SIXTY 2 ON WHARF - ESTABLISHMENTSuniversal one,m
www. myunivers alop.com
phone:i-O00-756-4675
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Commonwealth of Massachusetts
City of Salem
e Board of Health
120 Washington Street, 4th Floor Kimberley Driscoll
SALEM, MA 01970 Mayor
Food/Retail Establishment Permit
DATE PRINTED: 12/29/2011
ESTABLISHMENT NAME:
File Number: BHF -2003-000024.
Sixty 2 on Wharf
62 Wharf Street
PERMIT EXPIRES IDecember 31, 2012
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
120 WASHINGTON STREET, 4'" FLOOR
IJMBERLEY DRISCOLL TEL (978) 741-1800
FA -x (978) 745-0343
NL\YOR Iraindiott7r salem com
LARRY RAMI)IN, RS/IUi1IS, (:110, (:p -IS
Hi .AIAII AGFNt
201_ APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT 6,-e;- gee-WICIr F- W,:,fe 106FQeTEL # !`Jy--
ADDRESS OF ESTABLISHMENT -6--:1, Sf
FAX # ye;; 7 `/`( //lo w
MAI LING ADDRESS (if different)
EMAIL- Business':_ (v e7,�-✓c cC rz¢�q ���e 4rQro� eo
Website: (b o`I- 0,e2,304cf �.2'a..✓�
OWNER'S
ADDRESS /g
L�C_�
s 1 KttT CITY
_�� STATE
CERTIFIED FOOD MANAGER'S NAMES) �✓�'"� ��//-�. ccoc rel CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON �^�� 6G��✓c v 4 HOME TEL #
Please write in time of day.
(For example 11 am -11 amt C/cS e-9
RETAIL STORE YES
-----------`---------------
RESTAURANT
(Outdoor Stationary Food Cart $210) ,
self,-/;?
e;�6o
ZIP
� �N 5-:3/
less than 1000sq.ft.
1000-10,000sq.ft.
more than 10,000sq.ft.
=$ 70
=$280
=$420
-
--------------------- -
less than 25 seats
- ----------
25-99 seats
more than 99 seats =$420
----------------------------------------------- - ---------------------
BED/BREAKFAST/ - ----""--'
YES NO--------------------------------------------------------------
CHILDCARE SERVICES/NURSING HOME--_-__--__
ADDITIONAL PERMITS ----- ---------- I ------------------------
- - ----____
$100
--
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO
TOBACCO VENDOR
ALL NON-PROFIT (such as church kitchens)YES NO
YES NO
$25
$135
$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
mums a ' id all state taxes reayo_.^' • ^�^-�� � -
Date
Updated 523/11 F00DAP201 I.adm Check# & Date
Social Securitv or Federal
Mas. khusetts Department of Public;.HealtW
DMaim of Food ariii Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
W
j Salem Board of Health
120 Washington Street, 0 Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name
_l __ __
Dae
Operation
Tvpe of s)
Tvce of Inspection
✓%� ✓ ,� / o, <.:�ge-1
o�Bages
Food Service
❑ Retail
Routine
❑ Re -inspection
Address
Risk
Level
❑ Residential Kitchen
❑ Mobile
El Temporary
Previous Inspection
Date: �
❑ Pre-bp9eefaWn
Telephone
N y
Owner
HACCP YM
j J
❑ Caterer
❑ Bed & Breakfast
❑ Suspect Illness
❑ General Complaint
Person in Charge (PIC)
Time
y
In: y 1t'
❑ HACCP
Inspector L_
Out:
Permit No.
❑ Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisfon(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 w
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE • a rK.
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 6. Tags/Records/Acduracy 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
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: 5WMSP Ft 14.E
W
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
'PROTECTION FROM CHEMICALS ..
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIMEREMPERATURE 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
[122. 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: 1A
_l __ __
Print: -
PIC's Signature:
✓%� ✓ ,� / o, <.:�ge-1
o�Bages
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assignment of Responsibility*
590.003(B) Demonstration of Knowledge`
2-103.11 Person in charge - duties
EMPLOYEE HEALTH
2
590.(X)3(C)
Responsibility of. the person in charge to
Compliance with Food law*
3-201.1.2
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 S stent*
590.006(A)
Charge*
590.(H)6(B)
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 Restri'etions
4
C
LN
FOOD FROM APPROVED SOURCE
* Denotes critical item in the Weral 1999 Fwd Cade or 10 CMR 59000.
C
.t
PROTECTION FROM CONTAMINATION
Food and Water From Regulated Sources__ J
590.004(A -B)
Compliance with Food law*
3-201.1.2
Food in a Hermetically Sealed Container*
3-201.13
Fluid Milk and Milk Products"
3-202.13
Shell Eggs*
3-202.14
F. ,-s and Milk Products. Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-101.'I.I
'Drinking Water from an Approved S stent*
590.006(A)
Bottled Drinking Water*
590.(H)6(B)
Water Meets Standards in 310 CMR 22.0*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Shellfish and Fish From, an Approved Source
3-201.14
Fish and Rec rationaliv Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
Proper, Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulato Authonl
3-202.18
Shellstock identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
2-301.14
Receiving/Condition
3-202.1.1
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained*
12
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records. Creation and Retention`
590.0040)
Labeling of Ingredients*
Handwash Facilities
Conformance with Approved Procedures
/HACCP Pians
3-502.11
Specialized Processing Methods*
3-502.12
Reduced oxygen packaging, criteria*
8-103.12
Conformance with An roved Procedures*
* Denotes critical item in the Weral 1999 Fwd Cade or 10 CMR 59000.
C
.t
PROTECTION FROM CONTAMINATION
9
Cross -contamination
3302.11(A)(])
Raw Animal Foods Separated from
Cooked and RTE Foods*
4-501..111.
Contamination from Raw Ingredients
3-302.1.1(A)(2)
Raw Animal Foods Separated from Each
Other*
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
Contamination from the Environment
3-302.11(A)
I Food Protection*
3-302.15
Washing Fruits and Vegetables
3-304.11.
Food Contact with Equipment and
Utensils*
4-602.1.1
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe Fest-
9
Food Contact Surfaces -
4-501..111.
Manual Warewashing - Hot Water
Sanitization Tet eratures*
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*
4-602.1.1
Cleaning Frequency of Equipment F(xA-
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*
10
Proper, Adequate Handwashing
2-301.1. t
Clean Condition - Hands and Arms*
2-301.12
Cleanin Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventing Contamination When Tasting"
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Employees*
13
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.
.f
J
SALEM _
>F HEALTH
Date: i� Page: 7 of
nem
No.
Code
Reference
C -Critical Rem �.
R - Red ltem l
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
m - I
PLEASE PRINT CLEARLY
Date
verified
JJ''
7u.ic
ed 3 fi ):
-r -a,o car P o - C c
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2r
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Ike S �� n f--- .�,� c✓ Ge
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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 ip daily fines of twenty-five dollars or suspensionlrevo- tion of
'Mur food permit.
Corrective Action Required: ❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction r
Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension,
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors (ftems 1-72) (Cont.)
A4
Food or Color Additives
3-202.12
Additives*
3-302.14
Protection from Un toyed Additives*
1S
Poisonous or Toxic Subetsnces_
7-101.11
Identifying information -Original
Containers*
7-302.21.
Common Name - Working Containers*,....,
7-101.11
_...,_..,
Separation - Stora *
7-202.11
. Restriction - Presence and Use*
7-202.12
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Sanitize", Criteria - Chemicals*
7-204.12
Chemicals for Washing Produce, Criteria*
7-204.14
Drying Agents. Criteria*
7-205.11
hicidental Food Co rrtam Lubricants*
7-206.11
Restricted Use Pesticides, Criteria*
7-206.12
Rodent Bait Stanoms*
7-206.13
Tracking Powders', Pest Control and
Monitoring!
IN
FM -
'' Demres critical tam in the federal 1999 Find Cale or IV CMR 90.000.
3-501.14(C) PHFs Received at Temperatures
According to law Cooled to
41'F/45`F Within 4 Hours.
Proper Cooking Temperatures tar
19
PRFs
340LIIA(i)(2)
Eggs- 155F 15 Sec.
Eggs- immediate Service 145'F15see-
3401.11(A)(2)
Comminuted Fish. Meats & Come
3-801.11(C)
Animals - 155'F 15 sec. *
3.401.1I(B)(1)(2)
Pork and Beef Roast - 130'F 121 min*
3-401.11{A)(2)
Ratites, Injected Meats -155°F 15
see. *
3.401.11(A)(3)
Poulty, Wild Game, Stuffed PHFs,
Stuffing Containing Fish, Meat,
Poultry or Ratites -165°F 15 sec.*
3.401.11((2)(3)
Whole -muscle, Intact Beef Steaks
1450F"
3-401.12
Raw Animal Foods Cooked in a
Microwave 165F *
3401,11(A)(1')(b)
All Other PHFs - 145'F 15 sec.
Retreating for Hot bolding
3-403A I(A)MD)
j PHFs 165°F 15 sec. *
3-403.11(B)
Microwave- 16Y F 2 Minute Standing
Time*
3-403.11(C)
Commercially Processed RTE Food -
140gF
3-Z I I (E)
Remaining Unsliced Portions of Beef
Roasts*
Proper Cooling of PRFs
3-501.14(A)
Cooling Cooked PHFs from 140'F to
70'F Within 2 Hours and From 70'F
to 41 °F/45017 Within 4 Hours. *
3-501.14(6)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41 OF/45°F
Within 4 Hours*
'' Demres critical tam in the federal 1999 Find Cale or IV CMR 90.000.
3-501.14(C) PHFs Received at Temperatures
According to law Cooled to
41'F/45`F Within 4 Hours.
3-50IA6(B) Cold PHFs btamwtied at or below
590.004(F) 41-f4Y F*
3-501,16(A) Hot PHFs Maintained at or above
Roasts Held at of above 130'F. w
Time as a Public Health Control
21
3-501.15 Cooling Methods for PRFs
19
1 PHF Hot and Cold Holding
3-50IA6(B) Cold PHFs btamwtied at or below
590.004(F) 41-f4Y F*
3-501,16(A) Hot PHFs Maintained at or above
Roasts Held at of above 130'F. w
Time as a Public Health Control
21
3-801.11(A)
Unpasteurized Pre-packaged Juices and
Beverages with Warning labels*
3$01.11(6)
Use of Paoetwiml Eggs*
3-801..11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
3-801.11(C)
Unopened Food Package Not Re -served. "
22
3-6M.I I
Consumer Advisory Posted for Consumption of
Animal Foods That are Raw, Undercooked or
I
Not OtherwiseProcessedto Eliminate
Path o *ens.*
3-302.13
Pasteurized Eggs Substitute for Raw Shell
1 E *
SPECIAL REQUIREMENTS
590.009(A) -(D) Violations of Section .590.009(A) -(D) in
catering, mobile fwd, 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 • • r t �•3tiZrFiFsTi;t:T��[l�'�&[s�atfN.�'i
(Items 23-30)
Critical, and non-critical violations, which do not relate to the
foodborne illness interventions and risk_ {actors listed above, can be
found !it the following sections of the Food Code and 105 CMR
son Min
DATE PRINTED:
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street, 4th Floor
SALEM, MA 01970
Food/Retail Establishment Permit
01/06/2011
ESTABLISHMENT NAME:
File Number: BHF -2003-000024
Kimberley Driscoll
Mayor
Sixty 2 on Wharf
62 Wharf Street
Salem MA 01970
LOCATED AT: 0062 WHARF STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
FOOD SERVICE BHP -2011-0266 Jan 1, 2011 Dec 31, 2011 $280.00
ESTABLISHMENT
PERMIT EXPIRES
Total Fees: $280.00
31, 2011
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made,
all plans for such must be submitted to and approved by the Salem Board of Health. Page 1
KIMBERLEY DRISCOLL
MAYOR
DAVID GRE_ENBAUM, RS
ACTING HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4" FLOOR
TEL. (978) 741-1800
F As (978) 745-0343
DGREEN6AUM(rs77,3ALEM. COM
2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT_ W
Oil
WhQrP
TEL# M-
Nq-00(0,9
ADDRESS OF ESTABLISHMENT
W
WjIarF o4_
Sglvm ma 01970 FAX# 9`)?-
lVq- 11(0A
MAILING ADDRESS (if different)
EMAIL -Business':
A5e4e-rc„ur+
O (od
(?J44ml.
437y7 Website:
(aa U)+a.wo+f_
c /.?
OWNER'S NAME
qL,,,
a
+
Ilai7riC
De
r�rrqu�f
TEL# 49�
9Y`/-00602
ADDRESS (002 rnlha�F 5f_ OPG6a
_. STREET .. _ .. CITY
STATE
®/9 40
CERTIFIED FOOD MANAGERSNAME(S) CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared) _
EMERGENCY RESPONSE PERSON (�f ' L B e444,7 LOVE HOME TEL # g? s3/ ism
`DAYS OFOPERATIQN , ` tMond Tuesday;= - Wednesday>az�hursday, 3i.,`' Fnday F„ I, Saturday,`>.,bSunda
HOURS OF OPERATION
Please write in time of .
For examoe Ilam-11dayCLO �P-(�cp S m - I d qrv) 3a,/ 50�, - - 4^-,— S4w2: SPpI - r/pm
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
RESIAUrwN`iI fC01 iso
(Outdoor Stationary Food Cart $
seais
mere than U9 seats =$420
BED/BREAKFAST/ YES NO $100
CI -III r)CARF CFR\/ICFs/nll IRCIAI!_ — -- .,
AVVI I IVIYNL rr-KMI 10 -
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NON $25
TOBACCO VENDOR YES NO $135
ALL NON-PROFIT (such as church kitchens) YES O $25
u -
*Please pay total witli 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 lax
re)u" and paid allstate taxes required under the law.
Z_ op- 33a y
Date - Social Security or Federal Identification
Revised I0n11l FOODAP201 Ladm Check# & Date
r Commonwealth of Massachusetts
C
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street, 4th Floor Mayor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED:, 01/04/2010
ESTABLISHMENT NAME:
File Number: BHF -2003-000024
Sixty 2 on Wharf
62 Wharf Street
Salem MA 01970
LOCATED AT: 0062 WHARF STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
FOOD SERVICE BHP -2010-0084 Jan 4, 2010 Dec 31, 2010 $280.00
ESTABLISHMENT
PERMIT EXPIRES
Total Fees: $280.00
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. Paye 1
+ CITY OF SALEM, MASSACHUSETTS
r BOARD OF HEALTH
120 WASHINGTON STREET, 4r" FLOOR
TEL. (978) 741-1800
KINIBERLEY DRISCOLL FAX (978) 745-0343
MAYOR DGRFENBAUM@SALFM. COM
DAVID GREENBAum,
ACTING HEALTH AGENT
2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT S`ly
y,? 0/1 Li harp
Caal-4
TEL#
W-'YV-0060?
ADDRESS OF ESTABLISHMENT
(Dd Wl,prF
S4.
FAX #
tgA401);0
MAILING ADDRESS (if different)
EMAIL -Business':
&44t
Caal-4
@ 6? an W:crC.
c,
Website: UwW.
On w4c�/.
