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SEA LION MINI FOOD MART - ESTABLISHMENTSSEA LION MINI FOOD MART 10 FRONT STREET 4b CARLSON GMAC REAL ESTATc�..,, 434 Humphrey Street Swampscott, MA 01907 Email: kardlfabio@aolcom Office: (781) 599-5170 fll Fax: (781)599-5760 Voice Mail: (761) 477-2503 KAREN D. DiROCCO, ABR, GRI GRI REALTOR` Mufti MJlion DoIW CWE Commonwealth of Massachusetts r b City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: File Number: BHF -2004-0315 LOCATED AT: Sea Lion Mini Food Mart 10 Front Street Salem MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2006-0206 Jan 3, 2006 Dec 31, 2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 3 of 10 41,111, „ STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TOO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT glEA L-1 f1``Q"tll TEL # H- ) 7'H aha ADDRESS OF ESTABLISHMENT 10 tFW l 91AE 'J 4 SWJM I Mft"4_6 MAILING ADDRESS (if different) OWNER'S NAME S'I� Rfl u TEL # (q � 7 �I CITY a(` 1 N CERTIFIED FOOD MANAGER'S NAM (required in an establishment where potent EMERGENCY RESPONSE PERSON_ HOURS OF OPERATION: Mon. ✓ TYPE OF ESTABLISHMENT RETAIL STORE YES (QO RESTAURANT YE YES grJW_E_T STATE M4 -V ZIP Oa I vP c AN AA ��CERTIFICATE#(s) 7 2 g 33 i IN a783 lo?, (v) Pr zardous food is prepared.) N9flZA '� til HOME TEL # Wed. Thu. Fri. ✓ Sat. ✓ Sun. FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ............. ------------------------------------------------- --------------....--..... NO less than 25 sseeats =$10 than =$150 more more than 99 seats =$200 ----------------------------------------------------------------------------------$100 ............... - ----- --............................ --------------------------- MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES 5 TOBACCO VENDOR YES $50 ALL NON-PROFIT (such as church kitchens) YES O $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant 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. IfIzr�IuO `306— 0ey - Signature Social Security or Federal m Number ---------------------------------------------------- I------------------------------------------- Revised 11/03/05 FOODAP2.adm Check# & Date�yj '/ / 0 Q 10 Front Street Sea Lion Mini Food Mart City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: - - _ Item Status Violation Critical Urgency Nature of problem or correction Non-compliance with: Done 741-2223 Owner: ' Anti -Choking PASS ❑ Sandra Yu .-s Tobacco PASS ❑ PIC. - _ Sandra Yu FOOD PROTECTION MANAGEMENT Done PIC Assigned / Knowledgeable / Duties PASS RED Inspector: EMPLOYEE HEALTH Done David Greenbaum Date Inspected: Correct By. Reporting of Diseases by Food Employee and PIC PASS ❑d RED 5/13/2005 .a 3' Personnel with Infections Restricted/Excluded PASS RED Risk Level: K - FOOD FROM APPROVED SOURCE Done Food and Water from Approved Source PASS ❑ RED Permit Number - BHP -2005-0134 '' Receiving/Condition Tags/Records/Accuracy of Ingredient Statements PASS PASS ❑� ❑J RED RED +. Status: _�* , 4 SIGNED OFF Conformance with Approved Procedures/HACCP Plans PASS RED _ # of Critical Violations: PROTECTION FROM CONTAMINATION Done _-' _ •' Time IN jime OUT Separation/ Segregation/ Protection PASS ❑J RED Food Contact Surfaces Cleaning and Sanitizing Proper Adequate Handwashing PASS PASS ❑d RED RED Notes.., 144: Urgency Description(s): m Good Hygienic Practices PASS Q RED BLUE: " , 15 - 'k Violations Related to Good Prevention of Contamination from Hands PASS /❑ RED Retail Practices (Critical Handwash Facilities PASS Q RED violations must be corrected immediately or within 10 days) (Non-critical violations GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 16,2005) Page 1 o(2 10 Front Street Done Sea Lion Mini Food Mart must be Corrected Immediately PROTECTION FROM CHEMICALS Done Food and Food Protection PASS or within 90 days)" - .. Approved Food or Color Additives PASS FAIL Non -Critical RED RED:e = { Related to Violations Toxic Chemicals PASS ❑d RED Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS (Potentially Haz Done BLUE Physical Facility and Risk Factors (Require - Cooking Temperatures PASS ❑d RED immediate corrective action) - BLUE Special Requirements PASS ❑ BLUE Reheating PASS ❑d RED Cooling PASS ❑d RED Hot and Cold Holding PASSd❑ RED Time As a Public Health Control PASSd❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASS ❑J RED CONSUMER ADVISORY Done Posting of Consumer Advisories PASS RED Violations Related to Good Retail Practices (Blue Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils FAIL Non -Critical ❑ BLUE Beverage air cooling unit has accumulation of food debris. Thoroughly claen unit. 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 GeOTMS02005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 16,2005 ) Page oft CITY OF SALEM, MASSACHUSETTS ' BOARD OF HEALTH ' 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Sea Lion Mini Food Mart Address of Establishment: 10 Front Street Owner's Name: Sandra Yu Restrictions: Application Date: 11/24/2004 Permit for Food Establishment 67-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR a' SALEM, MA 01970 TEL. 978-741-1800 NOV 2 3 2004 FAX 978-745-0343 STANLEYJ. HEAAGENT BO OVICZ, JR. JOANNE SCOTT, RS, CHO ARDop OOFSALB M 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT HEATH NAME OF ESTABLISHMENT 9U LiOnt 2- Z 2- 3 ADDRESS OF ESTABLISHMENT I0 F"NT 9T t- E,T MAILING ADDRESS (if different) OWNER'S NAME �plv��A Ytk TEL# ADDRESS 2 UF-OA)HP-D R ET CITY yl)F_-N STATE PVI Iq ZIP 0 D 1 14 f CERTIFIED FOOD MANAGER'S NAME(S) ` "RTIFICATE#(s) T2 9 9 Kr'? IA (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Sir V LSA 1 HOME TEL # -% f-) 32 %'I HOURS OF OPERATION: Mon.g1 Tue.6L_ZWed.6[- LThu.Fri.JESat. 