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ROUTE 114 CITGO - ESTABLISHMENTS ROutr illi c11yo fah Nail sire ftNIVERSAL® UNV-12110 MADE IN USA SUUR5E51R E MPl.�EDY�ID l IMIi1EAS1 LtiNIB1fW% CartiReA Fbor$wrciip POSTaN$U a mrw.ffiPrWnmarY YIII�L+A JV Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Route 114 Citgo File Number:BHF-2003-000008 105 North Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes RETAIL FOOD BHP-2011-0035 Jan 1,2011 Dec 31,2011 $70.00 TOBACCO VENDOR BHP-2011-0036 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $205.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health /: This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH $..a.r 120 WASHINGTON STREET,4TI'FLOOR TEL. (978) 741-1800 KINIBERLEY DRISCOLL F_x(978) 745-0343 MAYOR DGREENBAU.NI([I�SALEM CONI DAVID GREENBAUm,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT D U / F J/� <fITG.U TEL# ADDRESS OF ESTABLISHMENT_ /05— �V 'h_2 FAX# MAILING ADDRESS(if different) EMAIL- Business':aeT/ZSTe!WtaYl . Q/"LWLL/"ebsite: OWNER'S NAME V� TEL# o 1 . - 4 a— U00@, ADDRESS J/9' IV -Ts ,L7/I/ STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# ;DA,YS OF'OPERATION Monday ? Tuesday`s: .. .W.ed i day r,.l .'.Thursday - y F.Fdtlay' ` a, +Saturday . ,,`j! Sunday J HOURS OF OPERATION Please write in time of day. For example 1lam-11pm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YE NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 ---------- ----/� - - RESTAURANT YES ilii- less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 B E D/B REAKFAST/--------------------YES----(8)-------------------------------------------------------------------------------$100----- CHILDCARE SERVICES/NURSING HOME--------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES TOBACCO VENDOR <UD NO 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. I 'D C) {3 _ X99 S �� Signature Date Social Security o Federal entification Number ---- --------- ---- ---- — - s- — Revised lollli I FOODAP201 Ladm Check#&Date Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'"Floor _ Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name1 Date Tvoe of Ooeration(s) T f Ins ction ❑ Food Service Routine Address \G /rte Risk Retail Re-inspection Level [] �{esidential Kitchen Previouu Inspection Telephone /lC� _ It I C)q O ❑ Mobile Date: (�'era J� Owner 00 I / HACCP YM El Temporary ❑ Pre-obera'tiont y) ❑ Caterer ❑Suspect Illness Person in Charge(PIC) M Time, ❑ Bed&Breakfast El General Complaint El HACCP Inspector \ Ojir i Permit No. ❑Other Each violation checked requires an xplanation 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 x Violations marked may pose an imminent health hazard and require immediate corrective 590• (E) LJ 590.009(F) action as determined by the Board of Health. TODD PROTECTION MANAGEMENT _ ❑ 12. Prevention of Contamination from Hands 11 1. PIC Assigned/Knowledgeable/Duties ❑ 13. 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 El.� -_ 15.Toxic Chemicals FOOD FROM APPROVED SDURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Haziirdoue Fooda) ❑ 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 7__71' w'. ❑ 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.(HSPi C3 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP � ❑ 11. Good Hygienic Practices CONSUMER(ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below C x 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 a)(sso.o0s) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 55901 SPP Fo 14.x Inspector's Signature: Print: PIC's Signature: Print f Page of6a Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION S Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) Raw Animal Foods Separated from 1 590A03(A) Assignment of Res ponsibilit * Cooked and RTE Fads* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(0) Responsibility of the person in charge to 3_302.1 L(A) Fuad Protection* require reporting by fo<xi employees and 3-302.15 1 Washing Fruits and Ve*etables applicants* 3-304.11. Food Contact with Equipment and 590.003(F) Responsibility Of A Furl Employee Or An Utensils* Applicant To Report To The Person In - Contamination from the Consumer Charge* 33 d* 06.14(A)(B) Returned Food and Reservice of Foo 590.603 G) Ke ore n b Person in Charge* 3 F 590.003(D) Exclusions and Restrictions" Disposition don of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Res tr ct ons 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501..111 Manual Warewashing-Hot Water 3-201.12 Fcod in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products' 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures*- 1 3-202.14 Eggs and Milk Products.Pasteurized* 4-561.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 10 5-101.11 Drinking Water from an Approved System-tem* 4-60 Ll I(A) Equipment Food Contact Surfaces and- 590.006(A) Bottled Drinking Water* Utensils Clean* a 590.006(13) Water Meets Standards in 3 10Approved CMR 22.0 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Su 4-702.11 Frequency of Sanitization of Utensils and - 3-261.14 Fish and Recreationally Caught Molluscan Shellfish'" Food Contact Surfaces of Equipment* 4-703.11 Methods ofSanitization-Hot Water and 3-26115 Molluscan Shellfish from NSSP Listed Methods Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re utoryAuthority 2-361.11 Clean Condition-Hands and Arms* la 3-202.18 Shellstoek Identification Present" 2-301.12 Cleaning Procedure* 590.604(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* 11 Good Hygienic Practices 5 ReceivingfCondition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11- PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-10111. Food We and Unadulterated* 3-301.12 Preventing Contamination When Tastin F6 Tags/Records:Shelistock 12 - Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 ShellstockIdentification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance lHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11. Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drving Provision *Denotes critical item in the federal 1999 Fond Cale or 10i CMR 590,000. CITY OF SALEM e BOARD OF HEALTH Establishment Name: (/1ilt �/ , l .cwt /Yo Date: —1 O Page:-- of _ Item Code C-Critical Item ( ,DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference "R-Red Item �-/ Verified � a. O PLEASE PRINT CLEARLY �'�;'�,q ��l 7 /OP v.�. xP, Y Q 1 f'n f rQ r r`iJ n ./1 _ A A /� �4', n+•/,, n�� l!it Q,;V^ ( l%/l�\MMrl ko'1( � V r i n v1s,/1/1I171 n.tn ItA _ 9 '__�On A A r� L C) �Aa AK.1' J i �/a iD2,Pit-c.,i,t,�a\) �i r'�G✓l _ /P�f Qia (�/{� .. 11 e � A /l f_n _P, \ n _ _ OA eg U 7A 0. IP,4 4ann i1' / n a J i �nn/nnr aan � tA -2 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 �a-( Exclusion nspection-Schedale! ❑ 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. 13 Voluntary Disposal ❑ Other: / 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Heyns 1-V) (Cont.) - 41'F/45"F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 CoolingMethods for PHFs 14 Food or Color Additives - 19 PHF Not and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590A04(F) 410/450 F* 3-30214 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 140°F.* 7-1011 L Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers* 7-102.11. Common Name-WorkingContainers* Time as a Public Health Control 3-501.19 Time as a Public Hen th Control* 701.1.1 Separation-Stora * 7-20111 .Restriction-PresenceandUse* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11 SanChemicals Criteria Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for WashingProduce,Criteria* 7-204.14 Drying Agents.Criteria* Beverages with R'an ina labels* 7-205.t 1 Incidental Food Contact,Lubricants* 3 801.11(8) Use of Pasteurized E as* 7-206.11 Restricted Use Pesticides,Criteria* 3-801 A I(D) Raw or Partially Cooked Animal Food and 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served * 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw-Undercooked or PHFs Not Otherwise Processed to Eliminate 3401.11A(1)(2) Eggs- 155°F 15 See. Path° ens'*E`"`'"� Eggs-Immediate Service 145°Fl5sec* 3-302.13Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E s* Animals-155°F 15 sec.* 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3.401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590,009(A)-(D)in sec. * catering, mobile food, temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401,11(A)(1)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO G000 RETAIL PRACTICES 3-403,11(A)&(D) PHFs 165T 15 sec. * (Items 23-30) 3.403.11(B) Microwave-165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 340111(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portiints of Beef Karr+ I Good Retail Practices .Fc 590,000 Roasts* 21 Martanoment and Personnel FC-2 .003 18 Proper Cooling of PHFs i 24. Food and Food Protection _ FC-3 .004 3-501.14(A) CoolingCooked PHFs from 140°F to 25. Equipment melt and Utensils FC-4 .6X15 26. Water,Plumbing and Waste I FC-5 .006 70°,1?Within 2 Hours and From 70T _ 27. -Physical Facility i FC-6 .007 to 41°F/45'F Within 4 Hours. " 28. Poisonous or Todc Marerials i FC-7 ,008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements - ,008 Temperature Ingredients to 41°F/45°F 30- i Other l _. Within 4 Hours* sse: ec.zn 'Ihnotes critical item in the federal 1999 Foal Code or 105 CMR 590.000. .vi/`� e'._ viS. oC:yfir+Yr{k�illssgt�N*^C'u..h?'W++.�.}-'l:•nr. .4..;. .,µ,,.E.p,y,i '�I''rT7�4�f.`'j�'.�'A" '4T�+'"'TS�4+p7tr'y't', 1�*.t'�ff.. Massachusetts Department of Public Health Salem Board of Health 120 Washington Sreet, Division of Food and Drugs Salem, MA 01970-t35234 th 190=35234" Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name U �" ate Type of Overation(s) Type of Inspection 0 1 1 D I t-a) ❑ Food Service Routine AddressRisk Retail Re-inspection o c7 �� Level Residential Kitchen Previous Inspection Telephone _ ❑ Mobile Date: Owner _ _I HACCP Y/N El Temporary ElPre-operation F 1 �, a A ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) /11 Time �� ❑ Bed&Breakfast ❑❑ General HACCP Complaint ,I1 1 � In: Inspector I r OC Permit No. El Other. Each violation checked require slan 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-Chokin� 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. y m "FOOD PROTECTION MANAGEMENT,--,my� �. , ;- v�t ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties p ❑ 13. Handwash FacilitiesEMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC "PROTECTION FROM CHEMICALSa A Y^n L q �'r ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals "'FOOD FROM APPROVED SOURCE_Approve,d„ ,,,. TIME/TEMPERATURE CONTROLS Potential) Hazardous food """ s -`.