnal Food Cornact.I,uln ieantsl� --- 1-80f Ew or Panjallv Cookcd Ammal Food and 7-206_t I Restrioed Vu PeNticides,Cfitcnal 7-206A2 Rodent Bait Slmons' 3-80Li 10�) 'raNereal Food Pack aitc Not Re-served. _j tia-in-4 -.--MoniI CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3.60? 11 0)usuroer Adviso!v Posted for Consturlotion of, )iawl foodChat art!Rikw. Undercooked a 16 Proper Cooking Temperatures for PHFs Not Otherv,ice Processed tohlirmnate A(I)(--) Egg,, 155'F 15 Sc s. jTo) chate Service 145'F15sec, 3 3-30".13 flogtcurtfA FgvSubstitute fa kAw Shell Comininoted Fi.*Mews&Gane Animals 15,5"F 15 sec. I PorBeet Roast - 110'F 121 nan' SPECIAL REQUIREMENTS 'iola (,�i2,, Rafite�' lj�jeclod Meats - 155 P IS 'iolatioa'� f Section 590,(X)9(A)-(D) in sec. cateringmobill: teKicl, temporaly and 3 401-11(Ali 3) Paula).Wild Game $tuffed PHFs, rexidera'al kitchen operations should be Sniffialv Containing Fish,Meat, debited L)lldCf the appropriate sections (Lialtry or Radhes-165'IF 15 sec. abovce it'rehited to foodborne illness 3-401.11(C)(3) Whole intia-le,Intact Beef Steaks interventions and risk factors. Other 145OF* 590.009 violations relating to 000d retail I 3--401.12 Raw Animal Foi)as(—ooked In a practices whould be debited tinder #29 Mita owave 165°f;* Sp"611 Requirements. .!-40JAl(A)(1)(b) All Othei PHFr-- 145'1 15 sec * Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 03.11(,A)&-f D) Pifl,,, 165"F IJ sec. (items 23-30) 3-403.11(B) JMilnowave- 165'F 2 Minute Standing Ctitowl and non-critical viokitunij, which do not +'ehae to the Time, can be :3-403.I 1(C) Commercially Processed RTF Food found in the ft)iloh tog.sections of the Food Code and)05 CAY'R 14001c* 590,000, 3-403,Tl(E) Remaining Uncliced Portions of Beef Roasts* -23,1 I Man taifementjand LPer onnef FC- Proper Cooling of PHFs Fuad and Food Protection..------- 008 FC 3 004------ L EE 25, Equip 2(Stand_1Ulte;ih; FC 4 -75(') L4(A) Cm,ling Cooked h I-I1401`t26, andWaste —PC 5 --006 701:Within 2Flu"and From70'F P cal Fac i C6 �007 hy -I------il!Yto 4 Il,'145'F Wiin 4 Hour, 28. Poisonous or Toxic Materials FC -7 y 06L 3.501 14(B) Cooling Pffs Made From Ambient 29, 2cAf Temperature InLredients lo 4J 1/45°F I Within 4 llcuret wern in the loderal RRA.:` r . • v. .r - , Commonwealth of Massachusetts City of Salem Board of Health lQmberley Drisooll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/07/2008 ESTABLISHMENT NAME: Ana Miguel Restaurant File Number:BHF-2004-000107 101 Lafayette Street Salem MA 01970 LOCATED AT: 0101 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0231 Jan 4,2008 Dec 31,2008 $140.00 ESTABLISHMENT Total Fees: $140.00 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 1 of 25 s CITY OF SALEM, MASSACE IUSEM BOARD OF HEALTH 120 WASHINGTON STREET,4" FLOOR TEL.(978) 741-1800 KINiBERLEY DRISCOLL FAx(978) 745-0343 MAYOR IsGOTrna SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT gt.U$4( ' A&P TEL# OW- ? ADDRESS OF ESTABLISHMENT�L ,/� / f�G� C�= FAX# MAILING ADDRESS (if different) EMAIL-Business': Website: OWNER'S NAME_Kc�C )t7�[S>� TEL# � A _�p/f� 2�/�i� ADDRESS �� /P?�'I ✓�1� ©�� STREET I CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S)� , RlCERTIFICATE#(S).�Q© ��/o (Required in an establishment where potentially hhaJzardous food is prepared) EMERGENCY RESPONSE PERSON fGtZ4,st_/-) HOME TEL DAYS OF OPERATION Monday Tuesday Wednesday Thursday FridaySaturday Sunda HOURS OF OPERATION �f 1,1`4 f Please write in time of day X19 f� /A� For example 11am-11 m) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - ------------------------------------------------------------------------------- ' � PIS rte 'essih6r� 25 -eats =$140 (Outdoor Stationary Food Cart$21 25-99 sea s J =$280 more than 99 seats =$420 - --------------------YES------- :..... '1,0.0 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 fled all state tax retw nd paid all state taxes require under the law. Signature Date Social Security or Federal Idenhfica ion Number ------ ------------------------------ nn^^ ---------7---/-�-- ----------- ------------------------- Revised 4/24/07 FOODAP2008.adm Check#&Date ;?& ( 7-/Lt/1 / $ 1 0101 Lafayette Street Ana Miguel Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 741-2446 Handwash Facilities FAIL Critical RED Owner: Comment:The kitchen hand wash sink found completely obstructed. Keep hand washs sink clear and accessible at all times. Rosa Hernandez - There is no hot water in the restrooms. Restore hot water to a minimum temperature of 110°F immediately. PIC: Violations Related to Good Retail Practices (Blue Items) Adrian Arias Physical Facility FAIL Non-Critical BLUE Inspector: Comment:There is a large broken window in the dining room. Repair or replace the window. David Greenbaum Date Inspected:Correct By: 7/17/2008 Risk Level: Permit Number: BHP-2008-0231 Status: PARTIAL COMPLY #of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: All other violations cited in the 6/26/08 inspection report have been corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS@ 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 21,2008 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 21,2008 ) Page 2 oft COURT DOCKET NO. CITATION NO. QCITY SALEM PD6 p 5 4 VIOLATIOIO N NOTICE r L� NAME(LAST,FIRST,INITIAL) AWA MICaJr-1, 4Z�5 A�2gaT STREETADDRESS CITY/TOWN STATE ZIP 1a1 'rr�yw s; St>L:aK.1*� '907o LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) viv' TNgn� 2 —1b;' Sc.. STREETADDRESS CITY/OyAW�N STATE ZIP �1 tXN-t\ )i ti Fi sotfTdC -ice. ('v rT 0I) 70 REGISTRATION NO. STATE EXP.DATE MAKE/TYPE YEAR COLOR DATE OF`VIOLATION ry TIME DATE CITATION WRITTEN iwuav"AL (, ."'t V 'O O M R y ❑YES ❑NO LOCATION OF VIOLATION ENFORCING DEPT. OFFENSE CHAP.I SECT. FINES A r( , -AALt 1<, 1 a 1 !aS lxv,,-'six B Y \ f'�7 c OFFICERI.D.NO. TOTAL i W1\1 t "_V,�,1�.!'IJ l\ FINE $ •� DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ❑J IN HAND X '90w f Q�BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE/ SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 0101 Lafayette Street Ana Miguel Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 741-2446 Handwash Facilities FAIL Critical Q RED Owner: Comment:The kitchen hand wash sink found completely obstructed. Keep hand washs sink clear and accessible at all times. Rosa Hernandez �-- There is no hot water in the restrooms. Restore hot water to a minimum temperature of 110°F immediately. PIC' TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Adrian Arias Hot and Cold Holding FAIL Critical RED Inspector: C David Greenbaum ment:The Continental unit had a temperature of 50°F. Repair unit to maintain a temperature of 41°F or below. Date Inspected:Correct By: Meat and chicken out at room temperature. Store meat and chicken in a refrigerator at a temperature of 41°F or below. All placed 6/26/2006 o refrigeration at the time of inspection. Risk Level: Permit Number: BHP-2008-0231 Status: VIOLATION #of Critical Violations: 3 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 1 oft Jk s Item Status Violation Critical Urgency RED: ' Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Foo rotection FAIL Critical BLUE Foodborne Illness InteNentiOrlSomment:The 400 SeriesE reach in has uncovered food. All food in storage must be covered. and Risk Factors (Require Equipment and ensils FAIL Non-Critical BLUE immediate corrective action) C mni The 400 SeriesE reach in needs a thorough cleaning. Th a �fiorel0 freezer needs a thorough cleaning. same,unit needs a visible,accurate thermometer. T Frigid 're freezer needs a thorough cleaning. Th ani unit needs a visible,accurate thermometer. e Hotpoint unit needs a visible,accurate thermometer in the freezer compartment. Thetiire Ansul system has an accumulation of grrease. Thoroughly clean the entire Ansul system. Professional cleaning is in rder. T to freezer in the kitchen needs a thorough cleaning and defrosting. e GE freezer in the kitchen needs a visble,accurate thermometer. Physical Facility FAIL Non-Critical BLUE -ti Comment:There is a large broken window in the dining room. Repair or replace the window. Special Requirements FAIL BLUE ,_�Zmment:Owner must provide six consecutive months of extermination inviloices at the time of reinspection. Reinspection in two weeks, all violations to be corrected. _Z4— 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 1 Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 NameDate/ Two of Operation(s) Type of Inspection Ao" �Gn / 1 EF Food Service ❑ Routine Address iJ ( Risk' ❑ Retail ® Re-inspection Level ❑ Residential Kitchen Previousns ectio Telephone ElMobile Date: /��leL�� Owner "ACCP YM ❑ Temporary ❑ Pre-operation An O/k- L ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ElBed&Breakfast ElGeneral Complaint IU I 1�r In: a;4 - ElHACCP Inspector Off: O1 Permit No. El 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. PbPRO[E ¢NtNPQFNENT� �° t ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties � � � � ❑ 13. Handwash Facilities ❑ 2. Reporting of Diseases by Food Employee and PIC ee ❑ 14.Approved Food or Color Additives ❑ 3.. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals �FOtJA FAOM hPPRQv1=Q S01lAGE4„�.„;�s� ❑ 4. Food and Water from Approved Source 'nN�J1`EYtIA7UHECpNTRi1LS(Pbtemial)yfi"aaeo§ sods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling $ PRQ1ECnONFtiTCOH�jIiNATt(Nj ; ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing RE4I11REMENTS Ft3R HIdHLY S1i$CEPi7at1 .PUPUTATKINS{I13F)21 ❑21. Food and Food Preparation for HSP I ❑ 10. Proper Adequate Handwashing s _ El 11.Good Hygienic Practices _ '.CON U- ---AUYI Y!m ' ,-3 �., .. `„m• ❑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' 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-4)(590 ) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005 0a) the food establishment permit and cessation of food S.- 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. ' 30. Other DATE OF RE-INSPECTION: n Nny'j�l� 5:5801napecfForm610.Eac 1 Inspector's Siguature: Print: PIC'sSignature: Print: // Page- / ofZRag& Violations Related to Foodborne Illness - Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination . 1 596.003(A) Assignment of Responsibility* 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 char e-duties Contamination from Raw Ingredients - 3-302.1.I(A)(2) Raw Anirual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-3011.1(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 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* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes" 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590A04(A-B) Compliance with Food law* 4-501.1.11 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Tet eratures* - 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* 4-501.11.4 Chemical Sanitization-temp.,pH, - 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. " 5-101.11 DrinkingWater from an Approved System 4-601:11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602.11 Cleaning Frequency of E ui ment Food- . ,: € 9 y 4 p 590.006(B) Water Meets Standards in 310 CMR 22.0 � Contact Surfaces and Utensils' SheWrsh and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.1.4 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 RegulatoryRagulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* II Good Hygienic Practices - Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* - 3-202.11 - PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and - 3-202.15 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-30L12 Preventing Contamination When Tasting" 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590DO4(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to s* - Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible - 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.0040) Labeling of Ingredientsw 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced oxygen acka 'ng,criteria* 6-301.11. Handwashin Cleanser,Availability 8-103.12 - Conformance whit Approved Procedures* 6-301..12 Hand Drying Provision Denotes ciidud item in the federal 1999. Food Cade oa-105 CMR 590.000. - - CITY OF SALEM BOARD OF HEALTH Establishment Name: c', Date: (��t C7� Page:_ of Item Codea„ Critical Item fi �j�DESCRIPTION OF VIOLATION/PLAN OF CORRECTION „' Date„ r No Fieterence .R-Red Item,;'' t^�s,•.r '% ^ %- r?'3 r�^ .yr..