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STAPLES THE OFFICE SUPER STORE - ESTABLISHMENTStniversal oneTm nho"! 1-600-'56-4�,o ftglkf IAI offlrn Surer fo doe Italic! Df�ut Cl0 t�K�t d �.c��l�t Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: File Number: BHF -2004-000323 LOCATED AT: Kimberley Driscoll Mayor Staples the Office -Superstore 500 Staples Drive c/o Taxes & Licenses Framingham MA 01702 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2011-0047 Jan 1, 2011 Dec 31, 2011 $70.00 Total Fees: $70.00 PERMIT EXPIRES December 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 iN4AYOR DAVID GREENB Aum, RS ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"' FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DCRrr•,Nt;n l(a tinr.cnt. COM 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT U NAME OF ESTABLISHMEN TEL # t L 0� ` /I��1��//� ' ��y7 ADDRESS OF ESTABLISHMENT � $�C_ FAX It _-,�� / `�'�_ - 0 MAILING ADDRESS (if differ U U 4 , wln n� a.nc� Q EMAIL - Business: S Website: OWNER'S ADDRESS CERTIFIED FOOD MANAGER'S (Required in an establishment where CERTIFICATE#(S) EMERGENCY RESPONSE PERSON HOME TEL # HOURS OF OPERATION `� q Please write in time of day. For example llam-11pm) O t i TYPE OF ESTABLISHMENT E check onl RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 �1 RESTAURANT YES (Outdoor Stationary Food Cart $210) less than 25 seats =$1417 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YESNI O / $100 CHILDCARE SERVICESMURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YESNO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT (such as church kitchens) YES $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C. Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax etums and paid a ate taxes require er � IV —n. A _ 1 r I. 0 i (54-,4 1--)-( ' /1 <1 7 I � Revised 10n1I YFOODAP201 Ladm Check# & or Commonwealth of Massachusetts s e City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/28/2011 ESTABLISHMENT NAME: File Number: BHF -2004-000323 Staples the Office Superstore 500 Staples Drive c/o Taxes & Licenses Framingham MA 01702 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2012-0155 Jan 1,'2011 Dec 31, 2011 $70.00 Total Fees: $70.00 PERMIT EXPIRES ecember 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations; improvements, or equipment changes are made, all plans for. such must be submitted to and approved by the Salem Board of Health. page t KIi BER_EYDRISCOI-L Nt\YOR LARRY RVNIDIN, 16/ltHI IS, CI 1f), III•:.\1;1'11 AGP:N'I' <336�8� CITY OF SALEM( NIASSACHUSL'ITS BOARD OF HETL11I 120 WASHI V Gt-ON STREETJ"FL t o m TI,'L. (978) 741-180(i FAX (978) 745-0343 l aa"Idin(laden, cwn 201_ APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT .�}�pleS the Office SU�E'fStOfe TEI to 978-741-424A ADDRESS OF ESTABLISHMENT 17 Paradise Road FAx# X78-741-0759 MAILING ADDRESS (if different) 500 Staples Drive Framingham MA 01702 EMAIL - Business': nancy.whiteCa-)_staples.com Website: OWNER'S NAME_StaDIes the Office Superstore East Inc. TEL # 508-253-4732 ADDRESS 500 Staples Drive Framingham MA 01702 lily STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Facilities HOME TEL # 508-253-7700 DAYS OF OPERATION Monday Tuesday 1 Wednesday Thursday Fr day Satu day Sad HOURS OF OPERATION , (Fay exampetlam-write i lana d day. (Fa 8-9 8-9 8-9 ! 8-9 11 8-9 I 9-9 1 10-6 ex11pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YEW NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 - - ..... ........... .­----------------------- RESTAURANT YES f�0 ------------- less than 25 seats =$140 (Outdoor Stationary Food Cart $2109 25-99 seats - =$280 more than 99 seats =$420 ._....----------- -------------------------------------...-Q ---------------- -----------------------.---------------------......$10- BED/BREAKFAST/ YES N —-- _ 0--- CHILDCARE SERVICES/NURSING HOME -- ADDITIONAL PERMITS - - - - -- MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES W $25 TOBACCO VENDOR YES NQ $135 ALL NON-PROFIT (such as church kitchens) YES NQ $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 *`?14 and paid all state tabes regyilsid under the few. -•e••-•-• varc-�-' Joa�a�ll�SSeccurity or Federal Identification Number Updated 5/13111 FOODAP201 Ladm Chmk4 & Date------ 500 Staples Drive c% Taxes & Licenses Telephone: ? 741-4244 Owner: Staples the Office Superstor PIC: Edin Vukicevic Inspector: 9 Elizabeth Salandrea Date Inspected: Correct By: 8/1/2011 !Risk Level Permit Number: BHP -2011-0047 P Status: PARTIAL COMPLY # of Critical Violations: 1 =Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) f i Staples the Office Superstore City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comment: Some bottled drinks in storage are being stored on the floor. All food and drinks must be kept at least 6.8" off the floor. Physical Facility FAIL Non -Critical BLUE Comment: There are stained ceiling tiles in food storage room. Investigate for leaks and replace the tiles. Please forward last 3 months' extermination receipts to the Board of Health within one week. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800 GeoTMS® 2012 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 27,2012 ) Page 1 oft Item Status Violation Critical Urgency RED: - Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2012 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 27,2012) Page 2 oft FOR I 1 �/1 IJ A. M. DATE TIME P.M. OF JIGz,O�il U hl .� PHONE AREA CODE NUMBER EXTENSION ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE. YOU ': RUSHY RETURNED YOUR CALL WILL FAX TO YOU SIGNED 48005 MADE IN U.S.A. at.- in tris ,h tttp- --- Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/11/2010 I*IN:11130MI,lu104a8U41%uiDR File Number: BHF -2004-000323 LOCATED AT: Staples the Office Superstore 500 Staples Drive c/o Taxes & Licenses Framingham MA 01702 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires . Fee Restrictions / Notes RETAIL FOOD BHP -2010-0219 Jan 4, 2010 Dec 31, 2010 $70.00 Total Fees: $70.00 PERMIT EXPIRES (December 31.2010 Board of Health`��/,. This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL --�n I MAYOR DAVID GREENBAUIII, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETfiS BOARD OF HEALTH 120 WASHINGTON STREET, 4'FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGREENBAUM@SALEM. COM 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLIStH.,M�ECNT L� NAME OF ESTABLISHMENT _._TEL#�yD- h,I - LZ ADDRESS'OF ESTABLISHMENT I o-CAt�S`C.Ti D A FAX#q MAILING ADDRESS (if different) A-h.g)4%P5__0T- U EMAIL -Business': \\ Website: OWNER'S NAMEC_�'�(A�.��°� ADDRESS n U Y . GGA STREET - CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) ba CERTIFICATE#(S A (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE Please write in time TYPE OF ESTABLISHMENT RETAIL STORE S NO TEL t: Cj' —� FEE (check only) less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT YES d0 !ess than 25 seats =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES U $100 CHILDCARE SERVICES/NURSING HOME ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT (such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax kqums and paid all state taxes-Vquired u9der the law. _ Date Revised 424/07 FOODAP2008.adm Check# IT) - o - �S'lJd�i�i1. or ... :.�, � �-• ,• .. � . t qR �.r,: ' Ii"rr�4y7!�7R � .. �. -r y- •r ♦ � ,..Y�: lr .if'�.' T �.'FA"j�..,t5'^^�y rr .