Com
OWNER'S NAME
tgA401);0
t I/ajfiit
i9e4j0C0u'1
TEL#
99k JW
WLri
ADDRESS It 040a,01JA L141 aL44 &In 0'/9(00
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) 017(";Q h4 406*w,/1 CERTIFICATE#(S)
(Required in an establishment where potentially
rr hazardous food is prepared)
EMERGENCY RESPONSE PERSON— UGI PriC 02e4mCoc"4 HOME TEL#
0N,Y P 0 N YLW, WMonday al. Tuesd, Wedngsd�y y';` Thgrsday . Fnda_
Saturday ': fSunday
HOURS OF OPERATION 1
Please write in time of day. j
l� WA
SA,-
For example 11am-11 m �SjM-
At
TYPE OF ESTABLISHMENT
RETAIL STORE
(Outdoor Stationary Food Cart $21
FEE (check only)
YES less than 1000sq.ft. _$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
BED/BREAKFAST/ YES / NO
less than seats =$14025-99 seats
�8�
more than 99 seats =$420
$100
ADDITIONAL PERMITS i
MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES` %NO $25
TOBACCO VENDOR YES / NO $135
ALL NON-PROFIT (such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance'with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns tfnd,paid all state taxes required undeylhe law.
Date
Revised 424/07 FOODAP2008.adm Check# & Date
1.
y& - (]3Usy
Security or Federal Identification Number.
Massachusetts Department of
Division of Food and Drugs
Public Health
FOOD ESTABLISHMENT INSPECTION REPORT
t
Salem Board of Health
120 Washington Street, 4" Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name C
Print:
G7
Da
T e of O eration s
Type of Inspection
X`
OIJ
/ (�
Food Service
❑ Retail
Routine
Re -inspection
Address
G
Risk
1.
Level
❑ Residential Kitchen
El Mobile
Previous Inspection
Date:
Telephone (� lD060
❑ Temporary
❑ Caterer
❑ Pre-operation
❑ Suspect Illness
Owner
(
HACCP YIN
/
❑ Bed & Breakfast
❑ General Complaint
Person in Charge (PIC)
Time
`
p O�
Permit No.
El HACCP
ElO herr
Inspectorh
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) El 590.009 (F) E]action as determined by the Board of Health. Vj o--) ��r�ed�tiA
FOOD PROTECTION MANAGEMENT =° _"�,+,,,,, ` __1 1 " 1, ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned / Knowledgeable / Duties ❑ 13. Handwash Facilities
n EMPLOYEE HEALTH"
___4 . ' 3 ,,,� �.m, �d- ..; V CF'j )' PROTECinON FROM CHEMICALS ;V' r' 1 ' I 'I -t F " "F '
-«
❑ 2. Reporting of Diseases by Food Employee and PIC �_-- • �m,m��� "mom a•m"-� -�� 1 f.
❑ 14. Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE'1' TL ekm „?,,,, "c�wt+senr=4?'+i+el
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
a 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.
Ca 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
❑ 15. Toxic Chemicals
TIMElrEMPERA7t1RE CONTROLS (Poiemwlly Hazardous Foods) Ue3
Tem...,i�,�.,.,
❑ 16. Cooking peratures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
'_.� REQUIREMENTS FOR HIGHLY SUSGEPTIBI,E POPULATIONS (HSP);'
4❑ 21. Food and Food Preparation for HSP
("CONSUMER ADVISORY, `42 � + � " 7 , �", " 9",.-,R
❑ 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'sSi gature:
Prins, oNiJ �� P��O *rc
Page (of�/Pages
G-
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22)
FOOD PROTECTION MANAGEMENT
1 596.003(A) I Assignment of Responsibility*
590.003(B) Demonstration of 1Snowled e*
2-103.11 Personincharge-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
Tee Made From Potable Drinking Water*
Applicant To Report To The Person In
Drinking Water from an Approved System*
590.006(A)
Char e*
590.006(B)
59(1.003(G)
Reporting b Person in Charge*
3
590.003(D)
Exclusions and Restrictions*
3-201-15
590.003(E)
Removal of Exclusions and Restrictions
C
C
6
I
FOOD FROM APPROVED SOURCE
* Denotes critical item in the federal 1999 Paxl Cale or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
S
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*
3-202.1.4
Eggs and Milk Products, Pasteurized*
3-202.16
Tee Made From Potable Drinking Water*
5-101..1.1
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 3 10 CMR 22.07
Washin Fmits and Ve*eCables
Shelt7lsh and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201-15
Molluscan Shellfish from NSSP Iisted
Sources*
Contamination from the Consumer
Game and Wild Mushrooms Approved by
Regulatory Autho
3-20118
Shellst(x:k Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
3-701.11
Receiving/Condition r
3-202.11
PI-IFs Received at Proper Temperatures*
3-202. t5
Package Lite it
3-101.11
Food Safe and Unadulterated
Tags/Records: Shelistock
3-202.18
Shellstock Identification *
3-20112
Shellstock Identification Maintained"
TagsiRecords: Fish Products
3-402.11
Parasite Destruction -
3 -402.12
Records, Creation and Retention*
590.004(7)
Labeling of ingredients*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Conformance with Approved Procedures
IHACCP Plans
3-502.11
Specialized Processing Methods*
3-502.12
Reduced oxygen packaging, criteria*
8-103.12
Conformance with Approved Procedures*
* Denotes critical item in the federal 1999 Paxl Cale or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
S
Gross -contamination
3-302.11(A)(])
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-302.110)(2)
Raw Animal Foods Separated from Each
Other*
Contamination from the Environment
3-302.1.IfA)
Food Protection*
3-302.15
Washin Fmits and Ve*eCables
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*
9
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Tent eratures* -
4-501.112
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4501.114
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 Contact Surfaces of Equipment*
4-70311
Methods of Sanitization - Hot Water and
Chemical*
Ig
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Amos"
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
Il
Good Hygienic Practices
2401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes. Nose and
Mouth*
3-301.12
Preventin C;ontantination When Tasdn �`
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Employees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.11
Ixication and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11 -
Handwashin Cleanser, Availability
6-301.1.2
HandDrvim+Provision
�q�sn" i1�r.�° : . � ti�f4-fir _.�''".� .a?•` S rt". x,:.
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
jf __
L !
Da l
e� �Ug2,,Food
Type of Operation(s)
Type of Inspection
Service
❑ Retail
❑ Residential Kitchen
❑ Mobile
❑ Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
❑ Routine
-0-Re-inspection
Previou Inspection
Date:�rp/o
❑ Pr -operation
❑ Suspect Illness
❑ General Complaint
❑ HACCP
❑Other
Address
ai)(�
Risk
Level
Telephone 1 ��
Owner ex, I_ �y�
/l r o"11
HACCP Y/N
Person in Charge (PIC)
Time
In: 4
Out: 14 I �
Inspector ) O
Each violation check4d 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 '�.,;; ;j�ILL
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH
a
❑ry+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
u 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)
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
5: 5901nspectPomr614 da
n,,/ / / /
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTEC710NFROMCHEMICALSa€F." """re,iC,�;ta.,r„,„Yf,,a.wt,C.k
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
j TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods)'" t F.
f.. „ s.✓.«..».»,..........
❑ 16. Cooking Temperatures
[117. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
JREOUIREMERIIS FOR HIGHLY SUSi tOPLE PDPULATIUNS (HSP)'.° l
❑ 21. Food and Food Preparation for HSP
PFCONSUMERADVISORY ,i" ...;.h"®l,,.9......„.„era's..»-.»,..,,...
❑ 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:_ f„
Print: '
>-�
PIC's Signature:
Print: {,.:(
Page_L ofd` Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 5*003(A) Assignment of Responsibility*
590.003(B) Demanstration 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 F aployee 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(B)
.590.003(G)
Reporting by Person in Charge*
3
1 590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
4
in
Denotes critical acro in the Werad 1999 Fmd Carle or 105 ChiR 590.000,
PROTECTION FROM CONTAMINATION
8
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law -
3 -201.12
Food in a Hermetically Scaled 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..1.1
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0*
Wa dung Fruit's and Vegetables
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
Regulatory Authority
3-202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.1.7
Game Animals*
3-701.11
Receiving/Condition
3-20211
PHFs Received at Proper Temperatures*
3-202.15
Package htte it *
3-101.11
Food Safe and Unadulterated
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(7)
Labeling of Ingredients*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
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*
Denotes critical acro in the Werad 1999 Fmd Carle or 105 ChiR 590.000,
PROTECTION FROM CONTAMINATION
8
Cross -contamination
3-30211(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-30111(A)(2)
'Raw Animal Foods Separated from Each
Other*
Contamination from the Environment
3-302.11(A)
Food Protection*
3-30215
Wa dung Fruit's 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 Fund*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
9
Food Contact Surfaces
4-501.1.11.
Manual Warewashing- HotWater
Sanitization'rem eratures" - .
4-501.112
Mechanical Warewashinb Hot Water
Sanitization Tem eratures*
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*
4-70311
Methods of Sanitization - Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301_12
Cleaning Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2401.11
Eating, Drinkin or Using Tobacco*
2401.12
Discharges From the Eyes, Nose and
Mouth*
3-30LI2
Preventing Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Employees;*
13
Handwash Facilities
Conveniently Located and Accessible
5-20111
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
Accessibility, Operation andMaintenance
Supplied win Soap and Hand Drying
Devices
6-301.11
Handwashin Cleanser, Availability
6-301.12
Hand g * Provision
i
Establishment Name:
CITY OF SALEM
BOARD OF HEALTH
Date: I L(5�0
Page: of
ItemCode
Reference
C - Critical Item
R—RedItem
DESCRIPTION OF VIOLATION /PLAN OF CORRECTION "
rt
PLEASE PRINT CLEARLY
Date
VerifieC,$
`
t ��._.S / /VOn �l f a A),a Rlr+L,.
r
'I
I
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
nogcompliance may result in daily fines of tweryt lfive doollars oar suspension/revocation of
your. food permit.
Corrective Action Required:
❑ No
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
Re -inspection Scheduled ❑ Emergency Suspension
Embargo ❑ Emergency Closure
0 Voluntary Disposal ❑ Other:
Violations Related to Foodborne fitness interventions and Risk
Factors (ltehis 1.22) (Cont)
PROTECTYON FROM CHEMICALS
14
15
16
3-:€oI liAtI)L;
Food or Color Additives
3-262.12
;,dditive,* --
3-302.14
_
Protection front l,Inal>proved Additives"
—i
t
Poisonous or Toxic Substances
7 101.111deuUtyingtntounaticn
-On"'inal
r
!i(Au .,
� Contalrers- I
A02.i 1
Common ti+m¢ A , k o f oo Sin ra"—�
0_Lli
S�pn iuwl 5to ate__
7 �17i1 [
-�—�
�liestrni on Pa s..nu• uxi I; c
7102-12
Condition ofUsv
2703.11
1(X& C 0111 nnm Proli bl,tox '
7-204.11 lbain❑lett,(.iltell,
(hcmi(ils-' I
. 12
x. c Grtn.a�"A
2g4.14
r`
Dr�v,#ttt(nu
I -'-d—.,
o5.11
_1
-__
btctd nttll .)dCunlxc laibruant i
_
1 '7-206 1 I 1
J
Beat Rl r t..c. Pr ntc lr-- C:nten a*
� 7 06.12
Rkxleni But S.a(ion
-a
1:_06.1 '
h 4,ir g Poua'ehrv. ...:. Co,itrl and
I
11GiV O illi"
3-:€oI liAtI)L;
icy. 15 'F 15
___
1 I � s Lnm_<d� tte 4u is I S I�15sec
f3L11t02,
C to r muicd HAsienis ati iii nc
t
I
I 1i malt i55 ` n
„--�_
1c1.I�r�1t1 �.�
� � tt 1 ,
- ird lit Ru t 1 12 foin, I
r
!i(Au .,
_ . ,
Knne ly otAkl,ats1 s F ER_�..)
14
Tcmperatmel> >redieut'<u 4I"F745'F
I-4Pi1_i? A):3}
a I'rulrrv- Wild (Jame, Stu'4c r'lit s, I
`lin t tWL'41 >`?le'�<I
j St ,fii r l Fish. ileal,
I 1 at u, N „ try.'. .,
4d`!45° F"
4 50I IN A)
—— --1
Ilot PHFs Maintained at or above
1401'.
i
.ii f F�
i (1 :T 1x11 ..tti i
i
I Reheating#or riot HnNit 4 f
0,{.I I i A)r t1
iy
via. -
3 -11k)-,11(114
ti'.11-ti
1li.om _tc- 1r I ? Mmuc_ Standin;
r — ——
)(i.�i0ifH) 1
1 Ii P.:'C �u�tS7iC HiCia
�-a.3.i1�+.'j�
lt. n,.ir�s.. math P�cn aed Rti Fuad- ,
.i I(lc)
Rc- to Prn1; Utlshc"d llimicns of beet
PHFs Received at Temperatures'` .
Proper Cooling of PHFs
-- 'S(il.I4(A)
—�fa?hngCax d PHF5 Irm HtYl-, to
fi
70 1 Wiihin t i ou s awl From 701'
41"F/45'F Within 4 Hous. s
to 4j i'?5F Within 4 Him
`-501, i l(B)
Cooling PH'F: M4 is From Ambient
14
Tcmperatmel> >redieut'<u 4I"F745'F
PHF Hot and Eold Holding
`lin t tWL'41 >`?le'�<I
�i t'Uixta 'IP..r iiKC S '..3 Oitrl.
REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS {HSP)
rl [ �tillt r't+,)Ti�;ip�tcurizrd Pic. )>av}agcd Jtnc�c wrd
�—_�� Hetet es a=?ith l5 autinv�hah hT —
E &t; 1 131 Uttc t Pa. teuvtd t etc,`
5Ji i l (D)1 Ea` t or P=Jo'.111 { ivk it Animal Food and
i d 'waits Nol 4 ,ryt a
11((.1 Ur- a m,icd Toad Pact air Not R :.ervr I
CONSUMER ADVISORY _
2 1 3+'6 t 1 ('anent u r 'ids icor} 110.tcdl �iirr Consumption w
<x+d>'Iltat arc pww, l'ndeat;:x.:kcd cr
'Not Otl et t i t PrG:c es.d to Gliminau;
Patho'- t . ,.:r...
teunr ' 3 c z.� -=lL
i r:5 iae: tut: lotiw shell
SPECIAL REQUIREMENTS _
5)rn`.L,�cOr i violas rr)s ,i Section ')00( k)(D)to
" a term mi hil;, fkvoti. teanp;,ral_v wx1
kilchcn ctivrtmca s hould be j
� tiCIJt%.,C undcr tit£ ?) i)11'!3r:8it' SC, if OItS
� =Cxivz + lo f h,i.;tC, tY
VIOL S:`IDAIS HELATEG' r } GOOD RET ,,f- F ACTWES
(Items 23-30)
hr itt ':t,S3 nti t Ind Kat—Ju, lr t txaod boor, ora tw
(< x,<rt .tt? Mi •'a<tc ,c1,1h, r. cdcodacu rfrri(d1R
XXt
item Gnod Beta.i Pr, chces - FC S�O.ODG
30 Omer
and Uteoses
Lbrl�lPo ^I sto i FC - 5
tI�tl __- c _.'
of ti,__7
F i-5O1.14(C)
PHFs Received at Temperatures'` .
According to Iain Cooled to
41"F/45'F Within 4 Hous. s
1 7-501.15
Cooliq, Methods for 1)
14
PHF Hot and Eold Holding
3,5011b(B)
Cold PHFs Maintained ator bebtw
5901N11(I=)
4d`!45° F"
4 50I IN A)
—— --1
Ilot PHFs Maintained at or above
1401'.
t ,tii.l6tat
1 Rcaasts Held at or above UWE *`
L 20 lam.