✓-a , � , kx,..r, < «'f Y% r verified =`'� �'" '� • '"'`"e '� PLEASE PRINT CLEARLV'� "' �'t •�' t . dJr�_ � Q�r/ie A �C4P C'4 N 1 r i I ✓�v 4' f 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 oluntary Compliance h ❑ Employee Restriction/ / LlL Exclusion violations before the next inspection, to observe all conditions as-described, and to L P „ , �- -� LaRe-inspection Scheduled Emergency Suspension } comply with all mandates of the Mass/Federal/Food-Eod`e 'I understand that noncompliance may result in daily fines of twenty -oj us spension/revocation of ❑ Embargo ❑ Emergency Closure yoOr food permit. ❑ Voluntary Disposal ❑ Other: i 7561,74(( Pfff's Received at Temperatures Violations Related to Foodborne Iftness interventions and Risk According 10 Lav, Cooled to Factors((tarts,I-V) (Cont) I I"F/45'F Within 4 Hours, r Color Additives PROTECTION FROM CHEMICALS 3 3T.15 Cootin,,Methods for 111-fFs C4 Food o F, PHF Hot and Cold Holding 3-501,16(5) C0141 PHF.s Maintained at Of below 3-202.12 fAddnivc,* 590 004(F) 4j`/45`F, 'T 302 1 3-501.16(A) Hot NIB, Maintained at or above IS ---- Poisonous or Toxic Substances1 1 40'F -10111 Idowifyi 1l;information- Original Rugists Held at or above 13W as a Public Health Control 7-102A I Common 7-201.11SQrsaation-Sl 7-202.111 -202.12 Conditions of Use, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE -203.11 Toxh�colualner"-ProjubitionS7 POPULA I _S 1.204.11 Sarntizers,Criteria-Chemicals 7 204.12 Chenyicafs for cc,Critozia7- 21 ;-SQ1,I f(A) 1'nPlqoncn/zd Pre-part aged Juices and 7-204,14 Urmn Ascots.Critefia� -- Revera"'es with W-al—ull S-801.11(B) ljvc of, 7-205 I I Incidental Food Contactlatbi icarils'` 3-!;01.11(U} Rjw,)r 1",truMN Cooked Animal F(xyJ and 7-206.11 Criteiia� Rodent Bon Snitioris, _j�aw Sc ,d�Sirouts Vol- Served 7-206.12 . (ClIT21ned 112�Lka I, 7 206,11 Tracking Powders,fs�[Control and _ CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 1 1I Foasulner Advisory y Posted for Connuliption of Aninad FNtll< I'hat are Raw. Under,;ookcd el to Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs , D�,�...1, _7461.11A(l)(11) F.g&b- 155,E 15 Soc P h orins145,T15sec Pasteka,i7ed Egg,Substitute lot Raw Shell 3-401.11.(.0(2)' contninulted Fish, Meals&(J'allic 'T�— Aitituais 155"F 15 see. �' --.— SPECIAL REQUIREMENTS 1.11(11)(1)(2) Pork and Beef Rwsl 130"F121 min* 3-40111(A)(2) Ratites, Inliected Micitts - 175°F-15 -59001191A)-TU) Vielaliriws of Section 590.009(A)-(171 in sec.* ealerlllgnlolnV food,teznporary and - 3-401.11(A)(3) PoulPoultry,Wild G..., Stu F te, residential kitchen operations should be Stuffing Containing Fish,Meat, ticbaed under the appfonriate sections Poultry or Ratites-165"T 15 sec. above if related to foodh().—-11-1 Whole-nniscle, Intact Beef Steaks interventions and risk factors. Other 145"T* .5190.009 violations relating to gokxi retail 2 Raw Amoral Foods Cooked in a practices Miould be debited under#29 - Microwave 165'F Speehd Requirements. 3-401,11(Ai(1)(b) All Other 111711-'s-- 14 5'1-'15 sec Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403A 1(A)&(1)) Pf4l,s 165'T 15 sec. (Itenis 23-30) 3-403.1—,(B) Microwave- 165-F 2 Minuce, StanTiag, Ci airal and non-,,rilicla violavwtt, which do not rebate ii)ilge. Tinle, foodhorne cline's illu,rventionvand riAkjol bars Rcicd above, can ba 3-403.11(C) l Commercially Processed RTE Food- found it se(rions of the Fuad Code and 163 CUR 140'Fs 590.0(kl 3-403.11(11) Remainim,Unshced Portions of Reef 23 Manaliernent @.no Pemoncel FC 2 1 '003 Roasts* -—----- -�lFcodind F(xxJ Protection 1 FC 3 004 �i4 F Proper Cooling of PHFs --4- 25, Eq Lt e iMs FC,-4 005 (11j l$ J'hA) Cooling CN)h,,,d PHFs from 140'F to 26, WateljLlumbinqjvnLd Vlastt G 70'F Within 2 flours and From 701 --:L Lf : -E -------- Facility- F( -6 007 to 41 F/45 Within 4 Hunts 28. PoclonW3 or Toxic mater,3!5 FC 7 008 4(B) Cooling PHFs Made From Ambient s wai R- wernenin 009 30 l other Temperawre Ingredients to 411`145cF Within 4 Iloul-0 -J)encltea Critelli item in the l"Clenal f99 Foml Gxie or 105 CNTR 590 000, CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON .STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, FIS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT tl/ / (f 70 Jyae737- ' e�P TEL# ADDRESS OF ESTABLISHMENT � f � Sz FAX#T _ MAILING ADDRESS(if different) EMAiL--Business':_ Owner's:_ OWNER'S NAME TEL# ADDRESS l �� STREET CITY STATE �a ZIP I CERTIFIED FOOD MANAGER'S NAME(S)4 ) ! CERTIFICATE#(S) IC(JrK (Required in an establishment where potentially hazardous food is prepaarr of EMERGENCY RESPONSE PERSON 4 Y72 jxa„ ,62 Z'ZZ) 2 HOME TEL 4� 3 DAYS OfOPEHATiON Monday Tuesday Wednesday Thnrsdalf FndaY Saturday C� Sunday_ fT HOURS OF OPLUTION Please write In dine of doll. (For example I1am41pnU j TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT ----- NO--------- .. _ . ----- ----- less than 25...... ... ... . - ...seats/- ES 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 YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem, This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGI. Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, h i e all state to returns and paidtate taxes required under the law. - Signature Date Social Security or Federal Identification Number - ---- ------ ------------ -- - -- ------ ------ ------ -- ------------ -- --- --- -- - --- ------ ------ Revised 11113/06 POODAP2007.adm Check#&Dnte_-+1/—Ly 4h�Qb S /pP,e0 rlYtme� �ndm .Lv.ct. A Off? 5533 5`C35W 'a a aR- • m.>�`� dk' dS �q.�a +.�c�.'a 'a :. � ,+ e. "x `f" -Mem�"'�4 "��'�Agl}'�`"a"` ��`. +.w ,� ,„yam[ �, `,,,�Commonwealth of Ma acyhuu.se'l'ls� {i'� � ''�'�y� ��'p��" � _ 't �• '#r,c 5�,}y �"'�� _"� �r 4n qr �„ .`4. Yl�r'"�`u•d�l yw,r�xs.��?� ��' �'�.�s�'e '".� �C+�, X t ` � G..... Board of Health 120 Washington Street,4th Floor, IGRIbEtIeY Onsooll' i rr w rd¢„y3, ♦ r `r P'` = "? ,',�. a?e."',._ roC.:, ;rx�.'Y�w w. ; ; ,,•' *z .�x4 '� .`' Es_�;,'+� . -Mayor �l,,;C` '3� SALEM,MA ,01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Ana Miguel Restaurant File Number:BHF-2004-000107 101 Lafayette Street Salem MA 01970 LOCATED AT: 0101 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0149 Dec 20,2006 Dec 31,2007 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES 'December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 16 0101 Lafayette Street Ana Miguel Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-2446 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:The Hotpoinpt refrigerator/freezer unit needs visible,accurate thermometers. Rosa Hernandez PIC: Adrian Arias Physical Facility FAIL Critical BLUE Inspector: Comment:The counter at the microwaves has worn areas. Repair counter to be impervious and easily cleanable. David Greenbaum The back stairs and floor need to be repainted. Date Inspected:Correct By: i 11/13/2006 There are unfinished wood shelves in back. Seal shelves to be ipmervious and easily cleanable. Risk Level: These violations must be corrected by the next routine inspection. II Permit Number: GENERAL COMMENTS: BHP-2006-0008 973:AI1 other violations cited in the 11/2/06 inspection report have been corrected. Status: SIGNED OFF #of Critical Violations: 1 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 GeoTMSS 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 13,2006 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 13,2006 ) Page 2 oft 0101 Lafayette Street Ana Miguel Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 741-2446 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical E/1 RED Owner: Commn>t:There is no sanitizing solution available. Sanitizing solution of proper concentration must be readily available at all Rosa Hernandez 1 workstations at all times. PIC: Handwash Facilities FAIL Critical RED Adrian Arias Com t:The kitchen hand wash sink found obstructed. Keep hand wash sinks clear and accessible at all times. Inspector: David Greenbaum Date Inspected:Correct By: 11/2/2006 Risk Level: Permit Number: BHP-2006-0008 Status: VIOLATION # of Critical Violations: 4 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 02,2006 ) Page 1 oft r Item Status Violation Critical Urgency r' RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Foo rotection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require C m nt:The flour bin under the prep table found uncovered. Keep flour covered at all times. immediate corrective action) T e big silver reach in in back has uncovered food. All food in storage must be covered. Equip ntand ensils FAIL Non-Critical BLUE omment:The Continental deli unit needs a thorough cleaning. Th ig silver reach in in back needs a thorough cleaning. 7 Hotpoint refrigerator/freezer needs a thorough cleaning. _, cThe same unit needs visible,accurate thermometers. T right Frigidaire freezer needs a thorough cleaning. T eft Frigidaire freezer needs a visible,accurate thermometer. Physical Facility FAIL Critical BLUE Comment:The counter at the microwaves has worn areas. Repair counter to be impervious and easily cleanable. {� The back stairs and floor need to be repainted. ere is a gap at the bottom of the back door. Provide a sweep at the bottom of the door. There are unfinished wood shelves in back. Seal shelves to be ipmervious and easily cleanable. The ck room is in need of a thorough cleaning and organizing. Remove all items that are not pertinent to the business. GENE COMMENTS: 956:11einspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 02,2006 ) Page 2 oft I Y f Massachusetts Department of P, blic Health Salem Board of Health Division of Food and Drugs i! 120 Washington Street,4 Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name /` Dae T e of Operation(s) Type of Inspection u Ani",(, �n l S Food Service ❑ outine Addresi Risk Retail L Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: �6 �0 4 Owner a HACCP YM El❑ Pre-operation O^;C� ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ()'t� ElHACCP Inspector Q Outa <J Permit No. El Other Each violation checked McIdiies 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. El12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties pi i , a t t ,•, g ❑ 13. Handwash Facilities EMPLOYEE HEALTH �, i21, ,�.,, , a -, q„ q • spy„,•res El2. Reporting of Diseases by Food Employee and PIC M d E [PROTECTION FROM Cli¢MICALB ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals „FOOD FROMAPPROVED SOURCE= ,.E;;!i} _�c° .�.�u'"'t",°,„, �'i, rt - i,�r„.y� ❑ 4. Food and Water from Approved S '' ce TIME/IEMPERATURE CONTROLS(Potentially Hazarc(ous Foods) ❑ 5. Receiving/Condition t ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling r �. ;w ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION� �E 1 y e, , , . ❑ 8. Separation/Segregation/Protection ❑20;Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ^Ry, (REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(MSP)_ ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ' ,„ '�__ ^' °"�` '- " ;, „ • "' ❑ 11. Good Hygienic Practices x CONSUMEP ADVISORY E142. " 2 Posting of Consumer Advisories \t 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 immediately or within 90 days as determined by the Board Official Order for Correction: Based on an inspection of Health. today, the items checked indicate violations of 105 CMR yin 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)(990.009) 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)(560.006) 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., 1111 30. Other DATE OF RE-INSPECTION: 5nn :5901nspecfFom5la Doc ' "� `. \t Inspector's Signatur /� Print: PIC's Signature, / l Print:Am;at �� I�_S;d Page ofjPages r Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination , 1 590.003(A) Assignment of Responsibility* 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)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 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* Charge* Contamination from the Consumer 590.003(0) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal It Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Ftp* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590A04(A-B) 'Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Foal in a Hermetically Sealed Container* Sanitization Temperatures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.1.3 Shell Eggs* Sanitization Temperatures* * 4-501.11.4 Chemical Sanitization-temp.,pH, I 3-202.14 Ice <s and Milk Products.Pasteurized 3-202.16 ce Made From Potable Drinking Water* concentration and hardness. * 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4602.11 Cleaning Frequency of Equipment Food-- 590.006(B) Water Meets Standards in 310 CMR 22.04, Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4_702.11 Frequency of Sanitization of Utensils and 3-201.1,4 Fish and Recreationally Caught Molluscan Food Contact Surfaces of ai ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1g Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulato Au2-301.11 - Clean Condition-Hands and Arms* thorit 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Came Animals* Il Good Hygienic Practices Receiving/Condition 2401.11 Eatin ,Drinking or Using Tobacco* 3-202.11 PHFs,Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes,Nose and - 3-202.15 Package hits it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin * 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shelistock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em to ees* Tags/Records: Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11. Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision 'Denotes cmic l item in the Wid al 1999 Food Code or 105 CMR 590.000. CITY OF SALEM F BOARD OF HEALTH a Establishment Name: . Date: SAO Page: of Item Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date ,C No. Reference R—Red Item Verified __II PLEASE PRINT CLEARLY. L oI lel ff- rr a -floc c. 0 CIL 'r (. I ce c of ✓ C' 126in t• I t Discussion With Person in Charge: Corrective Action Required r ❑ No Yes Ir I have read this report, have had the opportunity to ask questions and agree to correct all voluntary compliance ❑ Employee Restriction/ rr violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension complywith-allmandates of the Mass/Federal ood Code. I understand that noncompliance may result in daily fines of tw y- ive rsusp iens oiens o /revocation of ❑ Embargo ❑ Emergency Closure . � Iyourfood permit. _ _ j ❑ Voluntary Disposal ❑ Other: A IL 3-50 L 1 IT ,PRFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According Lo taw Cooled to Factors(items 1.22) (Cont.) 4I'F/45'F Within 4 Routs. 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 PilFs Maintained at or below -T202 12 Additives* 590.004(F) 41`745°F* 3-302.14 Protection from Unapproved Additives* 3-501,16(A) tint PHFs Maintained at or above 1.5 Poisonous or Toxic Substances 7-101.11 Identifying Information-Original 140'F. 3-501 MIA) Roasts Held at or above 130`F. Containers" 7-102.11 Common Name-Working Containers` 20 Time as a Public Health Control 7-201.11 1 Separation-StonuW 3-501.19 Time as a Public HealthConnol* 7-202.11 Restriction-Presence aid Use" 590.004(H) Variance,Re uirement 7-202.12 Conditions of Use* 7-20311 Toxic Containers-Prohibitions+ REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.,11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing]'reduce,Criteria* 21 3-80'L11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Beverages with Warning Labels* Dr in A ants,Criteria* 3-80 Ll I(B Use of Pasteurized Eggs* t7-2O6.13 Incidental Food Contact. Lubricants* --)- Restricted Use Pesticides.Criteria* 3-801.1 1(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * Rodent Bait Stations" 3-801.11(C) Unopened Foal Packa�e Not Re-served. Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Faxls"Pkat are Raw,Undercooked or PRFs Not Otherwise Processed to Elitrrinate 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*ermcove vvzooi Eggs-hiunediate Service 145'1715sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Came E s' Animals- 155'F 15 sec. * 3-401.11(B)(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 Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry of Ratites-165°F 15 sec. u, above if related to foodborne illness 3-401.1 1(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 N29- Microwave 165'F* Special Requirements. 3401.11(A)(1)(b) All Other PHFs--145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES ;-403.11(A)&(D) PHFs 165'F 15 sec. * (items 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing C itical and non-critical violations, which do nor relate to the Time* foodborne illness inter vendors,and risk factars listed above, can he 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Cade and 105 CMit 140'F* 590.000. 3-403.1.1(F) Remaining Unsliced Portions of Beef Item Good Retail Practices- FC 590.000 Roasts* 23. Mona amen and Personnel FC-2 .003 24. _ Food and Food Protection ]g Proper Cooling of PRFs FC 3 .004 25. _ Equip menu and Utenstls _F_C 4 __ .005 3-501..14(A) Cooling Cooked PRFs from 140`F Co 26 Water, Plumbin and Waste FC 5 006 - 70'F Within 2]lours Laid From 70'F 27. Physical Facility_ _- FC-6 -.007--- to 007to 41.'F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC -7 .008 7-501.14(13) Coolin;PRFs Made From Ambient 29. Special R uirements _ .009 Temperature Ingredients to 41`F/45'F -3-0-------- _other__ Within 4 Hours" „�wnm„m=u z,ax "-Dwioles critical item in the federal 1999 blood Code or 105 CMR 590,000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Sreet, Division of Food and Drugs Salem, MA 019 0-35234" Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date Type of Operation(s) Type of Inspection Oa ! 17Food Service Routine Address ' ' i Risk Retail, Re-inspection Level ❑ Residential Kitchen Previous Inspe tion Telephone /^ ❑ Mobile Date:/ � J7 Owner ' HACCP YM ❑ Temporary ❑ Pre-operation ( ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In:I-o3 ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Ami-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 PROTECTIOi4 MANAGEMENT-,� El 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities aEMPLOYEEHEALTH - 4...„...,..a-„s PROTECTIONFROM CHEMICALS'p"aws a �r ,- P r i,r r ❑"2. Reporting of Diseases by Food Employee and PIC ' - -.» - "� « El 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded H x,re+�nrNm MA'^y�aatii x('+^c,,�e�2 v ^pae At 5.Toxic Chemicals +"FOOD,FROM APPROVEDSOURCE �,-a ,,�„,„m,,,,,�mm�.,..�.,-„,,,�,„,;„ ❑ 4. Food and WaterfromApproved Source 4 TIME1rEMPkRATURE CONTROL§(Potentially Hazardous Foods)-, p,,..,; ,.czar ,.s ,,.......:.....,e,3 E] 5. Receiving/Condition EI 16. Cooking Temperatures .,... ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATIONh'.""`� i""��;""�' ❑ 19. Hot and Cold Holding 0"8 Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑'9. Food Contact Surfaces Cleaning and Sanitizing ,REQUIREMENTS FOR HIGHLY SUBGEP,TIBLE POPULATIONS(HSP); „ El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP CONSUMER ADUISOR7;, ❑ 11.Good Hygienic Practices �� -�-- ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions -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 N by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-x)( 23. Management and Personnel (FC-2)(590.0 4)) order of the Board of Health. Failure to correct violations \ cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(5590.090.0 065)) the food establishment permit and cessation of food X26. Water, Plumbing and Waste (FC-6)(660.006) 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: H rl7 ��f s:ssainspecrFome-ia.eoc ^ / " �� ja Inspector's Signature* Print: Q PIC's Signature: Print: (� � � Page e of Pages i Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination . C 5,96.003(A I Assignment of Responsibility* 3-302.1I(A)(1) Raw Animal Foods Separated from 590.003(R) Demonstration of Knowledge* Cooked and RTE Ftxxls*, 2-103.11. Person in charge-duties Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Fond Employee Or An 3-3(411 Food Contact with Equipment and Applicant To Report To The Person In Utensils'* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food taw* 4-501..1.11. Manual Warewashing-Hot Water Sanitization Temperatures* 3-201.12 Food fluid i Hermetically Products" Container* 4-501.11.2 Mechanical Warewashing-Hot Water 3-20'1.13 Fluid Milk and Milk Products" 3-202.1.3 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.11.4 Chemical Sanifiration-temp.,pH,- 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 DrinkingWater from an Approved System* 4-(i0Ll 1{A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(0) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Foocl- 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 E ui ment" Shellfish* 4-703.11 Methods of Sanitization-I-lot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources" 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Peoulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Presem* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 - PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and - 3-202.15 Package hiteit * Mouth* 3-101.11, Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 TogsfRecords:Shellstock 12 Prevention of Contamination from Hands It 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-00211 Tarasite ords:Fish Conveniently Located and Accessible 5-203.11 3-402.12 Reards,Creation and Retention* . Numbers and Capacities*s* 590.004(1) Labeling of Ingredients` 5-204.11 Location and Placement* 9 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance 1HACCP Plans - Supplied with Soap and Hand Drying 3-502.11 1 Specialized Processing Methods* Devices 3-502.1.2 Reduced oxMen packagmg,criteria* 6-301.11. Handwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in the federal 1999 Foal Cale or 105 CM R 590.(010. P L r CITY OF SALEM BOARD OF HEALTH S Establishment Name: Date: Pagerof '/1 _ a Item Code C-Critical Item DESCRIPTIONOF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY. O� J� l J t,n 1 and A '_ of k' J3 +� AA ,e / 1 r (a 47i .I e c J �l , rn r MelL� r' c -cw, H A} t �#--n K t r r Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 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 y r4oncompliance may result in daily fines of twenty-f"16—olldrs o sU pension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. c h ❑ Voluntary Disposal ❑ Other: r 3-501.14(0) .� PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Uaw Cooled to Factors(Items 1.22) (Cont.) 41°F/45°F Within 4 Hours. " PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding - 3-501.16(B) Cold PFIFs Maintained at or below 3-202.12 Additives* 590.004(F) 41V45° F* 3-302.14 Prou ction from Unapproved Addifives* 3-501.1(i(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 1.40"F. * 7-101.11 Identifying lniormation-Original 3-501.t6(A) Roasts Held at or above 130°F. Containers* 7-102.11 Common Name-Working Containers* 2U Time as a Public Health Control 3-501.79 Time as a Public Health Control*7-201.11 Separation-Storae* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Re uirement 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 Cheaucals for Washing Produce,Criteria- 21 3-801.11(A) UnpastemIccYi Pre-packaged Juices and Bevera>es wirl W imine;I nbeis* 7-204.14 Drying Agents,Ceteris" 3-801,11(B) Use of Pasteurized kegs* 7-205.11 .Incidental Food Contact,Lubrictmfs* 7-206.11 Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Partially Cooked Annual Food and Raw Seed S soots Not'Served. 7-206.12 Rodent Bait Stations* 3-801.11(C) Uno.ened Food Packs<=e Not Re-served * 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY_ TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401 1.IA(7)(2) Eggs 155�F 1.5 Sec. Pathogcns necob� oo� E Qs Immediate Service 145'F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.1'1(.A)(2) Comminuted Fish,Meats&Ganie Eggs!' Animals-155'F 15 sec. 3-401.1 I(B)(1)(2) Pork and Beef Roast-130'17]27 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of SecCion 590.009(A)-(D)in sec catering, mobile food, temporary and 3-401.1.1Qv)(3) Poultry,Wild Game, Stuffed PHFs, residentialkitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections poultry or Ratites-165'1715 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- _ Microwave 165`17* Special Requirements. 3-401.11(A)(1)(h) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. °' (Items 23-30) 3-403.11(&) Microwave-165'F 2 Minnie Standing Critical and non-critical violations, n-hich do not relate to the Time* foodborne diness interventions and risk factors listed above, can he 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections o'l the Food Code and 105 CMR 140'F* 590.000. 