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WANTS TO SEE YOU RUSH
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Commonwealth of Massachusetts
19D City of Salem
Board of Health lGmberiey Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/29/2008
ESTABLISHMENT NAME: Rose Medallion
File Number:BHF-2007-000033 184 Essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2009-0253 Dec 29,2008 Dec 31,2009 $140.00
Total Fees: $140.00
PERMIT EXPIRES December 31, 2009
Board of Health r
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page t
.ry
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL Fax(978) 745-0343
MAYOR IDIONNE SALEM.COM
JANET DIONNE,
ACTING HEALTH AGENT
2009 APPLICATION FOR
ggPERMIT
,I1TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT L4JJ7E_ 1+& 36J'&9JU,0nL&t TEL# L? C243
ADDRESS OF ESTABLISHMENT 184 6�mz.4 Skti li FAX.# q7? - NY a3 8s'
MAILING ADDRESS/(if different)
EMAIL- Business':iq&)A)_ Lr 53 PVP, VZ-01-&att; Website:
OWNER'S NAME Ak),L) �LTEL# fir?! 595-S;frlO
ADDRESS /0 d)Q RR1uwL WHY :3 JJ/ AA
STREET r CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) No Le-r CERTIFICATE#(S) 5500I e)G
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON AN ) /wE HOME TEL#
I DAYSOFOPERATION., -.1 Monday . - li -Tuesday" .i Wednesday-';I:` -Thursday -1, .-' Friday ,. 'Saturday, ( ' Sunday-
HOURS OF OPERATION ii $ _ - 12- 5P✓YI
Please write in time of day. i0
(For example 11 am-11 pm) 5 JP171 Vol &tom (o>°/Y) I
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES VIVO J less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
-------------- - - ------------------------------------------------------------------------- ---
RESTAURANT YES NO less than 25 seats
(Outdoor Stationary Food Can$21 25-99 seats = 280
more than 99 seats =$420
-------------------------------------------------- ---------- - --- --------------------------------------------------------------------------------------------
BED/BREAKFAST/ YESO $100
CHILDCARE SERVICES - ---
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25
TOBACCO VENDOR YES $135
ALL NON-PROFIT(such as church kitchens) YES $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
ret sand paid all taxes required under the l
4/p & -0&66 7a �
Signature v Dater Social Security or Federal Identification Number
Revised 424/07 FOODAP2008.adm Check#&DateA&1 124(IYh)A� $ 1 o.00
Commonwealth of Massachusetts
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Temporary Food Permit
DATE PRINTED: 09/23/2008
ESTABLISHMENT NAME: Rose Medallion
Fite Number: BHF-2007-000033 184 Essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
TEMPORARY FOOD BHP-2008-0581 Sep 23,2008 Sep 23,2008 Food to be served: Coffee tea scones
muffins bowl of mixed fruit
brownies&water
Total Fees:
PERMIT EXPIRES ISeptember23, 2008
n I
Board of Health
Page 1
'S '-23-2008 01 : 10 AM PM 19?82242833
" P. 01
CITY OF SALEM, MASSACHUSETTS
BOARD Cm i'SF1, tIl
I2U WA;SIIINtTttTN S7 RT:l1,4'xI I'I.00SR ��
FAX 978) 74I 0343 �
KIMBERLF.Y FJRISCt7I.L FAx(978}745•i1343 I /�,
MdYC)R IDIONNP ANAIAN.COM et)
Sli,NIOR SANITARIAN
��e oaSa�M
y�CTy
APPLICATION FOR A TEMPORARY FOOD SERWCE PERMIT
FEE: A-3DAYsm, , $300 NON-PROFIT*$25
4-7 DAYS- $800
OVER 7 DAYS o >7 DWIDED BY 7 X 800 a THE AMOUNT DUE.
{OUAIPtE:f4DAYsaMM3DBYf+-ttABDgI�QZ
QIECK PAYABLE TOTNECDYOF I r NO 1� '
NAME OF EvEM ?ertyN ai Ct kWt LOCATION 1y;-� Ef1AA�k
DATS(S)OF EVEM_�/,2.2i
NANE OF JrPpUCAMQ
AODREBSJ� M ft tray �u7 T pC'Ot�r ✓14all�q /� p
NAMEOFBUSpWEssLf`a�iQa... ,mZAllr�e-/�l�?OXR4i1TELePHONEIrT7D'"Z�t/-�3 /
ADDRESS 18V Cga+W-•s JJ
CERTIFIED FOOD MANAGER'S Mwuam Lelr-- CERTIFICATION#.S JM�,GX7 l SI�n,,.
A PLAN OF THE ESTABLISHMENT IS: ENCLOSED DRAWN ON THE BACK
TYPE OF REFRIGERATION; _GAS ICE DRY tea —EL/'ATNER
METHOD FOR COOKINGWT HOLDING:. OAS OTHER
METHOD FOR SAWtIZNG: _J/„CHEMICAL
A,�OTHER
SOURCE OF FGOO. NAINE�110�2 /170 + ADDRESS /�� v
I� F SE RATION; e _Q
I HAVE R6t0 THE BOARD Of HEALTH, •REOIAREMBNTB FOR TEMPORARY FOOD ESTABU8HA1FNf5."l HAVE HAD THE OPPORTUNlTYTOASKQUESTXNNB
RE(LaROING THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREETO ABIDE BY THEM AND UNDEASTANO THAT FAILURE TODD 80 WILL RESULT IN RBVOCATIONT
OF MY TEMPORARY FOOD ESTABUSWAENT PERMIT
PERstMM TD MGL C62C,S49A,I CER",rtWDERTHEPEIMlTIES-OFPERIWY THAT-!,TOMY am XNOW%MW AND BELIEF,FNVE PRED ALL STATE TAX
RETURNS AND PAIAIDD STATE Tay7.tEe"IQUIRED
UNDERLAW'. C.�YA1,1,( 1) lLY _ `1040-9- ti�LP-C.+StiTL� -T� !J
SIGNATURE / OATE SOCIAL SECURITY OR FEDERAL ID# ,,D
TEKPAPKa rtOMD P~o C�eWBM•• { •yt,�
e0.
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street,4th Floor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 04/08/2008
ESTABLISHMENT NAME: Rose Medallion
File Number'BHF-2007-000033 184 Essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
TEMPORARY FOOD BHP-2008-0436 Apr 4,2008 Apr 6,2008 Food to be served; quiche,cheese
and crackers,strawberries in
chocolate.
Total Fees:
PERMIT EXPIRES April 6, 2008
Board of Health ,`
LJ
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1
APR-04-2008 09 :39 PM PM 19782242833 P. 01
CITY OF SALEM, MASSACHUSETTS
BOARD OF WALT'H
120 WAMuN(rrDN SnEF.T,4"'FtfH)R
To..(978)741-1800
KIMBERLEY DRISCOLL FAX(978)745-0343
MAYOR lyxvi-rcalgmsm.com
JOANNE.S(.OTI*,
HRAL'I'H AGFN7
APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT
FEE: 1-3 DAYS= $300 NoN-PRoFrr■$25
4.7 DAYS■ $800
OVER 7 DAYS■ s7 DMoEO BY 7 X BOO=THE AMOUNT DUE.
(ERAMRt:14 OAYO 0M0E0 r! 2 K 000 0111200)
CHECK PAYb4GrQ TNF C�11(Lf.RC CMN
NAME of EVENTJQFFA Wgr. �I P-1 �S LOCATION J.��h
DATES)OF EVENT-8,W; //n -- �y
NAME OF APPLICANlee-e- TELEPHONE#7 78"J U U-Z/3
ADDRESS R ^'
2(
�J II ry y7B �4y 3
NAME OFBUSINESS I\USa-M��Q.XX[11n I.�1L TELEPHdiEB G
ADDRESS / 5'r{(.//��
CERTIFIED FOOD MANAGER'S NAME f-14 IA I.G.C_ CERTIFICATIONM SSa)18W
A PLAN OF THE ESTABLISHMENT IS: ENCLOSED DRAVM ON THE BACK
TYPE OF REFRIGERATION: GAS ICE _DRY K'E �` ,OTHER
ML'(HOD FOR CODKINB/HOT HOLDING: OAS OTHER
METHOD FOR SANITIZING' _CHEMICAL _OTHER
SO • ADDRESS
^FOODS fD DC lFR'vF1INCLUDING INGRECriFNTS AND M TROD O/�F FREPARATION'C9Uk•Pl.Q
kf
__.....All- wlixt 51�lwzil -) 74�*!;Ip
— - ....
1 IVl,'i RI:'A11'I1 i CiUAHU U1 HEA:TN, 'I:LQIi::SMEN1 J tJR flLN"URAI1e(vvC G:AlSL1EliMlA l:i.' I I U.VI P1vU I I IC OPPUf11 UNITY IU A:iK DUCE IIONu
Ift 1.4fUINI51tk l;.h nHll llGfL'MPN I:. IIIN{i�nCtPNO ILu'-M M:1(tl:1(ICbr11(.(Lr IwIM AWJINnkkN7YNP IwGT can 1111I'iOf1f3 SD Wln NFFIAI W ItF VfNWII(IN
pt'bt':SEAVVf,WA:P:F.'/.'I(`1:r 1 ALI'1,1 IF•hd!VI:MYT
�id:-.I IANIIIiVTr+iinir �d(1i i1.hHIrFT VW rrn rMi-L'1i.Rl1-\lll :+''Inlr.v rnurl 11IL1V Mhti1 rNUN+HN:F.LNi 11111 q-t MY1H•vn rr1A11 �1Y11- rY4
Itt.;;aNS AM16 fA:O P.11 J'•'.r'fid IAdtt:iiCUtLP.cu
I INO:F LYvv.
JIGNATURE DATE SUCNL SECURITY Oil f EDERAL IDA
Teunww 'ul•,..r •Yr,.•,I rl Ire.
i
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street,4th Floor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 04/08/2008
ESTABLISHMENT NAME: Rose Medallion
He Number:BHF-2007-000033 184 Essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
TEMPORARY FOOD BHP-2008-0435 Apr 4,2008 Apr 6,2008 Food to be served quiche,chicken
salad,bruschetta,banana bread,&
scones.
Total Fees:
PERMIT EXPIRES April 6, 2008
Board of Health _
s .
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1
RPR-04-2008 09 :40 PM PM - -- -- 19782242833
y
CITY of SALEM, MASSACHUSETTS
BOARD OV HeAi.Tll
120 WASMNGTON STULrf,Ont l'IDOR
T.(979)741.1800
KIMBERLEY DRISCOLL FAx(978)745-0343
MAYOR ljc(yrrolmuim.COM
JOANNF,SCCITI,
HPN:i'II AGENT
APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT
FFI' 1.3 DAYS= 5300 NON-PROFIT-$25
4.7 DAY$• $600
OVER 7 DAYS ;-7 DIVIDED BY 7 X 800=THE AMI`N4JNT DUE,
(aAANPLvt4 DAVO awaft BY 7.t A No-$ *)
���{{'',}}� � j/ _�� /L�,,.,, -, QMCK►�"TOTNE art Of cat ..Au
NAME of EVENT"?t5 R,[Q.JJt1UeP"J 1C.a'� LDCA'ON�"1��.'`_LiL,L.'`✓""7„JG"
DATE(8)OF EVENT
w,r Or RPPOCANTf14 Yl tib+ TELEPHONEII
ADDRESS �QI/I�•4n—� ,,/�� �AF . �]�
P6^w'•Fiis•ISV.nC4e`S:i3 1CITPHO EV 7 70?
