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Massachusetts .Depprtment of Public Health Salem Board OT Health IF
Division of Food and Drugs 120 Washington Street 4 th Floor
Salem, MA 011970452�
FOOD ESTABLISHMENT INSPECTION REPORT �-TeL(978) 74�1711�q'00 Fax (978) 745-0343
Name D Type Operation(s) lyge—o!Inspection
LJ Food Service 43 Rout,;e
Address CO-Retail El Re-inspection
15- Level El Residential Kitchen Previous Inspection
Telephone qIr- El Mobile Date:
Person in Ch!aMe(PIC) Ti El Bed&Breakfast El General Complaint
[_1 HACCP
Inspector -Perrnit No. El Other
Each violation checked rbquires an explanation on the narrative page(s) ends 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 cuno(Xivo 590.009(E) [] 580.009(F) El
�
action oodetermined bythe Board ufHealth.FOOD
[]� ECTION MANAGEMENT
El 12. Prevention of�Contaminatjon from Hands
1. ��Assigned/Knowledgeable/Du�oo \
�
El 13. HandwashFooi
OAPLOYEEHEALTH
F� 2. Reporting of Diseases by Food Employee and PIC tip -A T
Approved Food or Color Additives
El 3. �
.
LJ15.Toxic Chemicals
;,FOOD FeOM� Al
04. Food and Water from Approved Source
El�l5� Rooeiving/Condiion � �
�
[] 0. T8ga/R0000do�\oouraoy��Ingredient Statements E] 17. Reheating
�
` [] 10� Cooling
El 7. Conformununw�h8ppnnoedPmooduneu/MACCPP|ano
� []
�
� �PR'-T- -M� 19. Hot and Cold Ho|ding'
[] 8. Segregation/Protection / LJ2O /imeAaaPublic Health Control
� ����
[] 9. FuoUCon�u�Gu�a000C|oaningandGanitizing �
� El 2/. rvvuaovFood Preparation for nnr
` Lj1KProper Adequate Hondwmnhing
[] 11. Good Hygienic Practices . aeS"�/�,M
El 22. Posting of Consumer Advisories
Violations
�
^ Related to Good Retail Practices \ .
Numnber of Violated Provisions Related
Critical (C) violations marked must becorrected ToFoodborne Illnesses Interventions `
immediately orwithin 10days oodetermined bVthe Board a�d Risk Factors/|�enns1~��\:
nfHeu|thNon'oridna| /N}vio|a1iunumu�tbecorrected �
� ` ' � Based nnoninspection
immediately mtrwithin 90days uodetermined bythe Board
toU8y, �A� |��nnonAookeUin�|oat�viO|�d0nso� 10SCW1R
-of Health. ' '
� 590.008�edn:y| Food Code. This repo¢ vvhonsigned below
. Management and Personnel (FC'2)(590o03) hyuBoard ofHealth member orits agent constitutes un
ou1nrnf�h8Boordo� Hoo|1h� Fai|un8�ncorron1vio|o1iono
Food (FC'3>(�90
� .oUw) � ui1udin1hion�p0dm8yro�u|�inyuop�nSinnnrr�vnnmkion0f
Equipment (FC�*)(s9oo0�) �
� � . ihof0nd �6tob|ishmen1permi1andCessadnnoffood
VVuter. P|unnbingand Waste (FC'SKsS0.»»6> ootob|inhnnontoperations. |faggrieved bythis order, you
. Phyaina| Fooi|ity� (FC-6)<590.007} have aright tnohearing. Your request must beinwriting
28. Poisonous orToxic Materials (FC'/)(590.008) and submitted 10the Board ofHealth aithe above address
� 29. Special Requirements (590.000) within 10days Vfreceipt ofthis order.
30. Other DATE OF RE-INSPECTION-
S.50M°�F"=*14.d.
-x5mw�m"=*nm"
Inspector's Signature: Print:
PIC's Signature: Print: Page-A—ofIZPages
~ �
Violations Related to Foodborne illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Gross-contamination
1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated,from
590.003(BF Demonstration of Knowledge* Cooked and RTE Foods*
2-J 03.11 Person in charge-duties Contamination from Raw Ingredients
3-302.11(A)(2) Raw Animal Foals Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by foal employees and 3302.1.1(A) Food Protection*
a nccants* 3-302.15 Washin FmitsandVe=etables
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 Char=e* 3-306.14(A)(B) Returned Food and Reservice of Foot*
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 Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4
Food and Water From Regulated Sources L9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewasbing-Hot Water
3-201.1.2 _rood in a Hermetically Scaled Container* Sanitivition Tem erahires*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs*
Sanitization Tem eratures*
3-202.14 Fe=s and Milk Products.Pasteurized* 4501.114 Chemical ion aiz�hard temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness."
5-101.11 DrinkingWater from an Approved System* 4-601A J(A) Utensils
Clean*nt Contact Surfaces and
590.006(A) bottled Drinking Water* Utensils Clean*
4-602.1 t Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0
ShelNtsh and Fish From an Approved Source Contact Surfaces and Utensils'
4-702.11 Prequency of Sanitization of Utensils and
3-201.14 Fish and Reereadonal'ly Caught Molluscan Food Contact Surfaces of E ui mint*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Genre and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Anus*
Re ulato Authority
3-202.18 Shel[Wock Identification Present* 2-301.12 Cleanine Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.1 t PITFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-202.1.5 Package h to it=* Mouth*
3-101.11 Food Safe and Unadulterated* 3301.12 Preventing Contamination When Tasting*
6 Tags/Records:Sheilstock 12 Prevention of Contamination from Hands
3-202.18 Sbellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstoek Identification Maintained* Em to•ees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J) Labeling of Ingredients' 5-214.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
-3-502.11 Specialized Processing Methods*
Devices
3-502.1.2 Reduced oxygen packaging.criteria* 6-301.11. Hindwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision
A
Denotes critical item in the fedeod 1999 Ford Code or 105 CMR 590.000.
CITY OF SALEM, MASSACHUSETTS
- BOARD OF HEkLTH
120 WASHINGTON STREET,4'FLOOR
TEL. (978) 741-1800
KIMBF_RLEY DRISCOLL FAx(978)745-0343
MAYOR DGREENBAUM@SALr.m.CONI
DAVID GREENBAuNi,
ACTING HEALTH AGENT
2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENTn//�/{/
NAME OF ESTABLISHMENT 1 TEL# R C 1"1 l` y Ai?1f-0
ADDRESS OF ESTABLISHMENT r4odfillu i;P we 1h1 FAX#!11j -7Nq g7I I
MAILING ADDRESS(if different) T
EMAIL-Business': Website:
OWNER'S NAME t TEL#
ADDRESSv
REET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON Wti 5e thil. HOME TEL#
�DAYS(OF'OP,ERA710N� �;: `��Monday�;7k"` 7�uesda�'€�Wed_riesda pJThursday�"�r,� rFiiaay�' giSaturday�� ,Sunday
HOURS OF OPERATION
Please write in time of day.
For example 11am-11pm)
! I -
TYPE OF ESTABLISHMENTFEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280u
more than 10,000sq.ft. =$420
------------------------------------I..................;------- --------------------------------------------------------------------------------------•----
RESTAURANT YES O less than 25 seats =$140
(Outdoor Stationary Food Cart$210) 25-99 seats =$280
more than 99 seats =$420
--------------------------ES------ 6 ---------------------------------------------------------------------------------------------
BED/BREAKFAST/ Y $100
CHILDCARE SERVICES/NURSING HOME - - - '
ADDITIONAL PERMITS
MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR 11ES) NO $135`✓
ALL NON-PROFIT(such as church kitchens) ES 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 o MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns a p 'd allslat xes required undart a law.
.9-Signature Date Social Security or Federal Identification Number.
