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QUICK PICK CONVENIENCE - ESTABLISHMENTS r ViCIC �ic (C (COVE niyAct 'RNIVERSAL® UNV-12110 MADE IN USA SUSTAINPBLE MN RECYCLED FORESTRY '0 NITIAPVC c.reg.e FL.r sour.Ng rosTtaNsuRAER mvw.fiprogram ag SI u1TA Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 Cit /Town of ,SRL Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name Date Type of Operationfs) Type of Inspection L LIZ ❑ Food Service ❑Routine Address o f7Zt i Risk Ea Retail ❑Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection �'i �O ❑ Mobile Date: Owner HACCPYM [I Temporary Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint r^� In: El HACCP Inspecto Out: Permit No. ❑.Other Each violation chocked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) El Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. pOOD_aRGTECTION MANAGEMENT' _ - ❑ 12. Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties ---- _ _ _ ❑ 13. Handwash Facilities LO rEMPYEEHEALTH -� - - � -T ❑ 2. Reporting of Diseases by Food Employee and PIC ;PROTECTION FROM'CHEMICACS_ _ _ _ ❑ w ❑ 3. Personnel with Infections Restricted/Excluded 14.Approved Food or Color Additives _ �. ❑ 15 Toxic Chemicals L,FOOD'FROMAPPROVED SOURCE . __. _ y ❑ 4.- Food-and Water from Approved Source �TIMEITEMPERATORE"CONTROLS(t?otentlally Hazardous Foods)_. ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling - - - - .. ..___nom -_-.-_. l -` 19. Hot and Cold Holding �PROTECTION FROM CONTAMINATION __ _ _ ) 9 ❑ 8.Separation/Segregation/Protection y r ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR,HIGHLY4US..CEPTIBLE=POPULATt6NS ❑10. Proper Adequate Handwashing ❑21.Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices ,CONSUMERAOVISORY_�___ .J ❑22. Posting of Consumer Advisones 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 detennined by the Board today, the items checked indicate violations of 105 CMR of Health. C N p 9 590.000/federal Food Code.This report,when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations Equipment and Utensils (FC-4X590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S: lsfArtm Inspector's SignaPrin tut:D \.D � J� 1 PICS Signature: Print: I Page/ as ages Violations Related to Foodbome Illness Interventions and Risk Factors(Nems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge' Contamination from Raw Ingredients 2-1.03,11 Person in charge-duties 3-302.1.1(A)(2) Raw Anirr l Foods Separated from Each Oihcr* 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 Washin Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Foul Employee Or An * Applicant To Report To The Person In Utensils Contamination from the Consumer Charge* 3-306,14(A)(B Returned Food and Reservice of Food* 590.003(0Re y ting b Person in Charee* D 3 590.003(D) Exclusions and Restrictions* �posdion of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe _ FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources FT Food Contact surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 ManualWarewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanitization Te ratures" _ 3.201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* - Sanitization Temperatures* 3-202.14 ,Eggs and h&ilk Products.Pasteurized* 4-501.114 - Chemical Sanitization-temp.,pH, 3-202.1,6 ice Made From Potable Drinking Water* concentration and hardness.* 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(.0 Borded Drinking Water* - Utensils Clean* 590.006tEj Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequencv of Equipment Food ShettTsh and Fish Fron an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3 201.15 Molluscan Shellfish from NSSP Lested Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulatoAuthorit 2-301.11 Clean Condition-Hands and Arms* 3-202.1.8 SheilstockIdentificationPresent" 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* . 1 11 Good Hygienic Practices g Receiving/Condition 2.401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Tem eratures+ 2-401.12 Discharges.From the Eyes,Nose and 3-202.15 Package line grit * - Mouth* 3 I0;A I Food Safe and Unadulterated* 3-301,12 Ereventin Contaznination When Tastin * 6 Tags/Records:she0stocit 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Sheilstock Identification Maintained* Employees,* Tags/Records:Pish 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(n Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans SuppW with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,critera* 6-3(11.11 Handwashing Cleanser,.Availabili 8-103.!2 Conformance with Approved Procedures°` 6-301.1.2 Hand Drying Provision Denotes critical kem in.the Federal 1999 Fond Code or 105 CMR 590.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: PIUL- Date: 1v- 12 Page: Z of 2 Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R-Red Item Verltled PLEASE PRINT CLEARLY �'$,r�t Ie�S � � C�•r�vL; � salvo �� NoL]�jeA1a-t b ' >J -i 4_- TDRA)%S Wt) S E% fA 0)c L\v sJ p1 v iT S2 rc1A t9� LL 1v. 