AaUT1OM / ey t" 9SA4t%
+~.rr,T;rlce,�a:^.nMa�ln;;rr•srinrlrnhn � Coan�trnTlnNu 5S'Cx31 ?;6
!,I PLN:nF 7;ILL:,ans3ii61 ih!iiMT is: E!ri.L05"�'T Dr^.".`AM ON T''1f-,ttACli
'('vnr tJr YCE,„"RI(;CP.AT!C)N. ,A^., ICC URY !Ci OV IN<
IV'1CTli0U FUii COOKLKi/liOT HVLDING, GAS UTHER
nrcva::P)tnu?'.:,.'Jri.rnntf:; � ^f-tFM•J:Ai _tI PHFR
Lv
- - Illi.',..r... .,.:rv�.G,-•: 6 •.,u„I
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$'A$,wr-�'�b�"�Rustta.e�i(cltrl
,. . ..�..,.x... .,�.: "„'.:!::!,nl Nl.. ...... .....I l.w nn .,...; ^..r;:: IIY In .., .... ....•,1} - ... ..1
(//^p/�l, viaal let,.i,.y ate\f,(r/- .:a.:v.:.ry�v..^.vi/a`,^ 'JI',.7,.:iL.'i.��+t•n
. - a .` .ems ._ �, �, -4'• . ,aq ..y�:�r„ ....
Fr^vv�x`y M- r a,_ �. a+C. ,.: +A4a`.{a+p . :',�:^;n.,n..rw�.o... ..•..». ..:. ..',--Y�^5.+,.yuYt..+e 'u,:. -t,F"" i
. •�: 'S: . .>n .�• 'tk`:.,",•�-';-?a y-:.•. _,-"f„_•�, kw-%, ::. .a...r ,�."+,-rv;S:i: K
nt ...,.` �.r o. ""ir' �t, ,� y,._ '= . . ..: � - ',�. _ .. �. a t•• "}e��ta. �x;�?a:•.a�•�.aTw
Commonwealth of MassachusettsY
City of Salem
s �
Board of Health IGmbedey Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/03/2008
ESTABLISHMENT NAME: Rose Medallion
File Numbs:BHF-2007-000033 184 Essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2008-0096 Jan 3,2008 Dec 31,2008 $140.00
Total Fees: $140.00
PERMIT EXPIRES December 31, 2008
Board of Health
V
This Permit is not transferable and must be reissueduponchange of ownership'or location:The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health: page 23 of 46
I' 1
\ /I
lVt
e
3 CITY OF SALEM, MASSAGE IUSEM
> fro BOARD OF HEALTH
`rags r 120 WASHINGTON STREET,4T FLOOR
TEL. (978)741-1800 necelv
KIMBERLEY DRISCOLL FAx(978) 745-0343 e®
MAYOR TsooTrOsALEM.00M Nov 2 72001
JOANNE SCOTT,
HEALTH AGENT _
r-f
2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT 11705C ,,/ 6_bALLrO tt�J1 I CQ�4 / TEL#
ADDRESS OF ESTABLISHMENT1T E5"5-2.I1 JL ,� ,)Uh FAX# 7/�78- 7V y- C 3s3—,
MAILING ADDRESS(if different) /�
EMAIL-Business':H✓I U) -LCe.:5730 CUYk(r� 1� Website:
�nn II __ � _
OWNER'S NAME AAP1 Le, TEL# n��S�'�
ADDRESS ID A� �1�1k U)dLy �ft�(�*g A*
STREET / CITY STATE zip
CERTIFIED FOOD MANAGER'S NAME(SAI.U) 10-C CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON Nn 1 -`L HOME TEL# 7S(-��� ,8VL/0
DAYS OF OPERATION I Monday Tuesday Wednesday Thursday Friday Saturday Sunday
HOURS OF OPERATION mn.� R 3tcAlkk _ : 1'�2w.4VL- Po 44� - ®30 6 OP /aPm-5Pal 1
Please write in time of day. ! 30 3o / b o PNi
(Forexample llam-11pm) 5 119A_ `°/ PVA • 6-10mI l0 Pot . 7
TYPE OF ESTABLISHMENTFEE (check only)
RETAIL STORE Y NO less than I000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
........................................ -------------------------------------------------------------
RESTAURANT YES NO less than 25 seats =$140
I—..'ti'w'JJr$ tlOnary Food Cart$2?O) � '25-99 seats =$280
more than 99 seats =$420
- ------------------- -- ---- -----------......----------------------------
BED/BREAKFAST/ YES � $100
CHILDCARESERVICES----------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25
TOBACCO VENDOR YES $135
ALL NON-PROFIT(such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem.
- This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns and paid all state taxes required under the law. -/,,
a(P- D/WW6 7a
Signature Date Socciial'l Security or Federal Identification Number
------------------------------TTjj -- -----`--------------------
Revised 4/24/07 FOODAP2008 adm Check4&Date;
{
1
CITY OF SALEM
Jif BOARD OF HEALTH
` Establishment Name: /70 D5r Date: /) 0- U`7 Page: I of /
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item Verified
( PLEASE PRINT CLEARLY "
ae fi/o-e,7Ira I /l ew / /l� G,Iis ��lnhl��Gig
T1ree'(✓! Y/d'/I ai4
A0 . (00'ifjdr-' � aitl k ` USC 0 k-h Pl9-
to'
7 I
i I /A'I"o A , �/s-h V)/, /C .9 rl )79(9 a-(- 41e, C41>/n/A ,A SJR is
�P'� Lam up 4D -Ji't'o 'L,�✓�s z?., cl.� r� i its
I I
1
I 1
I
1
I I
I
II
1
Discussion With Person in Charge: Corrective Action Required: ( ❑ No �❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction /
violations before the next inspection, to observe all conditions as described, and to Exclusion
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other: i
a(t': PHFa Rec.tved eit lernp erature
Violations f?utaied to Foodborne fitness to;ervrntions and Risk Acv)rdny to f.xu" {;(vOd;o
Factors(ftsms 1-221 (Cont: 11`F'145,{a%,edtire•t }i;+urr.
I 'Jill p:� Catling\',,thcid, for PHF. I
PROTECTION FROM CHEMICALS I;f9
2.221._ PHF Hot and Cold Holding j
14 i Food er Cofer Additives
i.5ti;.iff}t} Cvkl PHF,Nlumi,:ieted at•ir tc-h,n,
?-302"14 E Prv,.Ctiou from ti,t.,ltpr,xv
"i '„)i,4fi,r\j li„t l'Iila Siainla±2nd,:i.:r ats•wr
15 , Peiscneus of Toxrc 3e+be#enceu I i j
i sJ0'F. `
ltil.lF t„saau tyi±ig intL:,nst,:=n - Uir;;nal i
?-`.=:l.1 s ”\i Ki>.sxtc H0,I a[v¢ %bote PVT,
a
i Cv;u.euter'" , 20 f Time as a Public Health Control
7.lf)2 ti Ca:u;a„n Naw-- likork;rq'.'t+uat±:,r,” If i
3:ct71 E:t 'Ciera:a�a l'uhlic f i;talth ConimP ,
i-2ttl.li S"tewacit,x--SIL:ra t` p }:�.:tt}1i};) C':uianc•eKrgtnrc,;±cut 3
7.202.11 kc,trichon -}`rc;us,.x"scd t cc` --
7-202..12 i C,,dniore�of U,;c*
7-203 I f Tr,•cic C'owitia,t.--Proh„IIVWnt 1 REQUIREMENTS ICOR HIGHLY SUSCEPTIBLE
1 7-20,1.1. i Satestizet„ C'r3tcria--C`ietnic,
POPULATIONS(HSP)
24 1,1,01 liaAa Unp:nrcetwr dere-pt.eeF:tned;tncts'aid
( 7.104 l7 ( {'bn)e icnt: for t\ach±::>' Pt,ki,tct,C•tit:.i±a^ I Re.tetacenwith Was-asuX2.e3;dL j
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landertai p=,kJ f7vinxt.Llkb,l,,awv I
I7-?tt(.ii j{,.ir,e�i.Y..+e Pe,aI ivfe,'t•:,t.^i:.i' 1
i, ; c.r Pattlsily Cert}rt3 Auimel i=,xrd a,,J
`;{rri eiM'�r., S a t"ed. -
j 7-'UCi.i2 t'+.xper.: };;�t tilt:;nn:.' j A i-Ail l.i i tt:; t'ts,nc ned F.X>l Patkagc No
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i 206 I: t,x;p ins;r=:•t,lcr.. t;'<•nirra ante
;'fu3sitnrin„' CONSUMER ADVISORY
22 3160� i l :.c•n~wrtct:\3,in(vt Ptnied l n”('knt tnnp:tivn of
TIME/TEMPERATURE CONTROLS e Anin;±1 F••„d� lhat.,rc kat Ln:2e,ax,}.rd(%
Proper CockkingingTamper Mutes to;
id
Pests
Not CH3.Krr,-ise tYt+•cssrd to Fi;ranatr
? •lUl i 1.1(1,(.": rgrx. (i`,'F E ...._-�._.�--
r :.lii.'..I t !'::re,, ,rizctt fi "LiNt;mv to Rau Shen,
hen l
4 ::,- inatee sec:rt,acr E ,ac _R c t
-40,1.11;.1)(:-: C01ni uui+.d I cit. 1[: s.f:<:.tirt:
SPECIAL REQUiREMENTS
3.101.3i(13}(€)'2} jPor kas.dt?:':tKcttrt - }itl"f t2' wit)
* 5)0.009(A).i€)S Vit-kntont of Section 90.0(}S}trlti (D) t, k
i.4:Jl.lt(<„{?; Melita,. liai,'."e,i .'ilcLYo i:iK'F i`
et tatcring. muhili_ ftxxl,leinpotarc a„d
j 401.Ih AWA) Pnnitry. 11',!.-i t;,,snc Stut1"z,i lelfis n:.Nttlept';al fit(nen etpej, tti(eos OtotfId tv
c;u{;r.: t:•ret:tt.:tt;"ri:t,. At^:u. dvhiied wid-r tete appropriate acs.^.; )ns
al^•t crttatt:,-tr,_;"l• t a c. ° Ax,t'u if,et.ued It,ti)xlbvrtt:. iptne:c
`E _;.at3l.t;tCt�Sa •+h:d, nx,•e•i.., G?rr,:t C�:'f:tteah� ±mertYnti�nc and risk factors, lithe{
!us"I 54(}.+}(40 violation.,relatini,to;:okel retail
3-4{);.12 Kae, -ininut Foul"t'rxkc<l:n s ? ;rt(.tici:.'lloulu to dcbitc(t,.ndi-r#29 .-
_ plot,,• v lb>-}' I , `i{<c:'t:,l lt.gnircttt,:nt�
!401.[7 tA3(i it hi =\it [itli¢i Pit].,1 . 345
17 rieheating for Hat Hoid"tng VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3--1u3.11(A)S=01 F'4{l ft's-F i?:e:' ( (ItemsZ -3tit
-70.`.l i(K) 4€irro,,:tertitnnrfi,4g I CrWrrn4,m,!non,rite.al violuium;, whir*do ren, selene r•ri,.,
T,m,: !: liitmehcrrr ell...utrerrnttiorr�md ri.,,:farsort I:acct a6:n+r ""'be
-403.11(C e G;nnn_rc:.tii�P;o.eaae.i f?TF tz+•t+<"t . ( found in rhe rood f ade.u.d if:' CIlk
i 4()'F'
34(A 1 tW± Renamiml UiO.t ed Port? t: of Pirci' E I fiom �t",aod Hetart Yraotrces_ -- - _, i FC -�-'�SNJ-OtX7
23 'Alre {aemrim and Peizmnel ', FC ”2 00?