-------------------------f -------- ------------------------------------------
Revised 4/24/07 FOODAP2008.adm Cheek#&Date t�>a1W17 $
'y e v''' 1 xn, T x"R 5'*u4 ..i',Cv'(' .a •.'vnr^�.i ',.i` t"71"` @'+/'.8. >
♦ r- r� .Md -+..R.0 1q vn.,�:; i n y i ' tai ,..s4:. N kJ�t �.�+:.+,.r •a..r : ..�.1
w '��'1 +
Massachusetts Department of Public Health Salem Board of Health
Division of Food and Drugs 120 Sa emaMA Oton St35234'" Floor
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Date T of 0 eration(s) Type of Inspection
J/ _57/k/ ❑ Food Service Routine
Address Risk` [-Retail 6 Re-inspection
^r c1k Levet ❑ Residential Kitchen Previous Inspection
Telephone ( : �_ (� � ❑ Mobile Date:
Ownert HACCP Y)i ❑ Temporary ElPre-operation
❑ Caterer ❑ Suspect Illness
Person in Charge'(PIC) Time ❑ Bed&Breakfast ❑General Complaint
In: I,' ❑ HACCP
Inspector Out:'d. 7j Permit No. ❑Other
Each violation checked re uires 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 PROTECTIQN MANAGEMENT a w t; 7-7 1 ❑ 12. Prevention of Contamination from Hands
❑ 1 PIC Assigned/Knowledgeable/Duties
Tyr [113. Handwash Facilities
#EMPLOYEE HEALTH s�� aeA��grre-�t.�l2,aF" ��k$ �- P
r'-21....E 'sa.1"W.t ;3kt.�as. PR45TECT16N FROM CHEMICALS rd:a r� r,"'�' ata dri +ypH �=
❑ 2. Reporting of Diseases by Food Employee and PIC r- ®� •�� ..��'a,d, t El 14.Approved Food or Color A ; Iw
Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals
,FOQp FRC`M APPROYEb SOURCE `T`, -� "��- �`r"` `'"
` " "" �' ' " r,�;rre: + "" ;TIMEl1`EMPERATURE CONTRLS` otentlallY aar
Ffxdous Favids 1 m`
El 4. Food and Water from Approved Source yn r y � naOm(; "q � g ) i,
a
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
"pROTECTibN FROM CONTAAkATION i_ e ?�` m ,`pyp t',"`'' "r t`i, [119. Hot and Cold Holding
a9. ` ..,gym.-�,.wrw-'ek.«. v?,+...: 1 ,
ElJ8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing ,IREdUIREMEN75 FOR,H16dL_Y SUSf,EPTI L"OPUtATION$(tISPQ
El 21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
„GONSUMER A0VISORY,0 X11,,_r'. :;r�"d@a.?Xe"j wEI,:. .„:
El22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
C N 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of
26. Water, Plumbing and Waste (Fc-9)(990.009) the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
4`.r '30. Other DATE OF RE-INSPECTION:
S'501nVwfFoT 14 C0[ -D 3 L
Inspector's Signature: Print:
PIC's Signature: Print: M Page of ages
J
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination _
1 I 590.003(A I Assignment of Responsibility*-- 3-30111(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
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 WashingFruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To ReportTo The Person In Utensils*
Char*e* Contamination from the Consumer
590.003(G) 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 of EXCInSions and Restrictions Food
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) Com fliance with Food_Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-20L.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..11.4 Chemical.Sanitization-temp.,pH,-
3-202.16 Ice Made From Potable Drinking Water"
concentration and hardness. *
5-101.1.1 DrinkingWater from an Approved S stemUtensils Clean** 4-601.11(A) Equipment an* Contact Surfaces and
590.006(A) Bottled Drinking Water*
4-602.11 Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0
Contact Surfaces and Utensils'
Shellfish and Fish Froman Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-20J.14 Fish and Recreationally Caught Molluscan Foi Contact Surfaces of E ui ment"
Shellfish* 4-703.11 Methods of Sanitization-HotWaterand
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authorityia2-301.11. Clean Condition-Hands and Ars*
3-202.18 Shellstock IdentificationPrescnc* 2301_12 Cleaning Procedure*
-590.004(C) Wild Mushrooms* 2301.14 When to Wash*
3-201.17 Game Animals* 1.1 Good Hygienic Practices
Receiving/Condition 2-401.11 Eating,Drinking or Usin Tobacco*
3-202.11 - PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
L6 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'" m Eto ces*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* _
590.004(J) 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
3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Hindwashing Cleanser,Availability
8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision
"Denotes critical item in the federal 1999 Form Code of]05 CvIR 590.000. -
- LL CITY OF SALEM
BOARD OF HEALTH
Establishment Name: , — Date: 1`t�,/cam/ Pager of 1>
f nem , yCode C Critical item p!_ x DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date
Reference ;R=Red item ,? ° 7 + * �. '.� £" '>.� >:�s .s.�'c,o s rmy a Verified
Sv *PLEASE PRI NT CLEARLY •r&"4 - � � �" ` ' `- '
�7- � � • r l T fTrV r r l r� r c� '-- � � �.r.: ..—,�. .� .� 2t c� !'�s�`,-.
i I r7 At A,QW nor h
!/ I Al !' � t✓ lnJ�., . l —! �e /r` . 101/ / �✓1 (A )n � �'
FOCQ4l I J
+1.0.4 - r O LA j).p n n .J
�/(�... -'�t� . i 1/l�aGr i�d 1(� n� r•��.e• J. ni" i ✓�O Y— ..1 n �A C
' f
r
r
, j
l ✓ nom. ,cr 4- 4- _ kt., 7 o
r r
1
Fr AA.0 r+ �
t Discussion With Person in Charge: Corrective Action Required: ❑ No - �Y@s
-�
I have read this report, have had the opportunity to ask questions and agree to correct all C3 voluntary Compliance ❑ Employee Restriction
Exclusion
violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension
that
comply with all mandates of the Mass/Federal Food Code. I understand t at
noncompliance may result in daily fines of twenty_fiue-dollars-or uspension/revocation of C) Embargo Ll Emergency Closure
your food permit. -_ s�
..d ❑ Voluntary Disposal 0 Other:
F
Violations Rotated to Foodborne illness interventions and Risk Av,*rding In Lav- Cwlud to
Factors{geywl-22} (Cont) T/45'F Within" Hours.
PROTECTION FROM CHEMICALS 3-501,15 Colin,, S of — 's
Food or Color Additives Lit- PHF Hot and Gold Holding
1=4 1 5m�16(B) Cold PHF,�Nfemokined at or below
3-202.32 AthmiNes'r 5W,0041', 4P/45��F'
�—MT14 Prosedion from 0-----
ill Unapproved 3-501 16kA'j Hot PPIIF.Maintained at or above
L Poisonous or Toxic Substances 1400F.
7-103.11 Identifying hittil mation OnVaid
3-50IJ6(Ad Roasts Held at or aiZll I ()-F
Time as a Public Health Control
—7 102-11 Common Name- Workm�Co itainer.0
7-201.11 -50 1,19 11�dfle i'100,il'th�Com"0
--�12 --- 590'Jot�li) Varian
i-2011 t Roshiction-Presence and (11,c*
7-202.12 Conditions of(ise' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-?0111 Toxic coldamel"- vroldla:ionv` POPULA IONS(HSP
7-204.11 Satiiii7en,Criteria-ChenticAls* rrr
7— 121 3-801.1](A) Unponeurized Juicts and
1-204�12 Ileum als i�)r N�ashi ng,Prodi Revvrwm�with Wandi
L 204,14 Drvin,,ALent,�.Crite,mly
t lab Is*
7 z"�
7,2115,11 Incidemal f-�sxl Contact,Luhricimts'� 3-801111(1t) U"ce of paqeumed L
I 3-b01.JliJJ)
7-20&11 Rcsoioed-Use Petieidea.Critekia
Served
k 7-206.12 R(XICUI Bail
, Stations �
LR lEf—E 11 r"2c ! x xL Packs�LNot R e-served"
200 13 backing Powdori,Yes[Control and — �i -
mon )v n-
CONSUMER ADVISORY
--� - -
TIMF/TEMPERATURE CONTROLS F22 If 3-60 I ori V Posted lior Consumption of
Proper Cooking Temperatures for Animal FKxf�11ou art!Raw, undercooked ta
16 Not(Itisviwise Pro<,issed to I-tlhlawae
."1", .111,
346I1JA(I)(2) Falls- 155'F 15 S,'c-
P
A-302.13 Pastekirorec!F.g
5,eol Siibowoe for Raw Shell
--�.ihatc Service 1451
[A I(A)(,-) Comminuted Fish, Nleats n Ganite
Anfluais F» 117 sec.
SPECIAL REQUIREMENTS
3-401.11 Pork and Beef Roast - 1104-' 121 ruin
59(f()09(A)-(f))7 1 i oils 0,f Sectio R 5()0.(0)(A)-(D1 )in
3-401 11(1k)(2) Fatit es,lr�jeeied Meals-- 155 3F 15
catcriqn mobilo "A,temporary and
Ponfto,,Wild hare, Stuffed PHFs,
reside tit ial kitchen opciations.should be
SniffingC'nantining Fish, Mein,
debited undei the appropriate sections
Posit it Ratites 165'f 15 sec ' aboyo if relaied to fixxibc
-401 11 CC0) vhote mu k. Intact Beef Steaks inter sent ons and tisk factors, Otbcr
145"F 5"40.009 violaliolls relating to ,ced reulli
1 5-401.12
Raw Animal Fooik Cookedula-
practices �Aiould be debited under #29 -
_
TFMiciowave 165°F Special Requirements
4l,iI(As(l)ito AllOffietPHF-s-- 145T15sec,
I--- i
L17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.1uA)&, D) P[IF" 1 15 sec. (Items 23-30)
'-403.11(B) Nficrruvavc- 105f2 Minute,Swadin., Criti(wland non-crowal vwlanuiii,which do nor remote to oir
Time" Mound
illness iisA jailorshied above, can be
3-403.11(C) commervi,11V Plo�'CsQ 1-1XIj found in (if tho,Food Codc mad 105("WR
item
I(F) ------
1401 J Remainim, Uwlwed Portions of Beef T Good Rem;/Practices 1 FC Sgaditio
-5--i-loaqvemert ndft,onnef 1 FC 2 1 �003
Priori, 4- _a___ = — --- --
i T�-and Food Protiection FC M4
gg Proper Cooling or PHFs 77L -
7— 25. 'Eqjsp r� Utensils FC-4 005
501 14(A) Cwhae Cooktd,PHF� from 14WF to me, and
26, 1 watol,Plumbing and Waste i FG-5 W6
J� --------------
700f:Within 2 Hours and From 79F FC-6 i rG 7-^t �007
_thysical Faciilly
to 41 1,145F 16Vitln ti 4 Homs- 28 Poisonous or Tim Materials
008
41B� Cooling PRFs M,',,do From Ambient 29 Sp
dog
'I'sinperature Ingredmias lt,411F145'14 LOther
Within 4 Hours'
mthe iv'iera! i9t)')F(xx1C"'dC0T 105{:NIR 59`z t3t3f3.