( E] 4. Food and Water from Approved Source � ( y ) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION'r i f s� 11 'r'" i ` ❑ 19. Hot and Cold Holding ❑ 8 Separation/Segregation/Protection _ ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing "REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)s,fi ❑21. Food and Food Preparation for HSP E] 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices I"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 ah'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 by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-1),590.om) 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:ssorrlspecrForm614.aoc Inspector's Signature:.;, t �'f V1� /� Print: PIC's Signature: (7 �w �� , �) Print: �.� \ `�,� Pagel of�Pages ,lI ► Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Gross-contamination . 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 37302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-30215 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char*e* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.7.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fps` 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance With Food Law* 4-501..111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 E >s and Milk Products.Pasteurized* 4-501.11.4 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clem- 590.006(A) 602.1 t Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source Contact Surfaces and Utensils'4-702.1 1. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re utato Author 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202AS Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-30L 12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(8) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* - Employees.* Tags/Records:Fish Products 13 Handwash Facilities 3-40211 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* Location and Placement* 590.004(1) Labeling of Ingredients" q Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance fHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Metbods* Devices 3-502.12 Reduced oxyaen packaging.criteria* 6-301.11. Handwashin Cleanser,Availability 8-103.12 Confo mance with A oved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in the federal 1999 Fad Cate or 105 CMR 590.000. - r CITY OF SALEM R", !" BOARD OF HEALTH Establishment Name: +"ti,AfG' 1 S lid �i� Date: �— �—�/Cl Page: of _ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION - Date - No. Reference R-Red Item +. .Verified PLEASE PRINT CLEARLY F 04/ A tNr V"1, Ayk — Y )(I 2 All _P A dl "/ V/ n ,D .{ K c.r,vt /Y/� � � //�� lw, n n i,A nn a/l, �1 - A� n —UGI y J . f s � � Discussion With Person in Charge: Corrective Action Required: ❑ No ❑/Ves I have read this report, have had the opportunity to ask questions and agree to correct all ❑i 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. 'FS ❑ Voluntary Disposal ❑ Other: Y PRFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to Lau Cooled to Factors(11eMs 1-22) (Cont) 41'F/45"F Within 4 Howl. * _ PROTECTION FROM CHEMICALS 3-501.15 Cooling,Method for PHFs 19 PHF Hot and Fold Hold 1q Food or Color Additives ing 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Ahhtives* _-- - 590,004(F) 410/450 F, 3-302.14 Protection front Unapproved Additives° 1-5f"i.NriAj 7 ini PHF>:vtaintained at rx above 15 Poisonous or Toxic Substances 7-ttil.11 . Identifyinglntbmatio„n-Original — - 1 Containers^ "01.160) Roasts Heid at or above 1300E — �-- — Lz0—i Time as a Public Health Control t-102.1( Common\+me Fl ntkin Couto r.* —111 - - 161 19 i mu as a Public Health Contrk)V_ I?01.11 ai.itrin Sttnakc — t °40..10f1sH) -- itr trecKw�airement 7-202,11 _ Retitn�tion-Pr uncc and (, —7-2202.12 Toxicuon of en, REOUiREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.f 1 Toxic f ontainar rola-mic t, POPULATIONS -204.1'I SannvettiCtiteiin Chzmiuds - � � 11(A) UnpateurizedPreptckagedJui'esmid 7-204.12 Ch nuc t(s for li Whin 1 rxluce Crir r,;t" _� Beveta yes with 4tawm I,abc,ls, 7-204,14 D., rs1i A eutc_C riu i i -- _ 80 j l l fflr �t)� (if pa tuuwv d ELL,s 7 2 05,11 Ink'td w al) xx1 Coni U Lobi is ms1-- i -- (.SO1 i l(!)) kww or P attall C il.�d Aonnnl Food and rit' - t — - _ Kmc Scd tiat, 'tint Scrycd 7-206.12 R:xL h u*Si I(R)R+'- - ^--+ t 801 t c n a nt u od Food i' xlac'�r c Nut �i-.06-1� 9Yticl.ing Pnvvdtr .Y._st Conn.! and ------- 4liemtotim' i CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 3 603 11 1 Corminw, ici sorb Paved for Cou nmp6on of v nisi 1 ,ur 1Yatate Ra Underc")ked c 6 Proper Cooking Tempet?tures tot j �t <ryr L PHFs ns_ 'r<„cs� a inaimutrr —'7 Puha r, " " 55c' , ?52 r t f�>3i fFfr>5hsnrut for Rau Shell i --J i tnmta (u Servrm 1 5 ll Msec= j 3-i0,1.11tA i' C ivilifimcdMelmc . t.at.le irscc_ SPECIAL REQUIREMENTS 11 Ri 21 drd 13ct Ru ci 4_,10 I titin - )f.3 l alt 1 1' h it at5 I I !� 54J }�,)t.�iy S)t t L GEa 't(i of S 141 r(l f$r9t 1� t1�j i.l 5 !ttYt )fl llohil'"-t xxL t"k 1poi ai v and _.. . 461 1,�A s) ( 110t0m, 1kilJ t 3 Stuffed i tits, rcxicl ❑t a1 4atcE;c t pp r tictrs houtd Ise j 1C'on tri n` gist. i ucthi et( n,xter fit -a,,rsrtprsatc .mss itou j i : 5 Or Rai ct r)q i!kYC t rt.l2ib3li '; i$Y kl±`i+T?3: ly 2SF. --- in;,j „n .r,rsaria - ' � � `�A�- s til�;-�i releei�n�t , .(cttro.a,r I oil jN h i a..; '. 3i. .`;_ t r_ r � fIOLATiONS RELA my rQGoob_RET—Am_.., PRacrrcE- RP7 t Reheating tae Hot Holding 1)311(1) (D) PKI 6+ 71 liuti23-30) 403.11 rki} --- Nr nuc tic- It ' L1mu e Standin„ E G rrt + `tc rr al _ I of I }iodho ri ,u i i's iw r vW i.Oib iMil V!i,(jrrro et=ord ncca,mlr c sccot,n,, o, iii r wd tt vert I t ;H? unsliceu FC nrm l8 tit l[tA} P4opertrCaoBk gi P1 1HFs t�Sinit _-'4, F3 a Retail FoatfP of r4u � KC j 500-4 +-----i- ---+-- S c a n ent an0 Weosfl 3 P 4 (0 t Ft1 Cx f i 14101-,t. 2e INatir piombin,,an lase ' FC-5 i ty t ithin ' Iiou -te -:_� Z9 � S� StI R.tei ci trvi� ._. FC-_U Fain 11' to ?i1-1/15'h tv tl t i t tfou� 2d esa Sus or x�RA iter als C- 7 008 3 a0! H(t;i "flims PI IF 4t o Front Anl icnt _ 9• OQa i atpc rature It r^d.,nts tr.-t, tela }• u.. --- ------ —_-' -- 1 R tt'in-117txtr.` Commonwealth of Massachusetts f City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12123/2008 ESTABLISHMENT NAME: Route 114 Citgo File Number:BHF-2003-009408 105 North Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes RETAIL FOOD BHP-2009-01 10 Dec 23,2008 Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0111 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $205.00 i I PERMIT EXPIRES (December 31,2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pagel CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR _ TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 : MAYOR IDIONNEt7a sALEnt.COM a O ,atio JANET DIONNE, ®Ev ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT kOvT C11?etcZTEL# ADDRESS OF ESTABLISHMENT _1CS A, oii h St 5411-&-2 FAX# 8- 31i/-07 & t-- MAILING —31i/,07dt--MAILING ADDRESS(if different) EMAIL- Business': /2X I_h S-T/ c.c7e_ i2 MS7V1GAd(Vebsite: OWNER'S NAME tI(2 11411 i& h S �£�-/�Q�! TEL# ey.,L 5�,_ ADDRESS �Yt-�s ir/a,! 2 L SL 5 v✓rl STREET CITY S ATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# Fda Sunday.,DAYFAPERATIONMonday, JOesdaWednesda HOURS OF OPERATION Please write in time of day (For example Ilam-1113m) �—�� GJ - TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE ES NO less than 1000sq.ft. 70 1000-10,000sq.ft. $28 more than 10,000sq.ft. =$420 ------------------------------_---------- RESTAURANT YES less than 25 seats $140 -------- (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 -------------------------------------------------------------- ----- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES - - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVEY NO TOBACCO VENDOR S� NO 135 ALL NON-PROFIT(such as church kitchens) S NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all stale tax returns and paid ail state taxes required under the law. W067yet kj' � /�2_ 0s oIW adz qqf S£r� Signature Date Social Security or Federal Identification Number ----------------------------------------- —7q�7 ----r^-- —----------- 5 Revised 424/07 FOODAP2008.adm Check#&Date �/�7 7 �� f(/ink $ a i n� �rAIIK 105 North Street Route 114 Citgo City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-0906 Food and Food Protection FAIL Critical BLUE Owner: Comment:There are some price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price Mohamed Karim labels. PIC: The following items removed outdated: Hahy Al-freiahy 16-Slim jims Inspector: 2-Ritz bits 16-Naked fruit drinks. David Greenbaum - Closely monitor all expiration dates. Date Inspected:Correct By: 7/1612008 Risk Level: Permit Number: BHP-2008-0075 Status: SIGNED OFF #of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 16,2008 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 16,2008 ) Page 2 of R Commonwealth of Massachusetts ` e City of Salem Board of Health IGmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/11/2010 ESTABLISHMENT NAME: Route 114 Citgo File Number:BHF-2003-000008 105 North Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0247 Jan 4,2010 Dec 31,2010 $70.00 TOBACCO VENDOR BHP-2010-0246 Jan 4,2010 Dec 31,2010 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 • CITY OF SALEM, MASSACHUSE,--TTS d BOARD OF HEALTH � 120 WASHINGTON STREET 4"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 FC f MAYOR DGREENBAUMSALEM.COM D�j. y,LO O w-S DAN7iD GREENBAuNi, OiOy�<Fjy� ACTING HEALTH AGENT 1, 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT / �ry r_ NAME OF ESTABLISHMENT 900 /P_ �� [�7�C� TEL# 7 -87 - U / C)QD ADDRESS OF ESTABLISHMENT � Fp #a _— C�'r D MAILING ADDRESS(if different) EMAIL- Business': A/6 4 -51A1 6/, oe) 7 N-Ca✓h" Website: OWNER'S NAME / .,�J /s?r.. I /rel 6 TEL# ADDRESS �./R YV A-L leo-&I� fl�;�'- M�� /t'l/'9' 15 STREET CITY STATE ZIP' CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON_ P19HOMETEL#_L � w - ,§qJ,pYfFq,QF,O,PERAO)I. Mpndaya %W, Tg3fl'T;WTfiursday ," Frida=`_; Saturday ySuriday=, HOURS OF OPERATION o(��rQ �Ay�r , VII G, / i C Please write in time of d / 6 rr C A � I to I /� Far example llam-17 m (( l� ��µ G /' TYPE OF ESTABLISHMENT FEE (check only) RETAIL STOREYES NO fess than 1000sq.ft. = rZ 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ---------- ------- ------------------------------------------- ------------------------------------------------------------------------------......