ROOSEVELTS - ESTABLISHMENTS ROOSEVELT'S
300 DERBY STREET
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TOWN OF SAUGUS
Inspectional Services
Ronald Atkinson Sr.
Code Enforcement Officer
298 Central Street (781)231-4147
Saugus, MA 01906 Fax(781)231-4109
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CITY OF SALEM, MASSACHUSETTS
R BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
Fax 978-745-0343
Kimberley Driscoll WWW.SALEM.COM
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
2006 APPLICATION FOR P/�ERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT A0-5?v o/JJ/1� TEL#
ADDRESS OF ESTABLISHMENT 36a D/Pr4
MAILING ADDRESS (if different)
Y UI$-G (vlarO t+GC.
OWNER'S NAME 366 ��r6 y �Pf�4vacp 4r >��, �L C TELL# 6/7 6,L&,SPZ
ADDRESS -3VO007c
°nvl/I CITY -R(.WR't67 STATE yLJfI— ZIP D/970
CERTIFIED FOOD MANAGER'S NAME(S) f>lPnnPA CERTIFICATE#(s) ylk �/O
-o cy
(required in an establishment where potentially��hazardous food isprep�ar d.) �(
EMERGENCY RESPONSE PERSON rAav-r, ✓fe'04 L
jf , HOME TEL#
HOURS OF OPERATION: Mon. v/ Tue. ✓ Wed. ✓ Thu. ✓ Fri. e--Sat. ✓ Sun.
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
--------- .............................................
...................................... ... l-ess-----t-h-an---2--5.-.s.ea.-- s------------
=. . .$10.0..
RESTAURANT YY� NO 2ts
25-99 seats ;4-M)
more than 99 seats =$200
BED/BREAKFAST YES NO $100
---------------------------------------------------------------------------------------------....................................--------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem .
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes
are made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best
kn wledge and of ,f, have filed ill state tax returns a d paid all state taxes required under the law.
OA,(c I i
Sin Ire Dat Social Security or Federal Identification Number
-------------------------------------------------------------------------------------------------------------------------------------
Revised 11/03/05 FOODAP2.adm Check#&Date 1oSZ k)zs/'eL
Student Name KENNETH FOLEY
Class Number 525995
Exam Date 3/21/2006
Expiration Date 3/21/2011
Type of Training Classroom
Hours of Training 12
Instructor Name Sharon H McCabe
Sponsor Name Salem Board of Hlth®
Exam Location MA
Exam Form Name 4259
Overall Point Score 80 t
Overall%Score 100
Passing%Score 75
Status PASSED
Perfect Your
Poird Point
Score Score
80 8o
Domain Names
Foods 38 38
Clean/Sanitize/Maint. 5 5
Facilities 13 13
Personnel 10 10
Temp. Measuring Devices 2 2
Allergens 2 2
High-Risk Populations 2 2
Legal/Regulatory Issues 3 3
Facility Layout/Design 3 3
Training Employees 2 2
To have a certificate reprinted,complete a Certificate Request Form on our
Web site at vuwa:nreeforg(click on Duplicate Certificates for more details).
National Restaurant Association _
EDUCATIONAL FOUNDATION
4HaNa The Naoanal Reneurant Rasociaticn Educational Rundauon
amim v09a
rmam Fon,No.4259
Cert.No. 4784310
ServSa#W Certification
,,,
To KENNETH FOLEY
to aysri.Nlryanpldaatbmr4em oalcdawde WIwW Rn.euaraaaeshoon Edaaaval
faa0alonla an 6erv5ae®fao4RaepwnMenpeCclifrNmFmnMim
Date of Examination:3/21/2006
Date of Ezpi ation: 3/21/2011
asft. 6 1 a.ala...teamcnaaa.a,
EXAM FORM NO. 4259
y.
15lervS CERTIFICATE NO. 4784310
I
.0 Noun a
ServSafe Cerrinclation
TO KENRETH' FOLEY
for successfully completing the standards set forth by the National Restaurant Association Educational Foundation
for the ServSafe"Food Protection Manager Certification Examination, which is accredited by the American National
Standards Institute (ANSI)-Conference for Food Protection (CFP).
Presented by the National Restaurant Association Educational Foundation
3/21/2006
DATE OF EXAMINATION
3/21/2011
DATE OF EXPIRATION
local laws apply.Check with your local regulatory agency for recertification requirements.
kit)
National Restaurant Association
Mary M.Adolf EDUCATIONAL FOUNDATION C
President and Chief Operating Officer
National Restaurant Association Educational Foundation www nraef.org
02666 The National Restaurant Association Educational Foundation
65661462 v,6663
CITY OF SALEM
Q, BOARD OF HEALTH
Establishment Name: /JO C O ���7`t Date: /a//�/ Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION I Date
No. Reference R—Red Item _ Verified
' PLEASE PRINT CLEARLY
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' a /f, r%Irx ns a.r,-d- o•De.<c aA>2al) Juc "-e c
Discussion With Person in Charge: Corrective Action Required: I ❑ No ( ❑ Yes
°k I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
g inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
p LI 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:
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3-50:.'':;C) PHFs Received at lentpeiatores
Violations Related io Foodborne Illness Interventions and Risk Accor dim,to Law Cooled to
Factors(Ifems 1.22 (Com.)} fC41 F;45`'F 3b"ith.n 3 Hours.
PROTECTtON FROM CHEMICALS 3-501.15 Cooling Methotli for PHFs
19 PHF Hot and Cold Holding
14 Food or Colne Add!rves 3-5W i6(B) Cold PH17s Msmtained at or Lelow
3-202.12 Adrutivcs`
,-302.1,1 Protection from Unaopru,ad Ad;litiar=` ( 590 004(F) 41'745"F" j
' 3-501.16(A) Hot PHFs Nfaintarned at or above
15 Poisonous or Toxic Substances 140 l-
7-I!)1 I1 hle,:;aymc fntbnnanoo -O:i F,nui
f Container;," 3-501.16(A) Roach Held at or above 130'3'. r
7 102 11 Compton Name.--Wo6 m Corttainet s* 2U Time as a Public Health Control
7-201.11 Separari,)n-Storage" 3-501.P) Truro as a Public Health Control* I
7-20211P.e,triclu)n-Presence and l.ise" 590.004(H) Vat lance Requirement j
7-202,12 Cont rtions of use,
-7-203 11 { 'Cork Container.: --Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.i? ( Sanitizers,C-riteri.: - i'henrcals"
POPULATIONS(HSP)
-130-1 i2 ( Chemical for Washl-m,1'r.r3:,:,c,Crt.ria" ( 21 ;RQI.II(A) th+P;stcm',redPre-packagcdSuims -ad
7-204.14 D;ting Apents.Criteria' Beverages with R'arnine Labels*
7-205.11 3-801.11(B) U:seofPzsuwizedlLgs^
hrcnlental Food Ccatao- I ulmrcn s,t..^
3-0101A
7-206.1 l Restricted Lsc Pesticides.Criteria"
71.I I(D) Raw ur Partially Cooked Animal Food and
- R:nv Seed Sprouts No' Sewed.'r
7-206.12 Rodent Bait Srnticos- ! i
L 11(0) Unopened Potx: Package Not Re-served. T
17--06.13 ; Trxct,ng Pc:vders.Prot Cumrol and �
Monitorin t
CONSUMER ADVISORY
TIMEffEMPERATURE CONTROLS 22 ` 3-603.11 Consumer Advisory Pusted for Can<umptiun of
Amoral Foods Flue ore Raw,Undercooked or
1fi Proper CoaLsl:g Temperature-far Not(aher-aosc Processed to lilinu tale
PHFs
3-301.11A(11(2) Eggs- 155`'F 15 Sec. ( Patho:,ens.*
E _s-hunediire Service 1 a YF 15ccc ( 3-30'.13 Pas)eunzee 8@z+Substiute tn Raw Shell
a
3-401 I I(A)(2) Comnt
mrned Fish,M8c Ci
eat, sme Eggsr:
Annrvfl;;- 155-" 15::-c. "
3-401.11(8),,1)(2) Pork and Becf Roast 130''F 121 min'" SPECIAL REQUIREMENTS
401.11(A)(2) Ratites. In erted btra,- 15SF 15 590.0091A)-(D) Violations of Section 59o.009(A-(D)in
sCe, z catering, mobile food, Leemporary and
3-401.11(A)(?) Poultry, wild Game,Sr:,fted PHFs, residential kitchen operations should he
Stuffing Containing Fish, M-at, del-+iled under the appropriate seclinoa
! Poultry'or Ratites-165°F 15 sic above if related to foodborne illness
3-MIA IiC)(3! li'h,1e-nwsre, Intact Beef Steaks i intervention, and risk factor. Other
590.009 violations relating w good rctall
3-401.12 Ram;Animal -,,„(,ds Cooked in a I pfnt.tL;es should be debited under,F_9 --
Musovra,e 165'F* Special Requirements.
3401.11(A)(1)(b) All Other PHFs- ld5''F 15 see h
17 Reheating for Hot Hotomg ( VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
PHFs Ri5"F t i see, " (1 23-30)
3-403.1 i(B) :Viic:ow:ive- 165'F 2:11nune Standin_u C,hien/and non-rrraul iiiolut)ons, which du not relate to the
Tim, 4 1 loudborn^illness interventions and risk f i(tors lisied above ,-an be
3-403.11 Comn!crcndFy Processed RTF Fund- faawd in the foiloe Ing teetkms of the Food Code and 105 OUR
;40-'F`` 590.U00.
3-403A1IF) Renraioin;,U,isliced !"onionsoffice., I Item Good Retail Practices FC 590,000
Roasts" 23. Manarlement and Personn-1 FC-2 .003
13 Proper Cooling of PHFs 24 Food and Food Protection FC-3 0,04 1
- 25. Equipment and Utensils FC--4 .005
3-501 14(A) Cooling Cooked PHFs from 140'-F to 26, Water, wtimbinq and Waste F^,-5 : 006 1
70"F With:n 2 flours and From 70`8 27. Phvsical Facility FC-6 1 007
to 411 Fl4.5°F Within 4 Hour!;. " I 28. Poisonous or Toxic Materials FC - 7 '': .008
3-50:.la(B) Crcairr< PHF:: r,laaeF;(,r_:. _ - ---
knibiert 29. Sp:tiia!F.enuhements 1 00?
,
t
'Cemu)
p�tare Fr:gredients to 3t>'C(45`F I 30. Other
i ,auf nr M1<,Wi m¢
! \inl;:n 4 flours"
ticno:ds cruris;it.m it,ihr trderal 1090 t=otal Code or 1 ili 0.112 5i+(1000.
CITY OF SALEM "
BOARD OF HEALTH a
Estab4ment,Name: �GtJ�I/� l Y Date: 1a/1//-iz- Page: of
Item Bode C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Peference R—Red Item a. Verified
PLEASE PRINT CLEARLY
F ( `'t As- f�-'Gh
; -
` I lAln 9 .rn .0-f /h sire 2,1 -lis) �iP ,. 6wlzee /WS/-
I l'nn�s/ C 1/11 /nlhm AWt o? /s aD /19a -A r 0(/ ///�D
f I I
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- fylm�l�h/i e ihofidn 7) _�2e n " Loa S2 /Cvo� Gly 1
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Discussion With Person in Charge: Corrective Action Required: I ❑ No Yes
- tet L Ja, ❑ Voluntary Compliance ❑ Employee Restriction/
T I have read this report, have had the opportunity to ask questions and agree to correct all
inspection, to observe all conditions as described, and to 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 pr suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
EI Voluntary Disposal ❑ Other:
ti
0,. [iC) PHFl,Received at Tentperaoures
Viniations Rotated to Foodborne JI+95ss interventions and Risk - According to t.ae Cooled to
Factors(!term;-22 Cont. 1
1 1 ! 41'F345'FWithin•LH+vasa ' i
PROTECTION FROMI CHEMICALS 3-50! 15 Cooling Nlethods for PHI-,
19 Food or Color Additives 19 I PHF Hot and Cold holding
3-501,.IG(B) Cold PFIF,MLuntained at ori
3202.12 Additives' 590.004(F) 91145` P'
" u'1
'02.14 Protecuon iron) Iinzppru%ud Ado,;eves' ( 3-501.Ib1A1 Hut PIIFs rMaiutanted at or above
i s Poisonous or TOXIC substances
7-101.11 klentitying Intorntal n ^r:<; , 140-F,'F.
1 -.:.1 na" 1-Sill MMA) Roasts field•at or above I I"P. "
C
1 ontaitters'
r< Coruai net n" ( 120 1 ire as a Public Health Control
� 7-102.11 Comtnoulvaotr,"
I
7--2iiL11 &_ arti,+n-Stortee'; ! 3-St)I IQ ( Tinw as a Public H�,a1th Control* j
Re
17-2U2 If Reit:ictian--Pre-on500.0041H? Variance Requirement
and t;ge.; t i
1-Jf°,t3 Cord, Co c of Use, REQUIREMENTS FOR HIGHLY'SUSCEPTIBLE
7-204 11 inx;.^C'muain:c;--Ihohernics,s'' POPULATIONS(HSP)
17-204.11 °^niuzers,Criteria --Chemicals' i
7-_(}1 i
o .1r Chemals tu:tie u,hmt• >mdu-e,Criteria" I 121 3-801,11(A, Unpasteurized Pte-packaged Juices.uid I
_ !
7-204.14 Or I Beveial_es with WarninL• 1abelsil !
g Ascots.Criteria' 3-801.1 li B) t'se of Pasteurized Esgs'^
?-205.1 ( L:cideriel Poor Conta_t.Lubr+eant,�
7-206.11 f trued l:ar Pec;;._ r ; 3-801.1 I(D) Raw or Partially Cooked An:mal Real and
? ,, ides. .t ,cern*
Kate Seed Sprouts Not Screed.
7-206.12 Ro.;ent fiaa Stations- I 3-80!A 1(0
7-206.13 Tracking Fow&is,Fest Coutrol and ) Uno peyed Food Package
Not Re-sewed.
hl,mib.,rin;�`'
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS27- 3-603 11 Consumer Advisory Posted for Consumption of
16 Proper Cooking T temperatures for
Animal Foods'1'hat arc Kate'. UnderuX>ked rT
FHF^, Not Otherwise Froc.essrd is Eliminate
?-401-11A(l l'2 E,g - 159"F I S Sec. Pathogens.* 'l : row
tree•"Inmteciiate Syn ice 145°Fl5sec 3-302.13 Pasteurized Figgs Substitute Ib: Raw Sh,11
3-401.11(A�Q) Cvnutunined Fish, MAats 8:Cams Eggs*
Animals - 155-F 15 see. '-
3-40!.1 UB)(1)(2) P,lrk 2nd cef Roast- 130'F 131 ntin* I SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites, Injec ai bicats- I'15'F 15 I 590009(A)-(D) Violations of Section 590.009(AF(D) In
sec. etttering. mobile food, temporatil and
3-d0t.1 I(A);3} Poultry,`,Wild U.3me, Stuffed PHFc revdential kitchen operations should be
Stuffing Cu:rtmnu>;, Fish, bleat, debited under the appropriate sections
,eonnry ar Ratite!,-165'F 15 s-c. * above if related to foodborne illness
3-401.111(_')(3) Whale-mu,cle, luvict Beef Steaks interventions and risk factors. Other
145`7 l ) 590.009 violations relating to good ret-ml
3-401.12 R•tvt Animal Fo,,ds Cooked:n n ! practices should be debited under/!29-
bfi.rowave 165`F* ! Special Requirements.
s 4C I A IiAI(t;ih) A1!althea'PIIF, 145°F l5 sec.
17 Reheating for Hot Holding ( VIOLATiO14S R:LATED TO GOOD RETAIL PRACTICES
3. 0: .I1(Al&(D) PAFs 165'F 15 sec. * (Items 23.39)
3-403.11(B) Mierow:ve- 165'F 1.Minute Staudm^ Crier n(and non-critical vtofrgiuns, "hich do not slate to the,
Time* ,foodborne diness in;,v vcnhons and risk r(tors listed above, ran he
3-403.11(C) Conunemcit} Proc=sseC RTF-F,�-,d- ,foarnd iv theJodletevntg secrion.N til the Feud Code and 105 CIR
140'F- 590000.
403.11(E) Remaining L:nsliecd Portiunsol'Rccf I I Itom Good Retail Practices FC 590.000
Roosts' 1 23. Management end Personnel FC-2_ _.003_
j Is Proper Cooling of PHFs ( 124 Food and Food Protection FC-3 004
-51)11- ; , r;- r j 25. Equipment and Utensils FC--4 :705
( ) Cooling Cooked I N ,from 140'r to 1 26, Water,Plumoinq end Waste FC 006_
701;1•v r,hin 2 flours arc! From 70'F ! 27. Physical Facility FC-6 007 i
tri 41"F/=i5'F Within 4 Hours. ; ( 28. Poisonous or Ton;Materials I FC-7 I .008
3-501.14(13) C,uLn PFIFs blade From Ambient 129 SuecL-rl Requirements i I 009
'temperature lul7ed30. Other
to 41`'P/di"'r �
9::Hnn4hours;# 1,..,m,„�.,.�:.,, � Vit!
"Per,oteceril-I it'll,mine brie nal Ii9u Feud Co,:+ art I(ic C[vlit Syr alas [ y'�, / 10 f�WIm
CITY OF SALEM
BOARD OF HEALTH
Date: September 13, 2006
Name of Establishment: Roosevelt's
Address: 300 Derby Street
Owner(s): Louise Marotta
Phone:
The proposed manager of this establishment, Kenneth Joseph Foley, Jr.
presented a preliminary Floor Plan and Menu for review in accordance with the
State Food Code.
An updated Floor Plan must be submitted. Please include location of all
equipment.
CERTIFICATION
Mr. Foley will be the Certified Food Manager (CFM) who will work full time
at this location.
A "Person in Charge" or "Ply' must be available at this location when the
CFM is not present. The PIC must have knowledge of sanitation techniques,
holding temperatures, operations, etc.
FLOOR PLAN
A Hand Sink must be located in each food prep and service area..
The hand sink must have a wall hung soap and paper towel dispenser.
These must be stocked at all times. The hand sink must be used for hand
washing only.
All floors, walls, and ceilings where food, utensils, paper products, etc, are
stored, prepared or served must be intact, impervious, and easily cleanable. This
includes any storage of these items in the basement.
A dishwasher and a three bay sink for washing, rinsing and sanitizing all
utensils equipment, dishes will be used. The dishwasher must have a final rinse
temperature of 180 degrees in the final rinse OR an automatically fed chemical
sanitizer in the final rinse with an audible alarm.
MENU/FOOD PREP
Reviewed preparation of a chowder.
All food must be held at 41'F or lower, or 140"F or higher, at all times.
Therefore, soup and other hot items should be brought to boiling before being
held hot.
i
i
Food may not be added to containers in holding unit. Instead, a sanitized
container with new product may replace the existing container and the old
product may be placed on top of the new product.
There may be no bare hand contact of ready-to-eat foods. Gloves, tongs,
or tissues must be used when handling such food.
All refrigerator/freezer units must have internal thermometers.
All equipment in the establishment must be operating properly. Any
unused equipment must be removed.
UNDERCOOKED FOODS
The advisory was given to the owner.
CHOKE SAVING
A person trained in choke saving techniques must be available whenever
this establishment is open for business.
EXTERMINATION
Monthly services of a Licensed Pest Control Operator are required.
Please keep receipts for inspections.
SANITIZING SOLUTION
Sanitizing Solution must be accessible at each prep station and for the
patrons' tables.
Test strips corresponding to the kind of sanitizer, must be on hand to
check concentration of solution. Solution must be made daily, tested, and the
results recorded on a log sheet for examination by Board of Health inspectors.
Solution may be prepared in the 3rd bay of the 3-bay sink and spray
bottles may be filled there. Spray bottles with clean paper towels may be used,
as well as wiping pails with wiping clothes always held in the solution in the pail.
Outside area of premises, including the dumpster area, must be kept clean and
sanitary.
Please call to submit the final floor plan
An application and check was submitted for the permit.
Che k # 1056
Ja6nne Scott Date
Health Agent
Kenneth Jostoley Date
�//'�nor ���
[7��
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TOWN OF SAUGUS
Inspectional Services
Ron Atkinson
Local Building Inspector
8:15-9:30 AM Mon.-Fri.
298 Central Street (781)231-4147
Saugus, MA 01906 Fax(781)231-4109
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Inspectional Services
Ron Atkinson
Local Building Inspector
8:15-9:30 AM Mon.-Fri.
298 Central Street (781)231-4147
Saugus, MA 01906 Fax(781)231-4109
HP Fax Series 900 Fax History Report for
Plain Paper fai/Cdpier Joanne Scott Salem BOH
978 745 0343
Nov 13 2007 10:09am
Last Fax
Date Time Twe Identification Duration Pa
ees Result
Nov 13 10:09am Sent 917812314109 0:42 2 OK
Result:
OK - black and white fax
Proposed Menu 300 Derby St
Appertizers
Basket of Fries.....3.50
Cherrystones on the Half Shell..6....7.99
Garlic Bread....3.50
Shrimp Cocktail....7.99
Scallops Wrapped in Bacon....8.50
Large Fried Shrimp....8.99
Homemade Onion Rings....3.50
Fried Mushrooms....4.25
Mozzarella Sticks....5.95
Chicken Fingers or Wings....5.95
Fire Fingers or Wings....6.50
Soup and Salad
Caesar....4.99
Garden....3.50
Chicken Caesar....7.99
Steak Tip....7.99
Baked French Onion Soup....3.95
Cup or Bowl of Clam Chowder...2.95....3.75
Sandwiches
Basic Burger....4.99
Build your Own
Bacon,Peppers,Onion Cheese....65
Grilled Chicken Sandwich....5.75
Fried Haddock Sandwich....6.25
Scallop Roll....6.99
Shrimp Roll....7.25
Fried Clam Strip Roll....6.99
Lobster Roll....market
From The Grill
llb Boneless Sirloin Steak....12.50
Ribs...Half or Full Rack....8.99....12.99
Mixed Grill..Ribs Tips Chicken....12.99
Broiled Sirloin Tips....8.99
Grilled BBQ Chicken Breast....7.99
From The Ocean
Haddock Fried or Baked....10.95
Broiled Salmon....9.95
Scallops Fried or Baked....13.95
Lobster Pie....market
Fish and Chips....8.95
Fried Native Clams....13.95
Fisherman Platter Scallops Haddock Clams Lobster....19.95
Roosevelt's October Picks
For Starters:
Boneless Chicken Fingers $6.99
Severed with choice of barbeque or honey mustard dipping sauce
Boneless Buffalo Wings $6.99
A specialty...served with carrots, celery and blue cheese dressing
Baked Potato Skins ,; $6.99
With melted cheddar, chives, bacon, and sour cream
Fried Calamari $7.99
Salem's best... served with jalapenos and cocktail dipping sauce!
Chicken Quesada $6.99
Grilled to perfection with our blend of cheeses, onions,peppers, scallions.
Served with sour cream and salsa.
Nacho Supreme $6.99
Topped with melted cheddar, tomatoes, scallions, sliced jalapenos,
and sour cream. Served with salsa.
Add Chicken.... $7.99
Basket of Fries and/or Onion Rings $4.99
Soup and Salads:
New England Clam Chowder $3.99
Texas Chili $3.99
Soup of the Day $3.99
House Salad $4.99
w/Grilled Chicken $6.99
Caesar Salad $4.99
Crisp romaine tossed with seasoned croutons,parmesan cheese, Caesar dressing
W/Grilled Chicken $699
Sides:
Rice pilaf, Veggie of the Day
Fries or Coleslaw
The following will be served with fries unless specified or w/pasta:
Cheese Steak $7.99
Grilled with onions and peppers and topped with cheddar!
Chicken Cheese Steak $7.99
House favorite! Grilled chicken with onions,peppers and topped with cheddar!
Burgers- Choose from
Beef Burger $7.99
Madefrom 100%AngusBeef.!
Chicken Sandwich $7.99
Grilled, Blackened, Barbeque or Honey Mustard
Chicken and Broccoli $11.99
Sauteed in our special sauce and served over linguini.
Steak or Turkey Tips $12.99
Marinated in our special sauce and grilled to your liking
Grilled chicken Breast $11.99
Marinated in our special sauce.
Fish and Chips $10.99
Golden fried Haddock served over a mound of fries and onion rings.