18 Proper Cooling of Pest~& I_z't._ e=.ice;nd Food Prate'.ction _ i r0 � 3 ,v
ot:" Eau;'inti and i;'._itsila ,=C -.1 .rt65 {
901141A) C'cx'ltneCo:ik•�di'Hiaclr,+mJ407 "'tt, - — .r' - - -_-_
25, j IJatot.Pit.mbotp•trd.Neste i f'C -5 l (h)o
7;rF 11'itfa,ei ; hexer,:a::ri Ensne 731': i i 2, Physir.a!Fwif,itZ'. ._ - FC
ft,d t'T�tiSF Nitina 4}t•;tv<. ' j ` 26t'tn.unws or rnxi_A9atenals I rC-- I 008 --
i-;0t.1•ttki) C;n•linn€^Hf- 'Mvdt:Ffemi Ambient E_:=9.__.l-SpacislR: (iVremenis _ .a_.)
'F;mperareue livre6;cm,to 41°1,'45rr= (__}�. Oihe•r_ — - -_- ---, -
Within 41iAar..` � "`.•�•�:°•.
+IJenote.trsnc.t2 sen,,:,eh:&.4orai i"av Pn:ki t'-1t•.r }t}5 t 1412 9•R,flrtt7
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page: of
Item Code C-Critical Item*, DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date l
No. Reference R-Red Item - - - ,, Verified
PLEASE PRINT CLEARLY' 1
I 1
I
I I
1
I 1
1
I
I
I
I
I
I
I I
1
1
I
Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes
1 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 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:
i ?-5tiiA 4(4,:l PHF} Recrrved ni'Frntp::ratutc¢ 1
Violations Related to Foodborne fitness tntervent;ans Ord Risk A:<otdit+&to lac:C:ocl'd to IIJ
Factors jdtehis 1-22) (Cont.) S 1"l,'dS`F W'itH;a Hours
I j 3.5tA 15 Ctx'tiu M'thtkk'nr Pl pF
PROTECTION FROM CHEMICALS
1.4 Food or Calor Additives ( 1 19 PHF Hot and 6cid Hold€ng
-50',.16(B) Cold PHl•s lvinini.,,nc+l at ere 1)dow '
3-202 12 j n,ItlifiFes* � 1 5dtt.irt}•.('k-) .17=14)' F'
� 3-302.14 Prune•ixer fro+nI'NPpru ed tkddnives' 1
j lc 3 SC , i 1', 12I + 'u
va;nd at
Poisonous oe Toxic Substances ur abovr
1.+{.,}". n
7 101.11 identifying tnfu:miwon - 011, nal � .;=, r ,
j Co3 t € ]cit:.r Rv,.+':t:fluid a.:,t ab'rcr }3U`I�
ntaine[s` i
7-102 11 t ontaion Vnn,e- W'„rking i''rnratner;,' 1 20 Time as a Public Health Control j
1 t.StEI l ' 'na-as'iPuh}ic. Ik+aldiC�Jntt'o}°
7-201.1€ 'rpatatwn-5tn,age•' ' Sort.'Et}Ii}ti t'<_tiantc egttircntrnt
7-202.11 Rdct6i.t+on-Pa•srncc and L"C” .
7-2G2.12 Conditions of the"
7-?it3 11 Tr+xie.{`untatn;t: -Ptolrzbi:r,[n.! ( REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
17-'204.1 1 :iann izerti,C nteria --Chemiculca 1,11(A POPULATIONS{H5P}
j
7-2C4.12 Chcndcak for't'_�•a_chirne t'rodi cc (Alc6a' � � at � 1.11 t.�;, 1'npacteurizrd l''re-lra•..::t{:cd Jutcec and I
j 7-?ltd.la Lir?vi;:Agents.C:rEt,.riaY.. with Watmnx l,ticls'.
7-21}5.11
Incidental PW Contact, lzdnican±r t %-SOL i 1(14, t'sv of Pa>teui;zed bees'
J illi ,;tt cl'i',rtti.tEl, r+=<:,..l Atlituat Ftxsd.+nd
7-106.11 Raatne ird Usr Pe:ticutes Ca iEert.t' j
l2"EP 5t'•+d SpTOnlw 1�Ui 7CrVt"d.
i 7_>,3{i.€2 }i(XIC[Sl K:;t 4i:tUtNi1" i 3 :iii:.)1'C,: {..:,,Z,cned Nx'd}'ad:,g Nt,t FG-scn'cd
j 1,206 l? "i racking Pnw,ierc,}:;st Control and
titunitorin CONW,,11ER ADVISORY
1 >2 3r,it: ti jC"emsualur=ltftitnty ;'tnrcd1l'rC'on<umptit+nof
TiME1TEMPERATURE CONTROLS C
t
1 16 ' Proper Cooking Temperatures for 1 utinw 3 €:.y d, diet.ire•R:to l.htaer.,x3,cd e„
j PHFS I *+t'Jtwt=.trisePn+estirdt,,l'.lni:w.rte
3 AOI l I.1(lt(_? is<=g._ 155"F 13
};gsis-lmnediatc:Sei':ta:r 1 45'I iSsec .l3 I'i.,te< ;d F.g;:>Subsututr tee R.:w Shell
} 9a
3-401.i1iA)(2, Cotmtentt,tedFi',}t, ntCar.;rt,(iaroc
Animals b.5'F 15 _
401.tIf13)i1;W3t Pot ai,d bozi'ko,ni 130'1 121 nor.` SPECIAL REQUIREMENTS
t-d:11.11tA)(2) K.nite>, lnjw,,d 14c.its I: F' €5
y`016lot A', 11), Vi(,l tttrnt,of Secltcnt 5?U.t1 t4{ 1}-4I7} 1n
sec. ` awdog. nit+lnlc f�x3d, lehipt•ruiv and
i ?401.11(Ali 3) Poultry.Wild game. Stuffed PHFS, tc:•tdcnual kit.hen oper:16olls Qlould he
4wtlnwCon(+wring Fish, Meat. :;t+otA undet'thi appn•lmote eecliuus
{ P,tttltrvf,r kantcs-ih5'P
15 s,.c. alx e if reloled tofixrlhurne illness
3401.111Cti`) ',i'ltt,h• r,it.:.cfe lniact Iic,:f tirraks inwrvCw4li:ti and risk factor'. O1.bcr
t:7J°1' '' °iCai7.tll)<7 violatioliq relatinll 10 4ti+;hi f0id!
Raw:yrrfl,tl K.0,C ook.:d w a t lt,.:t.tices ,hould he dch'itai u'lder #29 -
;l9icrowaie €WI` Sp-cud Itcquirrn)etttt.
401111A!(1),b) All Otnex 1014F,-- 145`F :5.:e7 '
17 Reheating for Hot Holding 1 VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-.101 11(.4)hiD) 11111' )n9 F 13 n'o = ( Otetai5233f1)
' 3.403,}1(B) M ciowaw 165•:F 2 Mcn«t,r Standing C.ri;i.,r wut nwi ,riliva[ rt<lirl:„a;. aln'h r6,nn;ri tate tr,rkr
i 1'noe"' fdodh:,rrc•ilt::ess ao:rre•u:,,na•and ri,k f%n iorc R,±rd ahw,:, c,ni Lr
3--403.11!(,'} C'nwnruic'ialkproa";
l�
CITY OF SALEM
BOARD OF HEALTH ,
Establishment Name: Date: Page: of
j Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION -
k Na. Reference I R-Red Item �„ _ erffled »
PLEASE PRINT CLEARLY V Data I
I ( ( I I
-
�
I
I I I
I I
I I I I
I` I I I I II
I
I I I
Discussion With Person in Charge: I Corrective Action Re uired: ❑ -no—' To yes
I I have read this report, have had the opportunity to ask questions and agree to correct all I G Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
I comply with all mandates of the Mass/Federal Food Code. 1 understand that U Re-inspection Scheduled ❑ Emergency Suspension
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo U Emergency Closure
your food permit.
i
— — — — — — - — — LoVolunta ry Disposal ❑ Other:
f
Virdatitiqls Related to Foodbarne Illness lnlarventlons and Rist.
Factors((tams 1.221 (Corl) Acc,,rji—Ill 1�1,z Gxkd ill
�! wid I in� R�lu I ll,
0xilitw Mofficd,to,
PROTECTION FROM CHEMICALS
1 19 PHF Hot llml Gold Holding
14 Food or Color Additives Coln PRI-V llliliraawed ator!,alow
?-202,12 Addintc<>
3-302.14 P,,,Lcc!itat Ifoll)Uylapllyu-ed 1,1 6i ill') I Irc VFIFMjimliueo't itt.ab"W
Poisonous of Toxic Substances
vit'll ld"nivi'v in, to#is wull:lm - 046aul
I 1"5ill lw�-') ;l
Holdt;,t �hoic 1 3V
,011tafilerS' .3 iil�e as a Public Hcalu;control
102,11 CoTaillErn
7 �)t 11 1,1Z a+a IlLblic 31
H- 'h Control,
7-2)111 Reqdcttoli ncewld I :e- Recuwml,un
7-)0}2.€2 C'm"bl'oo,ol Us,,t
7 ?t1., I I luxil;(':omainei; REGUIPMMENTS FOR HIGHLY SUSCEPTIBLE
POPULAIROWS(HSP)
7-204.11 1 Naiiiu;em Criicri., -Citemio W l I I Ao!.,I,,%' I'1 lnjqlclm:,if Pre-t=:Cl:.,ccj jwccc ald
7•294.12 Cll�'Illlcal�, f"i Nlia:hwg V:,rjuce,Ctimga I
"Vith, Wan!hl, 1 zh,Ul
7 2(A 14 Di%im,Amllim Crjr,ria�
I I W!l llf1j) i::=.•,:t
lmj&mal Fol,l C niam �-vnrivanN`
0 1 3-sw,; lo)) l"'V,or Namil" civ�k-d'Artani. ] FkXid am"
d.I 1 3 1
Cmerla-
i 7 206.12 RWew 13na Nuo',lis,
't '06 1? lrj:kmg,flm%drr;.I"m Uomrof and
CONSUMER ADVISORY
22, 34,00?, 11 Conu;*�r Poitrd ly;Conzwl,ption of
TIMErrEMPERATURE CONTROLS l , , 4
16 Proper Corking Temperatures for Atli ll� I I,4 dl, kbit lr�R4 -J
-, L PUMXX�,,w ill
is 1 Elimmaze
PRFs
lWF 15 ti;C.