---------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME ------------------- -------------------- ----------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YomNO $25 TOBACCO VENDOR _ NO $135- ALL NON-PROFIT(such as church kitchens) '7E-S NO $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved,by the Salem Board of Health. - Pursuant to MGL Chapter 62C,Section 49A, Icertify under the pains and penalties of pedury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes requiretLunder the law.' Signature Date Social Security or Federal Identification Number. --------------- Revised424/07 FOODAP2008.adm Check#&Date&�� BO'S Commonwealth of Massachusetts City of Salem Board of Health lftbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Route 114 Citgo File Number.BHF-2003-000008 105 North Street - Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FROZEN DESSERTS BHP-2008-0181 Jan 3,2008 Dec 31,2008 $25.00 RETAIL FOOD SHP-2008-0075 Jan 3,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2008-0111 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $230.00 PERMIT EXPIRES (December 31,2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 13 of 15 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120� WASHINGTON STREET 4' FLOOR nrne d� > TEL. (978) 741-1800 DRI LOLL 4 ne KIMBERLEY S FAX 978 745-0343 MAYOR ISCOT O&SALE vc COM JOANNE Soan, HEALTHAGENT N�lTjy 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD y ESTABLISHMENT NAME OF ESTABLISHMENT �7VT9 & ' ,,// G7 9L6 ADDRESS OF ESTABLISHMENT /Q (; WO)eTh 'S7— FAX# MAILING ADDRESS(if different) EMAIL-Business': �Vl U 57 re C)11- 6��.S/I A- :Wt�Nebsite: OWNER'S NAME MOL/ / IiCS �&/70e2> TEL# g 70 ADDRESS t3 �'&&/&-7 /d !7yg�o STREETCITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) M04✓J CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) II - 21"o _ �-' 1"" EMERGENCY RESPONSE PERSON-0-70 1/141`1 bQ 5 11£ 406 HOME TEL T (�T DAYS OF OPERATION E Monday Tuesda Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Please vette in 6me of day. (For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE NO less than 1000sq.ft. $70 1000-10,000sq.ft. more than 10,000sq.ft. =$420 ----------------- ---------- ------------------------------------------.............- --" "--...-------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Carl$2101 25-99 seats =$260 more than 99 seats =$420 �-N - - - - NAS --------------------------------------- --------- ----- ..--------------------------------------------- - ----- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES.----__- ------- ADDITIONAL PERMIT MAKE (not just serve ICE CREA OGURT/SOFT SERVE YES NO TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO '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 ,L- /zip -;L o4 1 -57 gg, - igna[ure Date Social Security o Federal n[i icauon Number ------------------------'-- -----------�—�—..�----------- --------------------------------- ------ Revised 4/24/07 FOODAP2008.adm Checkft&Date /OA �O�- $ l� 105 North Street Route 114 Citgo City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 741-0906 Handwash Facilities FAIL Critical Q RED Owner: Comment: Hand wash sink obstructed at time of inspection. Sink to be free and accessible at all times. Mohamed Karim PIC: I Same sink has visible leak. Repair sink. Mohamed Shehab Same sink missing Hand wash sign. Provide sign. Inspector: General cleaning required around sink. John Gehan Date Inspected:Correct By: Violations Related to Good Retail Practices (Blue Items) 5/15/2007 Food and Food Protection FAIL BLUE Risk Level: Comment:The following items were taken off of the shelves due to out dates: Permit Number: . 3 boxes Ritz crackers BHP-2007-0065 1 box club crackers Status: Equipment and Utensils FAIL BLUE SIGNED OFF Comment: Ice/ice cream freezer requires general cleaning. #of Critical Violations: 1 Same unit has no visible thermometer. Provide visible and accurate thermometer. Time IN: Time OUT: Ice cream freezer has no visible thermometer. Provide visible and accurate thermometer. Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 15,2007 ) Page 1 oft Item - Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 15,2007 ) Page 2 oft CITY OF SALEMI, MASSACHUSETTS RECEIVED � �� ® BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DEC ` 4 Z��s TEL. 978-741-1800 CITY Or S,4LEM FAx 978-745-0343 BOARD OF HEALTH Kimberley Driscoll WWW.SALEM.COM Mayor .JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTtqT' IN 7 C'/1 f S- TEL ADDRESS OF ESTABLISHMENT 1025 e`1VOKTk] :57— FAX# g aj?,2 / 69...O&, MAILING ADDRESS(if different) EMAIL--Business': IV IOA� 7'h t)ye 1914— 4P- NtAte,C .An,Owner's "y r w1 R00.2 &,041 /L) OWNER'S NAME MpNA/Li e0iA/1 F M 1TEL# R Y t! LUQ ADDRESS . Q &-L5 MA)/s•+ /" 'Z7-_ M k.721VJ A) /-I/q- al I STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# OATS OF OPERATION Monday Tuesday_ Wednesday Thursday i Friday SaFurdayHOURSunday Please FOPttime0N Pleaseapltorimeotday. /� � 16-1 [Far example Ilam-Tom) � TYPE OF ESTABLISHMNT FEE (check only) RETAIL STORE E NO less than 1000sq.ft. =$50 1000-10,000sq.fL =$100 more than 10,000sq.ft. =$250 - - - ------------ YES-.._"NO- -- -------------- —-------- ------ less_...than--,25 s---sea-.._.----- - -- RESTAURANT =$10—0 25-99 seats =$150 more than 99 seats =$200 __..-.._ _. - ---- -- --- - --- --------- ----- ------ .--- - -...... --- -_ _ .....------ ----- ----- ..... BED/BREAKFAST YES NO $100 . ..... ........ .------ .. -... ... ... -- -_.. - ------- ----- ------- ----- ----- - .... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) _Y7S— 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- Signature Date ocial curity o Federal I entification Nun O _ ber _ Revised 11/13186 FO00AP2007.adm "Eherk#& Date -,70Z, _ $ /[5tJ 0.tIwr;fr mt +Jry}x k�yy' i�Commoawealth of Massachusetts r �,a g �'dTe�?s°yese'y a • w • i�,x Y;. �°� �.i.., B08rd Of Health +�"5$$ �Y7#'-� ° CUxy�. � ek Y�� n 3��."2 h `� y �s�y"� �C "�'� � 120 WashiaJ,}oa Stree4 4th Floor.,,s 2f 4� � ,¢ Y a, fGmbefieY DnSCt)115 „ , ,. SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Route 114 Citgo File Number:BHF-2003-000008 105 North Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0065 Dec 19,2006 Dec 31,2007 $50.00 TOBACCO VENDOR BHP-2007-0087 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 16 of 24 105 North Street Route 114 Citgo City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-0906 Food and Food Protection FAIL Critical BLUE Owner: Comment: There are price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. Mohamed Karim PIC: The following items found outdated: 9-Gardettos Mohamed Shehab 3-cake mix 7 1 -Pancake mix Inspector: 3-Mac&Cheese David Greenbaum 2-salad dressing Date Correct By: 3-devil dogs Irl$PPFd@�6 2-apple pies 1 -suzy Q Risk Level: 1 -jar peanut butter J7-jars mYo Permit Number: Closely monitor all expiration dates to insure no expired product is out for sale. BHP-2006-0103 Physical Facility FAIL Non-Critical BLUE Status: Comment:The counter hand wash sink has a leak. Repair sink. SIGNED OFF #of Critical Violations: The counter hand wash sink has a worn spot. Repair counter. 1 GENERAL COMMENTS: Time IN: Time OUT: 694: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 18,2006 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) j4d� City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 18,2006 ) Page 2 oft 105 North Street Route 114 Citgo City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ kTelephone: - Item Status Violation Critical Urgency Nature of problem or correction '_.741-0908 Non-compliance with: Not Done Owner' Anti-Choking N/A ❑ .�. MObamed Karim Tobacco PASS ❑ PIC: 3 Mohamed Shehab FOOD PROTECTION MANAGEMENT Not Done Inspector: �,y. PIC Assigned/Knowledgeable/Duties PASS ❑d RED David Greenbaum Yi EMPLOYEE HEALTH Not Done Date Inspected Correct By::, Reporting of Diseases by Food Employee and PIC PASSd❑ RED 8/24/2005 Personnel with Infections Restricted/Excluded PASS ❑J RED Risk Level: = - FOOD FROM APPROVED SOURCE Not Done LLPermit Number: Food and Water from Approved Source PASS ❑J RED BHP-2005-0092 Receiving/Condition PASS ❑d RED StatUS:. Tags/Records/Accuracy of Ingredient Statements PASS ❑Q RED SIGNED OFF m - Conformance with Approved Procedures/HACCP PASS ❑d RED #of Critical Violations Plans -1 T PROTECTION FROM CONTAMINATION Not Done .;Time IN: Time OUT: Separation/Segregation/Protection PASS ❑d RED Notes.;. '^ _ -. Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED 253' = Proper Adequate Handwashing PASS RED r Urgency Description(s): Good Hygienic Practices PASS RED BLUE' Violations Related tcµGood Prevention of Contamination from Hands PASS ❑d RED Retail Practices (Critical Handwash Facilities FAIL Critical ❑Q RED Install paper towels in dispenser. Paper violations must be corrected-.. available at time of inspection. Immediately or within 10° Keep front hand wash sink clear and - accessible at all times. j.days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 24,2005 ) Page I oft i 105 North Street Route 114 Citgo must be corrected immediately PROTECTION FROM CHEMICALS Not Done or Within 90 days) Approved Food or Color Additives PASS ❑J RED RED. m Violations Related to .: Toxic Chemicals PASS ❑Q RED Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures N/A ❑Q RED immediate corrective action) " Reheating N/Ad❑ RED Cooling NIAd❑ RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP N/A 0 RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE 27 items found expired. Closely monitor all expiration/sell by dates to insure product that has expired is not being sold. Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 24,2005 ) Page 2 oft 64 ri` x `` i •s?'+�n�a« ,3 w a-w y� v a o-. rt4 n;ct k ,. Commonwealthh of Mksdfich,✓usetts sxz # y i )'lsr '1^s 'T.+w`�"` Lmf�'st�S` "ITSrtF4y `tw'w'r�w�lJq'biy -�t„1 # '_ri'.� 43 1rl + k.avY1k15" ,k�*"Y'Yn°°4 �4rc ','� `id4` ` + CftyofsalemL� Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 IT Q b Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Route 114 Citgo File Number:BHF-2003-0008 105 North Street Salem MA 01970 LOCATED AT: SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0103 Jan 3,2006 Dec 31,2006 $0.00 TOBACCO VENDOR BHP-2006-0079 Jan 3,2006 Dec 31,2006 $50.00 Total Fees: $50.00 PERMIT EXPIRES , December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 23 of 23 �. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH ( 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 i nme TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAX 978-745-0343 MAYOR WWW.SALEM.COM DEC 15 NGS JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT F�t(�J� ip�0 `J�Uj�Atl c. EdlA�!'