Baked Haddock $12.99
A House Specialty. Prepared with our bread crumbs and baked to perfection.
*Consumption of raw or uncooked
meats, eggs, shel fsh or poultryput you
at a high risk for.foodborne illness.
Certain medical conditions are considered
to be at higher risk.
Thank you for visiting us,please come back to enjoy our full menu after the
Halloween season.
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ASPINWALL PLUMBING & HEATING CO., INC. JOB WORK ORDER
BAYSTATE PLUMBING CO., INC. 3153
318 Furnace Brook Pkwy.
QUINCY, MASSACHUSETTS 02169 CUSTOMERS ORDER NO DATE ORDERED
BROOKLLINE (617) 127y7.-1261
QUINC (617) 472.8265 ORDER TAKEN BY DATE P_RSED PM
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BILL TO C f PHONE //��
ADDRESS VV+ / ....JJJ MECHANIC/,,,,
CITY
CITV _ HELPER
JOB NAME AND LOCATION v WORM
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❑ TONTRACT
DESCRIPTION OF WORK _ TA
�W%TPA
QUANT / DESCRIPTION OF MATERIAL USED PRICE AMOUNT
fE�r�Et� ,t>e'q/AJ
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HOURS LABOR AMOUNT
TOTAL
MECHANICS @ MATERIALS
HELPERS @ TOTAL
LABOR
I hereby acknowledge the satisfactory, TOTAL LABOR TAX
completion of the above described work
SIGNATUREDATE COMPLETE J
� ) e7 X0,5 TOTAL
JOB COST RECORD CUSTOMERS ORDER NO
MATERIAL RECO RD LABOR R CORD
REO NO DESCRIPTION PRICE COST DATE EMP. HOURS RATE COST
TOTAL LABOR COST
TRAVEL EXPENSES
DATE VEHICLE MILES RATE COST
MISC COSTS TOTAL TOTAL TRAVEL COST
COST RECORD
LESS RETURNED TOTAL MATERIAL COST
MATERIALS
COST OF
MATERIALALSS TOTAL LABOR COST
OTHER DIR.CT Cf STS TOTAL DIRECT COST
REO NO OESCRIMION __�.�_ -PRICE CO! '
SUB-CONTRACTORS
TOTAL TRAVEL COST
TAX/INSURANCE
PERMITS/MISC.COSTS
SPECIAL EQUIPMENT
TOTAL COST
•� PROFIT OR LOSS RECORD
TOTAL SELLING PRICE
OTHER
LESS TOTAL COST
GROSS PROFIT
TOTAL LESS OVERHEAD COSTS
DIRECT COST % SELLING PRICE
NET PROFIT (LOSS)
0300 DERBY STREET Roosevelt's Restaurant & Saloon
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE REINSPECTION Inspection
HACCP: ❑
Telephone: Item Status Violation Critical Urgency Nature of problem or correction
745-1133 Non-compliance with: Done
Owner: Anti-Choking PASS ❑
Grumpy's Pub & Grub Inc. Tobacco PASS ❑
PIC:
Maureen Lavin FOOD PROTECTION MANAGEMENT Done
Inspector: PIC Assigned/Knowledgeable/Duties PASS ❑d RED
Janet Dionne EMPLOYEE HEALTH Done
Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED
10/11/2005 Personnel with Infections Restricted/Excluded PASS [] RED
Risk Level:
FOOD FROM APPROVED SOURCE Done
'Permit Number: Food and Water from Approved Source PASS ❑J RED
BHP-2005-0217 _ Receiving/Condition PASS RED
Status: Tags/Records/Accuracy of Ingredient Statements PASS RED
PARTIAL COMPLY
#Of Critical Violations. Conformance with Approved Procedures/HACCP PASS Q RED
Plans
PROTECTION FROM CONTAMINATION Done
Time IN. Time OUT: Separation/Segregation/Protection PASS ❑Q RED
Notes: Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED
348:upstairs not to be used Proper Adequate Handwashing PASS ❑d RED
until inspection conducted
Good Hygienic Practices PASS ❑d RED
Maureen also stated that cola
lines will not be used until Prevention of Contamination from Hands PASS /❑ RED
supplier can come out. bottles Handwash Facilities PASS /❑ RED
and cans will be used until that
time.
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 14,2005 ) Page I of
03G0 DeRBY STREET Roosevelt's Restaurant & Saloon
Maureen also stated that PROTECTION FROM CHEMICALS Done
refrigeration company is Approved Food or Color Additives PASS ❑J RED
coming out to fix units. before Toxic Chemicals PASS ❑d RED
replacing any units contact
health agent with updated floor TIME/TEMPERATURE CONTROLS(Potentially Haz Done
plan for review. Cooking Temperatures PASSd❑ RED
Urgency Description(s): Reheating PASS ❑J RED
BLUE: Y; Cooling PASS RED
Violations Related to Good
Retail Practices (Critical Hot and Cold Holding PASS RED
violations must be corrected
Immediately or within 10 Time As a Public Health Control PASSd❑ RED
days)(Non-critical violations REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done
must be corrected immediately Food and Food Preparation for HSP PASS ❑/ RED
or within g0 days)
RED: CONSUMER ADVISORY Done
Violations Related to Posting of Consumer Advisories PASS RED
Foodborne Illness Interventions
and Risk Factors (Require _ Violations Related to Good Retail Practices (Blue Done
immediate corrective action) Management and Personnel PASS ❑ BLUE
Food and Food Protection PASS ❑ BLUE
Equipment and Utensils FAIL ❑ BLUE back door at bar area cracked and off
hinges repair and secure door.
There is cat urine odor detected upstairs.
odor and soiled carpets to be removed to
control odor
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
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 14,2005 ) Page 2 of
0360 DtRBY STREET Roosevelt's Restaurant & Saloon
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GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 14,2005 ) PaQe 3 o!3
CITY OF SALEM
__ ff 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
/7 {'O C7� TD✓ ill,�'J?��'�Gh� Q/�C v 1
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I
Discussion With Person in Charge: Corrective Action Required: I ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
ri•` �" •.. r •Y.64' ..�Y � 1'i" . - .a..s_ T :l^- . :. .^ '--:"'t.� s.-....�^,r 'arw'*w' k ^----,..r., \ - . '
-SOI It(C PRFs Recenedat'I'enaneratures
Violations Related to Foodborne Illness interventions and Risk According to Law'Cooled to.
Factors(items 1.22) (Cont.) 11`1714517 Within•?Hours.
PROTECTION FROM CHEMICALS
3-501.15 Cooling Methods for PHFs
14 Food or Color Additives I 19 PHF Hot and Cold Holding
3-50 L 16(6 i Cold FI IFs Maintained at or below
3-20212 Additive`= 59U.004(F) 41'MsF'
3-302.14 Prolection atom tinapproted Addihvee' ( 3_501.ICi(A) ?!lot P
-Iot PHFs Maintained at or above
15 Poisonous or Toxic Substances
7-101.11 Identifying Infnnnauon-Onginal ( 3-501 16(A) Roasts Held at or above 130`17. "
Containers"
7-102.11 Cotnttam Name--Working Containers' �� Time as a Public Health Control
7201.11 Separation-Storage- I 3-SOLI) Titn.asaPublic Health Control-
7-202.11
ontrol*7-202.1l Restriction-Presence and Use" 590.004(1-1) Variance Requirement
7-202.12 Conditions of User
7-203.11 Toxic Container-Ptohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-2W.11 Sau; iters,Cliterui --Chcnacals' POPULATIONS(HSP)
7-204 12 Chemicals for Wash ng Produce.Criteria` 21 3-801.11(A) Unpasteuiived Pre-packaged Juices acid
Bevettiees vnih Warning Lit),ls^
7-204.14 Diving Agents.Criteria" 3-801.11(6) Use of Pasteurized F.L_s"
7-205.11 htc:idertal Food Contact. Lubricants
7206.11 ResnictedlisePesticides.Criteria* � 3-y'�'t.l!(Di Raw otPaitiaityCooked AnimalFoixland
! Raw Sial Sprouts Not Set red. 'r
7.206.13 'Tracking Powder..Pest Control and
7-206.1Rodent ban Sinus.` Raw
I(C) Unopened food package Not Re-seed.
3 ' I n
Monitoring'
CONSUMER ADVISORY
TIMEfTEMPERATURE CONTROLS 22 3-603.11 Consumer Aah i',ory Posted for Coumiription of
16 Proper Cooking Temperatures for
Annual Fooris Trial are Raw.Undercooked at
PHFs Not Olheno se Processed to Eliminate
1-401.1?,4(1)(2) I ggs- 155"F 15 Sec.
Pathu;,*ens.* c`......: a
Eggs-hunicdiate Sen•ice 145%=(5se,'l ( i-302.13 floc eurized Eggs Suhstitute for Raw Shell
3-401.1!(A)(2) Comminuted Fish,Meats Fe Came
Animals- 155'F l5 sec. *
3-401.11(6)(!)(2) Pork ane'Beef Roast- 130°F 121min' 1 SPECIAL REQUIREMENTS
3-401.11(A)(2) Rntitec, InjectedMeats- 155'Fi5
590.009(A) (D) Violations of Section 590.009(A)4D) in
sec. ' ( catering. mobile food, temporary and
3-401.1 1(A)(3) Poultry, Wild Game,Stuffed PHFs, rcudential kitchen operations ghould be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165'17 15 sec. ' alcove if related to friodi,.orne illness
3-401.11,(7)(3) Whole-muvcle, Intact Beef Steaks interveation:•and risk factors. Other
145'F 590.009 violations relating to good retai 1
3-401.12 Raw Animal Foods Cathed in a mactices should he debited under 1(29-
Micruwave 165'F It Special Requirements.
3-401.11(A)(!)(b) .All OthoPHFs.- 145`F15see.
17 Reheating for Hot Holding ( VIOLATIONS Ri2LATED TO GOOD RETAIL PRACTICES
3-403.111AWD) PHFs 165'F 15 sec. * ( (Iteras 23-30)
3-403,11(B) Microwave- 165°F 2 Minute Standing I Cniaal and non-rrrti<at vwlotoms, which do not if*,,re u,the
Tune* foodburne ilinrry interranhona'and qsb fa(trr, listed above, ra rr be
3-463.11(C) Commercially Pioce<sed WIE Food- (nand ir, the fi)ltrmin,e sections of;he Fuad Codc soul 105 (WR
140"F* I 590.QOti. _
3-403.1 t(E) Remaining Unsirced Portiung of Beef i Item Good Retail Practices FC 590.000
Roasts` 23. Management and Persainei FC 2 _003
(g Proper Looting of PHFs
24 Foci and Food Protection Fr-3 004
-- - - t _ ) -- -- - - 25. Equipment and Utensils FC'-4 CCS
Ul 14(:1 Cooling Cooked PHFs from 140'-F to --006-
1 26. Plater, Plunibiru and Wasia FC-5 ' .008
70`1-Within 2 Hours and From 70'F 27, Physical Facility FC-6 .007 I
to 41`F/45`F Within 4 Hours. r 28. Poisonous nt Toxic Materials FC-7 .008
3-501.14(13) Cooling PI1F,Made Front Ambient29 Special Reora ements 009
Temperature huredieris to 41'P/45`p "40. Other
Within 4llouisr
f ien.,tes rrmwl item m 1110 Cuivlia 1999 Fund Code or 105 CMR 5qO 000.
CITY OF SALEM �.
BOARD OF HEALTH
Establishment Name: '4`()D_s'-_'V_e'jk Date: I Page: 1 of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
� PLEASE PRINT CLEARLY `
h, 12A r 111_S/ CT7GYL ���
1 U ,PS n/i`r_
/47siA04 �.I
-4Q/
T 1 �j /</ Cy /
PS�YI(77�S- �h P i/Y d ,!�'`GG7 Jl/ 3}4 Toa I
I 1� i
(/ h j
4 I
I 1.
Discussion With Person in Charge: Correctiv;i Action Required: ❑ No ❑ !es
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P L3 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.
I
Y'l 141, PI`F. Rece,ve t at'ren:peratures
Violations Related to Foodborne Illness Interventions and Risk According to Uri Co to
Factors(!tents 1.22) (Cont.) 1`Ft45'1'With a;4 Hours. ' j
PROTECTION FROM CHEMICALS
_;-+01.15 Cooling Mrilu,c:s for PHFs
Addilivcr`Color Additives at o
19 FHF Hot and Coll Haidi,g
3-202.11 ddi
i� 3-501.!6(B) fold PHFP, Maintained ! belo,,=
?;402 14 Protection from UOaoprm-d Additives' 590 0(14(F) 4l''/4S F'"
IS Poisonous or Toxic Substances I
-5,91,16(A) lint P1-IFn Maintained at or above
7-101.11 lcienul}�nclnfor!nanon-t)nginal a = 140'F.
Containers" I 1.INA),, Roast. Held at or above 13W F. :1 �
7-102A 1 Common Name-Workin- Canon hers' � ' 20 ' Time as a Public Haaith Control
7-201.11 Separation-sto;sec's ( 9 Time as a Public,Health Con'fol"
7-7.02.11 Restriction-Presenceand Use'; � 59o.n04(H) Variance Requirement
7-1202.12 Conditions 4 Uset
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203 11 Toxicizev,,riteri-Prohibitions" PQPUv ATIONS(HW
1 7-2(W.l 1 S.utitizers,Criteria-Ghenircals"P
7-2(4 12 Chemicals for W'ashi!in Produce,C'ute_=na,' 21 -,Q;'':(r^,) t:npasr=w'i.:cd Pia-pae'tcrecUu;ces and
7-204.14 1)rvutg Assure.Cnrerul' Bevetazes wnh Warning Labels^
i-801.11(6) i Use of Postetnized Et,-,
7-205.11 incidental Fxal Contact,Lobr,emtts" I ;-801.11 G) , Raw of ?mtially Cooked Animal Food and
7-_'06.11 Restricted Use Pesticides,Criteria :
Raw'Seed Sprouts tint:ie,ved.
7-206.12 Rodent Bart Stations' 1
7-206 13 Tracking Kmders,Pest Control .tad I 3-801.1 I(C) I Unopened Foot'Package Not Re-served.
M
onitoring"
CONSUMER ADVISORY'
TIMElTEMPERATURE CONTROLS 22 3-603.'1 Gmsam-r A&nsory Posted for Consumption of
,^<rtunol Faxds rhat me Raw, undercooked or
16 Proper Cooking Temperatures fol Not Othetwisc Processed to Eliminate
PHFs
3-401.11A111(2) Eggs- L55'F 15 Sec. Pathogens...
E.ugs-hnmedmie Sercict 145'F15secf j '-'f''-.13 Past^IICIled F241s SubatMue for Ra:v Shell
3=1ULI1(A`(7) Com!nnuned Fish, Meats a Gane
Animals- 155`F I;sec.
j 3-401.1 ltti)(1)(2) Pork and Beef Roast- 130'F 121 min" SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites. Injected Meats-155'F15 590.0(N(A)-(D; Violations oi'Section590.009(A)-(D)in
Cel, catering, mooile food, temporary and
3-401.11(A)(3) Poultry, W'iid Game,Stufhed PHFs testdential kitchen opetations should lie
Stuffing Containing Fish, Meat, debited under rite appropriaie sections
Poultry of Ratites-165°F 15 sic. a: mance if r Latrd to foodherne illness
3-401.11(C)(;) Whale-muscle,Intact Beef Stetiks interventions and risk tactors. other
145`9,. 590.009 violations relating to;;ond retail
3401.12 Rat=;Ani trial Foods Cooked in a ( practice, should he debited under#-N --
IM;61'uwape 165=F r Special Requirements.
3-401.IItA)(l)(b) All 0',hei PHFs 115'F15 ;et * j
17 Reheating for Hot Holding 'VIOLA;(DNS R.=LATED TO GOOD RETAIL PRACTICES
i 3-403.1 1(A)WD) PHFs 165`r 15 sec. " (Itetdts 23-31}}
3-403.11(6) Microwas-e- 165° F 2 Mimac Standing Critrral and nun-rrihe a[violationv. r,lrirh no not re&ter to tln=
i Time" foodborne;,Unrss Engen senrions and rias)furors Pswd above, can be
1 3-403.11(C) Continentally Processed Ii1h Food- found bi ,hc foib)mine.serriom ref the rood Code mel 105 CMRi40'•F* I 500.00x.
3-?U3.11(E) 12entainin2linc1ired Yortiunc cl'Acz( ! ( glum I Goad Retail PrscttcesFC .59G GGG
Roasts= 23. 1 Managernent and Persamel FC - 2 00a
! 1g Propet Cooling of PHFs 24. Fold and Food Protection FC-S 004
25. Equn)xent and Utens,is FC-4 .005
3-:501 I4(A) Cooling!Cooked PHFs from 140`17 to i 26. INate,,Pkimbinc and Waste FC -5 1.006 -----1
70'9 Within 2 hours and Front 70°F 27. PI-mical Facahty FC-C 007
to G 1''F/45`F Within 4 Hours. " I 28, 1 Pciscnous or Toxic Fetenals FC- 7 .008
3-501 14(B) Coolmg;Pt1Fs Made Front Ambient 24 SFec.al Regoiiements j 008
Tetnpzrature hti7edieuts to 41'9/45'F 30. : Omer ------A
Within 4 Hours;'
Denote"crucaI itc;n it Pte"'Jera 1 1999 Food Code or I1 15 CPAR 5911000
0300 DERBY STREET Roosevelt's Restaurant & Saloon
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Telephone: Item Status Violation Critical Urgency Nature of problem or correction
745-1133 Non-compliance with: Done
Owner: Anti-Choking PASS ❑ Owner to have full time staff employee
certified.
Grumpy's Pub & Grub Inc. Tobacco PASS ElPIC: - `
Maureen Lavin FOOD PROTECTION MANAGEMENT Done
Inspector' PIC Assigned/Knowledgeable/Duties PASS RED
Janet Dionne - EMPLOYEE HEALTH Done
Date Inspected: Correct By. Reporting of Diseases by Food Employee and PIC PASS ❑d RED
005
Risk Level:
Personnel with Infections Restricted/Excluded PASS ❑d RED
Risk L
FOOD FROM APPROVED SOURCE Done
Permit NumberFood and Water from Approved Source PASS ❑d RED
BHP-2005-0217 Receiving/Condition PASSd❑ RED
Status: _ Tags/Records/Accuracy of Ingredient Statements PASS ❑J RED
Open .
#of Critical Violations' Conformance with Approved Procedures/HACCP PASS ❑d RED
Plans
2
Time IN. Time OUT , -t
Notes:
344'
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 11,2005 ) Page 1 of
0300 DERBY STREET Roosevelt's Restaurant & Saloon
must be corrected immediately PROTECTION FROM CONTAMINATION Done
or within 90 days) Separation/Segregation/Protection PASS ❑J RED
RED:
VIOIatIOnS Related t0 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED ing boards throughout stained and
Foodborne Illness Interventions scored. replace cutting boards.
and Risk Factors (Require Proper Adequate Handwashing PASS ❑J RED
immediate corrective action) Good Hygienic Practices PASS ❑d RED
Prevention of Contamination from Hands PASS RED
Handwash Facilities FAIL Critical ❑J RED V'flar sink needs to be labeled and
designated for hand washing only. Provide
sign above sink handwashing only.Owner
to supply soap and paper towels at all
times
andicapped restroom missing soap.
provide soap in wall hung dispenser.
PROTECTION FROM CHEMICALS Done
Approved Food or Color Additives PASS RED
Toxic Chemicals PASS RED
TIME/TEMPERATURE CONTROLS(Potentially Haz Done
Cooking Temperatures PASS RED
Reheating PASS ❑d RED
Cooling PASS ❑d RED
Hot and Cold Holding PASS RED
Time As a Public Health Control PASS RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done
Food and Food Preparation for HSP PASS ❑d RED
CONSUMER ADVISORY Done
Posting of Consumer Advisories PASS ❑d RED veowner stated advisory will be on menu.
I copy of menu to be available at time of
reinspection.
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 11,2005 ) Page 2 Of
0300 DERBY STREET Roosevelt's Restaurant & Saloon_
Violations Related to Good Retail Practices (Blue Done
Management and Personnel PASS ❑ BLUE
Food and Food Protection PASS ❑ BLUE
Equipment and Utensils FAIL Critical ❑ BLUE ere are cooling units throughout that are
not working or were not on at time of
inspection. all units that are working must
have visible accurate thermometers
maintained at proper temperature.
refrigerators at 41°f or below and freezers
at��0°f or below as mandated.
,s5nitizing solution in spray type bottles to
be placed at each work stattion and made
available at all times.proper test strips to
be on hand to test that proper ppm is
maintained.
icrowave needs general cleaning.
,V6 scoop at ice machine and at bars to be
cleaned and sanitized and stored in
cleaned and sanitized container labeled
"Ice Scoop Only."
,T(ere are holes and gaps in walls and
ceilings throughout establishment seal all
holes and gaps.
- drygoods and utensils stored in storage
ea to be relocated.general cleaning of
area needed
Kabel two bay sink wash/rinse and sanitize.
tans in walkin have accumulation of mold
and dust. clean fans.
Ws restroom missing paper towelsand
oilet paper.owner to provide toilet paper
and papertowels at all times,
stairs handsink needs papertowels
p"roovvide papertowles.
xhwashing and glass/storage area
upstairs to be cleaned and organized
t/bar upstairs had infestation of fruit flies,
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 11,2005 ) Pace 3 of
0300 DERBY STREET Roosevelt, Restaurant & Saloon
contact exterminator and treat.discard any
V,nfested bottles.
jw—�'/rovide thermometers in bar area where
dairy is stored
Water, Plumbing and Waste PASS ❑ BLUE �,,Rwner stated that there is a leak in one of
the sewage pipes underground.an odor
was detected at time of inspection from
drains. hire services of licensed plumber
and repair.send copy of invoice to board of
health offuce for our records.
Physical Facility FAIL Critical ❑ BLUE )6e*exterior door has gaps at bottom of
door. provide door sweep to seal gaps to
exterior to prevent entrance of rodents and
insects.
back door to bar upstairs is cracked and
nn(� coming off hinges. repair door.
here was also an odor of cat urine
detected in upstairs dining area odor and
soiled carpets to be treated or removed to
control odor.
employee bathroom has hole in wall seal
ole.
yame bathroom had missing ceiling tiles
Vreplace all missing ceiling tiles.
Fele in wall behind door near bathrooms.
repair hole and cracking plaster.
'31- Liquor closet ceiling missing tiles and has
V evidence of water leak and damage.find
source of leak and repair, replace all
missing and stained ceiling tiles. hire
services of licensed plumber. invoice to be
sent to board of health office for our
records.
same storage area had missing floor tiles.
replace tiles
Poisonous or Toxic Materials PASS ❑ BLUE
Special Requirements PASS ❑ BLUE
Other-See Notes PASS ❑ BLUE , -6tside to be cleaned and cleared of all
debris
GeoTMS®2005 Des Laurlers Municipal Solutions, Inc. ( Rev. Oct 11,2005 ) Page 4 of
0300 DERBY STREET Roosevelt's Restaurant & Saloon
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 11,2005 ) Page 5 of
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street, 4`" Floor
Division of Fitsid and Drugs Salem, MA 01970-3523
FOOD 9STABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Nam-,^/ 1 Date ,r" Tyne of Ooeration(s), Tvpe of Insoection
/\A /KP)/o� P U�/{�/ �' )❑ Food Service ❑ Routine
Address ✓) U C,1 ! Risk ❑ Retail ❑V Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone" � ❑ Mobile Date: /-& O ,
Owner HACCP Y/N ElTemporary ElPre-operation
to Y� /'1 ❑ Caterer ❑Suspect Illness
Person in Charge(P�) I ti�D Time - ❑ Bed&Breakfast ❑ General Complaint
In: El HACCP
Inspector )V-%V1 -0 Out: Permit No. ❑ Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
El13. Handwash Facilities
EMPLOYEE HEALTH
PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ", ❑20. Time As a Public Health Control
E0 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
tEl 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY
❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
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
ofCeaNh . 590.000/federal Food Code. This report, when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of
26. Water, Plumbing and Waste (Fc-5>(sso.00s) the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
_ 30. Other DATE OF RE-INSPECTION:
S Wins (Form-10 tlOC
J '
ins pectnr's S g tur Print:
On ylt,f ,A I � F
PIC's'$ignaturel/ ,�4,y / print: W Y'w� ` I Page_nf G' ages
i
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination �
I ( 590,003iA) ( Assr:prnent of Respun::ibility,. I 3-302.11(An.l) Raw Animal F�xx!s Separaled horn
59�603(B) Demonstration of KnmOcdW Cooked and RTE Foods'.