_- �A
—
1 Time as a Public Health Control
—Health—
Ui 1
Iter asaPubli C pool' j
r — ——
)(i.�i0ifH) 1
1 Ii P.:'C �u�tS7iC HiCia
REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS {HSP)
rl [ �tillt r't+,)Ti�;ip�tcurizrd Pic. )>av}agcd Jtnc�c wrd
�—_�� Hetet es a=?ith l5 autinv�hah hT —
E &t; 1 131 Uttc t Pa. teuvtd t etc,`
5Ji i l (D)1 Ea` t or P=Jo'.111 { ivk it Animal Food and
i d 'waits Nol 4 ,ryt a
11((.1 Ur- a m,icd Toad Pact air Not R :.ervr I
CONSUMER ADVISORY _
2 1 3+'6 t 1 ('anent u r 'ids icor} 110.tcdl �iirr Consumption w
<x+d>'Iltat arc pww, l'ndeat;:x.:kcd cr
'Not Otl et t i t PrG:c es.d to Gliminau;
Patho'- t . ,.:r...
teunr ' 3 c z.� -=lL
i r:5 iae: tut: lotiw shell
SPECIAL REQUIREMENTS _
5)rn`.L,�cOr i violas rr)s ,i Section ')00( k)(D)to
" a term mi hil;, fkvoti. teanp;,ral_v wx1
kilchcn ctivrtmca s hould be j
� tiCIJt%.,C undcr tit£ ?) i)11'!3r:8it' SC, if OItS
� =Cxivz + lo f h,i.;tC, tY
VIOL S:`IDAIS HELATEG' r } GOOD RET ,,f- F ACTWES
(Items 23-30)
hr itt ':t,S3 nti t Ind Kat—Ju, lr t txaod boor, ora tw
(< x,<rt .tt? Mi •'a<tc ,c1,1h, r. cdcodacu rfrri(d1R
XXt
item Gnod Beta.i Pr, chces - FC S�O.ODG
30 Omer
and Uteoses
Lbrl�lPo ^I sto i FC - 5
tI�tl __- c _.'
of ti,__7
rer"+-�,":..,:.'it'%-+.a-,Cw,
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
Salem Board of Health
120 Washington Street, 0 Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name
i 11
0 UA
D e
Tvoe of Ooeration(sl
Type of Inspection
®Food Service
[_1 Retail
Routine
ElRe-inspection
(k
OA/ c./
o
Address)
Risk
v/ G
Level
❑ Residential Kitchen
Previous Inspection
Date:
TelephoneElMobile
El Temporary
ElPre-operation
Owner
��
HACCP YM
❑ Caterer
ElSuspect Illness
ElBed & Breakfast
E] General Complaint
Person in Charge (PIC)
Time
`
In:�'c,7�
Permit No.
E] HACCP
❑
Inspector
Out:
Other
nr
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. r
„006DPROTECTION MANAGEMENT '�; _f-
❑ 1. PIC Assigned / Knowledgeable / Duties
P EMPLOYEE HEALTH "_,1" ' ,I"r`i
❑ 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)
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 CHEMICALST;a's "
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
r tiME/rEMPERATURit CONTROLS (PoierttlaII j Hazardous Foods) M. -1
�❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
IREQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) pgip
❑ 21. Food and Food Preparation for HSP
q,_..CONSUMER ADVISORY.V M -1p
❑ 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:
r_'��C")aa 10
Inspector's Signature:
Print:
)
Page of ages
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 596.003(A) Assi2menlofRes onaibilit
590.003(B) Demonstration of Knowledge*
2-103.11 1 Person in charge -- duties
EMPLOYEE HEALTH
2
590.003(0)
Responsibility of the person in charge to
Compliance with Food Law*
3-201.12
require reporting by food employees and
3-201.13
Flui d Milk and Milk Products*
applicants*
Shell E s*
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(B)
590.003(6)
Reporting by Person in Charge"
3
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
4
in
FOOD FROM APPROVED SOURCE
* Denotes criduil item in the federal 1999 Pool Code or 105 CM K 590,000,
PROTECTION FROM CONTAMINATION
S
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
Flui d Milk and Milk Products*
3-202.13
Shell E s*
3-202.14
Eggs and Milk Products. Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-tO1.11
Drinking Water from an Approved System*_
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0*
Washing Fruits and Vegetables
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
Regulatory Authority
3-20218
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
3-701.11
Receiving/Condition
3-202.11
PHFs Received at Proper Tem eratures"
3-202.15
Package Hue it *
3-101.11.
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained*
-
Tags/Records: Fish Products
340111
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 -
3-502.11.
Specialized Processing Methods*
3-502.12
_
Reduced oxygen packaging. criteria*
8-103.12
Conformance with A roved Procedures*
* Denotes criduil item in the federal 1999 Pool Code or 105 CM K 590,000,
PROTECTION FROM CONTAMINATION
S
Cross -contamination
3-302-11(A)(])
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
3-302.1.1(A)
Food Protection*
3-302.15
Washing Fruits and Vegetables
3-304.11.
Food Contact with Equipment and
Uiensils*
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* .
9
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Temperatures* - -
4-501.112
Mechanical Warewashing- HotWater
Sanitization Temperatures*
4501..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 Famed -
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*
IQ
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301..1.2
Cleaning Procedure*
2-301.14
When to Wash*
Il
Good Hygienic Practices
2-401.11
Eating, Drinking or Usin Tobacco*
2-40112
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventing Contamination When Tri�
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Em lovees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.1. t
I-rication and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-3(11.1 t
Hindwashing Cleanser, Availability
6-301.12
Hand Drying Provision
iA
Establishment
CITY OF SALEM
BOARD OF HEALTH
Date: L /13 //0 Page: 4�?' of :
Item
No.
Code
Reference
C - Critical Item
R — Red item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
PLEASE PRINT/CLEARLY
Date, .
Verified
/
0
I
�T
/'/
ka Q
� -Y) i /O Uee—J GO o X OG/I
- G
G.%f rV V,,- IN
A' 3
"
Pai o ( L n/eD4) he
rCP6 ro
)40R—k) r
f CJ �
r
c('4 t n le G� nn cAL
jG.i.
1i) — Set u — ^
R(_p
-mac (11
(R� sh J+ 10 C co( aio)C11 z(AX _
1 R4s• n % o I IrJ J, /d i .�1 e/c`7/tlYl ActcAnp
,1J
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
inspection, to observe all conditions as described, and to
violations before the next ins 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. ___--,------��
Corrective Action Required:
❑ No
Yes
❑ Volunt *Compliance ❑ Employee Restriction /
Exclusion
Re -inspection Scheduled ❑ Emergency Suspension
o Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
It
Violations Related to Foodborne Illness Interventions and Risk
Factors (ttelft 1-22) (Cont)
PROTECTION FROM CHEMICALS
14
1 3St)1, 14(C)
Food or Calor Additives
_;-202.12
Additiyei,*
3-302.14
Protection front unapproved ridditlses"_
15
401,11(.1,)10_'
Poisonous or Toxic Substances
5
-101.11
Jdeatifyatifying Into.: mation- Original
i' ui r N'it i ru 31u r e
_
l omailiet
7 M),II
CommonA:me
'Ohl lIa
tttort 5trna
10_10_
c j
1010; 1010 10_10._ .{
_ �.a
I Re.,tntt ou 6-e l,.nce old F, e _
{ t :,H
1010_. _1010__ 1010 1010 __ _1
F�202.11
7 10) *2
Condition, of hist —
F111)�19i
F 7 11
roxic f oIt Sinel I t)F �o,,,
16 t
,lu t,3 ,.c- 7t h _ viinu., Siandow 1
_203,
Sanniru. Criteria id CLu )a Iti
1.403.1 IfC"_)
' t wmev,i; l} ESi ,l�icd Wit' Kiod - I
tin W t h� 4 u_nc, Crito ;a'- _
7-X04 14D
-im,,_AmiteC. rntri )
ft'+:11
m[yo ntll Food Comu Lublicaws,
P tudt Cit r ii)
7 206.112 ,
Bznl`<stionc
(-�06
�F , 'uckm2 Pofdcoz,}i s !biiV a 31td
l4nnilJpn:?"
16
18
flW,::.T w,.
i-5o1.14(A) C cmGnn Conh�si pill -'s flow 1 4Y F to
'IXF within 2 1 rourc ;,ttel From m /fPF
_ _ _ _ (t 1 T1.?�f � 4 thin How—
laT CiiIa vRllf- iizhHim mFisnt
1 m{ ratan le rcQri;ts tc 17"Pi-:{z
Within 4 Illmo,_
a; critical i o,. n. d , 7; ;i i 14,r<, { n. * 1 ac (_Nik t il()(I.
1 3St)1, 14(C)
PHFs Received at Teaiperat.ores
401.11_ fit...
.; f ni mu[te' f iah Mut, :t, & Clain-.
__
4uI;.{'Fiu
pit irrl'3. Ru 1701 I"Hing
401,11(.1,)10_'
_
Coolin,, Methods for PHFs
5
1 i
i-4(11.4 i (A)i 3;
i' ui r N'it i ru 31u r e
3-501.16($)
I
590 004(F)
-0d%45° F"
1010 1010.
-1010
v l � .0 1010 t: rF,. a
10_10_
c j
1010; 1010 10_10._ .{
1 i S
{ t :,H
1010_. _1010__ 1010 1010 __ _1
E
I t F9 'Stn f for ziOt Holding {
F111)�19i
1E111
F 1(7'.11(43)
16 t
,lu t,3 ,.c- 7t h _ viinu., Siandow 1
C til 1
[{m as a Public ttealh ContsolT
1.403.1 IfC"_)
' t wmev,i; l} ESi ,l�icd Wit' Kiod - I
S4031I(El
Rut unegCii,ccdPer.io.�ofBce,
i-5o1.14(A) C cmGnn Conh�si pill -'s flow 1 4Y F to
'IXF within 2 1 rourc ;,ttel From m /fPF
_ _ _ _ (t 1 T1.?�f � 4 thin How—
laT CiiIa vRllf- iizhHim mFisnt
1 m{ ratan le rcQri;ts tc 17"Pi-:{z
Within 4 Illmo,_
a; critical i o,. n. d , 7; ;i i 14,r<, { n. * 1 ac (_Nik t il()(I.
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP) _
f-217 3 -Sill I {t i� lnp tcuti sd Pr l- �. Led JuRcs
-SOI 1'(13) Its ol P.,qewiztdt
WLI i(D)�kar or P%iiill C+x,n:d Anunal € god and
lrn }c u �pnnn, � �c Ser3cd
.$fJl Io'(' 1 1 r ov[wd i,xx1 Y3ce.a_: idol R, verger{
CLONSi3MER ADVISORY _
r bCi' i L'oixmn s Sts.?'t iinvu I ttr t:c�fi-noiptian of
I linlal 1 iods Mai z #i,;u:. Undciox-iki:d e:
nalho,<r
.SIL' 3 t :Attlu c+ ! s {'2 a.: 1), Raw S;)4
'PECIAL REOU€REMENTS
{ { 0" Vii, i, ht-74C,!iirlk, tiK}/tA,i (i}i
at ; i i * ,ri„ii is Irmo;, trrip az v and.
tiC3tiiv .li,dci .?:
1010 � i i..iti:
GIC�AFiDh x ft%-i,27SC.` i=� Gt?C1C R!. .�:L. PHAt Ilii"sa i_.
# Items 23-30f
Cliff t 10 10: lam, i at < 1'+.i )tte(ch l7oi ttC r rete
r �d1 t s it. 5 leel s. cn )l, ilill ri 1ld t e b:ct< f iN rn cart tri
kr<: rn,a...d"i<(_i j`; r"d1R
_1010 r -_._ 10_10
rtanr Gnod Reta t f ractices FF: 5911-t70f1
__- ---.. .__ 1010_._
i f lanagrms t and Pe is n P C 2 l oS
1010 _ _ _1010 __1010._.
i o d Frvyt .nd FvX Protection ' FC, 3 � 10604
_. _. _
25 ...;_Eguipmen(and tJtensrs tC '1 t 10605
;_.
r° Water Pt rrbaFG-5 :u i' �l i ro a -ooi3
7 .
°h,r< a F1 'zY FC n 607 I
�' ,rs troy or T�xrt r�is C 7 668 _t
{1010. _ _ _1010 .t
l r &rte t{ R +i .ic,re,Plt _OQ9 r
_1010
1 3St)1, 14(C)
PHFs Received at Teaiperat.ores
According to Lau Cooled to -
__
-41 "F/45`F Within 4 Hout's. *
3-St1i.15
_
Coolin,, Methods for PHFs
19
PHF Hot and Cold Holding
3-501.16($)
Cold PHFs Maintained at or Ixlow
590 004(F)
-0d%45° F"
3-50 L I WA)
Hirt PHF.c Aiaintained at or above
--1
Rtaists Held at or shove C30°F. *
Z0
Time as a Pubf{c HeaFth Control
C til 1
[{m as a Public ttealh ContsolT
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP) _
f-217 3 -Sill I {t i� lnp tcuti sd Pr l- �. Led JuRcs
-SOI 1'(13) Its ol P.,qewiztdt
WLI i(D)�kar or P%iiill C+x,n:d Anunal € god and
lrn }c u �pnnn, � �c Ser3cd
.$fJl Io'(' 1 1 r ov[wd i,xx1 Y3ce.a_: idol R, verger{
CLONSi3MER ADVISORY _
r bCi' i L'oixmn s Sts.?'t iinvu I ttr t:c�fi-noiptian of
I linlal 1 iods Mai z #i,;u:. Undciox-iki:d e:
nalho,<r
.SIL' 3 t :Attlu c+ ! s {'2 a.: 1), Raw S;)4
'PECIAL REOU€REMENTS
{ { 0" Vii, i, ht-74C,!iirlk, tiK}/tA,i (i}i
at ; i i * ,ri„ii is Irmo;, trrip az v and.
tiC3tiiv .li,dci .?:
1010 � i i..iti:
GIC�AFiDh x ft%-i,27SC.` i=� Gt?C1C R!. .�:L. PHAt Ilii"sa i_.
# Items 23-30f
Cliff t 10 10: lam, i at < 1'+.i )tte(ch l7oi ttC r rete
r �d1 t s it. 5 leel s. cn )l, ilill ri 1ld t e b:ct< f iN rn cart tri
kr<: rn,a...d"i<(_i j`; r"d1R
_1010 r -_._ 10_10
rtanr Gnod Reta t f ractices FF: 5911-t70f1
__- ---.. .__ 1010_._
i f lanagrms t and Pe is n P C 2 l oS
1010 _ _ _1010 __1010._.
i o d Frvyt .nd FvX Protection ' FC, 3 � 10604
_. _. _
25 ...;_Eguipmen(and tJtensrs tC '1 t 10605
;_.
r° Water Pt rrbaFG-5 :u i' �l i ro a -ooi3
7 .
°h,r< a F1 'zY FC n 607 I
�' ,rs troy or T�xrt r�is C 7 668 _t
{1010. _ _ _1010 .t
l r &rte t{ R +i .ic,re,Plt _OQ9 r
_1010
.r
' 0062 WHARF STREET
Telephone:
(978) 744-0062
Owner:
Antonio Bettencourt
PIC:
Antonio Bettencourt
Inspector:
Elizabeth Salandrea
Date Inspected: Correct By:
3/5/2009
Risk Level
Permit Number:
BHP -2009-0320
Status:
VIOLATION
# of Critical Violations:
4
Time IN:
Time OUT:
Urgency Description(s):
BLUE:
.Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10 i
days)(Non-critical violations I
must be corrected immediately
or within 90 days) i
s +
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item
PROTECTION FROM CONTAMINATION
Status Violation
Sixty 2 on Wharf
Critical Urgency
Separation/ Segregation/ Protection FAIL Critical L� RED
�omment: True freezer had meat stored above/next to ready to eat food. Organize freezer to properly separate PHF from RTE food.
Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED
Comment: Cutting boards in kitchen are scored and stained. Resurface or replace cutting boards.
v4anitizer tooOsttroonng at approximately 400+ppm. Provide sanitizer of proper concentration (200ppm) at all times.