9_7 Sun. 1 U 30 -S oo TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 o'0-6 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$1 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) 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 nAd— b�e}f, have filed all state tax returns and paid all state taxes required under the law. TvV 'tom � I(l�rljoy `300- o, tQ- /I6 Signature Date �� Social Security or Federal Identification Number -------- -------- - ------ -- ----- - --- -- - Revised 11/03/03 FOODAP2.adm Check# & Date T ) f P m STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Sea Lion Mini Food Mart Address of Establishment: 10 Front Street Owner's Name: Sandra Yu Restrictions: Application Date: 11/14/2003 Permit for Food Establishment 009-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT STANLEY USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT SEP LION S WHA TEL #(q1&) T�j ADDRESS OF ESTABLISHMENT 10 F"N I STRPE T SALEM) MP,0 1 c1 7 0 MAILING ADDRESS (if different) g pN D&A OWNER'S U_ ADDRESS `Z3 LF -0 NA0.D' S V & e rt CITY JIM RUEN _ STATE_ CERTIFIED FOOD MANAGER'S NAME(S) __ efl NIRA TEL #_ ( � 14 ( —22L3 7_IP. Od(y - _ �� CERTIFICATE#(s) 7j,e_ '_ 9 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON SA NDGiA YLA= HOME TEL # i S 3 2-y - 3 � y HOURS OF OPERATION: Mon.l''4-Tue°-_+ Wed.�`4-Thu. °L�3 Fril-4 Sat._J-}sun. 1,6 -r TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 Q� more than10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats _00 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 $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT (such as church kitchens) YES O $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge Cyd beli f, hav filed all sta tax returns and aid all state taxes required under the law. 9 54"�7 , I I 31619 p '3 00 le -q00- OI Signature Date Social Security or Federal Identification Number --------- -------- ----------- ------------- - -- --------- -- Revised 11/03/03 FOODAP2.adm Check# & Date %�-/3 `d .3 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 /d eel T�v aAf Ooeration(s) [J`Food Service ❑ Retail E] Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. T e of_Inspection JI -outine ❑ Re -inspection Previous Inspection Date: ElPre-operation,r4a4 ❑ Suspect Illness ❑ General Complaint El HACCP El Other Address D 2 r Risk Level . M Telephone "� Owner V HACCP Y/N Person in Charge (PIC) t Time In: Inspector /Out: '14 IX 1ralu I.M r-acn vtoration cnecKea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT. ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE - .. ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. 23. Management and Personnel (FC -2)(590.003) g4'. -Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S:5WMN,UFO 14.dW ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS I - [114. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR. HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature• Print: PIC's Signature: Print: s �-iy� \� Pagel of ages �J Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 590.003(A) A.ssignrnent of Responsibility* 590.003(B) Demonstration of Knowled_ ear_ 2-103.11 Person in charge- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of'the person in charge to Com Bance with Food law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* a p .licantsx Shell Eggs* 590-003(17) Responsibility Of A Food Employee Or An 3202.16 lee Made From Potable Drinking Water" Applicant To Repoli To The Person hi Drinking, Water from ant Approved S -stem* 590.006(A) Charse* 590.006(B) 590.003(6) Re txdn� by Person itt Char*e 3 590.003(D) Exclusions and Restrictions* 3-201.15 59(1.003(E) Removal ofEsclusiotsand Restrictions 13 • r • 101 c De[xAe9 critical item in the federal 1999 Food Code or 105 C NIR 590.000. PROTECTION FROM CONTAMINATION EK: Food and Water From Regulated Sources 590.004 A -B) Com Bance with Food law* 3-201.12 Ford to a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 E gs sod Milk Products. Pastaurirxd* 3202.16 lee Made From Potable Drinking Water" 5-101.11 Drinking, Water from ant Approved S -stem* 590.006(A) Bottled Drinking Water" 590.006(B) WaterMeets Standards in 310 CMR 22.0* 1 Washine Fruits and Vegetables Shellfish and Fish From an Approved Source 3-20L14 Fish and Recreationally Caught Molluscan Shellfish' 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Re ulato Atithori 3-202.19 Shellstock Identification Present* 590.004(C) Wild Mushrooms` 3-201.17 Game Animals* 3-701.11 ReceivinglCondition 3-202.1 1 PHFs Received at Pro per Temperatures* 3-202.15 Package Hite = ity* 3-10'1.11 Fox; Safe and Unadultetated TagsfRecords. Shellstock 3-202.13 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention" 590-004(.1) Labeling of Ingredients* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures IHACCP Plans 3-50211 Specialized Processing Methods* 3-50212 1 Reduced oxygen packaging, criteria` 8-103.12 1 Conformance with Approved Procedures" c De[xAe9 critical item in the federal 1999 Food Code or 105 C NIR 590.000. PROTECTION FROM CONTAMINATION EK: Cross -contamination 3-302.11(A)(_1) Raw Animal Foods Separated from Cooked and RTE Ponds" Contamination from Raw Ingredients 3-30211.