"whstluli- 101 Paw shell
J111111"diaw I:Ci"'Ict 14,1
'0.401.1 NA}k2) Comminlif,,d & Ganic
SPFCIAL REQUIREMENTS
3.401A Pori ar,d 11-;d Kt tll FlVF 12; min;
401.111 1
C'MkMNF. MkA)&�k-vi:l,wiopuz,.li y and
-3, Ganle, icmijmlwl open;flon;sfi(luld be
SUdb;lc,CORZA1111411; F01 6eh;i;d undei the appn,priate qkctinns
ilc�uhry or kldii:s 1 WP 'IWV,: it lcljt,.d ik,fo'Ahl,mv 311110s..
lilwo lil�of"'ImKS imcrveotiorls and dqi, factors Otl)cr
to relwl
2 k�IW AIMU! FT,Kk.C04,-d W 3 ll;aoict�"hoold he debited under e29 -
Requirent;:TM
3 401,�JlA)'�l 0)) A!; Wict PHFk-- 145'F tt lec
17 fieheating for Hot Holding V101.4TIONS RELATED TO G0004FTAIL PRACTICES
3-403.1 15 tru. ^ I I teniq 13-314
'-40C.I VEl Mlcrtilvavc 10, F "Minw..Standing Grii-f.!�.''Ph'!N'W-,rill:ai do nn: :,latc r„Ple
- - I I IlqlO fou,i;':,rt,r r!b:,S,s i'll, n:kjrtl!vrs Iiwcda,*;;lre tum N,
3-103.11 K-) Comwei,iallN, R*F1'bqA fo:ipw,in st eolopf, of hood Code eeld 105(,.',;R
40,p
3403 I Remamin, Lnllmtd Kwiorlc,-f liof:l Good RetaflPractims FC 590.000
ponst" I 2j, !%4a9aP2-T')1I and FC .2 00,�
rT L F C 3
Proper Cooling of PHFs ......
; i:qurrInl IntiWcost- fC. - d k,,
14(A) ('willig PHI-', from1441'1't,� ------
API'Wiffim2 26, FAdk".1--P4n'rm 1rWNm',A I FC- 006 i
27. Ph y�
007
IIIw11i'i/45'FWdhin4H,,uk!, I 17E;Os�� ,),)z�r Trim '008
3 50! 3"4;13) Crosltu PHF.Mwit Rom Amilictit2 Sro,'14
Within 4 1 -X zo
lh,,k Voxi 10f,( N411 591)W(),
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page: of
Item Code _ -"' C-Critical Item _" - „;; ;'; DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION r t'' - Date
No. Reference; R—Red Item " - - - - -' - -' -- Verified
.. - PLEASE PRINT CLEARLY 1
1
I
I I
1
I 1
1
I
I
I
I
I 1
1
I 1
I 1
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 twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
-gi}l 1'411'. Plit,Rewn'cd al Teinper.unres
Violations Related to Foodborne Illness Interventions and Rist, ! :icc'erdin�to is Cualed to
Factors(items 1-22) (Conti -31 '(';»5`FWithin 7 Hasw%s °
PROTECTIONFROM CHEMICALS { Ul.tS C,x=toil Ltett cd.for PHFi, {
14 { Food or CoA Additives { I I4 PHF silt and Cold holding
}} ('4,i PHFs Maintained at or bubm
?-2112.12 I ndaLlin'e<* � j 54tii)I}=rT�t bl' �.•
3-301 to I PnnretLou ln)m Urappnr ed Aihlilwte * t ,4, F, !
3 +)l int:A; Itoti•H"-.Maintam. datorabnve
f 15 j Poisonous or Toxic Substances 140 I•. ,.
7 t(}t.l? I ldanttfyml:httirrnt<iu,>n Urir;in.,' ! !-5Ci I6{.;; + + 1
f Cnmait:e„' kuasl,belts ar=,r:,oc,ve l-t0'f'. ,
7 102.11 1 Common Nan,e- Wo kin;;'•,ut tarnrr,” Tim=.a as a Public Health Control i
7-201.11 Srpa(ldon -Snvagm" {
tis a Vitt)lw tlealth Control,
{ 7-262.11 Pc,trict,oa-Preis nu..wd I. :c` ( 5')6. it) V,:nonce ltealtum mat
7. 02.12 � C',tniii Cranof t!se
j7_'_203 1l 1 " ( REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
! 2,xi�f;outinet; -Prohlbt:uin�' i
{I samtizers.Criteria-Chc uncats" POPULATIONS{HSP)
7.204.1 1
{ 121 I ;t-t�tl.1itAi 1'+a(::sacuser:ci Pte-pael.ngedJaices411d
?-204.12 -- [ <'h,auicail for Lb'a<hinv,t'r„Ui,.r.C-tit�.tia'' i t
; { R,:rerrce.'.ciilt 1L'aratng #
7-204.14 { t)rving.Ai'mw.(rttrria" j
It! -i RU! 1'(111 ( 'e.'. .td"Paatis:izrd
`t-205.11 LFait,t' {
{ uid�nia# I+rxl tlmc-t.taLuht:carts` { z-SUTA i(D) 1c::V, of P,ullati, C,+tkrd Animal Fax,d and I
{ 7.206.11 I Re.ctrietcd l'se f'Coce,leS.C:rtteiiar { { R:,,'`i::u->4m,itts'",t :iet v.ti. I
7-206.12 ! Roticn: Ss=.t tit stto,l,' - ,
Pae Lags ti,;t R,: ,erved, ' t
i "t ?Oft f? I #�;:s:),hog P,rtidcr: }':'St t'.,ntitil uad 1
t I ,Iona„te'
n:;• CONSUMER At3V4SLiFtY
TiME.(TEMPERATURE CONTROLS 22 i{,): 1 , C on,u+,te# Ari a;cit ilosted for('cnumolptu,n„t
16 Proper Cooking tampeaatures for
:Ani a;.41 i==-,iXI' 1`hat.rt R:tw, Undwt )ked of 1
(
PtiFc
` ,.ot-tt!ter=,,iae T'r=,:cs:.ted to I�.limtnate
i I ( _ ., .
3-101 I3A{l;'<s F.es, 155=F !5,4,:,,, Aatho};rn,.'
FK?'.r-3nnrr:di:eta Sea vias F:`:.Snhilionc ",31 Rim ShOl
j 1401,11(A)(2) C„neamuted Fi:-h.A4eat,s r;t3atnt�
{E Animals - 157'1'15 sct. ' SPECIAL fiE(3da#REtd4ENTS
lifl)t21
-101.1100R,+tires lnicet�•dMc.s4� liIt:2t Put and ti;ei Roast i-15SFE>121 m,n_ 5?iltp)vt,tl-ti,) V:Jj!t„ti.fit Scetioit ;`ll}.iK1 W-(D) it)t-40l.i
sae. ”
cawrin;t ronin by)i.I. temporary and
3-401,11W,3) Pnulin•Wild Gin,c. Stuffed PHFo-. kit.hen01me'tions.:lxxddbe
Ct,ttfnig C'„alajmm� 1.166, Nleat I drha;,d tuxler the apprupriatc s(.ICIV ,s
Y^,iltty o.Bonne;-1651' is sec. 1 ah c;it r.}.11cd to iixxlt )Tnc• ii7.,es�.
;s-401.1 i(C)13z iL'tu,tc-nua:, 1e, intact €l,�JStc•a r ,111LracntiC1:,and C=st, fac-trns, (Xber
145'1+ t0o vi,o ;tions relal;nr to go•rd retail
5-401.12 RaW Animal Fon h C mired;t, i ! l,ra.Siccm ,hould be debiwd under 1129 -
_ 'Miarowaw, 165 1- ” { leegttircmallte.
--' 401.IS(A)(I lab) All Otho PUFs-- i-i5''F 15 sei 1
17 Reheating for hot holding { VIOL ADONS RELATED TO GOOD RETAIL PRACTICES
3--103.1 UA)5 ti')) P1 It., 105'r 15 sCC. ” { (hent;23-3111
.+-403.11(8) Mictosaavt- 105 F 2 Mimic Standing C)i+r�'a+,3Jrd r:ort- rrtn.ai yin+.rt+,arv. ,s•i++r1.doren) reFore in t(:r
Tame" ftwilho•rte illness im-rvo,P.mr wid rr;d'laactors li.,u:d above, cwt be
1_.IiI3.#)((') C„nimcrcially Pko, ss�J RTF t^vhl- { ((nu,d in rhe 1n%t,tts.ng.:<6,t:grew,4:s,, Food Code and 105 Cd;Y
i :dPF' c,tt2,"cit+1. _
-.. t-_.._ -. .-
3-103.#1( :) Rcm:nineg Un,}Isco F'ot tions of'ti;,t? i ttw,, Gnod Retail practices QFC 590.000 t
^3 S92napan�ent and Per,XWt -,, FC .?-..,._ y_-�. {
^: E FC,X o,o 5lied Prot�t:t�ar FG-3 ~-M,
4 _
1 t$ Proper Cooling of PhFs i 25 j u men =txl Uterts fs F+� - 4 —
?-5{},.t-iTA3 f'indhteC•+=},+dPtii>; Fr:a:, 140`17tu -- - ---'-- - - - '-----I
t 2B. _ !Y�lnt=t Ft.,maina,u',d b`tasQ ! FC-5 C#)F
7wr•withn+ 2 1 fours is d From
007
.......,
i 21 : Physical Fac,lity _. .. . !
i to d i j/45 F Wnlun 4 Howo-. ' j rr: I Pot,onous cr To,nc rAi;el,w _ ��Ft; -7 003 {
t 3561 l4{8) C.;,otiu4 PHFn Marie Fi,au Ambient i F gh. +3aeaal R�uirementr i i .W9
remperatore hit'redieut:o,411V45 F ! 3:).
umC.tt ren;of ih;lydet:: I°'}9 Foo,!Gnfe•:•105(;\ttt'9t)(go
i
i
CITY OF SALEM
i BOARD OF HEALTH
r Establishment Name: Date: Page: Of
Item Code ' - C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item - <' verified
1( - PLEASE PRINT CLEARLY -
� I �
I �
I 1
I I
� I 1
1
1
I 1 -
I 1
I 1
I 1
I .
I _ 1
Discussion With Person in Charge: Corrective Action Required: I ❑ No ❑ fes
I have read this report, have had the opportunity to ask questions and agree to"correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
I PRFu Revivad at
Violations Related to Foodborne Irises.,interventions and R1%A %'x-ord41l,to Lau'Civ,k:d to
Factors{diems 1-=) .:) (Conf) $
I i F Wiffi;rl I HoursPROTECTION FROM CHEMICALS ckxiloi:`Met;tml'I"J" P11F,
Food or Color Additives
19 PHF Hat and Cold Holding
Cok!
(12,12 Alhbfnos"
3-30114 ProteLtion 4on? I Inatprly-nd Addiiiyes'
](11 PH12,i Nlaos"ined at or abow
Poisonous of Tox'Ic,Substances
5'A if'.fA) ko,'sts Hull,at t�r�Ibo'c 1 10 F,
cortaill-'rs.,
;.i02.11 21, 1 lime as a Putdic Health Control
rim,- us a 1'unhc Il alrh('010mil
i varijwc
7-902.1 J Rem-'Iction -Pro.,Pcc Lud 1;
7-202 12 I Cotldjlionr of Uw,
- I REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
I �031 i I Toxic(,riorlinci,.-Proltif,)! oi!