VAanitizer log not being kept. Daily log of sanitizer concentration must be maintained.
�., Dishwasher in bar is not currently in use due to problem with sanitizer noted in previous inspection. Glassware and utensils from
bar are being washed in dishwasher in kitchen. PIC to call Board of Health when machine is repaired and ready to use.
Hand�wass4 Facilities FAIL Critical ❑d RED
V Comment: Handwash sinks at bar and in employee bathroom are missing paper towels and soap dispensers are empty. All hand
sinks must be stocked with soap & paper towels at all times.
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMS® 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 12,2009 ) Page I oft
Reinspection in one week, all violations to be corrected.
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800
GeoTMS® 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 12,2009 ) Page 2 oft
'
Item Status Violation Critical Urgency
RED:
Violations Related to Good Retail Practices (Blue Items)
Violations Related to
Food and Food Protection FAIL Critical BLUE
Foodborne Illness Interventions
Oleomment: Some uncovered food in right-hand fridge across from cookline. Cover all food in storage to prevent cross
and Risk Factors (Require
contamination.
immediate corrective action)
gar barrel was open at time of inspection. Close sugar barrel when not in use to prevent cross contamination.
Equipment and Utensils FAIL Non-Critical BLUE
I//mment: Dough machine needs general cleaning.
{'bay sink must be labelled 'wash', 'rinse'and'sanitize'.
V-Cod prep sink and hand sink at bar must be labelled appropriately.
Vue freezer needs general cleaning.
fr
/sugar barrel needs general cleaning.
Vegetable containers need general cleaning.
LAame containers must be labelled as to their contents.
Reinspection in one week, all violations to be corrected.
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800
GeoTMS® 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 12,2009 ) Page 2 oft
0062 WHARF STREET
Telephone:
(978) 744-0062
'Owner:
'Antonio Bettencourt
'PIC:
Antonio Bettencourt
Inspector:
Elizabeth Salandrea
Date Inspected: Correct By:
3/12/2009
Risk Level:
Permit Number:
I BHP -2009-0320
Status:
SIGNED OFF
# of Critical Violations:
1
Time IN:
Time OUT:
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item
PROTECTION FROM CONTAMINATION
Food Contact Surfaces Cleaning and Sanitizing
Status Violation
FAIL Critical
Sixty 2 on Wharf
Critical Urgency
Comment: Cutting boards in kitchen are scored and stained. PIC states new cutting boards have been ordered.
RED
Dishwasher in bar is not currently in use due to problem with sanitizer noted in previous inspection. Glassware and utensils from
bar are being washed in dishwasher in kitchen. PIC to call Board of Health when machine is repaired and ready to use.
Urgency Description(s):
BLUE: All other violations noted in the 3/5/09 inspection report have been corrected.
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® 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 12,2009) Page 1 oft
:�
Item
RED: --- — i
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require i
immediate corrective action)
Status Violation Critical Urgency
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMS® 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 12,2009) Page 2 oft
1 PO TANT
MESSAGE '
- --
-
FOR
WILL CALL AGAIN
WANTS TO SEE YOU
DATE
TIME T -Ld— .
RETURNED YOUR CALL
WILL FAX TO YOU
j
3VJ-00b
'
PHONIE�JK
AREA C O
NU BER EMENBION
O FAX
O MOBILE
AREA COBE
NUMBER TIME TO CALL
TELEPHONED
PLEASE CALL
CAME TO SEE YOU
WILL CALL AGAIN
WANTS TO SEE YOU
RUSH
RETURNED YOUR CALL
WILL FAX TO YOU
SIGNED
FORM 4009
MADE IN U.S.A.
��... y4'�� _ ...._..
Commonwealth of Massachusetts
i City of Salem
Board of Health lGmberiey Driscoll
120 Washington Street, 4th Floor Mayor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/30/2008
ESTABLISHMENT NAME:
File Number: BHF -2003-000024
LOCATED AT:
Sixty 2 on Wharf
62 Wharf Street
Salem MA 01970
0062 WHARF STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
FOOD SERVICE BHP -2009-0320 Dec 30, 2008 . Dec 31, 2009 $280.00
ESTABLISHMENT
PERMIT EXPIRES
Total Fees: $280.00
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
+ s BOARD OF HEALTH
120 WASHINGTON STREET, 4" FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAx (978) 745-0343
MAYOR IDIONNE , SALEM CO',A
JANET DIONNE,
ACTING HEALTH AGENT
2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT -' )i YJ -4 M UAtgrr— TEL # M 99Y -00(2a
ADDRESS OF ESTABLISHMENT bd, W{ QrP a� SGLpri Aff01-J90 FAX# ?9 �- 7YY' 7/(ao2
MAILING ADDRESS (if different)
EMAIL- Business':
1 Tuesda Wednesda
" .
01 Ldp- - CO n
Website: UWW.
cln e✓k, /F- caii
!S l�pm)
OWNER'S NAMEIqLj�YI
n +
Vnl4r;e i3e4 P/fCr741
TEL# q0F
!"
9i8- S3/9S'F7
ADDRESS
STREET
CITY
STATE
ZIP
CERTIFIED FOOD MANAGER'S NAME(S) Af4M i a &4-4- e O,31, ✓4 CERTIFICATE#(S)tJ r. Aa (
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON U4�erfe HOMETEL# (ol,) E13 -9%V')
<DAYSOF-.OP,ERATION- Mond - '
1 Tuesda Wednesda
" .
.r.�-Thursda '• :.
,: =Edda SatuMa . ';-- '' . Sudd
HOURS OF OPERATION 1
Please in time of day.
!S l�pm)
MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO
$25
wdte
I �' p�
ALL NON-PROFIT (such as church kitchens) YES NO
$25
(For example llam-11pm
TYPE OF ESTABLISHMENT
RETAIL STORE YES NO
(Outdoor Stationary Food Cart
FEE (checkonly)
less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
less than seats
25-99 seats
more than 99 seats =$420
BED/BREAKFAST/ YES NO
$100
CHILDCARESERVICES-------------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO
$25
TOBACCO VENDOR YES NO
$135
ALL NON-PROFIT (such as church kitchens) YES NO
$25
`Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns and paid all stale taxes required under the law.
Signature / Date
Revised 424/07 FOODAP2008.adm Check# & Date
or
• •dl � vM Ya _,eµ 't
!7
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street, 4th Floor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/29/2008
ESTABLISHMENT NAME:
File Number: BHF -2003-000024
IGmberley Driscoll
Mayor
62 on Wharf
62 Wharf Street
Salem MA 01970
LOCATED AT: 0062 WHARF STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
FOOD SERVICE BHF -2008-0403 Jan 29, 2008 Dec 31, 2008 $280.00
ESTABLISHMENT
Total Fees: $280.00
PERMIT EXPIRES D ecember 31, 2008
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1
J7 4
KIMBERLEY DRISCOLL
MAYOR
JOANNE SCOTT,
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4"r FLOOR
TEL. (978) 741-1800
FAX (978) 745-0343
ISCO,PI,na.SALE➢4. CONI
2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT 6 ao.J 14)), a f TEL #
ADDRESS OF ESTABLISHMENT 69 V)A60 S/ FAX #
MAILING ADDRESS (if different) / r� p
EMAIL- Business': i�/'�� 6,161^ a✓4A O� C Website: 0,;Z i;,^)
ADDRESS / *_ C
TEL # 9,; 8 S31 SSS i
Std /Gl.�4 4/9&O
STREET CITY ` STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S),2Q% ,P JtJ ietfAn) Cok2 CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is preparedd)) J
EMERGENCY RESPONSE PERSON /PDA 7/ �/O 9 COGc 2 pHOME TEL# 9 7k S3/ f f,f_
DAYS OF OPERATION Monday Tuesday i Wednesday Thursday Friday i Saturday Sunda
HOURS OF OPERATION
Please write in time of day.
(For example llam-11pm)
TYPE OF ESTABLISHMENT
FEE (check only)
RETAIL STORE YES NO
less than 1000sq.ft.
=$ 70
1000-10,000sq.ft.
=$280
more than 10,000sq.ft.
=$420
........................ ---------------------------------------------------------
Y NO
------ n, --------------------
less than 25 seats
_11".4, -----
(Outdoor Stationary Food Cart $210)
25-99 seats
= 280
more than 99 seats
=$420
-------------------------------146---------------------------------------------------------------------------
BED/BREAKFAST/ YES NO
------
$100--
CHILDCARE SERVICES
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE
YES NO
$25
TOBACCO VENDOR
YES NO
$135
ALL NON-PROFIT (such as church kitchens)
YES NO
$25
'Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all slate lax
returns and paid all state taxes required ypder the IV. _
Date
Social Security or Federal Identification Number
Revised 4/24/07 FOODAP2008.adm Check# & Date $
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
Salem Board of Health
120 Washington Street, 0 Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name
Date I /
Type of Operation(s)
TVDe of Inspection
Food Service
Retail
❑ Routine
,•gee -inspection
AddresV
I
7Lisfc
Level
❑ Residential Kitchen
❑ Mobile
Previous Inspection
Date:
Telephone d!
❑ Temporary
❑ Caterer
❑ Pre-operation
❑ Suspect Illness
Owner
HACCP Y/N
❑ Bed 8 Breakfast
❑ General Complaint
Person in Charge (PIC)
Time
In: 11�
Permit
El HACCP
Inspector e
Ou .1 a,�
No.
ElOther
Each violation checkedreq'u(res do explanation on the narrativd p`'Sge(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. R
FOOD PROTECTION MANAOEMENT„j-Li,�"
❑ 1. PIC Assigned / Knowledgeable / Duties
4, EMPLOYEE HEALTH"a s q% t -T'VT i -r F,
+3`r'4 fi?-i Ay ik�ii., a4 c"va i'IMx
». _ ',u,.......**,r��,ya�.®.,.eau§,.+-«�.•..»�,u,.,��.,»kn�.arais,3�.a adwxeivu,
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
x SII'
FOOD FROM APpROVEb SOURCE,,,.m�,,y,„„„„,,,.,�,,,s,,,,,�.,�„„„„ a,,,.;;,,;,,
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALw� z •_�f IMLn .
21
El 14. Approved
Food or Color Additives
❑ 15. Toxic Chemicals
'TIMErrEMPERATORE CQNTROLS (Poteeitlally Hazardous Fonds) �,"""
❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM -CONT iWATIOk ,?z1 �'��"''�'"�` ❑ 19. Hot and Cold Holding
❑ 8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control
e9. 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)
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: 5901ns,dFor 14. o
i;REQUIR�hIEtJ'[S FOR HIGFILY SUSOEPTI6LE PQPULATIONS(NSP)';fo
x ❑ 21. Food and Food Preparation for HSP
CON5UMERAOVISORY,9.;uE.,:4&g.ua,,.'�.`,.?.!...
❑ 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:
PIC's SI,'gnatare - -Print: ��Pa_o Pages
�UL`__�_
Violations Related to Foodborne Illness
interventions and Risk Factors (Items 1-22)
C
FOOD PROTECTION MANAGEMENT
590.003(A)
I 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 Iaw*
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-
ater*5-101.11
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
6
Denotes critical item in the federal 1999 Fond Cade or 105 C IR 590.000, r
s
a s •r
8
Food and Water From Regulated Sources
590A04(A-B)
Compliance with Food Iaw*
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
E<• s and MilkProducts. Pasteurized*
3-202.16
Ice Made From Potable Drinking Water-
ater*5-101.11
5- W I . I I-
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(8)
Water Meets Standards in 310 CMR 22.0*
Washin Fruits and Ve etables
Shri ish 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
Regulatory Authority
3-202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.1.7
Game Animals*
3-701,11
Receiving/Condition
3-202.11.
PHFs Received at Proper Temperatures*
3-202.1.5
Package Integrity'
3-101.11
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained*
Tags/Records: Fish Products
3402.11
Parasite Destruction*
3-402.12
Records, Creation and Retention`
590.004(7)
Labeling of Ingredients'
Frequency of Sanitization of Utensils and
Food Contact Surfaces of ui ment'e
Conformance with Approved Procedures
/HACCP Plans
3-502.11
Specialized ProcessinMethods*
3-502.12
Reduced oxygen packaging' criteria*
8-103.12
Conformance with Approved Procedures*
Denotes critical item in the federal 1999 Fond Cade or 105 C IR 590.000, r
s
a s •r
8
Cross -contamination
3-302.11(A)(])
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-302.11(A)(2)
Raw Annual Foods Separated from Each
Other*
Contamination from the Environment
3-302.1](A)
IFoodPmtecdnn*
3-302.15
Washin Fruits and Ve 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
Food*
y
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Tem eratures* -
4-501.112
Mechanical Warewashino Ilot Water
Sanitization Tem matures*
4-501.114
Chemical. Sanitization- temp., pH,
concentration and hardness. *
4-60LII(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency of Equipment Foai-
Contact Surfaces and Utensils*
4-702.11.
Frequency of Sanitization of Utensils and
Food Contact Surfaces of ui ment'e
4-703.11
Methods of Sanitization - Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.1.1.
Clean Condition - Hands and Arms"
2-301.12
Cleaning* Procedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2-40L11
Eating, Drinking or Using Tobacco*
2401.12
Discharges From the Eyes, Nose and
Mouth*
3-30't.12
Preventing Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Employees,*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.11
Location and Plaeernent*
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
/� RCIARII nr: HFGI TI -1
0 -
Violations Related to Foodborne illness Interventions and Risk
Factors (Iran* 1-22) (Cont)
ld ' Food or Gator Additives
:3-202.12 I Additives* �.
3-302.14 Protcciicm front 1 nape) }vee! Addiuves*
l5 Poisonous or Toxic Suasfances
lUL1F klents t5mg infoiin,unn-Cho rnal
Containers° _
�-102.11 Conetuon Name Wi>rkineC ancuners*
l�bU l.tl JC JiiI SlSVli -'9t4»ft'�V�
..202.11
Renction- Presenceaid Use*
at
_3
7-202.12
Csmdrtxms of i)sa"�
T203
Toxic Clatfairrnzr Ptohibititm s:
204.11
amn rets C itcri+ Chemic ds"
Corrnnnunod Fish. Meats & Gana:
�
i _t74.12
Chemtcata rot A4ashi 1'srjduc.c. €:r
7 204.id
t7rotti emit, Cna r i a"
205.11
Incidental I xxl f ono ac' ta)hr is ants'
Zt}G.11
Restricted Cse Pe, tuufe . critena*
(r 12
Rcxlwi Blasi, 1"Inz
7-"06.f
_
1 Tracking Pokdc r Pest ('antral and
jg
Proper Cooking Temperatures for
_
PHFs
i- At)l.tI All )("
Egg 155Ft5S r..�
E.g;�s- (mnud ate Servlet 14.51- l;5sec,
_ _
3-4t}I.11(A)(2)�
Corrnnnunod Fish. Meats & Gana:
�
Anitnals - li;i`F=15 sec. "
-�
7740L11(I'3}117(2)
Nwkand BM to to -130 t Ili naO
Tamp cawre lrv,4rcdnmtq to 411-/45`F
IInt PHF a Maintained at tr above
3-401.110)(11
3- i.11(A)(3i�
Fait+,, loWjected Meats 155 F 15
Porutrv, dd(;lnn , 5trttlet[ PFfFs,
i
sanftrit`OimI lturn"Fist 'til al,
20..
Poultry 01' katrtec 1654 15 sec.
3-401,1 iiC)33j
Wholenmscle intact Bezf Steaks
(45°lax
3-a+OL_42
_
itaaAnimalF<u>d Ccxkediva
Microwave 165`F *_ _
-201.1TtAt(i;th)
AttthherPkiftslµ5"P?5 sec.
