SSU CHARTWELLS - ESTABLISHMENTSFood Establishment Inspection Form I Page of
The Commonwealth of Massachusetts
City of Salem Board of Health
120 Washington Street, Salem MA 01970
978 741-1800
# Violations 0
Date
Time In !T; fffiQil1
Time Out z
priority- Priority foundation- n Core- 0
Soore (optional)
Fstabl'shmerd Name S
Risk Category
T O rations
ood SBNICR
[]Retail
❑Residential Kitchen
❑Mobile
[]Temporary❑Pre-0peration
[]Caterer
[]Bed & Breakfast
[]Bed
Market
❑Other:
Type of Inspection
❑ tine
M einspection
Pr ousi�nrspection Date:
yf///�2nn 12 Q-1,17
[]Suspect Illness
❑General Complaint
❑HACCP
❑Other.
Establishment Address
S -f q &4
Telephone2-- cc v/N
Owner permit
�{yy
Person-inLhazge (PIC) r Coes Safety Training /6p. a
Inspector
1'
_ > ' FOODB NE ILLNESS RISK FACTORS AND PUBLIC HEALTH'1NTERVENTIONS x :-
Circle designated compliance stella (IN, OUT, WO, WA) for each numbered Rem Made W in appropriate box for CAS and/orR
IN=inom liance OUT=notincom fiance NIO=notobserwd NJA=jotaiplicable COS =wnecfed ons&e during i "n R=repeat violation
Compliance Status COS R Compliance Status COS
R
-:,* ,r y Pm disposition of reNmedprewcusly
mp—.
SUperviston .;' �awa.�' �. �+.v2TCY�`-' 17 IN OUT served reconditioned 8 unsafe fad
1 IN OIfT
PIC presonk demonstrates knavdedge, and }.' ay_ :it h t Time / TemperatarQ Control for
domes tluties '
2 IN OUT WA
Certified Food Protection Manager 18 1 IN OUT WA WO Raper cooking fime & Iemperetums
=:r= t _.�.-, :- .....,,_ ,�, Em 10 Health 'fm"r""=i t ' .-.�. '_�-... 'n?'if- 19 1 IN OUr WA NAD Proper reheating procedures for hot holding
Management, food employee and mnditienal
3 IN OUT employee; knowledge, respensibiGties and 20 IN OUT WA N/O Proper cooling time and temperature
reporting
4 IN OUT Proper use of restriction and exclusion 21 IN OUT WA N/O Proper hot holding temperature
5 IN OUT Procedures for responding to vani ing and
diantreal events
22 IN OUT WA WO Proper colo holing temperature�•
.. �_ �L : Good lentc Practices r-�_ r�, t; q;_.
---- - „ -:+a=..,+a-.: 23 IN OUT WA WO Proper nate merttlng and disposition
6 1 IN OUT WO Proper Ming, fasting, ddnklog, or lobaeca use
24 IN OUT WA WO Tore as a Public Heagh Cmbd
7 IN OUT WO No discharge ban eyes. nose, antl mount
Consumer Adtii s.=:.t.�ssi.=-�x.>°t°r e �-n �*--,.•..4�
.Consumer
- "- - "- i t advwory Provided! fur mw /
m.Preverlbng Cordaminabtyn by Hands' :�,. 25 IN our NIA
m_ undercooked food
g IN our oro Hand clean &Pop" aahad :: irementsforH Susce leP0 Populations
9 IN OUT WA NIO No Cam hand tooted with RTE food 26 IN OUT WA Pastmr¢ed footls used; prohib&etl footle rid
Cera ed
Adequate handmahmg sinks property supplied t
10 IN OUT and accessible Food it Color Additives and`Tmik Substances „e, ' p , W Em:
Approvired $OUrpe 27 1 IN OUT WA Footl additives: approved & properly used
11 IN OUT Food obtained from approved source 28 IN OUr WA Toric sub. property identified, stored & used EEE
12 IN OUr WA WO Food received at Proper temperature Conformance. with proved PracedUBB
.Compliance
Food received in good condition, sem. 8 war variance / speciaf sx! process
13 IN Our unadulterated 29 IN OUT WA /HACCP Plan
14 IN OUr WA WO Required records available: shellsoar tags,
parasite destruction Risk Factors are important practices or procedures identified as the most
Protection from Contamination .:= r r. 'oris-=- =- prevalent contributing factors of foodborne illness or injury. Public health
15 1 IN OUT WA WO Food separated and protected interventions are control measures to prevent foodbome illness or injury.
16 1 IN OUr WA Food.eontact surfaces: claimed &sanitized
MPN'. GOOD RETAIL PRACTICES ° 'K�Nh.w �° -_
Good Retail Practices are preventative measures to control the addition of patipgens, chemicals, and physical objects into foods.
Mark '%" in brae R numbered item is not in compliance Mark W in box for COS andlor R COS = corrected onsite during inspection R = Nolati m
rprupriate
Compliance Status COS R Compliance Status COS R
Saio Food and Water_,;�,.!r..,�::-1. ....�t,_9ProUse Oi:Utorretls=•iia ._. _,: .... .. .r
30 1 PasteuRed eggs used where required 43Inusa utensils property stored
31 Water & ice from approved solace 44 Utensils, equipment & linens: property stored, dried, & handled
32 Vaname obtained for specialized processing methods 45 1 1 Single -use / single -service articles: property stored & used
p�r„r�=t:d.iSns.s+:n, Food Temperature Control 'n=v ver 46 1 1 Gloves used property
. 33 Prow fAOGng methods used; adequate equipment her ; %,11.- `z Utnslisrt Equipmentand Vending .1 r x
tempeature control '
Food & nonTmd contact surfaces cleanable, properly designed.
34 PMnt rood properly cooked foxtrot hunting 47 amswcted&used
35 Approved thawing methods used 46 Wons astrirg facilities: installed, maintained, & used; lest ships
36 Therrrpmelers provided & axumte 49 1 1 Non-food conned surfaces dean
�, ' .1 t_ u -,ys T . s-, •v ,-x Food Identification Ph Iral Facilities
37 1 Fad property labeled; original container 50 Hol &and wrier available; adequate presst a
r f'•i 'tk :''+-' "Prevention Of Food ' Contamination' ..+r�e...;;6�k.v r!; i 51 Plumbing irecalled; proper baadbw devices
38 Insects, rodents, & animals net present 52 Sewage & wade water property disposed
39 Contamination prevented during food preparation, storage and 53 Toilet features: Property constructed, supplied. & cleaned
display
40 Personal tleanliness 54 Garbage & refuse property disposed; Facilities maintained
41 wiling donhs: properly used a stored 55 Physical fedlNes installed, maintained, &dean
42 1 Washing hubs & vegetables 56 Atlequale ventilation & lighting; designated areas used
57I SPECIAL REOUIREMENTs IOTHER ?. ❑An&chokin 590.009 ❑Tobaxo 590.009 LIAJlergen Awareness (590.009113]) []Local law, regulation ❑Other
Official Order for Corecaon: Based on an inspection today, the items docked indicate vWadons of the Board of Health Food Require / 2b1 Federal Food Code. This report, when signed below by
a Board d Health member or IIs agent constitutes an order of the Board d Health. Failure to correct violations cited in this report may result' slop ra revdatim. of the food asbNishmem pe W. and cessation of mod establishment operations. N aggrt by oder, you have a right to a hond, r request must be In su itted to the Board d Health at th a ad" in f
ton 10 calendard dread' oder.