Massachusetts Department of Public Health Salem Board of Health
Division of Food and Drugs 120 Washington Street,4'"Floor
i Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Dat" + Type of 0 eration(s) Type of Inspection
)o •,.I'M (�I O ❑ Food Service ❑ Routine
Address 5 t Risk I2f.Retail ® Re-inspection
d Level ❑ Residential Kitchen Previous Inspection
Telephone �, �� ❑ Mobile Date: <1
/Jct
Owner HACCP YM ❑ Temporary ❑ Pre- %ition
G e n -C ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) n Time ❑ Bed&Breakfast ❑ General Complaint
In: ,4f- ❑ HACCP
Inspector -, J Out:z.ZD 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 PROTEGTI0I4MANAGEMENT , „ ant,µ,„, I, Z „ •„ „„�;.eF El 12. Prevention of Contamination from Hands
❑ 1 PIC Assigned/Knowledgeable/Duties
❑ 13 Handwash Facilities
EMPLOYEE HEALTH V.V"Z75,77 ' "UM V,174- a y3� ^°PROTECTION FROM CHEMICALS rt""`w r�,
o.�.z.az,M.mdmsEr s.°r-
❑ 2. Reporting of Diseases by Food Employee and PIC -» - � �� �,�� �� -6 (m:� �_� t^$�u .,„)
❑ 14.Approved Food or Color Additives
\ ❑ 3. Personnel with Infections Restricted/Excluded
�roEl15.Toxic Chemicals
(;FOOD FROM AP(+ROVED SOUREE � „��' ,w a �_,,, V, '� IME/TEMPERATUREOONTROLS(Poteantltty Haszardeus Foods)'� `�
El 4. Food and Water from Approved Source a a w y s � r
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
PROTECT(ON FROMCONTAMigATIONra�l 1I ❑ 19. Hot and Cold Holding
.a.maw€.ASa.axa.�}:§ ,w�acre:,Au+ �„, r
118. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing CREQUIREMENTSFOR HIGHLY SUSCEPTIBLE,P(ZPULATION$(HSP)�'R
❑21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
;CONSUMER.AUVI§OIiY e_"„ri ..u�'.-CM.r.,�'> �a Z4 ?..M.�a+.s..ake,a ?40"X71,I
❑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',' 1vs by a Board of Health member or its agent constitutes an
23. Management and Personnel F C-3)( 90.00 )) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-3)(sso.00a) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
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:
5:5801nspecfFomi6-14.tloc «-
Inspector's Signature: ( / _ Print: `
PIC's Signature: �� Y_/ Print: page-(of zPages
r
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* 3-302.1](A)(]) Raw Animal Foods Separated from
590.003(B) Demonstration of Know ledge* Cooked and RTE Foods*
2-I03.1'L Person in charge-duties �� Contamination from Raw Ingredients
3-302.11(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* 3-302.15 Washing Fruits and Vegetables
590.003(F) Responsibility Of A Foul 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(6) Re orting b Person in Chrr Vie* 3-306.14(A)(B) Returned Food and Resemce of Food*
11 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Res rictions Food
3-701.1.1 Discarding or Reconditioning unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources r 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law" 4-501.131 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Seated Container* Sanitization Temperatures, -
3-20'1.13 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* 4-501.114 Chemical Sanitization-temp., pH,
3-202.16 lee Made From Potable Drinking Water* concentration and hardness. 'k
5-1.01.11 DrinkingWater from an Approved System* 4-601.1I(A) Equipment Food Contact Surfaces and
590.006(A) Bottled DrinkingWater* Utensils Clean'
4-602.11 Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0"'
Shellfish Surfaces and Utensils*
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-HerWaterand
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Autho2 2-301.11 Clean Condition-Hands and Anes*
3-202-18 Shellstock Mentifrcation Present* 2-301..1.2 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 bVhen to Wash*
3-201-17 Game Animals* f.l Good Hygienic Practices
5 ReceivingtCondidon 2401.11 Eating,Drinkire or Using Tobacco*
3-202.11 - PHFs Received at to er Tem eratures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Package Inte it * Mouth*
3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tastin "
b Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(F) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Elnrlo xzs*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 ParasiteDcstruction* - Conveniently Located and Accessible
5 203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention"` 5-204.11 Location and Placement*
590.004(J) Labeling of Ingredients'
7 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 acka ing,criteria* 6-301.11 Handwashing Cleanser, Availabilit
8-103.12 Conformance with Approved Procedures" 6-301.1.2 Hand-D -ng Provision
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: �Y. ('-1'y��_IG'Jor .; Date: Page:Page: Z of 7
t Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
f No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
r`
f
r
Discussion With Person in Charge: Corrective Action Required: ❑ No l Yes
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
'r comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
- your food permit. — ❑ Voluntary Disposal ❑ Other:
v i i
>Sr
3-501,14(C) PIFs Received at Teinperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(items 1.22) {Cont) 41°F/45`F Within 4 Homs.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
19 PHF Hot and Cold Holding
14 Food Color Additives 3-501.16(B) Cold PIFs w
Maintained at or belo '
3-202.12 Additives" 3-501.16(B)
41°145° F' -
3-30114 Protection from Unapproved Additives* 3-501.TOW Hot PHFs Maintained at or above
1j Poisonous or Toxic Substances
4WR *
7-101..11 Identifying Information-Original 3-50116(A) Roasts Held at or above 130'17_
Container'
7-102.11 Common Name-Working Containers'" 20 Time as a Public Health Control
7-201.11 Separation-Stora e" 3-501.19 Time as a Public Health Control`
7-262.1.1 1 Restriction-Presence and User 590.004(H) Vuiance Re-uirentent
7-202.12 Conditions of Use-
9-303.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sarnazers,Criteria-Chemicals" POPULATIONS(HSP)
7-304.12 Chemicals for Washing.Produce Criteria* 21 3-80'1.1 1(A) Cnpaateurized Pre-packaged Ju ces and
BvetaleswithWarning Labels*
7-204.74 Uc ins eats.Criteria' 3-801 11(13) Use of Pasteurized H lis*
7-205.11 Incidental Foal Contact, Lubricants" ;;_801,11(D) Rau or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides. Criteria* -
Raw Seed S Trouts Not Served.
7-206,12 Rodent Bait Stations" 3-801.11(0) Unopened Rood Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-60311 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw.Undercooked or
16 p Proper Cooking Temperatures for
PIFs Not Otherwise Processed to Eliminate
''...
rtecna r vzoot
3-401.1.tA(1)(2) Fggs- 155"17 15 Sec. Patheens
Eggs-Immediate Service 145'F15sec-. 3-302.13 1 Pasteurized f ggs Substitute for Raw Shell
3-4 11.11(A)(2) Comminuted Fish, Meats&Came Eqs"
-3- Anneals,- 155'F 15 sec SPECIAL REQUIREMENTS
3-401.11.(B)(1)(2) Pork amd Beet Roast-130'F 121 min*
3-401.11(A)(2) Ranter,Injcctu Meats 155`17 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, Slotted PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165017 15 sec * alcove 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 gond retail
3-401.12 Raw Animal Foods Crooked in a practices should be debited under 7129--
Microwave 165'F* Special Requirements.
3-40 1.11(A)(1)(b) All Other PHFs- 145'F'15see.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-303.11(A)&(I)) PHFs 165'F 15 sec. * (1terns 23-30)
3-403.,11(13) Microwave- 165'F 2 Minute Standing Critical and non-critical ciolrawns, which do not relate to the
Thee* foodborne illness interventions and risk factors listed above can be
3-403.11(C) Commercially Processed RTE Fond- fiatnd in the fotlniving sections of the Food Code and 105 CAM
140"F* 5.90.000. _
3-403.11(E) Rema jimlg Unsliced Portions of Beef Item Good Retail Practices FC 590.000
Roasts* 23. Manariennent and Personnel FC-2 .003
18 Proper Cooling of PHFs 24. Food and Food Protection ___ _FC-3 .004
_25, pment and Utensils_ _EquiFC 4 .005
3-501.14(A) Contin¢Cooked PHFs from 140'F to 26 _ Water,Plumband Wastein FC 5 1 .006
70'F Within 2,Hours and From 70'F 27, Physical Facili FC-6 1 .007
to 417/457 Within 4 Hours. * 28.- Poisonous or Toxic Materials _ FC-7 1 .008
3-501.'14fB) Cooling PI[Fs Made From Ambient 29. S ecial Requirements .009
Temperature Ingredients to 41°F/45'F - 30 ,__,_,_,_ Other __ _.- --
Within 4 Hours* ssrnm„�wdr z*K
Denotes critical iter,in the lederal 199917ood Code or 105 C NIR 590.000.
!l o,-
i
Commonwealth of Massachusetts
s g City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/23/2008
ESTABLISHMENT NAME: Quality Liquors
Fite Number:BHF-2004-000070 Steve's Quality Market
36 Margin Street
Salem MA 01970
LOCATED AT: 0005 GEDNEY STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2009-0173 Dec 23,2008 Dec 31,2009 $280.00
TOBACCO VENDOR BHP-2009-0174 Dec 23,2008 Dec 31,2009 $135.00
Total Fees: $415.00
PERMIT EXPIRES December 31, 2009
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
4 +
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR
TF-L. (978) 741-1800 RECEIVE®
KIMBERLEY DRISCOLL FAx(978)745-0343
MAYOR IDIONNE sALYM COM DEC 15 2008
JANET DIONNE :LEM
ACTING HEALTH AGENT ESOARD OF HEALTH
2009 APPLICATION
FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT UIlAt'tM L PW� TEL# grl6
ADDRESS OF ESTABLISHMENT � 6AffliktM S� FAX# �� � 7 N� 93 7/
MAILING ADDRESS(if different)
EMAIL- Business': 414
'' Website:
`
OWNER'S NAME 4 i TEL#
ADDRESS m J
ET u CIT ST TE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared) /;
EMERGENCY RESPONSE PERSOjl. T HOME TEL# Q 1 8 7� Z �`7
DAYS OF OPERATION, Monda ': I, Tuesda WeCnesda Thursda f.Fnda - Saturday. Sunday'
HOURS OF OPERATION 'q4l-y� qvr A,,,, r f A� ft
Floe xamplee write'n time 11am-17pm 030 wtp30 day ,� to3ulpl^" (a�j4r^ j �to3�r- Jho IalAn��::.
TYPE OF ESTABLISHMENT FEE (check only) r
RETAIL STORE YE NO less than 1000sq.ft. =$ 70�
1000-10,000sq.ft. =$28
more than 10,000sq.ft. =$420
-
-------------------------------------------------------------- -- --------------------------------------------------------------------- ------------------------
RESTAURANT YES NO less than 25 seats =$140
(Outdoor Stationary Food Cart$2101 25-99 seats =5280
more than 99 seats =$420
K,F --- ---------------------------------------------------------------------------------------------
BED/BREAKFAST/ YES O $100
CHILDCARE SERVICES
ADDITIONAL PERMITS -
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR ES NO $135✓
ALL NON-PROFIT(such as church kitchens) S NO $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes,are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to)MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns an a all state taxes quired under the law.
A �;a/g/d rya a i
Signature— Date Social Security or Vederal Identification Number
------------------------------------ -- - ----
-- ---- -------------------------
Revised 424/07 FOODAP2008.adm Check#&Dateig 13 67- /arm-o>3 $ 1 5.,—
I
COMMERCIAL SERVICES
May 20, 2008 EECEIVE®
Elizabeth Salandrea MAY 232000
Salem Board of Health
C.FY OF SALEM
120 Washington Street ISOARD OF HEALTH
4th Floor
Salem MA 01970
Re: Pest Control Service; Quality Liquors
Dear Ms. Salandrea:
At the request of our customer,.Quality Liquors, located at 5 Gedney
Street, Salem MA we are providing information pertaining to pest
control service performed at this location.