3-403.1.1(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts*, 23. Management and Personnel- FC FC -2 .003 1£3 Proper Cooling of PHFs 24. Food and Food Protection FC -3 .004 25__E ui ment and Utensils FC 4 .005 3-501.14(A) Cooling Crtuked PHFs from 140'F to 26 Water, Plumbin and W aste FC 5 .006 701-Within 2 flours and From 70-F 27. Ph sical Facility_ _ FC-6 .007 - to 41°17/45OF Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.'14(13) Cooling PHFs Made From Ambient 29. S eaial R uirements _ .009 'Temperature Ingredients to 41°F/45°F _30_____I Other Within 41lour.0 ssvom,-�nAazao, T'DCnixeS cziticnl ileo in 1ho loderil 1999 Food Code or 105 Chili 590.000. r CITY OF SALEM E BOARD OF HEALTH Establishment Name: �Se�e.Q I >litzul�an { - Date: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTIONDate No. Reference -R-.Red Item - - - Verified - PLEASE PRINT CLEARLY G fl 4 :t 4 " s : ...E is t Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P Re-inspection Scheduled O Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that X noncompliance may result in daily fines of twenty ive dollars or uspension/revocation of ❑ Embargo ❑ Emergency Closure Your food permit. � ❑ Voluntary Disposal ❑ Other: 'Y 3-501.,14(C) TPRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I-aw Cooled to Factors(items 1.22) (Cont.) 41".F/45"F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods li)r PHFs Food or Color Additives 19 PHF Hot and Cold Holding 14 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41%45"F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Ifol,140140 PHFs Maintained at or above °F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers* 7-1.0211 Comrnon Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.1.1 Restriction-Presence and User 590.004(H) Variance Re j uirement 7-202.12 Conditions urt Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions°` POPULATIONS(HSP) 7-204.,11 Sanitizers,Criteria-Chemicals" 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-SOLI I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying. ents.Criteria' Beverages with Wnninel-abels* 3-W1_11(B) UscofFasteuneedtit.as` 7-205.11 Incidental Food Contact, Lubricants`" 7-206.11 Restricted Use Pesticides.Criteria* 3-801A 1(D) Raw or Partially Cooked Annual Food and Raw Seed S vronts Not Served. =r 7-206.1213 Rodent Bait Stations* 3-501.11(C) Unopened Fond Packa ge Not Re-served. -206.' Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603A 1 Consumer Advlsoy Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods"That arc Raw.Undercooked or PHFs Not 011rerwise Processed to Eliminate 3-40'1.IIA('U(2) i'1,Es- 155'F 15 Sec. Pathogens., Eggs-Inmediate Service 145°.F15sec, 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game g,Kgw Animals- 155°F 15 sec. 3-401.11(13)(1)(2) Pork and Beef Roast -130'17 121 min* SPECIAL REQUIREMENTS i-401.11(A)(2) Ratites,Injected Meats 155°F 1.5 590.009(A)-(D) Violations of Section',90.009(A)-(D)in sec.* Catering, mobile food, temporary and 3-401.1.1(A)(3) Poultry,Wild Game,Stuffed PRFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 see. * above if related to foodborne illness 3-401A 1(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 1629 -- Microwave 165°F* Special Requirements, 3-401.11(A)(I)(b) All Other PHFs--1.45°F'15sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-40111(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Crilical and non-critical violations, which do not relate to the Time* foodborne illness imerventions and risk factors listed above,, can be 3-403.11(C) Commercially Processed RTE Food- found inthe fallowing sections of the Food Code and 105 CMR 14WF* 590.000. 3-403.HIT) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts` 23. Manaciornent and Personnel FC- 2 .003 ._-....................--------- 18 Proper Cooling of PHFs -24. Food and Fond Protection __- FC-3 .004 25 Equipment and Utensils _ FC-4 3-501.14(A) Cooling Cooked PHFs from 140°F to 26 Water,Plumbin and W ante FG .006 70°F Within 2 hours and From 70°F 27. Physical Facili� FC-6 ', .007 to 41°17145°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29Special Requirements ' .008 Temperature Ingredients to 41°F/45°F 30._ -Other Within 4 Hours* S or .Krk6.2dx "Denotes critical 11011 in the federal 1999 Foal Code or 105 CMR 590.000. i " :,� -n i,.> L"H�`sA'.5,ekY'x°"'�'r�'°"'�wwa..s+mruxA+T*vFCF�aHHrM11-e .'� +,•.'+#nB.rk'?ktR' acXN�tia.»a'CRA ,.:FYI^n."ei}�-kAP}': a+aRM.�v,Fn•:*rnr+rms^.,., Commonwealth of Massachusetts +� City of Salem t t Health Board of H e 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2006 WHO'S PLACE OF BUSINESS IS: Ana Miguel Restaurant File Number:BHF-2004-0107 101 Lafayette Street Salem MA 01970 LOCATED AT: 0101 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0008 Jan 1,2006 Dec 31,2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. page 5 of 18 r CITY OF SALEM, MASSACHUSETTS a. BOARD OF HEALTH ; g(C [gj\V 120 WASHINGTON STREET, 4TH FLOOR o SALEM, MA 01970 TEL. 978-741-1800 DEC 0 8 2005 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR WWW.SALEM.COM CITY OF SALEM JOANNE SCOTT, MPH, Rs, cHo BOARD OF HEALTH HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABL SHMENT NAME OF ESTABLISHMENT V N/l ( TEL# S " ADDRESS OF ESTABLISHMENT /©J '/L Fi�y � � MAILING ADDRESS (if ddiffferent),, y y OWNER'S NAME_- - 1y 1 �✓�A> L`79 TEL ADDRESS _ CITY STA- E ZIP CERTIFIED FOOD 9ANAGEIn NA (S) D CERTIFICATE#(s)_2v ) DD 3 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON A '�w_AKLVASOME TEL# HOURS OF OPERATION: Mon. Tue. Wed. Thu. FrLSat. Sun. TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 . ........... .............. . . . ........... .. . .. ........... ---------------------- RESTAURANT /YE NO � zq _ / less than 25 seat =$100 ((„V�5(�/, 25-99 seats =$150 more than 99 seats =$200 ------------------------------------------------------------..--------------------- 10---....---------- BED/BREAKFAST YES NO $ 0 ADDITIONAL PERMITS ---------------------------------------------------------------------------------------------------------------------------- MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I Certify under the pains and penalties of perjury that I, to my best /kno ledge and belief, have file all state tax returns and paid all state taxes required under the law. Signature Date Social Security r Federal Identification Number -----------------------------------------------------------------------�----N-----�---�-©--------/a g d�------------ Revised 11/03/05 FOODAP2.adm Check#&Date& '39 ,6713 S ��PO 0101 Lafayette Street Ana Miguel Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 741-2446 Non-compliance with: Not Done Owner:- Anti-Choking PASS ❑ Rosa Hernandez Tobacco PASS ❑ PIC: Adrian Arias FOOD PROTECTION MANAGEMENT Not Done Inspector: PIC Assigned/Knowledgeable/Duties PASS ❑J RED David Greenbaum EMPLOYEE HEALTH Not Done Date IDSpected: Correct By. Reporting of Diseases by Food Employee and PIC PASS RED 7/28/2005 Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: FOOD FROM APPROVED SOURCE Not Done Permit Number:4 Food and Water from Approved Source PASS ❑Q RED BHP-2005-0348 Receiving/Condition PASS ❑Q RED `Status Ia ..` Tags/Records/Accuracy of Ingredient Statements PASS ❑Q RED VIOLATION Conformance with Approved Procedures/HACCP PASS ❑d RED #of Critical Violations: _ Plans 2 - PROTECTION FROM CONTAMINATION Not Done !Time IN: Time OUT: - Separation/Segregation/Protection PASS RED Notes: , = - v Food Contact Surfaces Cleaning and Sanitizing PASS RED 236: Proper Adequate Handwashing PASSd❑ RED Urgency Description(s): Good Hygienic Practices PASS Q RED BLUE V Prevention of Contamination from Hands PASS d❑ RED Violations Related to Good Retail Practices (Critical ,.,-. Handwash Facilities FAIL Criticald❑ RED Kitchen handwash sink missing soap. violations must be corrected Provide soap at the handwash sink at all immediately or within 10 " times. days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 01,2005 ) Page I o{3 t` 0101 Lafayette Street Ana Miguel Restaurant must be Corrected Immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) " Approved Food or Color Additives PASS ❑J RED Viol tiO s Related to Toxic Chemicals PASS ❑Q RED Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require - Cooking Temperatures PASS ❑Q RED immediate corrective action) Reheating PASS ❑d RED Cooling PASS RED Hot and Cold Holding FAIL Critical 0 RED The tall white freezer in the kitchen has a temperature of 15oF. Repair unit to maintain a temperature of 0"or below. The right side Frigideaire freezer has a temperature of 30°F. Repair unit to maintain a temperature of OoF or below. The Frigidaire cooling unit in back has a temperature of 50oF. Repair unit to maintain a temperature of 41°F or below. Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS 0 RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS RED GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 01,2005 ) Pate 2 of s ' 0101 Lafayette Street Ana Miguel Restaurant Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE The large silver cooling unit in back has some uncovered food. All food in storage must be covered. Equipment and Utensils FAIL Non-Critical ❑ BLUE Victory cooling unit at top of stairs needs avisible accurate thermometer. Left hand Frigidaire freezer in back needs a visible, accurate thermometer. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non-Critical ❑ BLUE Remove all items not pertinent items from back room The back screen door needs a sweep a the bottom. The backroom Floor and stairs need to be repainted. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE GeoTMS®.2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 01,2005 ) Page 3 of CITY OF SALEM BOARD OF HEALTH Name of Establishment: Ana Miguel Restaurant Address: 101 Lafayette Street Owner(s): Rosa Hernandez Phone: 978-741-2446 Date: June 30, 2005 The owner of this establishment presented a Floor Plan showing additional seating for review in accordance with the State Food Code. FLOOR PLAN There will be six additional tables in a newly acquired space next door at 103 Lafayette Street. Therefore, there will be an increase in the amount of food prepared, the number of dishes and utensils to be washed, rinsed and sanitized, and the amount of food and other related items to be stored. This increase may not increase the chance of cross-contamination, or other causes of food related illnesses. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. The Plan is approved. However, if the operation is not able to sustain the increase number of seats without increasing the risk of foodborne illness, as observed during inspections, the Health Agent may suspend the use of the increased seating. o _ t C 3o - ate J nne Scott Date Health Agent � 1�7 - � Owner Date l � E-Yr71a {c � -(sr �ki.+aFr*r z�.�...r.+•LLw,._.. .._...:..._....�.._�,... ?..s!.... .sa+., _ � .R��' �.. ,. .- a .:a,..ar,.+.., ;t,Yz.:i. 4 y CITY OF SALEMI, MASSACHUSETTS y ' ' BOARD OF HEALTH _ s 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 III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Ana Miguel Restaurant Address of Establishment: 101 Lafayette Street Owner's Name: Rosa Hernandez Restrictions: Application Date: 12/13/2004 Permit for Food Establishment 236-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 51-04 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 L • CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 4 120 WASHINGTON STREET, 4TH FLOOR A (4 E,'{(/] zziI r SALEM, MA 01970 ry � TEL. 978-741-1800 I'tbi' VVV""" FAx 978-745-0343 IV7 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO DEC ' 7 Z�� MAYOR HEALTH AGENT ' 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLIS OF SALEM D OF HEALTH NAME OF ESTABLISHMENT -�7? 4,bA L/�Qr�'✓/ /, TEL# ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME �j�/ y/� � tQ TEL# ADDRESS Ar 12 A,) Y CITY STATE ZIP CERTIFIED FO MANAGER'S NAME(S) TIFICATE#(s) Z�1j3 14 PA (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON14n�� t/J �iI 0 M E TEL# ' 3 HOURS OF OPERATION: MonTueWed.F Thu. Fri. Sat Sun. 11A_ __:! � TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 / more than 10,000sq.ft. =$250 RESTAURANT YES NO 1 3a�65 ess than 25 seat =$100 p 25-99 sea s =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SE`'RVE YES NO $5 TOBACCO VENDOR 51-d l YES NO <- 5o ALL NON-PROFIT(such as church kitchens) YES NO $7_5 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. Purs ant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my hignatuorei k wledge andbelef, have fall state tax returns andpaid all statte (�xessrequired under the law. ate S ci Security r Federal Idc en T�fication Number --------------------------------------------------I ___- V----- ` Revised 11/03/03 FOODAP2.adm Check#&Date /,;2 CTTJ CITY OF SALEM9 MASSACHUSETTS u 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 III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Ana Miguel Restaurant Address of Establishment: 101 Lafayette Street Owner's Name: Rosa Hernandez Restrictions: Application Date: 12/11/2003 Permit for Food Establishment 152-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 38-04 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 Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT ~ CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3 • 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 HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT ,� NAME OF ESTABLISHMENT/a, )/a,)& AC,C, /K(�', TEL X( �`,x// ADDRESS OF ESTABLISHMENT�� ✓�X G� 4 7 MAILING ADDRESS (if different) OWNER'S NAME ADDRESS I�Jjj➢Z / CITY STATE�� ZIP CERTIFIED FOOD N NAME(S) �� /J Q/ TIFICAT #( m e2.Cl� (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON0dD:KL,) y HOME TEL# HOURS OF OPERATION: Mon uel gm-,Wed/,( huh �ri��Lgat l Adir1 > TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES' NO �t ss than 25 seat =$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 SERE YES NO $5 FI TOBACCO VENDOR U ES 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 e now dg d belief, hav ed all state tax returns and paid all state t xes r qui ed and r the law. Signature Date Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Dates/-• Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T e Operation(s) T e of inspection L- /2� dV Ny ood Service outine Address/re1 Risk LJRetail E] Re-inspection( f 1 Level ❑ Residential Kitchen Previous Inspection Telephone „? yi ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation /4 3& e Nd)t.A1AKfjC Z ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Q A Time El Bed&Breakfast ❑General Complaint Inspector��f ,i AT D/s.