'X' V V V t"m Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twent five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: A 3-501,14(C) PHFs Received at Temperatures Violations Related to Foodborne fitness interventions and Risk According to taw Cooled to Factors(Home 1-22) (Cont.) 41'F145°F Within Hours. PROTECTION FROM CHEMICALS 3-50t.15 Coolin Methods for PHFs ,t 14 - Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41°145°F* ,I 3-302.14 Protection frorn Unapproved Additives* n - 15 Poisonous or Toxic Substances 3-50 L l6(A) Hot PRFs Maintained at or above t Map. 7-101,11 IdentifyingInformation-Original 3-.501.16(A) Roasts Heid at or above 130'F. Containers` 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* - 7-201..I I Separation-Stora e* - - 3-501:14 Time as a Public health Control* 7-202..11 ,Restriction-Presenceand Use* 590.004(R) Varianceuirement i 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREM FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitize".Criteria-Chemicals* POPULATIONNSS(HSP) 7-204.12 Chemicals Sir Washing Produce,Criteria* 21 3-801.1I(A) Unpasteurized Pre-packaged Juices and Beverages with Wanting Labels* 7-204.14 Drying Agents.Criteria* 3-801.11(11) Use of Pasteurized Eggs* - 7-205.11 incidental Food Contact,Lubricants* 3-801.1 i(D) Raw or Partially Cooked Animal Foal and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed S ds 3LTot Served- 7-206-12 erved7-206.12 1 Rodent Bait Stations* 3-801.11(C) Unopened F(wd Package Not Re-served. 7-206.13 Tracking Powders, Pest Control and Momtnnn * CONSUMER ADVISORY CONTROLS 22 3-603.11 Consumer Advis ry Posted for Consumption of TIMEIfEMPERATURE C 16 Proper C ONTR Temperatures for Animal Foods That are Raw,Undercooked or r Not Otherwise Processed to Eliminate PHFS Pathogens.*m«e.*ui2oet TZI.IIA(i)(2) Eggs- 155°F 15 Sec. 'i Egos-Immediate Service 145°Fd5sec* 3-302.13 E steurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game Animals-155°F IS sec.* SPECIAL REQUIREMENTS 3-401.11(11)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in t 3-40IA I(A)(2) Ratites,Injected Meats-155`F 15 k Sec.* catering,mobile foots,temporary and tresidential kitchen operations should be a-401.I.I(A)(3) Poultry,Wild Game,Staffed PHFs, Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-I65°F 15 sec, * above if related to foodborne ilb less 3 401.11(C)(3) Whole-muscie,Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail l 3-401.12 Raw Animal Fords Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401:11(A)(I)(b) All Other PHFs-- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 34-03.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403A I(B) Microwave- 1650 F 2 Minute Standing Critical and non-critical violations,which do not relate to the Tine* foodborne illness interventions and risk factors listed above, can be 3-403,11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3403.1I(E) Remaining Unsliced Portions of Beef item Goad Retail Practices FC 540.0U4-i Roasts* L23_ itafanagementandPersonnel IFC-2 .003 + 1 24.. Toad and Food Protection ( FC--3 .004 18 Proper Cooling of PHFs .005 -- { 1 26. Equipment and Utensils I FG-4 3-501.14(A) Cowling Cooked PHFs from 140`F to 126, 1 Water.Plumbing and Waste i FC-5 066 70°F Widtin 2 Hours and From 70°F 27. Physical Facility007 i to 41'F/45'F Within 4 Hours.* 1 28. { Poisonous ar Toxic Materials i FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient y2� 9. �S�l�iaj Requirements 009 f Temperature Ingredients to 41°F/45°F i Other - - ` Within 4 Hours* Dmotm critical ivtn in the federal 1999 Food Cale or 105 Calk 590.000. 4 s4=,.- Commonwealth of Massachusetts y� X, � CIof Salem r.,� ..� K�mbedeDriscoll` s *� Board of Health „ a f� mom# Mayor'- 120 ayo 120 Washington Street,4th Floor SALEM,MAT 01970 a r Food/Retail Establishinent Permit I)ATEPRINTED 08/2012012 It a � . : " ESTABLISHMENT NAME s Quick Pick Convenience J �,_:! File Number BHF-2004-000025 �`. 207 No[th St[eetall 1401 7 r Salem' 3 a; M a 01970 k LOCATED AT 0207 NORTH STREET <kj;z� SALEM ,-MA 01970 Permit Type Permit No.` Per�rut Issued 'Permit Expires Fee,Restrictions/Notes E A 'RETAIL,FOOD � BHP-2012-0590 " A g 20,2012; Dec 31;2012 -$280.00= TOBACCO VENDOR'BHP-2012-0589 Aug 20,2012 Dee 31,2012 0,,$135 00 , 5 yTotal Fees $415.00 ti e a ` s � .h F � 4 fis d 3 tC orl - PERM TT-EXPIRES December 3120121 3 y � Board of Health c " ••. .d g i I aru ILL ss'.. ,„� .�a € M This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be pasted' ffi.