�d �� !�FlW-Iq 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT P om (Z Ti_ �I Ci ��TEL# �7 S�— (t ADDRESS OF ESTABLISHMENT 1D /VO,rE'Th S S�L4 d Z y MAILING ADDRESS (if different) OWNER'S NAME,610/ TEL# ADDRESS IEZf�rA/ 424019,V,� CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) �/f� EMERGENCY RESPONSE PERSON �`td�/f//'�� 0 S/�` ME TEL# 3 y ?Lo HOURS OF OPERATION: Mon. ue.4--Wed. Thu. Fri._) Sat. Sun. TYPE OF ESTABLISHM FEE (check onlV) RETAIL STORE &ES rPNO less than 1000sq.ft. = 50 l 1 �� 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 -------------------------- ---------------------------------------------l-es- -s--than- --- ea---t---- -- $100-- ............. RESTAURANT YES NO - -25-- ss 25-99 seats =$150 more than 99 seats =$200 .............--------------......--------------------------------------------------$...10"----------------- BED/BREAKFAST YES NO 0 ...... .............. gnDITIONAL PERMITS MAKE_(not,just-serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR t��—Old YES NO 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. 12�ja&elyi /A_ 8-oS , 4"S2- /3_ /-9Z8 Signature Date Social Security or Federal Identification Number --- --------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date��6 �a?b a— /170 —/17d ' 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, RS, CHO HEALTH AGENT April 24, 2006 Route 114 Citgo 105 North Street Salem, MA 01970 Dear Owner: On Wednesday April 12, 2006 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old male purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Route 114 Citgo is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section, the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of (One Hundred Dollar fine)for the First offense. FOLLOWING THE THIRD (3RD) OFFENSE, THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore, you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street, 4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, _ r 'I. Joanne Scott Health Agent JSlmfp CERTIFIED MAIL: 7003 3110 0005 1992 2278 :c Nnrih Shnru I nhar.r.0 Coniml I'my;1ni 1 airr;lnni I1,11mv;lun, l;unnl ul I lq:nllh (;hnlrrnun nnrl Mun�l u:r, { NORTH STAR OIL COMPANY, INC. 2793 DBA ROUTE 114 CITGO 105 NORTH ST. SALEM, MA O1970 53-7116/2113 DATE ✓ ,c� �� PAY �� L TO THE G ' ORDER O -77 P..... _.... G C/it,aSV sr,�. DOLLARS '2' Danvers Savings Bank =n�a One Conant5tret,Danwm,MA01923 916-771.2200 it .2 FOR-----, 1- ��'00279311' 1: 21137i1621: 35 0039061' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR c SALEM, MA 01970 qq4 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: RETAIL FOOD Name of Establishment: Route 114 Citgo Address of Establishment: 105 North Street Owner's Name: Mohamed Karim Restrictions: Application Date: 11/19/2004 Permit for Food Establishment 31-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 001-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. I� , vz"", HEALTH AGENT 1 i . CITY OF SALEM, MASSACHU BOARD OF HEALTH 0 120 WASHINGTON4TH FLO SALEM, MA 01970 TEL. 978-741-1800 NOV 1 2004 FAX 978-745-0343 STANLEY J. USOV ICZ, JR. JOANNE SCOTT, MPH, RS, CHO CITY OF SALEM MAYOR HEALTH AGENT BOARD OF HEALTH 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT RT Ii e/TU Q TEL# 9'46- ''Y-40?06 ADDRESS OF ESTABLISHMENT 101—, JVQ9 I H f? /4A Ot ?31 0 MAILING ADDRESS (if different) OWNER'S NAME /10t5fl& Y 0 JW IM TEL ADDRESS //S /99/1, 5711coh/6 AV S, CITY M*THr/ C'/V STATE "A4 ZIP o/9 )d CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSONZVp&,d/ZrE0 S IS HOME TEL HOURS OF OPERATION: Mon.IF-Tue.f :�- Wed._-(:)--Thu. I-�- Fri.aSat. It ),- Sun. TYPE OF ESTABLISHME FEE check only RETAIL STORE ES NO 3-0s, less than 1000sq.ft. 50 1000-10,000sq.ft. =$100" more than 10,000sq.ft. RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 � z ADDITIONAL PERMITS 001-05 MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE ES NO TOBACCO VENDOR oo8-OS NO 50 v ALL NON-PROFIT(s-ch a -hurch, kitchens) YES NO 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 ynd belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number --------------------------------------------------------------- S ---t S_ Sr! Revised 11/03/03 FOODAP2.adm Check#&Dale �. - 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH �n 5{ 120 WASHINGTON STREET, 4TH FLOOR "I a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Route 114 Citgo Address of Establishment: 105 North Street Owner's Name: Mohamed Shelab Restrictions: Application Date: 11/14/2003 Permit for Food Establishment 15-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 007-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT i u CITY OF SALEM, MASSACHUSETTS 3" BOARD OF HEALTH •. 120 WASHINGTON STREET, 4TH FLOOR . SALEM, MA 01970 �V)VV NOV 13 2003 TEL. 978-741-1800 FAX 978-745-0343 _ STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO CITY Y OF SALEM MAYOR HEALTH AGENT BOARD OF HEALTH 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT IV0 I h s7''kr tb ;YVC- TEL# 'P-S- �N/- 0?06 ADDRESS OF ESTABLISHMENT /KNJo)' IH 5-T 56ZAL 1 MAILING ADDRESS (if different) OWN ER'SNAMEt2JC&,�MCO S/L�a TEL# 9 V- �-Q0 ADDRESS f1/V CITY STATE ZIP c '�o14 -J CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON_ / M HOME TEL# 7a-6ES- �o /., Yy HOURS OF OPERATION: Mon. Tu4.}Wed._L?Thu. Fri. / }Sat. Sun TYPE OF ESTABLISHMEUT FEE check only RETAIL STORE YE . NO less than 1000sq.ft. 50 1{/ 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 1 RESTAURANT YES NO ` less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO 5 � , TOBACCO VENDORC�ES�� NO 50 ALL Nutt-r'RvFiT(such as church kiicnens) S NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. SiynattreDate Social Security r Federal Identification Number Revised 11/03/03 FOODAP2.adm Check#&Date a y �= 1/I62-r)3 jo/�• Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date T of Operations) Tvde of Inspection A/v �i�� U 0 ❑ Food Service °❑ Routine Address / Risk I Retail St � El Re-inspection 4 Telephone � Level ❑ Residential Kitchen Previous Inspection 16,75� I 0906 ❑ Mobile Date: v-/�/-o 3 Owner I " ' HACCP Y/N ElTemporary ElPre-operation /L/A/. mW /./a13 El Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint B f` .7 14 10.4 2 Inc ❑ HACCP Inspector ' ,.m 4 icOut: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. l:FOOD PROTECTION MANAGEMENT "" '"` . _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS ❑ 3. Personnel with Infections Restricted/Excluded E] 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals v "'` ` ' '" ""' ❑ 4. Food and Water from Approved'Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous.Foods) ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing [321. 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): d 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 ofC earth. 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)(590.006) 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:501nVmFcrT 14dn Inspe tor'�Sig ure: Ier/Jpe Print: PIC's Signature: /// / Print: C Page or�Pages e2 RAS//1s Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Grass-contamination 1 590.003(A) Assignment of Responsibility* 3-302,11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge" Cooked and RTE Foods* 2-103.1'1. Person in char e--duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Annul Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(C) Responsibility of the person in charge to _ Contamination from the Environment .require repealing by food employees and 3 302.11(A) Food Protection I a plicants* 3-302.15 WashingFruits and Vegetables 590.003(F) Responsibility Of A Foal Employee Or An 3-304.11 Food Contact with Equipment and Applie mt To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting b-Person in Charge* 3-306.14(A)(,B) Returned Food and Resemce of Food* 3 590.003(D) Exclusionsand Restrictions* DLsposition of Adulterated or Contaminated 590.003(,F) Removal of Exclusions and Restrictions Food 3-701.11 Discarding of Reconditionin¢Unsafe FOOD_FROM APPROVED SOURCE Food* L4 Food and Water From Regulated Sources F9 Food Contact Surfaces 590.0(}9(A-B) Coml,)lianee with Food Law* 4-501.1.11 Manual Warewashmv-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tent eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202 _02.14 E =s and Milk Products.Pasteurized* 4-501,114 Cheancal Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.' 5-1.01..11 DrinkingWater firm an A roved S stem* 4-(i01.11(A) Equipment Food Contact Surfaces and I'tensils Clean` 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B} Water Meets Standards in 310 CMR 22J0* Contact Surfaces and Utensils'" Shellfish and Flsh From an Approved Source 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and,Recreationally Caught Mollu.wam Food Contact Surfaces of Equi menO Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1g Proper,Adequate Handwashing Oame and Wild Mushrooms Approved by 2-301.1 1. Clean Condition-Hands and Arms* Regulatory Authority 3-202.18 Shellstock Identification Present`r 2-301.12 Cleanlnv Procedure* 590.004(C) Wild Mushrooms* 2-301.14 1 When to Wash* 3-201,17 Game Animals* ll Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,DEinking or Using Tobacco* 3-202.11. PHFs Received at Pioter Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-20215 Package]nte it-* Mouth- 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin * 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* -EELees* Handwash Facilities Tags/Records:Fish Products 13 Conveniently Located and Accessible 3-402'11 Parasite Destruction* 3-402.12 1 Records.Creation and Retention* 5-203.11 Numbers and Ca acities* 590,004(f) Labeling of ingredients' S-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Aeeessibilit O aeration and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 S eeializedProeessingMethods* Devices 3-502.12 Reduced as Ren aaeka nom-criteria* 6-301.11 Handwashirm Cleanser,Atailabilit 8-103.12 Conformance with Approved Procedures" 6-301-12 Hand Drama Provision 4 Denotes critical item in the federal 1999 Foai Code of 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: -Ap Py ely-100 Date: -t'lfi�t,`I Page: a of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION> Date No. Reference R-.Red Item Verified PLEASE PRINT CLEARLY L Nc SdJ ' P iLo.lvd � u ' l e es ti F C'0&L ZZ P Z T Td!r 09 d v d aS r N9 r n. F 06- 0 Q/ -m h. r i I I Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask que6tio s 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 