�Yff•... r-�,..1_.., � +- Massachusetts Department of Public ,Health alum Board Health 120 Washington Street, 41h Floor Division of Food and Drugs ft Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) /745.0343 Name Management and Personnel Dat 1 Type of Operation(s) Type of Inspection El Routine ®.Re -inspection Previous Inspection Date: 1`J/3f/uf ElPre-operation ❑ Suspect Illness ❑ General Complaint E] HACCP ElO herr Ll Food Service Retail Residential Kitchen ❑ Mobile [_1Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address' (( ( fuelUL ) Ju J Risk Level ,I Telephone k' - Owner (FC -5)(590.006) HACCP YM Person in Charge (PIC) Time In f d T Out: Inspector Each violation checked iequires 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 -y ,_„„, „o�0 .A ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH r „ ❑ 13. Handwash Facilities r >"PROTECTION FROM CHEMICALS v ❑ 2. Reporting of Diseases by Food Employee and PIC 1 u -�- - 14. t. �I m n• .� �_. ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ''=`TIME/rEMPERATURE CONTROLS (Potemlally Hazardous Foods) 115" ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans 'PROTECTIONFROM CONTAMINATION =`.` ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices <Critical (C) violations marked must be corrected 71 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: 500bn,p tF m6 14.d. ' ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control r REQUIREMENTS FOR FtIGHLY SUSCEPTIBLE POPULATIONS ❑ 21. Food and Food Preparation for HSP ,'CONSUMER ADVISORY;4 ° _ [:]22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE-INSPECTION:��� Inspector's Signature: Print: ^- PIC's Signature: Print: Page of des u Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 596.003(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* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid .Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Ford Employee Or An 3-202.16 - 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* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C C IN FOOD FROM APPROVED SOURCE * Denotes critical item in the Iederal 1999 Foci Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION 8 Food and Water From Regulated Sources 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 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* 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 3-202.18 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 Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated TagslRecords: 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 EgaipmenV Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxy an packagping, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the Iederal 1999 Foci Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-30215 Fruits and Vegetables 3-304.11. ..Washing Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food'* - Disposition ofAdulterated orContaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501..111. Manual Warewashing - Hot Water Sanitization Teut eratares?' - - 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem eratures* 4-501,11.4 Chemical Sanitization- temp., pH, concentration and hardness. 4-601.11(A) Equipment Fool 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 EgaipmenV 4-703.11 Methods of Sanitization - Hot Water and - Chemical* 10 Proper, Adequate Handwashing 2-301.1 t Clean Condition - Hands and Arms* 2-30IA2 ..Cleaning Procedure* 2-301.14 When to Wash* 1.1 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* 5-204.1.1 Location and Placement* 5-205.11 - - Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11. Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: 1 Page:_ of Item No. Code Reference C — Critical Item R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION ;. !` PLEASE PRINT CLEARLY tete: , verified. h �21coo / GF?y Oar K Qr?Glz n L ( o r ?7 ate% -,(,f ri As 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 twent -five dollars or ur pension/revocation of I your food permit. Corrective Action Required: ❑ NoI I in Yes IT Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension 't ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Iteblis 1.22) (Cont.) PROTECTION FROM CHEMICALS F14 16 Food or rotor Additives 14"Filo 3-202,12 Additives* 3-30214 Protection from lfnapplYJv -d Adda... —101JI(Aiti! '-101.1I I Poisonous or Toxic Substances il.,11; n I;I, 411, 11 its Ii fli, and li,- Rtm,i 1 !'�VF 12! '-475-) 3-501.16B) I Corrtafm 3-40'.3 I;A)'.41 41%45° 7. i011 I C(iiaraoriNaroe "t !63 7-26TTF-- d, I", 1 7-202.11 ric6oji -- PoIuoceand L j0 7-2102. 12 -Rest Condi i ioiof Use t j Ppheating to ti 5t Holding i Tim, at, a Public I lealth Con .. I'M I i6VIJ- i5z;vk" H17-204.11 Sanitriers. Criteria - Cbemic;iN [],-M4T 12 Chemicals for tNa,hili It 'CC(itok ;;I 403.11 kc) Almts. Criwria�f 7 205.11 Imid"..mal Fivxl ("'mltro' IAIN icazlW i "'tiv Peol, ide, Critei n' . L 7- �06.12 Rotlew Bo Stn twll' 11 06 11 'Fra k i ro, I',,, dvi ("aimnIl ww NI'mootin-, TIMEITEMPERATURE CONTROLS 16 Proper Coekirig Tempeiatwps for 14"Filo PHFS 0 1` Withm, 2 1 rorirc uod From '!'!"I i,ii '1115F �k'fltinA Hout 41'.F/45"F Witbin 4 Homs. —101JI(Aiti! Commmwck� F;A' "le, (I'i' T,-mp- r4i (ire 111 L re d� em, I I 1'45'P Itkir", il.,11; n I;I, 411, 11 its Ii fli, and li,- Rtm,i 1 !'�VF 12! '-475-) 3-501.16B) Cold Pffs Maintained at or below 3-40'.3 I;A)'.41 41%45° 7. 3-501 INA) Har PHP. Maintained at or above "t !63 -;01, I, d, I", 3-501.16(A) Roasts Held at or above 130,�F j0 0 as a �PublicHeatlh ConirT t j Ppheating to ti 5t Holding i Tim, at, a Public I lealth Con .. I'M I i6VIJ- i5z;vk" 11 (B) 1 lofi"f`2 403.11 kc) i KTH [,I, 3-463A 1(E) 1 Remmiiw3 Portions of, IFS I Proper Cooling of Ptil's 01.14(A} 14"Filo 0 1` Withm, 2 1 rorirc uod From '!'!"I i,ii '1115F �k'fltinA Hout 41'.F/45"F Witbin 4 Homs. PHFI Nbdv Flom Ambient 3-501.15 T,-mp- r4i (ire 111 L re d� em, I I 1'45'P Itkir", il.,11; n I;I, i:dvr t' r,"N ro"! f W it, V ! Rt seta e. with L+ from tat .Is' I of Patewwd R ; i w or In I i tal Ji, G IoL,d Animal FuxJ and P 1z' - i ". " iv. I '- ... I , Uit-Pond F,4xi Pac'llaec Not CONSUMER ADVISORY 22 3 -60.; 11 oo,:ijom Art, lmwv Potzcd I)i, Cmimoptioo of tit i))0 [alt I" WOLA t rDNS RELA T ELI rO G ODD RE I'Ait PRA C f('CS fltenN 23.3(1) C'Uwarid I S 1 1 1 L t, £ft ,£x ttn 1 IG rpx £ aP the r [iRt ri P i l t t I soofona 'Ind roj hl6 for( !;VeIl avow, "in bf, ;It !,It I,,, of Jo Fwd Code iii, ,' jQ5 CWR 3-501.14(C) PHFi; Received at Temperatures According to Ils v,✓ Cooled te, 41'.F/45"F Witbin 4 Homs. 3-501.15 Coolin. Methods for PHFS- 19 l ITHF Hot and Gold Holding 3-501.16B) Cold Pffs Maintained at or below 190.004(F) 41%45° 7. 