-,14f Out: Permit No. ❑ Other Each violation checked requi es 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) [__1 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT,' , El12.,-revention of Contamination from Hands E] 1. PIC Assigned/Knowledgeable/Duties �1! EMPLOYEE HEALTH -. © 3. Handwash Facilities :PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC El j4. Approved Food or Color Additives El 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE El 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 ❑ 18. Cooling PROTECTION FROM CONTAMINATION _ 0,T9. Hot and Cold Holding 9-8TE. Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) E] 10. Proper Adequate Handwashing El21. 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): 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 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 cited in this report may result in suspension or revocation of ". 25r Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 216. 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 5Mo IWFbm -ia dac n I P r' r t 1' Print: l 11 PIC's Signature: ' �' V Print: /L Page of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 Grass-contamination 1 59l).003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Fcxxls Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foals* 2 103.!1 Perscm in charge-duties Contamination from Raw Ingredients 3-302.TI(A)(2) Raw Anirnal Foods Separated from Each EMPLOYEE HEALTH Other- 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by fii A employees and 3-30211(A) Food Protection* a plicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Fund Employee Or An 3-304.11 Food Contact with Equipment and Applicara To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reportiritky Person in Charge* 3-306.14(A)('B) Returned Food and Reservice of Food- --3, 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(17) Removal of Exclusions and Restric:onsFood 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Iaw* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food inn Hermeticall•Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashm.-Hot"Water 3-202.13 Shell Eras* Sanitization Tem eratures* 3-202.14F gs and Milk Pmdnet>.Pasteurized* 4-501114 Chemical Sanitization-temp.,pH; 3-202.16 Ice Made From Potable Drinking Water* concentration and but dross. 'k 5-101.11 Drinking Water from an Approved System* 4-6011'I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater' Utensils Clean* r 4-602.1 1 Cleaning Frequency of Equipment Food- S10.006(B) Water Meets Standards in 3 CMR 22.04' Contact Surfaces and Utensils"' Food- Shellfish and Fish From an Approved oved Source 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Foal Contact Surfaces of E ii merit* Shelltish* 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 Regulatory Authord 2.301.11 Clean Condition-Hands and Arms* 3-20118 Shellstock Identification Present' 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals" 1.1 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinkin�obaccos' 3-202.11. PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.1.5 Package Integrity- Mouth* 3-101.11 Food Safe and Unadulterated* 12 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records: Shellstock Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(R) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" En� Tags/Records:Fish Products I3 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca acities* 590.004(.1) Labeling of Ingredients' 5-204.11 1 Ax;ation and Placement* 7 Conformance with Approved Procedures 5-205.11 Aacessibilit Oreration and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced oxygen packaging.criteria* 6-301.11 Handwashin Cleanser, Avtitabllit 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in the federal 1999 food Cale or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH ) / Establishment Name: Date: /0-) `off -D `J Page: of / Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red ItemVerified _.. PLEA/SE PRINT CLEARLY n "' C/ Yd d ° a✓z a A /!TG / e / c n IJ,",49 ° . I_,&2127Zil- a IT sera 42 ° s a s � , - - d1,Y e 69J. _l Qd - neo l - e �cJ Ck4 SS' - SrJv Oky k Ai/ n - ] l ) e Sa IV' © ahuz iY91r<> rfAj Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes e I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion 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 t/wen y-five dollars:or suspension/revocation of c3 Embargo ❑ Emergency Closure I` your food permit. ` -'G 0 Voluntary Disposal ❑ Other: 3-50 L 14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk .According to Law Cooled to Factors(Items 1-22) (Cont.) 4I'F/45'F Within 4 How-s. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives l9 PHF Hot and Cold Holding 3-501.168) Cold PEIFs Maintained at or below 3-2D2-12 Addttrses" 590.004(F) 41V45°F* 3-302.14 Protection from Una) roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances t40°F. 7-101.11 Idenlitying taformarion-Original containers'" 3-501.1.6(A) Roasts Held at or above 130°F. Co 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.I I Se oration-Stora e" 3-501.19 Time as a Public Health Control* 7202.11 Restriction-Presenc;o and Use's 590.004(H) Variance Requirement uirenent 7-202.12 Conditions of Lase* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Swtitizers,Criteria-Chemicals POPULATIONS HSP) 7-204.12 Chemicals for Washing Produce,Criteria" 21 3-801.1](A) Unpasteurized Pre-packaged Juices and 7-204.14 Dr'in*. ants,Criteria"` Beverages with Warning,Libels* 7-205.11 htoidentat Food Contact.CaMicants* 3-801.11(,$) Use of Pasteurized'Ev�rs* 7-206.11 Restricted lise Pesticides.Criteria* 3-801.1 l(D) Raw or Partially Cuoked Anima]Food and Raw Seed S aronts Not Served. 'x 7-206.12 RodenTrack ing Bait Stations* P" 1401.11(C) Unopened Food Package Not Re-served. 7-206.13 Trae.king Powders,Pest Control and Modrtoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603-11 Consumer Advisory Posted for Consumption of Animal Foods'lliat are Raw.Undercooked of 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs 3-401.1 1x(1)(2) Eggs- 1.55-F 1.5 Sec. Puthrme.ns * """01 uroxooi L Yes-Ltmledrate Service 145°P15sec* 3-302.19 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game E s"` Animals- 155'F 15 sec. 3-401.11(13)(1)(2) Pork.and Beef Roast- 20 F 121 corn* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec, * catering, mobile food,temporary.cod 3-401 11(x)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Contaiiung Fish, Meat, debited wider the appropriate sections Poultry or Ratites-165°F 15 see. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle„Intact Beef Steaks interventions and risk factors. Other 1=45°F+ 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under 1129- Microwave 1650F* Special Requirements. 3401.11(A)(1)(1)) All Wier PHFs- 145'F'15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-40111(A)r&(D) PHFs 165`F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165° U2 Minute Standing_ Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above. can be 3-403.11(C) Commercially Processed IYPE Food- ,found in the following sections of the Food Code and 105 CMR 140"F* 590.000. _ 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000_ Roasts* 23. Manaciernent and Personnel FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection __ FC_3 .004 25. Equipment and Utensils FC-4 .005 3-50L1.4(rA) Cooling Cooked PHFs from 140'F to 26. Water, Plumbing __ and Waste FC-5 .006___ 70°F Within 2 Ftoars and From 70'F 27. Physical Facility-_ FC-6 .007 to 41°1/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC- 7 .008 3-501.14(73) Cooling PIIFs Made Front.Ambient 29. Special Requirements .009 Temperature'Ingredients to 41'F/45'F 30:_ _ Other Within 4 Hours's , ori„r Denote,,mucal iim,in the federal 1999 Prod Code or 105 CMR 590 000. CITY OF SALEM BOARD OF HEALTH Establishment Name 0 / L ljop 4 Date: I —0 Page: of Item Code C-critical Hem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified - PLEASE PRINT CLEARLY. . ' bfJ X �i I R226 �a f. /.l } Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal/Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars cr suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. -j-L "7 (Z r L 0 Voluntary Disposal 0 Other: 3-501.14(C) PHFS Received at'Temperatures Violations Related to Foodborne fitness Interventions and Risk According to taw Cooled to Factors(Items 1-22) (Cont.) 41°F/45'F Within 4 Howl. PROTECTION FROM CHEMICALS 3-501.'15 Coolin«Methods for PHFS 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHBs Maintainer)at or below 540.004(F) 41%45°F* 3-302.14 Protection from Unapproved Additives" 4-501.4(F) Hot PHFS Maintained at orabove 15 Poisonous or Toxic Substances 140°F. 7-101.17 t(leConti tainers,tnfonnation-Original 3-501.16(A) Roasts Held at or above 130'F. * Containers* 7-102.11 Common Naire-Working Containers* 20 Time as a Public Health Control 7-201.17 Se aratioo-Storage"` 3-501.19 Time as a Public Health Control* 7-202-11 Restriction-Presence and Use 590,004(H) Variance Requirement 7-202.12 Conditions of Use, 7-20311 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Swnidzets,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 Beverages with Warning Labels* Dr in Agents,Criteria* 3-801.11(B) Use of Pasteurized Ti !,s* 7-205.11 Incidental Food Contact_ Lubricants* 7-206.11. Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or,Partially CookedAnimal Food and Raw Seed S xronts Not Served.s 7-206.7'3 'Tracking Powders. e 7-206.12 Rodent Bait Sers.Pest Control and 3-801.11(C) Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMETTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or PHFS 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate 3-401.IlA(1)(2) Eggs- t55°F IS Sec. Pathogens.* "'"2`01 S=�s-hmm�ediate Service 145°F15sec= 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11.(A)(2) Comminuted Fish, Meats&Game Eggs* Animals- 155'F 15 sec. 's 3-401.1l(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats-155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. . catering. mobile food,temporary and 3-401.11(A)(3) Poultry, Wild Game, SniffedPFfFs, residential kitchen operations should be Scoffing Containing Fish,Meat, debited under the appropriate sections Poultry of Ratites-165".17 15 sec. 4. 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. 3-401.11(A)(1)(b) All Other PHFS-- 145'F'15 sec 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFS 165'F 15 sec. * (Items 23-30) 3-403.11.(B) Microwave- 165°P 2,Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140"F* 590.000. 3-403.1.1(E) Remaining Unsliced Flortions of,Beef Item Good Retail Practices FC 590.0o0 Roasts* 23. Manu ement and Personnel ____ FC-2 .003 1g Proper Cooling of PHFS 24. Food and Food Protection FC-3 .004 25. Equipment and Utensils FO-4 .005 3-501..14(A) Cooling Cooked PRFs from 140`F to 26. Water,Plumbin and Waste FC-5 .006__ 70'F Within 2)-lours and From 70'F 27. Ph sical Facies FC-6 .007 to 417/45"F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PRFs Made From Ambient 29. Special Requirements __ .009 Temperature Ingredients to 41'Fl45'F _30_ Other ----- Within -Within 4 Hours* nsaro..... 