2-103 11 Person in eharge--duties I Contamination frorn Raw ingi edients
3-302.11(.1)(2) Raw Animal Funds Separated tncn Each
EPdPLOYEE HEALTH other'
2 $-)0.003(C) Responsibility of the person in charge to ( Contamination from the&M., nment
require reporting by f rod employees and 3-30,211(A, Food ITotrction` �
applicants* 3-30115 Washing Ftui;s and Ve^etablcs
590 003(F> Responsibility Of A Food Employee Or An ( 3-301 11 Food Contact with Equipment znd
4pphcurt To Report To The Person In j Utensils"
Chin gr' Contamination from,'no Consumer
.590.003(G) Reporting by Pelson in Charge" j 3-300.14(A)(13) Remi tied Food and Re,ett,ice n; Fax]^ j
j 3 590.003(D) Exclusions and Restrictions' ( Di>pos;lion of Aaultersted or Ccntam:nated f
590.003(1:) Removal of Exclusions and Restrictions Food I
3-701.11 Discarding or Reconditioning U isate
FOOD F'3OM APPROVED SOURCE Foo`i
q I Food and Water From Reguiatea Sources 9 Food Contact Surfaces
590 004(A-B) Comphancc with Food Law` 4-501.111 Manual W,,vewash m_-Hot Water
;-401.12 Food to a Ileuuetically Seaied Container" Sanitization'PemperaturcO
' !3-205).13 Fluid Milk and A10!:products'" ! 501.112 Mechanical W"arewaslang,Hnt Waterµ Sanitization Temperatures*
3-102.5)3 Shell Eggs^ 4.50!.. 14 Che!ni.al Sanitization-temp.,pH,
3-20_.14 Eggs and Milk Products.Pasteurized'"
3-202.1! kc ;blade From Potable[irinking Water' ccmt_enhat inn and hardne:s. "
5 -101.11 Drinking W�atcr from an.approved System" j 14-t;'ll 11(A) Equipment Fad Contact Snrraces and
590.0061 A) Bottled Dr'inkine Warer, ! L"en:als Clean'
j
i 1602.1' Cleaningrn
FregneyofEguipma]
entFn -590.006(B) Water Mects Standards in 3)0 CMR 22.0"
Contact Surfaces and Utensils".
SheNish and Fish From an Approved Source j ( 4-''02.11 Frequency of Sanitization of UtensiisXand
3-201.14 Fish and Recrci;oonally Caught Molluscan
Fad Contact Surlaccs of houipme!
She!lli<h*
j 4-703.11 Methods of Samt;i;uinn-Hot`Fater and
3-201.15 Molluscan Shellfish iioin NSSP listed {'heroical'
j Source,, i to ( Proper,Adequate Handwashing j
Game and Wild Mushrooms App,oved by ( � 2-30111 (Iran Condidon--hands and Anus"
Pegulator y Authority
1 3-20118 Shellstock Identification Present- j 11-301.12 ('leaning Procrd-u:e"
590.0044) Wild Mush oom,` I i 2-301.14 R7ten to Wash'
!
3-20 i.17 Game Anunals` 1I Good Hygienic Practices
5 Receiving/Condition ( 2-40].11 Esti::f.Donk;rig or Using'iabacco^
3='0<.1] PI-IFs Received at Proper Tenytermnres;' 2-401 12 Discharges Frout the Eyes,Nose end
3"02.15) Package haelany` ! MoutV
3-301!2 Preventing Contarninat;or 4b'heu'fxstin*'-
j 3-15)11.t l Fay d Safe and C,'nadwta arc<1'' j 12 Prevention of Contamination from Hands
j Tags/Records:Shellstock
j 3-201,!8 Sitellsuxk Identification
I 540.004iE) Presenting Cuneamnatwa from
3-20'1. H
.12 Shellmock Identification Maintained` � arEniidwash
Facilities
tt
Tags/Records:Fish Products I t3 ardw
.rsm enontly t.oca'ed acrd Accessitle
,�+r 13+02.11 Pautsi:e Desti�ction^ C
I
`S S'03.11 !�kimbers:mJCapa.:ities" j
3 40' l2 Records.Creation and Retention"
`-X}.00d(i) Labeling of Ingredients" ; `-20 I.I Lcx;ahon and Placement'
!
j 7 ' Conformance with Approved Procedures -t.2tA.1 ( Access;Mlity, Operation and N1.nnienatue
rHACCP Plans Suopkcd with,Soap a.nd Na^d Drv:hg
3-502.11 S cuahzed Pramssin, ( Devices
G , pe Methods'^
f 5) 3-:5)0_'.i 2 Redaced oxygen pack.tgutg,croc ia'
� fi-301.1] tiaudwashiup�Cte;:nscr ;'warlabaitY �
8-103.12 Connor mance with Approved procedures'
' 6-30!.1' Hand Drtir,,�Pnn^,ren
D,•xde;mi ical 11cm in ac fide:it I TO rood Code or 105 CMR pmt 00f
CITY OF SALEM
�j , �nj BOARD OF HEALTH
Establishment Name: I \11/ 'eV� Date: I " � J QS Page: P of a
Item Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION �./ Date
No. Reference R—Red Item Verified
PLEASE,PHtNT CLEARLY -
.r� I � C.: (;��thi�i� �r�1s-i'(�, ►�Uc.r_ Inns�+�"517 ► Vi�CI � SC�Y�Pct . J�sor�
I ,oaK W i -t7) UM Pv ( 't Hh h1_1 V)0 yrtS - co Lt 1504
rQ, 1 nkm I to .
llfD
I '
: I
' I
' I
Discussion With Person in Charge: Corrective Action Required: ( ❑ No I ❑ fes —�
G
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violialions 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 twen / ive dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. /� -
�/[�l/iGu-----__ 0 Voluntary Disposal ❑ Other:
3-50!.i i,C) ! PHFs Recessed at Ten tFrarnres
Violations Related to Foodborne Illness Interventions and Risk ,ccurdin„tri Idv+Coo:rd k• •: Ill
Factors(items 1.22) (Cont.) 4;'Fii-5'F wuiv n d Hours.
5(1].15 Qa;hng\Fethod:, (or Plff=s i
PROTECTION FROM CHEMICALS
)q I PHF Hot and Coll Holding
14
Food or Color Additives e .o 1.16(3. ) Cold PI IF,, Manna,ned at or below
'1-20_.12 ,Additives
: j 590.004'Fi 41'11_:-'F.`
3-302.14 Protection front Unapproved Additives" 13-501.i6fA) 1-lot PHF, hlauaamed at
or above
1.5 Poisonous or Toxic Subsfanaes •4{t,F t
7-101.!I Identifying Int:s'tu.un:n--Original ! i 3-501, ( Roasts Held ai or above 130'.'
t(i .'r: i r :
C.OIQa n:CC1"` .
7-102 11 Cottnnon Nance-W.ukin„C'ontainers� ( 120 ( Ytme as a Pubic Health Cartrol
3-501.1 Q Time as a Public lLaith C'nnnoP`
i 7'01.11 Separation-Storage- ( 590004;1-0 V'wiance Requirement
7-202 11 Restriction-Preaence and Use'
7-202.12 Condition of 1h;,- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203 It Toxic Containers-Prohibitions' I POPt LA'YIONS{HSP)
7-204.11 Saritizers,Criteria --Cheuticals* _
}1 j 3 SOLA(,) Unpssteurizcd Prc-pa kagcd 10ces and
7-2(P.11. Chemicals for W-ashu:c i'r«b,ce,Cru•:ria'
7-204.11 Drying Aeents.Crnei a" Use ul'g,es welt ed Pine t.abels"
7-205.11 Incidental Fn:xl Contact,Lubucamsr;- 1 3-&0!.11(13) Ra ui Pasteurized okcd
7-206.11 Restricted Ilse Pesticides,Criteria`
3-30:.i 1 U?) Raw ur Paetialli Cuar$ed Animal Pirad and
Rare-Deed Spnn::s Not Sated. "
7-206 12 Rodent Raiz Ctati:,ns" 3-EOL 11(C) Unopened Food Pactage Not Re served.
7-106 13 -]racking Pov,ders,P-4 Cartrol and !
Monitoring* CONSUMER ADVISORY
TIMElTEMPERaTURE CONTROLS 22 i 3-603.!I Consumer Advisor-,Postrd for Cot:suluir inn of
16 I Proper Cooking Temperatures for
i Anun"t Foods'rhat are Rav,,Ilndeicook.ed or
PRFs Net Otherwise Processed to Eliminate
3-401.1 l.At 1 t(2) Eggs- 155"F I.$Sec.
Pathu ecus to`„`"."'r:;•,, '
Eggs- In nrdiab_ Scr,ice 115 Fi Ssec° I -''-3')=.13 Pa;teurired F,gg;Suhstitutr for Raw Shril
3-401.11(A)(2) Couaninutzd Fish, Meat, k Game t"gF'
Animals- 155'F 15 ser. SPECIAL REQUIREMENTS3-4'01.11(R)II)(2) Put and Beel'RoF ast- 130" 121 min*
3-4UL1 I(A}(2) Ralnrs,InjectedMcats- 155`F 15 590 \)
.009(. -t D) Violatio;s.of Section 590.009(A)-(D)in
sec. catering. mobile food,tempurmy and
3-401-11(A)(3) Poultry,W9id Game,Stuffed PHFs, rc sider_tial kitchen operations should be
Stuffing Containing Fish,Meet, debited under the appropriate Secttons
Pouhry nr Ratite:-165'F 15 ,vc. I above if related to(ocdbome 4hiess
3-401A 1(C)(3) Whole-muscle, Intact Beel Steaks interventions and rich !actors. Other
1450F T I 590.0,09 viohttiuns relating to good retail
3-+01.12 Raw Anintal Fonds Conked in a I ;practices should be debited under/(29 -
Micruwave 165'F* Special Rcquin:rneats.
` 34:)1.1 It kfl (b) All Othcr PHF,- 1.15'F 15 sec
17 I Reheating for Hot Holding ( VIOLATIONS R�LATEO TO GOOD RETAIL PRACTICES
3-41)111(A)&(D1 PHFs IWF 15 sec. (ltemit; 23-30)
i ? 403-11(B) RS:cioa,ave- 1650 F2 Minute Standins I CIi.,W,Inti non-rri!irni vioiatto:,t, which do not runt:to tkc
Time" toodborne ithicsy:n!r,vention.,and nsA, ,tars iis!ed obnrr, can he
€ 3-403.11(C) Commercially Processed R'lh Food- finned in the fntl„t,.ing scrtions o-f the Fond Code a,:d 105 (WR
I 140"F" 590.-900.
3-403.1 I(F) Remaining Gnhced Puttions of ileef ! F item Gadd Retai(i'racrices FC 59u.060
Roasts" I 123. %lanaocmert and Personrel FC-2 -0'Y•
18 Proper Cooling of PHFs 24 7ood and Food Proteeton 1-C--3 .004
25, cqu4ansm arc:U I isds F0--c .005
3-S01.14(A) Cooking Cooked PHPs frau 140'F t° 26. Water,Plumbiuo z ,d Waste �C-5 AO
70:1 Within 2 flours anti From 70'F 27. Physical FaCtRy =C__6 .007
to 41`Fr l-5'F Within 4]lours. * 28 Poisorrus or Toz:c lAaieria!s =C. 7 .002
3-501.14(x) Cooling PHFs Made From Ambient 29, Special Reau:remeni3 .009 I
Tempe;attire fivnedientsto4l`F(45'F 1_30 4the!
Within f flours:.
�. ^ Dennis critical ituvm([to Rdersl 19119Fano Code;.r L t5Cb1R590000,
• -'r r..Yi ... . .,"11!'L^'1V�'���K U.S"^.n.'n.t14'��..na..,ifF Y1.n#Gi'y'�^w..Al.'�' . .n.-r+ ... Ik.M4n.n.•b1 ..n`. y...� f^G1kft«'-'-..V�9.... r + ..
Massaesusetts Department of Public Health Salem Board Health
S
p ,20 Washington Street,4'" Floor
DivisiorTof Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978}741-1800 Fax (978)745-0343
r Name Date Type of Onerationfsk :ry of inattention
Name C] Food Service ® Routine
Addre s / Risk/ C] Retail ❑ Re-inspection
`Vt I _ Pte_ VevBP` ❑ Residential'Kitchen Previous Inspection
Telephone- ' ❑ Mobile Date:
K `83.3 El Temporary ❑ Pre-operation
Owner / HACCP Y/N ( ❑ Caterer ❑ Suspect Illness
Person in Charge(�Jt) f Time I F-1Bed 8 Breakfast ❑General Complaint
In: ❑ HACCP
Inspector 1, i Out: Permit No. ❑Other
Each violat on 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 d ,�„}"� D12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties , /11
® 13. Handwash Facilities
EMPLOYEE HEALTH
,'} PROTECTION FROM CHEMICALS ,
❑ 2. Reporting of Diseases by Foal Employee and PIC
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
D 4. Food and Water from Approved Source TIME/fEMPERATUREOONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
'
[16. 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
[1 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control
0/9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
Di 1. Good Hygienic Practices CONSUMER ADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): �✓
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report,when signed below
CI- X0.
by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations
�4. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of
�3. 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address
Special Requirements (590.009) within 10 days of receipt of this order.
Other DATE OF RE-INSPECTION:
5 5401nspertform6J40 .'
Ine
'P � � natu e: /r' Print: r
Sat��11�ttJf�, JI � � �//
Pages
PIC'Is'Signa'�ur•e� i ',� C I/"r.�i n 1 Print: �+ r� ('\/ Page of/
1
.,I
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 9-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT j N Cross-rvnSsmina on
1 5':0(10311) Assvgnment of Kesponesbility" I 30:.11(A)(1) Raw Ammal Foods Jep;uarrd ficin
590.003(B) ! Detnonstrstson of Knowledge* I Cooked and R'IF gouda` r
2-103.1 1 ( Person in charge - duti^s j Contamination from Rain Ingredients i
3-30111(A)(21Raw Animal Foods Separated from Each
EMPLOYEE HEALTH ( Other' (
2 500.003(C) P:aponsibtlity ul:he Pelson in difir.e to ( Centomination fromthe Fnvfrenmeot
require reporting be focal emphgers and 13-302.11(A) Foul Proiaction"
apph,mm"4 13-302.1� W ishmlt Fruits and Vegetan),ts
590 003(F) Kesponsibility Of A hxxl Employee Or An 3-3V)4.11 Food Contac t,i?h fSyuipmrnt and
Applicant To Repwi To The Person In : LitensD #
Charge` I I Contam%nation from the Consumer
S90.003(G) Reporting b} Person in Charge`" 13-306,14(Ai(Bl Returned Fcad.md Re:,c06,e of FoodT
j 3 590003(0) Eeclusionsand Restfichons* I Drspcsih"on ofAdu,'tera!ed rr Conran%rated !
590.00-,F) Removal of Exclusion n d Restneuons ( i Food
3-701.11 Discarding or Reconditioning Unsafe i
FOOD FgOM APPROVED SOURCE I Food
! 4 Food and Water From Regulated Sources 19 I rood Contact Surfaces
590.004(:1-B) CunzphanrcwititF'oudLaw` I 4-501.1?; LlantwlWarew'asllhlg-tlottii'aar
' 3-201,12 Food m a Ilermeticalty Seaded Container* ! Sutit;rttion`f emperauues''
3-201.13 Fluid Milk and Milk Products* 14-501 112 Mechanical4V�rei+anprag�Hot Water
( :3-202.1= Shelf E, Sanitm:ironTemperairr:s"
3-202 Id Egg: and Milk Products,Pasteurized" ( 14-501.i 1-1 Chenucai Sanitization- temp.,pFF,
iU7-. ( ctmcenhat'on and has direr. '
16 ke Made From Potable Drinking Water' !
5-101,11 1)r,nkin;,Water from an An coved Syctem;` ( 4-ti!}l.(1(d) Equipment'
Food Canmrt Surtliees and
540006(A) Bottled Drinking Water` 1 Cleaninsrk Clean-
590
lean^
i s40.006(B) Water Alee.ts Standards m 310 CMR 22 0" i -1-ti02.1 I Cleaninv mfac enay dl Eympmtttl Food-
590.006(B) C'onrzct Sw lacca and tRemtis:`
1 Sloeflfish and Fisn From air Approved Source 1
i i 4-102.11 Prcyuency of Sattitizauon of Uten,i L;and
3-201.14 0:;h and Recreationally Caught Molluscan I j Fo:,d Contaet Surfaces of la.impir
Shetlfish* 4-703.i i Llerbods of Sanitization-Her Water and
3-_201.15 Molluscan Shu ilfish front!VSSP Lisled l I Chernical'
I Sources*
Game and t4'fid Mushrooms Aoproved by i 1CleaProper,A Condition
Hand-,and g
Regulatory Authoety 1 � -30:.,r Clean i:onditiun-Hwxi;and Ann,
202.13 Sheltstock Identification Piesenr" I 12-301 12 Cleaning Procedure" �
I.
590.004-IT) Wild NIWhtuxxrn" 12 301.14 When uo Wash"
3-'201.17 Gatne Anunzlsi'
I t Good Hygien=e Practicer
c Receiving/Condition 2-401.11 Faimv, Drmkmg or USIm,rl'obacco�
! 3-2(:2.1 i PFiFs Recci ved at Proper Temperatures: 12-40(.12 Uisdrtrgec From it:e E}'es,hose and
' 3a112.15 Prcka;:e hurgrity* Mouth'.
1 3-301.12 Pre"cntine Conhunmatioir when Tasting.'
01.1 I TagsI-ood Safe and Unadulterated* r 12 Prevention of Contamination trom Hands
fi Tags/Records:Shellsfrsck
3-202.13 SheOauockIdentification;' 590.OU1fE) F'reeentingG_,ntanu:oationfrum
3-203.12 Sheilstock Identification IMaintamed'- Employees"
TagslRecnrd- Fish Products 113 Handwash Facilities
Conveniently Located and Access,ble
3-102.11 ParasiteDesh'action'° !
5-203.! ! Nanttrrrs and Cap.rcitien''
?-402 12 Recor(a.Creation and Retention'
590.00=1(J) Labelingof In redients* ,
5-204.1 I Locaoon wid l'1lcrrnem':
g( ;-205 l! ,A.,cess:hdity,Oper.d:uo and ,btasntenauce 7 Conformance with Approved Procedures i
iHACCP Pians Supplied mPt)Sean;Ind Han,-'Drying
Devras
3002 11 Specialized Processing Methods'' 1
0-301 11 1lwdwash:n,Cleanser.Availahllity
9-5tt2.i2 Reduced oxygen packagms?,criteria" I
3-103.12 ConRprocedures„`
with Approved procedures ( b-301.1_ F(:uxl Drying Prooisiun 1
*l)enoie�critical nem in rh;fvde;al 1999 rroad r'nd:or 105 CMR 540.000
CITY OF SALEM
I / / BOARD OF HEALTH
Establishment NameU7�SQ l/r?f' (�f�7-/I//ll�l�t} Date: I — 10-OS Page: of 7
Item Code C-Critical item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date
No. Reference R—Red Item I Verified
' PLEASE PRINT CLEARLY
r I ,I lI P tllq�W,- ,o 1 1'LU4f'&W -)Ilhlnin
3 I / G�S - rPt7a/d?411 ( )h,( f I InQl(10_ 11000 <" c;:II\?m0110� o I �/b tl_I vio,
N1IlII"dIrr'i_ a X104 AS ria Inn.1nt � �, SPGII4il(�
•, c��S' I -- ('n,uTv� ll � n �� 11nl�lnr{ �
I 1�,l�Y�Mn�np i.1 �vY)rr ri1-fid G4 r --�ellxA]l � r)GF
�Ln I��2 {lmn n)� �dIS TI�1blDUCs�ltl C`10(tJ^,
n m 4 Qa\nI71 � . J
I ✓ �� I )�NeOkYIVIP fir) t/ae C'--nogrl hrinA(P- 1Cta_ 1 )0 -
(aa' r) Opp" 2 hGA n r�.r )mm o
1 ))n-hr -P 4)cJ Ao hHS- fG)r -Ir
x�l I u
I C la c(-n -t- 5-,sah I-h-2e _1
11x.2 -Y\A0 to 6 fn u hGC�1 rx�rl �m � ,lnhnr, rrT Yvu�f��l' l'.lpr t'�
1 I A-'nad+1 -7' -
/� '11M A r,(l h n/ -1)(A1110- (7X l Lylt-IZA j in Wiz -{ 1TP_ t d'C_k "(-e -
I
I HI/J 3 G - %Ctl hn uV�l l _ ��/1 G•,\y�1�S i l� ,��sb t�\1 c_ 1,�vto �� ;4 vin l_)S-f �i n uP_ G�'2:�
2- Jpl/)D2r1In 'ls r QPr/)nA -{=1 702 �Y1/11SSlYtC� ( r�irPr�.
IO �n00
✓a Ll -kriA <:�-"o 1,r)( 1)( m(A 47nA_ A _k �
r! �� '�A i)ck V)v (ye—rPrl
C/ C kv� _ lrvrt YAS iN,YAC) m.4 -eqn H ri1YY9114 5jA I VI and k S;r-P \qR - YDSUY iTitl�JQ�Y�I�i
Discussion With Person in Charge: J J Corrective Action Required:❑ No I ❑ Yes` I
have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
oblations before the next inspection, to observe all conditions as described,/and to LIRe-inspection Scheduled ❑ Emergency suspension .
t omply with all mandates of the Mass/Federal F6�od Code. Iunderstand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. I
❑ Voluntary Disposal ❑ Other:
1 I
3-=n:;. 4t C"} PiiFs I:eceir-ed at le,rgmrature
Violations Related to Foodborn:fitness Interventions and Risk i Ac,ror<ling to Ia„'Cooled to
Factors(items 1.22) (Cont.) -11"F45'p Within 4 Hums.
3-301,15 Cuoim ,V--11_ods for PHF1:
PROTECTION FROM CHEMICALS eq I r
14 Food or Color Additives PHF Hot and Cold Holding
3-501 I6(B) Cold PI IPs Mamtainea at or bel(w
3-202.12 Additp en'' i c,gt;u04(F) +1'145 F”
3
'402,14 Protection tmm Um,•mored Additives'
I Ui(A} aoti-'FIFti Maintained at or above
15 Poisonous or Toxic Substances
7-101.11 Identitywa lninrm:r,um-Or;ginai ( 3-50iA6(A) R,,asts Held a:or abnwe 130017
Contaiiwns"
1-102.11 Cummu,; Nano -Working Cnnutinen` ! ( 20 Time as a Public Health Control
i-9I'A Io Time as a Public health Control*
7-201.11 Separation-Storage` y0.004{I-F) 4'ariane'r Rc+aairema j
7-202 If Re::triction--Presence and Uce
7-202.13 Conditions oft';e'
7-203.11 'toxic Container,-Prohibir,,nO REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
204.11 Sanitizets,Criteria-Che oicals' POPULATIONS(HSP)
'
7-204 12 Chemicals for Washtug 1'-)duce,Crl::ria'
21 3-FG1 !'(A, I:u,.^.astirtri'.:cd Pre-packaged Races zinc(
Bev
e:nee:: tt-;tL Warring Label.=.*
7-204.11 Drying Agents.Criceti.,' 3-86 I I(B) Use of Pasteurized
7-205.11 Ltcidentel Feud Contact. Lubricants- 13-80LI l;D) Raw or Pmliallv Cooked Aerm;d Mxxl aa:
7-206,11 Restricted Use Pesticides.Criteria'
( 7 2061 12 Rodent B.at St:tions" haFv Sccd StR6tt15 Not Sci ved.