3-501 INA) Har PHP. Maintained at or above 140'F. 3-501.16(A) Roasts Held at or above 130,�F j0 0 as a �PublicHeatlh ConirT I Tim, at, a Public I lealth Con .. V ! Rt seta e. with L+ from tat .Is' I of Patewwd R ; i w or In I i tal Ji, G IoL,d Animal FuxJ and P 1z' - i ". " iv. I '- ... I , Uit-Pond F,4xi Pac'llaec Not CONSUMER ADVISORY 22 3 -60.; 11 oo,:ijom Art, lmwv Potzcd I)i, Cmimoptioo of tit i))0 [alt I" WOLA t rDNS RELA T ELI rO G ODD RE I'Ait PRA C f('CS fltenN 23.3(1) C'Uwarid I S 1 1 1 L t, £ft ,£x ttn 1 IG rpx £ aP the r [iRt ri P i l t t I soofona 'Ind roj hl6 for( !;VeIl avow, "in bf, ;It !,It I,,, of Jo Fwd Code iii, ,' jQ5 CWR WORK ORDER U.S. Roofing a division of Building Maintenance Corp. P.O. Box 3118 Peabody, MA 01961-3118 Telephone: (978) 532-6300 Fax: (978)977-0803 Date i I – I q" Q q Contact XY i Company S 1 fA l7IT C Foreman -,Nq✓ Q Time Address f r P SCA Crew Y _ r CHECKLIST Repair RUBBER ROOF ❑ Ballast ❑ Adhered 4PVC/Other ASPHALT ROOF ❑Gravel Coat ❑ Flood Coat ❑ Silver Coat ❑ Torch Apply SHINGLE ROOF ❑ Asphalt Shingle ❑ Wood Shakes ❑ Slate ❑ Tile METAL ROOF Copper ❑ Aluminum ❑ Steel REPAIR STATUS ❑ Permanent NO RETURN) Temporary (RETURN NECESSARY) WEATHER CONDITIONS CLEAR d RAIN ❑ SNOW ❑ SLEET ❑ ICE `\\o TEMPERATURE V H2 ROOF DIAGRAM MEMBRANE i ADHESIVES INSULATION CLEANER CAULKING (TYPE) ACCESSORIES I 1 I I I I i I 44 I — , I — TT i kn;4s 5�t,9 ,� r s;�e o� ti,�ll loot' 7�0 �� %L�)�n� C, V) p fl, S, �, �errt'hq�,'>1� ��r ��Vic oaf I MATERIAL USED: AMnLINT i LRFn AMOUNT USED MISCELLANEOUS I ROOF CEMENT FLASHING ( LIST) ) MEMBRANE ADHESIVES INSULATION CLEANER CAULKING (TYPE) ACCESSORIES I HAVE THE AUTHORITY TO ORDER THE ABOVE WORK AND DO SO ORDER ABOVE AS OUTLINED ABOVE. IT IS AGREED THAT THE SELLER WILL RETAIN TITLE i TO ANY EQUIPMENT OR MATERIAL FURNISHED UNTIL FINAL & COMPLETE PAYMENT IS MADE. AN EXPRESS MECHANICS LIEN IS HEREBY f ACKNOWLEDGED FOR SECURITY OF THIS DEBT AND THE TOTAL AMOUNT X — WILL BE PAID WITHIN (30) THIRTY DAYS. �A -4� R.:nmz! CaII NESS CUST4,M "printing service tCLL FHA'.E 1 KOG BW 6127 AU 55, l c. ve e =58. HAS COMPLETED AND I ACKNOWLEDGES RECEIPT OF /MY COPY. DATE Ret. a v o I it M. ^Y � ..:�M..nM1F.t'r�.,Tr;7./.,.yh.�":.+4t3`^M1.".�4`5=:��r'Z-.'��.e=a'-r;sy-lt t.i',#•,w::. t,:�e'+�r`n °'i+4a 't..wr '..f�:, _��. w4�Yl,F.,,��i.� I Massa'chusetts Department of Public Health i' Salem Board of Health Division of Food and Drugs / 120 Salem, MA Washington 4` Floor 1970-3523 FOOD ESTABLISHMENT INSPECTION REPORT ). Tel. (978) 741-1800 Fax (978) 745-0343 J Name Date TVDe of Operation(s) " Te of Inspection LJFood Service Retail Residential Kitchen Mobile [IS C1 Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Routine E]Re-inspection Previous Inspection Date: /i u 5�P E] Pre-operation ❑ Suspect Illness ❑ General Complaint El HACCP ElOther, Address�j d Risk Level Telephone Owner HACCP Y/N Person in Charge (PIC) Time In. optt:: �/las � Inspector Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. ;w 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) [-1 590.009 (F) ❑ action as determined by the Board of Health. „FOOD PROTECTION' MANAGEMENT,;, �.,,�F �,°`�`",Y,'k`S, d ❑ 1. PIC Assigned/ Knowledgeable /Duties LI 2. Reporting of Diseases by Food Employee and I ❑ 3. Personnel with Infections Restricted/Excluded ,�-FOOD FROM APPROVED, d E]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 x ❑ 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) 4. 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 IFom 14," ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities ;PROTECTION FROM CHEMICAL$ � �T- I. `� AV",'� ae =_Y Faµ ,R ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods) t`i--' ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control RE0UIREM ENTS FOR HIGHLY SUSCEPTIBLE POPULAt10us (HSP);_i' ❑ 21. Food and Food Preparation for HSP a CONSUMER ADASORY,i,. 5` - A� 41.:_"u �;,A"m ❑ 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: NJJ"µA Kaoxi, Inspector's Signa re Print: PIC's Signature: Print: jA <O Page of , ages 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 incharge -- duties EMPLOYEE HEALTH 2 590:003(0) Responsibility of the person in charge to Com liance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge." 590.006(11) 590.003(G) Re or n b Person in Char e* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 C C I FOOD FROM APPROVED SOURCE *Denotes critical item in thefederal 1999 Foal Code of 105 CZAR 590.000. PROTECTION FROM CONTAMINATION $ Food and Water From Regulated Sources 590.004(A -B) Com liance 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* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinkin Water* 590.006(11) 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 3-202.18 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 Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3=20118 Shellstock Identification * - 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-40111 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 E ui tnent* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformancewith Ai roved Procedures* *Denotes critical item in thefederal 1999 Foal Code of 105 CZAR 590.000. PROTECTION FROM CONTAMINATION $ Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1,1(A)(2) Raw Animal Foods Separated from Each Other" Contamination from the Environment 3-302.1t(A) Food Protection - rotection*3-302.[5 3 -302. 15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111. Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 MechanicalWarewashinb Hot Water Sanitization Temperatures* 4-501.11.4 Chenical Sanitization- temp., pH, concentration and hardness. '" 4-601,11(A) Equipment Foci 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 E ui tnent* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 14 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Anus* 2-301.12 Cleaning Procedure* 2.301.14 When to Wash* 1.1 Good Hygienic Practices 2401-11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 730112 Preventing Contamination When Tasting* 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* 5-204.11 Location and Placetnent* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashin Cleanser, Availabilit 6-301.1.2 Hand Drying Provision w CITY OF SALEM BOARD OF HEALTH Establishment Name: �Q� Date: /c)/3//c)5 Pager_ of ---- Item No. Code Reference c - Critical Item R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION >: PLEASE PRINT CLEARLY Date . . Verified C P r >n l— J`4r — �- u 4 0 -f S r'C.,uc �� rl 1,a C(✓ * _ U� ?31 = C e,-) a --a I. P . i n ,, c7 n c n� 1 ii s V .n (, JdJ4(,-� r / o.47�v ¢.e n +- CC K�n r2 e ( Al dG�In7 �1akj•l> 2,. -,NrQDJ -6 612.Ar, LlQU`n F A� W! V , I r Yet, f? 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 finesof� y -five dollars uspension/revocation of❑ your food permit. r Corrective Action Required: ❑ No -Yes ❑ Voluntary Compliance ❑ Employee Restriction Exclusion Re -inspection Scheduled Ei Emergency Suspension - Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne illness Interventions and Risk Factors (7lem 1-22) (Cont) PROTECTION FROM CHEMICALS 14 Food or Color Additives PHFsReceived atTejrr FsecataLes 3-26312 --T- mdt,,,� 1 3-30114 Protection front ( fiiapprovedAddinve-s° 15 Poisonous or Toxic Substances 41 =F/45"F Within 4 H(ju,,, * I 01,15 11 Idt"litifying Infoi inanon - 06, nji 19 Container PHF Hot and Cold Holding 7 1 O�L I I Common 'Nanw - workj." L'milmil'-n 3 501.16(li) Cold PHFs Maintained at or below ;-202.11 l Rcst, in on - ht'l� wx "old 4t /45` F' 2 i Coadmon, (it U,Q' 501.16(A) 7 103 H v. 'k Xic Cowainefz - V'ohibwwj) 04.11 sankt7els. Crilcm, - chrmic:'N 140'1-'. �104,12 '1'emi "tr 11, for 'A a, h i t. h 0,1! Ice i rN i'll i-501, 16)A) I ? Dnnw.Aimin�- Crim4i L 26 1 Time as a Public —Heafth CiTnTo­f-- —', r7 2i, , I C. m i 06.! 1 1, ! li,ickiliQ Pl),lderl, (',mtoland vam"owc Recumment - --------- j Proper Cooking Temoe!Mves for !Afl cc.' I -103.11(b) 3 lz I I J-40" I I,'F i Rc mamm, UnOicvJ Poi 6oi, N Proper Cooling or PHFs 3 �,i 1 . Lam'—(A} "�'Twithin 2 dour. ,!nd From Pill f I ''1 115 F Within 4 i(l,i4iB) PHR Mikd;: Front Ambient lo 41 `Fi-i F %%ifli,ril lhruisl, 'Alt J�. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 3 8u I I lCi I T%xd Packaiii: Not R.