0c2A,� *Denotes radical item in the federal 1999 Fbod Code or 105 CMR 590.000- w i Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Divisio�,of Food and'Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Datei T e of 0 eration s Type of Inspection / Food Se vice ❑ Routine Address Risk ❑ Retail C2_15ie-inspection Telephone / LevelEl Residential Kitchen Previous Inspection r _ /i�l ElMobile Date: Owner HACCP Y/N [__1 Temporary El Pre-operation ❑ Caterer ❑ Suspect Illness Person !if Charge(PIC) / Time ❑ Bed& Breakfast ❑ General Complaint In: El Inspector e.1 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) ❑ i action as determined by the Board of Health. .FOOD PROTECTION MANAGEMENT •, E] 12. Prevention of Contamination from Hands El1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH a : • ' _- ` ' ' t aPROTECTION FROM CHEMICALS = ` ❑ 2. Reporting of Diseases by Food Employee and PIC • . - El3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives ❑ FOOD FROM APPROVED SOURCE` � ;,i ' � � ' -": 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURECONTROLS(Potentially Haiardous Foods) ` I ❑ 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 _' ' ` ;;. � :i ❑ 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)' ❑ F-1 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP i ❑ 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 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 cited in this report may result in suspension or revocation of, (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)(510.00a) 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: S5901nsWfFcrm 14 dC I Inspector's Signature: Print: // --77 PIC's Signature: Print: Pagel of -Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) g r PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(3) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.1 1(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003(0) {, Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11.(A) Food Protection' applicants* 3302.1.5 Washinv Fruits and Vegetables 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* Charge* Contamination from the Consumer 590.003((3) Reporting by Person in Charge* 3-306.14(A)(B) Retained Food and Reservice of Food 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditionine Unsafe FOOD FROM APPROVED SOURCE Foods' 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Seated Container* Sanitization Teiu eratares* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Erns* Sanitization Tem cratures* 3-202.1.4 Eg gs and Milk ProdnctS.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.,r 5-101.11 Drinking Water from an Approved System* 4-601,11(A) F,uluipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22944-602'11 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils' ShetHish and Fish Froman Approved Source 4-702.11 Frequency of Sanitizeuion of Utensils and 3-201.14. Fish and Recreationally Caught Molluscan. Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Mot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical" Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands end Arms* 3-202.18 Shetlstock Identification Present* 2-301..1.2 Cleaning Procedure" 590.004(C) Wild Mushrooms* r 2-301.14 When to Wash* 3-201.17 Game Animals" ll Good Hygienic Practices S Receiving/Condition 2-401.11 Eating,Drinking or Using Tobaccos` 3-202.11 PI3Fs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained'* Em loyees* Tags/Records:Fish Products 13 Handwash Facilities 7402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retentions' S-203.11 Numbers and C',a aeities* 590.00461) Labeling of Ingredients' 5-204.11 I-sxation and Placement* q Conformance with Approved Procedures 5-205.11 Accessibilh Operation and Maintenance /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 Handwashin Cleanser,Avuilabilit 8-103.1.2 Crntftmnance with A roved Procedures'" 6-301.12 Hand Drying Provision ."Denotes critical item in the federal 1999 Foal Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: l' Date: l -Ile y Page: Z of Z Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified ' - PLEASE PRINT CLEARLY yl e S u� Al Q� T Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes w 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 L) Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that nonG6mpliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal 0 Other: 3-501.11(2) PRFs Receive(1 at T'emperaturl. Violations Related to Foodborne Illness Interventions and Risk A"ording to Law Cooled to Factors(items 1.22) (Cont:) 41'.P/45°F Within 4 How s. PROTECTION FRO_M CHEMICALS 3-501.15 Coahu°Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(11) Cold Plif's Maintained at or below 3-292.12 Additives" 590.004(F) 41°/45°F* 3-302.14 Protection front Unapproved Additives* 3-507.16(A) Hix PHFs Maintained at or above 15 Poisonous or Toxic Substances - 7-101..1,1 Identifying Information-Original 14WE Containers" 3-501.16(A) Roasts Held at or above 130°F.7- 20 Time as a Public Health Control 1.02.1'1 Common Name-Working Containers* - 3-501.19 Time as a Public Health Control* 7-201.11 Separation-Storage„ 7-202.1.1 Restriction-Presence and Use* 590.004(H) Variance Re uirement 7-292.12 Conditions of Use* 7-203.1.1 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. ends,Criteria* Beverages wiljiT,uaine,labels` -1-801,11(B) Usc of Pasteuttzed Eggs* s* 7-205.11 Incidental Food Contact,Lubricants* 3.801 11(D) Raw or Partially Conked Annual Food and 7-206.11. Restricted Use Pesticides,Criteria* Raw Seed S gouts Not Served. 7-206.12 Rodent Bait Stations* 3.$01,11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitorin-* CONSUMER ADVISORY TIME)TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods'Phat are Raw. Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs Pathogens.'*e'rncnve vvzooi 3-401.1.111(1)(2) Eggs- m15 Sec. 3_302.13 Pasteurized Eggs Substitute for Raw Shell Eggs-Immediate Service 145°FI Ssec* 3-401.11(A)(2) Comminuted Fish,Meats&Game E sr Animals- 155'F 15 sec. 3-401.1 l(B)(1)(2) Pork.and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS _ 3-401.11(11)(2) Ratites, Injected Meats-155°F 1.5 590,009(A)-(D) Violations of Section 590.009(A)-(D) in sec. * catering, mobile food,temporary and 3-401.)1(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 raid risk factors. tither 1450F* 590.009 violations relating to good retail. 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165"F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F '15see. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. * (items 23-30) 3-403.11(6) Microwave- 165'F2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above can be 3-403.11(C) Commercially Processed RTE FmI- found in the following sections of the Food Cade and 10.5 CMR 140°F* 590.000. _ 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 580.000 Roasts* 23. Mama ament and Personnel_ FC-P .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25 _Equipment attd Utensils FC 4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to26 _ _Water, Plumbin and Waste FC 5 .00_6 _ 70'F Within 2 Flours and From 70'F 27. Ph sical Facility _ FG-6 .007 to 41.`F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC -7 .008 3-50'1.'14(Bj Cooling PHFs Matle From Ambient 29. Sp ecial R quirements Temperature hugredients to 41'F/45'F 30. _ _Other Within 4 Hours* 5")F" ar 6-2 a"' '*Denotes critical item in tort federal 1999 Food Code or 105 CMR 590.000. Massachusetts Department of Public Health Salem Board S Health M 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 NameDate Type of operations) T a of Inspection ItAZ� Q . ,(', S e R-Food Service Routine tAddre's`s f' Risk Li ❑ Re-inspection � ` Jk e-I- Leve ❑ Residential Kitchen Previous Inspection Telephone r ❑ Mobile Date: ? HACCP Y/N El Temporary ElPre-operation Owner warls 1 e� Ti ❑ Caterer El Suspect Illness Person in'Chaige(PIC) me L] Bed& Breakfast El General Complaint lr N /a/c AIn: ❑HACCP Inspector exOut: Permit No. C3Other ._ Each violation c ecked requires an planation on the narrative page(s) and a citation of specific provision(s) violated. Mon-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) ❑ 590.0119(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 0 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE . . --- TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ ❑ 16.Cooking Temperatures 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 1/8.Cooling PROTECTION FROM CONTAMINATION Ekil 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 CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑22. Pasting 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 123. by a Board of Health member or its agent constitutes an Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 4. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 5. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 6. 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 8. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 9. Special Requirements (590.009) within 10 days of receipt of this order.0. Other DATE OF RE-INSPECTION: 5:59GInsp¢clFp,m6-I<.tlee I p tor' ig lure / Print: 2 PIC's Sign Print:Print: _ n�( /� Page of ✓ Pages L 1 ! Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Res ronsibilit * 3-302.11(A)(1) Raw Animal Footle Separated from 590.003(B) Demonstration of Knowled e* Cooked and RTE Fo(vls* 2-103]1 Person in charge--duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1 l(A) Food Protection* a r ]ieams* 3-302.15 Washine Fruits and Vegetables 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* Chm-ge* Contamination from the Consumer 590.003(G) Re ortin,,b Person in Char e 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.0030) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(1'7) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Foocl* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111. 'Manual W:n'ewashing-Fdor Water 3-201.12 Food in u Henneticall Sealed Container* Sanitization lain erannes* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewas3ning-Itot tauter 3-202.13 Shell Eggs* Sanitization Tem eramces* 3-202.14 E sand Milk.Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. 3-202.16 Ice Made From Potable,Drinking Water" 4.601.11(A) Equipment Faxi Contact Surfaces and 5-1.01.11 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 220* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Fmquency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui mem* Shellfish* 4-703.11 Methods of Sanirirnion-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chernical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by -301.1Hands and Arms* Regulatory Authorityz Clean CondiLion 3-202.18 Shellstock Identification Present*` 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 _. Latin Drinkin or Using Tobacco* ...�,� 3-202.11 PFIFs Received at Proper Tem erztmes* 2-401.12 Discharges From the Eyes,Noseand 3-202.15 Package Inte it * Month* _ 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastia g* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.,18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em lovees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11. Parasite Destruction* Conveniently Located and Accessible ' 3-402.12 Records.Creation and Retention* 5=203.11 Numbers and Ca asitias* Labelle of Ingredients5-204.11. Location and Placement* 590.004(.1) 9 9 Conformance with Approved Procedures 5-205.11 Accessibility, (} eration and Maintcnauce 7 fHACCP 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.Avuilabilit 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provision Denote,critical item in the federal 1999 Food Code or 105 Chill 590,000. CITY OF SALEM BOARD OF HEALTH / Establishment Name: /,l-M t91/9;4/XZ- ie.1 7; Date: 5 1��r Page: of Item Code C—Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference - -R—Red Item Verified -PLEASE PRINT CLEARLY ars J 2 � Z7 J G 27 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that - noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: M 3-501.t4((',) PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 4I'F/45'F Within 4 Hours. PROTECTION FROM M CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives iy PHF Hot and Cold Holding 3-50'1 16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 411/45'F* 3-302.14 Protection from Unapproved Additives* 7-501.L6(.4) 7{ot PfIFs Maintained at or above 15 Poisonous or Toxic Substances 7-10t.1 l Identifying Information-Original 3-501.16(A) Roasts Roasts Held Public above 130'6. Containers* 7-102.11 Common Name-Working Containers` 20 Time as a Public Health Control 3-501.19 Time as a Public Health Contro'.