7-''06.13 Tr.:cking Powder,, Pent Cnmro; ,Ind Unopened Food PaAagv No Re-served. * I
1vlrmitorin�T CONSUMER ADVISORY
TIME(TEMPERATURE CONTROLS 22 3-6,03.11 Consumer Adsisoty Posted fn.,Consumption of
!6 Proper Cooking Temperatures tot Anoosi Foods'That are Raw, Undcrceuked in
PHFs ( No Orherwisa Processed to El;rninatc
3-101.11A(1)(2) 1'gg,�- 15i'F15Sec. P.:u,gaenc.�
rer.mre r.rn.n
? 302 13 1'a SI briZed R,>�zs Subaututr for Raw Shell
Eggs- tnunedia,c Service 145°Pl Ssec' -
3-401.11(A)(2) ComminutedF'i;h, Meat.&Gan;e C i "_-S"
^
Animals- 15i'F 15 sec. ,k
3-401.11(B)r•1)(2r Pork and Beet Roast 130"F 121 mSPECIAL REQUIREMENTS
R
in" 590 O;F9(A) E; Vi t o
3-401.11(A)(2) Ratites, htjectetl Meats-- 155`F 15 olations of Section 590.00.r,A)-(D) in
Sec - catering. rnvbile food,ten iporary and
1 3-401.11(A)(3) Poultry,Wild Game.Stu1'fcd PHI's, j residential kitth.n operations.6otild be
Stuttln;t Containing Fish,Meat, debited under 1h:appropriate ;Cottons
Poultry or Ratitc<-165'F 15 we I above if related to >oodboruc ili:ess
3-401.1I(C)(+) yShole-rm:sde, boast Bcel'Sicaks interventions and risk factors, Othcr
145'F„ I `90.009 violations relating to good tetail
3-401.12 Raw Animal Fna!s Cooked in a practice,should be debited under #29-
Mrcicwave 165=1:* ! Spccial Rrgunerucnt.c.
3-40 i A I r A)(I it b) All Other PIIFs- 145'F 15 iec. '
17 Reheating for Hot Holding VIOLATIOMS RcLATED TO GOOD RETAIL PRACTICES
3-403.11cA)&(D) PHPn 169'F 15 sec. (Items 1-3-30)
3-403.11(B) Microwave- 165'F 2 Minute Standing Ciitirrl and non-rrdicat vu:Grr,,�rs, wh:ch do not r elatc w Ila'
'Imre ,ktpdbo)ne illness inroventions earl riakjtors listed above, ran be
3 403.11(C) Commercialiv Pnxessed 12TE Food- i found:n die johriwbr,g seetiotis q ,he Food Codc,md!05 C XfR
140"F""
3-40311(1,) Remainm; Unslrced Pvrtirnsol'Bcet Item Good Retail Practices fC 5aC.0(t0
Roasts" 23. talarattement and Personnel FC -2 003 _
18 Proper Cooling of PHFs 1 24. Foo;and Food Prorr-,ction FC--3 ! 004
1 25 Equenient and Utensils FC-4 .005
3-50i 14(A) Cooling Cooked PHFs from 140`Ftr' 28 '.Vater. P!umbinq and Waste FC-5 1 .006 �
70"F Vrithin 2 Rums and From 7WF 2-r _ Ptrynrral Facility rC-o" 007
Lo 41'F/45"F Within 4 Hours. " :g Poisonous or Tox'c Materials FC -7 .008 —�
3-501 Idr B) Cooling PI-IPs Made Flom Ambient i 1 29, Special Requ�rome-ts .009
Temperature htcredient�in 41"F/45`17 30. Othzr
Within 4 Hours
Denotes el:nL11 deo!at ihr fcde,al ]IN';Fona Bode,�r l tS CbIR S80'1t10
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: 7/TUT�S��/elTs b��S'r�U/GC/� Date: - (�-L � Page: of � L
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION bate
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
/d S
-5M UM /rt Q erz l2 nn I ss 1 nc,A-G)o Y n n nu A-e e '`DrDm do v o t\-)uL,
e - it o wm o m Oce v I,\ o d M a 4-e n.A r) n ten, t'_Y1 n ti
I t <n4'Ao 1tn0 i(\of Cle- (yLIX14
t7h0Ar) `
lvhttc-+,\d-�. Y\,4S�i�1(�1 jho-vyvtnin�C -?0)0 zR_ V«iwc Garro �,a t4` Q yikonco_l�
Imalv��lgo GA a4eW6 (9P 1A * CV 0S Cft�dCk s�
V -IVic
ll:
"� Y�
rlr'� Co-\=_ Qrrd i5-eA " hnt�'c t " t act- ok-oh
I �cxt� n-4 Ail)'��,In�IS
t I I n o s 4�A c rn)-m o i n41A-Fl -tom k n ra ff �� I
I✓ate -I�1olnrr, -4 Ci - 1C) 000lq (-),P1&0Ad (1_Q(tPLf) I
IP . s- e - C�dn o I t o r� °herd r, �r ? t 1 ca_hon CC bQ h H-S `T t�oruc�kh( U
_ I
Cloak �
T'ncr���� �� -�n `�e 41a.c�.r� cin (��lztnor2 LC4heln� " �Ce Sr-��D`dnl�f Ilj '�
I OY� i7jIYID,1? lie C`lnr(-Ikoaf i �ro1AI+\ rl I
Discussion With Person in Charge: Corrective Action Required: j ❑ No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
vl lations before the next inspection, to observe all conditions as described, and to Exclusion
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
mply with all mandates of the Mass/Federa1wood Code-l-understand that
noncompliance may result in daily fines oft �r f�Vce
to tars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. jt { ry p
' ` { I ❑ Voluntary Disposal ❑ Other:
3-51!1!-1t•:;)[-h PHFs Pec.ived at I eniaeratur,,s'
Violations Related to Foodborne Ii Interventions and 91*1"k
Ac::ordin-to Law Cl,v!cd to
Factors(Items 1-221 (Cont.)
41"F/-15'F Within 4 le,
PROTECTION FROM CHEMICALS 3-50Li5 Coolinc,Method.;for PEE-s
14 Food or Color Additives 119 F9F Hntqnd Cold Holding
50 i.I O(B) C,Iti PFIFt. Maintained at(it below
3-202.12 Additj�esi`
Prot, fnappr cs'
3-302 14 —,non fmri ioied Additiv, 3 501 tr(A) Hot fflf S klailitaine"I at(�r above
15 Poisonous or Toxic Sublhances 1,10"F
7-101.11 Identibnae Information-Orig!jial 3-50116(A) R,ats Held at or above !30'F
Containers" rime as a Public Health Control
7-102.11 Common.Natne-Working Cowanwrs" 1-501,19 Time as a Public Health Cvqnro!v
7-201.11 Soparafion-Storage,
7-20111 Rtstlittam-Presenicc arid Use 590.004(H) VarianceRoqu�rcuy�nt
7-202.12 coric,tions of Use'
'1,,xic Containers-Prohibidon0i 5 RLE
7-203 11 EQUIREMENTS FOR HIGHLY SUSCEP iT IB
POPULATIONS(HSP)
7204,11 Sanitize,s.Criteria-Chemicals' ! ?1 3-801 ll(A�, Jrip,i�teurcnedl Fre-pat1aged Jwce�and
7-204.12 Clierineak for Washing Produce,Criteria-
-/-.104.14 Devitt-,Agency.Criteria'" he,,eniges—ith'A,riunq Labels':
3-,,,'Il 1',(!3) Uae of Paoew;/,d I-i-ws*
7-265.11 Incidental Food Contact illibricants, I(D) Raw or Patrial1v Cookod Aninia! Foodand
7-2oti.H Restricted Use Pesticides Cri:crui*
Raw Sed Spowis Not Served.
7-206.12 Rodent Bait Stations'
7-106.i 3 'Tracking Powders,Feist Control and 3-11)1,i I iC, Unoneued Pood Package RotRe-served.
I
Moldtlrin- CONSUMER ADVISORY
*
12 -61)p, I I Consumer Atli isory Posted for Coa,cuanption of
TIMEtTEMPERATURE CONTROLS Animal Foo 1s 11t,rt it are Raw, Undercooked(it
16 Proper Cooking Temperatures for Not Orlwir"iso Processed to 1--liminate
PHFs ......
-40 1.11 A(I)('I) Eggs- 155�F 15 See. Padta 3-301:3 P"I'teurizt-d Eg,�Substitute fin Raw She!]
Eggs-hininediate Servicc J45,f`I5.S,-0
1 1
3-4ol.1 I(A)(2) Comminuted Fish,Mcas;&Came Eggs*
Animals- 155'F 15 see. ii
3-401.11(8)(1)(2) Pork and Beef Resist- 130`'F 121 litin, SPECIAL REQUIREMENTS
3-40 1.11(A)(2) Ratites, InJected %ft-als- 155'F 15 A)-(D) VilolatKIDS of Section 590.009(A)-''D) in
ec.
catering. mobile food,temporary and
s
3-401.11(A)(3) POL;itry, Wild Ciame, Stuffed PI My, residential kitchen op,-taflons should lie
Sluffirw Contaima- Fish,Meat, debited Under the appropriate sections
Pculny or li 05'F 15 sec. above if;elated to foodbunic illness
3-401.11(C)(3) Whole-nimcle, hitti Beet Steaks i interventions and t;sk Other
145+
500.009 violations relalirig to good retail
3-401.12 Rate Annual Foods Cooked in a practices Aiould],,e dcHin-d under 1129
Nlicamave 1651, Szpa,--ial RqUircrnents,
,140i.]1(A)(1)(h) All Other PHFc- 145'F 15 sec
17 Reheating for Hot Holding VIOLATIONS R.ELA TED TO GOOD RETAIL PRACTICES
3-403.11(:1,1&(D) f`HFs 165'F IS sec. * (Items 23-3(i)
3-403.11(B) Microwave- 165' F'2 Munin:Standiin, Gw,,al and!a,or,(ritical violations, ;Ihich do not relate it,tile
Tone' filloirlltwn�,llnesv allelvenlionvand rkvkj'a(ivra hated obove con ter'
4-403.11(C) Commerciail) Pr,,ne,,sed RTE Food- fiv,end;;i diefollonwig ae(,tions ot the Food Code and 105 CAIR
140 1,' 2`C)0.000.
3-403.1 1(F) Remairnig, Urishced Portions of Beef I —Iiem--- -Good Retail Practices li 590.000
Roasts" 1 23. Management and Personnel FG-2 .001
Is Proper Cooling of PHFs I 24 rood ai-ci Food PICteGy:cn 3 .004
25, Equipment and(Ji"llsils FC-4 .005
3-501 4(A) Coolint Cooked PHF,-from 14(FF to 1; ;+g Weser Pluibinq and V/Fste F0-5 006
70'F\k thin 2 1[our,and From 70T 27. Prys;cal Facility rc-6 .007
u,41'F/43°F Within 4 Hollis t 28, Poisonous or Toxic Materials FC -1 1 .008
3-501 1103) Conlin,PHFs M,9,-'e Fri-an Ambient 29, specalFricluremerts M9
Ttrapetature Ingredients in 41'F/,4 5 T 0, Other
Within 4 P,airs
Denows crintat lell)ITI dW 11dCla; 19119 Fod Cod,("TN6('Ml',590 000,
c
CITY OF SALEM
BOARD OF HEALTH L
Establishment Name: £)y, Date:Date: i /�- !y C_ Page: of I
Item Code C-Critical Item v DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PAINT CLEARLY
0 i. vi ti �1 �7) "D Qp(b f O C +)� '-
%J P.Q�n {.
0
# (�nn \1n;7C1Y11APY7 1��b11C.'4 \(151 �71F
C � � ^ A. /l �f V_M n /)-�
I I � I
-
�I zinc - � — � , , n 02 �, �DI ! - _ lZ Yl0( Vier
�V/21At \na o+ 0-
I i I Yl Jf)J ,-, )I f' ' n1k y�
\�! I I Vl C O/T/)X/ - �� /h f 111 0 ok
\ / 0
n . f \nSCtY �C tl�
r. � -(�,rl� ' Aninn`igNknyl 1v1�1Jl�1)W, i
Discussion With Person in Charge: Corrective Action Required: I LlNo ❑ Yes
I, r \ I /
I have read this report, have had the opportunity to ask quu ❑ Voluntary Compliance ❑ Employee Restriction
questions and agree to correct all Exclusion
viplations 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. I I 1 ,/
CA ❑ Voluntary Disposal ❑ Other:
r L I u • t kr . V
t`tt :.
> s(17 -,,C, PHFt,Re_ei-ce : .it Temperatures '
Violations Related to Foodborne Illness Interventions and Flisx A.ccerdirn,to L,w Cooled io
Factors(items 1-22) (Cont.) <'.I Fi45°F kkiain,l Hom-i. "
PROTECTION FROM CHEMICALS -,711.15 Cooling Methods for PHFa
14 Food or Color.Additives j i 19 PHF Hot and Cold Ho1d:r:y
3-50 i.16(b) Cold Pffs Maintinedai or bellow
3-202.12 Additiiec'" 1i-(45`F`
3-302.1+Pfotection Krum Unapproied A;!dinoesk j
j 15 'Poisonous or Toxic Substar:.:es ,-501.161Ai [lot PRFs Maintained at orabo%e
7-101.11 Id",litymg iniorm,dinn--Onw;al 140'F.
I
3-50i A 6(A) Roasts Held w or above 1301F.
Containers' '
7-102,11 Common Name-Working Containers" j ( ZU Time as a Public Health Control
-201.11 Separation-Storage' j '-5'11.(9 Time a:;a Public Health Conti ol*
7-202.11 ( Rcstrictiun-Pre:.ence and I lset 590.004(1-1) Variancu RVqu6rCTX1U j
j 7-21)2.12 Conditions cut Us,+ REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
� 7-'_0311 � Toxixicc Cnnurinrn- Prnhibuions�` �
7-204.!! Samtirets,Criteria-Chemicals POPULATIONS(HSP;
7-20-1.12Chemicals for Washing Proda,,e,Cr '1 mr¢
iteria'' 3-801 11(A: Unpr:steed Pr.-p:e_l:aged Juices::nd
j I I i 264.1He•.mages with bX a-linL*[abela'
1 Drying Aeznts.CriteriaT -
7=205.11 Incidental Food Contact.Lnbrwanns`- i 3-80 1.! !(B) Use of Paaleurved Eggs4
3-80 i.:!(D) Raga ur Patitally Cooked Anima! Food and
7�Ob 17 itestr!cted Use Pesbcrtles.C'ntena=- Raw Stcd Spi-oins Not Served.
7-2,06.12 Rodent Brut Stations'" j > Re
3-80 L 11.C i ;)nope!ted Fox{PackNotage "t Re-served.
7-206.13 '[racking Poudrrs, Pest Centro? and
Monitoring` !
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.1 1 Consumer Advisory Posted for Consumption cif
16 Proper Cooking Temperaturrs for I Aran,cd !'',mds'I'hat etc Raw. Llndereuoked o:
Nut Otheiwisc Processed to Fbminate
PHFs Pat;)(g;en,., r_.n r*,,.n,a,
3 401.1 lA(1 q'_) Egos- I j5"F 1.5 Sec.
Eggs-hams,!;ate Service 1.15'1'1 iso:' ;.;))7.13 Pasteacized Eggs Subst,tute ror Raw Shelf
� �
3._!61.1 t(A)(2) Comminuted Fisly Meat,;&_Game n,.;s>
Animals- 155-F 15 sec.
3_, WA 1(B)(1)(2) Pork and Beef Roast. 130"F 1^_1 :--iin` SPECIAL REQUIREMENTS
3-401.17(A)(2) Ratner. Infected M:at:,-755'F 15
590 f)o9(A)-(D) Vioiations of Section 590.00v(A)-(D) in
ec * catctiumobile obile food, temporary and
'�I.1 I(A)(3) Pouhr),Wild C.une,Stuffed PHFs, resldent;ei kitchen, operation;should be
Stuffing Containing Fish, Meat, debitcJ under tic appropriate sections
_ Poultry;or Ratites-165"F !,'I sec. " alcove if ielatcd to Iodhorne illness
3-401.11(C)(3) Wt ole-muscle;beast Bert Steaks inten,entiona and r;sk. factors. Other
145°F+ 590.009 violations relating to good retail
3-4101.12 Raw Animal Foods Cooked in a ( !acuses should be,debited under J129-
Microwave 105`1'* Special Rquireatents.
3-401.11(A)(I0) All Other fHFs- 14VF 15 see.
17 Reheating For Hot Holding VIOLATIONS Fi._LATED TO GOOD RETAIL PRACTICES
3-403.!1(A)&(D) PF!Fs 165"17 13 sec. ^: {Iiemti?3-3ti)
3-403.11(B) Microwave- I65°F 2 Mnnue Staudiaa Ciltaw.!mod n„n-r,1icul vioL,00ne, which do not relate to fhe
Timci ,foodborne illness intoveniion,s,and ris jouors tiwed n0ere, earn he
3-403.11(C) CoernerCudly Processed RTE Rmil- ,(raid in the f oIbai iag.strtions of the Food Cbde rod 10.5 CAIR
140'F` _590.000.
3-403.t1(F) Remaining UnshcedPortioueoi'Beef horn GoodRetatiPractices FC 690.000 I
Roasts" 2., Manaocroont and Personnel FC-2 .00'
IS Proper Cooling of PHFs ( 24 Food and Food Protecuon FC--3 .004 I
_25. Equilemcnt and Utensils FC -4 .005
3-5u t W(A) Cooling Cooked PHFs from 110`P(n 26.--_- Water,P!urrbinq and Waste FC-S 006
701-Within 2 hours and Frnm 70'F i 27. Physical Faciii!y FC -6 007 j
to 41'F/45`F Within 4 Hours. * ' 28 Poisonous or Toxic Matsfialc FC -7 .008
3-501.14(1.') Cooling PHPs Madc Ficrnt Ambient 29. S
-Pectat Requirements _009
Temperature Ingredients to 41�F/45`1- 1_30 tither
Within 4 Ilotirs7l ,
Uux,ies,ritical itcm 11)111,,fader l I`)9d Fond('ad;or 105 CNIR 590000.
T"J
Ak
CITY OF SALEM'MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter 111, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Roosevelt's Restaurant
Address of Establishment: 300 Derby Street
Owner's Name: Hugh McGowan
Restrictions:
Application Date: 12/2/2004
Permit for Food Establishment 136-05
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2005
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH GENT
CITY OF SALEM9 MASSACHUS C 19 W
BOARD OF HEALTH ro
120 WASHINGTON STREET, 4TH FLOO ,1 �d
SALEM, MA 01970 NOV 2 4 2004
.�L TEL. 978-741-1800
FAX 978-745-0343 CITY OF SALEM
STANLEY J. UISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH
MAYOR HEALTH AGENT
2005 APPLICATIOTnsfz_or�
PERMIT OPERATE A FOOD ESTABLISHMENT_
NAME OF ESTABLISH MENTI TEL# 97� 7tl 'n /( 3 3
ADDRESS OF ESTABLISHMENT c16-D
' - l
MAILING ADDRESS (ififfier nt)
OWNER'S NAME _ 0QJ r I` �h(ti1 At j TEL# �i����'1 C 0'1
ADDRESS I / �I LY 4 o s t,, 1111 __ ;
CITY_ �FA e O4/ 1 STATE zip O ( Z le
CERTIFIED FOOD MANAGER'S NAAME(S) .I ASIS o� t v.) CERTIFICATE#(s) oSS
(required in an establishment where potentially hazardous/food is prepared.)
EMERGENCY RESPONSE PERSON /909 ` UN HOME TEL# cl ( J
O
HOURS OF OPERATION: Mon. /�Tue. -/Wed. r Thu. � Fri. — Sat. Sun. — P eD A�
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
RESTAURANT YES) NO 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 YESNO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(.such as.church kitchens) YES O $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 MILL Ch
terC � ction 49A, 1 certify under the pains and penalties of perjury that I, to my
best knowled /an led all state tax returns and aid all state tI xPr NoVI` � ll -- l -AV-0"t p q
SiDate /Social SecurityorFederal Identification jjNumber
Revised 11/03/03 FOODAP2 adm Check#&Dale
I «
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
� SALEM, MA 01970
q��gl TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Roosevelt's Restaurant
Address of Establishment: 300 Derby Street
Owner's Name: Hugh McGowan
Restrictions: 1ST FLOOR USE ONLY
Application Date: 12/2/2004
Permit for Food Establishment 136-05
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2005
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
qV`
HEALTH AGENT
T-CCO I Cl d ani 1 ear s sa c��,
(CMU
V
�II II
Ci o{ a(em Massachuseo
� J 5 i OCT 31 2005
Fire Department
tPo CITY OF SALEM
>�sy�
48 Lafayette Street BOARD OF HEALTH
Davuf'W Cody Safem, jbtassachusetts 01970-3655 fire Prevention
Ch,f Tel 978-744-1Z35 Bureau
978-744-6990 fax 978-745-4646 978-745-7777
dcody@salem.com
oose lts
00 Derby Stre
Sa em;MA' 1970
October 26, 2005
DEAR PROPERTY/BUSINESS OWNER:
RE: INSPECTION,TESTING,AND MAINTENANCE OF FIRE PROTECTION
SYSTEMS.
To Whom It May Concern:
The Fire Prevention Bureau has no recent records of any inspection,testing,or
maintenance of your fire alarm and/or sprinkler systems. These fire detection and fire
suppression systems are to be tested annually by a licensed, qualified company.
All fire detection and suppression systems are to be inspected, tested, and maintained in
accordance with the State Building Code, 780 CMR Chapter 9:Fire Protection
Systems;NFPA 25:standard for the Inspection, Testing, and Maintenance of Water-
Based Fire Protection Systems;and NFPA 72:National Fire Alarm Code.
Inspection, testing, and maintenance of these systems is the responsibility of
the owner of the fire alarm and/or sprinkler system.
In addition,commercial kitchen hood and duct systems are to be inspected, tested, and
maintained in accordance with NFPA 96:standard for Ventilation Control and Fire
Protection of Commercial Cooking Operations.
A copy of the Fire Prevention Bureau's hood and duct notification letter has been
enclosed with this letter where applicable.
Inspection, testing, and maintenance of the kitchen system is the system
owner's responsibility.
Proper documentation of a schedule of system compliance will be a
requirement for renewal of an annual food service permit and an
annual liquor license.
Please forward to this office documentation of any recent work or testing performed on
such systems so that we can update your file.
We look forward to your anticipated cooperation in this matter.
Please call this ffiice with any questions.
It �\
Lt. Erin Griffin
Fire Marshal
CC: file Health Licensing Building
City of Sakm, Massachusetts
ti fire Department
48 Lafayette Street
" Grn�a Salem,Massachusetts 01-970-3695
Tel 978-744-1235 fire Prevention
Dav�.f'{V CodyBureau
ChVf Fax 978-745-4646 978-745-7777
978-744-6990
dcmfyC'salem com
MAINTENANCE, CLEANING, AND TESTING OF FIXED FIRE EXTINGUISHING SYSTEMS.
MAINTENANCE, CLEANING OF HOOD AND DUCT SYSTEMS WHERE COOKING GREASE
IS GENERATED.................
The Salem Fire Prevention Bureau requires that all hood and duct systems are to be cleaned
from the Cooking area (hood) in the kitchen, all the way to the extreme end of the duct. THIS
CLEANING WILL OCCUR ON A QUARTERLY BASIS,
A certificate showing the name of the company, the person, and the date of the cleaning shall be
posted near the hood area. The certificate will indicate what work was performed, and will also
indicate areas not cleaned.
ALL FIXED FIRE EXTINGUISHING SYSTEMS ARE TO BE TESTED AND CHECKED SEMI-
ANNUALLY. THIS TEST WILL ALSO INCLUDE A TEST OF THE INTERIOR FIRE ALARM
SYSTEM.
The cleaning company and the fixed extinguishing service company shall file within (5) five days
after the work is performed, a report with the Salem Fire Prevention Bureau of all their activities
relative to the above listed systems. The report shall also list any and all deficiences of the
systems and the remedial action to be taken. Failure to adhere to this public safety requirement
will result in the shut down of the systems. Prior to resuming operations an inspection will be
conducted by this office.