(A)(2) Raw Animal Foods Separated from Each Other' Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 1 Washine Fruits and Vegetables 3-304.11 Foci Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14iA)(13) Returned Food and Reservice of Faxt* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food` 9 Food Contact Surfaces 4-501.11 t Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Ivlechanival Warewashing- Hot Water Sanitization Tem neratnr'es* 4-501.114 Chemical Sanitization- temp., pl-I, concentration and hardness. * 4-601.11(A) Equipment Fol Contact Surfaces and Utensils Clean" 4-602.11 _ Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils', 4-702'11. Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4.-703.11 Methods of Saitiza@on--- Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.1 i Clean Condition -Hands and Arms* 2-301-12 CleaningPrccedur0 2-301.14 When to Wash" , Good Hygienic Practices 2-401.111 ating, Drinking or Using Tobacco* 27401.12 _ Discharges From the Dyes. Nose and Month* 3-301.12 Preventing Contamination When Tastin� 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em plo •ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Ca aeities'' 5-204.11 Location and Placement* M-,05 I -i A cessibilit r, O erasion atpd Maintenauee Supplied with Soap and Hand Drying IDevices 6-301,.11 1landwashine Cleanser. Availabilitv 6-301.12 Hand Drvin , Provision CITY OF SALEM BOARD OF HEALTHti., Establishment Name: S� rV Lt uN MleI oe6W iMs4rfr— Date: ��/ Page: 'Z of Item Code C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R — Red item - Verified q - PLEASE PRINT CLEARLY e r-Yvw.r d4erVAdtjK- #41 X /t LZCFX C V !C r it /r,04,*y 16x, re. JLrf-f-� 0'�IkvA4,3 rJ r- /'f /'89 rJ jAr d&< ✓fig. /za no s_ej ar r ,q 11 ^f t) F 40 M aott 19,04 r C t3� E It or, d F /y niter 4eI g Y_ - L u ,� .Y~0 WArI6 01-- IeW/ N ,D / % 40^fYv Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to Exclusion P Li Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspense n/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �C ❑ Voluntary Disposal ❑ Other: l Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 17 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives' 3-302.14 Protection from Unapproved Additives* 3-50L16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102:11 Common Natne - Working Containers'" 7-20'1.1 1 1 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-20311 Toxic Containers - Prohibitions" 7-204.11 Sanitizer. Criteria - Chemicals" 7-264.12 Chemicals for Washing Produce, Criteria* 7-204.14 Dryirig.Agents. Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-206.1 I Restricted Use Pesticides, Criteria* 7-206.12 1 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS -" Denotes critical item in the. federal 1999 Food Code or 105 CMR 590A0n. 20 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.1.1A(1)(2) Eggs- 155°F 15 Sec. 3-50L16(B) 590.004(F) Eggs- hi mediate Service 145°F75sec* 3-401.11(A)(2) Comminuted Fish, Meats At Game 3-501-16(A) Animals - 155'F 15 sec. * 3-401.1I(B)(1)(2) Pork and Beef Roast - 130`P 121 min* 3-401.1 t(A)(2) Ratites, Injected Meats - 155°F '15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed P14171, Physical Facility_______ Stuffing Containing Fish, Meat, .007 __--_ Poulix or Ratites -165°P 15 see. �= 3-401.11(C)(3) Whole-muscle,11ttact Beef Steaks .008 145°P * 34011.2 Raw Animal Foods Cooked in a I Microwave 165'F * 3-401.11(A)(7)(b) All Other PHFs -- 145°F 15 sec. .009 Reheating for Hot Holding 3 403.11(A)&(i)) PHFs 165°F 15 sec. * 3-403.11(B) Microwave- 165° F 2 Minute Standing Time* 3-40311(C) Commercially Processed RTE Food - 140" F* 3-401 11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 14WF to 70'F Within 2 Flours and From 70°F to 41°F145°F Within 4 Hours. 3-501.14(13) Cooling P1fFs Made From Ambient Temperature Ingredients to 41 '17-145'17 Within 4 Hours* -" Denotes critical item in the. federal 1999 Food Code or 105 CMR 590A0n. 20 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F145°F Within 4 Homs. 3-501.15 Cooting Methods for PHFs 3-301.1 1(D) PHF Hot and Cold Holding 3-50L16(B) 590.004(F) Cold PHFs Maintained at or below 41%45°F* 3-501.16(A) Plot PHFs Maintained at or above 140'F. * 3-501-16(A) Roasts Held at or above Li0°F. _Equipment and Utensils _ _ Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variane Re ulremenC 21 3-801.1 t(A) Unpasteurized Pre-packaged Juices and Beverages with Warnine Labels* 3-801 l l(B) Use of Pasteurized Eggs* 3-301.1 1(D) Raw or Partially Cooked Animal Focal and Raw Seed S routs Not Served. 3-801.1 ] {C) Uno cried F<xrd Package Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 23. Animal Foods That are Raw. Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate Food and Fuad Protection FC-- 3 I ,004 Pathogens.* _Equipment and Utensils _ _ 3-302.13 Pasteurized Eggs Substitute for Raw Shell 26. _Water,Plumbing and waste E >s � Kt:UUI"LMLN 15 590.009(.A) -(D) ( Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be. debited under the appropriate sections above if related to foodborne illness Interventions and risk factors. Other 590.009 violations relating to good retail }practices should be debited under #29 - Special Requirements. 141M (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interoern oirt and risk f i, tors listed above, eon be - found in the follo,4ug sections q/ the Food Code and 105 CMR 590.000. Item Good Retail Practices FC 590.000 23. Marra agent and Personnel FC - 2 .003 24. Food and Fuad Protection FC-- 3 I ,004 -25........ _Equipment and Utensils _ _ FC - 4 .005 26. _Water,Plumbing and waste FC -5 .000 27. Physical Facility_______ FC -6 .007 __--_ 28. Poisonous or Toxic Materials FC - 7 .008 S ecial Re virements I 1I--29: _ Other .009 S'S?�Nn:.F vO'6=R.Mc Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name P. _ vi cd 17aw Date - �J-Uv S e of O eration s T e of Inspection Food Service � Retail Routine ❑ Re -inspection Address Rlsk ii x0 i-. 7' G1( Level El Residential Kitchen Previous Inspection Telephone _ 23 ❑ Mobile ❑ Temporary Date: y Da. 041 ❑ Pre-operation Owner HACCP WN �I � ^ & ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) / Time S/ v In:❑ HACCP Inspector �� POS ndY✓/ 1� ✓;'1-rtklS Out: Permit No. ❑Other Each vioianon cnecxea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE _ ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ' ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C 'N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S 501ws 'For„s is me [112. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS - ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) " ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) " ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: s ectorr ig re: �'%/�%%gPDr! Print: PIC's Signature: ,M Print: SA �( PageL of;�- Pages r Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) Li - FOOD PROTECTION MANAGEMENT 590,003(A) Assi>nnentol`Responsibility' 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge --duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Comliance with Food Law* 3-201.-12 require reporting by food employees and 3 201.13 Fluid Milk and Milk Products* applicants* Shell E- 590.003(F) Responsibility Of AFood Employee Or Art 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an A unved Svstern* 590.006(A) Charge* 590.006(8) 590.003(G) Re ortinR b Person in Char e* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(L) Removal of Exclusions and Restrictions 0 in C C 7i7iTr79sT�7�T,I_1s77 T�ITI�r�Yi71FT�F ,r Denote, nitital Item in the federal 1999 Fowd Code or 105 CMR 590.000. C, + : • F-87- Food and Water From Regulated Sources 590,004(A B) Comliance with Food Law* 3-201.-12 Food in a Hermetically Sealed Container* 3 201.13 Fluid Milk and Milk Products* 3-20113 Shell E- 1-202.14 li=ps and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-19111 Drinking Water from an A unved Svstern* 590.006(A) Bottled Drinking Water* 590.006(8) Water Meets Standards in 310 CMR 22.0" Washutg Fruits and Va�etables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources` Contamination from the Consumer Game and Wild Mushrooms Approved by Re ulato Authori 3-202.18 Shelistock Identification Present* 590.004(C) Wild Mushrooms* 3-201-17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PRFs Reccived at Proper Temperatures* 3-202.15 Package Imc itv* 3-101.11 Food Sate and Unadulterated Tags/Records: Sheilstock 3-202.18 She0snrck Identification* 3-203.12 Shellsbrek Identification Maintained* TagsiRecords: Fish Products 3--402.11 Parasite Destruction°' 3-402.12 Records. Creation and Retention* 590.0040) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Coma Het Surfaces of Er ui anent* Conformance with Approved Procedures /HACCP Pians 3-502.11. Specialized Processing Methods - 3 -502.12 Reduced oxygen Packaging, criteria* 8-103.12 Conformance with ApIxoved Prceednres* ,r Denote, nitital Item in the federal 1999 Fowd Code or 105 CMR 590.000. C, + : • F-87- Cross-contamination 3-3102.1 1(Au l) Raw Animal Foods Separated fi ran Cooked and RTF Foods* Contamination from Raw Ingredients 3-30111 (A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302A I(A) Food Protection` 3-302.15 Washutg Fruits and Va�etables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Foods' 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Ilot Water San itization Tem eratures* 4-501.1.12 Mechanical Warewashing-Hot Water Sanitimtk n Tem teratures` 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.1 ] (A) Equipment Food Contact Surfaces and Utensils Clean - 4 -602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and Food Coma Het Surfaces of Er ui anent* 4-703.11. Methods of Sanitization -'Hot Water and Chemical* 1g Proper, Adequate Handwashing 2 301.11 CleanCondition - Hands and Arms* 2-301.12 Clearing Procedure'* 2-301.14 When to Wash" 1:1 Good Hygienic Practices 2-401.11 ,Farm , Drinkin or CJsing Tobacco* 2-401.12 Discharges From the Eves. Now and Month* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Fan rho ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Ca acmes* 5-204.17. Location and Placement" 5-205.11 Accessibility, O eration and Maintenance Supplied with Soap and Nand Drying Devices 6-301.11 I-Eurdwashing Cleanser-Availablit 6-301.12 Hutd Drvin *Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: StI4 1,1,-a %1,v1 -2Tat' Date: l{ 024 6w Page: of Item No. Code Reference C - Critical Item R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION _ PLEASE PRINT CLEARLY Date Verified 'l J ,�� / .41 q n /-»e--"l ltl,-Y-ei/' )` Y Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to P 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 your food permit. (` p� iii' J � Corrective Action Required: a No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Hems 1-22) (Cont.) 14 Proper Cooking Temperatures for Food or Color Additives PRFs 3-202.1.2 Additives 3-50'1.16(B) 590.004(f) 3-302.14 Protection from'Una r moved Additives* 15 3-501.1.6(A) Poisonous or Toxic Substances 3-401.17.