Orkin Commercial Services has been providing pest control service to
the above named customer since February, 2003 on a consistent
basis. Currently service is provided every other month, and in the
event of a pest issue, follow up services are provided to this customer
as needed, at no additional charge.
As of this date, no ongoing pest issues have been noted at this
location, and preventative applications and monitoring are provided to
this customer during each scheduled service.
In our opinion, the current service frequency is adequate, but if pest
activity increases, or conditions warrant, monthly service frequency is
available.
Sincerely yours,
��wLl�
Michael.A. Cable
Branch Manager
Orkin Commercial Services
I OB Roessler Road
Woburn, MA 01801
c IMPORTANT MESSAGE
;4
FOR I
DATE TIME _L_P.P0
OF
PHONE
AREA.COOE NUMBER EXTENSION
U FAX
U MOBILE
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE.YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE 7T L
I
SIGNED
FORM 4009
■�//�rYiii.... MARE IN U.S.A.
C I _ = }
, 1
eb
3
! ,
Permit Number 7
61HP-2008-0238
Status s�•- � �. � .�`. ^ '�-
,SIGNEDOFF N �o
#of Critical Violations:
0
Time IN: Time OUT:
urgency Description(s):
BLUE: ,' I All other violations noted in the 4115108 insp
'
Violations Related to Good - '
Retail Practices(Critical PIC to have owner call board of health when
.violations must be corrected
immediately or within 10"
Wys)(Non-critical violations
must be corrected immediately
within 90
City of Salem Board of Health 120 Washington Stre
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth oll
r
Memorandum
Date: Tuesday April 29, 2008
To: File
From: Elizabeth Salandrea
RE: Extermination
During a routine inspection, it was noted that establishment is getting
exterminated every other month, not once a month. Spoke with senior
sanitarian Janet Dionne, and it was determined that establishment must begin
getting exterminated once a month; I discussed this with owner Peter
Ingemi, who agreed to the determination.
00'L�
Elizabeth Salandrea, Sanitarian
APR-28-2008 11 :58 AM STEVES MARKET 9787449371 P. 01
`L
Steve's Quality Market 97$•744-9371
Deliver to:
r aS44
Sent by:
Message:
u
s k
rrvl W .� -
na�
HP Fax Series 900 Fax History Report for
Plain Paper Fax/Copier Joanne Scott Salem BOH
978 745 0343
Apr 28 2008 11:39am
Last Fax
D= 1bg IYM Identification Duration g Result
Apr 28 11:38am Sent 919787403086 1:20 4 OK
Result:
OK - black and white fax
;Ilia Ow"Ce Am wrIA.
Roo W OU"
8- -.CIA
U t JA M&> ! K VIA
' APR-28-2008 12 :01 PM STEVES MARKET 9787449371 P.03
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0005 Gedney Street Quality Liquors
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: _ Violations Related to Good Retail Practices (Blue Items)
744-4220 Equipment and Utensils FAIL Non-Critical BLUE
Owner: Comment: Employee microwave needs general cleaning.
Kathleen' Ingeml Physical Facility FAIL Non-Critical BLUE
PIC: _ - Comment:3 water-stained ceiling tiles in middle of store.Investigate source of leak and replace tiles.
Peter,Ingemi
Inspector
Elizabeth Salandrea
Date Inspected:Correct By:
14/28/2008
Risk
4/28/2008Risk Level:
Permit Number: .
BHP-2008-0064
.Status:'
SIGNED OFF
#of Critical Violations:
0
4Time 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. Apr 30,2008 ) Page 1 of
7
r
Item Status Violation Critical Urgency
RED:
Violations Related to
Foodborne Illness Interventions
:and.Risk Factors (Require I
immediate corrective action) i
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. Apr 30,2008 ) Page 2 oft
f] > r
S4 �/�� f
+t sf-�'Y '�tACmaa"W.f'*T*iMyTnRO��na. �T_'R^":�w'Y.F'�+"M"��� '^i-rtru'1�H �J�+— -r'k� �4.
a-:
Commonwealth 0 Massachusetts .s
• �>
City'ofSalem
Board of Health
120 Washington Street,4th Floor IQmberley Driscoll
- Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/03/2008
ESTABLISHMENT NAME: Quality Liquors
File Number:BHF-2004-000070 Steve's Quality Market
36 Margin Street
Salem MA 01970
LOCATED AT: 0005 GEDNEY STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2008-0064 Jan 3,2008 Dec 31,2008 $280.00
TOBACCO VENDOR BHP-2008-0103 Jan 3,2008 Dec 31,2008 $135.00
Total Fees: $415.00
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 approvedbythe Salem Board of Health. Page 20 of 46
1 CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4' FLOOR
TEL.(978) 741-1800
KIMBERLEYDRISCOLL FAX(978) 745-0343 ®® 9l. ""
MAYOR ISCorr(@ SALEM.COM R E C L_ 1� IE D
JoANNE ScOTr, DEC 6- 2001
HEALTH AGENT CITY OF SALP"A
BOARD OF HEALTH
2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT U d`_S TEL# n l ' /C,X 'L q/`��'I))�-O
ADDRESS OF ESTABLISHMENT le ' FAX# "1 1 E �I L � "G 311
MAILING ADDRESS(if different)
EMAIL-Business': Website:
OWNER'S NAME �. t TEL# V g i q ( Igt,l
ADDRESS C'/1'a
STREET 0 Cn STATE QIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared) ," //JJ
EMERGENCY RESPONSE PERSON 1 HOME TEL# I ) 0 u y U (.W
DAYS OF OPERATION 1 Monday Tuesday Wednesda Thursda Friday
SaturdaySunda
HOURS OF OPERATION '144,n C,4 `Y4 nl� Gl/ RMI'l I i !JU 11 n`
Please write in fine of day. /
For example Ilam-11 m) k3b eir•.! l�V U PM toga n, ed) c n, i -0` �OLrYfI
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280 Y
more than 10,000sq.ft. =$420
RESTAURANT YES O less than 25 seats =$140
(Outdoor Stationary Food Cart$2101 25-99 seats =$280
more than 99 seats =$420
----------------------------------------------------------------
BED/BREAKFAST/ YES NO $100
CHILDCARE SERVICES .......... - - ...... —
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25
TOBACCO VENDOR TYES> NO $135
ALL NON-PROFIT(such as church kitchens) TES NO $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns andpaidall sta fazes required under the law. /r ey
l r, '1 ,(Dmi t JAG Lla,64 ciY a d a q&
Signature Date Social Security or Federal Identification Number
------------------------'------------- A-----------'---jj--- �{,-�— -------'--------------
Revised 4/24/07 FOODAP2008.adm Check#&Date
x005 Gedney Street Quality Liquors
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: FOOD PROTECTION MANAGEMENT
744-4220 PIC Assigned/Knowledgeable/Duties PASSd❑ RED
Owner:
Non-compliance with:
Kathleen Ingemi Anti-Choking PASS
PIC:
Peter Ingemi Tobacco PASS
Inspector:
John Gehan EMPLOYEE HEALTH
Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS RED
2/22/2007 Personnel with Infections Restricted/Excluded PASS ❑ RED
Risk Level:
FOOD FROM APPROVED SOURCE
Permit Number: Food and Water from Approved Source PASS ❑ RED
BHP-2007-0009 Receiving/Condition PASS RED
Status:
SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS ❑ RED
#of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED
0
Time IN: Time OUT:
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 22,2007 ) Page 1 of
j Item Status Violation Critical Urgency
RED: PROTECTION FROM CONTAMINATION
Violations Related to Separation/Segregation/Protection PASS 0 RED
Foodborne Illness Interventions
and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS 0 RED
immediate corrective action) PASS 0 RED
Proper Adequate Handwashing
Good Hygienic Practices PASS 0 RED
Prevention of Contamination from Hands PASS 0 RED
Handwash Facilities PASS 0 RED
PROTECTION FROM CHEMICALS
Approved Food or Color Additives PASS 0 RED
Toxic Chemicals PASS 0 RED
TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
Cooking Temperatures PASS ❑d RED
Reheating PASS RED
Cooling PASS RED
Hot and Cold Holding PASS ❑d RED
Time As a Public Health Control PASS RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food and Food Preparation for HSP PASS RED
CONSUMER ADVISORY
Posting of Consumer Advisories PASS ❑d RED
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 22,2007 ) Page 2 of
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection FAIL BLUE
Comments: Personal foods being stored with drinks to be sold. All personal foods must be stored in appropriate designated areas.
Equipment and Utensils FAIL BLUE
Comments: Employee microwave requires general cleaning.
Water, Plumbing and Waste PASS BLUE
Physical Facility PASS BLUE
Management and Personnel PASS BLUE
Poisonous or Toxic Materials PASS BLUE
Special Requirements PASS BLUE
Other-See Notes PASS BLUE
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 22,2007 ) Page 3 of
CITY OF SALEM, R MASSACHUSETTS � �� ��
o s SOME)OF HEALTH
120 WASHINGTON STREET,4TH FLOOR
SALEM, MA 01970 DEC - 4 2006
TEL. 978-741-1800 CITY OF SALEM
FAX 978-745-0349 BOARD OF HEALTH
Kimberley Driscoll WWW.SALEM.COM
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
2007 APPLICATION
ii FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT TEL# QLl�qG�1�(�lt� �
ADDRESS OF ESTABLISHMENT bP ) pA FAX# �Ap �/(f
—'4 1
MAILING ADDRESS(if different)
EMAIL--Business': Owner's: ,d /"
OWNER'S NAME "I'leyi_-f 1 t"i v TEL# jj g qqy�//_f/,�1
ADDRESS 1lA 0
STREET V CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
ppr^repp�ared)
EMERGENCY RESPONSE PERSON thl yen --yy1VYFl1 s HOME TEL#---------------
qrI d � t'C
UAYSUFUPERATtON Monday Tuesday Wednesday Thursday Friday Saturday Snnday
NUUR50FUPERAiIUNrah
Pleasewriteinumeotday, —y�:3D
lforexameleflam-anal 190.'