17
Reheating for Hot Holding
11t.4)&all}
Pfits I65'F
3-403.1 1(8)
hvcxowavc 16T, r 2 Monte standing
-403.11(C)
Time^ __
tt)mrnaraialivPaixeSsedRTFhsx+d-
�a
3-40351{Er �
; Rcmannng [ nshrcd Portions al'FieeF
Ig i
PHFsPe"rvedatTemperatums
Proper Goottng of wnrs
-5{71:3.4(A1
�._..._—`.�`_f,
Carling CwItaxt PHHs tram 140"1- to
taxilic, McEtxxl:; for PHFs
1 7u F Within 21Tourc and From 70'F
3-:iQLl4flt)
�
to 31-1-145 P W tibio 4 Hour- * _
Cooling PHRMadeFloor Ambient
i
.. 4t"/450 F,
Tamp cawre lrv,4rcdnmtq to 411-/45`F
IInt PHF a Maintained at tr above
1ti'ithin 4 Htxns'"
Uenotrs coireat nein in ih
+'ler;=i N94 rood L:ede r 105 (MR 590 OIXI-
:>Of-}4fC,j
PHFsPe"rvedatTemperatums
Axtrdiag m Lam Cooled to
�._..._—`.�`_f,
I'F45`F Within -, Hours-
taxilic, McEtxxl:; for PHFs
19
PHF Hot and Cold Holding
3-501-16M
Cold PHFs Mainiriined at or below
590.004(F)
.. 4t"/450 F,
3 501.16(A)
IInt PHF a Maintained at tr above
3-501, lbti.#)
R ,fv Held at or above 130'1-' �
20..
1 Time as a Public Health Control
3 ri.,, a. , earn+,,, rig. r.H
RFOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (H5(
21� 3-801 + (A) Czip ),aeurizrat Prs n cls aged Tunes and
t3esei i es with R'armng
I 1 f 1(}11 Us of Pa wnractd Lv,,s
3-htrl i i(D) Raw or PaiwAl:y t Kakcd Annnil F<xxi and
R a
__ v S, -,d snrirnts Not sertcd
37801 1 j (C Ln ibened hexed Pac hasr hos Re nerved.
22 310:.11 Coneuiner Adaismy Posted ftsr f rnteomption of
Animal k aid l'hat ary Pau Lnderaxoked rr
NcAOtlrerui%crrv,tsscd ofAmirree
-302.1 s 1 Paste n`ir il Fgg:: Stibriinni ton Raw Shelf
iWQ.iXi9(P.}-(L7) Violnusnr oi-Sution590JX)9(A)-(D)in
catering, mobilo tixxI ternporaru and
resida m at kitchen operations should be
debited under the appropriate seoions
atx,ve if tetated to Coodhorne illness
iutelientions and risk factors Other
590.009 -violaotinv relating to good retail
fatRactices :ifiradd be debited wider #29 -
Scciat3t Ret nircrnentt-
l�r
(Items 23-30)
Giulia;' and son, rUh al i we'Unous, U hinh :ret 1101 relate to lite
firodhorne dba sr ruervi ntions meed risd inctocr 2 wed ahovei can be
foiold in tht ) odor, 7tg si tr lm+ of the. Food Code matt '05 CMR
5yo. (2(X1.
..'c.: ,"'1 a.:r-
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 11
en
C�
U
Dae
�/ ��
T e of 0 erasion s
Type of Insoection
Routine
Re -inspection
Previous Inspection
Datey�(�
El Pr" 01 eratio
❑ Suspect Illness
❑ General Complaint
❑ HACCP
❑ Other
Food Service
El Retail
❑ Residential Kitchen
❑ Mobile
El Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
AddressOff
Rik
Level
Telephone �.I _
•fH�t
Owner
V o �1 �j �i�
HACCP YM
Person in Charge (PIC _
Time
Ou&/ 0'
Inspector r
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009 (F) ❑
action as determined by the Board of Health.
`FOOD PROTECTIONMANAOEMENT,� ;z�` r,�•r(�„.,.i1 Z94j.4.,
❑ 1. PIC Assigned/ Knowledgeable/ Duties
r EMPLOYEE
�,✓.�� �„a�.,.�®�.5.,a".�o',. s.�u.a.mw �..�.,dzN�-a -. �.,�r .
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOUFa
RC
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
f PROTECTION FROM CONTAMINATION T `" `!''' "'- 2'
3 - 3 _. ° r' -:;b. ,w 4 z Eg. .m, ' �.�4u�i ' , aW,M.,��r, ;ti:.„ � -.,• >�a; w`,t�.m
❑ 8 Separation/ Segregation/ Protection
P. 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'i N'
23. Management and Personnel (FC -2)(590.003)
. 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:58�InSpBCiFo//II&1C.tlCE f�
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEh11CALSk r "� G �# It r Yt€
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
�>TIMEITEMPERATURE CONTROLS (Potentially Ha:anious Fcxids}'g,� qg
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 16. Cooling
❑ 19. Hot and Cold Holding
[120. Time As a Public Health Control
-REOUIREMENT$FOR H(GHLY,goSd HbQ POPULATIONS (HSP}- 1
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORYI=.„=,i.,rsmr�t
❑ 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'sSignature:
Print: �
aa.y r�--rl
Page of zPages
iMw
L
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22)
_ FOOD PROTECTION MANAGEMENT
1 590.003(A) Assignment of Responsibility*
590.003(B) DenxmsfraYion 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
3-20113
Fluid Milk and Milk Products*
applicants*
Shell Eg s*
590.003(F)
Responsibility Of A Food Employee Or An
3-202.16
Ice Made From Potable Drinking Water*
Applicant To Report'ro The Person In
Drinking Water from an Approved System*
590.006(A)
Charge*
590.006(B)
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
in
-Denotes critical item in the tederad 1999 Food Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
S
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Foat in a Hermetically Scaled Container*
3-20113
Fluid Milk and Milk Products*
3-202.13
Shell Eg s*
3-202.14
E a �s and Milk Products, Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-101.1.1
Drinking Water from an Approved System*
590.006(A)
Bottle dDrinkingR'ater *
590.006(B)
Water Meets Standards in 310 CMR 22.04`
Washing Fruits and Ve *etables
Sha ish 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
Regulanoty Authority
3-202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
3-701.1'1
Receiving/Condition
3-202.11
PHFs Received at Proper Temperatures*
3-202.15
Package hue it *
3-101.11.
Food Safe and Unadulterated
TagstRecords: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shelistock Identification Maintained*
Tags/Records: Fish Products
3402.11
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(J)
Labeling of Ingredients'
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Conformance with Approved Procedures
/HACCP Plans
3-502.11
S ecialized ProcessingMethods*
3-502.12 -
Reduced oxygen packaging, criteria*
8-103.12
Conformance with A. roved Procedures*
-Denotes critical item in the tederad 1999 Food Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
S
Cross -contamination
3-302.11(A)(1)
Raw Annual Food -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 Ve *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
3-701.1'1
Discarding or Reconditioning unsafe
F(W*
9
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Tem eratures*
4-501.112
.Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-501114
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-60 IA I(A)
Equipment Food Contact Surf=aces and
Utensils Clean*
4-602.11.
Cleaning Frequency of Equipment Fnucl-
Contact Surfaces and Utensils*
4-702.11.
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization - HotWaterand
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition -Hands and Arms*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2401.11
Eatn! , Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-30112
Preventing Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Em to ees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacifies*
5-204.1.1.
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11
Handwashina Cleanser, Availability
6-301.12
Hand Drying Provision
CITY OF SALEM
BOARD OF HEALTH
Date: a tedog Page: C7- of
Item,,
Nomow-.
Code'C
7'
Reference
- Critical Item
R - Red Item
'I DESCRIPTION OF, VIOLATION/ PLAWOF CORRECTION
W on, fes.
PRI' 4
NIT CLEARLY
Date
Verified
S -7A
_�W I. Jan Ll I 1) r
"I.N re CC Ste. r,-I�. lki S
I-%"] vr)4 L r e( Q -It' Q- 6A
C�
r J, sf-
/7
r
Discussion With Person inCharge:
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.
No IF Ves
El Voluntary Compliance C1 Employed'. R6stricljon
1_� Exclusion
U Re -inspection Scheduled 0 Emergency Suspension
1��
El Embargo 0 Emergency Closure
Voluntary Disposal L3 Other:
Violations Rotated to Foodborne Illness intemerumns and Risk
Factors (helms 1.22) (Cont)
_...._'
Food or Color Additives
202.12
�i-302.14 Maori; no front Una ppimed Adc,11i ves".
rt�--P-�oiisso-nous at Toxic .Substances _Y
7--(oi li RR,iZo , inti. ...Ton-Ornnnal -�
I Cotna�
�.., 102,11 Comnron'Yame t§'nrkinii { rurtri rets*�
7-20 L I I Se atrtton-sAna < _
72011; Restnct;cn-Ys scare and 1.�c` --
7-202.12 f_ondmtms of Uso,
'
7-203 . U Tostc Container Prohibirwm4 _
2(76.]1 Sanimeit Crile in CllellAcr!s'
t�T°04 Chcnncak fill W tshi!j,t rodnce Ctiteaia,'
-7 2tk6.14 Drtm�A�cntc o tau t r' _-
1 t 2US_ i l In cr mai t xxl Contact, Lubucants*
11_4±estlided U&e pe ti ides. Criterm*
21 R4m Bait Srauon�' _
I Tracking Pr,wdus. Pt -s[ Control and
Ib . Proper Cooking Temperatures for
__ ___ PHFs
-4f}i.I l A(i)(t} I:.gga- 155'F 15 ser:.
_ _ F.sImmetli;rte.Ser:icr. 145"7^15ser_
-IJI(0) Ctrntmnmrdlieh Meatst,..tramc
Animals - I i5"F I7 vec _
-401.11111)(1)(2) Prsrt, and Beef R aisl 1 r0 112) man*
3-401.i1(A)(2} luaiteS, lnjcaw Melo 155'F'15
3=401.11fA(3) Poultry, Wild Gawc. staf"ed PHFs,
Stnnin�Containing Fisl Mat,
Rouhry or Rauu,c 165` la zro_
3-AOLi 1iC2(3)
WhOe-lawde, ht act Be f Steaks
31101.12 Raw Anu*'ort Fooxis Cociked in a
Microfaval6`F
-40117(A)(i}(b) All Other PHS i-i5°E i5 sea "�
l7 mm Reheating for Hot Holding
3.403.11(.43&,(5) PFIF 769°1' 15
-403.11(5) Nlicrowavc. 165' F2 Minuue, standing
_ Time''
3-40111(C) C nanercially Proresseo RTE Fwd -
_ 40'F'
3403, 3 1(E} Remaining Unslwvxl Portions of Beef
Roasts*
_. WO PRFs Recciwd at Tem e-rawres
lrsordin to L.aw Cowled to
31 Fi45"'F Within 4 Hous.
Girding M _alods for PffFs
PHF Hot and Cold Holding
3 5W.16(W Cold lilts i Maintained at or beltaw
590 004(F) 41 V45° F"
Proper Cooling of PHFS
3-501.14(A)
Coithae, Cooked PHI's trans 14(`F to
7G`1 Wlthtn 2 )lour: and From 7f)d'
RrsasR held at or above 130 R *
to 41 T145'F \Nuts in 4 Hou[
,;Tol.IT(b)
C imhng PIF Made From Ambient j
Ttrnu as r Puiskra stealth Control*�
Temperature Ingredients to 41 Ff45`F
.
within.gHrxus*
* Uctxtrs.�inurt ikem in the
ie k rat i9,J9 Pond GAeer )65 4 =MR 5+70006.
_. WO PRFs Recciwd at Tem e-rawres
lrsordin to L.aw Cowled to
31 Fi45"'F Within 4 Hous.
Girding M _alods for PffFs
PHF Hot and Cold Holding
3 5W.16(W Cold lilts i Maintained at or beltaw
590 004(F) 41 V45° F"
3-Y) L I6(A)
Hat PHi Maintained a or above
i 5t)l io(o4}
RrsasR held at or above 130 R *
Time as a Public Heatth Conti at
So' it
Ttrnu as r Puiskra stealth Control*�
59Ci.':7ik1tR1
Varian CB Rearit T2nl81r1:
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
21 ! +-8[)1.13{A1 I i;rrpasteuri�tdfre-pad:nged3aices:urd
t,ticctF'nteunzedre,�'�..._
?-St I 1 I (ft} k rr or Faitialiv C.�k' d Aminal Raid and
R nt S< d_Suka IN t Se[ ted.' _
2_Rt;! 13t{�, { F- nrAt:.vvrO�rbx,n.t�neiro-co-.as<.i
22 3-60? 11 i onsui air Adsisorc Posted fur Constrmption of
Z
I ih t r xxt� Thu are kau=, Lltmercxwked rrr
j volOther ee toFliminate
0-...13 1 Paster zcd P: s.> Substitute for Raw
A} (l)7 I Violas ons of Section 590,4)9f A) (D).jn
atering. inohiic haul temporary and
resideld�ai kitchen operations should he
debttad under the appropriate eertions
{ :drove if refitted to foodb0rT1e illness
inlei eid;ons and risk factors. Other
590.009) violations reladni7 to good retail
pra,c,dces should be debited under #f29 -
j special Requirements_
(Items 23-3{0)
Gridrai and mon-(ruwat ;+ivtalfvors, rvirich do nw rebate to r1.r
foodborne r6trxss tors lived aPmre We be,
fturnd in rhe Jotfon-irrg .certions of rhe tined Code eurd 10_5 C+.CR
5r70,0W.
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
r.
Salem Board of Health
120 Washington Street, 4th Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name
IGOC Ott/
r
qq
Dat
c�
T e of 0 erasion s
T e of Ins ection
'Routine "
Re -inspection
Previous Inspection
Date:
ElPre-operation
❑ Suspect Illness
❑ General Complaint
❑ HACCP
❑ Other
Food Service
❑ Retail
❑ Residential Kitchen
ElMobile
El Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
Address
S
Risk
Level
TelephoneG t �6 a
Owner 1�'�r7_
l`t LO 11<� q
HACCP YM
Person in Charge (PIC)
Time
In:�
Out:
Inspector ��
Each violation checked requires an explanation on the narrativepage(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
❑ 1. PIC Assigned / Knowledgeable / Duties
°' EMPLOYEE HEALTH
1:1 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
'mrererem rwwgPov K Fi,
.FOOD FROM APPROVED SOURCE,I�,Zks„,h„,
,. - .; 'µ�,M,
❑ 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;• &=
w,: LIP 3. -I&A
❑ 8. Separation/ Segregation/ Protection
2r9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practicesmom
°•
e.
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.
EG l 2Q
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:5 maps tFom 14,E /^I
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
��"-PROTECTION FROM
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIMEITEMPERATURE CONTROLS (Potentially HazaMous Foods)'_ it 911[
Zw
❑ 16. Cooking:T.emperatures _
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
�REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP);,A`j
❑ 21. Food and Food Preparation for HSP
%:.CONSUMER ADVISOR Y,` ., jry '. i'..��;a,3.,wwr°,. *�,:.re.v ...