- 204.!I Sanilizel 1,Crocrun -clwolic:'Js' j POPULATiONS iHSP)
'-'-q#.12 Chewicak for Wa,hing,V:od,tcc,Ciiwr ial 21 1 11(A) Uipi,.Icui wrd
Nsaroill- lzk'
1 1)4 14 Dning,4"xtiv. twritt'
- -( 15) Ise of
if R,,J"k)r j1,jjjj:.jj,Cj',k.(j knortsl FkXd and
Rat" St N"t S�i wd
7-2 or).12) R(Kit'ail Batl Sotti'W,'
7 206 1S i
I rackliti;Nudc,i, il.,-si and
Morttolm'! CONSUMER ADVISORY
TIMErrEMPERATURE CONTROLS 21 i-60', I I Coutlkowr Ad+ ftos'toi; rcor Coploonotion 4
16 Proper Cooking Temperatures for
PHFc Pi-,'osse-d t,j I-Aimirrt4'
Ir( I� 5,'C. ---—----
2.1 3 t'l K.Aw'111011
hali, �ci�I" I t5+
Comminvicd Fizh, Gantt:
SFEC!AL REQU!RFtAENTS
401.1 1{B!k 1):2) j Oorl, and B�,O Room 130`1 i2i mili•
40 1.11 Wt 2) R itites, li�licct,�d 151 F i5
r"r. , fth)d' trultPoral'y and
'1_1101 WA)0) Poalo-N' Wild Gralle Sioffekl t'PF's, kilot-11 ripel::tirrns ,h(ft!tfl be
slofflau Fo,h' Nlruk' ii;Acr ih,,appv.priat- ",Lious
alru'c if 10.1altd w It.'ilborric illness
3-4iolJlt(:),3i Nhok-lma,Ltv bitact Rof Steals j itoci:ciitions 4:oi rill: !rrcrwOtor-r
yjoi;i�j
I , oils r0atkizL, If)t'oss:t rclail
Rax An=nul Fi,uL((s,ked Ili a hoolj be dchiteil riniltr #29 -
sllr"ovaw lWF .spC.-n0
1-401,1 li,k?l! ;bo AL('tka PrW 1 5,1 L5 sec
1 17 Reheating for Hot Holding j VIOL4 TIONS RELATED TO GOOD RETAIL PRACTICES
3-103.1 I(A)&f0) Jt'tjr,F 15 we - 23.30,
103A 1(B) Microwal 165"F 2 Miquo.sumdir.n -v:,W wseiehdo ow rebio,:')Mr
lijkle, ;oviiborrw;Im"a tit!,iii-ioma aini Rwdai',nw, 'an be
t-40,3.11(C) j Corrimemallv lho:ecwd RTI- Kios! form:in thefi4b,wi:;};:.ei nam, (o the I"ood Cn4cw4 11i;CUR
lleat Good Ret,
'1403A I(E) I R,-majituo', UpQwed Voyqorvi ol ticcl lit practices FC 5.90.000
Mariaii;?rn4nt wall Pill,otinr'l I FC
SS Proper Cooling of PHFS� g4-
FC-13 004
'i-501,14(A) C(Nliag Coi)k�it VHI-'s horn P*f�ui'�m�m 4W We FC -_4 --o,15
2F, bw
- W- pi�.mwcj�'or aa"�: -'i -1u-16 661"
7(),E Within 2 llottr� :nd From
21, Phti-cal
to 41'F;d5'F l%Willi� Houi,: tr-0,r klutcf -0- I
b) t-ool ilig VHF:.Madt ?;"u %W"
Si
R'ndrei '—
t:eiu're tit wal On';1i lhr 1— 1,1 1,;t 79'loilf"
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page: of
Item " Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION ;, Date
No. .Reference R—Red Item Verified
PLEASE PRINT CLEARLY I
I
I 1
II I 1
I 1
I
i
I 1
1
I
I
I
I
1
I
1
1
I .
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/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal 0 Other:
3-is#1.3di(.t f't#Pc ketrilrd;tt T:^ntpe:rab)res
Violations Related to Foodborne fitness Interventions and Risk Accordin to Um Ctx,ied to
Factors(Items 1-22) (Cont) ;I lF/4.SF 16-ifihini ({,rtu,.
C:,x,iml: Mkrdl+d,, Pox PHFi,
PROTECTION FROM CHEMICALS 19 I PHF Hari and Cold Holding
14 i Food or Color Additives i :i.51t!.2ritE3} !
Ctlt: Pi33° Rlaiut need at.n'betnw
?-2t�2.12 ,iudittlV<,t
3-30114 � P,,,tottion
:-t.,t.tb(.1) 1#,y 1HF,t Min+attted at or above
j 3`^ I Poisonous or Toxic Substances ( 14WF
7 101.11 ! kiesttli}'mg tninrtn.:tiun- Uu};inal -501 16(,1) ka*.=.�a,Held at vt atslwe 1 i0-T * !
colaainer•:
7 162.t 3 Comm„n\anti Wl,rkin} i,n)tainrr>” 20 ( Thrill as a Public Health Control �
7-201.11 Slpaiaoon- snnagc'' i 13Nn,r=.t.aYubli:11,aith(:unv'nl'" �
�.o6;,s0.trH) R+x!utrcn;ent
7.2f)2.i i Rc>i;ict:on-Yt.u n,z:a),l E,C" � Variance
7-202.12 ,uJniun:of Usk , REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
i 7 ,,o3 i i Toxic.C:ontainear-Prohthi*wiW,
7-204.1( i Sanatiiers,C'riter'ia--Chclnic;,W POi!(A)UL IQNS(ekc-
7-204.!2 11.11 L'srasrrurved Pa: .tacfa}tiG;wtr�s wtd
Chemicals for Ws,hire Yxx4iet,Critcua
' Be.aaasedlhW"asilln.=i,altos'
7-21}3 13 Dry-nrgr'lhentn.L;ntcria' I "I'IHt `
1 7-205.1 i Incidental }-:axl contact.t.nh::eanis' ( t :e ut Pa,srrciz,d i:ee,
' ( 3"Ul ;I l};) lieu ,,r}'att)aL'�;t�,arnrrl Amitnai irxxl anal
j '-206 11 ( Re,trict,,d t:5t- Pi,tita+it,"t,ntel l.:'
3 c„gr.,d�;a,at€c 10: :iertai. ,
7-2Rtxl
06.12 i ent Bail Simiot''- I Ifr:! t.r„per,ed itxxl Pacl,a"w Not lk -,Cn•cd '
7 206 1:r Twcking Ponder P,st Cantml and
Nlonivirimv CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 31,1 i; „a,�urwr.lit,f ,Iry Ptnt,,,l 1)x ('oltson)pti,+n hf
A,limtl F,,td,'iha, art,ka,v Unrler4 ,nrd til
16Proper Cooking Temperatures for
I ,,,,t rhiter.:isc Prc*rssed!o ITirvoare
I PHFs
3.171 1i,1(lt}Gt Fqg,- 155`F 15 Sl:,;- Yatfru,:n• `_`+". .
tigt'c immcdiatc Set•'tee l,i l'75aec : tic .,2 gg: ,balawr tui Kew Shell
3-401.1 I(A)(") <'ounwimnet3 F;ch. Ytcaf & (,atnc
Aniwai„- !-151= 15.cc. " SP%CIAL REQUIREMENTS
301.11,13)t 1);"21 Port liedlicit k,x'tt - 13,0'1 121 tun' ;
3-4Ul.ti(A)t3) F.nite, h)ira,d lfcata I>5'F 1J
91iy:9( ) M) Vio auon,of 5e,i.io:1 :=)il.ikt)(Al-t C)1 in
s.:
catcrir=g. nt,ibit:lix)rl,tt')?tpc,cat✓and
3 301.1I(A).'l) Puultr},Wild Came, Srutf'e,l Yt1Fs, tesnkot :t1 xitchvil operations,hotdd he
su,ltilte cunl:ollw Fir.h, pleat. ( iehtird under the apprupri atc. ;el liolls
llonitry,x k:rtitt Ihi'f' 15„et. ` , slx,ly if rdlied it)IixAl;orric illnc,s
3-401.ti(C)!�) i1,},vic-nm°t•Ci, }nias.t ISeet'Sieaks j inter*t lion,;wid risk tailor,. Chher
13501• 3 514(l.1 ;9 vwlaiiont rolatinr_ to ,okA told!
3-401,12 ( Rat Fu,dl;C.".tatlted ill ay-" piacticet,aheold 1'r dvbitcd udder 1129 ..
1•1loowalt I6`•'}- *_ _ `sp,'clai Rl..{gkiircllh,llts
' 301.11iA)(lub) I i0(Xhei PHF,-. 1.15°P 15 sec .
j 17 Reheating for Hot Holding i VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
i103.1ItA)(0) PfIF, 165`'F t",tee. " E11enl5 23-30j
3-403.11(B) Nicromivl � 165,1"2 A2:nttre siandmr C ii, rr•i crd e of q llnla riotatf rn :rlrk:h down elur;'r,)Lir,,
Time' trrodhrrnr•,Ik,:rs nt fert r.wona,:ed n,klar tore 1:v"ll al",r, (an b,-
-103.I
,'-(03.1 i(C) C+rmnt.,t;•ialll_•P,u,e c.,d CTI= F,.r*1" C',e,:.c'i,t t7;c.f,,'t;=wrrrg se;tion. ,3;A, Haul Ce,ic mar!J'6 CUR
3.303.11(1:) Rcmeuvng,Ui,hccdPortiontat},et,t i Item GOodRrfai?Ptactices ---.._ IFC=..._. x590,000_]
poa>l* ` 23 t,r~an;,ue)neni and Plimorinei
ig ( Proper Cooling at PHFs x_24, 1 Ft.1A and Food Praection -- F( 3
2:. Equ!;,nieni:,nd tltensi- "QFC-4 UDGv
5561 id(A} Cc><dutf_C,x,l,cd PHI,', i++n, idr,y+',+: F25Yule!;PFa litpry�"•d`,1r,te i FC-5 _
, tt i n . . 006
7i) E1.''i0un: lioure a:xl From ,0'1 u. 1 FC-u 1 007_",�
� e�:s.mi)as ar r'tx,,A�tater :ls .. -7 008
ldi6j fnulir7 PHF,?4;t:r1e Frout Acibil a 1 L's. __1..�Px_a1 R�:GUSreme,94• _ ...- "009 ;
'30, 1
etapta ` "Other
( i Within31mir;: .a
ll,•nOh=.trsnenl i:en:is 16. t,•lerai h„W p+,pd t.<xk os 105t Yii{J'i,i I M$i
{ CITY OF SALEM
BOARD OF HEALTH
l 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 -
I 1
1
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� I
I
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Y
,
1
1
I I 1 -
t 1
I
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I
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' I 1
11 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/
P PP Y 4 9 Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal ❑ Other:
Violations Rotated to Fardibarne fffnes;6 interventions and Risk
A-IwTdivy,to Uv Cot,I-A to
Factors(items I-W) lCont) W1.145`," W41 in" Hoary
PRoTEC'nON FROM CHEMICALS MINrj,for PHF�
PHF Hot and Gold 40ding
14 Food or Color AdditivesPUFS
blattrtet,red at<m hei,nv
1.202,12 I Adrllli%etz' 590rjsf1a(j-) it ;is"
i-302-302 14 x-,Y)1 16,A�, 11,-l rlil`� %lainijitledar oI ab,wc
H;
Poisonous or Toxic Subslssssuce,,I
[01.11 I IlItin;fying Int'ltirw1oll. -06"ina,
or# ? ff
20 Time as 0 Public Health Control
1-1112 It (I,.mnronNtnoe I I realth
slo,at,'c',
I
7-'02.12 Oaldlliolls of U,el
AEOUIRFMENTS FOR HIGHLY SUSCEPTIBLE
7-203 it 1,1,,-,iQ Cotnainci, - fN(Aii1ai:i(,jt0- POPULAtIONS(HSP)
1.11 SAmliZeN,Cfilerkl—ChLU&!Ist' 21 1 111 A, ,,gLd Jrswcs ancl
7-'_111.;2 hollic"vs,for \v:e,hj11,*llnwlimc!Clowl'.1
L wr.i�Ic\wim
7 204 14 D;�nw Ailing.Crites ij
7-205.31 ("t-ni'act, I
F 1w C,'PsIu,tfl,, Ck.'k,d Aisinial Food .+1111
ko,mcteIi;.'�v Pv>o,ole+ t:i iterm'
7-20(1.12 liokw 13,11t s„kuolr'
g Po1%,lcm Peat"ontrol totst
CONSUMER ADVISORY
2, 3t,(': s I lor f, "'mPtion of
onqim"I on,
TIMEITEMPERATURE CONTROLS f,I:&'Mm it-, UodmoI,saad tj
16 Proper Cooking Temperatures for
Not to itInin a,
PHFS
3 t0i JIA'I)(-'i I:gg,,- ln,p 1.51""c.