TYPE OF ESTABLIS FEE (check only)
RETAIL STOREES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$too-- ^
more than 10,000sq.ft. =$250
- - ...... . . --..--------- - ---- -------- ----------- ----- le--ss--... ...-- - _
ts
RESTAURANT YES O le than 25 sea $100
25-99 seats =$150
more than 99 seats =$200
BE6/,B--
.EA.. KF...A...ST.. YE. ....... ....S -- - -- - _ ..- ------- ------- --
NO $100
---- --- -- -----......_ - -._._ ........-------------------- ... --.._....._ ...----
ADDITIONAL PERMITS
MAKE(not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR � NO $50✓
ALL NON-PROFIT(such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a
prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are
made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief,
1h.'3vitfi4ed all state,tax returns and paid all state taxes required under the law.
Signature Date Social Security or Federal Identification Number
------------------------- ---------- ----- -------- -----------
Revised
-------Revised 11/13/06 FOODAP2007.adm Check#&Date4A/ /2 oY"4 5 f�,7�,pU
0I
�qkA `�" ,jy_�ydt�+ a..t.d,.�y�� .. �� d s�i,�,w#N.arxras`��5"•.:Ae+r dZ .d �� ^� '� g y'V,k sd"a�k$: �° �� � fig,,, ,
Common{M{ealthi of Massathuse b. "+ , ,..3s ,, "'•
CityofSalem'
"�e'}44,p,. • 'r r `.,�.` '.qe sP `"x`, Yn Y Board Of Health
lumbel-ey Driscoll
4 s r 120 Washington Street,4th Floor < C s,M r
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/19/2006
ESTABLISHMENT NAME: Quality Liquors
File Number:BHF-2004-000070 Steve's Quality Market
36 Margin Street
Salem MA 01970
LOCATED AT: 0005 GEDNEY STREET
SALEM,MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD SHP-2007-0009 Dec 19,2006 Dec 31,2007 $100.00
TOBACCO VENDOR BHP-2007-0033 Dec 19,2006 Dec 31,2007 $50.00
Total Fees: $150.00
PERMIT EXPIRES December 31, 2007
1009
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 19 of 29
r"
0005 Gedney Street Quality Liquors
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: FOOD PROTECTION MANAGEMENT
-:744-4220 - PIC Assigned/Knowledgeable/Duties PASS ❑J RED
'Owner.
Non-compliance with:
Kathleen Ingemi
Anti-Choking PASS
PIC.
" Tobacco PASS
Inspector: --
David Greenbaum EMPLOYEE HEALTH
Date Inspected: Correct By: "; Reporting of Diseases by Food Employee and PIC PASS ❑Q RED
3/28/2006 Personnel with Infections Restricted/Excluded PASS ❑J RED
Risk Level:
fix FOOD FROM APPROVED SOURCE
Permit Number: Food and Water from Approved Source PASS ❑? RED
BHP-2006-0184 Receiving/Condition PASS RED
Status:
SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS RED
#of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED
0
.Time IN. Time OUT. -
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeOTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 28,2006 ) Page I of
Item Status Violation Critical Urgency
RED: PROTECTION FROM CONTAMINATION
Violations Related to - Separation/Segregation/Protection PASS RED
Foodborne Illness Interventions
and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED
immediate correctiveaction)`
Proper Adequate Handwashing PASS 0 RED
Good Hygienic Practices PASSd❑ RED
Prevention of Contamination from Hands PASS Q RED
Handwash Facilities PASS RED
PROTECTION FROM CHEMICALS
Approved Food or Color Additives PASS RED
Toxic Chemicals PASS RED
TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
Cooking Temperatures PASS RED
Reheating PASS 0 RED
Cooling PASS 0 RED
Hot and Cold Holding PASS 0 RED
Time As a Public Health Control PASS RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food and Food Preparation for HSP PASS 0 RED
CONSUMER ADVISORY
Posting of Consumer Advisories PASS RED
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 28,2006 ) Page 2 of
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection PASS BLUE
Equipment and Utensils PASS BLUE
Water, Plumbing and Waste PASS BLUE
Physical Facility PASS BLUE
Management and Personnel PASS BLUE
Poisonous or Toxic Materials PASS BLUE
Special Requirements PASS BLUE
Other-See Notes PASS BLUE
GENERAL COMMENTS:
544:The restroom behind the counter has product stored in side. Product must be stored in an appropriate
storage area not in the restroom. If this room is a storage room the owner must remove the toilet. If this is a
restroom owner must remove all product. Owner will notify the Board od Health within one week regarding the
use of this room.
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. Mar 28,2006 ) Page 3 of
1
Commonwealth of Massachusetts
• i City of Salem
Board of Health
g� 120 Washington Street,4th Floor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/03/2006
WHO'S PLACE OF BUSINESS IS: Quality Liquors
File Number:BHF-2004-0070 Steve's Quality Market
36 Margin Street
Salem MA 01970
LOCATED AT: 0005 GEDNEY STREET
SALEM,MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2006-0184 Jan 3,2006 Dec 31,2006 $100.00
TOBACCO VENDOR BHP-2006-0185 Jan 3,2006 Dec 31,2006 $50.00
Total Fees: $150.00
PERMIT EXPIRES December 31, 2006
Board of Health 9"41ix Le lE�
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 6 of 10
a
CITY OF SALEM, MASSACHUSETTS o
BOARD OF HEALTH
j 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 -. lllddd''999(I
TEL. 978-741-1800 DEC 0 5 2005
STANLEY J. USOVICZ, JR. FAX 978-745-0343 CITY
MAYOR WWW.SALEM.COM UP S4
1
em
JOANNE SCOTT, MPH, RS, CHO SOARI) OP H
HEALTH AGENT EALrH
2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMErN/T,�p
NAME OF ESTABLISHMENT UGLY/ �QuhiS ,�TIE,L# l` l't91d(_d
ADDRESS OF ESTABLISHMENT l9 S YU!�A- AX 61Q IO
MAILING ADDRESS (if different)_ /�, t, t L'f
OWNER'SNAME�f,QP✓I urhCPM It TEL# 1l0 t 1 �I�'
ADDRESS
Alm
CITY STATE 4d. ZIP
CERTIFIED FOOD MAN GER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON HOME TEL#
HOURS OF OPERATION: Mon. ✓Tue. '--Wed.
✓Thu. -- Fri. Sat. Sun. ��—�
TYPE OF ESTABLISHM ` T,YI' V3V FEE (check only)
[RETAIL S &ES NO less than 1000sq.ft. =$ 50
0,000 =$100
more than
✓
more than 10,00000sq.ft. =$250
............... - - .............. - --- -- .......- -------- _.. .
RESTAURANT YES NO less than 25 seats $100
25-99 seats =$150
more than 99 seats =$200
------------------------ ----.......-------------------------------------- ----------------
BED/BREAKFAST YES NO ... $100
- ...
-----------------------------------....... ----------.-..........-------------------------------.......... . .......
ADDiTIC........NAL PERMITS
MAKE(not just-serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
NO 0
ALLL NON ROFITO(such as church kitc7iensJ` �a� YES NO $25 L/
'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
K.povNdge,and belief„have filed all state tax returns and.paid all state taxes required under the law .
Signature Date Social Securiri y-or Federal Identification Number
---------------------------------------------------------------- - - - ---------- ------------- ------------
Revised 11/03/05 FOODAP2.adm Check#&Date
i ,�
19::::,1[.'! -•^.
r,
CITY OF SALEM, MASSACHUSETTS
• . BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
STANLEY J. USOVICZ, JR. FAx 978-745-0343 /D-a�-07
MAYOR wW W SALEM.COM
JOANNE SCOTT, MPH, RS, CHO
October 19, 2005 HEALTH AGENT
Quality Liquor
Gedney Street
Salem, MA 01970
Dear Owner:
On Monday October 3,2005 personnel from the Tobacco Control Program conducted a compliance check
to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old female
purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health
regarding that sale.
Quality Liquor is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the
Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco,snuff,
or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of
(Two Hundred Dollar fine)for the Second offense.
FOLLOWING THE THIRD(3RD)OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION
OR SUSPENSION OF THE PERMIT.
The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your
employees to demonstrate methods to ensure compliance with this regulation.
Therefore, you are ordered to pay a fine of$200.00 for the violation stated above. A check or money
order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th
floor,within ten days of receipt of this notice.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health.
A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)
days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present
witness and documentary evidence as to why this Order should be modified or withdrawn. You may be
represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of
all relevant inspection or investigation reports,orders,and other documentary information in the possession
of this Board, and that any adverse party has the right to be present at the hearing.
If you have any questions regarding this notification please call me at 741-1800.
Sin7erely yours,
Onne Scott
Health Agent
JS/mfp
CERTIFIED MAIL: 7003 3110 0005 1992 2155
cc: North Shore Tobacco Control Program
Christina Harrington, Board of Health Chairman and Members
s
{.'t ��'.�-aa 3 G't. �. c` `A3"°�i� � w4'�c,Y`z. ��,�.<0d2�'9- ? ,."� v ��''�' " �
"'- s " CENTURY BANK AND TRUST COMPANY & tlf, ,y- "
Quality Liquors a_,; 3504
5 Gedney Street ; ' o `BOSTON MA 02110 ^ ' � ' x�`
Salem,Ma.01970 53-139/113:
978-744-4220 ' ^"
PAY TO THE Ci of Salem $--200.00
ORDER OF �'
TWO Hundred and 00/100RRif##fi#ifiifitkikkkkkkkkktkki#Rf RRRRf ki#k RRi RRRff#f###kfi#i#i#Pkkk#tkk#k##ff#if itf iifi
DOLLARS a
City of sateen
z
t
MEMO w
11'00350411' 1:0113013901: o2i 27010 4ii'
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
2 p SALEM, MA 01970
TEL, 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
June 22.2005
Quality Liquor
5 Gedney Street
Salem, MA 01970
Dear Owner:
On Wednesday June 15, 2005 personnel from the Tobacco Control Program conducted a compliance
check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old
female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of
Health regarding that sale.
Quality Liquor is in violation of Section MIA)of the Salem Board of Health Regulation Affecting the
Purchasing of Tobacco Products. According to this section,the sale of cigarettes, chewing tobacco, snuff,
or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of
(ONE Hundred Dollar fine)for the,FIRSFoffense.
4'rK4
FOLLOWING THE THIRD(3RD)OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION
OR SUSPENSION OF THE PERMIT.