-SmO, J 1 ':orm1mCf A Not nhiv'.' Pt',' 'l:' -.J SPECIAL PECIAL REQUIRE&IFNTS vidoljno' "i se""lo'l U -�idcis fib ------ ------- - NS REILATFL- TO 3000 AETAIL P,;dA C TfCES titeins C',tu'w tJh'rr' i!N'�Sl "Pt'i't �ill Ill" md 1!,t joc wrB li, 1, J fibowiamb" �c� :':e lii,id CoUC rB.d 1; Cifi( ou 00i i front 'Good Rota," pramucii FC 590,00v FC 2 00- 24, FcV- Sod Fo,xt FC :.004 i 26, Wiliet, plwntvlazalc 1 2 rn riFa!%_ FC - 6 00 1 FC - 7 003 30 ' tittle -31-501A) (c) --- PHFsReceived atTejrr FsecataLes 1 According to Lair Cooled to 41 =F/45"F Within 4 H(ju,,, * I 01,15 Coolin� Methods for Pfffis- 19 PHF Hot and Cold Holding 3 501.16(li) Cold PHFs Maintained at or below 590,6()4(f) 4t /45` F' 501.16(A) [lot PHFl Maintained at or above 140'1-'. i-501, 16)A) I ktmi,'ts Held u[ or above L 26 1 Time as a Public —Heafth CiTnTo­f-- —', r7 i orAas a Public 1 loal th no OF r - vam"owc Recumment - --------- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 3 8u I I lCi I T%xd Packaiii: Not R.-SmO, J 1 ':orm1mCf A Not nhiv'.' Pt',' 'l:' -.J SPECIAL PECIAL REQUIRE&IFNTS vidoljno' "i se""lo'l U -�idcis fib ------ ------- - NS REILATFL- TO 3000 AETAIL P,;dA C TfCES titeins C',tu'w tJh'rr' i!N'�Sl "Pt'i't �ill Ill" md 1!,t joc wrB li, 1, J fibowiamb" �c� :':e lii,id CoUC rB.d 1; Cifi( ou 00i i front 'Good Rota," pramucii FC 590,00v FC 2 00- 24, FcV- Sod Fo,xt FC :.004 i 26, Wiliet, plwntvlazalc 1 2 rn riFa!%_ FC - 6 00 1 FC - 7 003 30 ' tittle Commonwealth of Massachusetts. VW City of Salem Board of Health lQmberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: File Number: BBF -2004-000323 LOCATED AT: Staples the Office Superstore 500 Staples Drive c/o Taxes & Licenses Framingham MA 01702 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2009-0118 Dec 23, 2008 Dec 31, 2009 $70.00 PERMIT EXPIRES Total Fees: $70.00 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 JANET DIONNE, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4r" FLOOR TEL. (978) 741-1800 F.ax (978) 745-0343 IDIONNE&ALEM. COM 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT - NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT, MAILING ADDRESS (if different) EMAIL-Business1\40"fI t(A OWNER'S NAME-SrVrNL�k�,o ADDRESS STREET CERTIFIED FOOD MANAGER'S NAME(S)� (Required in an establishment where potentially hazardous TEL ##�, t - -t 2- FAX # I `'Y I Py'i CITY I STATE ZIP CERTIFICATE#(S) EMERGENCY RESPONSE PERSON&SSnC— i CLf1 CCI) HOME TEL #'V'? - WSO DAYS OF OPERATION Mond ,Tuesday I '; Wednesda Thursda - ' ' : F.rida - '-Saturda . "' Sunda ' - HOURS OF OPERATION Please write in time day. j I , q 1 1 1 111 i D — Ira (For example Ilam-1111pm i 1000-10,000sq.ft. TYPE OF ESTABLISHMENTFEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70� 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ------------------------------------------------------------- --- --- ---------------------------------------------------------------------------------------- REST,A lA� !1? VCC �c v 13 s than 25 Seats =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 --------------------------------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES 00 $135 ALL NON-PROFIT (such as church kitchens) YES $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax n7/1 and paid all state taxes re yuved un er the law. , r 4� \/1AAhA �I 1Inl9 1I�f'I�n �C -3(i( 9S Date Revised 424/07 FOODAP2008.adm Check# & or Federal Identification Number I�4 I-. CITY OF SALEM BOARD OF HEALTH Establishment Name: i-aliDate: 9 Ih/Q3 Page: of Item Code C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R — Red Item - Verified PLEASE PRINT CLEARLY.. o J MinMcCIN nutrlcdecl iln dxl'ilL aJ'ii'e . C VvIo4 clovel mn t c(i( exutr D�l 1-ItPS.. s Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of tw�nty-fivp =orpension/revocation of L3 Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Control PROTECTION FROM CHEMICALS I9 Is 17 3-202.12 Food or Color Additives Additives'% 3-302.14 Protection from Unapproved Additives* 3-401.1.1A(1)(2) Poisonous or Toxic Substances 7-101.11 Identifying Information - C)riginal Containers" 7-102.11 Common Name - Workino Containers"` 7-201.11 Se tion - Sloraee'` 7-202.11 Restriction - Presence mid User 7-202.12 Conditions of Use - 7 -203.11 Toxic Containers- Prohihl,rions': 7-204.11 Sanitizeis.Criteria-Chemicals* 7-204.12 Chenileals for Washin t Produce, Ci iteria"° 7-204.14 Drvin > r ruts. Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-266.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-266.13 Tracking Powders, Pest Control and Monitoring,* "Denotes critical item in rhe faferal 1999 Food Code or 105 CMR 5901900. 3-501.14(C) Proper Cooking Temperatures for Unpasteurized Pte -packaged Juices and Beverages woh Warning 1, bels* PHFs 3-401.1.1A(1)(2) Eggs- 1_55°F 15 Sec. 3-501-15 E res- linmediate Service 145"1".l5sec* 3401.11(A)(2) Comminuted Fish, Meats & Game 3 501.16(B) Animals - 155°F 15 sec. 3-401.11($)( 1)(2) Pork: and Beef Roast - 130`P 121 min* 3-401.11(A)(2) Ratites, Injected Meats- 155°F 15 28. 29.- sec. 3-401..1 (A)(3) Poultry, Wild Game, Stuffed PHFs, 26 Stuffing Containing Fish, Moat, 3-501-19 Poultry or Ratites -165°F 15 sec. 3-401.11(0)(3) Whole-musele, Intact Beef Steaks 145°F 4' 3-401.12 Raw Andred Foods Cooked in a Microwave 165°F * 3-40 1.11 (A)(1)(b) All Other PHFs - 145°F 15 sec. Reheating for Hot Holding 3-403.11(4)&(D) PHF, 165°F 15 sec. 3-403.11(B) A4icrowave- 165° F 2 Minute Standing Time"` 3-403.11(,C) Commercially Processed RTE Food - 140"F* 3-40311(13) Retraining Unslieed Portions of Beef Roasti," Proper Cooling of PHFs 3-501.1.4(A) Cooling Cooked PHFs from 1403 to 70`F Within 2 Hours and From 70°F to 41°F/45°F Within 4 Hours. 3-501.1403) Cooling PFIFs Made Frotn. Ambient Temperature Ingredients to 41 `F/45°F Within 4 Hours" "Denotes critical item in rhe faferal 1999 Food Code or 105 CMR 5901900. 3-501.14(C) i PlIFsReceived at Temperatures Unpasteurized Pte -packaged Juices and Beverages woh Warning 1, bels* Accordtna to "w Cooled to 3-901.A I(B) 41"17145 F Witliin 4 Houtz. 3-501-15 C<x9i�Memods for PHFs 19 PHF Hot and Cold Holding 3 501.16(B) Cold PRFs Maintained at or below 590.004(F) 41 %45° F° 3-501.16(A) Not PHFs'vLia rained at or above 28. 29.- 140°F. 3-501.16(A) Roasts Held at or above 130°F. 26 Time as a Public Health Control 3-501-19 Time as a Public HeaRh Control" 590.00".(H) Variance Re uirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP) 2I 3-801-'11(A) Unpasteurized Pte -packaged Juices and Beverages woh Warning 1, bels* Animal Foods That are Raw. Undercooked or 3-901.A I(B) Use of Pasteurized ELos* FC - 3 3-801.11(D) Raw or Partially Cooked Animal Foal and Raw Seed Sprouts Not Served. 3-303.73 Pasteurized Eggs Substitute for Raw Shell 3-£01.11(C) Uno erred Fatd Packa =e Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of -- FC FC - 2 Animal Foods That are Raw. Undercooked or 24. Not Otherwise Processed to Eliminate FC - 3 Pathogens.* 25._ 26. _ 3-303.73 Pasteurized Eggs Substitute for Raw Shell _ FC_- -4 FC - 5 B ,sr 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and tisk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. WAKlIJi (Items 23-30) Critical and non-critical violations, which do not relate to the ,foodborne illness nuerventions and risk.14ctors listed above, can be found in the following sections o/ the Food Code and 145 CMR .5.90.400 Item 23. Goad Retail Practices Management and Personnel -- FC FC - 2 - - 590.000 .003 24. ______ Food and Food Protection FC - 3 .004 25._ 26. _ _ _ ernent and Utensils _ W a_ter, Plumbin and Waste _ FC_- -4 FC - 5 .005 27- Ph sical Facility _ _ FC - 6 _.008 _ 407 28. 