f noncompliance may result in daily fines of twenty-fi a dollar ors s,pensi6n/revocation of :3 Embargo :3 Emergency Closure your food-permit. Z 2r �j ❑ Voluntary Disposal ❑ Other: L 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'(145°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolin-Methods for PRFs 14 Food or Color Additives I9 PHF Hot and Cold Holding 3-202J2 Additives* 3-501.16(B) Cold PFIFs Maintained at or below 590,004(9 41°145°F" 3-302.14 Protection froth Unapproved Additives* 3-501.16(.4) Hot PHFs Maintained at or above IS Poisonous or Toxic Substances 40'F. * 7-101.11 Identifying Information-Original 3-50t.1C(A) Roasts Held at or above 150"(-" Containers* 7-102.11 Common Name -Workin«Containers* 20 Time as a Public Health Control 7-201.11 Se aration-Storages` 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use'K 590.004(H) Variance Res-uirement 7-202.12 Conditions of Use* 7203.11 Toxic Containers-Prohibitions REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitozers,Criterin-Chemicals* POPULATIONS(HSP) _ 7-2(}4.12 Chemicals for Washing Prodaee. Criteria* 21 3-s0'1.11(A) Unpasteurized Pre-packaged Juices and 7-204-14 Drina Agents.Criteria* Beveraees with Warning Labels* 7-20511 Incidental Food Contact. Lubricants'* 3-501.11(B) Use of Pasteurized Eggs* 7-206.11. Restricted U.se Pesticides.Criteria* 3401.1 f(D) Raw or Partially Cooked Animal Food and Raw Seed S roues NoC Served. �� 7-206.12 Rodent Bait Stations' 3-$01.11{C) Uno erred Foci Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring- CONSUMER ADVISORY TIME)TEMPERATURE CONTROLS 11-360' 11Consumer Advisory Posted for Consumption of Animal Foods"That are Raw.Undercooked or PHFsProper Conking Temperatures far Not Otherwise Processed to Eliminate 3-407.L1A(1)(2) Fggs 155 F t5 Sec. Path02.13 Pasteurized Eggs Substitute for flaw Shell 3-401.11.(A)(2) Comminuted Fish,Meats&Came Animak- 155°F 15 sec. * 3-401.11(,8)(1)(2) Porkand Beef Roast- 130°F 121 minx' SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.11(A)(3) Poultry, Wild Game,Stuffed PHFs, residentialkitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections Poultry of Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail. 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F« Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec. " 17 Reheating for Hot Holding VIOLATIOVS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2,Minute Standing Critical and non-critical vtoleriionr , which do not relate to the Time* foodborne idlness interventions and risk factors fisted above, can be ,403.11(C) Commercially Processed RTE Food- ,found in the fallowing sections of the Food Code and l05 CMR 140°F* 590.090. 3-403-1,1(E) Remaining Umliced Portions of Beef Item Good Retail Practices FC 590000 Roasts" 23. Marra ement and Personnel _ Fc -2 603 IA Proper Cooling of PHFs _24. Food and Food Protection ---FC-3 .404 25 ___ Ec}ui ment and Utensils FC 4 `_.005_ 3-5O1.14(A) Cooling Cooked PHFs from 140°F to 26 Water,Plumbing and W rite FC 5 1 006 70"F Within 2 Hours and From 70°F 27. Ph scat Facility FG-6 i .007 to 41.°F(450F Within 4 Hours. * 28, Poisonous or Toxic Materials - ----FC-7 -75i)-8 - 3-501.'l4(B) Cooling PHFs Made From Ambient 29. S ectal Re uiremsnis _ .009 Temperature Ingredients to 41°17/45`17 30 Other Within 4 Hours:r -"Denotes critical item in lhr ttximil 1999 Food Code or 105 CNIR 590.600. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 0 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. .JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT March 22,2004 Route 114 Citgo 105 North Street Salem,MA 01970 Dear Owner, On February 18,2004 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Route 114 Citgo is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco,snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of ONE hundred dollars($100)for the FIRST offense. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4'h Boor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders,and other documentary information in the possession of this Board,and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, oa' 6r oanne Scott Health Agent JS/bas Cc: North Shore Tobacco Control Program Christina Harrington,Board of Health Chairman a N2 2147 City of Salem - Board of Health m.gym•"° Violation Notice- Tobacco Sale to Minors This notice is to inform you that during a tobacco sales compliance check,your establishment violated the Salem Board of Health regulation#24 prohibiting the sale of tobacco products to persons under 18 years of age. Name of esta ishmentent Y IoS ��v �h SCt�F�`l Address , FEB 2 4 2004 G -{ �//� (��O� '\ �U ` 1 f-1I�Pwi'a�Jl_ -1.� Le L- .all Date of sale Time of sale Minor's age/gender Mm ro s ID# — S�)Q�LL Adultsupe Narrative report of incident and description of seller by adult supervisor who will testify at the Salem Board of Health meeting including a description of the seller: I affirm, under the pains Apenallsry, that the above report is true to the best of my knowledge nd elief. Adult sue isor(Signatu no. in in Adult supervisor Print name) VENDOR STAT ENT: I acknowledge I received this Violation Notice on _, � at I'.1 M and I am being given a carbon copy of this notice. I also acknowledge that I have been told that a letter regarding Board of Health follow-up to this violation will be mailed to me at the above address. Owner onagg er/r/Clerk(Signature) , Owner/Manager/Clerk(Print name) If vendor refuses this Notice or if Adult Supervisor feels unsafe in delivering it,an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information, contact the North Shore Tobacco Control Program at 978/741-5646. Board of Health-white/NSTCP-yellow/Establishment-pink p� 1 ii u r CITY OF SALEM, MASSACHUSETTS 3�6 BOARD OF HEALTH • F 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 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 : Mohamed Shelab Name of Establishment : Route 114 Citgo Address of Establishment : 105 North Street Type of Establishment : RETAIL FOOD Application Date : 12/10/2002 Restrictions: Permit for Food Establishment 47-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 10-03 These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT :�. `� CITY OF SALEM. MASSACHUSETTS IIII "• =' '_ j � �.c �y �cormfr,� fl JIB BOARD OF H;E=\L"I"H �c 120 WASHINGTON SA 0Ei. 4TH rLoof' 2002 SALE Nf. MA 01970 DECLl/ 27 U L TCL. 978-711- 7 800 9ffC/,qyp FAX 978-745-0343 CITY G S} LEM S"rANLEY Usovicz. JR. BOARD OF HEALTH .loAN r.•E scorn. MPH, cHo MAYOR HEX LTH A.C,E;'.1 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT dC"r #-132—:G iT(9a : TEL ADDRESS OF ESTABLISHMENT 10L A MAILING ADDRESS (if different) OWNER'S NAME MO#A ct 6 S /Yr A(A TEL# 1�3 6"_aV!cT_� �q0 ADDRESS -3 &P r4 ,L0 L40 CITY!5A Z !i:� _ STATE J/]_ ,M14 _ ZIP 7-c) CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Mo14r4o,4e a 1 M HOME TEL#al a SS— GgC:`f9Y HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun. TYPE OF ESTABLISH M T M FEE check only RETAIL STORE ES NO 3 less than 1000sq.ft. _$ 50 1000-10,000sq.ft. more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES 1O �v-v 3 $5 TOBACCO VENDOR 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 andIie�f, have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Secunty 6F Federal Identification Numbe ---- -------------------------------------------------------------------------------------------------------------------------------- Revised 11/25/02 FOODAP2.adm Check#&Date i :J;,�+e..�.rbrr•..�...•r.-L,....--�.+:....rn,;yrfd+�Anr'�-rrYf*n`�, -Y't+`r.^",�.�iiii..✓.'SAIY+,^'�1vA%r+r.:�s...n++4&f'Rar.mYYFbRwm+.+•Au+w'•*�+-.:.Prr...+m;�a...-.,:.�:w.,.^ro THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978)745-0343 Name Date Tvpe of Operations) Tyoe of In ep ction /TOUT.7 //H (11,11-17,1 ////e 1-40 5-114- X13 El Food Service n( Routine Address .. _ Risk [[]Retail ElRe-inspection 10,5- N� Y S t Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: �9/k 7v - 0901 6-/G-a�2-- Owner HACCP Y/N ❑ Temporary ❑ Pre-operation //'POfl�aime. .ti/>t HAfS ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint /Yl7 rJ2nm v 1 /� 'iin In: ❑ HACCP ¢' Inspector V JlOut: Permit No. EJOther4s,= nrir kiC Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH 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 El 4. Food and Water from Approved Source TIMEJEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating ❑ 7. Conformance with Approved Procedures/ HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control ❑ S. Separation/Segregation/ Protection 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ El 10. Proper Adequate Handwashing El 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 I by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: �j �/y� -//ee Print: PIC's Signature: '_�_A k-61 (,U),C� Print: M Page_�__04,9_ Pages FORM 734A HOBBS&WARREN -BOSTON / t Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assi nment of Responsibility* Cooked and RTE Foods* k590.003(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 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and Applicants* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 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 g" Food Contact Surfaces III'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-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4.702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* dd"il Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 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 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(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures /HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: iFA'/7E /4w Date: S`141-a3 Page: of�? Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 'I No. Reference R—Red Item - - Verified PLEASE PRINT CLEARLY rn�a'i S� i ��/GGGtY/fizfC � e �or7/ eGG �`e C 7 t: 7r �n � x ez7 /e-w'/r l /.'f s _ L%LPI�c 24�FliK f/ I'O M/ f drY 4IC- 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 comply with all mandates of the Mass/Federal Food Code. I understand that p ❑ Re-inspection Scheduled ❑ Emergency Suspension noncoMpliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. A ❑ Voluntary Disposal ❑ Other: i 1 f c 3-501.14(C} •PRFs Received aT Temperatures Violations Related to Foodborne Illness interventions and Risk According to L.aw Cooled to Factors(items 1-22) (Cont.) __ 41'F(45'F Within 4 Hours. PROTECTION FROM CHEMICALS .3-501.15 - Cooling Methods for PHFs 14 Food or Color Additives 19 PHP Hot and Cold Holding 3-202.12 Additives'r 3-501-16(B) Cold PHFs Maintained at or below 590.004( ) 4'1°/45'F* _ 3-302.14 Protection from ltna>>roved Additives* 3:501.16(A) Hot P11Fs Maintained at or above 15 Poisonous or Toxic Substances 140`17. * 7-101.11 Ident'ifyingInfornition-original 3-501.16(4) RoasteHeldatorabove730°F. ' Containers" 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7.201 J.1 Separation-Sfortr?e"' 3-501.19 Time as a Public Health ControP` 7-202.11 Restriction-PresencearndUse� Ego-o( Varianceiauiremeut 7-202.12 Conditionsof else* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions"' POPULATIONS�HSP) 7-204.11 Sanitizers.Criteria -Chemicals* - 7-204.12 Chemicals for Washing Produce. Criteria* 21 3-801.1 I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drving Agents_Criteria* Beverasiff with WanimgLabek* 7-20511 Incidental Foal Corona,Lubricants* 3-901.11(B) Use of Pasteurized F s* 7-206.11 Res..icteii.Use Pesticides,Criteria* 3-301 11(D) Raw or PartiAly Cooked Animal Foocl and Raw Seed S merit's Not'Served " 7-206.l2 Rodcut Bait Stations" 3-801.11(C) Uno coned Food Package Not Re-served 7-206.13 Tracking Powders, Pest Control mid Mone tonin * CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods that are Raw, Undercooked or PRFs Not Otherwise Processed to 73luninata 3-401.11A(1)(2) Errs 1557 15 Sec. Pathoacns - F s Immediate Service 145'F15sec* 3-302.13 Pasteurized Fggs Substitute for Raw Shell 3-401-1 1(A)(2) Comminuted Fish.Meats&dame Animals- 155'F 15 see. * 3-401.1t(B)(I)(2} Pork acid Beef Roast- 130°F 121 mit* SPECIAL REQUIREMENTS 3-401_11(A)(2) Ratites,Injected Meats- 155,F 15 590.009(A)-(D) Violations of Section 590.009(A)-(I))in sec. * carering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Merit, debited corder the appropriate sections Poultry or Ratites-165°F 15 sec.` above if related to foodborne illness 3-40LI I(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animsl Foods C(Y)ked in a practices should be debited under#129- Microwave 165-F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.4)&(,D) PRFs 165`F 15 sec. * (Items 23-30) 3-403.1.1(13) Microwave-165°F 2 Minute Standin« (3thical and non-critical violations, which do not relate to Ike Time* foodborne illness internenfions and risk factots listed above, (:(in be 3.403.11(C) Commercially Processed RTE Food- found in the foilan•ing sec eioas cr/'the Food Code and 10.5 CN7k 140017* 590.000. 3-403.11(E) Reaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 m Roasts* 23, latanagement and Personnel 1 FC-2 .003 24 Food and Food Protection FC-3 -004 18 Proper Cooling of PHFs --- -- o 26 g and Waste FG 4 005 3-501.94(4) Caolinv Cooked PHFs from 940"F to Equipment an -6: Utensils F Nater Plumbin �C 5 006 70`F Within 2 Hours and Front 70`17 27. Physical Facility FC-6 .007 to 41 F145"I Within 4 Hours. * 128 Poisonous or Toxic Materials FC-7 008 3-501.14(B) Coo) nningPIl InMtale From tai 1C Ambient 9 S ecial,Re�cuiremenis 0.09 30 Other Within 4 Hours' 2'AX, *Denotei aitia�l item in the federal 1999 Food Codc or 105 ChaR 590.000. r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH n :9 120 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 TEMPORARY FOOD PERMIT 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: Name of Applicant: Rt. 114 Citgo - Mohamed Shehab Address of Applicant: 105 North Street, Salem, MA Name of Event: Customer Appreciation Day Location of Event: 105 North Street FOOD TO BE SERVED: Hot dogs, nachos & cheese, popcorn, soda. Permit#: 29-03 Application Date: 08/08/2003 Date(s) Event Held: 8/6/2003/thru 8/9/2003 Permit Expires: 08/09/2003 (� HEALTH AGENT D CITY OF SALEM, MASSACHUSETTS �y� BOARD OF HEALTH 3 120 WASHINGTON STREET, 4TH FLOOR � SALEM, MA 01970 yeq TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT FEE: 1-3 DAYS= $200 4-7 DAYS= $300 MORE THAN 7 DAYS= $400 �4 I_ ��/ CHECK PAYABLE TO THE WY OF SAL NO CASH NAME OF EVENT( l4 7E o'1'PO'edg l �9 LOCATION KT �� CT O DATE(S)OF EVENT c`�i 01 9��/�3 n I/ /� / '� 7 /w �//,'o-7SIQ NAMEOFAPPLICANT ITl!_l /�)/^Ily (�17�0�/TELEPHO7NE# 7�7Yf -30 w� ADDRESS &ffilwo-el / NAME OFBUSINESS RT I Cld TELEPHONE# /(O- (y 7^3/7e) ADDRESS )b5- � � eRt4lAl l xl - ofyo CERTIFIED FOOD MANAGERS NAME CERTIFICATION# A PLAN OF THE ESTABLISHMENT IS: ENCLOSED DRAWN ON THE BACK TYPE OF REFRIGERATION: _GAS ICE DRY ICE _OTHER iL/bjl,�•+-r.� . METHOD FOR COOKINGIHOT HOL91NG: GAS VDROTHER METHOD FOR SANITIZING: // CHEMICAL OTHER SOURCE OF FOOD: NAME: ADDRESS FOODS TO BE SERVED INCLUDING IINGREDIENTT/S AND METHOD OF P EPP�ARATION: ec� com- 1 HAVE READ THE BOARD OF HEALTH, "REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS." I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PERSUANT TO MGL C62C, S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, TO MY BEST KNOWLEDGE AND BELIEF, HAVE FILED ALL ST D A ST TE TAXES R QUIRED UNDERLAW. SIGN URE DATE SOCIAL SECURITY OR FEDERAL ID# TEMPAPPL REVISED 1112W2 PEWITN CHECK#B DATE CITY OF SALEM; MASSACt HUSETTS p x411 # : , f BOARD OF HEALTHp . { k� n 120 WASHINGTON STREET,-4TH FLOOR, ' SALEM, MA 01970 - TEL. 978-741-1800a ' FAX 978-745-0343 STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT - COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A. FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws , to operate a Food Establishment in the City of Salem is hereby granted to: Owner' s' Name: Mohamed Shelab /°CQ,OVIM , Name of Establishment : Route 114 Citgo Addres's of Establishment : 105 North Street Type of` Establishment : RETAIL FOOD Application Date : 11/28/2001 Restrictions: e Perntitxfor' Food Establishment 1 :"A2 _ Frozen, Desserts/'Ice Cream r ' Permit for,the Sale of Tobacco Products , 17£02 These Permits :Expire December: 31;: 2002 K , ' This permitiis 'not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the&sEstablishment. 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 6 o CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH �A 120 WASHINGTON STREET, 4TH FLOOR '• _ SALEM, MA 01970 j� TEL. 978-741-1800 ® �LEI 11� FAx 978-745-0343 STANLEY USOVICZ, HEALTH AGENT JR. JOANNE SCOTT, MPH, RS, CHO J) ]n MAYOR NUV [ 8 LV0I CITY OF SALEM HEALTH DEPT, 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT rQ7 / 14, TEL#/ 4 Y I •s o 90.� ADDRESS OF ESTABLISHMENT )ph4)1Q 1 f t S T S AN?,. n MA MAILING ADDRESS (if different) OWNER'SNAME tAoNAMtn TEL# :�:Fl— 6L;t 1cl ADDRESS- ig it AIA 6 AK ST CITY 4La:L, fir' -,_ STATE k/} ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON KnIJAPtaf) HOME TEL# Y� DAYS/ HOURS OF OPERATION: Mon. ue._ic�_Wed.__aThu._VL Fri. c Sat. I Sun. P+,1 P r TYPE OF ESTABLISHMENT FEE check only RETAIL STORE ES NO / ,(3a $40 RESTAURANT NO $40 BED & BREAKFAST YES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO $5 TOBACCO VENDOR YE NO 10 NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPTFORM 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. f__-QI1,x Wn=C2Ci Yom— l-z�- 0i Asa q3— ( - z—F Signature Date Social Security or Federal Identification number ------------------------------------------------------------------g-------------------------- ----------------------------------- Revised 11/1/01 foodapZadm Check#&Date w*.^.-.w--+-.'%.J''!i{ ,�,F'ow.r^Jrt. y..b. .w�...:zr.0 �. . ,w.y u.�a...._ ..e.:c-aw}..�:.o. ,,:: THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street Board Of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 740-9705 Name Date Type of Operation(s) of Ins ection X77 / ' f 14--16 0 2.- Ll Food Service Routine Address a / Risk 2 Retail ❑ Re-inspection OS /1/nRn Sf Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: 7-ay_Clo/ k7 ❑ Temporary ❑ Pre-operation Owner HACCP Y/N ❑ Caterer ❑ Suspect Illness /,0 f} P // Person in Charge(PIC) Time [I Bed &Breakfast El General Complaint M,1 H� �Q ,yl ❑ HACCP Inspector - / In: LlOther )l /O s-- / Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) Violated. Non-compliance with: RED Violations (1-22) 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. Local Law ❑ 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 ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals f FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP 1:110. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations (23-30) 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(RED Items 1-22): of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C' N' 590.000/Federal Food Code.This report,when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 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: A Inspector's Signature: /) Print: ' PIC's Signatyre:b� e %G Pr i t: Page__L of Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT 8 +, Cross-contamination 1 1 590.003(A) I Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2. 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Chare* Contamination from the Consumer _ 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003E Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ _ Food* 4 Food and Water From Regulated Sources :__9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness* 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensilsand Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by 110 Proper,Adequate Handwashing Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* F-117 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges from the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6£ Ta s/Records:Shellstock 12( Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13, Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients` 5-204.11 Location and Placement* 7*' Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. T CITY OF SALEM 9 BOARD OF HEALTH j A Establishment Name: /ajn.Ve Date: Page: of " t Item Code " C Critical,item y DESCRIPTION OF VIOLATION / PLAN OF.CORRECTION s Date •' ` , ' i� '• Verified No. Refer Red Item JI „ S -, T PLEASE PRINT CLEARLY a '. S a b P�71rL vCfd�2: 111)W01 LY t M15 7-1,179 e- i' "t Ler c to P .v / zo s e u-/�v Gx , oafs r 'S A � r N Sri? P. 1 .f/ S r.7lr✓C/ /ii/a /e // iv/T/�U' //?.Ps9c/><C n�ix-/.rr-sc_ "r k a R t d c F ' Discussion With Person in Charge: Corrective Action Required:%" ❑No) ❑Yes s{ 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 comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension 'r result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure r S .,� ❑ Voluntary Disposal ❑ Other { FORM 734B HOBBS& WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1.22) (Cont.) According to Law Cooled to 41°F/45'F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/450F* 1L Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* ,::20... Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21: 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* ,«•- Beverages with blaming Labels* 7-204.14 Drying Agents,Criteria* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(6) Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw, Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Erfectw 11112001 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(6)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17( Reheating for Hot Holding (Blue Items 23.30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.1l(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18:; Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41°F/45°F Within 4 Hours.* 28, Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name D t Type of Operation(s) Type of Inspection L 6 ( ❑ Food Service ❑Routine Address O RI [-Retail [�Re-inspection Telephone Level ❑ Residential Kitchen Previous Ins ecti99nn p 0 i d El❑ ❑ Mobile Date: )U / Owner HACCP YIN Temporary Pre-o roti � / 2 /" ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time ElBed&Breakfast ❑General Complaint ❑ HACCP Inspector ( Permit No. ❑Other Each violation c ecked requires an explanation on the narrative-page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) [I pose an imminent health hazard and require immediate Tobacco 590.009(F) Violations marked may ❑ y p q Allergen Awareness 590.009(G) ❑ corrective 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'CHEMICACS ❑ 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded - ❑ 15.Toxic Chemicals 171 4. Rod and APPROVED SOURCE 'lIMEITEMPERATURE CONTROLS(Potentfally kazaidpus F0000.) ' ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION - [119. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HtGHIY-$U$CEP.TIBLE=POPULATIONS(H$P). E]21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMERADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below' C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2x590.00order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3X590.004)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5x590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing 8. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. .3D. Other DATEOFRE-INSPECTION: s. o-radoo /V rN Inspector's Signature: Print: PICS Signature: Print: S' Page=ZXsges Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(]) Raw Animal Foais Separated from 1 590.003(A) IAssu,rnem of Responsibilit * Cooked and RTE Ftxtcls* 590.003(6) I 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 reportingby food employees and 3-302,t5 Washing Fruits and Vegetables a tfivants* 3-304.11 Food Contact with Equipment and 590.003(P) Responsibility Of A Food Employee Or An Utensils* Applicant To Report'ro'I11e Person In Contamination from the Consumer Chu"^* 3-306.14(A)(B) Returned Food and Resetvice of Foal* 590.0113(6) Re rrdn b Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restdctinns 3-701.11 Discarding or Reconditioning Unsafe Food.* FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 rood in a Hermetically Sealed Container* Sanitization Temperatures* 3.201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical WarewaOfing-Hot Water 3-'202.13 Shell E s* __ Sanitization Temperatures* 3-202.14 EMs and Milk Pr xirtcts,Pasteurized* 4-501.114 Chemical,-Samlization-temp.,pH, 3-202.16 tee Made From Potable Drinking Water* EquipconcentrationnF and Contact hardness. 5-1.01.11 Drinking Water from an Approved System* 4-60L11(A) Utensils Cl Food Contaci Sutfaccs and Utensils Clean* 590.006(A) Bottled Dri nkmg Water* 4-602.11 Cleaning Frequency of Equipment Fund- 590.006(6) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Sheflfish and Fish From an Approved Source 4-70� t'l. Frequency of Sanitization of Utensils and 3-201.14 Fish and ftecrcaCi<mall}�Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and. 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Re ulato Authorff '3-202.1.8 Shelistock Identification Present* 2-301.-12 Cleaning Procedure* 590.004 C} Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* ll Good Hygienic Practices g ReceivinglConditlon 2-401.(1 Eating,Drinkingor UsingTobacco* 3-202.11 PHFs Received at Proper Tent natures* 2401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tastin t 6 TagalRecords:Shelistock 12 Prevention of Contamination from Hands _3-2A2.18 Shelistock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em>lo ees* TagstRecords: Fish Products 13 Handwash Facilities . Parasite Destruction* - Conveniently Located and Accessible 3-402,11 3-402.12 Records.Creation,and Retention* 5-203.11. N cation add Capacities*emn 590.0040 Labeling of Ingredients* 5-204.11 Location and:Placement* Conformance with Approved Procedures 5-205.11 -Accessibility, (enation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying Devices 3602.11 Specialized Processing Methods* 6-301.11 Handwashin Cleanser,Availability 3-502.12 Reduced oxygen ack " a,criteria* 6-301,12 Hand Dr 'n Provision 8-103.12 Conformance with Approved Procedures* -Denotes critical items in the federal 1999 Fa>d Code or 105 CNIR 590.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: t Date: Page: a Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Deter No. Reference R-Red Item -Verified PLEASE PRINT CLEARLY (- Q 0 SUI, lC Vk 4,, 62 ✓U Discussion With Person in Charge: Corrective Action Required: ❑ No I have read this report, have had the opportunity to ask questions and agree to correct all oluntary 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: I 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(Items 1-22) (Cont.) 41'F145°F Within 4 Hours. ' PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs _ 14 Food or Color Additives - 19 PHF Hot and Cold Holding I 3-242.12 Additives* 3-50136(13) Cold PRFs Maintained at or below 3-302.14 Protection from Un roved Additives" 590.004(F) 41°t4S°F* 1g Poisonous or Toxic Substances 3-50IA6(A) Hot PHFsMaintained atorabove 140°P. * 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F.* Containers* 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* * 3-501.19 Time as a Public Health Control*Separation-Stora ge7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement + 7-202.12 Conditions of Use* lREQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-243.11 Toxic Containers-Prohibitions* POPULATIONS NSP 7-204.11 Sanitizers.Criteria-Chemicals* i 7-204.12 Chemicals fru Washing Produce,Criteria° 21 3-801.1](A) Unpasteurized Pre-packaged juices and 1 7-204.14 Drying Agents.Criteria" .Beverages with Warning Labels* 3-801.11M) Use of Pasteurized Eggs* 4 7-205.11 Incidents]Food Contact Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and + 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Saved- 7 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re=served. + 7-206.13 Tracking Powders, Pest Control and Momturm t CONSUMER ADVISORY ' TIME([EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted fur Consumption of t ib Proper Cooking ONTR Temperatures for Animal Foods That are Raw.Undercooked or PHFs rop Not Otherwise Processed to Eliminate Pathogens,'e"14'3-40i.1IA(1)(2) Eggs- 155°F 15 Sec. Eggs-Immediate Service 145°F15see• 3-302.13. Pasteurized Eggs Substitute forRaw Sheol EggO 3401.11(A)(2) Comminuted Fish.Meats&Came Animals-155°F 15 ser. " SPECIAL REQUIREMENTS I 3-441.11(8)(1)(2) Port:and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3401.11(A)(2) Ratites,Injected Meats-155°F 15 sec.* catering,,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Comaining Fish,Meat, debited under the appropriate sections I Poultry or Ratites-165'F 15 sec * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145'F 9c 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 340LI I(A)(1)(b) All Other PHFs- 145'F 15 sec { 1 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PR4C77CES 3-403.41(A)&(D) PRFs 16ST 15 sec.* (Items 23-30) j 3403.11(13) Microwave-165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the k Time* foodborne illness interventions and risk factors listed abuse, cars be 3-403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 1 140°F* 590.000. 6 3-403.i1(E) RemainingLiaslicedPorticrosofBeef (_GoodRetailPractices .FC 590.000 Roasts* 23. Management and Personnel 1 FC-2 .003 1s Proper Cooling of PRFs 24. Food and Fnod Protection ! FC-3 .5HI4 ! i 1 2fi. EqulPmeru and utensils j FC-4 .005 3--5101.14(A) Cooling Cooked PHFs from 140°F to ! 26, + Water.Plumbing and Waste i FC-5 606 70°FWithin 2 Hours and From 70°F 27. Physical Facility i FC-6 .007 to 41°F/45°F Within 4 Hours.* 128_ " Poisonous or Toxic Materials - ! FC 7 .008 3-501-.14(B) Cooling PHFs Made From Ambient 29. �Special Requirements ' I .009 Temperature Ingredients to 41°F/45T30. l Other -----i-- - Within4Homs* ssvar, t *Denotes critical rem in the federal P)99 Foci Came a,105 CMR 390.000. { r i Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"' Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTAKISHMENT INSPECTION REPORT Tel. Name / Dat Type of Operations) Type of Inspection _ C Food Service Routine Address Jg RistR7dil El Re-inspection Telephone Level ❑❑❑❑❑❑ Residential Kitchen Previo.u��nnsp cion )- ❑ Mobile Date:,�I( Owner HACCP YIN [I Temporary ❑Pre per io (tri JA ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Tim ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out Permit No. ❑.Other Each violation checked requires an explanation on the narrative ages)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking 590.009(E) ❑ Items) Tobacco 590.009(F) ❑. Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. '• FOOD PROTECTION MANAGEMENT:,_ _ -_ _ 7_ [112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties E ' +" - - -- ❑ 13.. Handwash Facilities MPLOYEE HEALTH _ _ _.._._ ..... i pROTE_CTIONFRO.MCHEMICALS- -„�._ ❑ Cl2. Reporting of Diseases by Food Employee and PIC " 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El,_. 15.Toxic Chemicals FOOD.FROM APPROVEDSOURCE ,�„•_ _ - IMErrWPERATURE.CONTROLSPotentialtyMa¢aidousFoods ` -' ❑ 4. Food and Water from Approved Source IT ( ) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18.Cooling _- - -' 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ___�_�_� _ _ _ _ . 