< in a prominent location in the Establishment. p Ai} ; 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 �- k Page,1 o Cary or SAr_.F;M MASSACHUSETTS Public Health Bonito or HEAL I I 120 WAST IING ON SRF;p'j' V,F1.00R KIMBERLEY DRISCOLL, - Tvj-(978)741-1800 FAX(978)745-0343 LARIiI'RAMUIN,ILS�RI+FIS,CI-IU,CI'-I S MAYOR lramdin e salcm.com Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: Q V1-S,_C SCS *S Gtj( -c 2) Establishment Address: 2Q ( M (nQ 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: g - - -+ois 5) Applicant Name&Title: g `-SN GAI C O VJ N Z-A. 6) Applicant Address: fPHVP-STMr,-. SMA-018A ' ' ( Nt `V� t 7 Applicant Telephone No: '*81-111114410& y81 _ y�&Hour Emergency No:18l-AT6_9Email: 0 Fdd r� .8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation An individual �s sp5 �7� mANH4c�R ) Pzn,�NUl�Sr A partnership Other legal entity L.L-rl L�RscA m� 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: NQS C S 1� s' L Address: P Z Telephone No: k115- Fax:614-jj)j-hjj4j Email: Emergency Telephone No: �fisl-hlwy) -9�+09 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: ,JS 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) IR Retail( 1300 Sq. Ft) ❑ Caterer %ooPermanent Structure ❑ Food Service—( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service—Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service—Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: -----........................................................................Breakfast-Esta__b_li_s_h__m__e__n_ts------................... ESTAU (check one) RETAIL STORE RESTAURANT 1/Annual ❑ Less than I000sq.ft. $ 70 ❑ Less than 25 seats $140 SeasonallDates: NJ 1000-10,OOOsq.ft. (—R80- ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. 20 ❑25-99 seats $280 /4 J0 ❑ More than 99 seats $420 TemporarylDates/Time: f 7 t--- ------ ------------ ----- --------------- -------------------------- Bed&Breakfast/Childcare Services/Nursing Home $100 ----------------------- ---------------------------- ---------------------------------------------------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ° )SI TOBACCO VENDOR $135 ❑ALL NON-PROFIT (Including, church kitchens, state funded childcare 8 private clubs 23) Food Operations: Definitions: PHF-potentially hazardous food(timeRemperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) (check all that apply): RTE-ready-to-eat foods(Ex.sandwiches,salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs V Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- cgq� Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: / Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: Fa S_13 ='k 00I 0 Rc)9I J4 26) Signature of Individual or Corporate Name: �'lisl6�oJf3Gt'�� 1 The Commonwealth of Massachusetts I[ Print Form ` Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print �Legibly Business/Organization Name: SFiR� ✓ ss / �1 ;�la�At� S LL.0 �g�-0V-_—,.LKPZ-CR CC)0 V T=to M_U4,3 Ct-- Address: 9.0"4-1 tj02TH S 0 LF_-M j ODO` C2191=0 City/State/Zip: S �() l 00jff-_0 L 9TO Phone #: I'4"gl-A 4-04 Are you an employer?Check the appropriate box: Business Type(required): 1.14 I am a employer with employees(full and/ 5. K Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl. real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3 ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.E] Manufacturing no employees. [No workers' comp. insurance required]* 11 L] Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an -organization should check box#I. am an employer that is providing workers'compensation insurance for my employees. Below is the',p``olicy information. Insurance Company Name: N n"F-OL K � T�IJH A M -Mt)(J Sy JZG 1y1C Insurer's Address: !2_2,2 , AM cS TP,F� ) p f� ^� City/State/Zip: P.o Box'-9109 �-)I I© ` M t mot - o G-©� I Policy#or Self-ins. Lic. # O j9 2 Expiration Date: 6110k_0? 9_01 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. j do hereby certify,undg the pains and penalties of perjury that the information provided above is true and coorrect. Sign ore: � ,` y Date: 1 SU IY�� ' O(o� o� Phone#: Official use only. Do not write in this area,to be completed by city or town officiat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia y T� CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH PLLb]1CI'IQa1th 120 WASHINGTON STREET,4"FLOOR Prevent.promote,Protect TEL. (978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOLL 1ramdin&sa1em.com LARRY RAMllIN,l2S/ItEHS,C1 10,Cl'-IS MAYOR HEAI,'I'I-I AGENT 201A APPLICATION FOR PERMIT FOR SALE OF TOBACCO AND NICOTINE DELIVERY DEVICES S 7-S-z- AN J7 5 W ft�� -� _ PERMIT FEE $135 '� qq CONV�Ns�r� C� NAME OF ESTABLISHMENT MBO- QU:X r�sClt TEL# r�!;R1 -,415- 940 ADDRESS OF ESTABLISHMENT DDT, o\.bRTH SIRE-GT FAX# 07-- '41h- Ah*(7 DEPARTMENT OF REVENUE APPLICATION NUMBER: A�--' 189 C MAILING ADDRESS (if different) f I , t-S�Q H0 J95T Ay F IJU E' EMAIL-Business': l{�Z�S — K� D S®�AH Website OWNER'SNAME TEL# �^ ADDRESS SNE 'S CITY L sCA M C� 8 STREETSTATE ZIP EMERGENCY RESPONSE PERSON-K)--,s-'v--%,Q 1P0-TALL HOME TEL# jeIl- 4-/h- kN49 Type of Products Sold: Cigarettes L ' Cigars Chewing TobaccoL' Pipe/Cigarette Tobacco Lf Nicotine Delivery Devices le Other Tobacco Product(list in additional Sheet) DAYS OF OPERATION MondayTuesday /Wednesda�yr Thursday / Friday Saturday Sunday HOURS OF OPERATION 6TOOPRt GT0I0PMlJTOI01'PGTOIOPI� prO Pm! GTOI0P1 6-To 9P Please wile in time of day. (Forexample I1am-11pm) k Please a total with one check payable to the Ci of Salem. pay PY City 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. j(/ ` owl Signa ure Date Social Security or Federal Identification Number ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Updated 7/23/12 TOBACCO.doc Check4&Date $ IMPORTANT MESSAGE FOR RU A.M. DATE TIME P.M. M Wt OF M% KROs Kw I� - ��, b PHONE �6 " f6 9216 AREA CODE NUMBER EXTENSION ❑ FAX Cl MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED ` PLEASE CALL _.. CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE.YOU RUSH RETURNED YOUCALL WILL FAX TO YOU MESSAGE I Cs V�T esdn - VnQA SIGNED VNiVERSAL.. 