29.- Poisonous or Toxic fAateriala S ecial Re uirements FC - 7 .003 -009 30. Other :Srnrm'n�h�tAS.Juc M K i7 i Commonwealth of Massachusetts T City of Salem Board of Health lGmbedey Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000323 LOCATED AT: Staples the Office Superstore 500 Staples Drive c/o Taxes -& Licenses Framingham MA 01702 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires FeeRestrictions / Notes RETAIL FOOD . BHP -2008-0079 Jan 3, 2008 Dec 31, 2008 $70.00 Total Fees: $70.00 PERMIT EXPIRES IDecember 31, 2008 11 11-r: = Board of Health This Permit is not transferable and must be reissued upon change -of ownership or location. The permit must be_posted:in..:::._ a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 34 of 46 �o 6 � KIMBERLEY DRISCOLL: MAYOR JOANNE SCOTT, HEALTH AGENT sa�asar(::, CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"m FLOOR TSL. (978) 741-1800 FAX (978) 745-0343 RECEIVED e ISQQTTa�SALEM.00M RE V NOV 2 9 2007 CITY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT S ` TEL A '1'7) n i f/-� y aN ` I ADDRESS OF ESTABLISHMENT �� I CSA r���( `� FAX # "1 © 5 7 MAILING ADDRESS (if different) '300 SA o;2A,0�5 V�7V'a Y P-- (>� a or, t t EMAIL - Business':\_?1ACQj-j%kAJl OWNER'S NAME ADDRESS -5Q STREETS CERTIFIED FOOD MANAGER'S NAM (Required in an establishment where potent EMERGENCY RESPONSE PERSONA �t W ebsitte: ` n O S� CITY CERTIFICATE#(S) TEL #qW � '1 k0 _i ' '7501 HOURS OF OPERATION Please write in time of day. — / ^ — 9 _ T 7 " (For example 11am-t 1 pm) I TYPE OF ESTABLISHMENT FEE (check only) / RETAIL STORE ES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 --- -k------------------------.--(- ---------- .........--------les-------- --ea-t-----------=-40... -----------_ -40.... RESTAUANT YES NO less than 25 seats $140 (Outdoor Stationary Food Ca' $210) 25-99 seats =5280 more than 99 seats =$420 ---' '---"--- ---------------------------------------------------------- .....----------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES.. -------------...-------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YESNO $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 routQs and paid all state taxes requ)" under thIllaw. _ _ ,% v1e7- Date Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adin Check# & Date .3 ak0`o � it la&47 s a i CITY OF SALE BOARD OF HEALTH Establishment Name: Date: b / 2�z Page: ) of Item No. Code Reference C - Critical Nem R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Verified tovv`e.v- SG KS ✓Q. Drf r l7 C, C _r V- L 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 noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: o No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: J Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) 14 Food or Color Additives 3-202.12 Additives" _ 3-302.14 Protection from Una? roved Additives" 15 Poisonous or Toxic Substances 1-101 1 1 Identifying lnfornosi on - Original 3-501.16(A) Containers" 7-10111 Common Name - Working Containers* 7-201.11 Se aratittn-Storazel* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic. Container, - 1'roh[bitions,`� 7-20.11 Samtizers. Criteria -- Chemicals" 7.204.J.2 Chemicals for Washing Produce, Criteria* 7-204.14 Divin * Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rmfent Bait Stations - 7 ']'racking Powders. Pest Control and Monitu im, TIME/TEMPERATURE CONTROLS 16 3-501.14(0) -TPHFs Proper Cooking Temperatures for 19 3-501.1-5 PHFs _ 25. _ Equipment ment and Utensils 3-401.11A(3)(2) Eggs- 155'F 1.5 Sec. 26 `Nater, Plumbingand Waste 3-501.16(A) Eggs-Inmrediate Service 145'F15se_e* 27. Physical FacilityFC-6 _ 3-4(31.11(A)(2) Comminuted Fish, Meats & Game 20 FC - 7 Animals- 15Y 15 sec.'" 29. Special Requirements 3-401.11(B)(I)(2) Pork and Beef Roast - I30'F 121 min* 30. Other 3-401.11(A)(2) Ratites, Injected Meats -155`F 15 sec. t 3401..11(A)(3) Poultry, Wild (lame, Stuffed PHFs, Stuffing Containing Fish, Meat, POu1tZ or Ratites -165"F IS see. 3-401.11(0(3) Whole -muscle, Intact Beef Steaks 145°F , 3-401.12 Raw Anined Foods Conked in a Microwave 165='F * 3-401) I0)(1)(b) All Other PRFs- 145'F'15 sec. 17 Reheating for Hot Holding 3-403. I I (A)&(D) PHFs 165'F 15 sec. " 3-403.11(B) Microwave- 165' F 2 Minute Standing Time" 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(F,) Remaining Unsliced Portions of Beef Roasts': 18 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHN from 140`F to 70'F Within 2 Hours and From 70'F to 41."F/45'F A"ithin 4 Hours. * 3-501.1JIB) Cooling P1 lFs Made From Ambient Temperature Ingredients to 41'F/45 'I F Within 4 Hours" * Denotes critical iron, in the federal 1999 Food Code or I65 CMR 590000, 21 3-501.14(0) -TPHFs Received at'Tianperatures According to 1 ow Cooled to 41 `F/45'F Witlan 4 Hours'. * 19 3-501.1-5 Cooling Methods for PHFs PHF Hot and Cold Holding 25. _ Equipment ment and Utensils 3-501.16(B) 590.004(F) Cold PFIPs Mamouried at or below, 411745° F^ 26 `Nater, Plumbingand Waste 3-501.16(A) _ Riot PIIFs Maintained at or above 1401'.* 27. Physical FacilityFC-6 _ 3-501.16(A) Roasts Held at or above 130°F. 20 FC - 7 Time as a Public Health Control 29. Special Requirements 3-501.19 Time as a Public Health Control* 30. Other 590.004(H) Variance Requirement 21 3-901.1 I (A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 24. Food and Food Protection 3-801,11(B) Use of Pasteurized Peas* 25. _ Equipment ment and Utensils 3-801.11(,D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.., 26 `Nater, Plumbingand Waste 3-801.11(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603,11 Consumer Advisory Posted for Consumption of Anhnal Foods'llan are Raw. Undercooked or Not Otherwise Processed to Eliminate Pathogens:* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Ergs* 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under die appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited tinder #29 - Special Requireincnts. (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk jnctors listed above, can be fitund in the following sections' of the Food Code and 105 CMR 590.000. Item Good Retafl _Practices 23. Management and Personnel FC FC - 2 590000 ..003 24. Food and Food Protection FC -- 3 .004 25. _ Equipment ment and Utensils F_C 4 ' __:005 _ 26 `Nater, Plumbingand Waste FC 5 27. Physical FacilityFC-6 _ _ _.006_ 007 28. Poisonous or Toxic Materials FC - 7 1 .008 29. Special Requirements .009 30. Other I S11% ',I,&6 2d" 500 Staples Drive c% Taxes & Licenses Telephone: 741-4244 Owner: Staples the Office Supersto PIC: Loralee Hurley Inspector: John Gehan Date Inspected: Correct By: 6/2712007 Risk Level: Permit Number: BHP -2007-0071 Status: SIGNED OFF # of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) HACCP: ❑ Staples the Office Superstore City of Salem RETAIL FOOD - Food Establishment Inspection Item Status Violation Critical Urgency FOOD PROTECTION MANAGEMENT PIC Assigned / Knowledgeable / Duties PASS RED Noncompliance with: Anti -Choking PASS Tobacco PASS EMPLOYEE HEALTH Reporting of Diseases by Food Employee and PIC PASS RED Personnel with Infections Restricted/Excluded PASS RED FOOD FROM APPROVED SOURCE Food and Water from Approved