The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and our
g ��,,�� Y
employees to demonstrate methods to ensure compliance with this regulation. dL�L&ei"o ��
Therefore,you are ordered to pay a fine of.$48084for the violation stated above. A check or oney
order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th
floor,within ten days of receipt of this notice.
Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health.
A request for such a hearing must be received in writing in this office of the Board of Health within seven(7)
days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present
witness and documentary evidence as to why this Order should be modified or withdrawn. You may be
represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of
all relevant inspection or investigation reports,orders,and other documentary information in the possession
of this Board,and that any adverse party has the right to be present at the hearing.
If you have any questions regarding this notification please call me at 741-1800.
Sin erely yours,
oarne Scott
Health Agent
JS/mfp
CERTIFIED MAIL: 7003 3110 0005 1992 1516
cc: North Shore Tobacco Control Program
Christina Harrington, Board of Health Chairman and Members
0005 Gedney Street Quality Liquors
City of Salem
FOOD SERVICE ESTABLISHMENT - RETAIL FOOD INSPECTION Inspection
HACCP: ❑
Telephone: Item Status Violation Critical Urgency Nature of problem or correction
744_4220 Non-compliance with: Done
:Owner: Anti-Choking PASS ❑
Kathleen Ingemi Tobacco PASS ❑
:PIC:
Peter Ingemi FOOD PROTECTION MANAGEMENT Done
Peter Ing PIC Assigned/Knowledgeable/Duties PASS d❑ RED
David Greenbaum EMPLOYEE HEALTH Done
Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED
4/4/2005 Personnel with Infections Restricted/Excluded PASS ❑J RED
Risk Level:
_ FOOD FROM APPROVED SOURCE Done
r
Permit Number Food and Water from Approved Source PASS ❑ RED
BHP-2005-0141 Receiving/Condition PASS RED
Status: Tags/Records/Accuracy of Ingredient Statements PASS RED
SIGNED OFF R
#Of CfItIC81 Violations: - Conformance with Approved Procedures/HACCP PASS ❑�/ RED
Plans
PROTECTION FROM CONTAMINATION Done
Time IN: Time OUT: Separation/Segregation/Protection PASS ❑d RED
Notes r ; Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED
59 , T
Proper Adequate Handwashing PASS RED
Urgency Description(s): Good Hygienic Practices PASS RED
BLUE:'
Violations Related to Good :, Prevention of Contamination from Hands PASS �/❑ RED
Retail Practices (Critical - Handwash Facilities PASS ❑d RED
violations must be corrected
immediately or within 10
days)(Non-critical violations
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 05,2005 ) Page 1 oft
L 4
0005 Gedney Street Quality Liquors
must be corrected immediately PROTECTION FROM CHEMICALS Done
or within 90 days) Approved Food or Color Additives PASSd❑ RED
RED. Toxic Chemicals PASS ❑d RED
Violations Related to
Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS(Potentially Haz Done
and Risk Factors(Require Cooking Temperatures PASS ❑D RED
immediate corrective action) .
Reheating PASS ❑d RED
Cooling PASS RED
Hot and Cold Holding PASS 0 RED
Time As a Public Health Control PASS 0 RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done
Food and Food Preparation for HSP PASS 0 RED
CONSUMER ADVISORY Done
Posting of Consumer Advisories PASS - 0 RED -
Violations Related to Good Retail Practices (Blue Done
Management and Personnel PASS ❑ BLUE
Food and Food Protection PASS ❑ BLUE
Equipment and Utensils PASS ❑ BLUE
Water, Plumbing and Waste PASS ❑ BLUE
Physical Facility PASS ❑ BLUE
Poisonous or Toxic Materials PASS ❑ BLUE
Special Requirements PASS ❑ BLUE
Other-See Notes PASS ❑ BLUE Establishment sells a limited quantity of
pre packaged candy, nuts and snacks. No
health code violations cited at this time.
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 05,2005 ) Page 2 oft
I CITY OF SALEM, MASSACHUSETTS'
BOARD OF HEALTH _ r
120 WASHINGTON STREET, 4TH FLOOR
c SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: Liquor Store
Name of Establishment: Quality Liquors
Address of Establishment: 5 Gedney Street
Owner's Name: Kathleen Ingemi
Restrictions:
Application Date: 11/24/2004
Permit for Food Establishment 72-05
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products 20-05
These Permits Expire December 31, 2005
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
IJ��om
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS ,-,, ,
BOARD OF HEALTH ``
120 WASHINGTON STREET, 4TH FLOOR v/3
e SALEM, MA 01970 "•. �; '.i;\_
TEL. 978-741-1800
FAX 978-745-0343 H V�3Z0
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, C O Q C'�- Q¢ lV/
MAYOR HEALTH AGENT ci p,,�7,,op ^ V
2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMEY4
NAME OF ESTABLISHMENT Cj(l od i/q Ll Q(,ttn TEL# R'lY 1Ky y i)4 0 I
ADDRESS OF ESTABLISHMENT O US PO .ILE4 qL
MAILING ADDRESS (if different) ryry
OWNER'S NAME (IfT-- � l?� n M'1 TEL# 1 Y,1
ADDRESS A[ QnG(
CITY_ ¢tn STATE IMQ ZIP O1 ct'10
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potenntially' hazardous food is prepared.)
EMERGENCY RESPONSE PERSON ka4-ln10RA f,01PrM�HOMETEL# q�g!1yy�fq/
HOURS OF OPERATION: Mon.--L,, Tue. v Wed. Thu. L.-Fri. t-Sat. L- 134-4
M- to? Pm
TYPE OF ESTABLISHM ,- FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft... =$100+/
�1J% more than 10,000sq.ft. =$250
RESTAURANT YES NO g�'"" less than 25 seats =$100
/ 25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR �Q-OS /v€� NO $50%,/ALL NON-PROFIT(such as church kitchens) S 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
bet owledge and belief, have filed all st to tax returns and paid all tate taxes required under the law.
,Roan aq ItAiot, �J_ RX -q i ` kp
Signature ate Social Security or Federal Identification Number
------------------------------------------------------------- ----------- ------------ ------------------------------------
Revised 11/03/03 FOODAP2.adm Check#&Date
%� �curolr CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET. 4TH FLOOR
SALEM, MA OI 970
" W
'DB�aMMg T E L. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ. JR. JOANNE SCOTT, MPH, RS. CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter
94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate
a Food Establishment in the City of Salem is hereby granted to :
Owner ' s Name : Kathleen Ingemi
Name of Establishment : Quality Liquors
Address of Establishment : 5 Gedney Street
Type of Establishment : Liquor Store
Application Date : 12/11/2002
Restrictions :
Permit for Food Establishment 72-03
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products 18-03
These Permits Expire December 31, 2003
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
/^f
AD
L�
HE
VTI HEALTHTH iO
AGENT
+ a CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH �11
120 WASHINGTON STREET, 4TH FLOOR (�
a SALEM, MA 01970 DEC 112002
TEL. 978-741-1800
9' FAX 978-745-0343 /I
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
BOARD ON f-iLALTH
MAYOR HEALTH AGENT
2003 APPLICATION FOR PERMIT. 'ITO OPERATE A FOOD ESTABLISHMENT
I'(�
NAME OF ESTABLISHMENT QIkOU[l` q J ( TEL# q(I 6 V 7 I -1�� U
ADDRESS OF ESTABLISHMENT PGt��u 1
MAILING ADDRESS (if different)
OWNER'S NAME— ) V� � PVV� t, TEL#_ft D q I
ADDRESS- I ��(Cka ' 1 -
CITY_1,) QJ I 0/rik STATE__02A ZIP_ _
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentiialllly,Ihazardous food is prepared.)
EMERGENCY RESPONSE PERSON UN I LY��VAlq ,111`I HOME TEL# / E_qC
HOURS OF OPERATION: Mon. Tue. L-Wed. v Thu. Fri. Sat. Sun.
�v/jaD a, p
TYPE OF ESTABLISH M / FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
/O more than 10,000sq.ft. =$250
RESTAURANT YES NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO )FfIo3 $50v'-*�
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Signatur — _ Date Social Securi or ed�eralentifican N tuber
FOO�P2.adm
Check#&Date
Revised 77r25/02 �27a
AI�5—01. —
r:frr' .....y.-,..,zti,a,-:.-^�b....laif.•azimi5�i1*i✓.,+-5t�;..^N+.+an.;�^,sTM+,.A.17 sf�,ylil°�7r<r.k:..n.sir.�.......cRr9n+.r.�wfsYm-.94K+m•as..cmvev`u..,A^�- -"+
4 THE COMMONWEALTH OF MASSACHUSETTS
CITY OF SALEM Address: 120 Washington Street, 4th Floor
BOARD OF HEALTH Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343
Name Date Type of Operations) TvDe of Insnection
n J 3 E❑7Food Service Routine
N Address 6� Risk - Retail �] Re-inspection
Level 1 ❑ Residential Kitchen Previous Inspection
Telephone _ )(/(/ _ !l/ ` C-• ❑ Mobile Date:
Owner / �'� / /W a/ - HACCP Y/N ❑ Temporary ❑ Pre-operation
❑ Caterer ❑ Suspect Illness
Person In Charge(PIC) _ ---�/ G� Time ❑ Bed&Breakfast ❑ General Complaint
_ In: El HACCP
Inspector V V Cr� Out: Permit No. ElOther
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)
violated. Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health. Local Law ❑
FOOD PROTECTION MANAGEMENT 411 ❑ 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
El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
El 4. Food and Water from Approved Source
TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
... *-
❑
El 5. Receiving/Condition 16. Cooking Temperatures
El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating
❑ 18. Cooling
❑ 7. Conformance with Approved Procedures/ HACCP Plans
PROTECTION FROM CONTAMINATION El 19. Hot and Cold Holding
❑ 20. Time as a Public Health Control
❑ 8. Separation/Segregation/ Protection
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ El10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 11. Good Hygienic Practices
❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/Federal Food Code.This report, when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
i 26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you
A 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:
Inspector's Signature: Print J ��
PIC'sSignature: �r/ t Print: Pag(Z06Pages
FORM 734A HOBBS&WARREN/-BOSTON
Violations Related to Foodborne Illness
Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from
11 590.003(A) Assignment of Responsibility* Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2>, 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection*
require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables
Applicants
3.304.11 Food Contact with Equipment and
590.003(F) Responsibility of a Food Employee or an Utensils*
Applicant to Report to the Person in
Charge* Contamination from the Consumer
3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated
'if3: 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces Food and Water From Regulated Sources
4-501.111 Manual Warewashing-Hot Water
590.004(A-B) Compliance with Food Law* Sanitization Temperatures*
3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water
3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures*
3-202.13 Shell Eggs*
4-501.114 Chemical Sanitization-temp.,pH,
3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness*
3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and
5-101.11 Drinking Water from an Approved System* Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0*
Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment*
Shellfish*
4-703.11 Methods of Sanitization- Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources*
10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*
2-301.12 Cleaning Procedure*
3.202.18 Shellstock Identification Present* 2-301.14 When to Wash*
590.004(C) Wild Mushrooms* 11 Good Hygienic Practices
3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco*
5 Receiving/Condition 2-401.12 Discharges From the Eyes, Nose and
3-202.11 PHFs Received at Proper Temperatures* Mouth*
3-202.15Package Integrity* 3-301.12 Preventing Contamination When Tasting*
3-101.11 Food Safe and Unadulterated* f :12_ Prevention of Contamination from Hands
',..k... Tags/Records:Shellstock 590.004(E) Preventing Contamination from
3-202.18 Shellstock Identification* Employees*
3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities
Tags/Records:Fish Products Conveniently Located and Accessible
3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement*
590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance
7 Conformance with Approved Procedures Supplied with Soap and Hand Drying
/HACCP Plans Devices
3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability
3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision
8-103.12 Conformance with Approved Procedures*
•Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
CITY OF SALEM
( BOARD OF HEALTH
Establishment Name: _ \l 'C— Date: Page: 2. of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTIONDate
No. Reference R-Red Item - Verified
PLEASE PRINT CLEARLY
A C�f��-z v r /�� (4) st
,r
S - .-
it
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
iF
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
comply with all mandates of the Mass/Federal Food Code. I understand that Ll Re-inspection Scheduled ❑ Emergency Suspension
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
f ❑ Voluntary Disposal ❑ Other:
F
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Items 1-22) (Cont) 41'F/45'F Wi tbur 4 Hours.