F, SAihO:Ule lot RaI;I shel!
t 401A I(A)i,-) 0,millinisice,Fi\b, Mca!s tT lino w
; A I(Bli 1;€31 SPECIAL REQUIREMENTS
-40:
Pork :aid Boo Rol-st - 1,301, i2l lk)10
s-0i.ii(AW) -Ratite., IniecnA W,rta 155 F 15 519`1!(R!'t'At-J)7 ) (D) lit
caWriog. rv,,Nk,.lood, iemporwY and
" A -
I I S its'jilill oneralifhl:;should lit!
.44)1A I(AYT, PoqItr,,, Viid(Ione, StuL-',:sJ PHI,,
slitfro I v caal,olllns: Meal, 11W :e.livas
1>"U11r,or Kaoi-k-f 65„F, tS S-C. = IsIx,,le if&oLso,cl so hNx1horstv
Wjrle,wvl,:Iv. Ijr:)C1 Beoi Mcaks inicl VoO1.10b”, and cisk I,aclore Oliber
145'F 50-10.00) violatitsi:,;Ritarcla;oiq to l7(xA retail
'
3-4l) 1RitaAwl"131 FIrl, lit A tike. ,I-toold !xc dobits:a,i uss&r #29 -
MCsowzs,Iv 10,F
1 1-401 WAI(l)(b) \110tirtis'llk
L17 Reheating tot Hot Holding i VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
1-403.1]1 4,1&(0) PI*,, lafi"F 1,: qec, ' 1 ",11))
3-W.]!(IJj Vici*ov lr15,,P ,Nitit,tw scindirl"
Iar:,,,st, iOII,h It(,Isw eklret,)lit(
lame` I be
3-403.11W) s-onsarercialiv lrkotewl RTf^ ;od
th,, Psi CAfk
i41)fl
His F1 T r!Wtioo
F,,ylkx,d Food Prol,—L'of, 00'i
Proper Coming 0;PHFS
i 5W !4(A) Ctwliae Cook��d Isom 140-F n, tlftersft
70 F Wilton 2 "rid From?,;'l I 1 27, phjs,-Ial Fac;kty FC_t, 607
i,I 4,'F!45 F Witka A Hort, -2t, rc4:,Jnoos�tit roye m3te, 011 FC-11 OtXi
'Dug
1 501 Wit) Cooliol;Hit,MwIv Fiour Ainho�nt
`roup.tatarre Insiredi(Ilit, f(I 41,1�/I15 14
mle:.Il 00b!I;ts,ir,k, I Fond O'le t.r I W,UMEK ,t)WK
p
Rose Medallion Tea Room
184 Essex Street
Salem, Massachusetts
978-744-2131
Quiche
Spinach Salad Quiche $3 . 95
Vegetable Quiche $3 . 95
Artichoke Hearts, Tomato & Cheese $3 . 95
Ham and Cheese $3 . 95
Sandwich (Served with a bag of chips)
Corned Beef, Swiss Cheese, side of Cole Slaw $5 . 95
Ham & Cheese $5 . 95
Roast Beef, Boursin Cheese on Croissant $5 . 95
Turkey, Lettuce & Tomato $5 . 95
Chicken Salad $5 . 95
Tuna Salad $5 . 95
Peanut Butter & Jelly $2 . 00
Peanut Butter & Marshmallow $2 . 00
Salad
Tuna Stuffed Tomato $3 . 95
Fruit Salad $3 . 95
Toss Salad $3 . 95
With Tuna or Chicken Salad $5 . 95
Deserts
Brownie with Whipped Cream $1 . 50
Homemade Cookies Various
Pie $3 . 00
A la mode $4 . 00
Muffins
Assorted $1 . 00
Croissant $1 . 50
With Butter and Preserves $2 . 00
Also serving: Fresh Brewed Teas, Coffee, Cappuccino, Cafe
Mocha, French Vanilla, Hot Chocolate, Mulled Cider, various
cold drinks
4
Rose Medallion Tea Room
184 Tea Room
Salem MA, 01970
In addition to the regular menu items I would like to serve the following as daily specials:
• Pickup Drumsticks
• Zucchini Sausage Squares
• Fresh Mushroom and Green Onion Soup
• Mini Onion Quiches
• Hot Dogs and Baked Beans
• Meatloaf
• Chicken Cordon Bleu
• Chicken and Rice Casserole
• Texas Style Chili
• Hamburg Stroganoff
• Vegetable Pot Pie
• Chicken Pot Pie
• Baked Pizza Mac
• Macaroni and Cheese
• Spinach Salad with Hot Apple Dressing
• Oven Roasted Boston Scrod
• Mustard Crusted Roast Pork
• Hazelnut Coated Salmon Steaks
• Broccoli Frittata
• Sweet Potato Casserole
• Vegetable Saute
• Bread Pudding
• Caramelized Peaches & Cream
• Maple Caramel
• Apple Cranberry Tart
• Old Fashion Date Bars
To be able to make these recipes I will need to use a commercial one-burner hot plate and
in some instances an electric skillet. There is room on the counter next to the Nemco
Soup Maker. The hot plate is 12"x 12"by 2".
Meats would be purchased in the morning and cooked the same morning. I would not be
storing them at the store.
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Rose Medallion Tea Room
184 Essex Street
Salem, Massachusetts
978-744-2131
Quiche
Spinach Salad Quiche $3 . 95
Vegetable Quiche $3 . 95
Artichoke Hearts, Tomato & Cheese $3 . 95
Ham and Cheese $3 . 95
Sandwich (Served with a bag of chips)
Corned Beef, Swiss Cheese, side of Cole Slaw $5 . 95
Ham & Cheese $5 . 95
Roast Beef, Boursin Cheese on Croissant $5 . 95
Turkey, Lettuce & Tomato $5 . 95
Chicken Salad $5 . 95
Tuna Salad $5 . 95
Peanut Butter & Jelly $2 . 00
Peanut Butter & Marshmallow $2 . 00
Salad
Tuna Stuffed Tomato $3 . 95
Fruit Salad $3 . 95
Toss Salad $3 . 95
With Tuna or Chicken Salad $5 . 95
Deserts
Brownie with Whipped Cream $1 . 50
Homemade Cookies Various
Pie $3 . 00
A la mode $4 . 00
Muffins
Assorted $1 . 00
Croissant $1 . 50
With Butter and Preserves $2 . 00
Also serving: Fresh Brewed Teas, Coffee, Cappuccino, Cafe
Mocha, French Vanilla, Hot Chocolate, Mulled Cider, various
cold drinks
Rose Medallion Tea Room
184 Tea Room
Salem MA, 01970
In addition to the regular menu items I would like to serve the following as daily specials:
• Pickup Drumsticks
• Zucchini Sausage Squares
• Fresh Mushroom and Green Onion Soup
• Mini Onion Quiches
• Hot Dogs and Baked Beans
• Meatloaf
• Chicken Cordon Bleu
• Chicken and Rice Casserole
• Texas Style Chili
• Hamburg Stroganoff
• Vegetable Pot Pie
• Chicken Pot Pie
• Baked Pizza Mac
• Macaroni and Cheese
• Spinach Salad with Hot Apple Dressing
• Oven Roasted Boston Scrod
• Mustard Crusted Roast Pork
• Hazelnut Coated Salmon Steaks
• Broccoli Frittata
• Sweet Potato Casserole
• Vegetable Saute
• Bread Pudding
• Caramelized Peaches& Cream
• Maple Caramel
• Apple Cranberry Tart
• Old Fashion Date Bars
To be able to make these recipes I will need to use a commercial one-burner hot plate and
in some instances an electric skillet. There is room on the counter next to the Nemco
Soup Maker. The hot plate is 12"x 12"by 2".
Meats would be purchased in the morning and cooked the same morning. I would not be
storing them at the store.
Rose Medallion Tea Room
184 Tea Room
Salem MA, 01970
In addition to the regular menu items I would like to serve the following as daily specials:
• Pickup Drumsticks
• Zucchini Sausage Squares
• Fresh Mushroom and Green Onion Soup
• Mini Onion Quiches
• Hot Dogs and Baked Beans
• Meatloaf
• Chicken Cordon Bleu
• Chicken and Rice Casserole
• Texas Style Chili
• Hamburg Stroganoff
• Vegetable Pot Pie
• Chicken Pot Pie
• Baked Pizza Mac
• Macaroni and Cheese
• Spinach Salad with Hot Apple Dressing
• Oven Roasted Boston Scrod
• Mustard Crusted Roast Pork
• Hazelnut Coated Salmon Steaks
• Broccoli Frittata
• Sweet Potato Casserole
• Vegetable Saute
• Bread Pudding
• Caramelized Peaches & Cream
• Maple Caramel
• Apple Cranberry Tart
• Old Fashion Date Bars
To be able to make these recipes I will need to use a commercial one-burner hot plate and
in some instances an electric skillet. There is room on the counter next to the Nemco
Soup Maker. The hot plate is 12"x 12"by 2".
Meats would be purchased in the morning and cooked the same morning. I would not be
storing them at the store.
IMPORTANT MESSAGE
FOR
DATE�� /�-J TIME �P
M 7Y i'7 C�Oi-P
OF
PHONE
AREA COBE NUMBER EXTENSION
O FAX
O MOBII F
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU II WILL CALL AGAIN {
WANTS TO SEE YOU RUSH
fRETURNED YOUR CALL I WILL FAX TO YOU
MESSAGE
SIGNED
��'
f FORM 4 9
MAGE IN U A
NOTES
` Commonwealth of Massachusetts
s e
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 08/10/2007
ESTABLISHMENT NAME: Rose Medallion
File Number:BHF-2007-000033 184 essex Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2007-0588 Aug 10,2007 Dec 31,2007 $190.00
Total Fees: slgo.00
PERMIT EXPIRES December 31, 2007
Board of Health �de-v,� `c-.