Source PASS RED Receiving/Condition Tags/Records/Accuracy of Ingredient Statements Conformance with Approved Procedures/HACCP Plans PASS d❑ RED PASS 0 RED PASS 0 RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2007) Page 1 of TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION RED Reheating PASS Violations Related to Separation/ Segregation/ Protection PASS 0 RED Foodborne Illness Interventions Hot and Cold Holding PASS RED and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED RED immediate corrective action) Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS 0 RED Handwash Facilities PASS ❑d RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS RED TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS 0 RED Cooling PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) Food and Food Preparation for HSP PASS ❑ RED CONSUMER ADVISORY Posting of Consumer Advisories PASS Q RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800 GeoTMS@ 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2007) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other- See Notes PASS BLUE GENERAL COMMENTS: No Health code violations found at this time. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2007 ) Page 3 of A o©pi APPLICATION NAME OF ESTABLISH ADDRESS OF ESTABLISHMENT -tt- C;2, rl RECEIVE® NOV 15 2006 PERMIT, T\O OPERA FOOD ESTABLIS OF SALEM )��8 �t'r��Q�Ci`� OF HEALTH TEL # C1�� � - 'I-a MAILING ADDRESS (if different) 5d0 OWNER'S NAME, CERTIF rn19 0t-7o� TEL #SD' -,Q 5- 41`70 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE HOURS OF OPERATION: PERSON ASS OC HOME TEL #2W- 4 (,'7- - r] � 6 Mon. 4Tue�ed.�Thu Fri. 7671Sun.--4D- TYPE un.--4Q(p TYPE OF ESTABLISHM RETAIL STORE E5 NO RESTAURANT YES FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT. SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT (such as church kitchens) YES O $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Revised 11/03/05 Check# & Security or Federal Identification Number A so. 0-0 CITY OF SALEM, MASSACHUSETTS 4 ! BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAX 978-745-0343 MAYOR wW W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT A o©pi APPLICATION NAME OF ESTABLISH ADDRESS OF ESTABLISHMENT -tt- C;2, rl RECEIVE® NOV 15 2006 PERMIT, T\O OPERA FOOD ESTABLIS OF SALEM )��8 �t'r��Q�Ci`� OF HEALTH TEL # C1�� � - 'I-a MAILING ADDRESS (if different) 5d0 OWNER'S NAME, CERTIF rn19 0t-7o� TEL #SD' -,Q 5- 41`70 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE HOURS OF OPERATION: PERSON ASS OC HOME TEL #2W- 4 (,'7- - r] � 6 Mon. 4Tue�ed.�Thu Fri. 7671Sun.--4D- TYPE un.--4Q(p TYPE OF ESTABLISHM RETAIL STORE E5 NO RESTAURANT YES FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT. SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT (such as church kitchens) YES O $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Revised 11/03/05 Check# & Security or Federal Identification Number A so. 0-0 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: File Number: BHF -2004-000323 LOCATED AT: Staples the Office Superstore 500 Staples Drive c/o Taxes & Licenses Framingham MA 01702 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2007-0071 Dee 19, 2006 Dec 31, 2007 $50.00 Total Fees: $50.00 PERMIT EXPIRES 2007 Board of Health Driscoll 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 19 of 24 P 500 Staples Drive c% Taxes & Licenses Telephone: 741-4244 Owner: Staples the Office Superstor PIC: Kevin McGregor Inspector: David Greenbaum Date Inspected: Correct By: 8/16/2006 RED Risk Level: Permit Number: BHP -2006-0211 Status: SIGNED OFF # of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good' Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) HACCP: ❑ Staples the Office Superstore City of Salem RETAIL FOOD - Food Establishment Inspection Item Status Violation Critical Urgency FOOD PROTECTION MANAGEMENT PASS RED PIC Assigned / Knowledgeable / Duties PASS ❑d RED Anti -Choking PASS Tobacco PASS EMPLOYEE HEALTH Reporting of Diseases by Food Employee and PIC PASS ❑J RED Personnel with Infections Restricted/Excluded PASS k RED FOOD FROM APPROVED SOURCE Food and Water from Approved Source PASS RED Receiving/Condition PASSd❑ RED Tags/Records/Accuracy of Ingredient Statements PASS RED Conformance with Approved Procedures/HACCP Plans PASS ❑d RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 16,2006) Page I of ' Item Status Violation Critical Urgency RED; ' PROTECTION FROM CONTAMINATION RED Hot and Cold Holding PASS Violations Related to, Separation/ Segregation/ Protection PASS ❑d RED Foodborne Illness Interventions and Risk Factors (Require ,r Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED immediate corrective action) , ,, Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS ❑d RED Prevention of Contamination from Hands PASS ❑d RED Handwash Facilities PASS ❑J RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS ❑./ RED Toxic Chemicals PASSd❑ RED TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) Cooking Temperatures PASS ❑d RED Reheating PASS ❑d RED Cooling PASS ❑J RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS ❑J RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS ❑/ RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 16,2006) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other- See Notes PASS BLUE GENERAL COMMENTS: 745: Establishment sells a limited supply of pre packaged candy, chips, soda and miscellaneous snacks. No health code violations cited at this time. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 16,2006 ) Page 3 of DATE PRINTED: Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit 01/03/2006 WHO'S PLACE OF BUSINESS IS: File Number: BHF -2004-0323 LOCATED AT: Staples the Office Superstore 500 Staples Drive c/o Taxes & Licenses Framingham MA 01702 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2006-0211 Jan 3, 2006 Dec 31, 2006 $50.00 Total Fees: $50.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 7 of 10 CITY OF SALEM, MASSACHUSETTS II I� BOARD OF HEALTH Q RRCn '\v'°1 120 WASHINGTON STREET, 4TH FLOOR ��V U aQ9a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM BOARD OF HEALT)-1 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH. RS, CHO MAYOR HEALTH AGENT 2000APPLICATION F R PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTTEL # 9'17 - r) 4 1_�-c�(-� ADDRESS OF ESTABLISHMENT 90 r MAILING ADDRESS (if different) OWNER'S TEL #5aIi�-"orl5,'Lf'780 ADDRESS 17� CITY�r.r�" r� STAT ZIP CERTIFIED FOOD MANAGER'S NAME(S) _ERTiFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE HOURS OF OPERATION: Mon.�Tu�Wed.�Thu.r- Fri.4 �-SS8-'4to`1 - 7501 TEL # TYPE OF ESTABLISHM G FEE check only RETAIL STORE ES NO less than 1000sq-.ft. 1000-10,000sq.ft. GoQ more than 10,000sq.ft. RESTAURANT YES (!OJ less than 25 seats 25-99 seats BED/BREAKFAST YES �� NOS / more than 99 seats �� ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES TOBACCO VENDOR YES WN ALL NON-PROFIT (such as church kitchens) YES ISun. 10_ T _$ 50� =$100 =$250 =$100 =$150 =$200 $100 $5 $50 $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Si ature Date Social Security or Federal Identification Number Revised 11/25102 FQOD 2.adm Check# 6 Date �/ .2Sr a /� ���� W:5 e5p 500 Staples Drive c% Taxes & Licenses HACCP: ❑ Telephone: 741-4244 Owner: Staples the Office Su PIC: Kevin McGregor Inspector: _ M David Greenbaum' Date Inspected: Correct 9/21/2005 Risk Level: Permit Number: BHP -2005-0091 .:.