* 7-201.11 Separation-Stora e0` 7-202.11 Restriction-Presence and Use* 590.004(H) Vtuiance Re uirement 7-2012 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.111 Toxic Conmriter-Prohibitions" POPULATIONS(HSP) 7-204.71. Sanitizers,Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria"' 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 7-204.14 Dr in ants,Criteria* 3-901.11(B) Use of Pasteuttzed-E.n�s* 7-205.11 Incidental Food Contact.Lnbrica ts* 3-801.11(D) Raw or Partially Calked Animal Fail and 7-206.1 I Resl'ricted Use Pesticides.Criteria* Raw Seed Sprouts Not Setved. 7-206.12 Rcxient Bait Stations"` 3-801.1 l(C) Unopened Fwd Packa e Not Re-served. 41 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Anhnal Foods,chat are Raw. Undercooked(ir 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs 7 e1ia�,;,d 1/112001 3-401.11A(1)(2) Eggs- 1.55`F 1.5 Sec. i'sthoge-ns ," Eggs-lnunediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game E, s* Animals- 155°F 15 sec. * 3-401.11(6)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F15 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 1450F* 590.009 violations relating to good retail. 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Mierowave 165'F* Special Requirements. 3-401.11(A)(1(b) All Other PHFs-- 145'F '15 see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-40111(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute SGmdimt Critical and non-critical violations, which do nor relate to the Time* foodborne illness interventions and risk}irctors listed above, can he 3-403.1 1(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140"F* 590.000. 3-403.11(P) Remaining Unsliced Portions of Beef Item Good RetaPr Practices FC 590.000 Roasts* 23. Management and Personnel FC-2 .003 iS Proper Cooling of PHFs 24 Food and Food Protection FC-3 004-- -FC-425 _Equipment and Utensils __.005 3-501.14(A) Cooling Cooked PHFs from 140'F to 26 Water, Plumbing and Waste FC 5 .006 --Water- --- ----- 70'F Within 21tours and From 70'F 27. Ph sisal-Facili FC-9 .007_ to 41'F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(13) Cooling Pi{Fs Made From Ambient _29. S ogled R uiremenis _ .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4Idours* ssu0lo` ,,662d- -- *Denotes critical ileo in rhe bead 1999 Food CeAle or 105 C kilt 590,000. fs CITY OF SALEM BOARD OF HEALTH Establishment Name:ANAr� 1r,_rte[. 2l:Sf Date: Page: 3 of Item Code C Critical ItemDESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - - Verified t _... - ....__ _..PLEASE PRINT CLEARLY 7-77 f 27 i ,-c rr it i, ✓ r r�cl ✓ '-Ie o ✓ ' e, f' Discussion With Person in Charge: Corrective Action Required: '❑` No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ' p ,� Ll 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 oorrssa pension/revocation of ❑ Embargo ❑ Emergency Closure II Iyour food permit. 11 Voluntary Disposal El Other: 3-501.14(C) PHFs ReceivA at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1.22) (Cont.) 41'F/457 Within 4 Hours, PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PI-If s Maintained at or below 3-302.14 Protection from » Una caved Additives'' 590.004(F) 41'/45`6'* J5 Poisonous or Toxic Substances 3-501.16(A) Hot PHF&Maintained at or above 140`'F ` 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130"F. Containers* 7-102.11 Common Name-Working Containers` 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.14 Time as a Public Health Contral�" 7-202.11 Restriction-Presence and Use* 590r004(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) 7-204.1.2 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Diving Agents.Criteria* Beverages with Wannnl Labels* 3-801.1'1(B) Use of Pastecntzed h ,s* 7-205.11 Incidental Food Contact, ,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.1 I Rodent B Use Pesticides,Criteria" Raw Seed Sprouts Not Served.* 7.206.12 Rodent g Po Stations* 3-801.11(C) Unopened Food Package Not Re-served" 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisoly Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw. Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.* riaom Ls*s-Immeded iate Service 145`P t Ssec* 3-401.11 A(1)(2) Eggs- 155IS Sec. 3-302.13 1 Pasteurized Eggs Subsutate for Raw Shelf 3-401.1 I(A)(2) Comminuted Fish.Meats&(lame F""s* Animals- 155'F 15 sec. " SPECIAL REQUIREMENTS 3-401.11(13)(1)(2) Poll.and Beet Roast '130'F 121 min* 3-401.11(A)(2) Raines,Injected Meats- t55°F 15 590.009(A)-(I)7 Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Came.Staffied PHFa, residential kitchen operations should be Stuffim,Containing Fish,Meat, debited under the appropriate sections Poultryyor 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 ft29- Microwave 165'F* Special Requirements. 3-401.1](A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403.1 I(B) Microwave- 165'F 2 Minute Stuuding Critical and non-critical violations, which do not relate to the Time* foodborne illness.inten,enrions and risk factors listed above, can be 3-403.11(0) Commercially Processed RTE Fond- found in the fo(lorving sections of the Food Code and 105 CMR 14WF* 590.000. 3-403.11(E) Remaining UnslicedPortions of,Beef Item I Good Retail Practices FC 590.000 Roasts* 23._ Management and Personnel FC-2 7 003 18 Proper Cooling of PHFs 24. Food and Food Protection TFC--3 .004 25. Equipment and Utensils FG 4 .00b 3-501.14(A) Cooling Cooked PHFs from 140'F to _ - "" -- 26. Water,Plumbing and Waste IFC 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 29 t S ectal R uiremenM _ 3-501.14(B) Cooling PHFs Made From Ambient ,009� _� � Temperature Ingredients to 41'F/45'F 30 Othar Within 4 Hours* *Denotes critical item in the Yederal 1999 F(x)d Code or IW CMR 190.060. IMPOVRT7AMT MESSAGE FOR. DAT TIME P. r p M a OF AQ n PHONE AREA CODE NUMBER EXTENSION ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU 'r RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE U �U. aap plil SIGNED FORa MADE IN U0O9 ..,�.-..r.....,..-..-. .—... a J. ji.z� U a •f s a. 3 't £x` .n.,y y. Y ; Y' l" * r 1 KTt�o MSgP`¢�N{F•�+�� Cafe y tostada..............::................... 2.00 .............................Coffee & Toast Huevo, Jamon; Queso y Salami.......... 5.00 ..........Eggs, Ham, Cheese & Salami Mangu o Yuca Mashed Plantain or Cassava con Longaniza.................................. 7,VV with Sausage Mangu con Queso, Mashed Plantain Salami y Huevo..............................1. 6,00 ................w/Cheese, Salami & Egg Mangu o Yuca Mashed Plantain or con Salami...................................... .x..40 .........................Cassava w/Salami Mangu o Yuca con Huevo.................. 5,04 ...,..........Plantain or Cassava w/Egg Mangu o Yuca Mashed Plantain or con Bacalao..................................... 'j;,00 ........................Cassava w/Codfish RedRock......................................... 150 .....................................Red Rock . Jugo Goya....................................... f�tJfl .............................Goya Juice � - �.�C(/LIlG�S VC-?t�?E'l.IIIIlQ,A�fLJ� � �:'l"LL-?CC,�C_')�tJL-'�l'' ' .• � Bistec Encebollado............................ 9.00 -' .....................Beef Steak w/Onions Bistec Empanado.............................. /004 .........Breaded Beef Steak Bistec en Salsa................................. /0.00 .......................Beef Steak in Sauce Bistec Salteado.......... ............... l©; .....,....Pepper Steak .... ... 00 ..........,........., Bistec a Is Plancha............................ 9.00 .................................Grilled Steak Chuleta de Cordo Frita....................... 8.00 Fried Pork Chop ' Polio al Horno.................................. 8.00 ..............................Baked Chicken Chicharron de Polio o Cerdo............... 8.00 ....................Chicken or Pork Rings Longaniza Frita.............................:... 8.00 ......,.................Fried Pork Sausage Carne de Res Frita............................ 8.00 .......,....,.................,.....Fried Beef Carne de Cerdo Frita......................... 8.00 .............................Fried Pork Meat Polio Frito........................................ 8.00 ................................Fried Chicken ` Costillas de Cerdo............................. 8.00 .........................Pork Ribs Estos Servieios Vienen con Mora de Gandules a Tostones These Orders Are Served with Rice, Beans or Fried Plantains Carne de Res o Cerdo Guisada........... 8.00 ......................Stewed Beef or Pork Carne de Polio Guisada...................... 8.00 ...............................Chicken Stew Chuleta Guisada............................... q.00 .,,.........Pork Chop in Tomato Sauce Gallina Guisada................................ 8.00 ......... ..........................Fowl Stew �c Chivo, Higado o Rabo Guisado........... 8,00 ......" ......Goat, Liver or Oxtail Stew ttikttlkttt11'riltil :i �&9!+�+a-aiq � .�.., «� •+--� '� ... ��rj - ��.m�+.+_n-e ..� { .,.vim Camarones...................................... /2.00 .................Shrimp in Tomato Sauce t Camarones Enchilados...................... 12.00 .,.....................Shrimp in Chili Sauce Camarones al Ajillo........................... 1R.00 ................ ....Shrimp Garlic Sauce Camarones Empanizados....................1,2-00 .............................Breaded Shrimps Pescado Frito....................... 12'� `�D .00 .......................................Fried Fish Pescado en Salsa.................. ;4:La® 00 ..................................Fish h Sauce Filete de Pescado............................. 12.00 .......................................Fish Fillet Asopao de Langosta......................... 20.00 ........................Rice & Lobster Soup �t Asopao de Camarones....................... 12.00 .........................Rice & Shrimp Soup Asopao Mixto................................ 00 .......................Rice & Seafood Soup PUI/-® :._ �.............................../foo ....................... . soNcH - Ensalada`de Langosta....................... ::#00 .................................Lobster Salad Langosta Guisada............................. 2,200 ..................Lobster in Tomato Sauce Ensalada de Mariscos........................ .00 ................................Seafood Salad Arroz con Camarones......................./Z.00^^...........................Rice with Shrimps A�C�r4 fl� ®`l0 8.00 .................................Chicken Soup P� � ..................... S icocho......................................... 8.00 ..........,.................Spanish Consume C.ocido de Patas de Vaca................... 8.00 ................................Beef Consume Mondongo....................................... 8.00 ..............................Beef Tripe Soup Sandwich Cubano.............. ............. $ °O .............................Cuban Sandwich Sandwich de Jambn y Queso............. 3.50 .................Ham & Cheese Sandwich Sandwich de Pollo............................ 4.50 ...........................Chicken Sandwich Arroz Blanco.................................... 3.00 .....................................White Rice Tostones......................................... 3;00 ..................................Fried Banana Viveres, Platano, Yuca, etc............... 300 .....................Plantain, Cassava, Etc. LL � �irsal was � e5'ala-ds _ Ensalada del Chef............................. 4.00 ...................................Chef Salad Ensalada Verde................................. 'q'00 .................................Green Salad � Ensalada Mixta................................. ,4.OV .................................Mixed Salad Ensalada Rusa.................................. ,q. 00 ..............................Russian Salad Arroz con Habichuelas....................... 09 ,00 ............................Rice and Beans Arroz con Vegetales.......................... 5.00 .......Rice with Vegetables Moro de Gandules.....I....................... 4.00 .......................Rice with Gandules �. ........... 4.00 Moro de Habichuelas....��..,,.{{....... ...................Rice and Beans Mixed � �!.!�OS C%i��f'G�lll�l�S � CJY lCl�llllQL✓GG!CI��S � Jugo de Naranja...............................: 250 ...............................Orange Juice Jugo de Limon.................................. 2,670 ................................Lemon Juice Tamarindo........................................ Z,�j(� .....................................Tamarind Batidos con Leche............................. 2.75 ..................................Milk Shake Morir Sonando.................................. 2.75 ....................Orange Juice w/Milk Sodas...........................................:.. 1.00 ........................................,.Sodas Malta India....................................... /'60 ..................................Indian Malt Malta Alemana................................. 