Per Order,
to/ % —
� J
U l
Lt. Erin Griffin Date of Conveyance
Fire Marshal
FORM 81R (4105)
CITY OF SALEM, MASSACHUSETTS
'� !s • BOARD OF HEALTH
n ®'
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
1. COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter 111, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Roosevelt's Restaurant
Address of Establishment: 300 Derby Street
Owner's Name: Hugh McGowan
Restrictions:
Application Date: 1/13/2004
Permit for Food Establishment 257-04
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2004
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
of CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
c SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT ;
2004 APPLICATIO PERMIT T �ERATE A FOOD ESTABLISHMENT
T
i
NAME OF ESTABLISHMENT bOS _TEL 13
ADDRESS OF ESTABLISHMENT L4
MAILING ADDRESS (ifZdffere, t)
OWNER'S N/ ' JjjA l AA KA x- J TEL#
ADDRES1
CITY Fh > 1�( STATE ' ZIP U 1 %'yam) � h
CERTIFIED FOOD MANAGEITS NAME(S) _\ 1i-k6.c.) CERTIFICATE#(s),�)gXl S
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON HOME TEL#
d-� d-( >7-� 11 Ii-( li-1 t-I
HOURS OF OPERATION: Mon.�Tue. V Wed. ✓ Thu. l� Fri.J/ Sat. I� Sun. .L/
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO (� less than 1000sq.ft. =$ 50
1000-10,000sq.1t. =$100
ti n �rTc, f• —$250
RESTAURANT YES N less than 25 sea's =$100
25-99 seats
more than 99 seats =$200
BED/BREAKFAST YES NO
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership.The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant o M L Cha"Ve
, Section 49A, I certify under the pains and penalties of perjury that 1, to my
best kno led and bfiled all state tax returns and paid all state taxes required under the law.
SignaI Date 1,13-63 Social Secu or ear I sor�tification Number
-- -- --- -- --------------------- ------------------__ tor
/' ----------------
Revised 03 FO m Check#8 Date_.
COURT DOCKET NO. CITATION NO
CITY OF SALEM ZQ92
PD
VIOLATION NOTICE r 0` 2
NAME(LAST,FIRST,'N41TIAL)
_ /
1 S Pi�r21-GrisLCliY7 T_
STREET ADDRESS CITY/TOWN STATE ZIP
LICENSE NO LIC EXP.DATE DATE OF BIRTH
OWNER'S NAME(LAST,FIRST,INITIAL)
STREETADDRESS CITY//OWN STATE ZIP
REGISTRATION NO. STATE EXP DATEIII MAKEIiYPE YEAR(COLOR
DATE OF VIOLATION TIME DATE CITATION WRITTEN PEIWORRSONNL
EIAM
ES
LOCATION OF VIOLATION F,bFORC2
yfpt
OFFENSEGHA? SECT. FINES
AfdiLust,; 71nds3Yzv�,r/ � �.
e aee)-{ SPRd/Cu
C /dam E giT
OFFICER I D NO J .j TOTAL NE $ /,(}
V•1F'jT '�IS DIUE T `6A �
OFFICER CERTIFIES COPY GIVEN TO VIOLATOR
,� �
L] IN HAND
X c/ 0/ (((JCS SGC ❑ BY MAIL
DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY
ORDER OR BY CHECK MADE PAYABLE TO:
CITY CLERK
CITY HALL
93 WASHINGTON STREET
SALEM,MA 01970
TEL.(508)745-9595 X 251
1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE
PAYMENT IN THE AMOUNT OF
$ CASE#
SIGNATURE
SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL
i
- --- -- - -
DOCKET NO. ORATION NO.
CITY OF SALEM
T Oy9 '_ VIOLATION NOTICE PD 10921,
7 goy r? s
-0 m x "pNAMET,FIRST,INITIAL)
[SEG/
STREET ADDRESS CITYROWN STATE ZIP �
I LICENSE NO. ATE DATE OF BIRTH
i OWNER'S NAME •.KIRB'FICWIQAoL=/ ;
O O /vr q`l
O Nom70 d
n
r :/ mono - STREET ADDRESS ITY?OWN STATE ZIP
V -4
1111- .DZmD � p�y �T
r .O r REGISTRATION NO STATE EXP DATE I MAKERYPE YEAR(COLOR
j W y nNn< IIl
s'om
o
G.0
C-� DATE OF VIOLATION TIMEI DATE CITATION WRITTEN rensowL
m 1�l o
-1Z ❑AM
O /-1—e7 ❑PM ��G'V��OT LIVES
?�J ❑NO
f. Z LOCATION OF VIOLATION FOR D -1
" 3®aC�sys� i
w r
O : OFFENSE / �JQP. SECT. FINES j
r '4/CL7�/11J/f B 7a o/3 //✓
W )
0 n ^ e aoo`� �cr� S?ev�ee
.. (2
_ c �2eh/T
-
OFFICER ' / I.D.NO. TIN _ {
ry V ��44'rIZP�/S
DUE
Z-
r _ OFFICER CERTIFIES COPY GIVEN TO VIOLATOR {
Fu y. / 1 • /j/�/
El IN]HAND7y
lll... 1 c<J -X G �/� ElBY MAIL 7
? DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ]1
i
ORDER OR BY CHECK MADE PAYABLE TO CITY CLERK I
O"�'— �4 CITY HALL
3 WASHINGTON STREET
SALEM,MA 9 a
S � TEL.(508)7455-95959 5 X 251
1 A HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
�- REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE
( PAYMENT IN THE AMOUNT OF
i 9$ CASE#
}SIGNATURE ,{
\� gy SEE OTHER SIDE FOR FURTHER INFORMATION
5; ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL
n
1 �
4G CITY OF SALEM .t
/�(00 BOARD OF HEALTH
Establishment Name: Pq( um//5 Date: 7 /lo- OV Page: / of /
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
/ '/j
PLEASE PRINT CLEARLY l
I (�A� HcJ9G1 f 7000Qvf /S` YiPSS°�r� ,nom p/a[✓vt fai G /e
: I I
hQP OFl
I �
00 rai Git he,
��
I
All
I J a- A -50-n /-1/ r/J
I �
I
I
Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of tw my-fr",
a dolspension/revocation of Z) Embargo ❑ Emergency Closure
your food permit.
1 )� / �� LIoluntary Disposal LlOther:
3-501 1=;C PFIFs Re,.zived :tf Temper::?ores
Violations Related to Foodborne Illness Interventions and Hisk acc„die„ v^i.;rc C(xitni t.,
Factors(Items 1-22) (Cont.) JVF/45'F Within 4ltu,:i:s. T
PROTECTION FROM CHEMICALS i 5;i1 l5 Cixiling Methous fir PHF9
14 Food or Color Additives 19 PHF Hot sne Co!d Holding
292.'.' A(iditr-es'' 3-5Ul 16(61 C old PHFs Mainta:ncd at of bchuv
3-3011 11 PntzciionfromUnappruved.lddithux"r590.004(1-') -41'/4J'
Hot FHFs Maimahu.,d:t orabove i
15 Poisonous or Toxic Substances ! 1 1U`F
7-101.11 Identity tie Information-Original i0?.ib(is! ; I?iste Field at at abot'z 130`F '
Containers" --
7-10.11 Common Name - Working Coutamer;;: { ! 711 { time as a Pobgr,Hsalth Control
3-501.!9 Thi':.: as a Public FL-0th Control's
7 '.171.11 Separation-Stoialie'
i 7-262.11 Rcalricoun-Fon;eacr and l,cr"
`ciU,i)01(H 1 Variance Reynirement - {
i-?f)2 I1 Clvuhtionc of l!crT {
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7203 11 Toxic Containers-Prohibnions:
7-204.11 S.mitizzts.Criteria-Ctiemic:d s-
POPULATIONS(NSP)
{ 7 294 12 Chemicals for Washing Pnxhue.Ctiterix'. 21 3-801.11!.4! Unpasteurized Pre-package,; iuices and I
j 7-1W.14 [piing Agents.Crmrrr:.i:" I I He,erages %6th Warning Lsb,!s* _)
7-203 11 Licidrntai Fr)otl Contact,Lnbrieantea. 3-501.1 I(B, Use of Pasteurized Eggs'
? SOI I ITDi Ra:':of Partiall} Cooked Animal Food and
7-101.i i Re;tri�tzd Use Pesticides,Criteria"
17-rph.12 Rodent Bait Stations' Raw Seed Sprouts Nat Served. ^
- _'-8UI.11(C) Tinos coed Food Pockat?c Not Ru-served.
7-10h13 Trackn>Sq Powders,Pest Control and I
{ Mtlnittirine,
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 '-603.11 Consunier Ads:sor Posed for Consumption of
16 Proper Cooking Temperatures for Antnial Foods'P rat are Raw. Undcro-„ked of
PHFs
Not Others ise Processed to Eliminate
3-'101.1 I A(l)(2) Eggs- 155'F 15 Sec
Pathov:ns.' rr;•;>:c rn,r,;,;
Fe;?s- Immediate Service 145`FI i;ec, 3-30'2.13 Pasteurized Lggn Jubstitule for Raw She]]
3-401 1 1(A)(2) Comminuted Fish,Meats&Came L'gfis"
Animals- 155"'F
3-401.1 If B)(1)(2) Pork and Beef Roa,t- 130`F 111 non" SPECIAL REQUIREMENTS
3-401.11(A)(?) Ratites, Injected Meat;- 155"F li
SIO 069(1)1D) Vio)ut!ons o( Suction:340 OOt)(A)-(til in
er. . etuermg,mobile fimti, temporary and
3-101.11(A)(3r Poultry,Wild Game Sndfed PHF" I residential kilchen operations should be
Stuffing Containing Fish, !Heat debited under the appropriate sections
Poultry or Radius-I WF 15 sec "' j above if:elated to foodborne illness
3-101.11(Cl(3) Whole-muscle, Intact Beef Steaks inieiventions anti risk factors. Other
145'F" 590.009 violations relating to good retail
3 161.12 Raw i1»unal Foods Cooked in a practices should be debited under 1129-
Alietowa.e IGS`F " ! Special Requirements.
3-401.11(A}t l I(b) All Otiier PHFs - 14i'F S ;cc,
17 Reheating for Hot Holding VIOLATIONS R Z-ATED TO GOOD RETAIL PRACTICES
x-943 11(.AA(D) PIFs 1C5'F 15 Sit.. ° (Items 23-30)
3-103.1 U B) Microwave- 1,6-' F 2 Mural:Siandina Critical tn,d non-c rdowl ciolationc, which do no!relate to the
Thue* Juodhonte d(tt"ss ialen elitiwie,old riik faclors listed above, rat he
1 3-903.1 I(C) Commercially Pitxessed R-11- Food - j fmtnd ct the folioirtng.,e(tious qI the loom Codi and 105 C JIR
5(90.000.
3-403.11(E) Rcmainine Unshced Portions of Beef Item Good Retail Practices FC 590.000 I
R tasra+: 23 klanaoemeni and Personnel 's FC - 2 .003__
t g Proper Cooling of PHFs 24. Food and Foal Protection FC-3 .004
.i-507.14tA; Coolir.2 Cooked PHI--s front 140'F to 25 Equipment and Utensils FC-4 O05
12b. W Stec. Plumb:nq atxi Waste FC-S
'70T\4'ithin 2 Homs and Front 7WF 27 P?,mcal Ferilty FC-o 007
to 41'F/45'F Within 4 Hours * i 28. _ Poisonous or Toxic Materials '�, FC-7 008 I
3-50:.14(6) Coiling PHIS Made From .Atnhient 29. especial Recto remelts -_ (09 --I
Teu:peciture ingred:cnts to 41'F/45'F 30--- Other .�
Nihlun 4 Hours.:
`henolcl erine;d item in the tedsui r)99 F:od Code of I115 Chit 5190aift
"A
I .
A
( IMPORTANT MESSAGE )
FOR -/
OATF tea/ �' O 3 TIME p Y O P.M.
M l "p-l"iuc �.1 C Jl�c�(rri�
OF
PHONE
AREA COLE NUMBER EXTENSION
O FAX
O MOSII F
AREA COOE / NUMBER TIME TO CALL
TELEPHONED I PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU I ( RUSH
RETURNED YOUR CALL I I WILL FAX TO YOU I
MEnnS-SAGEQ /
Y SIGNED K
r
OPSFORM 4009 /
MADE IN U SA
NOTES
I
I
Massachusetts Department of Public Health - - Salem Board of"earth
M 120 Washington Street,4th Floor
Division of Food and Drt1'§s Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
IName a�'"/ ) Date Typf:of Operationts) Tyg of Inspection
ncl!/PL 7S YT,(IS rA�J A4 _ I //, /-04/ Food Service �y�outine
Address Risk ❑ Retail We-inspection
2no VP,N/i 1 r Ff Level ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:/-J3 4
HACCP Y!N
F-1Temporary ElPre-operation
Owner ( in/7 ❑ Caterer ❑Suspect Illness
Person inarg6(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
In: [-]HACCP
inspector Permit No. ❑Other
p �r�YYP/t?�S ILGl fiT? - l�' G!/r' �G? Out.
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT _ ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC [114,Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals
"FOOD FROM APPROVED SOURCE TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foals)
4. Food and Water from Approved Source
❑ 5. Receiving/Condition [116,Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling r
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
CONSUMER ADVISORY
❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions 1�
immediately or within 10 days as determined by the Board and Risk Factors(items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report, when signed below
c N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
X24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
t/ 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
r
?P. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
,1/ 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)(59o.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 S901nspecli'orme-14,tlac
re: Print:
PIC's Signature:. ��U,Z ( Print: k/ )(71,4 / P/'1 (AGI Page or APages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAIV.i NATION
FOOD PROTECT IOIkJ MANAGEMENT I 8 Cross-,;oW3,-mr-jfJ,)n
1 3-"�'02 11 iA)(!) kaAnimit! Foods scarar-d from
590.m3fBI, j Denwagn-imon of Kvo,4Ied-C* I Ccic*ed an-1 RTE food!,*
2-M1.11 1: Person in -,Sarre --',tics from Raver hyrad.enfs
I I(.A);2) Raw)inim:ii
EMPLOYEE HEALTH I Oth C r Y
2 59 i1.I i Ij 3(C Responsdbifiyy tit flii;person in marge to Crntrm,,naton from the
require nzportmg by food empluiVes and 3-:()2.1 it it' Foca Protection`
applicanr!,*
-2 I j Washing FraisaneIV, etaiflefl
,i90(f)3(F) Xt
kcsponefluility Of Food Fmpit,,yee Or An 3 KAJ Fo� Cuti(t,A with Uquipmeramid
applicant To R
VpOrt'rli Hit.PLr10n In
ChairLey,
0onlamimirton from the Con-
sumer
590.00:4C'i Kepoytjnsby Person in Ch;,ri,-'
3-306.14(A)(R) Returned Food and Rer.crace.iif Fothl,`
f st)ffow(D) Ek-fmioqqan; Rt-,I1ij:ij11,.4
ViscositionofAdu!toratadot Gor;f.anmated
590.003(E) Rentim at of Exclusions:std Restriction,, i Food
.3 '101.1 1 L'iwardin., jr Recon&lionmc Limahe
FOOD F1OM APPROVED SOURCE `:*d' I
4 Food and Water From Hegulated Sources 9 od Contact Surfaces
590.004(A-B) Compliance with Food 1aw* Manual Wareivashnu,-Hot Water
3-201 12 Food, n a Hertuncilify Scah2d Ointaincrt t4m,'vizatir-It TeroperaturesT
1.1.01 I; Fluid ltLnc and lt,11k Products* A-503.11 ttiareiva;hinu, ffotUstet
3-20?.13 Shelf s h,-g Tejupciatures'
a 1-5o 1.1',,1 -hernicil Sanitization !-nip
-202.14 E1,,gs uadN1flkP,c&ct, P;mtcLmze,(V' PH:
3-202.16 lee Nhide Fr-xii potable Drinking,Water' env, it m i on and hardness. " I
15-:01.11 Iiiinking Water hum an Approved System" 4-501.11(A) FAjuifrmc7*Food Contac SLI11"IC,,;and
590.006(A) Ron let', Drinking(Nater" Licns'k Clean,
59r)f 106l B) 4-6011! 1 Ch!aiuric Pregnancy vi Equipment Foot-
Surfaces and utensils"Shellfish and Fish From a,!Approved Source i
3-201,14 Fish and R�crcruionally Caught Molluscan Frequency Sanaiz,n 7on of Utensils and
Pm Con'tact Surfaces of
Shellfish,
4-?C.3.i
'AMho�'-;of Sanitization --Hot Waterand
3-201.15 Nfoliti,;can Shellfish from N.SSII Listed
i Cheruji,all
Sources'' to Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authotily 2-301.1 Clea::Condition--Kind!;and Arrnql
3-202,15 Site.Ilsiock Identification pletcrit, 1-301.i 1 Clcmine
590.001(C) Wild Mushrooms" 2-301 1-1 When,tc. tifashx
3-201.17 Garric Anima's* I I it Good Hygienic Practices
5 iReceivinglConclition I 2-401.1 Eatinia. Onrj:<;rtl-or wain„Tohacco"
3-2o,2.11 PIFFs,Received at Propel Temperatures" j ?-A01.12 F)isehargcs From the Eves,Nose and
3-202 L.5 Package fnte�-,rityl
tf�1'12 Preir-mir—Corit ;iiaaliom When I ai�,rin,*
3-101.11 Foixt Safe-.,d Un-�duheratcd
6 tags/Records:Shellatock Prevention of Contamination Vern Hands
3-2;j2AS Sh-listuck Identification 390.004(E) Preventing Coatanimation trout
-'.03,13 Shellstovk filmfiCication Maintaineell- Fjrrphivers, I
Tags/Records: Fish Products' 113 Handwash Facilities
3-402.1 t Patasitc Destruction* I � 0Convvnvmf� Located and Accessible
1-102.12 K:cords.Cieati.,- and Pcrcp;im. -23,II ria and Capa�::it:;"
590,()()q(j) Labeling of Ingredients' 15-20».11 I-,-N:atiuIa and Placement"
7 Conformance with Approved Procedures 5-205.11 A..ce:sdfnlitv.Operwicit, nal MamLenance
MACCP Plans Supplied mth Soap and Harts Dearirf
;-502.11 Specialized Pessang Methods`
3:,02.1 2 Reduced oxygen pavi.atrin, -,uletic"
6-301.11 HandwaOiin-1 Cleanser,Availabilitt,
` 111.11,ituCC",uh Appioved liivc�dt]TeS � i rtmi;inn
S-to.).11 ( 011f) 0-30 Hand Dmin, 'o
Denotes it,min the tedei 1 1991)Fo-d Code ur I0>(,%IR 00,
CITY OF SALEM
BOARD OF HEALTH y-
Establishment Name: 7"S Date: Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date
No. Reference R-Red Item Verified _
o
PLEASE PRINT CLEARLY
iY!7 14j��4a'--< 9'- /T�e_ .A1,(-,Q 1--r 7-7,j" ,7,0-r FnR'/Y', l- I U ,
z r
rn
- t I ,
/ f7((!P AG / /<liPG2 ITPA��n� T//rf /liriY� /�//rP 1i0/f110
AP'�'�
I ) 7 C I— f/ rt1G Lf/�/7 .Su
I Il/Sr �GDOe7J ti�y� _ ._
: I I � '7 I I — �/J/�/P c %"Grs�ri ,r"tFTOa/d✓q N2��c �p6/li:✓L ` �` (diI/Yn y9z�c� dPit7PL��i1r,�P
o/v /,�srG�,e a�� w/7'< ,leeve. , &/ /o� jcff 6(?=
/ �—///' /A� n crY7 a o /1�P� /Ssir/t fti(ear &,X eSr /v.f
GIs -VU
d /7
Discussion With Person in Charge: Corrective Action Required: ( ❑ No I ❑ res
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 C3Re-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:
r ✓
r
3-501.1-1(C) PHFs keceivedat Temperatures
Violations Related to Foodborne.Illness Interventions and Risk According to Laic Couled io
Factors(Items 1-22) (Cont) 41-F(45-F Within 4 Hc,drs
PROTECTION FROM CHEMICALS i 3-501 15 t"online 4lcthods for PHFs
1 119 PHF Hot and Cold bolding j
14 Food or Color Additives 3-501,16(H) Cold PHFs Nlainlatnzd at or below
3-202.12 Additives* 590.004(F) 41"1=45' F*
3-102 14 Protection trom Unapinnved Addi tikes* j 3-501,161 A) }ori PHFs Nlaintaineu at of above
15 Poisonous or Toxic Substances j 140`F
1-101.11 Identifiine Inforutannn-Original
3-501.19(9) Roasts Held at of above 13WR
Containers'
7-1101-11 Cotntnon Name-Working Containers* I 120 Time as a Public Health Control
7-201.11 Separation-Storage'
3-501.19 Tune as a Public I Iealth CoutroP' j
7-202.11 Restriction-Presence and Use` I 310.00411) Valiance Requirement j
202.1' Conditions ers I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203 111 `I oxic Quuaincrs-Prohibitions" I
j 7-204.11 Swutizers.Criteria-Chemicals* POPULATIONS(HSP)
j 7244 12 Chemicals for Washing Produce;Criteriak' I 21 13-801.11{A) Unpasteunnxl Pre-packagcd.lucost and
7-2W.14 Dryin=.Agents.Criteria* I BeSerages •vvith Warning labels"
13-8O . (B4 Use of Pastemized E,-g3"
72{)5 it Incidental Foot(Contact,Lubricant,,_ I ( 3-801 11(Lr) ( Raw of Partially Cooked Anunal Food and
7--206.11 Restricted Use Pesticides,Criteria"
Raw Seed SPL(?rris Not Served,
7-206,12 Rodent Bait Stationst' I 13-801.11;(7) j I Jnoputed Folxl Package Nk a Re-served,
7-706.13 Tiaeking Powders,Pest Control and
blonitoting" CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisor} Posted for Consumption of
Animal Foods That.ire Rase. Undercooked or
I6 I Proper Cooking Temperatures for I Not Otherwise Processed to Eliminate
PHFs
Pnthogcut.-
J
L-ggs-Immediate Service 145 TI Ssec-3-<}OLI IA(I)(2) Eggs- 155°F 15 Sce. ;-302.13 Pustcurized Fggs Substitute for Raa ShcH
; -
3-401 1 I(A)(2) Conuninuted Fi,b. Meats S Garne F:g€s'
Annuals- 155'F 15 we. r' SPECIAL REQUIREMENTS
13-401.11(6)(1)(21 Potnarrd Beef M tars-1 F 1F 15 M '; 590,009(A){D) Violations of Section 590.009(A)-(D to
3-401.11(A)(2) Ratner, hycded Metals- 155"F IS i )
Sec. ^ catering, mobile food, temporary and
3-401.11(A)f 3t POnin'v,Wild Game.SwlTed PHF., j residential kitchen operations should be
Stullmg t-onlauung Fish, meat, c1cbiit.1 Hader the
Poultry or Ratites 165°F 15 sec °` above if related to foodborne illness.y"
3-4oI i I(C)(3) Whole-muscle, Intact Beet Steaks intervention,and risk factors. Other
145'F 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165=F* Special Requirements.
3-401.11(A)(1)(b) Ali Other PFIFs - 145'F 15 see. * j
117 Reheating for Hot Holding VIOLATIONS R_LATED TO GOOD RETAIL PRACTICES
3-403 11(A)ffi(D) PHFii 165`F 15 sec. It (Items 23-30)
3-403.11(B) Microwave- 1650 F 2 Minute Standing Critical and nen-ennead rrn(ulions, which do not retail,to are
Time" foudnorne d/rress interreurious and iiak.fiwim,fisted abode, can be
3-103.1 1(C) Commercially Processed RTE Fond- found in the f slowbo; ser tions of the Food Code and 105 011?
140`F* 59o.olio.