= Status: SIGNED OFF # of Critical Violations: Staples the Office Superstore City of Salem RETAIL FOOD - Food Establishment Inspection - Item Status Violation Critical Urgency Nature of problem or correction RED Non-compliance with: Not Done RED PASS )ersto Anti -Choking Tobacco PASS PASS ❑ ❑ RED A, € _ _ FOOD PROTECTION MANAGEMENT Not Done (] RED PIC Assigned / Knowledgeable / Duties PASS ❑d RED - - EMPLOYEE HEALTH Not Done By: Reporting of Diseases by Food Employee and PIC Personnel with Infections Restricted/Excluded PASS PASS RED RED FOOD FROM APPROVED SOURCE Not Done mi Food and Water from Approved Source Receiving/Condition Tags/Records/Accuracy of Ingredient Statements Conformance with Approved Procedures/HACCP Plans PASS PASS PASS PASSd❑ ❑d RED RED RED RED PROTECTION FROM CONTAMINATION Time IN ;: - Time OUT.. .- # Separation/ Segregation/ Protection Notes Food Contact Surfaces Cleaning and Sanitizing 312: 3 _ Proper Adequate Handwashing Urgency Description(s): Good Hygienic Practices BLUE' Violations Related to Good Prevention of Contamination from Hands Retail Practices (Critical . Handwash Facilities violations must be corrected immediately or within 10 days)(Non-critical violations: GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc. Not Done N/A ❑/ RED N/A ❑J RED PASS ❑Q RED PASS RED PASS RED PASS (] RED ( Rev. Sep 21,2005 ) Paee I oft r 500 Staples Drive c% Taxes & Licenses must be corrected immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) Approved Food or Color Additives PASS RED' I BLUE Violations Related to Good Retail Practices (Blue Violations Related to Toxic Chemicals - PASS Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS (Potentially Haz Not Done and Risk Factors (Require:. Cooking Temperatures N/A immediate corrective action) '- 11 items removed from the shelves at time Other- See Notes N/A Reheating N/A Cooling N/A expiration dates. Hot and Cold Holding N/A Time As a Public Health Control N/A REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP N/A LI RED ❑d RED L/ RED ❑d RED ❑d RED ❑d RED ❑/ RED RED the Office CONSUMER ADVISORY Not Done ❑ BLUE Posting of Consumer Advisories N/Ad❑ RED BLUE Violations Related to Good Retail Practices (Blue Not Done ❑ BLUE Management and Personnel PASS ❑ BLUE BLUE Food and Food Protection FAIL Critical ❑ BLUE 11 items removed from the shelves at time Other- See Notes N/A ❑ of inspection. Closely monitor all expiration dates. Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other- See Notes N/A ❑ BLUE GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 21,2005) Page 2 oft 4 STANLEY J. USOVICZ, JR. MAYOR A t T !• CITY OF SALEMI, MASSACHUSE BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Staples the Office Superstore Address of Establishment: 17 Paradise Road Owner's Name: Staples the Office Superstore East Inc Restrictions: Application Date: 11/19/04 Permit for Food Establishment 30-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT „r CITY OF SALEM, MASSACHUSE� 0 BOARD HEALTH t4 U = 120 WASHINGTON STREET S, 4TH FLOOR SALEM, MA 01970 4 7 cam' STANLEY J. UISOVICZ, JR. MAYOR 2005 APPLICATION FOR NAME OF ADDRESS OF ESTABLISHMENT MAILING ADDR OWNER'S NAM TEL. 978-741-1800 Nov 2 04 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO CITY OF SALEM HEALTH AGENT BOARD OF HEALTH P RMIT TO OPERAIE Q ESTABLISHMENT It TEL # ESS (if differentj5� E `� �/ 0 TEL #Sir -- 3 ADDRESS,' CITY STATE`ZIP 0;� CERTIFIED FOOD MANAGERAME(S) CERTIFIC<'aTE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Y1 lS HOME TEL # l�44 '� Z54HOURS OF OPERATION: Mon.O---?/'Q� Tue. ” Thu. 7`l Fri.9 —tat. yI? Sd1` n. —7m "vg� TYPE OF ESTABLISHM T RETAIL STORE E NO RESTAURANT YES NO BED/BREAKFAST YES 10 FEE check only less than 1000sq.ft. 1000-10,000sq.ft. more than 10,000sq.ft. less than 25 seats 25-99 seats more than 99 seats ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES TOBACCO VENDOR YES ALL NON-PROFIT (such as church kitchens) YES =$ 50 =$100 =$250 =$100 =$150 =$200 $100 $5 $50 $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all slate taxes required under the law. Signa re Date 15 Social Security or Federal Identification Number Revised 11/03/03 FO A 2. adm Checktf & Date6_15j3 STAPCIES Vendor: 336282 SALEM, CITY OF Inv. Date 0 Charge Back TAX217FOOD041116 Check: 2083091 11/16/04 50.00 50.00 Charge Back 9T1 Wise. Returned to vendor AA7 Canon Shortage Codes: FTR Freight out Total: Sso.00 o.00 gso.00 FGT Freight in AA2 Unfavorable cost variance Patent 354,308 STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Staples the Office Superstore Address of Establishment: 17 Paradise Road Owner's Name: Staples the Office Superstore East Inc Restrictions: Application Date: 12/4/2003 Permit for Food Establishment 120-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. AGE' N , • u CITY OF SALEM MASSACHUSETTS BOARD OF HEALTH 3 120 WASHINGTON STREET, 4TH FLOOR NOV 17 2063 SALEM, MA 01970 /f' 1 TEL. 978-741-1800 S FAX 978-745-0343 UIT i ' f r SALEM STANLEY USOVICZ, JR. .JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION+ FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT" `� TEL #—q /�"/ IS / - / c ADDRESS OF ESTABLISHMENT Ck S e MAILING ADDRESS (if different) -'500 SACD Jc . ir_ �� m ply � �, mA- OWNER'S ADDRESS 5015 CITY STATE' ZIPS. CERTIFIED FOOD M?.NAGE. 'S NAMES) CERTIFICA (required in an establishment where potentially hazardous food is prepared.) -5o&l EMERGENCY RESPONSE PERSON HOME TEL # JJ HOURS OF OPERATION: Mon:Tue Wed.�hu.Fri.Sat.Sun.�t2 {p TYPE OF ESTABLISHM RETAIL STORE YES NO p� RESTAURANT YES QNO BED/BREAKFAST YES 0 FEE check only less than 1000sq.ft. P100 1000-10,000sq.ft. more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 $100 ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT (such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, SectbD_49A,-I certify under the pains and penalties of perjury that I, to my hes knowledge and elieahavEhfile,d all to to c returns and paid all state taxes requiredundeq, 'heella onatureate Social Security o Fed al Identification Number Revised 11/03/03 FOODAP2.adm Check#& x,50._ Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4`" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name sem. D e r� Type of Operation(s) T e of Inspection 0 F9od Service 21getall outine ❑ Re -inspection S FLS -Si 7 6 U a Address Risk 7 6 AA Level ❑ Residential Kitchen Previous Inspection Telephone *7&01, L L.. E] Mobile ❑ Temporary Date: ❑ Pre-operation Owner HACCP YM j,&pElCaterer ❑ Bed & Breakfast ElSuspect Illness ❑ General Complaint Person in Charge (PIC) Time In: Out: Permit No. ❑ HACCP ❑ Other Inspector f tacn violation cneckea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. "FOOD PROTECTION MANAGEMENT .m ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION :�- - ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. 23. Management and Personnel (FC -2)(590.003) 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 S5901n p aForm 14 Eoc ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS T ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals `TIMEITEMPERATURECONTROLS (Potentially Hazardous Foods) �❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY. SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY_ _ .. ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: I spe ton'is ig it A Print: IC,s aturr`- Print: ,os P Page % of�Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) a 3.73.1 1146104PRI7i#zlaETC] 4,ti MA al 990.