9 ❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR-HIGHLYSUS..CEP-r Bd:E.POPULATIONS;(HSP)4] 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing [3 ❑ 11. Good Hygienic Practices ,.CONSUMER ADVISORY _ _ ❑22. Posting of Consumer Advisones J 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-2x590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-sxs9o.004)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food 6.Water, Plumbing and Waste (FCsx590.006) establishment operations. If aggrieved b this order,you 99 Y 27. Physical Facility (Fc-6x590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTIOAk- s: ��e.da _ Inspector's Signature: Print: PICsSigoature: Print: S� �� Page7ofPages =7 k� AA 4, ai Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT F- 3-302.11(A)(1,) Raw Animal Foods Separated from Cooked and RTE Foods* B) I Demonstration of Knowledge" Contamination from Raw ingredients 2-103.11. Person in charge-do 3-302,11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment _j90 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 Eplicants* 3-30411 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report'Fo The Person In Contamination from the Consumer Charge* 3-306_14(A)(B) Returned Food and Resenice of flood* by person in Charge* Disposition of Adulterated or Contaminated 590.00N 1 31 590 003tM Ms and Restrictions* Food _590.003(E) Removal,of FxcluN ion"and t(.estnctions 3-70).11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE - r_4 Food and Water From Regulated Sources r-9 Food Contact Surfaces I Water .4-507."i.11 Manual Warewashing-Hat Water %590�10104(A-B) Com Ilumcer With Food Law" 'e' Sanitization Temperatures* mc 01 H Milk at dMl 3-201 12 Food in a Hermetical) Sealed Container* F 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202-13 Shelf E- 4-501.114, Chen-deal Sanitization-tempr,PH, 3-202.14 Es and Milk Products.Pasteuri7cil)l concentration and hardness. 7 1-202.16 lee Made From Potable DrmfsiuLWater* 4.601..11(A) Equipment Food Contact Surfaces and 5-101,11 Drinking'Water from an Approved System* Utensils Clear* 590.006(A) _1!�.tledDrifikmWat��. 4-602.11 Cleaning Frequency of Equipment Ford- 590.006(B) Water Meets Standards in 310 CNIR'2,0* Contact Surfaces and Utensils* Shellfish and Fish From i 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* 4-70311 Methods of Sanitization-Hot Water and 71:201.15 Molluscan Shclifish from NSSF Ustad Chemical* Sources* LLo- Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Reculatory AuthoA.. 2-301.1 2 Cleaning Procedure* Shellstmk idenfificatiou Present* 2-301.14 When to Wash* 590,004(C) Wild Mushrooms* 3-201.17 Game,Animals* 11 Good Hygienic practices RecelvinglConditton 2-401.11 Eating,Drinking or Using Tobacco* 5 3-202.11 PHN Received at Prover Tenveratutes* 2401,12 Discharges.From,the Eyes,Nose and 3-202.15 Package bite grityy._ Mouth*I 1-11)1.1 Food Safe and Unadulterated 3-30112 Preventing Contamination When Tasting* F-6 -" '. Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F) Preventing Contamination from 3-203.12 Shellstock identification Maintained* Employees* Tags/Records;Fish Products 13 Handwash Facilities Parasite D's 600 Conveniently Located and Accessible 3-402.11 -uc 5-203.11 Numbers and Capacifies* 3-41)22.12, Records.Creation and Retention, 5-204.11 Location and Placement* 590.004(1) Labeling of Ingredients' 5-205.11 Accessibility,Operation and Maintenance 7 Conforplans mance with Approved Procedures Supphod with Soap and Hand Drying JHACCP MDevices 3-502J2 02.11 Processing erhodsi' 6-301.11 HandwashingClean,�,er,,Availability =Sol_xygen packaging,criteria* ng 8-10316-301.12 Hand DryiProvision 2 Conformance with Approved Procedures* Dtmita critical item in the W=j 1999 ford 6&er 105 CMR 5901W, CITY OF SALEM ,��,// BOARD OF HEALTH Establishment Name: W Date: Page:_ of _ Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION pate No. Reference R—Red Item Verified PLE P INTCLEARLY f r � o cY d ✓ — Sol.l, Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 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 twe y-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: r i. . 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodbome Illness Interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont) 41'F/45°F Within 4 Hours, PROTECTION FROM CHEMICALS '-501.15 CoolingMethods for PHFs 14 Food or Color Additives 19 CHF Hot and Cold ine Holding 3-202.12 Additives* 590,(X16(8) 410/ PHFs Maintained at or below 590.004(F) 41 /45 F* 3-302.14 Protection from Unapproved Additives* I5 Poisonous or Toxic Substances 3-501.16(A) HotPHFs Maintained of or above 1400F. 7-101.11 Identifying Information-Original 3-501,16(A) Roasts Heid at or above13WF. Containers* - Time as a Public Health Control 7-102.11. Common Name-Working Comainers* 3-501.19 Time as c a Public Health Control* 7-201.11 Separation-Storage*. 7-202.11 Restriction-Prence and Use* 590.004(H) Variance Requirement es 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sur itizers.Criteria-Chemicals* 7-204.12 Chemicals for Washin Pmdtrce,Criteria° 21 3-80.1.11(.4) Unpasteurised Pre-packaged Juices and Bev7-204.14 in Agents.Criteria* .Use of with Warning Labels* 7-205.11 Incidental Food Contact,Iatbricants* 3-801.11(8 Use ofPasteurized Eggs* ed 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially is Not S Animal Foal and Raw Seed Sprouts Not Served. ,-206.12 RodenrBait Stations* 3-801.11(C) lino ened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11. Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.'�`/" 3 4 F 01.I1A{t}{2} Eggs- I55 IS Sec. . EM-Immediate Service 145'F15sec* 3-302.t3. Egsteurimd Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E * Animals-155°F 15 sec.* SPECIAL REQUIREMENTS 3.401 A I(B)(1)(2) Pork and Beef Roast 130°F 121 min* 3-401.11(A)(2) Ratites,Injected Meats 155°F 15 540.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PRFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 1.5 sec. * above if related to foodborne illness 3-40LIl(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F+' 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F a Special Requirements. 3-401.11(A)(1)(5) All Other PHFs-145'F 15 sec. 17 Retreating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403,11(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 31303.11(13) Microwave-'165°F 2 Minute Standing Critical,and non-crilicaI violations,which do nor relate to the - Time* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Cade aacd 105 CMR 1400Fu 590.000. 3403.11(E) Remaining Unsliccd Portions of Beef Nem . Good ROW Practices FC 590.000 Roasts* 23. 1 Management and Personnel FC-2 .00 tg Proper Coating of PHFs 2' 4. Foal and Food Protection FC-3 .004 25.- 1 Equipment and Utensils J FC-4 .005-� 3-501.14(A) Coaling Cooked PHFs from 140°F to 26. { Water,Plumbing and Waste 1 FC-5 .066 70°F With s2 Hours and Front 70 F 27. Physical FaclHi FC-6 .007 to 41°F/45°F Within 4 Hours. * *oxic Materials 1 FC-7 .408 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements 009 Temperature Ingredients to 41017/450F 30. 1 Other Within 4 Hours* *Denotes critical ism in the federal 1999 Find Coele or 105 CMR 590.000. / CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page:£ of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION note- No. Reference R-Red Nem verified LEAS PRINT CLEAR Y 2k4 -b5 V ✓ Z Kttu-- -(-hvC'QZILAIJ Y.Stj K S,n Cly S ,�/ r v. t i lL — 1 - —, — }}P✓�T 161) Afy 0"St S4,L3 1 cn( / o2L o k c3�IF 3r f Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction 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 twe -five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit ❑ Voluntary Disposal ❑ Other: - 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne 111ness.Interventions and Risk _ According to Law Cooled to Factors(items 1-22) (Cont-) 41."F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolia Methods for PHFs 19 PHF Not and Cold Holding 14 Food or Color Additives 3-501.16(B) Cold PHFs h9aintained at or below 3-202.12 Additives'' 590.004(F) 410/45°F* 3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 140 * 7-101.11 Identifying Information-Original 3-501.16(.9) Roasts Heid at or above 130'F. " Containers* 7-102.I1, Common Nance-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as if Public Health Control* 7-202.11 Restriction-Presence and Use* - 590.W4(H) Variance R uirement 7-202.12 Conditions of[Jse* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals° P AI(A) DNS HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(.4} Beverages wit Pre-packaged juices and 7-204.14 Drying Agents.Criteria* .Use of es with ed Egger Labels* 7-205.11 Incidental Fund Contact,Lubricants* 3-801.118 Use of Pasteurized C Eggs* 7-206.11. Restricted Use Pesticides;Criteria* 3-801.11@) Raw or Partially Canoed Animal Food and Raw Send Sprouts Not Served. 7-206.12 Rodent Bait Stau ns* 3-801.11(C) Unopened Food Package Not Re-served, 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY T1ME(TEMPERATURE CONTROLS 22 3-60331 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for - Not Otherwise Processed to Eliminate PHFs tl ubst' 3-401.11A(1)(2) Eggs- 155'F 15 Sec. Pa * Eggs-Immediate Service 145'F15sec* 3-302.1.3. Pasteurized Eggs Substitute for Rau'Shell Eggs* 3401.11(A)(2) Comminuted Fish.Meats&Game Animals-155*F 15 sec. * SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast- I309F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3401.11(A)(2) Ratites,Injected Meats- 155°F 15 sec.* catering,mobile food,temporary and 3401.1[(A)(3) . Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F I:5 sec.* above if related to foodborne illness 3-401.1I(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Fonds Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-14PF 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) 'PHFs 165-F 15 see.* (Items 23-30) 3-403.1.1(B) Microwave- 1650 F 2 Minute Standing Gritical,and non-critical violations,which do not relate to the Time* foodborne illness'interventions and riskfactors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in she following sections of the Food Code and 105 CMR 14001,'* 594.0010. 3-403.11(E) Remaining Unsliced Portions of Beef 1 Hen I Good Retal/Pracdees .FC 580.000 :Roasts* 123. 1 Managetttent and Personnel FC-2 .003 Proper Cooling of PHFs r (-24. 1 Food and Food Protection FC-3 .004 18 - �25. (�Equiament and Utensils - F7 C-4 .005 4 3-501.141A) Cooling Cooked PHFs from 140°F to 26. l Water,Plumbing and Waste FC-5 .006 -} 70OF Within 2 Hours and From 70`F - 27. 1 Pti sisal Facie FC-6 .007 to 41°F/45T Within 4 Hours. * 28. Poisonous or Toxic Materials ' FC=7 .008 l 3-501.14(B) Cooling PHFs Made From Ambient 29. s ecial Requirements .009 Temperature Ingredients to 4V'F/45o17 30. 1 Other Within 4 H(wrs* *Nnotea critical item in the federal 1999 F(ad CWe or 103 CZAR 590.W0.