3-403 11(E) Remaining Onshced Portions of Reef j Hem I Good Retail Practices FC 590.000
Roasts' 1 23, 1 Management and Personnel FC- 2 .003
18 I ' Proper Cooling of PHFs j 24, Food and Food Protection F, -3 .004
j 25, !, Equipment and Utensils ! FC-4 ,005
3-:i01.14(A) Cooling Cooked PH Fs from 140"F to ! 26. Water,Plurnhinq and Waste FC-5 005
70''F Within 2 Hours and Froin 70"F 1 j 27 Physical Facility FC-6 .007
to 41"Fi45'F'Within 4Hour" * I 28, Poisonous or I oxic Materials FC-7 .008 j
3-501.14(6) Cooling PHFs blade From ryrnbieniF25. ---- Special Heouiremenis 009
Temperature ingredients to 41"Ff45'F 30 Other j
j Within 4 Hour:.`
Doiole.cotienl arm in the redetel i 0119 Pmtd Code of 10at C\4K>90,000
( IMPORTANT MESSAGE )
FOR '4 ��
DATF a`3TIME(_
M v
OF
PHONE
AREA CODE NUMBER EXTENSION
❑ FAX
MOBIIF
❑ AREA CODE NUpRBER TIME TO CALL ISI
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU ' I RUSH
RETURNED YOUR CALL I I WILL FAX TO YOU j
MESSAGE -� � -�-n
61
SIGNED
mbps FORM 4009 V
MADE IN U.S.A
1
NOTES
r
�14u44hlYllul0i141i1N1.Y}gy/Ull�
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. II '1 ^ 0 Agent
■ Print your name and address on the reverse X I� ; nJ-t \'A l 1 � e_
"'rVO Addresse
so that we can return the Card to you. e. ReceNed by(Printed�p�°me) I C. Da of/p�livery
■ Attach this card to the back of the mailpiece, } � !+�(\�1i�f.�1J�M �f
or on the front if space permits. ``'' \\ _ _
D. Is delivdry address different from item 1? ❑Yes '
1. Article Addressed to: If YES,enter deliveryaddress below: 0 No
Roosevelt's
c/o Hugh McGowan
300 Derby Street
Salem, MA 01970
3. service Type
3M Certified Mail 0 Express Mail
0 Registered ❑Return Receipt for Merchandise
mp ❑ Insured Mail 0 C.O.D. _
4. Restricted Delivery?(Extra Fee) 0 Yes
Orans/er/mm service lad
z. Article Number I ?003680: 0006 599.5 9448
PS Form 3811,August 2001 Domestic Return Receipt 102595.02M-1540
1
UNITED STATES POSTAL SER(
ER GE_1 `� Y First-Class Mil"""
�"® -Postage&Fees Paid
USPS ' a
-
Permit No.•G-10
•�� Sender: Please painto
&rame, address and ZIP+4 inthisnbox
I
I
I
I
BOARD OF HEALTH
QN ".'� `SALEM, MA 01970
MAR 0 8 2004
Ll �
111 11111111111 ,61111111 1„I,L IJ LI�� Il
S
. I
CERTIFIED MAILTI, RECEIPT
(Domestic Mail Only;No Insurance Coverage Provided)
Ir
ul
cr
Er
Ln Postage I$
`D Certified Fee
O
C3rk
Return Redept Fee PoHstere
(Endorsement Required)
O Restricted Delivery Fee
0 (Endorsemem Required)
.0
ra Total Postage&Fees Is
M
p BeCt TO
C3 `
t` '$beet.Mi No.:.......................................................................
or Po Box No.
---------------------------------------------------------------------
Clry,Ba�,Z/Ptb �I 1�
IIS JA&W4.Ym&Q 2A., I t dA; i' iillll ii YYY�Y�e�YY�l�i�if�'IYfi�+ir
Certified Mail Provides:
■ A mailing receipt ewe eel zcoz eaar ooee vuuj sd
■ A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders.
■ Certified Mail may ONLY be combined with First-Class Made or Priority Mail,
■ Certified Mail is not avail able for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete antl attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery.
■ If apostmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail. -
IMPONTANT:Save this receipt andpresent it when making an inquiry.
Internet access to delivery information is not available on mail
addressed to APOs and FPOs.
.�o CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
$j 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01 970
gNnre TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
March 2, 2004
Roosevelt's
c/o Hugh McGowan
300 Derby Street
Salem, MA 01970
Dear Mr. McGowan:
Your check#1143 dated January 8, 2004 for Food Permit Fine has been returned because of insufficient
funds. Please send a money order or bank check for$150.00 ($125.00 to cover the check and $25.00 for
recovery fee).
If you have any questions, please call my office.
Very truly yours,
�_�y�.
/ k
oanne Scott
Health Agent
JS/mfp
CERTIFIED MAIL 7003 1680 0006 5995 9448
ADVICE FOR UNPAID DEPOSITED ITEMS Page 1 of 1
- HT04'02172-230 ACCT. NO. 9123881-0 02/17/2004
''OFFICE/BRANCH: 520/520 ACCOUNT TYPE: MUNICIPAL INT CHKG
THE FOLLOWING ITEMS HAVE BEEN RETURNED.
WE ARE CHARGING YOUR ACCOUNT FOR ITEMS) # ITEMS : 1
RETURNED UNPAID AS LISTED BELOW. AMOUNT: $125 . 00
FEES HAVE BEEN SENT TO ACCOUNT ANALYSIS . FEE: $0 . 00
TOTAL: $125 . 00
Reason: INSUFFICIENT 2nd TIME
CITY OF SALEM EASTERN BANK
GENERAL ACCOUNT - ZBA 195 MARKET ST
C/O TREASURER' S OFFICE LYNN MA 01901-1380
PO BOX 528 1-800-EASTERN
SALEM MA 01970-0528
l� i _ r I
f`' ,FEB 2 6 2004
fie..,:..,.:.s{-- Y.—•: ^3 <.--.-
Account No.: 9123881-0
Off i c e/Branch:520/520
------ --------- --------- --- ---- - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - -- - ---- - - - - - - --- - - --
POOEEYE�TS --- _ — >N 1143
�`: nw.e i , _ - alio �)''9"-`f'6➢$_-6553132�llC_CBGFE�•�5
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:_______ ____ _ __ _ __________ __ __ ______ _ _ __ i__ _ _ _ _ _ _ _ _ _ _ _ . _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ ___ _ _ _ _
rr--"_ -_- --�- - - — 0II3 ofw8
ROOSEVELT'S 1143
OPERATING ACCOUNT
300 DERBY STREET e,
SALEM, MA 01970 53-739/773
PAY
f Hic; r; ; i, ETURNED
TOTHE
l ORDER OF
OOLLARS
r Centur e,z
>,yQ Bank y r CHECK i Br AJG BETU �..
Salem,Massachusetts 01970 .
FOR
11'00114311' 71:0 1 1 30 1 3904 11521 - 269B Oli'F :' -_ ,.`.:,4'00000-1250014'.
f
ADVICE FOR UNPAID DEPOSITED ITEMS Page 1 of 1
HT0402172-230 ACCT. NO. 9123881-0 02/17/2004
-OFFICE/BRANCH: 520/520 ACCOUNT TYPE: MUNICIPAL INT CHKG
THE FOLLOWING ITEMS HAVE BEEN RETURNED. ;
WE ARE CHARGING YOUR ACCOUNT FOR ITEM (S) # ITEMS : 1
RETURNED UNPAID AS LISTED BELOW. AMOUNT : $125 . 00
FEES HAVE BEEN SENT TO ACCOUNT ANALYSIS . FEE: $0 . 00 t
TOTAL: $125 . 00
Reason: INSUFFICIENT 2nd TIME
6
4
CITY OF SALEM EASTERN BANK
GENERAL ACCOUNT - ZBA 195 MARKET ST °
C/O TREASURER' S OFFICE LYNN MA 01901-1380
PO BOX 528 1-800-EASTERN
SALEM MA 01970-0528 T:FEB�24
6 2004
Account No.: 9123881-0
Office/Branch:5201520
a
s
ROOSEVELT'M - � Jli_CF,SF'Et.:25 L
� wra..ore.a _ - p }"g 3'nD�_d6S5d:a..•r n o�_
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n I.iTllh; ElON1EU Ens reF:: s. on7 g7 F
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h
LA
1143
ROOSEVELT'S
OPERATING ACCOUNT ."; - �.. +'•,; ' ':.. -.'"" ". - - ,
i 300 DERBY STREET r • ` - - '` q „
:SALEM, MA'01970 '-:i;.,:.'r--1 -- "-_- _^' 'sj 53-139/113
PAY^ f;r
Il\ 4�S ET �.,._
TO THE UF�P'IECI- `^,� ,a _
ORDER OF �_ �O'9�2— (a] f',A -_ _1�. 91 . �'1> e s'....e..' ,
VI
�`-'� �OLLARS--n -
812
.�y�
l �:^ J ^rC• liar
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-cSalem.Missachusem 01970:^..,,`.:.,-0..;. r •'r 11�U i� ivt :111 1'r _T ,^: .,;s:n;•".-':i. r•„""” 4.. "`jr .l.;
FOR, ,m' .,..—'Y- -..- - "%k:•^-:'-i - " •. •-'�'., y`"°a."..-'�w_.
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,,1� 1 X rIY1I(1c3tCJfS sC PLEASEREMtt PAYMENT TO:
ttls SltE .�rR�EE't LYNN,MA01912-4110 INVOICE R0.8ox310Lynr,MA01W3.O310
�� fB1.5ei-aTat 1- MPSU M Paltret M-Ta41; CURRENT all paY3 BO DAYS aD DAY3
Past and Telt Its Control Protacslona's 143187
95u 0Q 194. 3 01. 0 0- 00
Rr �.>arE DSY .rvr•E aATs COD A=Tao. 'r.'.`4389091 1EC- .008//
0015 1124 Wacl I01 t i/R4'I-LA4
ROOSL;VELT° S F"!'8TAURANT Ct TROLPOR REGULAR FEST CONTROL ffiMVrrS,.lak&M 95,04
300 UERESY ST NUMEIER UMT PRICE AMOUNT
SALEM MA X31370Mous2OLeD
978-745-11.33 0/21/04 9:00 T,IM MUI7t3T TRAP
DATE ' ��7 k0irES:TA
GHEICK 140. PRO"Ef:TA LP
COMMENTS ' RTU NAT STA
❑MC ❑VISA ❑DISCOVER RAT 01.11E BD
THRU HACK DOW /'THERE, ON RIGH'I ACCT.e
K1TCH/ST0RAUEI91.L QTHER
AREAS/LARGE 3 ',;TORY RESTAURANT EXP DATE &als TAX 1
CONTIVETER OO�{RRR/�/}� HENRY/OlPEN 11AM c.aX.❑ CHOP Nrc❑ TL?AL DUS #
�! '� W TOTAL AMOUNT PD
• t
Rom, Sro;t,odl
cd Ir0er� J'.
4WITtONAL OOMTaMRYS
..
COMMERCIAL SA!ITATION REPORT
toora—ChanYRS NO
train aln Areae—Ch ........ ............ ❑ ❑
est Rooms—CI9an ......... ......... .....❑ ❑
mIrlg Areae—Claw ....... .............. ❑ ❑
mpbyae Areae—Clean .... ... .......
�Dker Areca Cis ....... ,4............. ❑ ❑ WARRAMMI'INFORMIATION
❑ ❑ DINFLUN4TYPE I' WAARAI*TY YES❑ NOD
omments 1 Family O 3 Fo ❑ 1 30 " 13 SO Days ❑
2 Family 13S FI= ❑ !{I1 gD Days ❑ S MOs. ❑
REASON FOR NO WARRANTY
+Pwlal service requested......................................... .........
POST APPLICATION 1EOUIREMINTS +Poor sardtation.............................. .............................1.7
+aosate.11ur iture of prepared
r pa not Prepared........................»....,..,.......,.,.......❑
OOUPIED AREAS MUST aE VAC;IEA FOREAS MDURB eGoaeta'fumkure not prepared.......................»..................»....»...,.........[I
HORCUOIEO. VENTILATENOT
AL TAEOWACII AREAS BEFODReW O THEY ARE +R0dan1 N
EEAT;D 1EO.00 NOT ALLOW AL'I _Ta,CHILDREN.Ofl Para ON prov ng naaded»»........»._._..»..........».............•.••.....................
.-_[]
iEAT'cQ SURFACa6 UNTIL DRV. -Other
NTRACTINO ENTITIES HAVE RECEr 1.-D ALL MASSACHUSETTS DEPARTMENT OF FOOD a AOflIGJI7URE'T5 PES O1DE TRNB a/ +71M8 OUT
REAu OONRUMER sHEM WRm( N STATEM15N'T8,POSTING NOTKES AND HAVE AMaED T1 NOTIFY TENANTS P-T r j r n r' i tea,
la PRIOR TSwilifLIGATTON TIM_E._7 dg ABOW NER111M"AS BE SN_ SATISFACTORILY COMPLETED. 1Nas-1
i+TCM - TURE j ( l U01 IR� � 91GNa RE ( 1��
BE R SIDE FOR PIER I+IINNENNTTINFFOORRMATION R�&p6131,rTTT/Mills-011"Copy CaaarY--Guricmar Copy Pink—RamiLLenoCm
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12/08/2004 13: 79 7B15927641 -- Al EXTERMINATORS PAGE 011
183 Shepard Street
Lynn, MA 01902 ,
Voice: 781-592-2731
800-525-825
Fax: 781-592-7641
Email: alinfor,�1exterminaWm,(om
www.al exterminatore.00m
i
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Tc; b f\ li From:
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F.: == ! Date=
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1: tlraoat 0 For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
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Comments . .
I
CITY OF SALEM, MASSACHUSETTS
.j BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
m.Y SALEM, MA 01970
Wig TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
March 2, 2004
Roosevelt's
c/o Hugh McGowan
300 Derby Street
Salem, MA 01970
Dear Mr. McGowan:
Your check#1143 dated January 8, 2004 for Food Permit Fine has been returned because of insufficient
funds. Please send a money order or bank check for$150.00 ($125.00 to cover the check and $25.00 for
recovery fee).
If you have any questions, please call my office.
Very truly yours,
oanne Scott
Health Agent
JS/mfp
CERTIFIED MAIL 7003 1680 0006 5995 9448
r
r ADVICE FOR UNPAID DEPOSITED ITEMS Page 1 of 1
HT0402172-230 ACCT. NO. 9123881-0 02/17/2004
OFFICE/BRANCH: 520/520 ACCOUNT TYPE: MUNICIPAL INT CHKG
THE FOLLOWING ITEMS HAVE BEEN RETURNED.
WE ARE CHARGING YOUR- ACCOUNT FOR ITEM (S) # ITEMS : 1
RETURNED UNPAID AS LISTED BELOW. AMOUNT : $125 . 00
FEES HAVE BEEN SENT TO ACCOUNT ANALYSIS . FEE: $0 . 00
TOTAL: $125 . 00
Reason: INSUFFICIENT 2nd TIME
CITY OF SALEM EASTERN BANK
GENERAL ACCOUNT - ZBA 195 MARKET ST
C/O TREASURER' S OFFICE LYNN MA 019.01-1380
PO BOX 528 1-800-EASTERN
SALEM MA 01970-0528 -
r.
3
P FEB 2 6 2004 ;?
Account No.: 9123881-0
Office/Branch:520/520
------ --------- - -------- - -- -- - - - - - -- - - - - - - - -- - -- - - - - - - - - - - - --- - - -- - - - - -
1143
RROOS VEv TS -
!I
R�,oT� li?'P3'3uv_'iF¢OE?C;Sf£G;i25
�l wumcr�a a 'vr a >Duaas:n
IyI YY l.j�Y ' `� pW1O EFSTERiI BN11[ LY11:1, Y D9Ci p2 y yvJ
9 �_ •JA AFYI 1 vC_ 4:Np
U�Century-13
_ olloo ., opx::
Bank riZ. �- eiunc[ alrs z 'z
Jb
o'nnttL3m-1;O1 H04390C 1.01 0690 0+ 1000004B540f
Y' •'Jc:vt_
'------- ---- - ------- ------ - - - -- - - --- - - -- __ --- -- - - - - - - - - - - - - - - -- - - - - - - - - - - - - -
Q 113 O/7//0
ROOSEVELT'S 1143
OPERATING ACCOUNT
300 DERBY STREET - al
SALEM, MA'01970 i{ j(/ 53-139/113
'+ F •_iPAY 4 CI
D TO THE ''EETUHt,IEU
ORDER OF O Dir Z (((»s 111p ' d��\r1-✓���1Y'1113,,\\, A�r n ���///"�"�\l�� i\f 'i . r 1_ �UIvI�J I .. ' ,.. . .
��i�OLLARS
I
u .Century as rst' Ec
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y Bank �•
rJri 5VS ± _ .
-.S alan,Masswtusetls 019711
FOR
-
11'001,L4 3111 `
.+i:0 L 130 L 3901: ip 2 L _ 2698 011'
;,'00000125001'
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type) 7
SALEM Mass. Date
City, Town Permit ff
BuildingInn e Owner's
AT: Location 1 ��.- t� 5Name
J FeP
Type of Occupancy:
GNewE1 Renovation E] Replacement
FIXTURES Plans Submitted Yes El No El
Q i
/nW a:
U) V En z ¢ W
U) Cr ¢Lij OUmL x (n
W
a O w Q a[ ¢ O OO Z F- ¢ }
U) ¢ (A (7 W W lq z O Cl O ¢ > W qO U'
W W0 1- U) W Z Q x w w (W7 Q W W> LL U J in r W 0 C
zQw � Q ¢ � 1— Y (nmZ0z W0U)> U) 1
a w > ¢ w z Q ¢ QO O w ¢ O w ¢ Q h '
¢ x00Mu- 5 0OgU_ ¢ > oaf LL00
SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR r t
3RD FLOOR 2
4TH FLOOR t
5TH FLOOR
6TH FLOQR
7TH FLOOR
8TH FLOOR
(Print or Type) /
Installing Company Name `r /fin* L Check One: Certificate
Address 2 /-L X rA Lt�2// J _ Y!//� L1 Corp.
i
®-Partnership
p O Firm/Company
Business Telephone Name of Licensed Plumber or Ga/sfitter
I hereby certify that all of the detail and information I have submitted(or entered)in above application are true and accurate to the beat of my knowledge
and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions
of the Massachusetts State Gas Code and Chapter 142 of the General Laws
I have Informed the owner or his agent that I do not have liability insurance including completed operations coverage.
ALL APPOINTMENTS FOR INSPECTION ARE
TO BE MADE BY LICENSED PLUMBERS ONLY.
Signature of Owner/Agent
I hav��rrent liability insuranc poo Include completed operations coverage. ❑
El Master GJo�an ❑Gasfitter
Signature of Licenssed PIupr or Gasfitter License Number
CITY OF SALEM
,/� BOARD OF HEALTH
Establishment Name: i�c.,/v L 75 1S�Sv�u.�7�n T Date: 1-13-0 J/ Page: of �3
Item Code c-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY ....._
I
2� N G —A�i Kv��'/(aian o ac > �•pPP�e.ps YY�ctS7' .�d L /�r_G/i.c�rl� (/iS/�L� �P2/�Jf.�u%�'cC I
<A�/ns �n fia �Yasis�i vagi_ df X17 D�iJ Q l3C' G/M/( f�?ry�P2s A7e
rt<.,G_Cie,F/J,,,e 2iNJ�/rr�n IeA7AYr,GsacOve (�'l�.ri�U lJ�t]!f. K_evrmi/i'P i,PrCZPp /(,
^L1'va�iocA.c/vim(!>=n�,au�(x� w�ay./c i/�Avtfo.R�b�hP��r,Ya,��S �run./®i3Le af'CILL fig- �s I
zer Lfa' ef7`/�"J �2ebe%f%xe��aJ/✓(.
I '2S G - Nom/ /a,4-iG.o.�P�.a�� Yr,��P_ ,FIv�iaes��FF•Pr,Sfr.c�;r,/ fr2/.�G SoL��i�-rr aids avtt/LarSL� I
I I �r, c'linP.0 �n„�rJisa�.vPPhl lirSPs��u� aY�r,e i,�J.P/� S-fzr�i6-�v6 . .SriLc�jc*�t �',(� I
1 127 C I�CC/land /Pe!ri,�q �7 r_ST/'4e )616'fre•r/l �GeiLiw4 ///bras ��Crx� p(P
7 /fC _GL�.arnrr� �i P_iri o f n/RP(,/c /r or eeka4 E Me,,4 TOECIdGLU
a l I IPs
x l
i
Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
rply with all mandates of the Mass/Federal Food Code. I understand that
ncompliance may result in daily fines of tw my-five dollars orsqspension/revocation of Li Embargo Li Emergency Closure
food permit. �)_ ❑ Voluntary Disposal ❑ Other:
3-501.14(7) PHFs Received at'remperrturts
Violations Related to Foodborne Illness Interventions and Risk According*m t•a.v Coiled to
Factors(items 1-22) (Cont) 41'F/45-F Within 4 Hours.
PROTECTION FROM CHEMICALS ;-5()1,15 Coniine Nletbrxls ter PIIFs
14 Food or Color Additives 19 PHF Ho:and Cold Holding
3-501.16(6) Cold I-'HFs Maintained at ur below
3-202.12 Additioes" 590.0(}4(p} 41`14i' F+
i 302.14 Protection from Unapproved Additives* i ;_51)1.1 b(„) Hot Pt-[Fs Maintained at or above
15 Poisonous or Toxic Substances i 4U'F.
1_101.11 Identifyine Minnnah nn-Original
container's' 3-501.16(A) Roast., Held at or above 130`F
7-102.11 Cunhuon Name-Working Containers'" ( 20 Time as a Public Health Control
7-201.I 1 Separation-Storage* 3-501.14 "Inne as a Public Health ControP`
7-202.11 Restriction-Presence and Use" ( 59C).004(H) Vananec Requucment
7-'02.12 Conditions of Use-
7 203,11
se-7-203.11 'Toxic Containers-Prohibitions^ j REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
� 7-204.11 Sanitizer::.Coterie- C'hermPOPULATIONS(HSP)cals* -I
7-nU4 14 Cheuu 121 3-s(i I.I I(.A; Uitnpasteurized Prc-prckagcd luicos d
'7-^_04.14 IJrving AA_,ents.Crneris*Cor Washing Pr,Hluce;Criteria_ ' Beverages with \karnin;;Labels`
g
7_201.11 Incident,,[ Food Contact,Lubricants'* 3-801.1 I(B) Use of Pasteurized Eggs'
7-206.11 Restricted Use ft^aieides,Criteria'" 1 3-801.11(1)) Raw or Partially Cooked Animal Food and
7 "` Raw'Seed S{xvuts Not Set'ted.
-206.12 Rodent Batt Stations "
3-80L!I(C) Unopened Food Package Not Rc-scrwd. '
7-206.13 Tracking Powders,Peet Control.tilt
Nhmitnrin¢" CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer.Adsisory Posted(i:rCunxnnption Of'
Animal F,nslt: find are Ravv. Undercooked or
16 I Proper Cooking Temperatures for Not Otherwise Processed to Elinuuate
PHFs :,„„�"'021.i-401.11 A(1)(2) Eggs- 155"F 15 Sec Pathogens."
3-302.13 Pa.teunzed E;; �Substitute for Raw Shell
Lgg,a-Immediate Service 1,35"F15sec` � 1'�^
3-407.1 I(A)(2) I Comminuted
Fish.Meats R Crmue I E^)''t
Animals-Beef Roast
15 see. " SPECIAL REQUIREMENTS
3-401.11(13)(1)(2) ( Ra te,, Injected
Nl t- 13(1'5 121 min', i00 009(A70)) Violations of Section 590.009(A)-(Ol in
3-401,1 I(A)(2) Ratite,, ht)eded N4eats- 155"F IS
sec x I catenrng,mobile f iod. temporary and
3-401.11(A)(3) Poultry,Wild Game. Stuffed PHF;, i residential kitchen operations should be
Starting t.onouaing Fish, a9eat, I cadet the
Poultry or Ratites-165'F' 15 sec above if related to lbodbot ne illness
14011llC)(3) Whole-muscle.IntactBee(Steaks interventions and risk factors. Other
145"F* 590.009 violations relating to gocxl retail
3-401.12 Raw Annual Foods Cooked in a I [nac•tices Should he debited under 029-
Microwave Ib5+x Special Requirements,
3-401.11(A)(1)(bl All Other PHF'c-- 145'F 15 sec. +
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.1 I(A)&(U) PHF:; 1655 15 sec. (items 23-30)
3-403.1](13) Microwave- I650 P 2 Minute StandingCritrrul and non-cmicai vioiations, which do not relate to thv
Time* Juodborne dlness interventions and riab(actors listed ubuvc, can be
3-403.1 1(C) Commercially Pnx'essed RTE Food- found in the foUtin ing su tions<f doe Food Cod,, aad 105 CAIR
140°Fx 590.0(N).
3-403 11(E) Remaining Unslicerl Portions of Beef Item Good Retail Practices FC 530.000
Roasts* I 23 Management and Personnel FC -2 .003
18 Proper Cooling of PHFs 124. Foud and Food Protection ( FC-3 004
25. EgwRment and Utensils ; FC--4 ,005
3-50L14(A) Cooling Cooked PHFsrroml•10"F to M. Water.Plumbmgand Waste FC-5 .006
71NF Within 2 Hours and From 70'F 27. 1 Physical Facility FC-6 .007
to 41'F/45"F Within 4 Hours. * 28. , Poisonous or Toxic Maarials FC-7 .008 'I
3-501.14(B) Cooling PHFs Made From Ambient20 ----- Special Requirements .009
Temperature Ingredients to 4l`F145`F 30. Other
Within 4 Hours'° """'"° "..