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2 103. S 1_ Pelson 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 Fluid Milk and Milk Products* applicants* Shell E-0 590.003(F) Rcsponsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Repots' To The Person Li Drinking Water from an A moved System* 590.006(A) Charge* 590.006(B) 590.003(0) Re crating b Person in Char �e* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 0 in 6 C 'K Denote, critical dem w the twlual 1999 Food Code or 105 CMR )90,000. g Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Fond in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell E-0 3-202.14 Eg s and Milk. Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.1 I Drinking Water from an A moved System* 590.006(A) BotttcdDrinkingWater* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Ve«etables SheiNish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Iasted Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Reoulatory Authofi 3-20118 1 Shellstock Identification Present* 590.004(0) Wild Mushrooms" 3=201.17 Carne Animals* 3-701.11. Receiving/Condition 3-202,11. PHFs Received at Proper Temperatures* 3-202.15 Package Snte it 3-101.1.1 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* 3-40212 Records. Creation and Retention* 590.004(1) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of E-ui meet* Conformance with Approved Procedures 1HACCP Pians 3-502.11 Specialized Processin> Methods* 3-502.12 1 Reduced oxygen packaging, criteria* 8-103.12 1 Conformance with A roved Ptacedures* 'K Denote, critical dem w the twlual 1999 Food Code or 105 CMR )90,000. g Cross -contamination 3-302.1 ] (A)(,1) Raw Animal Foods Separated from Coked and RTL L Foodsl` Contamination from Raw ingredients 3-302.11.(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-30211(A) I Food Protection* 3-30275 Washing Fruits and Ve«etables 3-304-11 Food Contact with Equipment and Utensils` Contamination from the Consumer 3-306.14(V0) Returned Food and Reserviee of Foal* Disposition of Adulterated or Contaminated Food 3-701.11. Discarding of Reconditioning Unsafe Food* 9 Food Contact surfaces 4-501.111 NbuualWarewashing- HotWater Sanitization Tent eranness` 4-501-112 Mechanical War'ewashinb Hot Water Sanitization Temperatures" 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(. Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702-'I I Frequency of Sanitization of Utensils and Food Contact Surfaces of E-ui meet* 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 2-401.11 Eatin ,Drinkin=or Using Tobacco* 2401.12 Discharges Froin the Eyes. Nosy and Mouth* 3-301.12 Preventing Contamination When Tastin t* 12 Prevention of Contamination from Hands 590-004(E) Preventing Contamination from Em to gees* 13 Handwash Facilities Conveniently located and Accessible 5-203.'11 Numbers and Capacities* 5-20411. Loc ationn and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-30L11 llandwashing Cleanser. Availability 6-301.12 Hand Drvin g Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: SV_4110145 /r4t,, _ Date: a I ' O U Page:_ of Item Code C - Critical Rem DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R - Red Item Verified PLEASE PRINT CLEARLY -/; s tir) - . r LJO S '!tt i t t piscussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal F d Code. I understand that noncompliance may result in daily fines of tw ty-five dollars of suspens vocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i Violations Related to Foodborne Illness Interventions and Risk Factors (items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 16 17 r •• Food or Color Additives 3-202.12 Additives* 3-302.14 Protection tromlJna) coved Additives* _LOI. i i (C) Poisonous or Toxic Substances 7-101..11 Identifying Information - Original Containers* 7-102-11 CommonName-Working Containers* 7-2011 I Se aration - Storaee* 7-202.1.1 Restriction - Presence and Use* 7-202.12 Conditions of 11sc* 7.203.1.1 Toxic Containers - Prohibitions* 7-204.11 Sanitize", Criterin - Chemicals* 7-204.12 Chemicals for Washine Produce, Criteria'' 7-204.14 Drying A eats- Cnterla* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-2--06.12 Rodent Bait Stations" 7-206.13 Tracking Powders, Pest Control and Monitoring* r •• ^ Denotes Critical item in the trderal 1999 Food Code or 105 CMR 590PO0. Proper Cooking Temperatures for Fg PHFs 3-401.11A(l )(2) . Eggs- 155"17 15 Sec. _LOI. i i (C) Ea>s-IumtediateSeraice 145°F7>sec" 3-401.11(A)(2) Comminuted Fish, Meats & Game .004 Animals - 155'F 15 sec, * 3-401.1 I(B)(1)(2) Pork and Beef Roast - 130°F 121 nun* 3-401.11.(A)(2) Ratites, Injected Meats -155"F '15 Poisonousor Tows Materials sec. * 3-401.11 (A)(3) Poultry, Wild Game, Stuffed PHFs, S eciai Re uirements Stuffing Containing Fish, Meat, 1.009 Poultry or Ratites -165"F 15 sec. *- 3-401.11(C)(3) Whole-musele,'hrtactBeef Steaks 145"F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165`F * 3-401..11(A)(I)(b) All Other PHFs - 1.45'F 15 sec. Reheating for Hot Holding 3-103.1 ](A)& (D) PHFs 165='F 15 sec. 3-403.11(B) Microwave -165" F 2Minutia Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140"F 3-40111(E) Retnahting Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501,A(A) Cooling Cooked PHFs from 140'17 to 70'F Within 2 Hours and From 70'F to 41'F145'F Within 4 Hours. 3-501.14(8) Cooling PRFs Made From Ambient Temperature Ingredients to 41 `F/45'F Within 4 Hours* ^ Denotes Critical item in the trderal 1999 Food Code or 105 CMR 590PO0. N r� r 3-80 Ll I (A) 3-501.14{C) PRFs Received at Temperatures According to L.aw Cooled to 4t'F145`F Within 4 Homs. Fg 3-501-15 Carlin- MetlnrdsforPHF's 3-801 I I iD) PHF Hot and Cold Holding _LOI. i i (C) ?-501.16(B) Cold PFIFs Maintained at or below 590,004(F) 41°145°F" Not Otherwise Processed to Elhninate 3-501.16(A) Het PHFs Maintained at or above 14W F .004 3-50116(A) Roasts Held at or above 130"F. 24 Time as a Public Health Control Pasteurized Eggs Substitute for Raw Shell 3-50119 Time as a Public Health Control* Poisonousor Tows Materials ar 590.004(H) Viance: Re uirement N r� r 3-80 Ll I (A) Unpasteurized Pm -packaged Juices and Beverages with Warning labels* 3-801.IJ(B) Use of PaswitizWami M 3-801 I I iD) I Raw or Partially Cooked Animal Food and Raw Seed S gouts Not Served. _LOI. i i (C) Una ened Food Package Not Re-serned. 22 3-603.11 Consumer Advisory Posted for Consumption of 23. Mata oment and Personnel Animal Foods'Phat are Raw, Undercooked or .003 24. Not Otherwise Processed to Elhninate FC - 3 .004 Pathavens* " a ""' and Utensils Water, Piumbinp and Waste Physical Facili � _.. _ 3-302.13 Pasteurized Eggs Substitute for Raw Shell 28. Poisonousor Tows Materials Eggs* 5r'MUAL flea UlHtMtN 15 590.00WA)-(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary raid 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 4129 - Special Requirements. Yf0"0I0+ f e r (Items 23-30) Ciiticol and reon-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Fond Code and 105 CMR 590.000 Item Good Retail Practices FC 590.000 - 23. Mata oment and Personnel FG -2 .003 24. Food and Food Protection FC - 3 .004 25, _Equipment 27. and Utensils Water, Piumbinp and Waste Physical Facili � _.. _ FC - 4 FC 5 FC - 6 .005 _.006 j .007 28. Poisonousor Tows Materials FC -7 .008 29. S eciai Re uirements 1.009 30. Other savor, �,,,m,ea.z.,wc