PIC's $i nature:
Print:
Ins don's SI nate
Follow -u E N K (1c a one Fo ate, it applicable, V
FOODBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH
INTERVENTIONS (Items 1-29
SUPERVISION
1
C
2-101.11
Assignment
590.003(A)(1)
Assignment
2-102.11(A),(B),
and (C)(1),(4 -16
Demonstration kPq
590.003(B)
Demonstration
2-103.111 A -O
Person -in -Charge Duties
2-102.12A)
Certified Food Protection Manager
590.003 A 2-4
Ansi nment
EMPLOYEE HEALTH
3
2-102.11(C)(2), Demonstration
(3), and 1
Eatin , Dnnldn , and UsingTobacco
3-301.12
2-103.11 M Person -in -Charge Duties
7 1 2-401.12
2-201.11(A)(1), Responsibility of the Permit Holder, PIC, and
m to ees IP•Pp
B C Conditional Employees
PREVENTING CONTAMINATION BY HANDS
590.003(C) FC2-201.11 A Health Status -Em to ee is 111
Hand Antiseptics
Responsibility of a Foci Employee or Applicant
590.003(F� to Report to the PIC M
Preventing Contamination from Hands
590.003(G) Reporting by the PIC
4
2-201.11(D) and Responsibility 1the -it Holder, IC, and
F Conditional Employees Responsibility of the
PIC to Exclude or Restrict IPI
Handwashin Sinks - Numbers 8 adties
5-204.11
2-101.12 Exclusions and Restrictions
5-205.11
590.003(D) Exclusions and Restrictions
6-301.11
2-201.13 Removal, Adjustment, or Retention of
Exclusions and Restrictions "
6-301.12
590.003E Removal or Exclusions and Restrictions
5
2-501.11 Clean-up of Vomiting and Diarrheal Events
GOOD HYGIENIC PRACTICES
6 i2-401.11
Eatin , Dnnldn , and UsingTobacco
3-301.12
Preventin Contamination When Tastin
7 1 2-401.12
1 Discharges from the Eyes, Nose, and Mouth
PREVENTING CONTAMINATION BY HANDS
8
Hand Antiseptics
3301.11 (B -C)
9
10
12
13
14
2.301.11 A,D-E
Clean condition -Hands and Arms
2-301.12Cieaenninto
Procedure
2-301.14
WhWash
2-301.15
Where to Wash
2-301.16
Hand Antiseptics
3301.11 (B -C)
Preventing Contamination from Hands
5-202.12
Handwashinp Sinks, Installation
5-203.11
Handwashin Sinks - Numbers 8 adties
5-204.11
Handwashin Sinks - Location &Placement
5-205.11
Using a Handwashing Sink - Operation and
Maintenance km
6-301.11
Handwashiing Cleanser, Availabilitv
6-301.12
Hand D in Provision
6-301.14
Handwashinq Signage
APPROVED SOURCE
Food obtained m an approved source
3-201.11(A) and
D -G
Compliance with Food Code m.PO
590.004(A)
Food Prepared in a Private Home IPI
590.004(B)
Parka ed Food, Labelin
3201.14
Fish
3201.15
Molluscan Shellfish
3-201.16(B)
Wild Mushrooms
590.004 C
Wild Mushrooms - Identification Required
3-201.17
Game Animals
3-202.13
Eggs (11
3-202.14
E and Milk Products, Pasteurized
590.004(D)
Frozen Milk Products
3202.110
Juice Treated - Commercial) Processed
590.006(A)
Bottled Dnniang Water
Food received at
ro r temperature
3-202.11
Temperature
Food received in
cod condition, safe, and unadulterated
3-101.11
Safe,
afe Unadulterated
3202.15 1
Package Integrity
R d. records available: Shellstock to aresite destruction
3202.1a
Shellstock Identification
3203.12
Shellstock, Maintaining Identification
3-402.11
Parasite Destruction
3-402.12 1 Records, Creation & Retention ,-
PROTECTION FROM CONTAMINATION
15
Food separated and protected
3-801.11(A),(B),
C , E , and G
3,302.111
Packaged and Unpackaged Food -
Sepamtion, Packaging, & Segregation i"•`7
Protection from Unapproved Additives
3-304.11
Food Contact with Equipment, Utensils, and
Linens (P)
7-101.11
3-304.15A)
Gloves, Use Limitation
16
Food -contact surfaces;
cleaned and sanitized
7-202.11
4-501.111
Manual Warewashing Equipment, Hot
Water Sanitization Temperatures IPI
Conditions of Use
4-501.112
Mechanical Warewashing Equipment, Hot
Water Sanitization Temperatures IPi
7-204.11
4-501.114
Manual and Mechanical Warewashing
Equipment, Chemical Sanitization -
Temperature, pH, Concentration and
Hardness kP•PO
Chemicals for Washin Produce, Criteria
4-601.11(A)
Equipment, Food -Contact Surfaces,
Nonfood -Contact Surfaces and Utensils
7-205.11
4-702.11
Before Use After Cleanin - F sank
Restricted Use Pesticides, Criteria
4-703.11
Hot Water and Chemical -Methods
17
Proper disposition of returned, previously served,
reconditioned and unsafe food
3306.14
Retumed Food and Re -Service of Food
TIME
3-701.11 Discarding or Reconditioning Unsafe
Adulterated, or Contaminated Food r0I
-TEMPERATURE CONTROL FOR SAFETY CS FOOD
18
ProDer cooking time and temperature_
3-401.11
1 Raw Animal Foods - Cookin
3-401.12
Microwave Cocking
3-401.14
Non -Continuous Cooking of Raw Animal
Foods (P•P4
19
Pro erreheatin
rocedures for hot holdin
3-403.11
Reheatin for hot holding
20
Pro r coolingtime and tem rature
3-501.14
ling M
21
Pro r hot holdin
tem nature
3501.16 A)(1)
TCS Food - Hot Holdin
22
Propercoldholdin tem reture
3501.16 A 2
TCS Food - Cold Holding
3-501.168
Eggs - Cold Holdin
23
Pro r date markin and disposition
3501.17
RTE TCS Food, Date Markin
3-501.18
RTE TCS Food, Dis ition
24
Time as a Public Health Control PHC
3-501.19
Time as a Public Health Control
590.004 H
TPHC- BOH Approval Required
Consumer Advisor
25 1 Consumer advisory provided for raw/ undercooked food
Consumption of Animal Foods that are
3-603.11 Raw, Undercooked, or Not Otherwise
Processed to Eliminate Pathogens
HIGHLY SUSCEPTIBLE POPULATION
26
Pasteurized foods
used; prohibited foods not offered
3-801.11(A),(B),
C , E , and G
Pasteurized Foods, Prohibited ReService,
and Prohibited Food (P -c
Food / Color Additives and Toxic Substances
27 Food additives: approved
and properly used
3202.12 1
Additives
3-302.14 1
Protection from Unapproved Additives
28 Toxic substances:
properly identified, stored and used
7-101.11
Identifying Information - Original
Containers IPO
7-102.11
Common Name -Workin Containers
7-201.11
Separation - Stora e
7-202.11
Restriction - Presence and Use
7-202.12
Conditions of Use
7-203.11
Poisonous /Toxic Container, Prohibitions
7-204.11
Sanitizers, Cnteria-Chemicals
7-204.12
Chemicals for Washin Produce, Criteria
7-204.14
Drying Agents, Crtteria
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
Monitoring(
Food Establishment Inspection Form Page 2 ofd
The Commonwealth of Massachusetts '
City of Salem Board of Health Establishment Name:
120 Washington Street, Salem MA 01970 (� (J _ 1
978 741-1800
Date: —L,�„5`
mIN-AD, -X—NIA .um ..".� .. ,—TEMPERATURE OBSERVATIONS
Item / Location Tem ° Item / Location Tem Item / Location Tem °F
OBSERVATIONS AND/OR CORRECTIVE ACTIONS
Violations dted
in this report must be corrected
within the time frames or as stated in Section 8-405.11 of the Food Code
Item
Number
Code Section
P - Priority Item
PF = Priority Foundation Item
Description of Violation
r �
Discussion with PIC:
Corrective Action -:Required r4:U1110
4. 1A,
Ljyes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other
PIC's Signature: Date: /b ,
i
Inspector's Signatu Date:
Rev. 11/2016
a
29
Com liancewithvariance/ s ecial rocesses / HACCP Plan
Pasteurized Eggs Substituted for Raw Eggs for
Certain Recipes jPj
3-404.11 TreatingJuice •
3-202.16
3-502.11 Variance Requirement
5-101.11
3-502.12 Reduced Oxygen Packs in , Criteria
590.006(B)
4-204.110 B Molluscan Shellfish Tanks
5-102.12
8-103.12 Conformance with Approved Procedures
5-104.12
8-103.13 When a HACCP Plan is R uired
Variance obtained for specialized processing methods
8-103.14 Contents of a HACCP Plan
GOOD RETAIL PRACTICES items 30 - 56
30
31
F-32-
33
F-34-
35 35
36
37
38
39
6Y 1y=1;wTod Jil:U14L\ 14.1
Pasteurized eggs used where required
3-302.13
Pasteurized Eggs Substituted for Raw Eggs for
Certain Recipes jPj
Water & ice from approved source
3-202.16
Ice
5-101.11
Approved System - Source
590.006(B)
Standards - Qual'
5-102.12
Nondrinkin Water
5-104.12
Ahemative Water Supply
Variance obtained for specialized processing methods
8-103.11 I _IDocumentation
of Proposed Variance and
Justification m
FOOD TEMPERATURE CONTROL
Proper cooling methods use; adequate equipment for
temperature control
3501.11
Frozen Food
3-501.15
Coolin Methods
4-301.11
Cooling, Heating, and Holding Capacities,
Equipment "
Plant food appro
riatel cooked for hot holding
3-401.13
Plant Food Cooking for Hot Holding
roved thawin methods used
3-501.12
TCS Food, Slacking
3-501.13
Thawing
Thermometers
provided & accurate
4-203.11
Temperature Measuring Devices, Food -
Accura (M
4-204.112
Temperature Measuring Devices -
Functionali O'c)
4302 12
Food Temperature Measuring Devices,
Numbers
4-502.11 B
Good Repair and Calibration
I Y0N7 U Is] :1 2171.1 WA UPI
Food properly
Is led; original container
3202.17
Shucked Shellfish, Packaging & Identification
3203.11
Molluscan Shellfish, Original Container
3302.11
Food Storage Containers Identified with
Common Name of Food
590.004(1)
Standards of Identity
3-601.12
Hones11 Presented
3602.11
Food Labels
PRE V EN I ION OF FOOD CONTAMINATION
Insecta, rodents, & animals not present
2-403.11
Handling Prohibitions -Animals
6-202.13
Insect Control Devices Design and Installation
6-202.15
Outer Openings, Protected
6-202.16
Exterior Walls and Roofs, Protective Barrier
6-501.111
Controlling Pests
6-501.112
Removing Dead or Trapped Binds, Insects,
Rodents and other Pests
Contamination prevented during food preparation, storage,
and display
3-202.19
Shellstock, Condition
3-303.11
Ice Used as Exterior Coolant, Prohibhed as
Ingredient m
330312
Storage or Display of Food in Contact with
Water or Ice
3-304.13
Linens and Napkins - Use Limitations
3-305.11
Food Storage - Preventing Contamination from
the Premises
3305.12
Food Storage, Prohibited Areas
3305.14
Food Preparation
3-306.11
Food Displa Preventing Contamination from
Consumers 1
3306.12
Condiments, Protection
3-306.13 B & Cj
Consumer Self -Service Operations
6-004.11
Segregation / Location - Distressed Items
C
41
42
43
44
C
46
47
C
Personal cleanliness
2-302.11
Maintenance - Fin Fingernails
2303.11
Jeweliv
2304.11
1 Clean Condition - Outer Clothing
2-402.11
1 Effectiveness - Hair Restraints
Wi in Grooths: rl used & stored
3-304.14
Wi in Cloths, Use Limitation
4-101.16
1 Sponges, Use Limitation
4-901.12
1 Wiping Cloths, Air Drying Location
Washina fruits & veoetables
3-302.15
Washing Fruits and V stables
7-204.12
Chemicals for Washing, Treatment, Storage
and Processing Fruits and Vegetables,
Criteria (P)
PROPER UNE OF U 1 ENNILN
In -use utensils ro IME
3-304.12 In -Use Utensils, Between -Use Storage
Utensils, t. & linens: properly stored, dried, & handled
Section 48
Laundering (except 4-803.12
Section 4-9
Protection of Clean Items (except 4-901.12,
4-902, 4-903.12, and 4-904.11
Sin le -use / sin le -service articles: properly stored & used
4-502.12
Single -Service and Single -Use Articles,
Required Use (P)
4-502.13
Single -Service and Single -Use Articles, Use
Limitations
4-502.14
Shells, Use Limitation
4-903.11 (A) and
(C)
Equipment, Utensils, Linens and Single -
Service and Single -use Articles -Storin
4-903.12
Storage Locations - Prohibited
Gloves used ro rl
3-304.15-(13) - D Gloves, Use Limitation
Food & non-food contact surfaces cleanable, properly
designed, constructed & used
3304.16
Using Clean Tableware for Second Portions
and Refills
3304.17
Refilling Retumables
Section 4-1
Materials for Construction and Repair
Design and Construction (except 4-202.18,
Section 4-2
4-203,4-204.11, 4-2134.110[B], 4-204.112
through 4-204.119)
Equipment, Clothes Washers, Dryers and
4-401.11
Storage Cabinets, Contamination
Prevention - Location
4-402.11
Fixed Equipment, Spacing or Sealing -
Installation
4-501.11
Good Repair and Proper Adjustment -
Equipment
4-501.12
CuttinQ Surfaces
4-501.13
Microwave Ovens
4-502.11(A)&(C)
Good Repair and Calibration - Utensils and
Temperature & Pressure Meas. Devices
4-603.11
Dry Cleaning - Methods
4-902.11
Food -Contact Surfaces - Lubricating and
Reassembling
4902.12
1 E ui ment- Lubricating and Reassemblin
Warewashing facilities: installed, maintained & used; test
strips
4203.13
Pressure Measuring Devices, Mechanical
Warewashing Equipment
4204.113
Warewashing Machine, Data Plate
Operation Specifications
4-204.115
Warewashing Machine, Temperature
Measurin Devices xm
4-204.116
Manual Warewashing Equipment, Heaters
and Baskets rvn
4-204.117
Warewashing Machines, Automatic
Dispensing or Detergents and Sanitizers
4-301.12
Manual Warewashing, Sink Compartment
Requirements la,�
4-302.13
Temperature Measuring Devices, Manual
vn
and Mechanical Warew Irn
4302.14
Sanitizing Solutions, Testing Devices
Section 4501.14
Equipment
t0 4-501.110
4-501.116
Warewashing Eqpt, Chem. San. Conc.