PROTECTION FROM CHEMICALS
3-50t.15 Cooling Methods for PHFs
Color Lo PNP Hot and Cold Holding
Ll-4 Food orolor Addio
3-501,16(11) Cold PI-fFs Maintainedai or below
3-202,12 Additives'( 590.004(F) 41`145°F*
1-302,14 Protection from Una pproved Additives*
Poisonous or Toxic Substances 3 501.16(A) Hot PITFs Maintained at or above
15 14VF. *
7-101.11 ldervtifyina,Information-Original 3-501.16(A) I Roasts Held at or above 130'F-
Containers"
7-102,11 Corninon Name-Working Containers" F20 Time as a Public Health Control
7-201,11 Separation-Slot asre* 3-501.19 Time as a Public Health Control',-
7-202,11 Restriction-Presence and Use 590.004(1-1) Variance Recluiveniciat
7-20112 Conditions of Use'
7-203.11 Toxic Containers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chcrincids* POPULATIONS(HSP)
7-204.12 Chemicals for Washina ProduceCriteria* 21 3-901A](A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents.Criteria* Beverages with Aarnml-ibcls*
7-205.11 Incidental Food Contact.Lubricants* 3-801.11(B) Use of Pasteurized Ea-gs,
11 411
7-206, Restricted Use Pesticide.,,Criteria" 3-801.11(D) Raw a; Partially Cooked Antmal Food and
-.L 1 1 Raw Seed Sprouts Not Served. :'
7-200.12 Rodent Bait Stations T 3-801.1.1(C)
I7no.ened Food Parka>e Not Re-served-
7-206.13 Trackir1�n,Powders,Pest Control and
--Monitorin>* CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
.6 Proper Cooking Temperatures for Animal Foods-fliat are Raw, Undercooked or
Processed to Eliminate
Not Otherwise Pro
PHFs 1/1111,001
3-401.1 lAi,])(2) Eggs- 155°F 15 See. Pathogens.,:
g
ha-s-Immediate Service 145'1--15scc* 3-302,13 Pasteurized Eggs Substitute for Raw Shelf
3-401.11( )(2) Commined Fish.Meats&Game Eg,s�
ut
Animals- 155'F 15 see. * SPECIAL REQUIREMENTS
3-401.11(8)(1)(2) Pat k and Beef Roast- 130'F 121 min"
3401.11(A)(2) Raines, Injected Meats- 155'F Ifi 596-009(A)-(D) Violations of Section 590.009(A)-(D) in
sem * 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 il'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-
Miciowave 165"F* Special Requirements.
3-401.11(A)(1)(b) AJlOther PHFs 145'Fl5sec.
� I
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICE
3-403,1 I(A)&(D) PI-1Fs 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
Tulle" foodhorne illness interventions and risk(actors listed above, can he
3-403.11(C) Commercially Processed RTE Food-
found in the folluivito,sections oj'the Food Code and 105 CMR
14017* 590.000.
- - e-1, Good Retail Practices L 000
3-403,1.1(E) Remaining Unsliced Portions ofBee f Ttm
Roasts" i 23. Management and Personnel
i
124 Food and Food Protection PC-3 .004
Proper Cooling of PHFs 25 Equilan
3-501.14(A) Cooling Cooked MIN from 140O7 to entamdUteresils FC-4 .005
-------- ---------- --- -
26. Water,Plumbing and Waste FO-5 '006
7(.)'F Within 2 Hours and From 70"F 27. F-C--6 007
21. Physical Facility
to 4l'F/45'FVrithin 4 Hours. 28. Poisonous or Toxic Materials FC-7 008
3-501.14(B) Cooling PHFs Made Front Ambient Requirements -foO9
Temperature Ingredients to 41'F/45-F 30. Other -------
Within 4 Hours''
'Donoie,critical item in the toleral 1999 Food Ccxle ur 103 CMR J90.000.
..... . . . . ..
.. .. .. . ... .. .. .
... .. .... .... .. ..............
...... .. .. .. .. . .. ..... .. .. ... .
. .. .. .. ... ... ..
H.H. Morant & Co., Inc.
Architects
P.O. Box 4485
69 Lafayette Street
Salem, Massachusetts 01970
-71
F
(978) 744-5354
(978) 740-9161 Fax
NCP Bath
. ..... .. ropoeeol Cooler Job Number:
2
By Others (Confirm Size
4 Configuration ui/ the
00-021
PCF Bath Owner Date:
June 20, 2000
NO. Date Revision Dr.
........... !Sales Ar
e/15/00 Plan
r
Q)
H
13
Project:
Q) Gedney Street
° - �', 'S / Renovation oua/[44 ma')te+
Neu Li t B Oth r5 0 0
(Cc iTirrri Size 4
Cot fieur ion
W/ tne Ow
Q)
U J
Gedney Street
Salem, Mas achusetts
4" Erick
Veneer
L — — — — — — — — — — — - -- Firet F-11 or Plan
Scale:
54'- 9
14'-1 114" 1/4 10
1 CITY OF SALEM, MASSACHUSETTS
• BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: Liquor Store
Name of Establishment: Quality Liquors
Address of Establishment: 5 Gedney Street
Owner's Name: Kathleen Ingemi
Restrictions:
Application Date: 12/2/2003
Permit for Food Establishment 64-04
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products 15-04
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
' j o CITY OF SALEM, MASSACHUSETTS 9-1
t l g
BOARD OF HEALTH I�
e 120 WASHINGTON STREET, 4TH FLOOR
• SALEM, MA 01970 NOV 212003
TEL. 978-741-1800
FAX 978-745-0343 OI I y OF SALEM
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH
MAYOR HEALTH AGENT
2004 APPLICATION FOR PERMIT+ J TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT �(tiQ 1 (/Yq �tAC( Od S TEL#
ADDRESS OF ESTABLISHMENT ��dytey V
MAILING ADDRESS (if different) , !
OWNER'S NAME , 1 -eQ ,/Yl PJ TEL# I0p ' IN �tql
ADDRESS � �l (- I^WhAaAd 6 u-L _
CITY n'Vy STATE YYkOL zip1 y
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON HOME TEL#
HOURS OF OPERATION: Mon. 1/Tue. L/Wed. IThu. Fri. Sat. t/ Sun.
TYPE OF ESTABLISHMEWR FEE check only
RETAIL STORE ES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
VVI more than 10,000sq.ft. =$250
RESTAURANT YES NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 /
TOBACCO VENDOR 15-0r YES NO $50✓
ALL NON-PROFIT(such as church kitchens) YES NO $25
?!ease pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Signatu, /n� Date j� fN/a.-Social Security or Federal Identification Number
61�CL - ------- 1 -- -----------------------------Ova- ----- r
Revised 11/03/03 FOO AP2.ad Check#&Date ��.S'9- �/�SL.,d 3 'i -------
'A
(�'-'- 1 "1�Q
r Salem Board of Health
Massachusetts, Department of Public Health 120 Washington Street,4r" Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978) 745-0343
Name Date Type of Operation(s) T 4 of Inspection
:s3-F ❑,i ood Service 97Routme
Address G' C.1 Risk ®'Retail [I Re-inspection
S 6 E N / .Sf Level ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:3-13-01
7('l 7�//_ 4,2 2 U [I Temporary ElPre-operation
Owner Crr �� HACCP YM F1Caterer C3 Suspect Illness
L ei
Person in Charge(PIC) / Time E] Bed&Breakfast 171 General Complaint
04✓* ar vm r In: ❑HACCP
Inspector 7)r p p� - y1 j /�f' jtOut: Permit No. ❑Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors, Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT,," . 4, ,.„. .__, a fi ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS • `'-` - " r
❑ 2. Reporting of Diseases by Food Employee and PIC [114.