❑ 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: (
�CILu i4. C?- a'O��
Inspector's Signature: �
Print:N
qq
PIC's Signature:
Print: / ti ��''%J�� �.� a �.. /,7-
Paged of='Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assinnment 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'9
3-201.12
require reporting, by food employees and
1 "
tom,
Fluid Milk and Milk Products*
applicants*
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assinnment 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'9
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 Ap ed System*
590.006(A)
Char e*
590.006(33)
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
C
C
N
'" Denotes critical item in the federal 1999 Fes)(] Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
S
Food and Water From Regulated Sources
590.0(M(A-B)
Compliance with Food Law'9
3-201.12
Food in a Hermetically Sealed Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.1.4
E z and Milk Products, Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-101.1.1
Drinking Water from an Ap ed System*
590.006(A)
Bottled Drinking Water*
590.006(33)
Water Meets Standards in 310 CMR 22.O1'
Washing Friars and Vegetables
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
Redulatort, Authority
3-202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
-7-201 -17
Came Animals"
701.11
Receiving/Condition
3-202.11.
PAFs, Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained"
Tags/Records: Fish Products
3402.11
Parasite Destruction''
3-402.12
Records. Creation and Retention*
590.004(J)
Labeling of ingredients'
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Conformance with Approved Procedures
IHACCP Plans
3-502.11
Specialized Processing Methods*
3-502.1.2
Reduced oxygen packaging. criteria*
8-103.12
Conformance with Approved Procedures*
'" Denotes critical item in the federal 1999 Fes)(] Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
S
Cross -contamination
3-302.11(A)(1)
RawAnimalFoodsSeparatedfrom
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-302.11(A)(2)
Raw Animal Foals Separated from Each
Other*
Contamination from the Environment
3-302.11(A)
Food Protection*
3-302.15
Washing Friars and Vegetables
3-304.11
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Resetvice of Food*
-73
Disposition of Adulterated or Contaminated
Food
701.11
Discarding or Reconditioning Unsafe
Food*
9
Food Contact Surfaces
4-501..111
Manual Warewashmn - Hot Water
Sanitization Temperatures*
4-501.11.2
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-601.A I(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*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition -Hands and Arras"
2-301.12Cleanin
Prt>cedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2-401.11
Eating, Drinking or Using Tobacco*
2401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventing Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Employees
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Ca achies*
5-204.11
Location and Placernent*
5-205.11
Accessibility. Operation and Maintenance
Supplied with Soap and Nand Drying
Devices
6-301.11
Handwashing Cleanser, Availabilit'
6-301.12
Hand Drvin� Provision
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: c -g 2-i /I � n2 Date: fa %T� Page: of
Item,,
Code
C -Critical Item
�DESCRIPTION OF / PLAN OF CORRECTION �;r�' "� �,. _-;-°` ': , �''
�
`
Date
No.
Reference
R —Red Item
VIOLATION
" ` �; -. 3
PRINT LY
Verified
e--
/
c
1 v—� /
VPn �l,t /,!' On T- i/i,nr0 /�...I -�..0 �. ��.r� non r-'�n n....
QL 77-4�-1
-�_
i
'\r�CP eM ,n 14 nT. tf r9t J...eN
n
1 4111
(n A d. ! ir,i 'r-
,
_
( ir �.
Y.
i6111 rj
IX G'v . 10U'4 cmlin
/
�,).�.
l
nr
h C� 4,,. -s-av\ i
t.r i e.
.�
Discussion With Person in Charge:
Corrective Action Required:
❑ No
Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
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
,❑, Re -inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five_dollars or suspension/revocation of
❑ Embargo ❑ Emergency Closure
your food permit. �
❑ Voluntary Disposal ❑ Other:
Viotattoris Related to Foodborne illness Interventions and Risk
Factors (itehis 1.22) (Cone}
Y
I4
7722 12
3-302,14 �
2s
10111
dor solar Addnsves
Adrirti c., a
� Protect 6n fronj taNDLDY(d r�tjlti4f5''
Poisonous or Toxic Substances ____
1(lent; tjing.Intel mail on -QPI 36 ii
�Contatrren_
2.1I
Common Name, Wor�ifig onaixics"�
7.20L I 1
Sr station -Stora
7-202.11
Rcq-6ction-�Presto ce tmd Use"
?-Zt}2.12
CondiBonso€Use
1-263.13
Toxic Cmnainera- Problhztions*
'!-2264.11
58lllti leh Criteria chemicIs'`'
7104.12
C`hcanrzaisfor Wathum,Piadace Criteria"`
�� _._..�
7-704.14
Dryisp Agents. CYire�ia"
? 245.1 Ihwidentat
Faxl Contact, I,
7-206.11
Rc,�anef d Use Pe icidet. Giterta'i�
7-266.Iv
Roden BnitStarnoas
i 206.13
l'r�ackintg Powdtrs Ptsr (,, Introl and
Monnonn-� .�
36
Proper Cooking Temperatures for
PHFs
3-401.21At91(.:j
i>,);, 155'F i5 u_
res Imt�ica+tic tiervit 145,F] 5�ec,
_
-401.29.(_x.)(2)
Comrninut d T ish, Meat, & Game
Annuals - 155"IF 15 se(:
—}-
7401.11(Sb(1)(2) i
_
Prark and B e1 Raxret - 130':17 121 min,
3-f01.11(e3)f2)
h -R tire, irect.d Meats 155 F IS
SVI
3401.II(Ay 3)
1'ouitn'Wild(„trne $tuttciPltFs,
CmfhngContunm Fish Meat
'Youltrvor32aotes-1657
t5 sec
3-10F.t,ic) 3)
Vh le mos le intac, Bu.f Steak's
t45'I= *
3-401 12
Raw Animal Tams Conked in it
N[iciowaae 165'F
'-401.12iA){i)th)
Ani (.hlaer PHFs - 145'17 15 see.
I?
Reheating for Hot Holding
3-10311
fit 5"', t65'F 75 sec.
-403.13(13)
Microwave 105' P, 1tMinot, Standing
1(C)
J,one _.
Commercially Pnxes..ed STE,” Food -
146 F'
Remai,aing Unsticed Portions of HceE
Roast;*
Ig
Proper Cooling of PHFs
3-501.14(A?
Crx?ling Cooked PHFs from 1140-Fto
70`'F Within 2 7fours and From 70i'
tea 1 i b745 F Rif3rin 4 Haxas '
____
3-561.t4B)
Cooluig PH Made Fant Ambient
I
Temperawre. Ingredients ii 41'T14,517
L _--
Within 4 Eitxars`s
"Denwe" edtirst item ni ahr leck;rn' Is(),) Forxl Cudr or 10 f'?wfR 590 690.
PHFs 1°stL at Temperaturestel( (,
3-501 16(A)Roasts Held at or_ above 130'F.
i Time as a Public Health Control At illrding Rb to o Law £`Wt:.d iii
_ 4r x,45 e Within a How s,
Si;t.7 Cailu�t M thcuis for fTHFs
________._._...,_...... PNF Nat and Cold Holding
3 S0' I T6(B) Chief
HF. Maintained at or belo-i
�-jrll S t>t A) Hol PFI} v Maze&caned at
l imt as a Public Health Control'
VarianceRemdreioent �
RFOUIREMENTS FOR HIGHLY SUSCEPTIBLE
_ _
POPULATIONS(HS
21� 3-8t11. t itA) i npasrrurir s1 Pre-packaged loners and
3-W L I I (D) i P,iw or Pwlial3 t Otoked Aminal Fskean and
_ Raw 4r c d Sprouts Not Served
3-8(3 t f i (Cl Food Pack asc Not Re served. "
CONSUMER ADVISORY _
22 3-66 11 Coin caw ter Wil isU F t' wd for Cmrn nmptioo of
, nwuwi % xwd Ihat art Rain. Underwkedo.
Not Otherwise Processed to idiMisate
P stet= ircd Ugg S ibstione for Raw Shell
SPECIAL REQUIREMENTS _
549.I)t19EA)([)} Violations of Sea tion 590Si0)(A}-(I)) in
catering, mobilf. food totnp claw and
residr to at kitchen operations should be
debited wider the appropriate sections
alwve at related to fcxxiborne I[tness
interveoirins and risk factors. (M)cr
590.009 violations relating to goad rew!
latae trces should he debited wider #29 -
Spec tal Requirements.
RELATED TO GOOD RETAIL PRACTICES
(Items 23-30)
Ctit£cal raid nam -critical voilalwns ivies h di, not rebate to the
foodborne itkeesr iniarvenoons and nA torsi, s E6 ted above. (on be
found in the fotloeing+ sections of the Foul Code aaed 105 CMR
or aixJve
l imt as a Public Health Control'
VarianceRemdreioent �
RFOUIREMENTS FOR HIGHLY SUSCEPTIBLE
_ _
POPULATIONS(HS
21� 3-8t11. t itA) i npasrrurir s1 Pre-packaged loners and
3-W L I I (D) i P,iw or Pwlial3 t Otoked Aminal Fskean and
_ Raw 4r c d Sprouts Not Served
3-8(3 t f i (Cl Food Pack asc Not Re served. "
CONSUMER ADVISORY _
22 3-66 11 Coin caw ter Wil isU F t' wd for Cmrn nmptioo of
, nwuwi % xwd Ihat art Rain. Underwkedo.
Not Otherwise Processed to idiMisate
P stet= ircd Ugg S ibstione for Raw Shell
SPECIAL REQUIREMENTS _
549.I)t19EA)([)} Violations of Sea tion 590Si0)(A}-(I)) in
catering, mobilf. food totnp claw and
residr to at kitchen operations should be
debited wider the appropriate sections
alwve at related to fcxxiborne I[tness
interveoirins and risk factors. (M)cr
590.009 violations relating to goad rew!
latae trces should he debited wider #29 -
Spec tal Requirements.
RELATED TO GOOD RETAIL PRACTICES
(Items 23-30)
Ctit£cal raid nam -critical voilalwns ivies h di, not rebate to the
foodborne itkeesr iniarvenoons and nA torsi, s E6 ted above. (on be
found in the fotloeing+ sections of the Foul Code aaed 105 CMR
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: (s2 CSN Date: 2Page: ) of
Item
No. , rn4
Code
Reference -„�
C - Critical Item
_R -Red Item ycy
DESCRIPTION OF.VIOLATION / PLAN OF CORRECTION
F..z
a- °3} .�_ ' �.`p 3; e PLEASE PRINT CLEARLY
Date
Verified
� GL � ❑L. l NILS W 1 S'\a 1` Ht7, it- 1 NRiN��EO Pel �- 65:.,
1 N �G o c Ss vJ�t \^N 000x11 Q� t w, C's'� n ^\44F 5^ G S raN
-ra
SaaN. 5 V P6J r`tc&nc
Discussion With Person in Charge:Corrective
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 o nsion/revocation of
your food permit.
Action Required:
L)No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal 0 Other:
Violations Related to Foodborne Illness interventions and Risk
Factors (/ten's 1-22) (Cont)
H l*1=#ifIU,9E;at 3rM1TMMWM
r
L 14_
Food or Color Additives
3-202 12 Addiu%c,
Proper Cooking Temperatures
3-301 14�, Protectim from Additives'
1S
i Poisonous or Toxic Substances
10I.W Identifying Inforucloon -- Otigiflud
13ggN- 155'F 15 sec,
Lit -Time
3-501,19
590.004(11)
7-102,11 Cotramon'Narrie W,rrk,ngLourauler,*
7-20[.Il
Comminuted Fish, Meats & Game
7-202,11 Reztriction - f1rescirce and Lae*
Conditionsioof rise'
[;72{)2.12
3 1 Toxic Conuainer. - Prolabiiiort,�*
flott. and Beef Ro:oa 130'F 121 alhO
(A . It Samlizec,;, Cole, A -Cheolicals�
3-401.11(3)(2)
7-204.12 cheraicak for uarhi k ro ice Cliterial
7-204,14 Drvitsnt sente,Criteria"
sec.
7-205,11 Incidental. Foxj-Contact, I.Albricaras'
I 1 11
7-206-11 Rcsiri;:ted Use peficidcs, citenal;
7-206.12 Rocieta But StanoTo,'
7.206, 13 fracking Ptnvdcr,, Pest C.oturol and
S onfaitung Fish, Meat,
Stuffing C'
TIMEMEMPERATURE CONTROLS
16
F3 J) 4(C)
3-301.15
Proper Cooking Temperatures
19
PHFS
3-.401 11 A(l)(2)
13ggN- 155'F 15 sec,
Lit -Time
3-501,19
590.004(11)
as a Public Health Control
Time as a Public Health Control
Variance Rc�renleut
3A0lJ1(A)(2)
Comminuted Fish, Meats & Game
Animals 155`F 1,5 sec.
_7401.1
flott. and Beef Ro:oa 130'F 121 alhO
3-401.11(3)(2)
RantcInjet7,TMcxts 155+ 15
sec.
I 1 11
Poufrry. Wild Game, sluFted MIPS,,
p::
S onfaitung Fish, Meat,
Stuffing C'
[14:
Pouliffol 15 sec.
tl (A
_3 401 1 3;
Ac. Intact Beef Steaks
%VIx4e-muscle
145�F
3401.12
Raw Animal I'loot: 11 cook d in a
- --
Microwave 16S'f —
—I—
—
fb
'VI Chrer pF
17
Reheating for hot Holding
3-403A 1 tA)& (D)
PHI,a 165°+ 15 sea *
3-403A1(-8)
-m,—crowaw- l65° F 11 min rte standing
Time'
I(c)
Commercially Processed RTF Food -
1 14'0'F*
3-403,1 I(Ei
Reirainin", Urozhced Portions of lice"
Roasts*
Proper Cooling of PHFs
�ltV)
Cooling Ckx)ked PHF's front 14f)'F to
70'F Within 2 llcaur- and From 79rT
k-3-01
to 41'F/45'F Within 4 Houm "
14(8)
Coaling PHR Made Front Ambient
Ir
Temperature Ingredients to 41'f,/45'F
Within 4 Hours'
Denotes mticai n'ojc in the lo,kfral 1999 Ya) Fo,x! C,f& (If 105 C N4k 590 000,
REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATION§HSp
21 T 01.1 I (A) Cep teurizet! Pre-packaged Juices and
I ReVerace$ with Warflifla, Labels:.
1 3-801.1I(C) I Unopened Food Packiree Nor lie-scrved, ' I
22 3-b0).1 I Consumer Advisory Posted for Cowumption of
Animal Food, That are Raw. Undercooked ca
Not Otherwise Pox:etisefd to Flintimae,
Rs'4e W'Me'
302.13 I pasteurized Fio-m Substitute for Raw
Violaturws or Section 590J)09(A)-(D) in
catering. inotti1c. food, temporary and
residential kitchen operations should he
debited under the appropriate Sections
above if related to fbodbornC illness
interventions audrisk factors. Other
590.009 violations relating togoodretail
practices, should be debited under 1#29 -
Special Requirements.
VIOLATIONSRELATED TO GOOD RETAIL PRACTICES
(items 23-30)
Critical read nsm-(rnifarl viokawo, which do vat relate to the
,foodborne illness briorventionvand risk factors listed above, (on be,
found ria :he pflorting sections of the Food ('ode and 103 CMR
F3 J) 4(C)
3-301.15
PflFs Received at Temperatures
According In Luk Cooled to
41 °F/45F Within 4 How s'.
Cooliro,Mclhorf, for PffFs
19
PHF Hot and Cold Holding
3-501 _16(8)
590 044F)
50 1 16(A)
3-501.'16(A)
Cold PHI c Maintained at or beloa,
411145� F,
I lot PHI s Maintained at or above
140"F.
Roams Held at or above 131 °F.
Lit -Time
3-501,19
590.004(11)
as a Public Health Control
Time as a Public Health Control
Variance Rc�renleut
REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATION§HSp
21 T 01.1 I (A) Cep teurizet! Pre-packaged Juices and
I ReVerace$ with Warflifla, Labels:.