Food Establishment Inspection Form Page -L-_ of
The Commonwealth of Massachusetts
City of Salem Board of Health
120 Washington Street, Salem MA 01970
978 741-1800
# Violations
Date O
Time In q,t won 7
Time Out
Priority- Priority foundation- Core-
Score (optional
Establishment Nemm U•,
Risk catesomy
T of O rations
Wood Service
[]Retail
❑Residential Kitchen
[]Mobile
[]Temporary
❑Caterer
❑Bed & Breakfast
❑Fanners Market
❑Other.
Type of Inspection
ne
❑ oinsp
reinspection
Previous Inspection Date:
❑Pre-Operation
[]Suspect Illness
[]General Complaint
❑HACCP
[]Other.
Establishment Address
L
Telephone �+ _ CCP V/N
J
c Permit #;
ownar C J�!
Person-Iin-Charge(PIC) If Food Safety rminingl Lbrs^
moi/
InspmnrJ
&AVORIUA i5: FOODBORNE ILLNESS RISK FACTORS AND PUBLICHEALTH INTERVENTIONS"
Circle designated compliance sfaW (IN, OUT, WO, WA) for each numbered item Mark 7r m appropriate box for COS and/or R
IN = in mm liance OUT=notincompliance N/O = nol observed WA = note icable COS = connected on-site durin ins 'on R = vioiation
Compliance Status COS R Compliance Status COS
R
-., t'I SOpCNISIOn,_ :'=:s: ;°" �3u A `. 17 IN OUT Proper d'epositim of mWmed, previou*
rr -...N. u served, mx,nditioned & unsafe food
1
IN OUT. PIC present. demonstrates knowledge, ant..
inefforms duties
""'
, 1„ r , :.; .rx s;:.Time I Temperature Control for Safety ,�,ir -.max _
2
IN OUT WA Gargled Food Protection Manager
18 1 IN OUT WA WO Proper coolchg time & temperatures
Employee Health.d;_.tnalq _ - ° `:3'e -rri', 19 1 IN OUT WA N/O Proper reheating pr000dures for hot holding
3
IN OUT
Management, food employee and conditional
empbyee; knowledge, responsibtiNes and 20 IN OUT WA N/O Proper cooling time and temperature
reporting I
4
IN OUT
Proper use of restriction and exclusion 21 IN OUT WA N/O Proper hot holding temperature
L
5
IN OUT
Procedures for responding to vomiting anti 22 IN OUT WA WO
Proper cold holding temperature events
Good IeAk: Practices. , +'-.air`:i7,w riti ` 23 IN OIfT WA N/O Proper data marking and disposition
6
IN OUT WO
Proper eating, tasting, drinking, or iobamo use 24 IN OUT WA WO Time as a Public Health Control
7
IN OUT WO
No discharge fmm eyes, nose, anti mouth �.COnsumer Advise M, �+='4.=="S'-'I'r - V K.- 'Ru"' ,?.„ g'-$"
`r"`3 � -- Preventing Contaminationh Hands `� "- 25 IN OUT WA Consumer advisory provided for mw/
�+'=r.t:L :-•, tv_ n h, , Q Y 7.,....,�.k...�.' ', '.: undercooked food
8 IN ourWo Hantlsdcenaproperlywashed sR'ulremetdaforHi hl SusceptibleP` Populations SP a--sr-.k=•-w ,ea=:
9 IN OUT WA WO No here hand contact van RTE food 26 IN OUT WA Pasteunzetl faotls used; pombaed foods not
offered
Adequate handwashing sinks properly supplied
10 IN our and accessible Food I Color Additives and Toxic Substanc r.. *�": 7 (
,.
Approved 27 1IN OUT WA
Food additives: approved 8 properly used
11 IN OUT Food obtained f can approved source 28 IN OUT WA
Toric sub. properly identifed, attract & used
121 IN OUT WA WO Food received at propertempereWre - Conformance with Proved Procedures=-m—mrmnirw�
13 IN OUT Food mceivetl m good ctrditian, sate. & 29 IN OUT WA Campliance with variance / spedd'eed process
unadulterated / HACCP Plan
14 IN OUT WA WO Required records wadableshetistock tags, Rik Factors Ire
Parasite ecsnuctim, saCOa a' portant practices or procedures identified as the most
• - e, n;a n, a Protection from C6nt&mftsd 0n prevalent contributing factors of foodborne illness or injury. Public health
15 IN OUT WA WO Foed == and protedetl interventions are control measures to prevent foodborne illness or injury.
16 IN WA Footlruntact surfaces; cleaned & sana¢ed
gEemT�: —,z ., .a _' :l, ': '1t+ii.:, wF"tn. resw s ail GOOD. RETAIL PRACTICES `W9,d7�' a.
Good Retail Practices are preventative measures m control the addition of pathogens, chemicals, and physical objects into hods.
Meal, x in bre If numbered item is not in compliance Mark X in ate box for COS and/or R COS = connected on-site during inspecdan R =t violation
Compliance Status COS R Compliance Status COS R
a,:--nr a, :,.,"Z_.._�r_ +r_: Safe Food and Water �c-=•�-a _�:: - aa�-; �„ nv. - _,...ff..:,,,.�....,,,,--,.n Proper Use of Utensils
30 Pride novel eggs used-hem required 43 1 In-use treadle property stored
31 1 1 Water & ice from approved saline 44 1 Utensils, equipment & linens: properly steed, dried, & handled
32 1 1 Variance obtained for specialized processing methods 45 Single-use / single -service articles: properly shred & used
-:<.: Food Tem re Control 46 I Gloves used property
33 Proper caolin9 methods used; adequate equipment for , a I,Ni �,'„=,'' Utenslis;' Equipment and vending k,�p
":=
temperature mnWl .
34 Plant food DroceM cooked for hot holding 47 Food & non-food cooled surfaces cleanable, properly designed,
conswded & used
35 ADpoved the-in9 methods used 48 Waowashing facilites: Installed, maintained, & used; lest saes
36 Thermarefers provldetl 8 accurate 49 1 Non-food c ofed surfaces dean
Food Id fication Physical Facilities
37 Food properly labeled; onginal contains 50 1 Hol & mid water available; adequate pressure
, _�:, •� ice: y Prevention of Food Contaminattorl=__^li- s ' 51 Plumbing installed; proper baddlow devices
38 Insects, rodents, It animals not present 52 Sewage & vraste wafer property disposed
39 Contamination prevented during food preparation, storage and 53 Toilet features: Properly constructed, supplied, & cleaned
display
40 Personal cleanliness 54 Garbage & refuse properly disposed; facllities maintained
41 wiping cloths: properly used & stoned 55 Physical facilities Insulted, maintained, & dean
42 Washing fruits & vegetables 1 56 1 1 Adequate ventilation & lighting; designated areas used
=57 -SPECIAL RF.GUIREMENTSI OTHER. ❑Antichokin 590.009 ❑Tobacco 590.009 LJAJIerqen Awareness 590.009G []Local law regulation ❑Other
Official Order for Correction: Based on an inspection today, the items cher ad indicate violations of the Board of Health Food Regulation / 2013 Federal Fad Cale. This report, when signed below by
a Board of Health member or its ail constihdes an order of the Board of Health. Failure lo cored violations cited in this report may asuk m suspension tr revocation of the food establishment permit
and cessation at food establish operations. gage this order, you have a right to a hearing. Your request must be in writing and mbmiged b the Board of Health d the above address within
ten 10 celadar of most this order.
PIC's Si nature: /r
Print: Date:
Inspector's Si mat
F011owwjVg NO (elrele one) Follok-up Date, if applicable,l
FOODBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH
INTERVENTIONS (Items 1-29)
SUPERVISION
1
1
2-101.11
Assignment
590.003 A 1
Assignment
2-102.11(A),(B
and (C)(1),(4-1 6),.