14.Approved Food
or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE ` .ri,� - .;. - w•- .�• '=TIMFIT'EMPERATURS CONTROLS(PotenBally Hazardous Foods)
C] 4. Food and Water from Approved Source o_ , ' , ,_ � _,
❑ 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 ". " " E] 19.Hot and Cold Holding
❑ 8.Separation/Segreu
gation/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 [122, Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related o
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
i 7 F by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
S,501. aFo�14.r
•to 's• gz Print:
PIC's Signature: \ Print: f. - Pagel of CR Pages
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) Assi,,ment of Responsibrht,* 3-302.11(A)(1) Raw Animal Foods Separated from
090.00_3(B)�7 DemonstrttionofKnowliah, Cooked and RTE Foods`
2-103.11 ( Person in charge-duties _ Contamination from Raw ingredients
3-302.11(.4)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Rcsponsibilily of the person in charge to Contamination from the Environment
require repotting by food employees and 3-302.11(A) Food Protection'
amlicants* 3-302.15 Washia Fruits and Ve etables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person hr Utensils*
Chaise* Contamination from the Consumer
590,003(13) Re Martins by Person in Chuee'" 3-306.14(A)(B) returned Food and Rescmice of Food*
3 590.003(D) Exclusionsand Restrictions* Disposition of Adulterated or Contaminated
190.0030 Remoeal of Exclusions and Res fictions �- Food
3-701,1 11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Few*
4 Food and!Nater From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compli wce with Food Law'# 4-501 A I I Manual Warewashing-Hot Water
3-201.12 Foai in a Hermeticall Sealed Container* Sanitization Tem eratures*
3-201.13 Fluid Milk and Milk Products*
4-501.11.2 Mechanical Warewashing-Hot Water
3-202.13Shell E-s* Svutizatlon Tem eratazes*
3-202.1.4 F =s and 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(Aj Equipment Food Contact Surfaces and
5-101.11 Drinkin Water from an A roved S stem" Utensils Clean'
590.006(A) Bottled Drinkin Water* 4-b02.11 Cleaning Frequency of Equipment Food-
540.006(13) Water Meets Standards in 310 CMR 22.01` 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 Peereatianally Caught Molluscan Foal Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed _ Chemical*
sources* to Proper,Adequate Handwashing
- Game and[Mild Mushrooms Approved by _T301.11 Clean Condition-Hands and Aims*
fle utafo Authorit
3-202.18 Shellstock Identification Present* 2-301.12 CleaningPcoeednre*
590.004(1:) Wild Mushrooms* 2-301.14 When to Wash"
3-201.17 Carne Animals* 1.1 Good Hygienic Practices
K Receiving/Condition 2-401.11 Elan v,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Tem aeratures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Packa e hit e a�* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301..12 Preventin Contanrina[ion When'Fastin
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 rhoyees*
Tags/Records:Fish Products I3 Handwash Facilities
Conveniently Located and Accessible
3-402.7 I Parasite Destruction*
5-203.1Numbers and
3-402.12 Records,Creation and Retentions` Placement*
s*
590.004(7) Labeling of Ingredients' 1-20=4.7 1 1 Location and Placemen
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Pians Supplied with Soap and Hand Drying
3-502.11 S eeializsd ProcessingMethods* Devices
3-502.12 Reduced axvgen aacka ring,criteria* 6-301.11 Handwashin Cleanser,Availabdit
8-103.12 Conformance with A. p roved Procedures'" 6-301.1.2 Hand D in•*Provision
*Denotes critical item in the federal 1999 Food Code,or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: 04±11". > L (2 ,2oWDate: .R- J- c U Page: �;Z- of _2-
Item Code C-Crlticaritem *`- DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item Verified
- PLEASE PRINT CLEARLY ----
) AO yW )? a fly" n r/C /l fi/ /=7L'
U J
Ala A�
We
C
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
❑ 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- ollars or uspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. �
❑ Voluntary Disposal ❑ Other:
Y �
3-501.14(C) PHFs Received at Temperaftees
Violations Related to Foodborne Illness Interventions and Risk According*to Lrw Cooled to
Factors(/tents 1-22) (Cont.) _ 41"17(45°F Within 4 Hours. x
PROTECTION FROM CHEMICALS 3-50L15 Cotlin2Methods forPHFs
T9
14 Food or Color Additives PHF Hot and Cold Holding
-- 3-501.16(B) Cold P,IIFs Maintained at or below
3-202.12 Addiuves'' 590,004(F) 41`/45°F*
3-302,14 protection front Una roved Addumes* 3-501.16(A) Hot PFIFr,Nlainfained at or above
15 Poisonous or Toxic Substances
140"P,
7-161.11 Identifying Information-Original 3-501.10(A) Roasts Hetdat(it above '130'F."
Containers" -
7-102.11 Conttnon Mane-Working Containers' 20 Time as a Public Health Control
7-301.11 Separation-Stor3-501.19 Time as a Public Health Control
a c* _ --
7-20211 Restriction-Presence and User 590.004(11) Variance Ret wrumenY
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
-T-20-1 i1 Toxic Containers-Prohibitions*
7-264.11 Sanitzers.Criteria C'hemicnis POPULATIONS(HSP}
7-204.12 Chemicals for Washing Produce Criteria* 2T 3-801.11(A) Unpasteurized Prepackaged Juices and
7-2 4.14 D vine Agents.Criteria* Beverages with Warning Labels*
3-801.11(B) Use of Pasteurized Eggs*
'1-2(2,5.11 Incidental Food Contact,Lubricants*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.1.1(D) Raw or Partially Cooked Served. Eooct and
Stations* Raw Seed Sprouts Not Served a'
7-106,12 Rodent Bait Stators' 3-801,1 l(C) Unopened Food Package Not Re-served.
7 206.13 Traci rn�Powders, Pest Control and
Monitoring* CONSUMER ADVISORY
TIMEITEMPERA_TURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
iAnirmd fronds That are Raw. Undercooked or
16 Proper Cooking Temperatures for
PHFs Not Otherwise Processed to Eliminate
3-40i.I IA(1)(2) Eggs- 155 15 Sec
Pat] e g"
'17
Eggs-Train dirte Service 145"F15sec* 3-30113 1 Pasteurized F„os Substitute for Raw Shelf
3-401,11(A)(2) Comminuted Fish.Meats&Game Lgg't
Animals- 155".17 15 sec. *
3-401.11(B)(1)(2) Porkand;BeefRoast- 130"F 121 Tnin'r SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats- 155`17 15 590.009(A)-(D) Violations of Section 590.009(.A)-(D)in
le.0 * catering, mobile food, temporary and
3-<401.11(A)(3) Poultry,Wild Game. Stuffed PHF,, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Pouhry or Ratites-165°F 15 sec * above if related to Foodborne illness
3-401.1 I(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 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
3-403A 1(A)&(D) PHFs 165-F 15 see. * (Items 23-30)
3-403.11(B) Microwave-165'F 2 Minute Standing Critical and non-critical violations, which do riot relnte to the
Time* foodborne illness inten,entions and risk{actors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following+sections<rf the Food Code and 10.5 ChIR
I4WFt 5,90.000. _
3-40-3 11(E) Remaining Unsliced Portions of Beef item Good Retail Practices ? FC 590.000
Roasts* Management and Rarsonnel_ FC-2 .003
Ig Proper Conlin of PHFs 24. Food and Food Protection FC-3 .004
-- -__
25. _� Equ�ment and Utensils FC--4 .005.
3-501.14(A) tooting Conked PHFs Srom 140'F Co 26. Water Plumbing and Waste FC-5 006
70"F Within 2 Hours and Front 70°F 27. Ph sical Facllit 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 Ambien[ 129. Special Requirements j .009
30 Ot - - - - �- --
Temperature Ingredients to I I F745°F her -- r- _-
Within 4 Hours*
'Drnole,critical item in ihefederal 1999 Food Code or 10�CMR 590.000.
T
CITY OF SALEM, MASSACHUSETTS
' BOARD OF HEALTH ^l
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 �d ,
P, TEL. 978-741-1800 ^ ()
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO "(, r--
MAYOR HEALTH AGENT
April 12,2004
Quality Liquors
5 Gedney Street
Salem,MA 01970
Dear Owner,
On March 27,2004 personnel from the Tobacco Control Program conducted a compliance check to
determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old male
purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health
regarding that sale.
Quality Liquors is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the
Purchasing of Tobacco Products. According to this section, the sale of cigarettes,chewing tobacco, snuff,
or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of
ONE hundred dollars($100)for the FIRST offense.
The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your
employees to demonstrate methods to ensure compliance with this regulation.
Therefore,you are ordered to pay a tine of$100.00 for the violation stated above. A check or money
order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4ch
floor,within ten days of receipt of this notice.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health.
A request for such a hearing must be received in writing
in this office of the Board of Health withm seven
(7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to
present witness and documentary evidence as to why this Order should be modified or withdrawn. You may
be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies
of all relevant inspection or investigation reports, orders,and other documentary information in the
possession of this Board, and that any adverse party has the right to be present at the hearing.
If you have any questions regarding this notification please call me at 741-1800.
Sincerely yours,
oanneScott
Health
Agent
JS/bas
Cc:North Shore Tobacco Control Program
Christina Harrington,Board of Health Chairman
I
e �
f N2 2175
N Ser a City of Salem - Board of Health
Violation Notice - Tobacco Sale to Minors
Mw gym✓�
This notice is to inform you that during a tobacco sales compliance check,your establishment violated the
Salem Board of Health regulation#24 prohibiting the sale of tobacco products to persons under 18 years
of age.
CQljv6-t-tT'/ L_1 QLt4Dre•9
Name of establishment
�-
Address
9� //:-/fe.Yt !7
Dnate of sale Time of sale Minor's age/gender Minor's ID#
Adult
l sors
Narrative report of incident and description of seller by adult supervisor who will testify at the Salem
Board of Health meeting including a description of the seller:
I affirm, under the pains and penalties of perjury, that the above report is true to the best of my knowledge
a elief.
nAdQult supervisor(Signature)
Lro
Adult supervisor (Print name)
VENDOR STATEMENT: I acknowledge I received this Violation Notice on *9
at I L/ Mand I am being given a carbon copy of this notice. I also acknowledge that I
have been told that a letter regarding Board of Health follow-up to this violation will be mailed to me at
the above address.
c
Owner/Manager er (Si a re
Owner/Manager/Clerk( int name)
If vendor refuses this Notice or if Adult Supervisor feels unsafe in delivering it, an explanation must be
written on a note attached hereto. Mailing of this Notice is thus required.
For further information, contact the North Shore Tobacco Control Program at 978/741-5646.
Board of Health-white/NSTCP-yellow/Establishment-pink