1 3-801.1I(C) I Unopened Food Packiree Nor lie-scrved, ' I
22 3-b0).1 I Consumer Advisory Posted for Cowumption of
Animal Food, That are Raw. Undercooked ca
Not Otherwise Pox:etisefd to Flintimae,
Rs'4e W'Me'
302.13 I pasteurized Fio-m Substitute for Raw
Violaturws or Section 590J)09(A)-(D) in
catering. inotti1c. food, temporary and
residential kitchen operations should he
debited under the appropriate Sections
above if related to fbodbornC illness
interventions audrisk factors. Other
590.009 violations relating togoodretail
practices, should be debited under 1#29 -
Special Requirements.
VIOLATIONSRELATED TO GOOD RETAIL PRACTICES
(items 23-30)
Critical read nsm-(rnifarl viokawo, which do vat relate to the
,foodborne illness briorventionvand risk factors listed above, (on be,
found ria :he pflorting sections of the Food ('ode and 103 CMR
620NWHA-01 LYNI
ACORD,M CERTIFICATE OF LIABILITY INSURANCE
°A121212008 )
PRODUCER (508) 852.8500
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Protector Group Ins. Agency, Inc:
100 Front Street, Suite 80U
Worcester, MA 01608-1435
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
U
POLICY NUMBER
INSURERS AFFORDING COVERAGE NAIC #
INSURED Dinemed Restaurant Group, Inc. db 62 On Whart
INSURER A'. Selective Insurance Company
62 Wharf Street
Salem, MA 01970
INSURER B'.
INSURER C
NSURER U
'SURER E:
EACH OCCURRENCE $ 1,000,00
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
DD'L
U
POLICY NUMBER
POLICY EFFECTIVE
POLICY E%PIRATION
r I,IryI/ pIYY
LIMITS
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
GENERAL LIABILITY
AUTHORIZED REPRESENTATIVE
EACH OCCURRENCE $ 1,000,00
A
x COMMERCIAL GENERAL LIABILITY
TBD
12/2612007
12/26/2006
pREMISEs Ea pccurencel $ 500,00
CLAIMS MADE LK OCCUR
MED EXP (Any one I $ 5,000
PERSONAL B ADV INJURY $ 1,00000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES P R:
PRODUCTS - COMP/OP AGG $ 2,000.000
X POLICY 7 PRa 1-1 LOC
Liquor Liability $imil / $2mi
AUTOMOBILE
LIABILITY
PNY AUTO
COMBINED SINGLE LIMIT $
(Ea eccitleM)
430DILV INJURVk. � $
(Par parson) '
ALL OWNED AUTOS
SCHEDULEDAUTOS
BODILY INJURY $
(Per actidant)
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
(Per acpidenq
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT is
OTHER THAN EA ACC F$
ANY AUTO
AUf00NLY- AGO $
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR CLAIMS MADE
AGGREGATE $
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
YTU- OTH-
WC STA
TORLIMITS cR
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E L EACH ACCIDENT $
E!- DISEASE- EA EMPLO`EE I S
OFFICER/MEMBER EXO_UDED1
Ifyee describe ender
SPECIAL PROVISIONS below
EL. DISEASEPOLICYLIMIT 1 $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
City of Salem is designated as an additional Insured with respect to Liquor Liability insurance.
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2001108) 0 ACORD CORPORATION 1988
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Salem
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Washington Street
Salem, MA 01970-
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001108) 0 ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
CITY OF SALE:IVi,ASSACHUSETTS
LICENSING BOARD
120 WASHINGTON STREET
SALEM, MA 01970
TEL. 978-745-9595 EXT. 5648 DAVID J. SHEA, CHAIRMAN
FAX 978-744-6775 JOHN H. CASEY
RICHARD C. LEE
KIMBERLEY DRISCOLL ROUTING SLIP BARBARA A. SIROIS
MAYOR CLERK OF THE BOARD
The Salem Licensing Board requires each applicant to have the appropriate Departments sign
this Routing Slip and return it to the Licensing Board Office prior to the issuance of a license.
BUSINESS NAME
Corporate name: DineMed Restaurant Group, Inc.
d/b/a: 62 on Wharf
LOCATION: 62 Wharf Street, Salem, MA Tele. #
TYPE OF LICENSE: Liquor License
APPLICANTS NAME: Antonio Bettencourt
Residence
Street: 18 Oakland Street
City: Peabody
Home tele. # ( 978) 531-9559
State: MA Zip: 01960
TO ALL CITY DEPARTMENTS: your signature on this form is notifying the Licensing Board
that all requirements of your department have been met, at which time the LL' sing Board will
issue a license.
VI:JLcL� �Z� ela+z.I\�vp
�J
Salem H' ric'Commis on DATE
120 Was mgton Street
� Y�6AAc �i 4
Sign Review/Planning Dept. DATE
120 Washington Street
Salem Health Department DATE
120 Washington Street
Fire Prevention DATE
29 Fort Ave.
WashingtoK Street
W
TE
Department of Public Services DATE
(Water Dept.)
routine slip 120 Washington Street
k.
MOV -21-2007 09:36 AM NNE" SECONDS COUNT
i'
i'
Choke Saving Course Registrations
Each attendee must complete a Registration Form
To reserve a span: in the Choke Saving Course Registration Form, please complete and retut
Registration form to the Salem Board of Health. Course provided by When Seconds Coint, I
*Class size is limited and will be on a first come first serve basis.
*Registration Fee is Non -Refundable
i'
• Registration Deadline is Friday, December 28. 2007 at 4:00 p.m.
i
Date of Registration: c; / 1900 2 Form Completed by:
J�a ✓,o ✓route Restaurant: 6� o ✓ �J�tisr�
Name: %�
Business Address: �oZ �n/tiu�� St City/Town S� ern
Business Phone: 978 7 00 C9 a State & Zip
Email:
P.02
N
t Itx
I understand that the information provided to the City of Salem &When Seconds Count, li
confidential and 1 hereby attest that the information supplied on this Course Application is c
accurate.
Cost: Chokc Saving Class $5.00 per person
I
Course Date: Wednesday, January 16, 2008 0
Time: 2 p.m. to 4 p.m.
Location: City Ha11, 120 Washington Street, Floor 3, Salem, MR
I have read and understand the above registration form, its requirements.
Student Signature/%1 Date:
Return the completed application and payment to: Salem Board of
120 Washin.
Salem, MA Con
EXAM FORM NO. 1935
CERTIFICATE NO. 5628821
SelvSafe"Certification
Ta.:ANTONrlO CM BETYTENCOURT
for successfully completing the standards set forth by the National Restaurant Association Educational Foundation
for the ServSafe® Food Protection Manager Certification Examination, which is accredited by the American National
Standards Institute (ANSI) -Conference for Food Protection (CFP).
Presented by the National Restaurant Association Educational Foundation
11/13/2007
DATE OF EXAMINATION
11/13/2012
DATE OF EXPIRATION
Local laws apply. Check with your local regulatory agency for recertification requirements.
National Restaurant Association A
114 1® Mary M. Adolf EDUCATIONAL FOUNDATION
President and Chief Operating Officer
#0655 National Restaurant Association Educational Foundation www.rraef. org
FOR!!
DATE 11-1
i YJ%
TIMEI�A.M.
WILL CALL AGAIN
M
WANTS TO SEE YOU
RUSH
OF
WILL FAX TO YOU
PHONE
AREA CODE
- NUMBER EXTENSION
U FAX
U MOBILE
AREA CODE
NWBER TIME TO CALL
TELEPHONED
PLEASE CALL
CAME TO SEE YOU
WILL CALL AGAIN
WANTS TO SEE YOU
RUSH
RETURNED YOUR CALL
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IMPORTANT MESSAGE
FOR ` �',L)aO1C\
DATE TIME
LI�(i / TIME
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PHONE 9 (A
AREA CODE NUMBER EXTENSION
FAX L /
❑ MOBILE t—�/y l
AREA CODE NUMBER TIME TO CALL
TELEPHONED
PLEASE CALL
CAME TO SEE YOU
WILL CALL AGAIN
WANTS TO SEE YOU
RUSH
RETURNED YOUR CALV
WILL FAX TO YOU
MESSAGE r-) P-GgAA Ilf ia) a ! .
4009
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W
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zi
CITY OF SALEM, MASSACHUSETTS
LICENSING BOARD
120 WASHINGTON STREET
SALEM, MA 01970
TEL. 978-745.9595 EXT. 5648 DAVID J. SHEA, CHAIRMAN
JOHN H. CASEY
FAX 978-744.6775 RICHARD C. LEE
BARBARA A. SIROIS
KIMBERLEY DRISCOLL CLERK OF THE BOARD
MAYOR HEATH DEPARTMENT
NOTIFICATION FORM
IF YOUR APPLICATION INCLUDES THE SERVING OF FOOD YOU MUST HAVE THIS
FORM SIGNED BY THE HEALTH DEPARTMENT PRIOR TO SUBMITTING YOUR
APPLICATION TO THE LICENSING BOARD.
(this form MUST be signed and returned with your application).
NAME OF BUSINESS
Corporate name: DineMed Restaurant Group, Inc.
d/b/a: 62 on Wharf
LOCATION: 62 Wharf Street, Salem, MA
TELE. #
TYPE OF LICENSE Liquor License
APPLICANTS INFORMATION
Name: Antonio Bettencourt
Home address: 18 Oakland Street
City: Peabody State: MA Zip: 01960
Home tele. # ( 978) 531-9559
HEALTH AGENT/INSPECTOR'S COMMENTS:
Health Agent
eallh dept. notif f6mi
CITY OF SALEM
BOARD OF HEALTH
Date: November 28, 2007
Name of Establishment: 62 on Wharf
Address: 62 Wharf Street
Owner: Tony Bettencourt
Phone: 978-744-0062
The owner of this proposed establishment, Tony Bettencourt, presented a Floor
Plan and Menu for review in accordance with the State Food Code.
CERTIFICATION
There must be a Certified Food Manager working at this establishment full
time.
Mr. Bettencourt has taken a recertification class and is waiting for the
results. In addition, two other employees are certified.
FLOOR PLAN
There is a Hand Sink located at each end of the prep and services lines,
and an additional sink next to the prep sink.
The hand sink must have a wall hung soap and paper towel dispenser.
These must be stocked at all times. The hand sink must be used for hand
washing only.
All floors, walls, and ceilings where food, utensils, paper products, etc, are
stored, prepared or served must be intact, impervious, and easily cleanable. This
includes any storage of these items in the basement. K,
A dishwasher for washing, rinsing and sanitizing dishes and utensils will
be used. The dishwasher will have a final rinse temperature of 180 degrees in
the final rinse. In addition, a 3 -bay sink will be used for larger pots. This 3 -bay
sink may be covered when not in use and the space used for collecting items
from the dishwasher.
The Floor Plan as presented is approved.
MENU/FOOD PREP
All food must be purchased from a wholesaler licensed by the State.
Fruits and vegetables must be washed prior to preparation. A food prep
sink will be available. This sink must be sanitized prior to and following food
prep.
All food must be held at 41 °F or lower, or 140°F or higher, at all times.
Food may not be added to containers in the sandwich unit. Instead, a
sanitized container with new product may replace the existing container and the
old product may be placed on top of the new product.
There may be no bare hand contact of ready -to -eat foods. Gloves, tongs,
or tissues must be used when handling such food.
UNDERCOOKEDFOODS
The advisory was given to the owner.
CHOKE SAVING
A person trained in choke saving techniques must be available whenever
this establishment is open for business.
EXTERMINATION
Monthly services of a Licensed Pest Control Operator are required.
Please keep receipts for inspections.
SANITIZING SOLUTION
Sanitizing Solution must be accessible at each prep station and for the
patrons' tables.
Test strips corresponding to the kind of sanitizer, must be on hand to
check concentration of solution. Solution must be made daily, tested, and the
results recorded on a log sheet for examination by Board of Health inspectors. 11OW114
Solution may be prepared in the 3`d bay of the 3 -bay sink and spray
bottles may be filled there. Spray bottles with clean paper towels may be used,
as well as wiping pails with wiping clothes always held in the solution in the pail.
These must be clearly marked "sanitizer" in fie. Enq)i5hl pw-�Vese—
Grease traps will be installed according to the plumbing inspector's
requirements..
Outside area of premises, and the trash area, must be kept clean and
sanitary.
This establishment is scheduled to open in January. Please call one week
prior to opening to schedule an opening inspection.
The application was received without a check.
/- ;?k-() 7
Jeanne Scott
Health Agent
O
Tony Bettencourt
Owner
Tastes $4 Mains
Starters
Mushrooms
Mushrooms, olive oil and vinegar
Chickpea Salad
Chickpeas, carrots and garlic
Lentils
Beluga lentils, thyme and sherry
vinegar
Beets
Roasted baby golden beets
Feta
Sheep's milk feta, herbs and olive oil
Sweets
Banana Split $8
Fresh Brioche Doughnut $7
Hot Chocolate $7
With homemade marhmallows
Tirimisu $8
Toffee Pudding $8
Veal shortribs $12
Balsamic and orange glazed shortribs
Cauliflower Fritters $8
Potato Gnocchi $15
Lobster, basil, potato gnocchi
Arrancini $8
Fried saffron risotto with parmesan
Oyster Stew $12
Duxbury oysters, potatoes and leeks
Salame $10
Salome, cracked green olives, fennel and
olive oil
Salad $10
Wild arugula, potatoes, pancetta and black
truffle
Cod $24
Local cod, homemade linguica and
welo7eet clams in a spicy tomato broth
Beef $27
Red wine braised beef over creamy
polenta with mushrooms
Lamb $25
Roasted leg of lamb with long-stem
artichokes
Pork $23
Heritage breed pork chop with fennel
gratin
Garganelli $20
Hand- rolled garganelli with duck,
dried cherries and pignoli
Scallops $24
Seared sea scallops with pancetta,
raddichio and cauliflower
Chicken $20
Roasted Chicken with a winter
vegetable ragout
Massachusetts Department of Public Health
/ Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
i
Salem Board of Health
120 Washington Street, 0 Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name
I k ✓ U r
D
Type of Operation(s)
Food Service
8 Retail
❑ Residential Kitchen
❑ Mobile
[:1 Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
T❑Insoection
e
E,1c Re -inspection
previous I s action
Date: {f� t
❑ Prop' anon
❑ Suspect Illness
❑ General Complaint
El HACCP
El
El Other
Address
Telephone NY,
Level
Owner
'f WJE
HACCP YM
Person in Charge (PIC)
Inspector � I�o
Time
In: I
Out yPj
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) ❑ 550.009 (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:5WIn o, -,<.
in /,?,
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALS _
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
1TII ME rrEMPERATURE CONTROLS (Potentially Hazardous _Foods) J
❑ 16. Cooking Temperatures
❑ 17. Reheating
[118. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
REQUIREMENTS FOR _H(GHLY 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: 4
Inspector's Signature:
Print:
I
PIC's Signature:_
Print: ,�✓fe,-✓. j �� ✓ ('Ov
Page
or1 Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assignment of Responsibility*
590.003(B) Demonstration of Knowledge"
2-103.11 Person in charge - duties
EMPLOYEE HEALTH
2
590.003(0)
Responsibility of the person in charge to
Compliance with Food Law* --
3-201.12
require reporting by fiwci 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)
Char e*
590.006(B)
590.(103 G)
Re tan b Person in Charge'
3
590.003(D)
Exclusions and Restrictions*
3-201-15
590.003(F)
Removal of Exclusions and Restrictions
5
0
LE
FOOD FROM APPROVED SOURCE
v Denotes critical item in the federal 1999 Part Cale or 1010,111 590.000.