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made, all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1
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CITY OF SALEM, MASSACHUSETTS
+ . BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL 978-741-1800
FAx 978-745-0343
Kimberley Driscoll www.SALEM.COM
Mayor JOANNE SCOTT, MPH, AS, CHO
HEALTH AGENT
2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT Ili-, M ed cJ`f c r TEL# Ll 7 ?- 7q4 r4 -,Z d,3
ADDRESS OF ESTABLISHMENT 194 l SSeX FAX#
MAILING ADDRESS (if different)
EMAIL--Business': Owner's: !}h
Fv<rA i- 4? e II I y I - -Ito - '-t91tr e.cl1
OWNER'SNAME J-nc�vl,A-e C. Riciil tt TEL# 97Q- $S? 7 -
to t3a-elin,L WO-) Su SG 'tt
ADDRESS L4,O AAopv� pev7vt, 1)r` 30All r;� t)t9a/
STREET V J CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(SI JJOCcvrrt-P_ LL i4a -,:-„ CERTIFICATE#(S) Ct vL Ce.
(Required in an establishment where potentially hazardous food is prepared)
S
EMERGENCY RESPONSE PERSON , 6O c&nvi a L.- (1 a+dq HOME TEL# 4*7
DAYS Of OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday j
HOURS Of OPERATION
Please write in time of day. PMI, (M (o M /� 7 AM c f4rut
IForexamoleilam-iinml a �� 10M I
TYPE OF ESTABLIS NT FEE (check onlvJ
RETAIL STORE (;YES NO less than 1000sq.ft =$ 50
1000-10,000sq.ft. =$100
more than 10,000sgA. =$250
- - ---- ----- - _ ._....--.... . - ---- --- ............. i - -.... - ...- - ...-- .... _ - ...--
RESTAURANT YE NO less than 25 seats $100
25-99 seats =$150
more than 99 seats =$200
-- ...-._.. -- ---.-.._E . _... - -- -- - --- --
------ -- ---_. .--......--
BED78REAKFAST YES N $100
--- -... .... ._. -.... .... - -... ..... ..... .... ... ... - ..__ ...... ...... ...... ...... ...
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE: YESO $5
TOBACCO VENDOR YES $50
ALL NON-PROFIT(such as church kitchens) YES {? $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a
prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are
made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief,
have filed all stale tax returns and paid all state taxes required under the law. ,,
Signature p Date Social Secunty or Federal Identification Number
- - r� d - - ------------ It -
---- ----------------------- --------- --
Revised 1 1 /OG FOODAP2007 adm Check#& Date _ `e _ Q
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Ss5 /17TG6a f�oy, Date: -7 Page: of
Item . " Code C-critical ItemDESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date
7 No. Reference R-Red Item PLEASE PRINT CLEARLY Verified
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Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ fes
7 I
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
j violations before the next inspection, to observe all conditions as described, and to Exclusion
1 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
I your food permit. / /(
�/ � f ❑ Voluntary Disposal U Other:
VlAaHoos NAANd to Foodborne fliness tritervention5 end Rlsk tnrto Ja'A cwltd M)
Factors Illelfts,1-22) (Cont)
4 t'N45`F Widim,t Hou',.
PROTECTION FROM CHEMICALS j Sum (In dint NORMA, 0 PHFS
114 Food or Color Additives PHF Hat and GMd Holding
n SOL let! 501 PUP,Mautaitwd et Cx I,,fvW
3-202,12
i140 144(1-� 4 1 F,
310114 Pa,welion front
is 1 3 00 WA; 1 LA PHFs Alahimurd.+t o. able
PoNonous at Toxic Substances
With"itoWnr6un -th"Ka,
contaillef'- slil kk,Mt fiddat oi above :30*
7-102,11 j Coarnon sNrue Workinv(.,utam,.r, 20 Time as Public He,3hh Control
Woul 3 301 13 Tima=a A=Hewth C"Mus-
7.202.11 llcstricl= - We=uW I,�e- sni;in n I h W.riapkc R��wuri incit
7 An.12 ImAdoundto,
7-203 It TQ cyvwef" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS;HSP)
1-204,11 Sankimm Chien:-WishoW
him.12 Qviniols sw WwAint,I"Wim,Oveila 21 ;4`11.11 V1 UnixomunadlIvInikhaped Seive3nad
7 204,14 Drong Aij
��m.Crireria'7
'kith Warning IA'I",
11 i B of P�,�
bwulenl at F:,>d Cor"I-.(t,LaN��an!i"
Pe,ricide� Critel"17....... 3 00 V 110 R,1 W-„Y;-il IM 11', C,�)i-d Atw nal Fo,J and
korai
7-206.12 RIK!�Dl B,Iit N[ti1n)R!,' �n
U,miPa(kag� Not Rti scrvO,
71M13 luck,P�Wlempvm ASMA md
Mordinday
CONSUMER ADVISORY
TIMEfTEMPERATURE CONTROLS 22 3 40) W q,cw., is u uy IN Kod I )r Coivouription of
16 1 Proper Cooking I ernpelatures for hagt,i. kaw� L:fwer"x)kcJ i+j
FHFs
Oth"'r,",p,e :,j 1:Iiaauvv
340111 Atl)(I'l Fggz- 155 F15 S;(. ;
3, l,01tt ins ,d 1-9p Sum
bwe to Now Slid!
340 L I�I AX 2) Conrninu!,:d 154 Win a& Garnt
SPFC;AL REG UIREMENTS
14o 1 J RAU 2) Wairian WA NUmb MAY 15 0 MA! kfb %ikllah0i),� of Set:hoii 3')0,W%A)-(D) in
I r'ftwrlflg- o1ohik ftkXI, ttn+iporai y and
.3 401.14-AVM 11ouln) 'A ild(;.inle opzativns Aiocld Iv
sluffnie Conwinlo;Vkh, dulipled nnacr flicappruprint--ser:11killA
llonitrti tet K(itinex 165+ 15 qei. -,Wve,if+eljied to ftxAv)rrjc itltws�
3101.t hch') i Ila-misvin woo HWIF mum wwrvcntion� and "aciurt Othcr
1,152E l 590.00,4 viol;xtRm' rclaking to z7o(d retail
3 49 1.12 kau Aninud KNO CoWd in n f praclitc.Awuid itdebitedunder#29 -
%liktowave lfi`'F, 1tip
1400 I hA;U A I AR(blar PHIFY- 14T F 15
17 Reheating for Hot Holding
VIOLA 10150,NS DELATED TO GOOD RETAIL PRACTICES
3412•InAh 0) 1141A 161E 15 ilteoN 2,1-,10)
4A33. vH; N41couNavc- jf'^"1-,2 hQuiv sanding (AWSWwO rl"wql nlq,h f!o"o; clarr 1') fiyc
3owe, )WWvn.0 :1;;?vall:o7"y W)j i:",.k j"A tors li,ied ah"�,ve (""Lr'-MI I I W!
(013MMMMIN IfEkzand RTE WE Kul 'n riwo (V M, Foo",Ce"Jed4d IR5 CAIR
111W
3A0; I RL) Retn:mnng Uiihced Portw-ni,S Ffr,ta",Practices 5-40.ONO
T FC-2
l YS Proper Cooling of PhF6 -24. FcxAne.d Fcoti Frcwct:0,, C- 'i
2, t7qwpowq1 awl Usysms FC -r!05
5WAVA) Ccxsljnj�CsGY PHR Pon !OfF v ----i—--,----I
Fq-V) i
70T'NRhn2 ( FC- i
b"ITMY!"Iflon 4 Was. 4 FC; -7 1 00a
3 5(11.1011) cotiliu,4 PI IR, madr FroulAiniment
1y Cetnperakarr hu;re�iie't;t;x,41-1,415 F _j
kaw:'
C,ur--al itew.ni W:1,010 lop,Fad( le or l05(AIR 511006
A
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CITY OF SALEM
BOARD OF HEALTH
Name of Establishment: Rose Medallion Tea Room
Address: 184 Essex Street
Owner: Joanne Hatch
Phone:
The owner of this proposed establishment presented a preliminary Floor Plan
and Menu for review in accordance with the State Food Code.
FLOOR PLAN
A Hand Sink must be located in each food prep and service area.
Hand sinks must have wall hung soap and paper towel dispensers. These
must be stocked at all times. Hand sinks 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.
The use of carpeting is strongly discouraged in this establishment. If the
Sanitarians observe that it is unsanitary or creates an odor, the carpet must be
removed\
rAn accurate floor plan, drawn to scale must be submitted.-- ..�
MENU/�FOO—D PREP - --- -- --
Potentially Hazardous Food ingredients will be prepared at Gourmet Faire.
The owner understands that Gourmet Faire must be in compliance with the Food
Code and be able to prepare potentially hazardous foods to supply this location.
All food must be held at 41'F or lower, or 140°F or higher, at all times.
Reviewed preparation of several food items including soups and
sandwiches.
Food may not be added to containers in salad 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.
CERTIFICATION
There must be a Certified Food Manager working at this establishment full
time. Information regarding upcoming classes was given to the owner$. -Beth-wi&
b®se+�e-ee�tifi®d.
When a CFM is not onsite there must be a Person-in-Charge (PIC) who is
fully trained in sanitation techniques and has a thorough understanding of the
operation.
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UNDERCOOKED FOODS
If you plan not to sell undercooked foods, you menu must state this.
EXTERMINATION
Monthly services of a Licensed Pest Control Operator are required.
Please keep receipts for inspections.
SANITIZING
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 made in the food prep 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.
The owners plan to use an NSF approved dishwasher with a final rinse of
180 degrees.
Areas outside of premises, including the dumpster area, must be kept
clean and sanitary.
Joanne Scott Date
Health Agent
Joanne Hatch Date
Owner
1
1
# CITY OF SALEM
BOARD OF HEALTH
1/
Establishment Name: -PDsc � e d o ll t trn Date: (5- 9- 0 `7 Page: / of a
Item Code .C-Critical Item . :; Date
DESCRIPTION OF VIOLATION/PLAN OF CORRECTION
No. Reference R' Red Item Verified
t ' PLEASE PRINT CLEARLY
A Rre- open tI'1�,+ /hS-li-oa�/o�'t o-�' -f�+7s Qsfahlisht�� cues 1
ti l I I I
�7"h� -Fn/lo-w�.�� t�v�5 �sf �r QddrOs��l �rlU-✓ --1�d /SSv.��-
AII ° �vvl�vrs `shuc-1 be� /1-1-
//
a-1-// ✓0 �%r�P� 'e 4(/,� J_/1W, . n-r r>_ ,-/ 'b.'