48005 MADE IN U.S.A. 2. � o 1 � i , IMPORTANT MESSAGE FOR DATE TI ME1 -q-56 M Z�7n.�VVw..Gnr 6A. 01r OF PHONE N7,5 b AREA CODE NUMBE EXTENSION ❑FAX O 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 Z71(71I-v, OV-el 4 �a�i � 17��¢•�'s ��nvk,�er1 ,n )moi «�. SIGNED ONIVERSAL, 48005 MA"F w U.S.A. C:1, � � � � � � � � { i �� '1 � � �� Y � � � � � � � � �� 1 � � � �� '� 1 '� t � 1 ` .t i i , � � t 'ice �.�-� � _ i /� -� CITY OF SALEM BOARD OF HEALTH Establishment Name:/ VLl`lea' UCPh Y Date: V-7 Ila Page:--L— of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Verified PLEASE PRINT CLEARLY Y)int r i iijacj ow MS o Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ ;Fes — I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars o sion/revocati n of ❑ Embargo ❑ Emergency Closure your food permit. �a ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PHFs Roc rived at Tempemmres Violdhons Related to Foodborne lltnessInteraenttons and Risk According to law Cooled to' Factors(Hems 1-22) (Cont.) 41'F/45°F Within 4 Hours.*. . 3-501..15 Coohli&Methods for PHFs PROTECTION FROM CHEMICALS 49 PHF trot and Cold Holding 14 rFood be Color Additives 3-501.16(6) Cold.PLSFs Maintained at or below s 3-202.12 -�,.Additives*_ - 590.004{F) 41°( 5°F* 3-30214 Protection from Unapproved:4dditivas° 3-501.16(A) Hot PHFs Maintained at or above 15 - Poisonous or Toxic Substances 140°F. * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F. Conminem* 20 Time as a Public Health Control ?-102.11. Common Name-Worldug Containers* - 3-501.19 Time as a Public Health Cootroi* 7-201.11 Separation-Stena 7-202.11 .Restriction-Presence and Use* 590.U04 HI Variance R uirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPT16LE 7-203.11 . Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801.1.1(A) Unpasteuri'red Pre-packaged Juices and 7-204,1.2 Chemicals for WashingProduce,Criteria* - Severn es with Warning labels* 7-204.14 Drying Agents.Criteria* 3-801.11(6) Use of Panetwized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801..11(0) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served- 1-206.12 erved1-206.12 - - Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders, Pest Control and { Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs - PaSiio yens.*ce "°,n,2a!r E 3-401.11A(1)(2) Eggs- I 55 15 sec: 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs-immediate Senior 145°FL5sec* E ! 3-401.1 I(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sees. ' SPECIAL REQUIREMENTS 3.40LiI(B)(2)(2) Pork and Beef Roast-130°F 121 min* I 590.009(0)-(D) Violations of Section 590.009(A)-(D)590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec.* catering,,mobile food,temporary and 3401.1.I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 1.5 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F x' 590.009 violations relating to good.retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness mien'entions and risk,factors listed above, can he 3403.11(0) Coumtercially Ptacessed RTE Food- found let the following sections of the Food Code and 105 CMR 140°F* 590.000. 3403.11(E) - Remaining Uns[iced Pottioms of Beef IF ltem Good Retail Practices FC 590.000 23. 1 Mating Roam" nt and Personnel FG-2 .093 1g Proper Cooling of PHFs 21 4-- I Food and Food Protection I FC-3 004 25, 1 Equipment and Utensils _I FG-4 0p6 3-50L14(A) Cooling Cooked PRFs from 140°F to 26, 1 Water.Phimbinq and Waste i FG-5 E .006 i `. 70'F Within 2 Hours and From 70'F 27 Physical Feel FC-6 007 i to 41°F/45'F Within 4 Hours. * i 28. ' Poisonous or Time Materials ` FC 7 .008 3-501.14(.6) Cooling PHFs Made From Ambient dial R uiremams .009 I Temperature Ingredients to 41°F/45°F I Other - -- Within 4 Hours* savnr,ma-�:.ax c: "Dmao aitieat ivm in the te&ral 1999 Foal Cale or 105 CMR 590.0()0. 11 I` �, r . . . - • �eC—Critical Item 9 M FAJ wiloffel;ff 6101:1'.1=lei its]0R—Red Item F - 3-i01.14(C) PHFs Reo6ved at Temperatures Victorians Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors('items 1-22) (Cant.) 41'F/45*F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 547 Food or Calor Additives 19 PHF Not and Cold Holding 3-202.12__ Additives* 3-501.16(13) Cord PRFs Maintained at or below 590.004{F) 41 3-302.14 Protection from Unapproved Additives* 145'F* 3-501.16{A} Hat PHFsMaintained of or above 1$ Poisonous Or Toxic Substances IdoaF, * 7-101,11 identifying Information-Original 3.501.16(A) Roasts Heid at or above 130'F. * Containers* 2® Time as a Public Health Control 7-102.11. Common Name-WorkingContainers'' 7=201.11 Separation-Stn * i 3-501:19 Time as a Public Health Central* l 590.004(H) Variance Requirement 7-202.11 .Restriction-Presence and Use° 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE i ?