"Uenoic rilical nem in the federal 1999 fa,.,d Code o, 105 UNIR�90.u00.
kf
C
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: /oGiS�/i�CTS /,sfitce,f?c"7— Date: /—/3-6) `I Page: 3 of 3
s Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
lee, 7, -r,,e 9 Sref6-rna�n vred CIPayrNr CP'S'Coop -/�o he
4>Car'-4 ,'/orf Z_e s/D iff 2G6 i 4/ IC e,-na kr/c a2 .sem/-17-7- ,yCaaIO
fo HBe .�/Qc���ti, S�/fiir�E,' G�nc�GG�� l'�x�,exp i-t'claSc.,r�eXi//�i�I �o /Crn'a�8%K
I/ 1l� C1 ll�,r.PrriasJ Stiff �✓P�ds Saa�Jl/va/LaSle 47 -"In e-5
4 F�i2s> - sore Av' �J
G1,es1hg1a7e- n'nc &4,, 4twd-was1f/rte Y l'ole" oe se'-to-1-,0aAe'e �acrinL<c
ii4),e-41A/.acp71?a
d �* 1re Ae o,P i✓Sa 1n�.1r14,6aelYd(mt%lI�
ti l I I AV*; w1n/N9C16r_ s 7'016e x101 � I
I I I I CVRffF/rA �cs a"IY- /9�0_m/ 7-
4 goo &n L y
I I I FOocl 10.7n n S I
AW'�L/elecgek I
sofCr-io� nN� W�E_ le-
Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yea
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
cfmply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-fi a dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
ypUr food permit. ❑ Voluntary Disposal ❑ Other:
is
V
L
3-501.i4tC) PHFs Receivedat Temperature,
Violations Related to Foodborne Illness Interventions and Risk •Accordir, to Law Cooled to
Factors(Items 1-22) (Cont.) 4PF/45'F iVjtlon 4 Honrs
PROTECTION FROM CHEMICALS
3-501.15 Cooling Methods for PHFs
Cold 14 Food or Color Additives F') Cl Hot and Cold Holding
j
?-203.12 Addim.es'4 � ,',-501 16(B,, 1d PIiPs Alaintainer7 at or'r..e(o;v
Sa:),Uikl(F)
3-302 14 Protection from Unit Additives* 41'/45'F*
9-501.In(A: Hot PIT.s Maintained at ca'above
IS I Poisonous or Toxic Substances � 110`F K
7-101.11 Identifying Information -Original 3-5t)1J(-(A) Roasts He'd at(ir above 130'F.
j Container;" :0 Time as a Public Health Control
j
7-102.11 Concur,nNaute-Wurkingi:ontainere" ;-;U A9 Time as aPubL: Heath Control"
j 7-201.11 Separation-Storam:"
7-202.11 Restriction--Presence and Use" j 5`)(1 Otl4(H) 1 \'anano,Rcuuirement
7.202.12 Conditions of tlse*
7-203.11 Toxic Containers - ProhihiIions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizets.Criteria-Chemicals* POPULATIONS(HSP)
7-9-0412 Chemicals for F'r'uchiug Pnxhr;e,Criteria`
71 3-30!.1 (A) Unnaacunfed Pre packaged.Geri and
! Beverage, with Wannn. I-.abels*
7-204.14 Drying A,enta.C:rueti't' ;-801.:1(8) Use of Pasteurized EggsT
7-205.11 incidental Food Contac,, Lubricants'
3-301 ;1(D) Raw or Partiall}'Cooled Animal Food and
7-206.11 Restricted Use Pesticides,Criteria'" Rate Seed Sprouts Not Scrvrd. ^'
7-206.12 Rodent Bait Stations"
7-206.13 Tracking Powders,Pest Control and i t-801.11(0) Unopened Food Packaar Not Rc-wrvec( j
Monitoring
CONSUMER ADVISORY
TIME)TEMPERATURE CONTROLS 22 3-603.11 C onsurner Advisory Posted for Consumption of
f( Proper Cooking Temperatures for ni
Amal Fords That ate Raw, undercooked or
i PHFs Not Otherwise Processed to Ehma;ns
Path,,'• roe:"";va.mr
3-d(lLl1A(I)(2) Eggs- 155'FISSec.
-,-302.13 Pa;leurizcd Eevs Substitute for Raw Shell
Eggs-Immediate Service 145`F15sec° -
3-40LII(A)(2) Comminuted Fish. IvtratsRGame Lg,-,s
Animals . 155"F 15 mer. "
3-401.11(13)(1)(2) Pork and Beef Roast- 130'F121 min" SPECIAL REQUIREMENTS
So0.005tA)- D) Violations e)f 590,009 (D
3-401.1 I(A)(2) Rati«•,, htjrctrd bleats- 1554,' 15 SectionA( }- )in
see * catering, mobile food, temporary anti
3-401.1IfA)(3) Poultry,Wild Game.Stuffed PHFs._ I residential kitchen operations should be
Rtuffing Contarmna Fish,Meat, debited ander the appropriatc sections
Poulliv or Ratites-165'F 15 sec. " I above if related to foodborne illness
3-401.1 I(C H3) Whole-ma;cle, Intact Beef Steaks interventions and risk factors. Other
145'F* 590.009 violations relating In gaol(retail
3-401.12 Raw Animal Rads Cooked in a I practices should be dehited under#29-
Micruirace 165'F* Special Requirements.
3-401.11(A)(1)(h) All Other PHFs-- 145'F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RLLLATED TO GOOD RETAIL PRACTICES
3-403.11(A)&.(D) P11Fs 165'F 15 sec, A, (items 23-30)
3-103.11(B) Microwave- 165'F 2 Minute Standing I Critical and non-critical violations, which do not relaw fo the
Time* ,linidborne illnese b,rerventions and risk factors listed above, can be
3-403.1 1(C) Commercially Processed i2TE Food- found in the following sta tirnr,r of the Food Code rand 10.5 C AIR
1.10017* 590.0011.
3-403 1 1(E) Remainine Unsliced Portions of Beef 1 Item 1 Good Retail Practices FC 590.000 j
Roasts" 23. Manaclenent and Personnel FC--2 .005
18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004
1 25. Equipment and Utensils FC-4 .005
3-501.14(A) Cooling Cooked PHFs trout 14()'F to 26. Water.Plual and Waste FC--S C,66
-._. .
70'F Within 2 Hours and From 70'F 27. Physical Facibty FC-6 .007
to 41'F'/47'F Within 4 Hours. 2ff Poi2onous or Toxic Materials FC-7 008 1
3-501.14(B) Cooling PFIFs Macre From Ambient29. Special Reeuirementli 'i; 1 009
-Temperature Ingredients to 41 17/45'f"
Co Other
Within 4 Hours*
..Dcnote,critical item in the federal 1999 Pood Cxle ur M- C.N-tR 500.000.
Mdssaehusetts Department of Public Health Salem Board of Health
120 Washington Street, 4t" Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name -r t /rid/) Date I Tyke of Ooeration(s), Tyke of Insoection
_ nye fe a P_/_ C i7yii.11M� /-/,3-0# ❑ Food Service Ld Routine
Address Risk ❑ Retail ❑ Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone 7//S 3 El Mobile Date:,,;-�2-03 1/3
Owner HACCP Y/N ❑ Temporary ry ❑ Pre-operation
1-11)12A' ❑ Suspect Illness
Person in'Charge(PIC) I Time ❑ Bed&Breakfast ❑ General Complaint
In
Inspector / J Permit No. El Other
.f3nb/Y/i / Ll. P4i,C 7JC�llc I out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ❑� 1�2. Prevention of Contamination from Hands
E) 1. PIC Assigned/Knowledgeable/Duties I1f3. Handwash Facilities Gy
EMPLOYEE HEALTH
E] 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS
-E] 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives
FOOD FROM APPROVED SOURCE El15.Toxic Chemicals
❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
:E] 5. Receiving/Condition E:116.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 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)'
Ll 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions /
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
r_ Health.TN590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations
�l. Food and Fo',od Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590 006)
I 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 se l�dFo, is
s � 9star . /. �'h.cU.e.T.U7Piw, Print: I
PIC's Signature: / � Print: e J Pagel of Pages
Violations Related to Foodbornel,"Iness
britementions and Rim Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT
II -i-,W I i(A)(I) Row Ancor Fo
,' o.J.- :Sep.ii--.icd:'t-Lmo
590.003(B) C il 00kdamt R rE F,,ods
2-103A : I Person in chal-e--duties I Conta>ranabon"'C'm Raw/Irlitiled"Onis
i(A;.2j RvAk Aqirnal Foods Scwatc.j .'rom E'tch
EMPLOYEE HEALTH "'thelT I
2 500 00 ziC) i Responsibilitv Of the p,.-rsov, in chaip to j "Onfar-rination from the Envitonrlient
squire reporting by foodejurk,--.Itcc�L and
I(Ai Foto! prol'.-fion,
ac
1 3 302 11 %Vxshi:nv,^iuirsand Vegmible,;
590.003(F) Rc,,ponsibiliLy 01 A Food Employee U*/,,1 3- I I Font.,Contatit :yith B1111I)rDeRi N114
Applicant.TO Red-al To The P-rion.In Utrnsils"
argue Contamination from ft Consumer
590,00-,,G) Rervrtiv�,,by Person in Charge* -W(is) rued F,,Warid Reecrvicc,of Ymd'
3 59o.00-iff)) Eyclmionsand Restrictions' crAcuftrrated o,,Contaminated
:,,1;t)03(-) Removal Of EXCILISi011a and ReItat i,tions Food
3-7i 1.11 [?'';carding or ftecond'tion'u Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food End Watur F,om Regjk,;tcd Sour:es 9 Fund Contact Surfaces,
4-501.111 Manual Warewadiui--,-Hot Watt-
51e0.Q(l4(A-B) Couzphancc with Food Law'
3-2W.12 Food ina llernietivil�,, Sc,led Containci'
3-2101.13 Fluid Milh and:Milk Product;' 4-501.11- M.--chil.1iLal Warcteashing-Hot Water
3-2f ' 11 Sanitization Tennic�fatufes
Shelf E-3-
1)-. . ItIl
3-20241- Eggs and Mill.Products.Pasteurized" 4-501.1 ;4 Cheni:,Ld qanitiLano,:-to7np,. pf,
3-202.16 Ice Made Flom Potattt( Drinking, Water i -oncentranon and harine
:i-{0!.'I Drinking Ni iter from an Approved S"teal, 600 1 It A) Equipment 1MLOod COPI;wt Surfaces and
Clean-
300.006f A) Bottled Drinkinp Watcr-� —
11 Cleaning Frequency el Equipment F(xKl-
590.000(p) Water.'vleci,;Standaids in 1,10 C*VTR -11(p, Contact Surtiwesand Utensils-'
SheIMM and F,sh From an Approved Source
3-2ol.14 Fish and R�.creationBv(.-'aught ;Moilu�can '-70) 11 ofUietwils Lind
Shellfigh, Fo�j CootLLt Surfa,-,e> of EI
4-703.11 Methods Of Stttrwizatiiin-Um XNater and
3-201.15 MOIJUSLan Sh,-Ilifiqli titan NSSP Listed CN-111;cill*
Sources*
Proper,Adequate Handivashing
Garroe and Wild Mushroom;Aporoved by
14)1i 1 dean eaa Cotmitoon-hands and Arms
RegulatoryAuthority11
3-203.!8 i S)IC11s11tCk Id-allfiL.ItiOn PWSCOL* 2 301 12 Oes:id-,g'%-O,eduretL
590.004(Q 1 Wild Mushroom;'" 2-1.'l 14 When to Wasn
-�-2C,�1.17 -am, Animals'" it Good Hygienic Practises
Receiving/Condition I i 2-401.1,1 -aline,Drinking oi Uic.,-,Tobacco"
3-202.11 PHFs Received at Ptop-r Tcnw,!raturcs:' 1--Iol 12 Discharge,Prom the Eyes, \Lr,,,e and
3-202 15 package Latcgnt}It ),Topih-
3-101.1 i Ford Safe and Unad0wraicd ?01.12 Prevent,rw Conto.n.mmilion Wh-n Fasita-;'
6 TogsMecords:Shrillstock Prevention of Contamination from Hands
"3-20-` UK' L 5W)..001(F) I Preventing Contarnim-ion from
'i-2w.1 Shelist,,ck Identification Mxnianied, i
Tag;/Records:Fish Products j 13 Handwash Facilities
CGnver,ontiy Located and Accassibic
1-;1}2.1; Parasite Desirtwkii- 5-1203�I I Ntflfl�t-I`L and C`af)aL1bCS"`
-i-402.12 Recor&.Creation eation and K-Iejniorir
590.0040) Libeding of Ingredients' , ation,and plarealW
.3 )wi.I ,koessibiii- .Operation Maintenance
7 Conformance with Approved Procedures
IHACCP Plans Suppie-e wilt)Solo and Hann'Drying
Sul 11 Specialized Processing Nfi-din Is' Dvviccs
3-502 12 Reduced oxygco packaizia1g.critetial I I Hand-wailinit,Clctniwr, A,IailnbiliE�
t)-3ol,I Haal� DrOng Frov"oon
18403.11 Conlbnnanc�with Approircd Fraceduiet,'
acill In tor teutjj 1909 rood CLd, to: 105 CMR 59().0011,
- - - - - - Al
f
f
�1
u CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
1 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343 _
STANLEY USOVICZ, JR.
JOANNE SCOTT, MPH, R5, 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 : Hugh McGowan
Name of Establishment : Roosevelt ' s Restaurant
Address of Establishment : 300 Derby Street
Type of Establishment : FOOD SERVICE
Application Date : 12/30/2002
Restrictions:
Permit for Food Establishment 165-03
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
r
These Permits Expire December 31, 2003
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
' 1
CITY OF SALEM, MASSACHUSETTS
.d BOARD Of' HEALTH
c
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0349
STANLEY USOVICZ, JR. -JOANNE SCOTT, MPH- RS, CHO
MAYOR HEALTH AGENT
2003 APPLICATION F R PERMIT TO ORFfATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT
ADDRESS OF ESTABLISHMENT c � �J `� TEL^Y��
MAILING ADDRESS ('f it ere t) /1 r
V J�1J J
OWNER'SNAMEii `J GVH L,k�lci. f�� J/ TEL# j� _ /
s� 3a 3 / t, 0
ADDRE
CITY ^ wrl1 STATE�� ZIP—Q-(�'�d
CERTIFIED FOOD MANAGERtNAME (S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON HOME TEL#
tf- f I( -' It- I r(-!
HOURS OF OPERATION: Mon. Tue. l�Wed. V Thu.-. ._Fri._,- Sat.__I/ Sun. lr
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,004sq.ft. =$100
3 6 more than 10,000sq,ft. =$250
RESTAURANT YES NO Ik less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$20
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made,all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my
best knowiege�n d belief h ve filed all state tax returns and paid all state taxes required under the law.
Signa'tt(re.) Date�,j Social Security or a eral en�ti�ber
Revised ua 02 OODA .a m Check#&Date n�6� %a
�0'Rog
r CITY OF SALEM, MASSACHUSE"rTs
BOARD OF HEALTH
k + + 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 "
s TEL. 978-741-1800
4h�M FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
r �
August 28, 2003
Hugh McGowan
Roosevelt's Restaurant
300 Derby Street
Salem, MA 01970
Dear Mr. McGowan:
On August 8, 2003 at approximately 10:45 PM, in response to a complaint about
smoking allowed on the patio of your establishment, personnel from the Tobacco
Control Program conducted a compliance check to determine if your
establishment was in compliance with Salem Board of Health Regulation #24
Concerning Prohibiting of Smoking in Restaurants and Bars. At that time, the
door leading to the patio was observed to be wedged in the open position
allowing smoke to enter the indoor bar area. Staff were observed carrying
trays and serving drinks to patrons sitting in the patio area. In addition, a
patron was observed carrying a lit cigarette from the patio to the inside of
the establishment, walking past staff at that door. This patron threw the lit
cigarette onto the wooden floor. Documentation is on file at the Board of
Health regarding this violation.
Fire Safety concerns are being forwarded to the Salem Fire Department,
Fire Prevention Division.
The Compliance Inspectors presented a copy of the inspection report to the
owner at the time of inspection.
You are in violation of Section VIII of Salem Board of Health Regulation #24.
According to this section, it is unlawful for any person who owns, manages,
operates, or otherwise controls the use of any premises subject to regulation
under Sections IV, V, VI, to fail to comply with any provisions, or to allow smoking
where it is prohibited. Section VII C of this regulation states, "Any owner,
manager, operator, or employee of any establishment regulated by this
regulation must ensure that the establishment is in compliance and any such
person who violates any provision of this article shall be guilty of an infraction
punishable by a fine of$50 for a first violation, $100 for a second violation, and
$250 for each additional fine within one year.
Therefore, you are ordered to pay a fine of$50 for the violation stated
above since this is your first violation within one year. A check or money
order payable to the City of Salem must be at the Board of Health office,
120 Washington Street 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. An attorney may represent you. 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 978-741-
1800.
i
Sincerely yours,
oanne Scott
Health Agent
Cc: Christina Harrington, Board of Health Chair
John Keenan, City Solicitor
Joyce Redford, Director, North Shore Tobacco Control Program
Fire Prevention, Salem Fire Department
Mem ®
Date: 8/8/03 TH
To: Joanne Scott,Health Agent
From Patrick Mulligan, Compliance Inspector
Joyce Redford, Program Director
RE Salem Tobacco Inspections
On Wednesday,August 8,2003 Joyce Redford and I conduct two Environmental Tobacco Smoke(ETS)inspections. These
inspections were the result of violation complaints received by the Salem Board of Health. Both establishments were inspected
and both were found to be in violation of the regulation.
Non-Compliant
Tin Whistle Inspected 8/8/03
At approximately 10:20 pm Friday evening we inspected the Tin Whistle as a follow-up to several complaints received by the
Salem Board of Health. Upon entering the establishment there was an odor of cigarette smoke. We witnessed one patron
smoking in the rear area of the establishment who was playing darts;we also observed a full ashtray on the chair rail in this area.
When I spoke to the female bartender she went and got the establishment owner. We informed him of the violations and that we
were there to follow-up on a complaint. The owner stated he was unaware that a patron had entered the establishment with a lit
cigarette. The owner was advised of the terms of the regulation and given a copy of the inspection report. Given that the Board
of Health has received several complaints and that this establishment is so small I question their inability to monitor their patrons.
Roosevelt's Inspected 8/8/03
At approximately 10:45 pm Friday evening we inspected Roosevelts as a follow-up to a complaint received by the Salem Board
of Health about smoking on the patio area. Upon entering the establishment the first thing we observed was that the door leading
to the patio area was wedged open and therefore smoke was entering the indoor bar area. We also witnessed staff carrying
trays and serving drinks to patrons in this area. We then witnessed a patron carry a lit cigarette inside the establishment walking
right past staff at the door between the inside and outside areas. I (Joyce)followed this patron to watch and 9 and where he was
going to extinguish it. What I witnessed next alarmed me the patron tossed the lit cigarette onto the wooden floor,I quickly
extinguished it and brought it to the owners attention. The owner was in Irrted of�fie uiolationwitnessedand.was_given a copy
I
report__ -
worthy to mention that at the time of the inspection there were approximately 100-150 patrons in the
ment Upon witnessing the lit cigarette being tossed on the wooden floor I became concerned about capacity of
blishment as well as the ratio of staff to patrons and their ability to observe such behavior. Which also raised
about a person's ability to escape the patio area (which appears to be completely enclosed) in the case of a fire
was difficult to determine who were employees and who were patrons, it was only after observing that the
arrying drinks onto the patio was wearing a small black apron that we realized she was staff.
j�l e, 14 0
ROOSEVELT'S 1015
i OPERATING ACCOUNT
300 DERBY STREET a
SALEM, MA 01970
DAT-
,>z h 3 _739,,,3
PAY
TO THE
ORDER s
ORDER OF _ , l V c.�. Jd-
\\\111 <_.--
.4 C'enicrya,2
i
Bank
Salem,Ma55adm5cMs 01970
FOR ,. �
11600 L0 i 51I' 1:0113013901: 021 269 �II' -
_ 1015
ROOSEVELT'S - -
- -OPERATING
I' •^;,,�! 300 DERRY MEET' -
J.- ~�'r•" SALEM,MA 01970• !!/ f 53-139/111
i- -•_•„ �^ DATE � � " 3
•�..,,���:..+,•�n'YTCent�' 812.i",�.rr''�' y�4�,. 'w .t..p M1. 'x.�:x
,.=:'%._�� � �.Bariky_�,x,,,�,;..-• '�;; ..�� ..: Irl\; =:: �:'' �":..
. . .�".'• ,R��,,,,,��,.,,��,,..�,�sdan•,MauMme[s;m9m!_�_ �,.,e •~, � „:ro„_ \,• �-�'� •� -x � ���
.•• •.w:,•.". -y00,L�0i59,+�:01L30'L"390� 9,2.1-269
I
�`:,��.#ar�!_a_,.,-. ,� *�. � �. �:::,rs�•:cs�.' at'1c'"�"tr�Y��..,m,- �> -�-`2Fu.:�$..r:��s�.
CITY OF SALEM, MASSACHUSETTS
vQ� BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
J' TEL 978-741-1800
FAX 978-745-0343
STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
August 28, 2003
Hugh McGowan
Roosevelt's Restaurant
300 Derby Street
Salem, MA 01970
Dean-.M,-`-- �cGo_wanf
moo _ — -
-
On-August 8-=2003 at-approximately 10 45 P�ivt�n;respons�=teMomplaint about--, _ =k;
z., -_. 4
smoking-allowed on thepatioof youe.establishment'.pe�soniiefom.the Tobacco_
Control Program conducted a compliance check to determine if, your:
establishment was in compliance with,Salem Board of Health Regulation #24
Concerning Prohibiting of Smoking in Restaurants`,and,Bars.'At that time, the
-15 u- - - .n+a ..c -
door leading to the patio.'was, to be wedged. ri-&-o6en position,
allowing smoke to enter"the indoor bar area. St iffwere observed carrying
trays and serving drinks to patrons sitting;iri the patio-area. In addition, a
-. patron wasobserv4.6airying_4,litcigarette from,the patio to,the inside of
— `he establisl a alktng ZaJ --tAhat"lrior h►s.pafran�hiew the_ lit
cigarette onto the wooden'floor..N Documentation is on file at the Board of
Health regarding this violation.
Fire Safety concerns are being forwarded to the Salem Fire Department,
Fire Prevention Division.
The Compliance Inspectors presented a copy of the inspection report to the
owner at the time of inspection.
You are in violation of Section VIII of Salem Board of Health Regulation #24.
According to this section, it is unlawful for any person who owns, manages,
operates, or otherwise controls the use of any premises subject to regulation
under Sections IV, V, VI, to fail to comply with any provisions, or to allow smoking
where it is prohibited. Section VII C of thi§'regulation states, "Any owner,
manager, operator, or employee of any establishment regulated by this
regulation must ensure that the establishment is in compliance and any such
person who violates any provision of this article shall be guilty of an infraction
i
punishable by a fine of$50 for a first violation, $100 for a second violation, and
$250 for each additional fine within one year.
Therefore, you are ordered to pay a fine of$50 for the violation stated
above since this is your first violation within one year. A check or money
order payable to the City of Salem must be at the Board of Health office,
120 Washington Street within ten days of receipt of this notice.
Should you be aggrieved by this Order, you have the right to request a hearing
before the Board of Health. A-request for such a hearing must be received in
writing in this office of the Board of Health within seven (7) days of receipt of this
Order. At said hearing, you will be given the opportunity to be heard and to
present witness and documentary evidence as to why this Order should be
modified or withdrawn. An attorney may represent you. Please also be informed
that you have the right to inspect and obtain copies of all relevant inspection or
investigation reports, orders, and other documentary information in the
possession of this Board, and that any'adverse party has the right to be present
at the hearing.
If you have any questions regarding;this notification, please call_meat 978-74'1-
71800.