Demonstration (PO
590.003LB)
Demonstration
2-103.111(A-0)
Person -in -Charge Duties `
2-102.12(A)
Certified Food Protection Manager
590.003 A 2-4
Assi nment
EMPLOYEE HEALTH
3
2-102.11(C)(2), DemonstrationiPo
(3), and (1
2-301.12Cleanin
Procedure
2-103.11 M Person -in -Charge Duties
When to Wash TPT
2-201.11(A)(1), Responsibility of the Permit Holder, PIC, and
(13)(C) Conditional Emplo es (PA
Where to Wash
590.00LQ FC2-201.11 A Health Status -Employee is 111
Hand Antiseptics
590 003 Responsibility of a Food Employee or Applicant
(� to Report to the PIC (P)
Preventing Contamination from Hands
590.003(G) Reporting by the PIC
4
2-201.11(D) and Responsibility of the Permit Holder, PIC, and
Conditional Employees - Responsibility of the
(F) PIC to Exclude or Restrict (P)
Handwashin Sinks - Numbers 8 cities
5-204.11
2-101.12 Exclusions and Restrictions
5-205.11
590.003(D) Exclusions and Restrictions
6301.11
2-201.13 Removal, Adjustment, or Retention of
Exclusions and Restrictions (P)
6301.12
590. E Removal or Exclusions and Restrictions
5
2-501.11 Clean -u of Vomitin and Diarheal Events
GOOD HYGIENIC PRACTICES
6 2-401.11 Eatin , Drinking, and UsingTobacco
3-301.12 Preventing Contamination When Tasting
7 2-401.12 Discharges from the Eyes, Nose, and Mouth
PREVENTING CONTAMINATION BY HANDS
8
9
10
12
13
14
2301.11 A,D-E
Clean condition -Hands and Arms
2-301.12Cleanin
Procedure
2301.14
When to Wash TPT
2301.15
Where to Wash
2301.16
Hand Antiseptics
3-301.11 (B -C)
Preventing Contamination from Hands
5-202.12
Handwashing Sinks Installation
5-203.11
Handwashin Sinks - Numbers 8 cities
5-204.11
Handwashin Sinks - Location &Placement
5-205.11
Using a Handwashing Sink - Operation and
Maintenance (M
6301.11
Handwashin Cleanser, AvaiIability
6301.12
1 Hand Drying Provision
6-301.14
1 Handwashing Signage
Food obtained from an approved source
3-201.11(A) and
D -G
Compliance with Food Code (P.P0
590.004(A)
Food Prepared in a Private Home
590.004(B)
Packs ed Food, Labeling
3-201.14
Fish
3-201.15
Molluscan Shellfish
3-201.16(B)
Wild Mushrooms
590.004 C
Wild Mushrooms - Identification Required
3-201.17
Game Animals
3-202.13
Eggs
3-202.14
E s and Milk Products, Pasteurized
590.004(D)
Froaen Milk Products
3-202.110
Juice Treated - Commerciall Processed
590-006(A)
Bottled Drinkin Water
Food received at
proper temperature
3-202.11 1
Temperature
Food received in
pood condition, safe, and unadulterated
3-101.11 1
Safe, Unadulterated
3-202.15 1
Packs a integrity
R d. records available: Shellstock fa s, arasite destruction
3-202.16
Shellstock Identification
3-203.12
Shellstock, Maintainin Identification
3-402.11
Parasite Destruction
3-402.12 Records, Creation 8 Retention
PROTECTION FROM CONTAMINATION
15
Food se a rated and protected
3-202.12 1
3-302.111
Packaged and Unpackaged Food -
Separation, Packaging, 8 Segregation (PA
Protection from Unapproved Additives
3-304.11
Food Contact with Equipment, Utensils, and
Linens (P)
7-101.11
3-304.15(A)
Gloves, Use Limitation
16
Foodcontect surfaces;
cleaned and sanitized
7-202.11
4-501.111
Manual Warewashing Equipment, Hot
Water Sanitization Temperaturesm
Conditions of Use
4-501.112
Mechanical Warewashing Equipment, Hot
Water Sanitization Tempera (P)
7-204.11
4-501.114
Manual and Mechanical Warewashing
Equipment, Chemical Sanitization -
Temperature L pH, Concentration and
Hardness (P•RI
Chemicals for Washin Produce, Criteria
4-601.11 (A)
Equipment, Food -Contact Surfaces,
Nonfood -Contact Surfaces and Utensils
7-205.11
4-702.11
Before Use After Cleanin : Fr uen
Restricted Use Pesticides, Criteria
4-703.11
Hot Water and Chemical -Methods
17
Proper disposition of returned, previously served,
reconditioned and unsafe food
3-306.14
Returned Food and Re -Service of Food
TIME
3-701.11 Discarding or Reconditioning Unsafe
Adulterated, or Contaminated Food cd)
-TEMPERATURE CONTROL FOR SAFETY CS FOOD
18
Proper cooking time and temperature
3-401.11
Raw Animal Foods - Cooking
3-401.12 1
Microwave Cookin
3-401.14
Non -Continuous Cooking of Raw Animal
Foods (P•PQ
19
Pro er reheatin
rocedures for hot holdin
3-403.11
rReheating for hot holding
20
Pro r coolin time and tem roture
3-501.14
Ccolin
21
Proper hot holdin
tem rature
3-501.16 A 1
TCS Food - Hot Holdin
22
Props! cold hoiden temperature
-501.16 A 2
3-501.10)(2)
TCS Food - Cold Holdin
3-501.16(B)
Eqqs - Cold Holding
23
Proper date markin and disposition
3-501.17 1
RTE TCS Food, Date Markin
3-501.18
RTE TCS Food, Dis sition
24
Time as a Public Health Cool PHC
ntr
3-
Time as a Public Health Control
H501.19
590.004
TPHC- BOH Approval R wired
consumption of Animal Foods that are
3-603.11 Raw, Undercooked, or Not Otherwise
Processed to Eliminate Pathocens tm
ReService,
27 Food additives: approved
and properly used
3-202.12 1
Additives
3-302.14 1
Protection from Unapproved Additives
28 Toxic substances:
properly identified, stored and used
7-101.11
Identifying Information - Original
Containers iP4
7-102.11
Common Name - Working Containers
7-201.11
Separation - Stora e
7-202.11
Restriction - Presence and Use
7-202.12
Conditions of Use
7-203.11
Poisonous / Toxic Container, Prohibitions
7-204.11
Sanifizers, Criteria - Chemicals
7-204.12
Chemicals for Washin Produce, Criteria
7-204.14
Drying Agers, 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, Past Control and
Monitoring (PIC)
Food Establishment Inspection Form Page of 2
The Commonwealth of Massachusetts
City of Salem Board of Health Establishment Name:
120 Washington Street, Salem MA 01970 1'//
978 741-1800 S50— d
,
Date:
M_'.. � . tom-•3, nz,4 _.,.TEMPERATUREOBSERVATIONS tea..: _... ._ `..
Item / Location Tem Item / Location Tem ° Kom / Location Tem °
OBSERVATIONS AND/OR CORRECTIVE ACTIONS
Violations dted in this report must be corrected
within the time frames or as stated in Section 8-405.11 of the Food Code
Item
Number
Code Section
P = Priority Item
PF = Prio Foundation Item
Description of Violation
is A
Q � S
L
C r
e
U
WU84I
S 1
r r
All krr t ; v
Discussion with PIC:
Corrective Jtctiort Requir®d l
�'
Now ,w„ x
�,u,...� ,..gym.-M.
❑Yes" -
❑ Voluntary ComplianceY ❑ Employee Restriction /
Exclusion
❑ Re-inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other
PIC's Signature: t -. Date: 9
L
10 V1
Inspector's Sig Date:., m
Rev. 11/2016 //� /
29
Com liancewithvariance/ s ecial rocesses / HACCP Plan
3-302.13
3-404.11 TreatingJuice •
Water & ice from aroved source
3-502.11 Variance Requirement
Ice
3-502.12 Reduced Oxygen Packaging Criteria
1 A roved S tem - Souroe
4204.110 B Molluscan Shellfish Tanks
- Qual'
8-103.12 Conformance with Approved Procedures
1 Nondrinkin Water
8-103.13 When a HACCP Plan isuired
1 Alternative Water Supply
_,ad
8-103.14 Contents of a HACCP Plan
GOOD RETAIL PRACTICES hems 30 - 56
30
31
32
�.-r1ea19imva r mwin r =❑
Pasteurized eggs
used where required
3-302.13
Pasteurized Eggs Substituted for Raw Eggs for
Certain Recipes
Water & ice from aroved source
3-202.16
Ice
5-101.11
1 A roved S tem - Souroe
590.006(B)StandaNs
- Qual'
5-102.12
1 Nondrinkin Water
5-104.12
1 Alternative Water Supply
Variance obtained forspecialized processing methods
8-103.11
Documentation of Proposed Variance and
Justification (P)
7.H10 i:4,1 J=10A ill it;KN Ili:H]11
33
Proper cooling methods use; adequate equipment for
temperature control
3-202.17
3-501.11
FrozenFood
Molluscan Shellfish, Original Container
3-501.15
Coolin Methods
590.004(1)
4-301.11
Cooling, Heating, and Holding Capacities,
Equipment IPO
34
Plant food a
rortatel cooked for hot holdin
3-202.19
3-401.13
Plant Food Cookingfor Hot Holdin
35
Approved thawing methods used
Storage or Display of Food in Contact with
Water or Ice
3-501.12
1 TCS Food, Slacking
3-305.11
3-501.13
1 Thawing
36
Thermometers
provided & accurate
3.306 11
4-203.11
3306.12
Temperature Measuring Devices, Food -
Accura IPO
3-306.13 B & C
4-204.112
6-404.11
Temperature Measuring Devices -
Functionali tR,cl
4302.12
4-603.11
Food Temperature Measuring Devices,
Numbers IPO
4-902.11
4502.11 B
Good Repair and Calibration
4902.12
Equipment - Lubricating and Reassembling
Warewashing facilities: installed, maintained & used; test
Cnnn InCYTICI `ATInU
37
C
39
Food properly
labeled; original container
3-202.17
Shucked Shellfish, Packaging & Identification
3-203.11
Molluscan Shellfish, Original Container
3-302.11
Food Storage Containers Identified with
Common Name of Food
590.004(1)
Standards of Identify
3601.12
Honesty Presented
3602.11
Food Labels
I J.1 ATO 219101AS]y
Insects, rodents, & animals not present
2-003.11
Handling Prohibitions -Animals
6-202.13
Insect Control Devices, Design and Installation
6-202.15
Outer Openings, Protected
6-202.16
Exterior Walls and Roofs, Protective Barrier
6-501.111
Controlling Pests
6-501.112
Removing Dead or Trapped Birds, Insects,
Rodents and other Pests
Contamination prevented during food preparation, storage,
and display
3-202.19
Shellstock, Condition
3-303.11
Ice Used as Exterior Coolant, Prohibited as
In redient IPI
3-303.12
Storage or Display of Food in Contact with
Water or Ice
3304.13
Linens and Napkins - Use Limitations
3-305.11
Food Storage - Preventing Contamination from
the Premises
3-305.12
Food Storage, Prohibited Areas
3-305.14
Food Preparation
3.306 11
Food Display Preventing Contamination from
Consumers M
3306.12
Condiments, Protection
3-306.13 B & C
Consumer Self -Service Operations
6-404.11
Segregation / Location - Distressed Items
40
41
42
43
44
45
46
UTENSILS, EQUIPMENT, AND VENDING
47
Personal cleanliness
2-302.11
Maintenance - Fn entails
2-303.11
Prohibition - Jewel
2-304.11
Clean Condition - Outer Clothing
2-402.11
Effectiveness - Hair Restraints
Wiping cloths: ro rl used & stored
3-304.14
Wi in Cloths, Use Limitation
4-101.16
Sponges, Use Limitation
4-901.12
Wiping Cloths, Air Drying Location
Washin fruits &
etables
3-302.15
Washin Fruits and V stables
7-204.12
Chemicals for Washing, Treatment, Storage
and Processing Fruits and Vegetables,
Criteria �
ia:r.r�y:arw,y �.lyrl lya�yia_y
In -use utensils properly stored
3304.12 In -Use Utensils, Between -Use Storage
Utensils, L & linens: properly stored, dried, & handled
Section 4-8
Laundering(except4-803.12
Section 4-9
Protection of Clean Items (except 4-901.12,
4-902, 4-903.12, and 4-904.11
Sin le -use / sin le -service articles: properly stored & used
4-502.12
Single -Service and Single -Use Articles,.