(13)(1)(2) 7-101.11 Tdentityinglntot-o'c I I-Or'iginal Containers* Ratites, injected Meats- 155'F 15 7402.11 Common Nit= - Working Containers* 3-401.11(A)(3) 7-201.17 Se oration-Stora>?e"' Stuffing Containing Fish, Meat, 7-202-'tl Restriction - Presence and Ilse'" 3-401.1I(C)(3) 7-202.12 Conditions of Use' 145°F * 7-203.1.1 Toxic Containers - Prohibitions* 7-204.11 Sanitizers.Criteria- Chemicals* All Other PHFs - 145'F 15 sec. 7-204.1.2 Chemicals for Wash ine Produce. Cniene 3-403.11(.A)&tD) 7-204.14 Drvin=Agents. Crncria" Microwave- 165' F 2 Minute Standing 7-205.11 7-206.1 ] Incidental Food Contact, Lubricards* Restricted Use Pesticides. Criteria* 3-40111(C) 7-206.12 Rodent Bait Stations` 14WF* 7?06.13 TtackingPowders, PestControland Monitoring* 17 t *Denotes critical item (n the: federal 1999 Food Code or 105 CMF 596.000. y 19 20 3-501.14(C) Proper Cooking Temperatures for 3-501. I5 PRFs 3-401.11A(1)(2) 1,,gs- 155F '15 Sec. 3-50'1.16(B) 590.004(f) Li tgs- humetitate Service 145'Fi5sec* 3-401.11(A)(2) Comminuted Fish, Meats & Came 3-501.1.6(A) Animals - 155°F 15 see. 3-401.17.(13)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-40L71(,A)(2) Ratites, injected Meats- 155'F 15 590.004(li) sec. * 3-401.11(A)(3) Poultry, Wild Came, Stuffed PHFs, 27, Stuffing Containing Fish, Meat, FC-6 Poultry or Ratites -165"F 15 sec. " 3-401.1I(C)(3) Whole -muscle, Intact Beef Steaks FC - 7 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3401.11(A)(i)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403.11(.A)&tD) PHFs 165`715 sec. 3-403.11(B) Microwave- 165' F 2 Minute Standing Time" 3-40111(C) Commercially Processed RTE Food - 14WF* 3-403.11(1,) Remaining Unslieed Portions of Beef Roasts` Proper Cooling of PHFs 3-50114(A) Cooling Cooked PHFs from 140'F to 70"F Within 2 flours and From 70'F to 41"F/45'F Within 4 Hours. * 3-501.14(3) Cooling PPIFs Made From .Ambient Temperature Ingredients to 41'F/45cF Within 4 flours* *Denotes critical item (n the: federal 1999 Food Code or 105 CMF 596.000. y 19 20 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41`17/45`F Within 4 Hours. 3-501. I5 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-50'1.16(B) 590.004(f) Cold PFIFs Maintained at or below 41`/45° F- *3-501.16(A) 3-501 . 16(A) Het PHFs Maintained at or above 140'F.* 3-501.1.6(A) I Roasts Held at or above 130'7.'" 25. _ _ Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(li) Variance Re uiremen[ REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and with Warning Labels, 590 3-801.11(B) _Beverages Use of Pasteurized E „=s* FC - 2 3-801A 1(D) Raw or Partially Cooked Animal Food and Raw Seed S root's Not Served. 'z _ Food and Food Protection - 3-801.11(C) Unopened Foci Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Adviscny Posted for Consumption of 590 23. Animal Foods That are Kaw. Undercooked or FC - 2 .003 Net Otherwise Processed to Eliminate _ Food and Food Protection - FC -3 Pathogens.* FftPlev Y Y.00I 25. _ _ 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. Eggs* arMt IAS. M=VUm rfflr1V 1J 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. I/lfi]�idtC+linty (items 23-30) Critical and non-critical violations, which do nor relate to tine foodborne illness interventions and risk f actors listed above, can be Pound in the following sections of the Food Code and 105 CMR 590.000. Item Good Retail Practices FC 590 23. Management and Personnel FC - 2 .003 24. _ Food and Food Protection - FC -3 .004 25. _ _ Eft u�meni and Utensils FC- 4 .005 26. Water_Plumbin a ;Ind Waste FC -5 .006 27, Ph sical Facil_ity FC-6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29_ S ecial R uirements .009 30 Other _ tr �e,.xi*zAn� Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4t" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name JVA Date T e of O eration s Type of Inspection Food Service ❑ Retail feRoutine ❑ Re -inspection LeoN MlNt `// d Addressed Risk Level E] Residential Kitchen Previous I spection Telephone 7 2 /A4 El Mobile ❑Temporary ❑ Caterer E]Bed & Breakfast Date: 44110/0'2 Pre-operation E]Y/N ❑ Suspect Illness ❑ General Complaint Owner Si4NU � V HACCP Person in Charge (PIC)Time J, Out: Permit No. El Other Inspectoru �� cacn violation cnecxeo requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned/ Knowledgeable/ Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC v ❑ 3. Personnel with Infections Restricted/Excluded ._ FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTIONFROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. 23. Management and Personnel (FC -2)(590.003) 44. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29.Special Requirements (590.009) 30. Other S. 590,ns tFa, 14. d. ❑ 122.. Prevention of Contamination from Hands 913. Handwash Facilities PROTECTION FROM CHEMICALS a " - ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals 'TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control '- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP '. CONSUMER ADVISORY " ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): G Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this -1 order. I DATE OF RE -INSPECTION: 124 /oq Inspectlaw r' i n$ Ur.