Sincerely yours,
�d ��s e=E
oanne Scott
Health Agent
_ Cc- Chjj" in :_�i rringtori,_Qoard of:Health Chair
John_Keenan,City Solicitor "
Joyce Redford, Director, North Shore Tobacco Control Program
Fire Prevention, Salem Fire Department
6 ,
�
CERTIFIED MAIL RECEIPT
(Doene�tic Mail Only;No Insurance Coverage Provided)
0
U7 Postage I$
r
0
�- Certified Fee
Postmark
Ir Return Receipt Fee Here
C3 (Endorsement Required)
0 Restricted Delivery Fee
Cl (Endorsement Required)
O
O Total Postage&Fees $
fTl Name(Plea ' t Clearly)(to be comp)too by mailer)
Er Street,Apt No, rP0 Box No.
Er
r
1W illll�- Mqmmm
City,State,ZIP+4
Certified Mail Provides: '
■ A mailing receipt
■ A unique identifier for your mailpiece
■ A signature upon delivery
■ A record of delivery kept by the Postal Service for two years
e
Important Reminders: I
■ Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. I
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811 i to the article and add applicable postage to cover the
fee Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt, a USPS postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,July 1999(Reverse) 102595-99-M-2087
u CITY OF SALEM, MASSACHUSETTS p
_ BOARD OF HEALTH
• '4, 120 WASHINGTON STREET, 4TH FLOOR
a e SALEM, MA 01970
,>„ �• TEL 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
August 28, 2003
Hugh McGowan
Roosevelt's Restaurant
300 Derby Street
Salem, MA 01970
Dear Mr. McGowan:
On August 8, 2003 at approximately 10:45 PM, in response to a complaint about
smoking allowed on the patio of your establishment, personnel from the Tobacco
Control Program conducted a compliance check to determine if your
establishment was in compliance with Salem Board of Health Regulation #24
Concerning Prohibiting of Smoking in Restaurants and Bars. At that time, the
door leading to the patio was observed to be wedged in the open position
allowing smoke to enter the indoor bar area. Staff were observed carrying
trays and serving drinks to patrons sitting in the patio area. In addition, a
patron was observed carrying a lit cigarette from the patio to the inside of
the establishment, walking past staff at that door. This patron threw the lit
cigarette onto the wooden floor. Documentation is on file at the Board of
Health regarding this violation.
Fire Safety concerns are being forwarded to the Salem Fire Department,
Fire Prevention Division.
The Compliance Inspectors presented a copy of the inspection report to the
owner at the time of inspection.
You are in violation of Section VIII of Salem Board of Health Regulation #24.
According to this section, it is unlawful for any person who owns, manages,
operates, or otherwise controls the use of any premises subject to regulation
under Sections IV, V, VI, to fail to comply with any provisions, or to allow smoking
where it is prohibited. Section VII C of this regulation states, "Any owner,
manager, operator, or employee of any establishment regulated by this
regulation must ensure that the establishment is in compliance and any such
person who violates any provision of this article shall be guilty of an infraction
X
punishable by a fine of$50 for a first violation, $100 for a second violation, and
$250 for each additional fine within one year.
Therefore, you are ordered to pay a fine of$50 for the violation stated
above since this is your first violation within one year. A check or money
order payable to the City of Salem must be at the Board of Health office,
120 Washington Street 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. An attorney may represent you. 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 978-741-
1800.
Sincere! yours,
=
oanne Scott
Health Agent
Cc: Christina Harrington, Board of Health Chair
John Keenan, City Solicitor
Joyce Redford, Director, North Shore Tobacco Control Program
Fire Prevention, Salem Fire Department
E
Memo
ROS i; '_
Date: 8/8/03 TH
To: Joanne Scott, Health Agent
Ill Patrick Mulligan,Compliance Inspector
Joyce Redford, Program Director
RE Salem Tobacco Inspections
On Wednesday,August 8,2003 Joyce Redford and I conduct two Environmental Tobacco Smoke(ETS)inspections. These
inspections were the result of violation complaints received by the Salem Board of Health. Both establishments were inspected
and both were found to be in violation of the regulation.
Non-Compliant
Tin Whistle Inspected 8/8/03
At approximately 10:20 pm Friday evening we inspected the Tin Whistle as a follow-up to several complaints received by the
Salem Board of Health. Upon entering the establishment there was an odor of cigarette smoke. We witnessed one patron
smoking in the rear area of the establishment who was playing darts;we also observed a full ashtray on the chair rail in this area.
When I spoke to the female bartender she went and got the establishment owner. We informed him of the violations and that we
were there to follow-up on a complaint. The owner stated he was unaware that a patron had entered the establishment with a lit
cigarette. The owner was advised of the terms of the regulation and given a copy of the inspection report. Given that the Board
of Health has received several complaints and that this establishment is so small I question their inability to monitor their patrons.
Roosevelt's Inspected 8/8/03
At approximately 10:45 pm Friday evening we inspected Roosevelts as a follow-up to a complaint received by the Salem Board
of Health about smoking on the patio area. Upon entering the establishment the first thing we observed was that the door leading
to the patio area was wedged open and therefore smoke was entering the indoor bar area. We also witnessed staff carrying
trays and serving drinks to patrons in this area. We then witnessed a patron carry a lit cigarette inside the establishment walking
right past staff at the door between the inside and outside areas. I(Joyce)followed this patron to watch and if and where he was
going to extinguish it. What I witnessed next alarmed me the patron tossed the lit cigarette onto the wooden floor, I quickly
extinguished fl and brought it to the owner's attention. The ownerwas'n rmed�f the-violation-witnessedand-was given a copy
of the i -report--
• It is noteworthy to mention that at the time of the inspection there were approximately 100—150 patrons in the
establishment. Upon witnessing the lit cigarette being tossed on the wooden floor I became concerned about)afire
the establishment as well as the ratio of staff to patrons and their ability to observe such behavior Which also
concern about a person's ability to escape the patio area(which appears to be completely enclosed)in the caLastly, it was difficult to determine who were employees and who were patrons; it was only after observing tha
son carrying drinks onto the patio was wearing a small black apron that we realized she was staff
7'/DAJ
ROOSEVELT'S 1015
OPERATING ACCOUNT
300 DERBY STREET
SAtEM, MA 01970 -` 53-1391113
PAY
� � {
TO THE
/ J
ORDER O� 1 t`l� —, _ � DATE �
« DOLLARS
,. Cents■.]ry 812
' Bank
+ Salem,Massazhusells 01970
LOR
11'00 101511' i:0 1 i 30 13401: 11' 2 1 269LL
ll'
__. _
f
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA O 1970
�— TEL. 978.741.1800
mnetl� FAX 978-745.0343
STANLEY J. USOVICZ, JR- JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
Facsimile
�^ Transmittal
To: Y"IY� .
Fax # qL15^' q' �CO2.-.
Re: —
Date: A s-, o
Page(s): including this cover #4L
Message:
r
'wI&W --------------------------------------- For Your Information
Summer Office Hours: Effective July 7 through Friday, August 29, 2003
Monday, Tuesday, &Wednesday 8:00 A.M. to 4:00 P.M.
Thursday 8:00 A.M. to 7:00 P.M.
Friday 8:00 A.M. to 12:00 Noon
DO SALEM RESIDENTS KNOW ?— A product named Waste Paint Hardener may be useful
for large quantities of latex paint since a small amount dries up these large quantities.
f
CITY OF SALEM, MASSACHUSETTS
�;ca
��� ---��� BOARD OF HEALTH
3 + 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
,pB - TEL. 978-741-1800
�'� FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
August 28, 2003
Hugh McGowan
Roosevelt's Restaurant
300 Derby Street
Salem, MA 01970
Dear Mr. McGowan:
On August 8, 2003 at approximately 10:45 PM, in response to a complaint about
smoking allowed on the patio of your establishment, personnel from the Tobacco
Control Program conducted a compliance check to determine if your
establishment was in compliance with Salem Board of Health Regulation #24
Concerning Prohibiting of Smoking in Restaurants and Bars. At that time, the
door leading to the patio was observed to be wedged in the open position
allowing smoke to enter the indoor bar area. Staff were observed carrying
trays and serving drinks to patrons sitting in the patio area. In addition, a
patron was observed carrying a lit cigarette from the patio to the inside of
the establishment, walking past staff at that door. This patron threw the lit
cigarette onto the wooden floor. Documentation is on file at the Board of
Health regarding this violation.
Fire Safety concerns are being forwarded to the Salem Fire Department,
Fire Prevention Division.
The Compliance Inspectors presented a copy of the inspection report to the
owner at the time of inspection.
You are in violation of Section VIII of Salem Board of Health Regulation #24.
According to this section, it is unlawful for any person who owns, manages,
operates, or otherwise controls the use of any premises subject to regulation
under Sections IV, V, VI, to fail to comply with any provisions, or to allow smoking
where it is prohibited. Section VII C of this regulation states, "Any owner,
manager, operator, or employee of any establishment regulated by this
regulation must ensure that the establishment is in compliance and any such
person who violates any provision of this article shall be guilty of an infraction
�z
punishable by a fine of$50 for a first violation, $100 for a second violation, and
$250 for each additional fine within one year.
Therefore, you are ordered to pay a fine of$50 for the violation stated
above since this is your first violation within one year. A check or money
order payable to the City of Salem must be at the Board of Health office,
120 Washington Street 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. An attorney may represent you. 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 978-741-
1800.
Sincerely yours,
(do'anne Scott
Health Agent
Cc: Christina Harrington, Board of Health Chair
John Keenan, City Solicitor
Joyce Redford, Director, North Shore Tobacco Control Program
Fire Prevention, Salem Fire Department
f
1p1''-A
t 11
Memo
Date: 8/8/03
To: Joanne Scott, Health Agent
From: Patrick Mulligan,Compliance Inspector
Joyce Redford, Program Director
RE: Salem Tobacco Inspections
On Wednesday,August 8,2003 Joyce Redford and I conduct two Environmental Tobacco Smoke(ETS)inspections. These
inspections were the result of violation complaints received by the Salem Board of Health. Both establishments were inspected
and both were found to be in violation of the regulation.
Non-Compliant
Tin Whistle Inspected 8/8/03
At approximately 10:20 pm Friday evening we inspected the Tin Whistle as a follow-up to several complaints received by the
Salem Board of Health. Upon entering the establishment there was an odor of cigarette smoke. We witnessed one patron
smoking in the rear area of the establishment who was playing darts;we also observed a full ashtray on the chair rail in this area.
When I spoke to the female bartender she went and got the establishment owner. We informed him of the violations and that we
were there to follow-up on a complaint. The owner stated he was unaware that a patron had entered the establishment with a lit
cigarette. The owner was advised of the terms of the regulation and given a copy of the inspection report. Given that the Board
of Health has received several complaints and that this establishment is so small I question their inability to monitor their patrons.
Roosevelt's Inspected 8/8/03
At approximately 10:45 pm Friday evening we inspected Roosevelts as a follow-up to a complaint received by the Salem Board
of Health about smoking on the patio area. Upon entering the establishment the first thing we observed was that the door leading
to the patio area was wedged open and therefore smoke was entering the indoor bar area. We also witnessed staff carrying
trays and serving drinks to patrons in this area. We then witnessed a patron carry a lit cigarette inside the establishment walking
right past staff at the door between the inside and outside areas. I(Joyce)followed this patron to watch and if and where he was
going to extinguish it. What I witnessed next alarmed me the patron tossed the lit cigarette onto the wooden floor, I quickly
extinguished it and brought it to the owner's attention. The owner was in gLmed-of-the v elation w thessed and-was given a copy
of the irefrorl --------
— ' �.
• It is noteworthy to mention that at the time of the inspection there were approximately 100-150 patrons in the
establishment. Upon witnessing the lit cigarette being tossed on the wooden floor I became concerned about capacity of
the establishment as well as the ratio of staff to patrons and their ability to observe such behavior Which also raised
concern about a person's ability to escape the patio area(which appears to be completely enclosed)in the case of a fire
Lastly, it was difficult to determine who were employees and who were patrons; it was only after observing that the
rson carrying drinks onto the patio was wearing a small black apron that we realized she was staff.
HP Fax Series 900 Fax History Report for
Plain Paper Fax/Copier Joanne Scott Salem BOH
978 745 0343
Aug 28 2003 12:36pm
Last Fax
Date Time 1,= Identification Duration Paces &suft
Aug 28 12:34pm Sent 99787459402 1:56 4 OK
Result:
OK - black and white fax
f
�. �.afl3j. „fes 1
Memo :l ; t ., % 3
R04;,
Date: 8/8I03 : LTH
To: Joanne Scott, Health Agent
From: Patrick Mulligan,Compliance Inspector
Joyce Redford, Program Director
RE: Salem Tobacco Inspections
On Wednesday,August 8,2003 Joyce Redford and I conduct two Environmental Tobacco Smoke(ETS)inspections. These
inspections were the result of violation complaints received by the Salem Board of Health. Both establishments were inspected
and both were found to be in violation of the regulation.
Non-ComDliant
Tin Whistle Inspected 8/8/03
At approximately 10:20 pm Friday evening we inspected the Tin Whistle as a follow-up to several complaints received by the
Salem Board of Health. Upon entering the establishment there was an odor of cigarette smoke. We witnessed one patron
smoking in the rear area of the establishment who was playing darts;we also observed a full ashtray on the chair rail in this area.
When I spoke to the female bartender she went and got the establishment owner. We informed him of the violaflons and that we
were there to follow-up on a complaint. The owner stated he was unaware that a patron had entered the establishment with a lit
cigarette. The owner was advised of the terms of the regulation and given a copy of the inspection report. Given that the Board
of Health has received several complaints and that this establishment is so small I question their inability to monitor their patrons.
Roosevelt's Inspected 8/8/03
At approximately 10:45 pm Friday evening we inspected Roosevelts as a follow-up to a complaint received by the Salem Board
of Health about smoking on the patio area. Upon entering the establishment the first thing we observed was that the door leading
to the patio area was wedged open and therefore smoke was entering the indoor bar area. We also witnessed staff carrying
trays and serving drinks to patrons in this area. We then witnessed a patron carry a lit cigarette inside the establishment walking
right past staff at the door between the inside and outside areas. I (Joyce)followed this patron to watch and V and where he was
going to extinguish it. What I witnessed next alarmed me the patron tossed the lit cigarette onto the wooden floor, I quickly
extinguished it and brought it to the owner's attention. The owner was in 9[med_otthe-violation-witnessed and-was.given a copy
of the i TUP01 I. — -
• It is noteworthy to mention that at the time of the inspection there were approximately 100-150 patrons in the
establishment. Upon witnessing the lit cigarette being tossed on the wooden floor I became concerned about capacity of
the establishment as well as the ratio of staff to patrons and their ability to observe such behavior Which also raised
concern about a person's ability to escape the patio area (which appears to be completely enclosed)in the case of a fire
Lastly, it was difficult to determine who were employees and who were patrons; it was only after observing that the
rson carrying drinks onto the patio was wearing a small black apron that we realized she was staff.
19K EU C-A-) 7 /OBJ
-LI
North Shore Area Boards of Health Collaborative
Tobacco Control Progr
T1
85 Exchange Street, Suite 307 (791 -0432 Phone
Lynn,MA 01901 INSPECTION REPIr (781)477-0490 Fax
RTUG 1 B Z003www.nstrp.or9
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qr;mv, QAItN'0
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Ad&e-ss " --.",300"�' Det'b'y.',, stkd'e-t
Owners NameI45 Qn,
Person In Charge QTK OU
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Approximate Number of Patrons) m Establtshment� ==t�ther,, ,� ���
A-
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,wa,
:WIN
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101U$ales Board of Health Regulation1,
Areas.Of Colic
❑ shtrzy�Provided ETPirtYAsh*s �t?dor of SMoke� ..Wqs�nce oiStn'qke' -..[X�Oth�i N)ak Aat 17 j�.
,,,,,Coln
IJ le
Based on an inspection today,the items above indicate the status of compliance with the City of Salem's Board of Health
Regulation#24 Information will be forwarded over to the Salem Board of Health and further action may follow.
Board of Health-white/NSTCP Electronic/Establishment-Pink
._ y. -..,.,-�.. -. .. -�... ,-y r..-h-V: .. . ,-...-.-�. .. .,,..�.........;. .. ...wwrew•x�dd ..w-+-...- ..w...e.... �......--,. +,---� .n„ �.-,..+......-:.--...... ..-.. l
SHE COMMONWEALTH OF MASSACHUSETTS
.�: - ,C- ITY 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 Das/1-h Tvoe of O onlsl, e of Insoeetion,
/GL/�le S rXL�CJ7 Food Service Routine
Address /,�\ 1 I Risk Retail Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone
El Mobile Date:
Owner //,�y �r'^ �/j HACCP Y/N ❑ Temporary ❑ Pre-operation
❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) G1� / '� `\ rn - �` Time ❑ Bed 8 Breakfast ❑ General Complaint
F' '-?'^/ )��/�yJ� In: ❑ HACCP
Inspect` �1`',., � I Y lc Out: Permit No. ❑ Other
Each violation checked llrequires 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 fRed Items1 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 MANAGEMENT12. Prevention of Contamination from Hands
El 1. PIC Assigned/ Knowledgeable/ Duties
EMPLOYEE HEALTH
13. Handwash Facilitieg
El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS
El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
EJ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
El 16. Cooking Temperatures
❑ 5. Receiving/Condition
❑ 6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating
El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
El8. Separation/Segregation/ Protection El 20. Time as a Public Health Control
El 9.,Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related ///��❑
Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
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 ,p
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:
r
Inspector's Signature: Print-'-
PIC's Signature:Lfes, Print: PagPag
"_ es
FORM 734A HOBBS WW
`AIR/REN - BOSTON -/
i
Violations Related to Foodborne Illness
Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION !`
9 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from
1 1 590.003(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 Contac[with Equipment and
590.003(F) Responsibility of a Food Employee or an Utensils*
Applicant to Report to the Person in I
Charge* Contamination from the Consumer
13-306.14(A)(B)I Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE 9 I Food Contact Surfaces
4 Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water
590.004(A-B) Compliance with Food Law* Sanitization Temperatures*
3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water
3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures*
3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H,
3-202.14 Eggs and Milk Products,Pasteurized* Hardness* P
gg Concentration and
3-202.16 Ice Made from Potable Drinking Water* 4-601.1 I(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*
Game and Wild Mushrooms Approved by 1 10 Proper,Adequate Handwashing
Regulatory Authority 11
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*
3-201.17 Game Animals* 11 � Good Hygienic Practices
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*
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting*
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands
6 Tags/Records:Shellstock � 590.004(E) Preventing Contamination from
3-202.18 Shellstock Identification* Employees*
3-203.12 Shellstock Identification Maintained*
13 Handwash Facilities 1
1 1 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(7) 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 Ca1R 590.000.
it
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: J ZZ U.3 Page: of
Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
--T, S
�S" nsn ;o c r rrc - �d
t?�
I I Nab- s��ih��ss Js�q ern L�� ►� ;S /zcx�r -
I I I I
a r m s�
Discussion With Person in Charge: Corrective Action Required: I ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
p ❑ 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
yc'p food permit.
�� ❑ Voluntary Disposal ❑ Other:
4
3-561 14(Cl PHFs Received at.leutperatures W
Violations Related to Foodborne Illness Interventions and Risk According to Isw Cv)led w
Ferrers(Items 1-22) (Cont) 4 FF 45 F Within 4 Hours.
PROTECTION FROM CHEMICALS ' `01.17 Cooling Methods R' r PHF,
19 PHF Hot and Card Holding
14 Food or Color Additives i ;.5(11,16(8) Cold PtIFsMai n:ranedatorbelk, ,
3-202.12 Additkes` 590.004(171 41:145'F"
3-302.14 Protect ton from Un4%n uved Addicts-err
I ( 3->01.Iti(A) I-IoiPHPs M.emr=incd at or above
15 Poisonous or Toxic Substances
7-101.11 Identn'prig Information-Original
t.
Ccnrtainers, ;iOLI6(A) ItnastFleidaiorahnvel3J'F ..
7-102.11 Cot a ion Name-Workinh Contamern ( 20 Time as a Public Hearth Control
3-501 i9 Tune as a Public Health Control*
7-201.11 Separation-Storaiee"
7-202.11 Restricn,m-Ptasence and Use" ( )9OM04(fl) Vartanco Bequncluent
7-202.12 Conditions of lase-
'U3 71 ('otic Containers - Pndnbitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS(HSP)
7-204.11 Sanitizers,Criteria-Chemicidsr:
Unp
7-2-04,1' Chemicals kir Washing Ptaluce.Criteria' 2I 3-riUl.l ltAi Be%ciaemiav:t Pro-reinl-II Ltices and
7-1,04.14 Drving Agents,Cr feria' Isesetages with W'arninr L,lxh;'
3-801.1 11 B) Use Of Pastent'ized Lr es'
7-205.11 Incidental Food Contact,Lubricants* 13-SUI 1 t(t�) R:.w or Partially Conked Annual Food arid
7-206.1 I Rc strcted Use Pe;ticicdm Criteria
Raw Seed Sprouts Not Sened.
1 7-206.12 Rodent Bait Stations"
v-206.1; '-SOL I I(C) t)nopened Food Package Not Rr-served,
Tracking Powders,Pest Control and
64omtoring" CONSUMER ADVISORY
22 3-603.11 Consumer Adtiaoty Posted G,r Consumption of
TIMElTEMPERATURE CONTROLS Anima: Funds That are Raw.Undercooked of
16 Proper Cooking Temperatures for i Not Otliem;. e Proc sscd to Eliminate
PHFs Patlurgana.*sten,.:mE r;-eon,
3-401.1 L'ti(I)(2) Fees- 155"F I5 Sec 3-302-13 Pasteurized Fggs Subntit=.nc lir Raw Shell
Eegs- lmmeduue Service 145"Fl5sec`
3-101.1 (A)(2)(A)(2) Comminuted Hsh. Meats&Game
Animals- Ii5'F Is sec. '
� 3-401.11(6)(I)(2) nd Beef t- 13tinSPECIAL REQUIREMENTS
3-401.11(4)(2) Ratacs,Injected Meats- 155"F 15 590.009(A)-(D) Violations ofSectio
n 590.009(A)-(D) in
sec , catering, mobile load, temporary and
-401,11(A)(3) Poultry.Wild Game. Stuffed PHFs. residential kitchen operations should be
I coming luntaunne Fish,Daeal, ( ..-.%+�4.= ..adrr the -ca- 'i.I-r' ....--I,.
Poulhy or Ratites-165- 15sec " above if teiated to foodhorne illness
3-401 I1(C)(3) `v1'hole-muscle.Intact Beet)trigs interventions and risk factors. Other
145'F 590 009 violations relating to good retail
3-401.12 Raw Aninr4 Fortis Cooked in a practices should bee debited under#29-
Microwace 165`F* Spociai Requircment5.
3-401.11(A)(1)(b) All Other I'HPs- 145'F t5 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-40111(A)&tD) PHFs165'F15sec. ' (Itents23-30)
3-403.11(B) Microwave- 165'F 2 Minute Standing I Critical and non-crdical violations, which do not reta:e to the:
Thee* foodhnrue ilbtes::iruervenrioicv and irsb,racoon listed,ihoo e, rue+ he
3-403.11(C) Commercially Processed RTE Food- found in Ike jnitoning see tions nl'fire Food Code mrd 105 Cd•IR
140017' 590.t)O0.
3-403.1 1(E) Remaining Unsliced Portions of Rcef Item Good Retail Practices I FC 590.000
Roasts" i 23__ Management and Pert.onias FC-2 .003
18 Proper Cooling of PHFs 24. f Food and Food Protection FC-3 (704
25. Equipment and Utensils FC-4 .005 f
3-501 14(A) Cooling Cooked PHFs from 140'F to ; 26. water,Plumbino and Waste FG-5 .006
70.17 Within 2 Homs and Front 769 27 Physical Facility FC-6 0107
to 41-F/45"F Within 4 Hours. i 28. Poisonous or Toxic Materials FC-7 .008
3-501.1416) Cooing PHFs Made From Ambient 29. 1 Special Requirements ! ,009
Temperature Ingredients it 30. Other
Within 4 Homs"
Denote,,uncal icon in the ledmil N94 Fuad Code ui 1015 CSAR 590.000.
[7] [7]
Refrigerator
Ice Maker
1:I!,d r.I 11"1.1".1, i,ii:11 11!11, L 1:11", .1 1,:1 Ill Ili 1:1 i, 1., 11 il 1: l'.I I li 1.1 i 11,12l ii
.......I..I..............
Interior wall —Refrigerator
irrill
Fryolator