Required Use IPi
4-502.13
Single -Service and Single -Use Articles, Use
Limitations
4-502.14
Shells, Use Limitation
4-903.11 (A) and
(C)Service
Equipment, Utensils, Linens and Single-
and Sin IaUse Articles - Storing
4-903.12
Storage Locations - Prohibited
Gloves uro rl
3 -304.19 -(V) -(D) Gloves, Use Limitation
C
Food &non-food contact surfaces cleanable, properly
designed, constructed & used
3304 16
Using Clean Tableware for Second Portions
and Refills
3304.17
Refilling Ratumables
Section 41
Materials for Construction and Repair
Design and Construction (except 4202.18,
Section 42
4-203,4-204.11, 4-204.110[B), 4-204.112
through 4-204.119)
Equipment, Clothes Washers, Dryers and
4-401.11
Storage Cabinets, Contamination
Prevention - Location
4-402.11
Fixed Equipment, Spacing or Sealing -
Installation
4-501.11
Good Repair and Proper Adjustment -
Equipment
4-501.12
Cutting Surfaces
4-501.13
Microwave Ovens
4-502.11(A)&(C)
Good Repair and Calibration - Utensils and
Temperature & Pressure Maas. Devices
4-603.11
Dry Cleaning - Methods
4-902.11
Food -Contact Surfaces - Lubricating and
Reassembling
4902.12
Equipment - Lubricating and Reassembling
Warewashing facilities: installed, maintained & used; test
strips
4-203.13
Pressure Measuring Devices, Mechanical
Warewashino E ui mem
4204.113
Warewashing Machine, Data Plate
Operation Specifications
4204.115
Ware Machine, Temperature
aashing
Measurin Devices IPO
4-204.116
Manual Warewashing Equipment, Heaters
and Baskets IPO
4-204.117
Warewashing Machines, Automatic
Dispensing or Detergents and Sanitizers
4301.12
Manual Warewashing, Sink Compartment
Requirements "'cl
4302.13
Temperature Measuring Devices, Manual
and Mechanical Warewashin IPO
4302.14
Sanitizin Solutions, Testin Devices
Section 4501.14
Equipment
to 4-501.110
4501.116
Warewashing Eqpt., Chem. San. Conc.
Food Establishment Inspection Form I Page of
The Commonwealth of Massachusetts
City Salem Board Health
120 WWashington Street, Salem MA 01970
978 741-1800
# Violations
Date
Time In
�
Time Out
Priority- Priorityfoundation- Core-
Score (optional)
Establishment Name `U
Risk category
T of O rations
ood Service
❑Retail
❑Residential Kitchen
❑Mobile
❑Temporary
❑Caterer
❑Bed & Breakfast
Market
[]Other:
T of Iinspection
Routine
❑Reinspection
Previous Inspection Date:
[]Pre-Operation
[]Suspect Illness
[]General Complaint
❑HACCP
I ❑Other.
Establishment Address)
Telephone HACCP YIN
2_
Ower(`( G Permdk.
Person-IInn-Charge (PIC) / Food Safety Training /
Q-
Inspector W E[]Fanners
81
-FOOEIBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH INTERVENTIONS!
nn PH. _tip
Circle designated carnpliance, argue (IN, OUT, WO, WA) for each numbered item Met, W m appropriate bs: for COS and/or R
IN=in compliance OUT =not in compliance WO=not olservetl WA=nota Iloablo COS=cerrected on-site dumb i R=reiviolate
liance Status COS R Compliance Status COS R
COW--
17 IN UT
Proper dlsposibon of mumed, prev ously
served, reconditioned 8 unsafe food
1 IN UT PlC present, demonshntes knowledge. and "-
dams aatios tin ;aim: ,.:` ;a Jimer Y Temperature Control for Safety ya E.;;k.
2OUT WA Cortese! Fred Protection Manager 18 OUT WA WO Proper cooling time & temperatures3uc
A 'a;.: Employee Health ... .::_
19 N)OUT WA WO Proper reheating procedures for hot holding
3
Management, fad employee and conditional....
I OUT employee; knoWedge, responsibilities and
reporting
20 OUT WA N/O Proper noting time and temperature
4
1 OUT Proper use of restriction end exdudm
21 OUT WA N/O Proper hot holding temperature
5
Procedures fo responding to wmNng and
1OUT
dianheal events
22 a Our WA WO Proper Cott holding temperature
Good Hygienic Pr&ctices= =-u i� :s- gid•` --tr"=�-":i 23 our WA N/O Proper dale making and disposition
6 OUT O Proper eating, testing, drinking, ortobacm use 24 IN OUT Tim as a Public Health Control
7 IN OUT 1470 1 No discharge been eyes, nose, and mouth i:Onakkmeir Adviso
=''M` ::u Preventing Contaminationb Hands ' r-- :': 25 IN WA Consumer adwsory Imewded for ra.I
k Kms` ...__..._:. g Y .�. ...„a ..._ __.,..._. undewoked food
8 I Our coo Honda dean & popedy washed Requirements for Hi 1' Suscetible` Iationa. HSP
9 IN UT WA WO No tram hand cerhtad coin RTE food 26 IN OUT A Pesteuraed Jones used; prohibited fads not
oReretl
Adequate handwashin sinks properly supplied
10 I aur and accession g Food t Color diUV@s aid TOXic Sub8tanlxs, `,; _, --rk I ,
_.
roved Source �+'x:[ru 4ta:J:;eydnuf: :te a.._,.... 27 IN ouT._:.: Food oddities: approved&property used
11 IN OUT Food obtained from approved source 1 26 1 IWOUT WA I TOdc sub. property identified. stored &used
— =`: ?ice afr,
12 IN OUT WA O Foal received at pmConformance-with roved Procedures v_-
_. ,,:- .:
=�d•'= u:
%r
13 1 our Fuad received in good cend'Non, safe, 8 29 IN Otrr A Complance with variance / specie reed procoss
13 unadulterated / HACCP Plan
14IN OUT A WO Required records mounter shegdacic tags,
site dasbuctiOn Risk Factors ate important practices or procedures identified as the most
ni. k..�: •,>•. �'•� Protection from Contaminationti=--=' N_ prevalent contributing factors of foodbome illness or injury. Public health
15tar WA Wo Fad separated and protected interventions are control measures to prevent foodbome illness or injury.
16 IN U WA Food-contact surfaces; cleared & sanitized
..;'_:;.GOOD RETAIL PRACTICES.,z., ;: KTMIHM,:t<.
Good Relaid Practices are preventative measures to coning Me addition of pathogens, chemicals, asul physical objects into foods.
Mark'X” in bcr If numbered item's not in compliance Mark Win ropriale box for COS angler R COS = corrected ohsire during inspection R = t violation
Compliance Status I COS R I Compliance Status COS R
Safe Food and water-=.:u'-..,._ n,. � hid._ hhrr< . ,;; .T.: .,. ;;; - .vProper Use of lltensfls .:
30 1 Pasteurized eggs used where required 43 1 h,use utensils prvpedy stored
31 Water &ice from approved sauna 44 Utosils, equipment & linens: property stoned, dined, & handled
32 Variance obtained ter specialized processing Met hods 45 Singleuse / inglesenice articles: property some! & used
xw= u. a.==T ;. Food Temperature Control 46 Gloves used property
w _. ..
Proper tooting methods used; adequate equipment for t r . _...,._ .._ .
33 temperaturecontrw :-:, `- :lid `.:' , ! Utensils,'Equlpment..and Vending ?T' . :. .:::,,�:;,:•..
Food & non-food contact surfaces cleanable, property designed.
34 Plant fad property cooked for hot holding 47 constructed & used
35 Approved thawing methods used 48 Warewashmg facilities: ingested, maintained, & used; test strips
36 Thempmemrs provided & accurele, 49 1 Non-food contact surfaces dean
Food Identification .., ,,. Physical Facilltles F:
37 Food property labeled; original container
50 Hot & cold water available; adequate pressure
= �:. h ==:=••::.; Prevention of Food Contarniturdon
51 Plumbing instated; proper baddlow devices
38 1 Ircu ccs, rodents, & animals not present 52 Sewage & waste water property disposed
ed
39 Contamination pmventetl during food preparation. storage and 53 Toilet features: property mnsWcfed, supplied, & cleaned
splay
cleanliness 54 Garbage & reuse properly disposed; facilities maintained
41 coping cloths: properly used & stared 55 Physical facilities installed. maintained. & clean
42 1 Washing fruits & vegetables 56 Adequate ventitatioh & lighting; designated areas used
57 SPECULL REQUIREMENTS/OTHERS ❑Antichokin 590.009 []Tobacco 590.009 ElAllergen Awareness 590.009G ❑Local law regulation []Other
Official Order for Correction: Based on an inspection today, the items checked indicate violations of me Board of Hearer Food Regulation 12013 Federal Food Cade. This rep rt, when signed below by
a Board of Health member or its agent crest urs an order of the Board of Health. Failure to tong violations cited in this report may resuft in suspension or rewration of the food establishment permit
and cessation of food astablish operatics. If erg "Is oder, you here a right u a heating. Your request must be in writing and submitted b me Board of Health at the above address within
ten 10 ralerdar da Of mcei this er.