�P4f 61 can Print: I PIC'sSignature: Print: (,,A)r,)bq v(( Page-Lof¢Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 59D.003(A) Assr uncut otIResponsibrlitg' 590.003(Bi 2-103.11 Demons ration of KnoMedge*� Person in charge- duties EMPLOYEE HEALTH 2 590-003(0) Responsibility of: the person 1n charge to Food and Water FromReeulated Sources require reporting by foal employees and 590.004(A -B) applicants;* 590.003(F) Responsibility Of A Food Employee Or An Food in a Hermetical] • Scaled Container* Applicant To Report To The Person In 3-201.13 Chareo* 590 903(6) Re Cortin z lo Person in Charge" 3 590.003(D) Exclusions and Restrictions* 3-202.14 590.003(E) Removal of Exclusions and Restrictions L4 Cross -contamination Food and Water FromReeulated Sources 3-302.1l(A)(1) Raw Animal Foods Separated from 590.004(A -B) Law* 3-201.12 Food in a Hermetical] • Scaled Container* 3-302.1.1(A)(2) Raw Animal Foods Separated frorn Each 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-302.11.(A) Food Protection"' 3-202.14 E,,,s and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* Utensils* 5-1.01.11 Drinking Water from an Approved System, 590.006(A) Bottled Drinking Water* Disposition of Adulterated or Contaminated 590.006([3) Water Meets Standards in 310 CMR 229* 3-701.11 Discarding or Reconditioning Unsafe Shellfish and Fish Froman Approved Source Foods' 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 __ Molluscan Shellfish from NSSP Listed Sources* Sanitization'Petoerahres* Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present's 4501.114 Chemical Sanitisation- temp., pH, 590.004(C) Wild Mushrooms* 5 3-201.17 Game Animals* Receiving/Condition Utensils Clean* 3-202.11, P[iFs Received at Proper Teen eratores's 3-202.15 Package Integrity* 4-702.11 Frequency of Sanitization of Utensils rmd 3-101.11 Food Safe and Unadulterated 6 4-103.11 Methods of Saiutization- HotWaterand TagslRecords: Shellstock Chemical* 3-202.18 Shellstock Identification * 2-301.12 Cleaning Procedure* 3-20;.12 Shellstock Identification Maintained," l 2-401.11 Eatin >. Drinking m' Usin Tobacco* 2-401.12 Discharges From the Eyes, Nose and Tags/Records: Fish Products 3-301..12 Preventlue Contamination When Tastin ,L 3-402.11 Parasite Destruction* Fm lovees* 3-402.12 590.001(.1) Records, Creation and Retention* Labeling of Ingredients' 7 5-204.11 Location and Placement* Conformance with Approved Procedures lHACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods' 6-30T.72 HandDrProProvision 3-502,12 Reduced oxygen packaging. criteria* 8-103.12 Confonnance with A�cedures* Denote-; critical item in the federal 1999 Foal Cale or 105 CMR 590004. IJ S Cross -contamination 3-302.1l(A)(1) Raw Animal Foods Separated from _ Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated frorn Each Other` Contamination from the Environment 3-302.11.(A) Food Protection"' 3-36215 WashlneFruits and Ve-etables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(H) Returned Food and Resetvice of Food's Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Foods' 9 Food Contact Surfaces 4-501.111. Manual Warewashine-Hot Water Sanitization'Petoerahres* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tent eratures* 4501.114 Chemical Sanitisation- temp., pH, concentration and hardness. 's 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-1102.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils rmd Food Contact Surfaces ofE ui meat"° 4-103.11 Methods of Saiutization- HotWaterand Chemical* 10 Proper, Adequate Handwas hing 2-301.11 Clean Condition -Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* I t Good Hygienic Practices 2-401.11 Eatin >. Drinking m' Usin Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301..12 Preventlue Contamination When Tastin ,L 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Fm lovees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Nambers and Ca acities* 5-204.11 Location and Placement* 5-205.11 Accessibility.Orerationan�cc Supplied with Soap and Nand Drying Devices 6-301.11. Handwashin Cleanser, Availability 6-30T.72 HandDrProProvision 1.4 CITY OF SALEM BOARD OF HEALTH FstahlishmPnt NamP- .S&,A C.lcj/✓ MIM/r"—ddD A4.4.,ef' Date: 4{- /,'z` O Page: 4- of Item No. Code Reference C - Critical nem "R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION `- PLEASE PRINT CLEARLY Date Verified OU �/ r✓c �/ P2lr/c c /NS d h/r�t Ife l , EGD it 97 _ ' 3 fdrZe f G Ale rA&e71c Ps .e e n r Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to 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 your food permit. �r �` GL Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension LI Embargo ❑ Emergency Closure 0 Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 LL- Food 16 17 TIMEITEMPERATURE CONTROLS or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unmoved Addtbier" -1 I Equipment and Utensils Poisonous or Toxic Substances 7-101.11 Identifvine Information -Original Containers" 7-102.1 t Common Name -Working Containers* 7-201.tI Separation_ Snaa2e"_- 7-202.11 Restriction - Presence and Use* 1-202.12 Conditions of Uge* -T-2o3 -i1 TToxic Containers - Prohibitions"' 7-204.11 Sanitiizers. Criteria - Chemicals" 7-204.12 Chemicals for WV-hin Produce, Criteria* 7-204.14 Drvink .Agents. Criteria* 7x05.1.1 Incideuwi Food Contact, Lubricants* 7-206.11 Restricted Use. Pesticides, Criteria" 6.12 Rodent Bait Stations"'6.73 n Tracking Powders, Pest Control and Monnorinfl" TIMEITEMPERATURE CONTROLS * Denotes i:ritical item m the federal 1999 Paid (:ode m- 105 CMR 590.000. s - .4 Proper Cooking Temperatures for Unpasieuri7.ed Pre-packaged Juices and PHFs A(1)(2) Eggs- 155'F15Sec. -1 I Equipment and Utensils E' --s- Immediate Service 145°Fl5wct L3 -401,(A)(2) Comminuted Fish. Meats & Game 3-80 Ll I (D) Animals - 155`P 15 sec.1(13)(1)(2) .._,. FC -5 Pork and Beef Roast - 130"F 121 