C
PROTECTION FROM CONTAMINATION
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law* --
3-201.12
Food in a. Hermeticall • Scaled Container*
3-201.13
Fluid Milk and Milk Products*
3-202.,13
Shell Eggs*
3-202.14
Eggs and Milk Produces. Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-l0i.11
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.04'
Frequency of Sanitization of Utensils ;Td
Food Contact Surfaces of Equipment*
Shellfish and Fish From an Approved Source
3-201.14
Fish and Rea eationally Caught Molluscan
Shellfish"
3-201-15
_
Molluscan Shellfish from NSSP Iisted
Sources*
Proper, Adequate Handwashing
Game and Wild lv,'ushrooms Approved by
Regulatory Authority
3-202.18
Shellstock Identification Present"
590.004(0)
Wild Mushrooms*
3-201.17__
Game Animals*
2-301.14
Receiving/Condition
3-202.1.1
PHFs Received at Proper Temperatures*
3-202.1.5
Package 'lnte city*
3-101.11
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock: Identification
3-203.12
Shellstock Identification Maintained*
.12
Tags/Records:Fish Products
3-402.11
Parasite Destruction* -
3-402.12
Records, Creation and Retention*
590.004(1)
Labeling of Ingredients'
--
Handwash Facilities
Conformance with Approved Procedures
IHACCP Plans
3-502.11.
S ecdalimd Processing Methods*
3-502.12
Reduced oxygen packatdng, criteria*
8-103.12
Conformance with Approved Procedures*
v Denotes critical item in the federal 1999 Part Cale or 1010,111 590.000.
C
PROTECTION FROM CONTAMINATION
4
Cross -contamination
3-302.11 (An])
Raw Animal Foods Separated from
Cooked and RTE Foods*
4-501..1.11
_
Contamination from Raw Ingredients
3-3011l(A)(2)
Raw Andi nd Foods Separated from Each
Other'
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
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*
4-602.11
Contamination from the Consumer.
3-306.14(A)(B)
Returned Food and Reservice of flood*
Frequency of Sanitization of Utensils ;Td
Food Contact Surfaces of Equipment*
Disposition of Adulterated or Contaminated
Food
3-7� 01..1 1
L__.
Discarding or Reconditioning Unsafe
Food.*
4
Food Contact Surfaces
4-501..1.11
_
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.11.2
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 ;Td
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization - Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2401.11.
Eating, Drinking or Using Tobacco*
2401,12
Discharges From the Eyes, Nose and
Mouth*
3-30L. 12
Preventing Contamination When ITasting*
.12
Prevention of Contamination from Hands
590.004(F)
Preventing Contamination from
Employees*
13
--
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
Handwashin Cleanser, Availability
6-301.12
HandDr 'n Provision
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
n
Salem Board of Health
120 Washington Street, 4h Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name
Datif if
Type of Operation(s)
Lyps Of inspection
(
513111
IS Food Service
LJRetail
LAJ.Routine
Ej Re -inspection
AddressC
RIOICI
Level
❑ Residential Kitchen
Previous Inspection
Telephone
❑ Mobile
Date:
❑ Temporary
❑ Pre-operation
Owner
HACCP YM
(0 L
❑ Caterer
❑ Bed & Breakfast
❑ Suspect Illness
❑ General Complaint
Person in Charge (PIC)
Time
1 a
In:3 -
[I HACCP
Inspector
Out- -
Permit No.
❑Other
Each violation checked hequires 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 -HOLT -H,
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE
[14. 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. Managementand 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)
127. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.006)
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
YIME/TEMPERATURE CONTROLS (Potentially HazeMous Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
[118. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POP_ULATIONS_(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:
1+4� 10i 9311
Inspector's Signe:-
_
Print:
PIC -25- store:_ - - '., -- -
'Print:_-,Jo�./�O �'��1� /��4rPage
I of�Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
7 590.003(Aj Assig rment of Res onsibilit *
590.003(B) Demonstration of Knowledge*
2-1.03.11 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 Focal Employee Or An
3-202.16
Ice Made From Potable Drinking Water*
Applicant To Report To The Person in
Dri aking Water from an Approved System*
590.006(A)
Charge*
590.006(B)
003 G)
Ke orting b Person in Char =e*
Shellfish and F•sh From an Approved Source
003(D)
t
Exclusions and Restrictions*
3-201.15
003(E)
Removal of Exclusions and Restrictions
C
C
C
L
FOOD FROM APPROVED SOURCE
* Denotes critical item in the federal 1999 Fond Code or 10i CMR 590.000.
C
PROTECTION FROM CONTAMINATION
Food and Water From Regulated Sources
590.004(-0 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..1.1
Dri aking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0"
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Shellfish and F•sh From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
Proper, Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority
3-202.18
Shellstock Identification Present*
590-004(C)
Wild Mushrooms*
3-201.17
Game Animals*
2-301.14
Receiving/Condition
3-202.1.1
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-10111
Fond Safe and Unadulterated
TageMecords: Shellstock
3-202.18
Shellstock Identification
3-203.12
Shellstock Identification Maintained*
12
TagslRecords:Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records. Creation and Retention*
590.004(J)
Labeling of Ingredients'
Handwash Facilities
Conformance with Approved Procedures
IHACCP Plans
3-502.11.
Specialized Processing Methods*
3-502.12
Reduced oxygen packapng, criteria*
8-103.12
Conformance with Approved Procedures*
* Denotes critical item in the federal 1999 Fond Code or 10i CMR 590.000.
C
PROTECTION FROM CONTAMINATION
9
Cross -contamination
3-302.11(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Fads*
4-501.111
Contamination from Raw Ingredients
3-302.1.l(A)(2)
Raw Animal Foods Separated from Each
Other"
Mechanical Warewashing- Hot Water .
Sanitization Temperatures*
Contamination from the Environment
3-302.11(A)
Fiord Protection*
3-302.15
W'asMn Fruits and Vegetables
3304.11.
Food Contact with Equipment and
Utensils*
4-602.11
Contamination from the Consumer
3-306.14(A)(B
Returned Food and Reservice of Food*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Disposition of Adulterated or Contaminated
Food
3-701_11
Discarding or ReconditioningUnsafeFood*
9
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. ''
4-601.1'1(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 Contact Surfaces of Equipment*
4 703.11
Methods of Sanitization- Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-30111
Clean Condition - Hands and Arms*
2-301..1.2
Cleaning Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventing Contamination When Tasting*
12
-
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from _
Employees*
13
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
6-30]_1.2
HandD Provision
I
CITY OF SALEM
OARD OF HEALTH
Establishment Name: Jn lc�- — Date Page: 3 of -31
Item
No.
Code
Reference
C - Critical Item
R - Red Item
DESCRIPTION OF VIOLATION / PIIAN OF CORRECTION
PLEASE PRINT CLEARLY
Date
Verified
o r se
QCL
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 dollar. or suspensio_nlrev a� of
your food permit -- -6-- �_ "s l— ��f
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
b�—Re-inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other.
Viatatlons Related to Foodborne !tines& Interventions and Risk
Factors (Hems 1-22) {Cant.)
15
Im
is
* Denotes critical mra in the federal 1999 Foci Cade or 105 CMR 590.000.
19
3-501,14(C)
Food or Calor Additives
3-202.12
...__,
Additives',
3-302.14
Protection from Una roved Additives"
3-50L.16(13)
590.004(F)
Poisonous or Toxic Substances
7-10Li1
Identifying Information - Original
Containers*
7-102.11.
Common !Name - Working Containers*
7-201.11
Separation - Storage* -
7-20111
Restriction - Presence and Use°
7-202.12
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions*
7-204A I
Sanitize". Criteria - Chemicals*
7-204.12
Chemicals for Washing Produce, Criteria*
7-204.14
Drving,Agents. Criteria*
7-205-11
incidental Food Contact, Lubricants*
7-206A1
Restricted Use Pesticides, Criteria*
7-206.12
Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Monitoring*
* Denotes critical mra in the federal 1999 Foci Cade or 105 CMR 590.000.
19
3-501,14(C)
Proper Cooking Temperatures for
3-501.15
PHFa
3-401.IIA(1)(2)
Eggs- 155'F 15 Sec,
3-50L.16(13)
590.004(F)
E-ImmediateSenien145'F15sec*
3.401.11(A)(2)
Comminuted Fish. Meats & Game
3-501.16(A3
Animals -155'1715 sec. *
3401,11(B)(I)(2,)
Pork and Beef Roast -130'F121 min*
3-401.I1(A)(2)
Ratites, injected Meats -'155*F 15
590.004(H)
sec.
3-4011 t(A)(3)
Poultry-, Wild Game, Stuffed PHFB,
Stuffing Containing Fish, Meat,
Poultry or Ratites -165'F 15 sec.
3401.11(C)(3)
Whole -muscle, Intact Beef Steaks
145OF "
3-401.12
Raw Animal Foods Cooked in a
Microwave 165F *
3401:11(A)(1)(b)
At] Other PHFB -145'F 15 sec.
Reheating for Hot Holding
3-403.71(X)&(D)
PfiFs 165"F 15 see. *
3-403.11(B)
Microwave- 165° F 2 Minute Standing
Time*
3-403AI(C)
CommerciailyProcessed RTE Food -
140'F*
340311(E)
Remainim Unsliced Portions of Beef
Roasts`
Proper Cooling of PHFB
3-501.14(A)
Cowling Cooked PRFs from 140'F to
70°F Within 2 Hours and From 70'F
to 41'17/45'F Within 4 Hours. *
3-501.14(B)
Cooling PHFB Made From Ambient
Temperature Ingredients to 41'17/45°F
Within 4 Hours*
* Denotes critical mra in the federal 1999 Foci Cade or 105 CMR 590.000.
19
3-501,14(C)
PHFB Received at Temperatures
According to Law Cooled to
41'F/4_5'F Within 4 Hours.
3-501.15
Cooling Methods for PHFB
3 801.11(B
PHF Not and Cold Holding
3-50L.16(13)
590.004(F)
Cold PIJB Maintained at or below
4101450 F*
3-501.16(A)
Hot PHFB Maintained at or above
140'P. *
3-501.16(A3
Roasts Held at or above 1.30'F.
Time as a Public Health Control
3-501:19
Time as a Public Health Coatrol*
590.004(H)
Variance Requirement
a a- I _
..t.-. '....e..
21
3-801.11(A)
Unpasteurized Pre-packaged Juices and
:Bewmrzes with Warning Labels*
3 801.11(B
Use of Pastem-izetl Ego*
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
3-801.11 C
Unopened Food Package Not Reserved.
22
3-603.11
Consumer Advisory Posted for Consumption of
Animal Foods That are Raw. Undercooked or
Not Otherwise Processed to Eliminate
Patbo ens."esys ananr
3-30113.
Pasteurized Eggs Substitute for Raw Shell
1 E
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering, mobile fend, temporary, and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne iliness
interventions and risk factors. Other
590.009 violations relating to goal retail
practices should be debited under #29 -
Special Requirements.
(Items 23-30)
Critical, mrd non-critical violations, which do not relate to the
foodborne illness interveruions and risk,factors listed above, crurbe
found in the folloning sections. of the Food Code mrd 105 CMR
F SALEM
�
BOARD OF HEALTH
Establishment Name: `, fes✓ 0 0.1 �fl Date:
Page:_ of 3
Item
No.
Code
Reference
C -Critical Item
R - Red ItemVerifled
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
r PLEASE PRINT CLEARLY I
Date
6 ��. i
5 : k vv 4 -4L)D(-S -10 f w& -
_ U
'V a
4 e -k
Vonlmvr ccoeVC_
x J 8_
11'7 . AA- E4tvvio Q 40 1-9
•
u V
¢� r
I u
G
b P
i�410
6M
✓ I'
Orwj( 5A /�2 rS✓S U
• J --
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 -6f -twenty-five-doliars:or"suspension/revocation of
your food permit. % ter— - �__�`����
rrective Action Required:
❑ No
Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
e- inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
I
0 Voluntary Disposal ❑ Other: ;
I
triolailona Related to Foodborne fliness Interventions and Risk
Factors (Steins 1-172) (Cont.)
lam
16
TIMEtTEMPERATURE CONTROLS
Food or Color Additives
3-202.12
Additives ,
3-302.14
Protection from Una roved Additives'%
3-501.16(B)
590.004(F)
Poisonous or Toxic Substances
7-101,11
Identifying Information -Original
Containers*
7-102.11.
Common Name - Working Containers*
7-201.1.1
Separation - Storage*
7-202.11
. Restriction - Presence and Use*
7-202.12
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Sanitizars, Criteria - Chemicals*
7-204.12
Chemicals for Washing Produce, Criteria*
7-204.14
Drying Agents. Criteria"
7-205.11
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 *
TIMEtTEMPERATURE CONTROLS
`•Annte,critical!a,min the federal 14991'Wd Cale"105C.MR 90.000.
C
O
3-501.14(0
Proper Cooling Temperatures for
3-501.15
PHPs _
340f.IIA(1)(2)
Eggs- 155F 15 Sec.
3-501.16(B)
590.004(F)
Eggs- Immediate Service 145*Fl5see-
3-401.11(A)(2)
Comminuted Fish. Meats & dame
3-501.16(A)
Animals - 155'F 15 sec. *
3.401.11(B)(1)(2)
Pork and Beef Roast -130'F'121 min*
3-401.11(A)(2)
Ratites, Injected Meats - 155017 15
590.004(H)
sec. *
3-40LI I(A)(3)
Poultry, Wild Came, Stuffed PHFs,
Stuffing Containing Fish, Meat,
Poultry or Ratites -765°F 15 sec.
3-401.11(C)(3)
Whole -muscle, Intact Beef Steaks
145°F r
3-401.12
Raw Animal Foods Cooked in a
Microwave 165*F *
3-40LI I(A)(1)(b)
All Other PHFs - 145'1715 sec.'
Reheating for Not Holding
3403.11(A)&(D)
PRFs 165-F 15 sec. *
3-403.11(B)
Microwave- I65` F 2 Minute Stauding
Time"
340111(C)
CommerciallyProcessed RTE Food -
140°F*
3403.1 I(E)
Remaining Unsliced Portions of Beef
Roasts*
Proper Coaling of PHFs
3-501.14(A)
Cooling Cooked PRFs from 140`F to
70OF Within 2 Hours and From 70`F
to 41`F145OF Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41'Ft45'F
Within 4 Hours*
`•Annte,critical!a,min the federal 14991'Wd Cale"105C.MR 90.000.
C
O
3-501.14(0
PHFe Received at Temperances -
According to Law Cooled to
4t'F145°F Within 4 Hours.
3-501.15
Cooling Methods for PHFs
3-801.11(B)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold PRFs Maintained at or below
41'!45° Ft`
3-501.16(A)
Hot PHFs Maintained at or above
1400F. *
3-501.16(A)
Roasts Held at or above 130'F.
came as a Public Health Control
3-501.19
Time as a Public Health Control*
590.004(H)
Variance Read' xement
t •_
tea^ ,e
21
3-801.11(A)
Unpasteurized Pre-packaged Juices and
:Beverages with Warning Ubels*
3-801.11(B)
Use of Pastetaued Eggs'
3-801.21(D)
- -....._
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
3-801.11(C)
Unopened Food Package Not Re -served.
22
3-603.11
Consumer .Advisory Posted for Consumpriou of
Animal Foods That are Raw, Undercooked or
Not Otherwise Processed to Eliminate
Pathogens* Eft ' s 1/vWV,,1
3-302.13
Pasteurized Eggs Substitute for Raw Shell
Eggs*
590.o09(A)-(D) Violations of Section 590.009(A) -(D) in
catering, mobile food, temporary and
residential kitchen operations should be
debited udder 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.
(Items 23-30)
Critical, mrd non-criticai violations, which do not relate to the
joadborne illness interventions and riskfactors listed above, can be
fount in the following sections of the Food Code and 105 CMR