PIC's Si nature:
Print: 4 A, i1W W I Date:':
Inspector's SI nae
Follower O (chole one)Follow-up Date, if a licable:
FOODBORNE ILLNESS RISK FACTORS AND PUBLIC HEALTH
INTERVENTIONS (Items 1-29)
SUPERVISION
1
C
2-101.11 N
Assignment
590-003(A)(1)
Assi nment
2-102.11(A),(B),
and (C)(1),(4-16)
Demonstration (PQ
590.003(B)
Demonstration
2-103.111 A-0
Person-in-Charge Duties
2-102.12(A)
Certified Food Protection Manager
590.003 A 2-4
Ass' nment
EMPLOYEE HEALTH
3
2-102.11(C)(2), Demonstration lPfl
(3), and 17
2-301.12
•
2-103.11 M Person -in -Char a Duties
When to Wash
2-201.11(A)(1), Responsibility of the Permit Holder, PIC, and
(B)(C) Conditional Employees RM
Where to Wash
590.003(C) FC2-201.11 A Health Status -Employee is Ill
Hand Antiseptics
590.003(F) Responsibility o1 a Food Employee or Applicant
to Report to the PIC IPI
Preventing Contamination from Hands
590.003(G) Reporting by the PIC
4
2-201.11(D) and Responsibility of the Permit Holder, PIC, and
(F) Conditional Employees - Responsibility of the
PIC to Exclude or Restrict
Handwashin Sinks - Numbers & Ca es
5-204.11
2-101.12 Exclusions and Restrictions
5-205.11
590.003(0) Exclusions and Restrictions
6-301.11
2-201.13 Removal, Adjustrnent, or Retention of
Exclusions and Restrictions IPI
6-301.12
590.003E Removal or Exclusions and Restrictions
51
2-501.11 Clean-up of Vomiting and Dianheal Events
GOOD HYGIENIC PRACTICES
6 2-001.11 Eatin , Drinkin , and UsingTobacco
3-301.12 Preventin Contamination When Tastin
7 2-401.12 1 Discharges from the Eyes, Nose, and Mouth
PREVENTING CONTAMINATION BY HANDS
8
9
10
12
13
14
2-301.11
Clean condition -Hands and As
Arms
2-301.12
Cleanin Procedure
2-301.14
When to Wash
2-301.15
Where to Wash
2-301.16
Hand Antiseptics
3-301.11 (B -C)
Preventing Contamination from Hands
5-202.12
Handwashin Sinks, Installation
5-203.11
Handwashin Sinks - Numbers & Ca es
5-204.11
HanaWashin Sinks - Location &Placement
5-205.11
Using a Handwashing Sink - Operation and
Maintenance A
6-301.11
Handwashin Cleanser, Availabil'
6-301.12
Hand D inq Provision
6-301.14
Handwashing Signage
APPROVED SOURCE
Food obtained from an approved source
3-201.11(A) and
D -G
Compliance with Food Code IPA
590.004(A)
Food Prepared in a Private Home IPI
590.004(B)
Parka Food, Labelin
3-201.14
Fish
3-201.15
Molluscan Shellfish
3-201.16(B)
Wild Mushrooms
590.004 C
Wild Mushrooms - Identification Required"
3-201.17
Game Animals
3-202.13
E s
3-202.14
ilk Products, Pasteurized
590.004(D)
;= Products
3-202.110
Juice Treated - Commeroiall Processed
590-006(A)
Bottled Donkin Water
Foodceived
romerature
3-20211
Teture
Food received in
ood condition, safe, and unadulterated
3-101.11
Safe Unadulterated
3-202.15 1
Package Integrity
eq d. records available: site destruction
3-202.18
tShe
Sheock
3-203.12
Shlstock, Maintaining Identification
3-402.11
Parasite Destruction
3-402.12 1 Records, Creation & Retention _
PROTECTION FROM CONTAMINATION
15
Food separated and protected
time and temperature
3-302.111
Packaged and Unpackaged Food -
Separation, Packaging, & Segregation (P -G)
Raw Animal Foods - Cooking
3-304.11
Food Contact with Equipment, Utensils, and
Linens M
Microwave Cooking
3-304.15(A)
Gloves, Use Limitation
16
Food -contact surfaces;
cleaned and sanitized
rocedures for hot holdin
4-501.111
Manual Warewashing Equipment, Hot
Water Sanitization Temperatures IPI
rReheating for hot holding
4-501.112
Mechanical Warewashing Equipment, Hot
Water Sanitization Tem ratures (P)
7-204.11
4-501.114
Manual and Mechanical Warewashing
Equipment, Chemical Sanitization -
Tempereture, pH, Concentration and
Hardness IPPB
21
4-601.11A
()
Equipment, Food -Contact Surfaces,
Nonfood -Contact Surfaces and Utensils
7-205.11
4-702.11
Before Use After Cleaning - Frequency
22
4-703.11
1 Hot Water and Chemical - Methods
17
Proper disposition of returned, previously served,
reconditioned and unsafe food
3-501.16B
3-306.14
Retumed Food and Re -Service of Food
Proper date marking and disposition
3-701.11
Discarding or Reconditioning Unsafe
Adulterated, or Contaminated Food (4)
TIME -TEMPERATURE CONTROL FOR SAFETY CS FOOD
18
Consumer Advisor
25 1 Consumer advisory provided for raw/ undercooked food
Consumption of Animal Foods that are
3-603.11 Raw, Undercooked, or Not Otherwise
Processed to Eliminate Pathogens IPO
HIGHLY SUSCEPTIBLE POPULATION.
26
Pasteurized foods used; prohibited
Proper cooking
time and temperature
I Pasteurized Foods, Prohibited Re -Service,
and Prohibited Food IP•cI
3-401.11
Raw Animal Foods - Cooking
28 Toxic substances:
3-401.12
Microwave Cooking
Identifying Information - Original
Containers (M
3-401 14
Non -Continuous Cooking of Raw Animal
Foods (P.M
19
Pro er reheating
rocedures for hot holdin
Restriction - Presence and Use
3-403.1 T
rReheating for hot holding
20
Proper cooling time and temperature
7-204.11
3-501.14
1 cooling
21
r hot)(hold
e
7-205.11
16(A 1
Tre-H
CSur
ot Holding
22
Proper cold holding temperature
Rodent Bait Stations
3-501.16 A 2
TCS Food - Cold Holdin
3-501.16B
Eggs - Cold Holdin
23
Proper date marking and disposition
3-501.17
RTE TCS Food, Date Markin
3-501.18
RTE TCS Food, Disposition
24
Time as a Public Health Control PHC
3-501.19
Time as a Public Health Control
590. H
TPHC- BOH Approval Required
Consumer Advisor
25 1 Consumer advisory provided for raw/ undercooked food
Consumption of Animal Foods that are
3-603.11 Raw, Undercooked, or Not Otherwise
Processed to Eliminate Pathogens IPO
HIGHLY SUSCEPTIBLE POPULATION.
26
Pasteurized foods used; prohibited
Food / Color Additives and Toxic Substances
27 Food additives: a
foods not offered
3-801.11(A),(B),
C , E , and G
I Pasteurized Foods, Prohibited Re -Service,
and Prohibited Food IP•cI
Food / Color Additives and Toxic Substances
27 Food additives: a
roved and properly used
3-202.12
Additives
3-302.14 1
Protection from Unapproved Additives
28 Toxic substances:
properly identified, stored and used
7-101.11
Identifying Information - Original
Containers (M
7-102.11
Common Name - Working Containers
7-201.11
Separation - Stora e
7-202.11
Restriction - Presence and Use
7-202.12
Conditions of Use
7-203.11
Poisonous/ Toxic Container, Prohibitions
7-204.11
Sanitizers, 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
Monitoring IP.o1
Rev. 11/2016 �
Food Establishment Inspection Form I
Page of
The Commonwealth of Massachusetts
City of Salem Board of Health
120 Washington Street, Salem MA 01970
978 741-1800
Establishment Name:
`` // p,
V-
Date 9/7�Fj
._�F = , . mTEMPERi4TURE
OBSERVATIONS - t:. mv
Item / Location Tem
° Item / Location Tem Item / Location Tem "F
OBSERVATIONS AND/OR CORRECTIVE ACTIONS
Violations fated
in this report
must be corrected within the time frames or as stated in Section 8405.11 of the Food Code
Item
Number
Code Section
P - Priority Item
PF =Priori Foundation Item
Description of Violation
,
r f
gk°
u k,Lo
v] 0r
41
r
6
r
I
16
r
-,D)Awas q r cjllo
S
l f
�1
P
I's
r
$!J
O/ an: t
eo
S
s f ,
R
Discussion with PIC:
Corrective Action Required P,.i
ONo, Nir ME
Was qqppi, ;
❑ Vol tary Compliance
❑ Employee Restriction /
Exclusion
LVORe-Inspection Scheduled
❑ Emergency Suspension
❑ Embargo
❑ Emergency Closure
❑ Voluntary Disposal
❑ Other
PIC's Signature:
- -
Date:
Inspector's Signatu
Date:.