mitt* .1(41(2) Ratites, Injected Meats - 155'F 15 1 Physical Facility sec. * 3-401.12(A)(3) Poultry, Wild Game. Stuffed PHFs, 20 Stuffing Containing Fish. Meat, 008 Poultry rn. Ratites -165'F 15 sec 3401.11(C)(3) Whole -muscle. Intact Beef Steaks 145"F * 3--101.12 Raw Animal Foods Cooked in a 1_Other_-__-- Microwave 165'F 3-401.11(A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PFIFs 165'F 15 sec. 4' 3-403.1.1(13) Microwave- 165°F 2 Minute Standin}; Time" 3403.1.1(C) Commercially PoicessedRTE Food - 140°F" 3-4(013.1 I tE) Remaininu Unaliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.I4(A) Cooling Conked PHFs from 140"F to 70'F Within 2 Hours and Fr( 70'F to4I°F/45°F Within Hours. * 3-501.14(&) Cooling PHFs Made From Arobient Tempernure Ingredients to 41'Fb15°F Within 4 Hours* * Denotes i:ritical item m the federal 1999 Paid (:ode m- 105 CMR 590.000. s - .4 m 21 3-501.14(C) PHFs•ReTeived at Tentperanrres Unpasieuri7.ed Pre-packaged Juices and According to Law Cooled to 4VF/45'F Within 4 Houts. * -1 I Equipment and Utensils 3-501.15 C(a)ingMethods foi-PHFa� 19 _ i______ -- PHF Hot and Cold Holding 3-80 Ll I (D) 3-S01,16(g) Cold PHFs Maintained at or below .._,. FC -5 5)O.QOa(F) 41^/45' F" Rau Seed Surouts Not Served. * -501.16(A) Hut PHFs Maintained at or above 1 Physical Facility t4WF. -7 .007 3-501.16(A) Roasts Held of or above 130"F. 20 Time as a Public Health Control 008 3-501.19 Time as a Public Health Control 29 590.004(1`1I _ Van ace, Runuremern m 21 3-801.1.!(A) Unpasieuri7.ed Pre-packaged Juices and 590.000 .003 .004_ Beverases with Warnin" Lvibels* -1 I Equipment and Utensils 3-801.11(13) Use of Pasteurized Epgs* _ 3-80 Ll I (D) � Raw or Partially Cooked Animal Fowl and .._,. FC -5 .._... __...._i 006 Rau Seed Surouts Not Served. * 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods'1'hat are Raw, Uu&rcooked or Not Otberwise Processed to FI bninate Pnrhna.rnc ,�: ce„�ovF ,rrznm 13 1 Pastvurixed Fggs Substitute for Raw Shell Fo<rc' Violations of. Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to sood retail practices should be debited under ##29 -- Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (items 23-30) Critical and non-critical violations, which do not relate to the foodhome illness eaerrentions and 6sk,fac6-ois listed above, can he found in the following sectnms of the Food Code and 105 CA-tR 590.000. Item i23. 24._ I Good Retail Practices h1anagementand Personnel Food and Food Protection ) FC T FC'FC'--2 FC_ 3 590.000 .003 .004_ 1_25 -1 I Equipment and Utensils FC -4 .005 _ 26 _--.. Water Pumbmq and Waste .._,. FC -5 .._... __...._i 006 27 1 Physical Facility I FC 6 -7 .007 28 , Poisonous or Toxic Materials FC -7 008 29 cial R uiremants 009 130 1_Other_-__-- ss,>n,cI d, A CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-74 1-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT f 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: Sandra Yu Name of Establishment: Sea Lion Mini Food Mart Address of Establishment: 10 Front Street Type of Establishment: RETAIL FOOD Application Date: 12/10/2002 Restrictions: Permit for Food Establishment 18-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 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. .r ,F _� y, A .r • O�H AGEN "}"'. •y��i� •w apt✓ A CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • :. 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-74 1 -1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT SQA LIONM/0111 %Q. h!6J/r 7 TEL # ( �T� / LL — Z Z 2 3 ADDRESS OF ESTABLISHMENT 10 F lZ.0 N T s LKEE r SA-" , MP 0 16170 MAILING ADDRESS (if different) OWNER'S NAME SRI-JD90+ YU TEL #- daI D-Y'"f7LfI /_\f W CITY MR1-9)FN STATE IM 0 710 0J1 t-PA CERTIFIED FOOD MANAGER'S NAME(S) Q A)3)RA yI 1 CERTIFICATE#(s) 7 Z�-3 3Oaq (required in an establishment where potentially hazardous food is prepared.)�� EMERGENCY RESPONSE PERSON S Arn1DRR Y U HOME TEL # Ok 1! 32 y - 3 7 y I HOURS OF OPERATION: Mon. 0'4 Tue.y( Wed. 201( Thu.9 `7- Fri. 9- -Sat. °I -T Sun. Ib -S- 4-4- 9-- °1-T TYPE OF ESTABLISH NT RETAIL STORE E NO / J,p 3 RESTAURANT BED/BREAKFAST M YES NO ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES TOBACCO VENDOR YES QP ALL NON-PROFIT (such as church kitchens) YES CNw FEE check only less than 1000sq.ft._$ 5 1000-10,000sq.ft. 00 more than 10.000sq.ft. =$250 20 /-$$',200 $100 less than 25 seats 25-99 seats more than 99 seats $5 $50 $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. Xa i" 1Z/U3!OZ 2n0-OR4---i1n Social Security or Federal Identification Number Revised 11/25/02 FOODAP2.adm Check# & Date J';( (9 — M oe S-0.— SEA LION MINI FOODMART 10 FRONT ST SALEM, MA 01970 PAY THE G l OR � ORDER OF 0 o �e- H -i \ 0//" f--1 JtN �- 315 3 / 0�- saaun715 DATE j � - 715 $ IS_0-o0 I !- DOLLARS 8 a CITIZENS BANK Massachusetts >�'L FOR Pr -RMI T TO OpL�P\%} IF1!�'Y bJJ �ScTAg%$Nm. T 1100003ISum 4211"10701?Sl: 1 109 5 300 3 711' s^'+"-v'IM>mv.'y.�„�,�.,,�„T�C�,r,y.r.,,iii..-.,p'.•:e.Y-i`•'F"a+"'^rv^,M"T'+.--J :.v'"�v.-n..,�,r".�.-. THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel: (978) 741-1800 Fax: (978) 745-0343 Name Cooking Temperatures ❑ 17. Date / Type of Operation(s) Food Service LJ Retail ❑ Residential Kitchen El Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Type of Inspection [(Routine L Re -inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint ❑ HACCP ❑ Other AddressRisk S y Level /, Telephone ; � _ �/ _ z � z Y / Owner ,s� `J HACCP Y/N Person In Charge (PIC) Time In: Out: Inspector C'' h� -7 y y / ,✓1 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 ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION [18. Separation / Segregation / Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEJEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1.22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: Print:. 