3.00 ........:........................German Malt Soda Grande (Botella de 2 litros)......... ..............Large Soda (2 liter Bottle) �La Vogs&CS Y6'fezis Arroz con Leche............................... /. � ................................Rice Pudding tPudin de Pan.................................... ..............................Bread Pudding Flan................................................ JF�� ...........................Caramel Custard Plato De Frutas................................. 4.00 ...................................Fruit Bowl AF TO RfORDFR CALL 781-SR1-3J32 CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/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 Lttw Cooled to Factors(Items 1.22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding 14 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives'" 590.004(F) 41°/45`F` 3-302.14 Protection from Unapproved Additives* 3-501.1.(i(A) Hilt PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers" 20 Time as a Public Health Control 7-102.11 Common Name-Working Containers* 7-201.11 Separation-Storage"` 3-501.4( Variance acaPublic Health Control* 7-202"'LI Restriction-Presence and Use* 590.Otkl(H) Varianx Requirement 7-202.12 Conditions of Use* 7-20311 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS 7-204.11. Sattitizers,Criteria-Chemicals* (HSP) 7-20412 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-2 .14 DryingAgents.CoBeverages with W mmnKl abels* 7-205.1] IncidentalFoxl Contact. Lubricants* 3-801.11(B) Use of Pasteurized Egs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Sced S gouts NoC Served. 'x 7-206.12 Rodent Bait Stations* 3_801.11(C) Unopened Fond Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEffEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods'11tat are Raw,Undercooked or PHFs Not Otherwise Processed to Elhninate 3-401.t lA(1)(2) Eggs- 155"F 15 Sec. Pathogens."e�r"'vvzoai Eggs-bnntediate Service 145°Fl5sec* -1 .13 Pasteurized Eggs Substitute for;Raw Shell 3-401.11(A)(2) Comtninated Fish,Meats 8z Game E s:. Animals- 155°F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast-130°E 121 min* SPECIAL REQUIREMENTS 3-"IOL]1(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 Stuffing Containing Fish,Meat, debited under die appropriate sections Poultry or Ratites-165°F 15 sec. "` above if related to foodborne illness 3-40111(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1729- Microwave 165'F* Special Requirements. 3-40111(A)(1)(b) All Other PHFs-145'F15sec. * fl Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 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, n'hich do not relate to the Time* foodborne illness interventions and risk Jo(tors listed above; can he 3-403.11(C) Commercially Processed RTE Food- found is the following sections of the Food Code and 105 CHK 140°F* 590.000. -------------------- ---- 3-403.11(E) Remaining Unsliced Portions of Beef item Good Retail Practices FC 580.000-- Roasts* 23. Management and Personnel._ FC-2 .003 1gProper Cooling of PHFs 24. Food and Food Protection FC__3 .004 25 __ Egui�meni and Utensils FC4 ;--.005 3-501.L4(A) Cooling Cooked PHFs from 140°F to 26 Water, Plumbing _and Waste FC 5 006 70'F Within 2 f-lours and From 70°F 27. Ph sical Fa_cil_ity___,"____ FC-6 .007 -_-- to 41".F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PFIFs Made From Ambient 29 5 eciul Re uirements _ _009 Temperature ingredients to 41-F/45n F 30 Other---- - __ Within 4 hours' ssoorsn,trutb"xs,r Denotes critical item in the federal 1999 Food Code or 105 CMR 590 000, • r \r ,CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Rem Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I Piave read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction i Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: a 3-501. 4(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 CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.]2 Additives* 590.004(F) L16(B) Cold PHFs Maintained at or below 590.004(F) 41'/45'F* 3-302.14 Protection from Una roved Additives*Poisonous or Toxic Substances - 1.5 3-SOL 16(A) Hot'PHFs Maintained at or above 140'F * 7-101..11 ldenti(ying lnl'ormation-Ongitud 3-501,16(A) Purists Held at or above 130'F. Conrainers* 7-102.11 Common Name-Workin,Containers* 20 Time as a Public Health Control 7-201.11 Separation ation-Storages3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use" 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitlzers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washin¢Produce,Criteriaz 21 3-801.1 I(A) Unpasteurized Pre-packaged Juices and Beverages with Warning ning Labels* 7-204.14 Drtim A ents,Criteria* 3-801 11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food(*intact, Lubricants* and 7-206.12 Rodent Bait Statio3-$Ol.l l(D) Raw or Partially Cooked Animal Food7-206.11 Restricted Use Pesticides. Criteria* Raw Seed t lly Not Served. n* 3_801.1 3-801.14C) th o erred 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 Annual Foods`That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.1 lA(1)(2) Eggs- 155°F 15 Sec. Pathogens.*Elf,".11"2001 E>gs-bninediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell J-401.11(A)(2) Comminute Fish,Meats&Game Eggs* Animals- 155'F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats-155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec * catering, mobile food,temporary and 3-401.1.1(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 Steak's interventions and risk factors. Other 1450F* 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. 3401.1i(A)(1)(b) Ali Other PHFs-- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.4)&(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 nbove, ton be, _t-403.11.(C) Commercially Processed I2TE Food- ,found in the foRowbng sections of the Food Code and 105 CMI? 140'F" 590.000. ------Re------ --------- 3-403-1.1(L) Remaining Unsliced Portions of Beef Item Good tall Praetfces FC 580.600 Roasts* 23. Management and Personnel FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC--3 .004 3-501.14(6) Cooling Cooked PHFs from 140'F trr _ ...... Equipment and Utensils FC_4_____005 i_ 26. _Water,Plumbing and Waste FC-5 _.0_06 70'F Within 2 flours and From 70'F 27. Physical FacilityFC-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'( +swln,,,;n,ke aao� --9 Denotes critical item in the f,v Ieral 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Hem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified .. .PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No o Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-50L14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to Factors(items 1-22) (Cont.) 41'F/45`F Within 4 Howl. PROTECTION FROM CHEMICALS3-501.15 Coolinn Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.72 Additives* 3-50 F '1.16(B) Cold PIFs Maintained at or below 590.004(F) 41°/45`F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances t40"F. * 7-101.A I 'Identifying Information-Original 3-501.1.6(A) Roasts Held at or above 130'F. Containers- 7-102,11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 1 Separation-Stora e* 3-501_'19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use*R 590.004(H) Variance Requirement 7-202.12 Conditions of Use- 7-20111 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 Dt'in A eats,Cnteria* Beverages with Warning nin*Labels* 3-801,11(B) Use of Pasteurimd E, i s* nt 7-205.11 Incidental Food Contact.Lubricas* 3-801 11(D) Raw or Partially Calked Amnuil Food and 7-206.11. Restricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served. 7-206.12 RafeoY Bait Stations* 3-80'1.11(C) Unopened Food Package Not Re-served, +` 7-206.13 Tracking Powders,Pest Control and Monitorim," CONSUMER ADVISORY TIMEtfEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Animal Foods That are Raw.Undercooked or Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate �*e`droF a P•Jni 3-401.1IA(1)(2) Eggs- l55`FISSee. Pathogens.* E>gs-immediate Service 14501715sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs* Animals- 155`F 15 sec. * 3-401.1 l(B)(1)(2) Pork and Beef Roast-.130'F 121 min* SPECIAL REQUIREMENTS 3-401.1 I(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 PHFq, 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. Ocher 1450F* 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, 3-401A I(A)(1)(b) All Other PHFs-145`F '15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F I5 sec. 4: (Items 23-30) 3-403.11(6) Microwave- 165`F 2 Minute Standing Conical and non-mlicat 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 theft)/towing.sections of the Food Cade and 105 CNIR 1.40'F* 590.000. 3-401 I I(E) Remaining Unsliced Portions of Beef item GoodRetai!Practices__ FC 590.000 Roasts* 23. Management and Personnel FC-2 .003 1g Proper Cooling of PHFs 24, Food and Foal Protection FC-3 .004 -- 25 Egmpmeni and Utensils FC 4 .005 3-50L14(A) Cooling Cooked PHFs from 140'F u) - _-- _ -.006 - 26 Water,_Plumb and Waste FC 5 .006 70'17 Within 2 flours 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(13) Cooling PHFs Made From Ambient 29_ _ Special R uirements _ .009 Temperature htgredients to 41'F/45'F 30.------Ot--her -- Within 4llours" ssvrron.n.:�.e-zm '*Denotes c itical item in the federal 1999 Food Code or 105 CMR 590.060. A) _V\CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date ' No. Reference R—Red Item Verified - PLEASE PRINT CLEARLY -- ae k Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: > 3-501.1 l(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 CHEMICALS3-501.'15 Coo,Gng Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501. Cold PHFs Y,iaintainect at or below 540.004(F)4(F) 41145° F" 3-302.14 Protection from Unapproved Additives* 3-501.1.6(A) ]-lot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140,E '^ 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11 Common Name Working Containers* 20 7-201.11 as a Public Health Control 7-201.11 Se aration-Storage'; 3-501.19 Time as a Public Health Control* J 7-202.ll Restriction-Prescuce and Use 590.004(11) Variance Re-ulrement Ox' 7-202.12 Conditions of Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.1.1 Toxic Containers-Prohibitions` POPULATIONS HSP 7-204.11 Sanitizers,Criteria-Chemicals* -�. 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpastetuized Pre-packaged Juices and Beverages with Warnine i..abcls* --Q) 7-204.14 Drying r ent&Criteria* 3-801.II(B) Use of Pasteurized Eae;* O° 7-205.1.7 Incidental Food Contact, Lubricants* 3-801.11(7)) Raw or Partially Cooked Animal Food and 7-206.1 t Restricted Use Pesticides.Criteria* Raw Seed S Trouts NoC Served.'s - 7-206.12 Rodent Bait Stations' '3-801.11(0) Unopened Fax{Package Not Re-served, +` 7.206.'l3 Tracking Powders,Pest Control and Monitoring` CONSUMER ADVISORY TIMElfEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods'Phat are Raw,Undcrcooked or 16 Proper Cooking Temperatures for PHFs; Not Otherwise Processed to Etirninate viauo� 3-40'1.1.lA(i)(2) Eggs- 155°F 1.5 Sec. 11 thogcnti * Eire;NlP Eggs-IDunediate Service 145°Fl5sec* 3-303.13 pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meals 6c Game E gs* Aninuds- 155"F 15 sec. '% 3-401.1I(B)(l)(2) Pork and Beef Roast- 130"F 121 ntin* 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 sea * 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 sea °` above if related to foodborne illness --TI-011 t(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145"7* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under ff29- Microwave 165'F* Special Requirements. 3401.11(A)(1)(b) All Other PHFs-1.45°F 15 sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 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* foodborne illness interventions and riskfruxors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the fallowing sections of the Food Code and 10.5 CMR 140°F* .590.000. 3-403.1.1(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 580.000 Roasts* 23. Mena ement and Personnel - FG-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25. E ui meni and Utensils FC 4 �&007 3-501.14(A) Cooling Cooked PHFs from 140°F to "'----- --- ......... 26. Water,Plumbing and Waste FC 5 __ . 70°i'Within 2 flours and From 70°F 27. Physical Facill�+_! -FC-6 to 41°F/45"F Within 4 Hours. * 28. Poisonous or Toxic Materials -FC-1 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special R juirements _009 Temperature Ingredients to 41°F/45°F 30, Other Within 4 Hours* ssH�rmtF-zaou "Denotes mucal item in ihc.redeed 1999 Food Code or 105 CMR 590,000.