-203.11 'Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals fru WashingProduce,Criteria' 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with 7-204.14 � Agents.asteria* . `vYantina Labels* 7-205.11 Incidental Food Contact,Lzrbticauts* 3-801.11(B Use of Pasteurized B as* - i 3-801.11(D) Raw or Partially Cooked Animal Food and i 7-206.11 Restricted Use Pesticides;Criteria* 3-801.11 Seed Sprouts Not Served.* 7-206.12 Rodent Bait ere3-801.11 a Unopened Food PackageNot Re-served. 't 7-206.13 Tracking Powders, ,Pea st Control and Monitoring! CONSUMER ADVISORY I ; 22 3-603.11 ConsumerAdvisoty Pasted for Consumption of TIMEtFEMPERATURE CONTROLS Animal Foods That arc Raw,Undercooked or 26 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate r PHFs meow rn, r li 3-401.11A(I)(2) Eggs- 155F 15 Sec. P� is i E e+s-immediate Service 145'Fi5see" 3-302.13. Pasteurized Eggs Substitute for Raw SheIl i Eggs* 3401.11(A)(2) Comminuted Fish.Meats&Game Animals-155°F 15 sec." 3.401.11(8)(1x2) Pork and Beef Roast-130OF 121 mm* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-'155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and • 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Paultry or Ratites-I WF 15 sec, * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions anis risk factors. Other 1450F°' 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Not Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs I650F 15 sea* (Items 23-30) 3-403.11(B) Microwave I65`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Tits* foodborne illness interventions and risk_factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code mrd 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Porticos of Beef item 1 Good Retail Practices I FC 590.000 Roasts* 23. 1 Manaelament and Personnel 1 FC-2 .om 18 Proper Cooling of PHFe �24. FFoal and Food Protection FC-3 i 004 i 25. Equipment and Utensils i FC-4 .005 I 3-501.14(A) Cooling Cooked PHFs from 140`F to 25, Water.Plumbing and Waste i FC-5 .006 1 70"F Within 2 Hours and From 70'F 27. Pt sicat Facia FC-fi 007 to 4VF/450F Within 4 Hours.* 28. Poisonous or Toxic Materials FC 7 .008 3-501.14(.3) Cooling PHFs Made From Ambient 29. Spacial R urremams .009 Temperature ingredieno to 41'F/45'F ' 30 1 Other Within 4 How's* s:�unronn:�.c.xc; *17;'note,u critical iaxm in the federal 1999 Foci Cale w 105 CvtR 590.000. L. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: � � Page: oZ of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY • { I e S Ivomy C Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. pl ❑ Voluntary Disposal ❑ Other: i 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to Law Cooled to Factors mems 1-22) (Cont.) 41'F145`F Within 4 Hours. 3-501..15 Conlin Methods for PHFs PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding 14 Food or Color Additives - 3-501,16(B) Cold PRFs Maintained at or below 3-202.12 Additives* 590.004(F) 410145'F* 3-302.14 Protection froth Unapproved Additives" 3-501.16(X) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. * .1 7-101.11 identifying Information-Original 3-501.16(A) Roasts Heid at or above 130'F. ' ` Containers* 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* 3-501.19 Time as a Public Health Control' 7-201.11 Separaban-Storage* 590,004(11) - Variance Requirement 7-202.11 .Restriction-PresenceandUse* - 7-20112 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toric Containers-Prohibitions* POPULATIONS HSI 7-204.11 Sanitizers.Criteria-Chernicais* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and i 7-204.12 Chemicals for WashingProduce,Criteria* - Beverages with Warning labels* 7-204.14 Drying Agents.Criteria"' 3-901.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprotas Not Served, 7-206.12 Rodent Bait Stat ons° '4-801.11(C) Unopened ess Foul Parka Not Re erved. 7-206.13 Tracking Powders,Pest Control and Monitstrin * CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-6m,l l Consnmet:Advigoty Posted fur Consumption of Animal Ftxxis That are Raw.Undercooked or 16 - Proper Cooking Temperatures for _ Not Otherwise Processed to Eliminate PHFs - Pathogens.*F""e.«,nza.r t 3-401.11X(1)(2) Eggs- 155°F 15 Sec. 1. E Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell E z 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals-155°F 15 see.* SPECIAL REQUIREMENTS y 3401.11(13)(1)(2) Pork and Beef Roast-130°F 121 min% j 3-401.11(A)(2) Ratites,Injected Meats-155°F IS 590.009(X)-(D) Violations of Section 590.009(A)-(D)in r sec.* catering, mobile ford,temporary,and 3401.1 i(A)(3) Poultry,Wild Game,Scoffed PHFs, residential kitchen operations should be i debited under theappropriate sections ( Stuffing Containing Fish,Metal, i Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F It 590.009 violations relating to good retail } 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165T l5 sec. * (Items 23-30) 3-403.11(B) Microwave 165°F 2 Minute Standing Critical,mid non-critical violations,which do not relate to the Tire* foodborne illness interventions and risk factors listed above, can he 3-TX 3.I I(C) Commercially Processed RTE Food- found in the follon ing sections of the Food Corte and 105 CMR 140°F* 590.000. 