1 . )cc, n !/ PIC's Signature: /t�G. .2/ Print: Page/ of ages FORM 734A HOBBS& WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION MANAGEMENT ra(' 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in Charge - Duties EMPLOYEE HEALTH 2` 590.003(C) Responsibility of the Person in Charge to Compliance with Food Law* 3-201.12 require reporting by Food Employees and 3-201.13 Fluid Milk and Milk Products* Applicants* Shell Eggs* 590.003(F) Responsibility of a Food Employee or an 3-202.16 Ice Made from Potable Drinking Water* Applicant to Report to the Person in Drinking Water from an Approved System* 590.006(A) Charge* 590.006(8) 590.003(G) Reporting by Person in Charge* 3;: 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 5 6 E FOOD FROM APPROVED SOURCE * Dentes critical item in the federal 1999 Food Cade or 105 CMR 590.000. 8 9 12 13 'A PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made from Potable Drinking Water* 5-101.1 I Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(8) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3.201.14 Fish and Recreationally caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained" Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* '3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* * Dentes critical item in the federal 1999 Food Cade or 105 CMR 590.000. 8 9 12 13 'A PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: �_ , 6'1Z Date: /� Q� Pager of Z Item No. code Reference C - Critical Item R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Verified - 2- L - C - , UF) Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to 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 your food permit. L Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) (Cont) PROTECTION FROM CHEMICALS 14 17 TIME(TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives" 3-302.14 Protection from Una roved -,,Vkbfves* 3-501.16(A) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11 Common Name - Working- Containers ` 7-201.1.1 Separation - Stot ae"` 7-202.1 1 Restriction - Presence and Use" _ 7-202.12 Conditions of Use* 7-203.'11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers.Criteria - Chemicals, FC -6 Chemicals for Washin>Prodnce, Criteria* _7-204.12 7-204.14 Drying- Agents. Criteria* 7-205.1.1 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitorin �" TIME(TEMPERATURE CONTROLS * Denote, critical item in thefedend 1999 Fowd Code or 105 0MIZ 190.000. N 20 J 3-501.1,4(0 3-501.15 Proper Cooking Temperatures for FC PHFs 3-401.11A(1)(2) Eggs- 155'F15See. 3-501.16(A) Bgg-s- Immediate. Service 1450F1.5seck 3-401.11(A)(2) Comminuted Fish. Meats & Came T FC -3 Animals - 155°F 15 sea * 3-401.11('B)(1)(2) Pork and Beef Roast - 130'F 121. tniu,� 3-401.1 l (A)(2) Ratites, Injected Meats - 155'F 15 26. sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs. 27. Stuffing Comainin; Fish, bleat, FC -6 Pouitr or Ratites -t 65°F t5 sec. * 3-401.'1l(C)(3) Whale -muscle, Intact Beef Steaks _ FC - 7 145'F "' 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Gillet PHFs -- 145'F 15 sec. Reheating for Hot Holding 3-403.1.l(A)&(D) PHFs 165'F 15 ,sec. " 3-r403.11(B) Microwave- 165' P 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 14WF* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts" Proper Cooling of PHFs 3-501.14(A) Cowling Cooked PHFs from 140'F to 70`F Within 2 Hours and From 76"F to 41°'F/45'F Within 4 Hours. * 3-501.14(B) CoolingPHFs Made From Ambient Temperature ingredients to 41 _,F/45'F Within 4 Hours* * Denote, critical item in thefedend 1999 Fowd Code or 105 0MIZ 190.000. N 20 J 3-501.1,4(0 3-501.15 PHFs Received at Temperatures According to Law Cowled to 4'l'F'14.5°F Within 4 Hours, Cooling Methods for PHFs FC PHF Hot and Cold Holding 3-501-16(B') 590.004(F) Cold PHFs Maintained at or below 41'/45' Fr 3-501.16(A) Hot P,HFs Maintained at or above 140'F. * 3-501.16(A) Roasts Held at or above 1.30°F. T FC -3 Time as a Public Health Control 3-501.19 Time as a Public Health ControP 590.004(H) VarianceRecuirement 21. 3-801.11(A) i 7npastcurized Pre-packaged Juices and Beverages with Warning- Labels* FC 3-801.11(B) Use of PasteurizedEg-g-s* 23. 3-801..11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * FC -- 2 3-801.11(C) Unopened Food Package Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods Mat are Raw. Undercooked or Not Otherwise Processed to Eliminate Pathogens.* ecse.e vvaooi 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell SPECIAL REQUIREMENTS 590 -009(A) -(D) Violations of Section 590.009(A) -(U) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices sbotdd be debited under #29 - Special Requirements. (Items 23-30) Critical and non-critical violations, which do not relbte to the /bod "borne illness interventions and risk factors listed abm,e, can be found is the following sections orithe Food Code and 105 CMR 590.000. .Item Good Retail Practices FC 590.000 23. Manag ment and Personnel FC -- 2 .003 24. Food and Food Protection T FC -3 .004 _ 25. Equipment and Utensils FC -4 005 26. Water, Plumbingand Waste FC -6 .006 27. Physkal Facility FC -6 .007 28. '! Poisonous or Toxic Materials _ FC - 7 .008 29._Speaal 30 I Other s iWmnar 2 a _