A dot t f,r�q/ )'i se.4s ky'V_S4 !u , ra ix? /9h/c At -me__
I S/m"n']w 4 /�'Xd 4ke, bel
Ai lkwo,,ce, �✓ r>, lu .0/c�� n ,^ ��'� (tel
4-,Y
I — Anti LeeI tat.tl-, 6, 1a, T44.e,4 �'lrr,ro u • �i5 Lie
I I /$ t�ttf����-r duan-, a-�t &'•iY-o7• 7/ts" C'�r-fl.�r aa� anal -leu . I i
t-kwsf he, -Pos4Pd ,Y, a
s I t/� - Cub t'/r�/c�knau Y�tis� by able -moi lea,(. Co (.j S13- -S
I -h) (Jct IPfi5{ 1L/// ?y "cl Glgj� friPAY. tom'{ 1,l 4.ice,
/)'e Make✓ 1 iD°-
r-�a tO to
Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes
i
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
Viclations,Rotated to Foodborne Illness Interventions andRisk .c.;'ading to I.aV' ('001'A to
I-actors(Ifedis 1-22) (Cont) I I_F14 `V Within 1 flicii,
PROTECTION FROM CHEMICALS
14 Food or Color Additives 19 PHF Hot and Gold Haldtnq
PHF, NIRmvme'i ,it or Kdow
3-302 14 Pityection fi(An linappro,ed Addifives' 4 F,
5'1 i
15 Poisonous or Toxic Substances ,I(,I A lint PHFs %J:jjriiaijjed t,j(;r abort'
I+tcot;fyint? lnlo;Iaakl"r' - Ori{,azal f 140'l', * I
cksltah=s' N11.16tAl k
1- o,,a:I KId ator,)bow I-10'f,
1 2f) Time as a Public Health Control
Common Nanw - Workiti.1;C,twaip,�r,'
I _5_5W lrim,al" a Putific lididti,k'Anlyal
7 201.11 Srpacltion Si r;ige 4
Rrqiioion U,0 "tio Ixwll� Vanavvt Reqamcnwru
aditions of""w,
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS(HSP)
7-_-1 04 11 Imill,.I& (Im V�a,hilli7, Cjitotil'
7 1�4� %iq Crjwia'
Pa
7 �6751 F,xA Ctmla�t. Liil�rwams' Pj I
3 ��O,
7-206.11 U:v Pe�lmde,, Criteto' - Aniwal Fmd'joI
Riw
7-20(t.12 R(xlem fijil StmoT.,1
II -"6F13 1p�Iwd
CONSUMER ADVISORY
TIMFJTEMPERATURE CONTROLS 22 1 i Cocsunw Ad',:,�,,iy?;:.ted ior Cuasnuiption kit'
l6 Proper Cooking Temperatwes lot l 'f4in arc Ra,i Underaxiked ol
PHFs • to Flimio.ue
3 1�)1 I I_'Q9, :5 'F' 15&c.
FV't-'s Imk1'Cd':qQ 'icrvicc I 45"F1S'ec fo kLm ShO.1
341,11.11(A)i?) Ommmood R Gamr
Ailiumis - 15-)'T 15 SPECIAL,REQUIREMENTS
3_14u1A 1(131(1 iQ) NW), and I;Vci,kim,a 1101, 1 2 i niin
-4;)3.I 1 lAll P'Iliw" 'Mt il� 15's F 15 of A) (D) in
kemporatly and
3 4W I](Aif-3) Poww"Wild(`4aiie'"�'mned PFIP, kitchi;n opc'ratiml ,Ikotild he
6k+lled Lmrl%�k 11w applolm iatc. 'k:�Akows
S fh1w C(inutimm, vi�Nll' Mein,
P,eultrv(-r Rolnug-1651, 1 wc. "'Ixwc if mated io ftKAborric 41jicss
3 Ill 1,11:Cv' Isit'lo li,vf slcai%. j u'!'n vomion�and IWhoctor� Wier
59t009 vio)znion•.rolatin", to crtxi reltu!
3-461,;2 Rav, Ammil I'(,K1, it,a Imat ticis be dcbitLil uzidcr #?9
Miclov.4A, 165 f.
I 4fiJ,IfiA)(\1,(b) •Vi(rhe; !'HF, - I'll'I� 1svc
RohLathig for Hot Holding WOLATIONS PELATED TO GOOD RETAIL PRACTICES
3-4013.1 It AI&HI) tl ll'' [63 1 1 i Ncc. - (Itent;2 Lill)
3.403.!I(b) Micl ov avt- 10,r 2 mmw' standing C,air ii::n3 rt,,n,niwji ;v;,n:hd(,'nw Icha",,')Me
3-4013.11 W} dJ( f';1tk
140'F�
,
3.4{)311{F: Reamiiaw, Unsiw(ni tA llt«l a IFC 5Hft,t7t111
1 2.3 Nloraiinm(.M and Fersonni-I I FC 2N,
24, nolo NXI PMPN'liori FC 004
Proper Cooling of PHFr, I-- -- - _ --- I
)5 "'Id oi�"zla F0_4 00,
1-501.144) (1h.1mg co&:d VTIFs r""m 1,10, li)
26 1 FC-5 006
FO- CK)7
caI Favil:
1•'4 WtMi a-1 Hou: :,t T4)�:, VEitct
taiZ- FC -7 1 -00t;
5o1 l4861 t-Ooliwi PHR,,,lady From Aynb-evt Sp'.Ncia!R�-nremevt3 '009
30 01hp,
V'nh a HimnO
{
CITY OF SALEM
BOARD OF HEALTH
t
Establishment Name: p So �bll/llm Date: Page: of
t nem Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item - Verified
PLEASE PRINT CLEARLY
"'94 A,, s/ C WL/"o' kq"j-_� /moo
(�'14 ol/01 -P _ it Ati a I7n14�i.s fit./-/,
-f2o r.4 41 L„ AZ Cir �h c Gw,r 44- &,,,, .
I/VZ.10j"'C
t
h> . Y-,7 9 //74 Yus G
4-
0 0
Discussion With Person in Charge: 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 /
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
p Ll Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
P14F,iie,A,iwd at ftmperatures
Violations Related to Foodilcrno Illness Interventions and Risk A:vocluit;;1c,lay. Crxited to
Factors(diems 1-22) {Cont)
I i 115`F wiftne•: it"WS,
Lh'od,I'M PliFs
3-5i;l Me
PROTECTION FROM CHEMICALS 19 PHF H-C'n and Cold Holding
14 j j Food or Color Additives
!.10lB) cold PHI-'.Miltint'muJ at or below
-20?,12 % F
'Prolect!,ei frow Uniptirwed Nddiavc z' l NWI z
li(li I'M,l%Aainqw,i�d at(,r abov,
Is I Poisonous or Toxic Substances
140"F.
101.11 i j.demifying infol mallon 4(v'i) RkmNv 1-10d at or,ibu%e 130,E
'ontainarz:I
klmvion'Naftw - WorEne Cow;nrier,' L_2_1) Time as a Pubisc Heldth Control
I,! Tilrw as a hjhlic. Praldl Control
7-20 LI I Sc-parauon--snl;age'
7.20} I I Ro"vict,kvl- llrcscAcv.wd
7-20112 Condition"of Uwx REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
-,-?w (I Totic(:otnamctrPOPULATIONS(}ISP)
7,204.11 sxnwcr� critcli't -Ownvic'!N^
21 1 H(A) Pic pad'r'erd jorvn'and
7-3(}41.!2t'lleplical.'to(Wn'lliq llllltilwe:('14clial
7-^04.14 Dmine Aucut�,Crq-iia` lte%erlieex with Warning I ahok"
-1-,205,11 partvwi��d E-'�
If Dl R'Iv,or Paji'all, cl"" l'd.knanal F(xJ alid
'l-206 11 fkcs'-'Ictcd I:sv Pe�fqqdv-N Ciitenz)
ka'k'Sctj Sproul, Not :Yerlcd'
fn-m'ne,?
I I Tl icking Powdtlrc, P,� L Cuntrol ;,nd
hdumtrin ng' CONSUMER ADVISORY
con',Omr'l �'Nt,"d I'll �-'-)usnmptiort of
TIMEITEMPERATURE CONTROLS
16 1 Proper Cooking Temperatut as for j 1an:f<11- I1nd(rT0x,kcd ot
PHFs
3101 1 IA(Iii-y I-,,'g - i55 F I`,S,c.
-
1451-'Isc4 1 I*..qt�z%r!/%.d Fg'zz ".t4inulv fa: Raw shell
l-40IANA)(,) N'4eiw G2y1w
A.jnp,d8 15'i`F 15 gcc.
;-40#-1!(111(1 jl 2) Roil, and Floct Ro.lst - I 10"t' 121 nup° SPECIAL REQUIREMENTS
1-4J..2 1(A)i-1) Fff 590(}f tk)(lit)-lf)) Vivixion,,cji Sectlen 5o0JX)9fA)-(D) in
rrr)Nh:i'wtL fell ip-,i aryind
3 401.1 HAW?) i Nul tro''A ild Gaut", Sib I'tt"I PI iFs 0chcn upQli:tionl, 'hould be
Sluftrne Cont:11ning Fish, Mom, v!btted under the approfrruiteieCltonn
PoWfl-i'(w kaliie,,-105-F 15.�cc. :ixwe if fvLncd it,foodix,rric Illness
'Niwlv-'111',iv iw'w! i3el!i"Ntraks inicl vcnlioqs and risi, farto-s' (ftbff
1451; 590.E 7'# k"olations relating,
to itood retail
.1-401.1^_ Raw Aninvki K!odl,Cwkt,d ni it picoves 4honlkl he debited under #29 -
Req:6rerne!m
Ottila 11111:s- 14,5"F 15 v.
17 i Rpheatmq for Hot Holding WOL AWNS RELATED TO GOOD RETAIL PRACTICES
ifteoul 23-30)
140 .1 lfb) 1 Miciowavc 10'F 2 kinjuiv Sluntliq, I Criii-al avdWo:l" at which do lw: %'tau ;,,the
'I Lqed ab'we c"n b"
I I(c)
('!fanl3ea-iAlI) 1`1xxd �uw'd'*n 1;,)n'o"A'.fe"Id(")'le f';ld It,.i ('Af R
3403 Ih F) j Rrnlalnmy uns1wed Porti l-.or licet I ofiew Good R012li Practices Fc I 590n;00
11
M naumner!and rler,,onn-i I FC-2 oo-.
18 1 Ftv-YJ l,.nd�,-xkl Fmle�tiol t
Prap-w Cooling of PHFh ?.
;.Fr,—I ook
501,1 i(A) o"Inl"C'wk-'d Pfill� 11(ol 1 4N 11 -- --------
26, What,K!nnin�land,Wne Fc-5 1 006
1 21, PhVs,,',�Fac,41y r) ixi7
1,,4 IFi,15'F Within 4 Kqw pc'l;000U3'r-f,xc kl'lleoa',i 00
i 501 l4th) Cwlinv PHF: Made hoia Ambient i 29,
T"Inp:rlwr( lq'Tcdicln; {v ;11'i�/4
I Within 4 1 I(Alis
j
DATF 63-7055t2l,3
PAY TO THE
ORDER OF
/oa o C:)
"o- dWao� DOLLARS
Salerriliven
210 E}SCI Street,Sale.,MA 01970
FOR ==%/,C P
1: 2 113705581: 089904904311'
-07
IMPORTANT MESSAGE )
FOR �lM
DATE R- �'D 1-� TIME /23�
PHONIP
AREA CODE NUMBER EXTENSION
❑ FAX
❑ MOBIl F
AREA CODE NUMBER TIME TO CALL
TELEPHONED L j,4 PHASE CALL 4,,
CAME TO SEE YOU {I WILL CALL AGAIN
WANTS TO SEE YOU RUSH Y
rRETURNED YOUR CALL WILL FAX TO YOU
MESSAGE 7 tii�b�i7'v
SIGNED
VIEW FORM 4009
MADE IIN SA
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AREA CODE NUM ER EXTENSION
❑ FAX
O MOBII F
AREA CODE NUMBER TIME TO CALL
TELEPHONED PLEASE CALL
CAME TO SEE YOU WILL CALL AGAIN
f WANTS TO SEE YOU RUSH
RETURNED YOURC�ALL WILL FAX TO YOU
MESSAGE �n .
rmFORM 4000
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