11 3-403.11(E) Remainine Unsticed Portions of Beef ttc�n ! Good Retail Practices FC 590.UD0 i Roasts* j 23. i Ma entandPersonnel �-FC-2 .003 18 Proper Cooling of PHFs i 24. i Food and Food Protection 1 25. Equipment and Utensils FG-4 005 3-501.14(A) Cooling Cooked PHFs from 140`F tof 26, ~water.Plumbing and waste FG-5 '0066 70°F Within 2 Hours and From 70'F 27 PMvsical Facility FC-6 007 •i to 41'F(45'F Within 4 Hours. * 1 28 ' Poisonous or Toxic Materials ' FC-7 008 3-501.14(6) Cooling PER Made From Ambient ~29. S ecial R oiremems - .009it y Temperature Ingredients to 41°F/456F 30. I Other + Within 4 Hours* s:sa�sm�,ee.f n: r 1 'Drnotrs crifiaal netu in the federal 1999 Foal Cale m105 CMR 590.000, 1 r t CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date` No. Reference R-Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: - 3-501,14(0) PHFs Received at Temperntures . Violations Related to Foodborne,nines&interventions and Risk According to Law Cooled to Factors({terns 1-22) {Cont.) 4I'F/45`F Withia 4 Hours. PROTECTION FROM CHEMICALS 3-501,15 CoolingMethods PHFs for 14 Food or Color Additives _ 19 PHF Hot and Cold Holding 3-501.16(B) Cold PRFs Maintained at or below 3-202.12 Additives* 54U.004(F1 41°/�5°F* 3-302.14 Protection from Un roved Additiv s°k -501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances * 7-101.11 Identifying Information-Original 140 F, 3-501.1 (A) Roasts Held at or atxrve, 130°F. Containers" - 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* aration-Sto * 5-501:19 Time as a Public Health Control* 7-201.t 1 S 7-202.21 .Restriction-Presenc;eandUse* - 590.004(H) Variance uirement 7-202.12 Conditions of Use+ REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers,Criteria-Chemicals 7-204.12 Chemicals&n WashingProduce,Criteria* 21 3-801.11(A) BeveragesUnpasteurized with Iuices and Beverages with 4'arning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* - 7-245.11 Incidental Food Contact.Lubricants* 3-801.1 I(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served- 7 erved ,-206.12 Rodent Bait Stations* 3-801,11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Motdtorin * CONSUMER ADVISORY TIMEti EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures far Animal Foods That are Raw,ltndercooked or Not Otherwise Processed to Eliminate PHFs - Patbo+ens.*�Yxeva rnnmt 3-401.IIA(1)(2) Eggs- 155`F 15 Sec. E -immediate Service 145°F15sec* 3-302.13, Pasteurized Eggs Substitute for Raw Shelf E * 3-401.11(A)(2) Comminuted Fish,Meats&Game _ Animals-155'F 15 see. " SPECIAL REQUIREMENTS 3401.11(8)(1)(2) Port:and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D).in 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec.* catering,mobile foot,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat. debited under the appropriate sections Poultry or Ratites-165'F 15 sec * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to gold retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401AI(A)(1)(b) AD Other PHFs- 145F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(1)) 131117s 1657 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 16Y F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, canbe 3403.11(C) Conmrercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Uesliced Portions of Beef ! item R Good Retail Practices FC 590.400 r Roasts ! 23. 1 Management and Personnel I-FC-2 .003'1 124. 1 Food and Food Protection I FC-a 004 1s Draper Coating of PHFs - (1 2B. Equipment and Utensils IFC-4 005 I 3-501-14(A) Cooling Cooked PHFs from 140'F to26. Water.Pitirpbing and Waste ^I FC-5 .006 1 70°F Within 2 Hours and From 70'F -T7-1-Physical Facility 1 FC-6 007 to 41`F/45°F Within 4 Hours.* L28._ Poisonous or Toxic Materials ' FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 129. Spacial Requirements Temperature Ingredients to 41°F/45°F ' 30 1 Other !_ Within 4 Hours* s:snec.,,, :szr Denotes critical iwm in the federal 1999 Fuel Cale or 105 C NIR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code c-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ yes I have read this report, have had,the-opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3 3-iOI,14(C) PHFs Received at Temperatures Violations Related to Foodborne illness intervent/ons and Risk According to Law Cooled to Factors{hems 1-22) (Cont.) 41'F145F Within 4 Hours. 