712 7
Rev. 11/2016 �
29
Com liancewith riance/special rocesses / HACCP Plan
Pasteurized Eggs Substituted for Raw Eggs for
Certain Recipes t"
3404.11 TreatingJuice
3-202.16
-3-502.11 Variance Requirement
5-101.11
3-502.12 Reduced O , en Packaging Criteria
590.006 B
4-204.110 B Molluscan Shellfish Tanks
5-102.12
8-103.12 Conformance with roved Procedures
5-104.12
8-103.13 When a HACCP Plan is R wired
Variance obtained for specialized processing methods
8-103.14 Contents of a HACCP Plan
GOOD RETAIL PRACTICES Items 30-56
SAFE FOOD AND WATER
30
31
32
Pasteurized s used where aired
3-302.13
Pasteurized Eggs Substituted for Raw Eggs for
Certain Recipes t"
Water & ice from approved source
3-202.16
Ice
5-101.11
Approved System - Souroe TT -
590.006 B
Standards - Qual'
5-102.12
Nondrinkin Water
5-104.12
Alternative Water Su I
Variance obtained for specialized processing methods
8-103.11
Documentation of Proposed Variance and
Justification (r7
37
Food properly
Is led; original container
3202.17
Shucked Shellfish, Packaging & Identification
3-203.11
Molluscan Shellfish, Original Container
3-302.11
Food Storage Containers Identified Wth
Common Name of Food
590.0040)
Standards of Identify
3-601.12
Honestl Presented
3-602.11
Food Labels
PREVENTION OF FOOD CONTAMINATION
38
Insects, rodents, &animals not resent
39
2403.11
Handling Prohibitions -Animals
6-202.13
Insect Control Devices, Design and Installation
6-202.15
Outer Openings, Protected
6-202.16
Exterior Walls and Roofs, Protective Barrier
6-501.111
Controlling Pests
6-501.112
Removing Dead or Trapped Binds, Insects,
Rodents and other Pests
Contamination prevented during food preparation, storage,
and display
3202.19
Shellstock, Condition
3-303.11
Ice Used as Exterior Coolant, Prohibited as
Ingredient r"
3-303.12
Storage or Display of Food in Contact with
Water or loo
3304.13
Linens and N ins - Use Limitations
3-305.11
Food Storage - Preventing Contamination from
the Premises
3-305.12
Food Storage, Prohibited Areas
3-305.14
Food Preparation
3-306.11
Food DisplaPreventing Contamination from
Consumers)n
3306.12
Condiments, Protection
3-306.13(B)&(C)
Consumer Self -Service Operations
6-404.11
Segregation / Location - Distressed Items
40
41
42
43
44
45
46
47
C
Personal cleanliness
2-302.11
1 Maintenance -Fn emails
2-303.11
Prohibition -Jewel
2-304.11
1 Clean Condition - Outer Clothing
2-402.11
1 Effectiveness - Hair Restraints
Wiping cloths: rorl used & stored
3-304.14
Wi ping Cloths, Use Limitation
4-101.16
1 Sponges, Use Limitation
4-901.12
1 Wiping Cloths, Air Drying Location
Washing
fruits & vegetables
3302.15
Gloves used roart
Washing Fruits and Vegetables
7-204.12
4-402.11
Chemicals for Washing, Treatment, Storage
and Processing Fruits and Vegetables,
Criteria r"I
PROPER USE OF UTENSILS
In -use utensils pperIV stored
Tin -Use In -Use Utensils, Between -Use Storage
Utensils, eglyt. & linens: properly stored, dried, & handled
Section 4-8
1 Laundering (except 4-803.12
Section 4-9
Protection of Clean Items (except 4-901.12,
4902, 4-903.12, and 4-904.11
Sin le -use / sing! rvice articles: properly stored & used
4502.12
Single -Service and Single -Use Articles,
Required Use m
4-502.13
Single -Service and Single -Use Articles, Use
Limitations
4-502.14
Shells, Use Limitation
4-903.11 (A) and
(C)
Equipment, Utensils, Linens and Single -
Service and Single -Use Articles - Storing
4-903.12
Storage Locations - Prohibited
Gloves used roart
3-304.15 B - D Gloves, Use Limitation
UTENSILS. EQUIPMENT. AND VENDING
Food & non-food contact surfaces cleanable, properly
designed, constructed & used
3-304.16
Using Clean Tableware for Second Portions
and Refills
3-304.17
Refilling Retumables
Section 4-1
Materials for Construction and Repair
Design and Construction (except 4-202.18,
Sklion 4-2
4-203,4-204.11, 4-204.110[B], 4-204.112
through 4-204.119)
Equipment, Clothes Washers, Dryers and
4-401.11
Storage Cabinets, Contamination
-
Prevention - Location
4-402.11
Fixed Equipment, Spacing or Sealing -
Installation
4-501.11
Good Repair and Proper Adjustment -
Equipment
4-501.12
Cutting Surfaces
4-501.13
Microwave Ovens
4-502.11(A)&(C)
Good Repair and Calibration - Utensils and
Temperature & Pressure Maas. Devices
4-603.11
Dry Cleaning - Methods
4-902.11
Food -Contact Surfaces - Lubricating and
Reassemblin
4-902.12
Equipment - Lubricatin and Reassembling
Warewashing facilities: installed, maintained & used; test
strips
4-203.13
Pressure Measuring Devices, Mechanical
Warewashing Equipment
4204.113
Warewashing Machine, Data Plate
Operation Specifications
4-204.115
Warewashing Machine, Temperature
Measurin Devices ran
4-204.116
Manual Warewashing Equipment, Heaters
and Baskets rvn
4-204.117
Warewashing Machines, Automatic
Dispensing or Detergents and Sanitizers
4301.12
Manual Warewashing, Sink Compartment
Requirements rn.cq
4-302.13
Temperature Measuring Devices, Manual
and Mechanical Warewashm I
4-302.14
Sanitizing Solutions, Testing Devices im
Section 4501.14
Equipment
to 4501.110
4501.116
Warewashing Eqpt., Chem. San. Conc.
Food Establishment Inspection Form Page of
The Commonwealth of Massachusetts
City of Salem Board of Health
120 Washington Street, Salem MA 01970
978 741-1800
Establishment Name:
�` < PX
Date:
OBSERVATIONS AND/OR CORRECTIVE ACTIONS
Violations ated
in this report must be corrected
within the time frames or as stated in Section 8-405.11 of the Food Code
Item
Number
Code Section
P = Priority Item
PF = Priority Foundation Item
Description of Violation
t n
r
G
r o t
r=
1 7-
ko
-
v ^ a 4 Cam±er laek5
44 R
�
f f
C P
be,
c
PIC's Signature: T Date:
Inspector's Signature Date:
Rev. 11/2016
49 Non-food contact surfaces clean
4-601.11(8)&(C) Equipment, Food -Contact Surfaces, Nonfood -
Contact Surfaces, and Utensils
4-602.13 1 Nonfood Contact Surfaces
PHYSICAL FACILITIES
50
Hot & cold water available; adequate pressure
Additional Re uirements and Restrictions
5-103.11
Ci -Ou ' and Availabili
Food Preparation without a Water System
5-103.12
Pressure
Food Preparation with a Water System
5-104.11
S tem - Distribution, Delivery, & Retention
51
Plumbing installed; proper backflow devices
(8)
5-101.12
System Rushing and Disinfection
(9)
Section 5-2
Plumbing System (except sections 5-202.12, 5-
302.11, 5-203.12, 6-204.11, and 5-205.11)
(10)(a)
Section 5-3
Mobile Water Tank and Mobile Food
Establishment Water Tank
52
Sews a &waste water properly disposed
48
Section 5-4I
Sewage, Other Li uid Waste, and Rainwater
53
Toilet features: p operly constructed, supplied, and cleaned
Toilet Facilities
5-203.12
Toilets and Urinals - Numbers & Capacity
Base of Operations
5-501.17
Toilet Room Receptacle, Covered
Servicing Areas, Overhead Protection
6-202.14
Toilet Rooms, Enclosed
Mobile Identification Information
6-302.11
Toilet Tissue, Availability
Floors, Walls, and Ceilings
6-402.11
Toilet Room - Convenienti Located
Sewa e
6-501.18
Cleaning of Plumbing Fixtures
ANTI -CHOKING PROCEDURES -590.009 E
6-501.19
Closing Toilet Room Doors
64
Garbe use
pro MY disposed; facilities maintained
Section 5-5
Refuse, Recyclables, and Retumables
6-202.110
Outdoor Refuse Areas, Curbed and Graded to
Drain
55
Physical facilities
installed, maintained, & clean
4-301.15
Clothes Washers and Dryers
4-401.11(C)
Equipment, Clothes Washers and Dryers, and
Storage Cabinets, Contamination Prevention
4-803.13
Use of Laundry Facilities
6-101.11
Surface Characteristics - Indoor Areas
6-102.11
Surface Characteristics - Outdoor Areas
Section 6-201
Cleanability
6-202.17
Outdoor Food Vending Areas, Overhead Prot.
6-202.18
Outdoor Servicing Areas, Overhead Protection
6-202.19
Outdoor Walking and Driving Surfaces, Graded
to Drain
6-202.111
Private Homes and Living or Sleeping
Quarters, Use Prohibition IPi
6-202.112
Living or Sleeping QuartersSeparation
6-501.11
Repairing - Premises, Structures, Attachments,
and Fixtures - Methods
6-501.12
Cleaning, Fr uency and Restrictions
6-501.13
Cleaning Floors, Dustless Methods
6-501.15
Cleaning Maintenance Tools, Preventing
Contamination TO
6-501.16 1
Drying Mops
6-501.17
Absorbent Materials on Floors, Use Limitation
6-501.113
Storing Maintenance Tools
6-501.114
Maintaining Premises, Unnecessary Items and
Clutter
56
Adeguafte ventilation & lighting; designated areas used
4-202.18
Ventilation Hood Systems, Filters
4-204.11
Ventilation Hood Systems, Drip Prevention
4-301.14
Ventilation Hood Systems, Adequacy
6-202.11
Light Bulbs, Protective Shielding
6-303.11
Intensity - Lighting
6-604.11
Mechanical - Ventilation
6-305.11
Designation - Dressing Areas and Lockers
6-403.11
Designated Areas - Employee Accommodation
for Ealing / Drinking / Smoking
6-501.14
Cleaning Ventilation Systems, Nuisance and
Discharge Prohibition
6-501.110
Using Dressing Rooms and Lockers
SPECIAL
REQUIREMENTS/ OTHER
CATERERS - 590.009(A)
ji57 1 Base of O rations
57 2 Notification
MOBILE FOOD OPERATIONS - 59n_M9/RI
57
1
Additional Re uirements and Restrictions
31
2
Food Preparation without a Water System
57
3
Food Preparation with a Water System
57
4
Single -Service Articles for Use by Consumers
39
5
Condiments, Protection
33
6
Refrigeration - Capacity and Functionality
39
(6)
Food in Contact with Water or Undrained
Ice, Prohibited
57
4
Bulk Food / Hot Food, Sale and Disposibon
10
(8)
Handwashing Sinks - Number, Capacity,
Cleanser (PI)
47
(9)
No Bare Hand Signage for Consumer Sell -
Service Im
Service
47
(10)(a)
Equipment, Contamination Prevention -
Location and Installation
44'
10 b
E ui ent, Protection Against Contam.
48
(10)(c)
Warewashing Equipment, if Required
53
11
Toilet Facilities
57
12
Base of Operations
55
13
Servicing Areas, Overhead Protection
57
14
Mobile Identification Information
TEMPORARY FOOD ESTABLISHMENTS - 590.009(C)
57
1
Additional Requirements and Restrictions
57
2
Food Preparation
2
3
Certified Food Protection Manager
31
4
Ice In
10
5
Handwashinq Facilities
47
(6)(a)
Equipment, Contamination Prevention -
Locabon and Installation
44
(6)(b)
Equipment Protection Against Contam.
48
(6)(c)
Warewashing Equipment, if Required
57
(7)
Single -Service Articles, Required if
Warewashing Facilities Not Provided (Pn
50
8
Potable Water - Quantity and Pressure
33
9
Refrigeration - Caaci and Functionality
17Hot
(10)
Food - Discarding after Reheating for
Holdin IPI
52
11
Sewa e
55
12
Floors, Walls, and Ceilings
RESIDENTIAL KITCHENS - 590.009(D)
Beds & Breakfasts - 590.0090)(11
57
a
Permit Required
57
b
Inspection Requirements
57
(c)(1)
Prepare and Protected in Accordance with
Code
57
(c)(2)
Storage to Prevent Contamination
57
(c)(3)
Prohibited Acts - Reheating, Hot Holding
>2 Hours, Service of Leftovers run
21
(c)(4)
Hot Holding
22
c 4
Cold Holding
33
c 4
Hot and Cold Holding I Iui ent, Provided
Residential Kitchens: Retail Sale -590.009(D)(2
57
a Permit Required; Plan Review Exem
57
(b) Non -TCF Final Product; Wholesale
Prohibited; Access by Immediate Famil
General Reouirements - 590.009(D)(31
11
a
Food Obtained from an A roved Souroe
55
a
Personal Food Su lies, Se rated
3/8
b
Employee Health / Personal HVqa
10
c
Hand Cleanser and Hand D 'n , Avail
53
d
Toilet Room
47
e
Eqpt. & Utensils - Design, Constmc & Maint
47
Food -Contact Surfaces
16
Cleaning and Sanitizing Eqpt. and Utensils
38
h
Insect -Proof / Rodent -Proof
38
(i)(1)
Animals, Prohib. dudna Prep & Service
55
(i)(2)
Laundry Facilities - Location
57
(i)(3)
Cooking Facilities Inaccessible to Guests
54
Garbage Receptacles
50
(k)
Water Su ply - Approved Source and
Pressure m
52
I
Sewa e
57
ANTI -CHOKING PROCEDURES -590.009 E
57
TOBACCO PRODUCTS -590. G
FOOD ALLERGY AWARENESS REQUIREMENTS-590.009(Gl
57
1
Poster
57
2
Menu Notice
57
2 b
Menu Notice - Menu Board
57
3
Food Allergen Awareness Training
57
4
Exemptions
Rev. 08/2014
Kimberley Driscoll
Mayor
City of Salem, Massachusetts lu
Board of Health
120 Washington Street, 4th Floor, Salem, MA 01970
Tel. (978) 741-1800 Fax. (978) 745-0343 'F:
Prevent. Promote. Protect,.
health@salem.com
Larry Ramdin, MPH, RENS, CHO
Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2017
Permit Number: FM -17-39
Permit Type: Food Establishment 25-99 seats
Goods 8 Services: Food Service: >99
Name of License Holder: Chartwells - Salem State University
Name of Food Establishment SSU - Diner
Address of Food Establishment _ 11
Restrictions:
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2017 unless sooner suspended or revoked.
Permit Fee: $520.00
Effective: 1/1/2017
P—
Larry Ramdin, MPH, RENS, CHO
Health Agent
0
KIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM,
MASSACI IUSETTS
BOARD OF HEAiala
120 WASHINGTON STREET, 4" FLOOR
'I'LL. ()78) 741-1800 FAX (978) 745-0343
Iramdinowsalem.com
Pntiltwc,Health
LARRY RAMDIN, RS/RBHS, CHO, CP -FS
IIHAL'I'F[ AGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: Chartwells SSU Dining
2) Establishment Address: 352 Layfayette Street, Salam, MA 01970
3) Establishment Mailing Address (If different): 2400 Yorkmont Road / Licensing, Charlotte, NC 28217
4) Establishment Telephone No: 978-542-7290
5) Applicant Name & Title: Richard J. Rossitch, Assistant Secretary
s) Applicant Address: 2400 Yorkmont Road / Legal, Charlotte, NC 28217
7) Applicant Telephone No: 24 Hour Emergency No: Email:
8) Owner Name & Title (if different from applicant): Compass Group USA, Inc. dba Chartwells
9) Owner Address (if different from applicant):
10) Establishment Owned by:
An association
A corporation
An individual
A partnership
Other legal entity
11) If a corporation or partnership, give name, title and home address of
officers or partner.
Name Title Home Address
see officer listing attached
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manaer, etc.
Name & Title:
George Lua, Chef Manager
Address:
352 Lafaette Street, Salem, MA
Telephone No:
978-580-6452 Fax: 978-542-6833 Email: george.lue@compass-usa.com
Emergency Telephone No:
978-580-6452
13) District or Regional Supervisor (if applicable)
Name & Title:
John Hayes. RDM
Address:
352 LaFayette St.
Telephone No:
978-542-7290 Fax: 978-542-6833 Email:John.hayes@compass-usa.com
Check #: Date: - Amount: VC, —
10-0 fit
Food Establishment Information
14) Water Source: Municipal
15) Sewage Disposal: Municipal
DEP Public Water Supply No: ( if
applicable)
.
Mon-Thurs; 7:OOa - 7pm
16) Days and Hours of Operation:
Fri; 7am - 2 m
17) No. of Food Employees: 40
18) Name of Person in Charge Certified in Food Protection Management:
e Geor Lua, Cert. #12155252, ex 3/17(2020
Required as of 101112001 in accordance with 105 CMR 590.003(A) g p•
19) Person;Trained in Anti -Choking Procedures ( if 25 seats or more): N Yes
No
20) Location:
22) Establishment Type (check all that apply)
(check one)
❑ Retail ( Sq. Ft) -
❑ Caterer
XPermanent Structure
)b Food Service — ( Seats)
❑ Frozen Dessert Manufacturer
Mobile
❑ Food Service — Takeout
❑ Residential Kitchen for Retail Sale
❑ Food Service — Institution
❑ Residential Kitchen for Bed and
( Meals/Day)
Breakfast Home
❑ Food Delivery
.................................:............................................Breakfast
❑ Residential Kitchen for Bed and
Establishments......................
21) Length Of Permit:
(check one)
RETAIL STORE
RESTAURANT
Annual
M Less than 1000sq.ft. $ 70
0 Less than 25 seats $140
Seasonal/Dates:
13 1000.10,000sq.ft. $280
0 Residential Kitchens $140
❑ More than 10,000sq.ft. $420
1x15-99 seats $
1Pore than 99 seats 420
. . ....................................................................................................-- .................
❑ Bed & Breakfast/Childcare Services /Nursing Home $100
Temporary/Dates/Time:
.......--....................................
ADDITIONAL PERMITS
.........................................
❑ MAKE ICE CREAM, YOGURT/SOFT SERVE
$25
_ -
❑ PASTURIZATION
$25-
❑ ALL NON-PROFIT*
$25
*Including, church kitchens, state funded childcare 8 private club
23) Food Operations:
Definitions: PHF— potentially hazardous food (time/temperature controls required)
Non-PHFs — non -potentially hazardous
food (no time temperature controls required)
(check all that apply):
RTE— ready -to -eat foods Ex. sandwiches salads muffins which need no further processing
Sale of Commercially
PHF Cooked to Order
Hot PHF Cooked and Cooled or Hot Held
x Pre-packaged Non-PHFs
x
x for More Than a Single Meal Service
Sale of Commercially
Preparation of PHFs For Hot And
PHF and RTE Foods Prepared For Highly
x Pre-packaged PHFs
x Cold Holding for Single Meal Service
Susceptible Population Facility
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended to be
Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially
Customer Self -Service
Use of Process Requiring A Variance
Processed Foods for
and/or HACCP Plan (including bare hand
x Service Within 4 hours
x
contact alternative, time as public health
control.
Customer Self -Service of
Ice Manufactured and Packaged for
Offers Raw or Undercooked Food of
Non-PHF and Non-
Retail Sale
Animal Origin
Perishable Foods Only
x Preparation of Non-PHFs
Juice Manufactured and Packaged for
Prepares Food/Single Meals for Catered
Retail Sale
Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage, Out of Date
or Reconditioned Food Total Permit Fee: $520.00
Payment is due with application
I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
complywith 105 CMR 590.000 and all other applicable law. I have been instructed bythe Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: 56-1574931
26) Signature of Individual or Corporate Name: Compass Group USA, Inc. dba Chartwells
COMPASS GROUP USA, INC. PRINCIPAL OFFICERS/DIRECTORS
Name/Title
Residence/Phone No.
Adrian Llewelyn Meredith
5728 Canter Oaks Drive
President and Chief Financial
Waxhaw, NC 28173
Officer/Director
914.522.0641
Charles Palmer Brown
9705 Waterton Court
Executive Vice
Huntersville, NC 28078
President/Director
704.820.8263
Jennifer Lea McConnell
144 S. Canterbury Road
Executive VP, General Counsel
Charlotte, NC 28211
& Secretary
704-595-3550
Daniel Malcolm Thomas
2508 Maybank Drive,
Treasurer
Charlotte, NC 28211
704.910.6677
Kristin Elizabeth Briotte
54 Magnolia Avenue
Assistant Secretary
Larchmont, NY 10538
914/833-3549
Deborah Kay Delano
5101 Old Plantation Lane
Assistant Secretary -Tax
Charlotte, NC 28226
704/541-5855
Richard James Rossitch
9501 Brandemere Court,
Assistant Secretary
Charlotte, NC 28210
704/544-6877
Jan. 9. 2017 1:25PM
UESTIONAIRE-GREASE TRAPS 2016
I. NAME OFESTABLISHMENT:A� "
2. ADRESS OF ESTABLISHMENT: 3S'j
3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP?
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS :�S rA S
No -0229 P. 16
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY
AN OUTSIDE CLEANING SERVICE? au+ SId &,,�C,
6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP?
7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM OUR
ESTABLISHMENT? r /,AS�. I�P+vi�lS.
8. WHAT 15 THE DATEOF YOU LAST INVOICE FROM THE REMOVAL FIRM?
6-