3-501..15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS 1g PHF Hot and Cold Holding 14 Food or Color Additives 3-50136(B) Cold PHFs Maintained at or below 3-202.12 t Additives* 590.004(F) 41'/45°F* 3-342.14 Protection from Una roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 1400P 7-101,11 Identifying information-Original - 3-501.I6(A) Roasts Held at or above I300F. Containers* 20 Time as a Public Health Control 7-102.11 Common Name-Working Container* 3-501:19 Time as a Public Health Control- 7-201.11 ontrol*7-201.t1 Separation-S!g e* - jg(}t104(Hj Variance Requirement 7-202.11 ,Restriction-Presenceand Use* - 7-'0212 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 21 3-80I.11(A) UnpasteurizedPre-packaged Juices and 7-204.12 Chemicals for WashingProduce,Criteria* - :Beverages with Warning Labels* 7-204.14 Drying Agents.Criteria* 3-80LI I(B) Use of Pasteurized Eggs* 7-205,11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served* 7-206-12 Rodent Bait Stations* 3-801.11(C) Unopened Farad Package Not Re-served, 7-206.13 Tracking Powder,Pest Control and Monitoring* CONSUMER ADVISORY TIMEtFEMPERATlIRE CONTROLS 22 3-603.11 1 Consumer Advisory Pasted for Consumption of Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs - eprx fff 3-401.1IA(I)(2) Eggs- 155'F 15 Sec. Pathogens.' 3-302.13 E °s-Immediate Service 145'F15see- . Pasteurized Eggs Substitute for Rain Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155'F l5 sec. * SPECIAL REQUIREMENTS 3.401.11(3)(1)(2) Park:and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec.* catering, mobile food,temporary and 3-40LI1(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec, * above if related to foodborne illness 3-401_11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors, Other 145'F s` 590,009 violations relating to good retail 3-401.12 Raw Animal Fowls Cooked in a practices should be debited under#29- Microwave 1657* Special Requirements. 3-441.11(A)(1)(b) All Other PHFs--145'F 15 sec, 17 Reheating for Hot Holding VIOLATIONS RELATER TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 see.* (Items 23-30) 3403.11(13) Microwave- 165'F 2 Minute Standing Critical,mrd non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can he 34,D3.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-40121I(E) Remainfi a Unsiiced Portions of Beef ( Item Good Retail PractIces i .FC 1.690-OW i Roasts* Ln---i Management and PFC-2 .003 .I - 24.. Food and Food Protection FC-8 .044 18 Proper Cooling of PHFs 25. Equip ment and Utensils FC-4 005 .1 3-501.14(A) Cooling Cooked PHFs from 140°F to ! 2& Water.Plumbing and Waste ^i FC-5 I .006 70'F Within 2 Hours and From 70'F 27, Physical FacilityFC-6 .007 to 41`F/45'F Within 4 Hours. * [ 28Poisonous or Toric Materials i. FC--7 008 j 3-501,14(11) Cooling PHFs Made From Ambient 129. Special Requirements i .008 Temperature Ingredients to4i°17/4591 1 30, i Other -- - Within 4 Hours* 'D notes critical irLm in ttu.Geral 1999 Ford Calc w 175 CMR 590.OX IMPORTANT MESSAGE FOR L-y 7- DATE DATE TIME M f �J OF PHONE 1 AREA CODE NUMBER EXTENSION U FAX U MOBILE AREA IQDDE 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 Lk SIGNED �CC FORM 4009 Y. MADE IN LI.S.A. NOTES Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date T 122 of Ooeration(s) T f Ins tion . ❑ Food Service Routine Address . Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors 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 _ El 12. Prevention of Contamination from Hands El 1. PIC Assigned/.Knowledgeable/Duties EMPLOYEE HEALTH El 13. Handwash-Facilities -�" PROTECTION FROM CHEMICALS"° • : ,,.,, •a �'>. ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOODFR,OM.APPROVEQSOURCE_-� .•...•f • - Ej 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Fooda).- ❑ 5. ReceiAng/Condition ❑ 16. Cooking Temperatures. ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION '- ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS-(HSP); ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical N violations must be corrected ) immediately or within 90 days as determined by the Board Official Order for Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C N 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (Fc-3)(590.004) order of the Board of Health. Failure to correct violations 5. Equipment and Utensils (Fc-a)(sso.005) cited in this report may result in suspension or revocation of 25. Water,Plumbing and Waste (FC-5)(590.005) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-8)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-0(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.MnvpecfF0r 44.e Inspector's Signature: Print: PIC's Signature: Print: Page_oilPages �. .. y. „s4.-rte. �.M.. r s. ... a ♦ .. �. Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION $ Crass-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) AssignmentDemonstration of Responsibility*owldCooked and RTE.Faxis* 2-103.11 Demonstration of duties d e* Contamination from Raw Ingredients 2-103.1.1 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 Focal Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusionsand Restrictions* Disposdiono£AdutteratedorContaminated . Food 590,003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE b od* 4 1Food and Water From Regulated Sources 9 Food Contact Surfaces - 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Stmitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501. concentration and baroness. ChemicalSanitization-tem PH; P' 3-202.16 lee Made From Potable DrinkingWater" 5-101.11 Drinking Water from an Approved$ tem* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) I Bottled Drmlcin Water* 4 602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0'! Contact Surfaces and Utensils*- ` SheltJish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Foal Contact Surfaces of E ui ment* Shellfish` 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,'Adequate Handwashing Regulatory Authority Game and rMushrooms Approved by 2-301.11 - Clean Condition-Hands and Arms* 3-202.18 Shellstcxk Identification Present* 2301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..1.7 Game Aninads* 11 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eatin ,Ddnkin or Using Tobacco* 3-202.1.1 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes;Nose and 3-202.1.5 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock L12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F,) Preventing Contamination from - - 3-203.1.2 Shellstock Identification Maintained* - Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 - Parasite Destruction* Conveniently Located and Accessible 3402.12 Records,Creation,and Retention* 5-203.11. Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502:1.2 Reduced . gen packaging,criteria* 6-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures* b-301.1.2 Hand Drying Provision *Denotes critical item in the federal 1999 Fond Code or 105 CMR 590.000. A Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax (978) 745-0343 Name Date Typeof Operations) Tvoe of Inspection ❑ Food Service ❑ Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint In: ❑HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT-`,r _ _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _ ❑ 13. Handwash Facilities EMPLOYEE HEALTHPROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives __ ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE -4.�.-"_._._"_ TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4 Food and Water from Approved Source _ ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION [119. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing E REQUIREMENTS FOR HIGHLYSUSCEPTIBLE POPULATIONS(HSP)'. 21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY,� _ •rv0 x. [122. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C x by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590 23. Management and Personnel (FC-2)(ss0.0 4) order of the Board of Health. Failure to correct violations cited in this report=may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(sso.005)oos) 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.Mnspeol 0, 14.E Inspector's Signature. Print: ^"- PIC's Signature: Print: Page_of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) Raw Animal Foods Separated from 1 590.003(A) Assignment of Res nsibilit * Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge" _ Contamination from Raw ingredients 2-103 I 1 son 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 3-302.1 I(A) Food Protection* require repotting by food employees and 3-302.15 1 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Fate Employee Or An * Applicant To Report To The Person in Utensils _ Chase* Contamination from the Consumer b Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590A03(G) Reporting 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) I Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Fx i* FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590A04(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Foci in a Hermetically Sealed Container* Sanitization Temperatures" 3-201.13 Fluid Milk and Milk Products* 4-501.1 t2 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.1,4 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH; 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101..1 Drinkin Water from an Approved System- 4-601.1[(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.,14 Fish and Recreationally Caught Molluscan 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* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Author 2-301.11 - Clean Condition-Hands and Arms* 3.202.18 ShellstockIdentification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms` 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2401.11 Estrus,Drinking or Using Tobacco* 3-202.1.1 PHFs Received at Proper Temperatures* 2401.12. Discharges From the Eyes,Nose and 3-202.15 Package hate it y* Mouth* - 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification" 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" IEmployees* TagslRecords:-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 Capacifies* 590.004(7) 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 3-502.12 Reduced ox en packagingT criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Confo mance with A rove Procedures* 6-301.1.2 Hand Drying Provision i t Denoie.critical item in the fedcad 1999 Food Cate or 105 CMR 590.00).