BANI MARKET - ESTABLISHMENTS (2) B ni M?rket
73 Harbor Street
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' CITY OF SALEM,
MASSACHUSETT'S
BOARD OF HEALTH 1th
N1 Prevent.Promote.Protest.
120 WASHINGTON STREET,4°'FLOOR �1
KIMBERLEY DRISCOLL TEL. (978) 741-1800 Fax (978) 745-0343
Itamdin@salem.com LARRY R\MDIN,RS/Rkl IS,(1110,Cl'-F.;
S
MAYOR H I:?.V,II I AGI{N'P
August 10, 2015
Bani
70 Harbor Street
Salem, MA 01970
Dear Owner:
On Monday July 27, 201512:47pm personnel from the Tobacco Control Program conducted a compliance check
to determine if your permitted establishment would sell a tobacco product to a minor. A 17 year-old female
purchased tobacco from a clerk in your store. Documentation is now on file at the Board of Health regarding
that sale.
Ban! is in violation of Section III (A)of the Salem Board of Health Regulation Affecting the Sales of tobacco to a
minor. According to this section,the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms
to any person under the age of eighteen shall be punished by a fine of$100.00 Hundred Dollars for the first
offense.
FOLLOWING THE THIRD(3"0)OFFENSE, THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR
SUSPENSION OF THE PERMIT.
The North Shore/Cape Ann Tobacco Alcohol Policy Program and the Salem Board of Health have worked with you
and your employees to demonstrate methods to ensure compliance with this regulation.
Therefore, you are ordered to pay a fine of$100.00 for the violations stated above. A check or money order
payable to the City of Salem must be at the Board of Health office, 120 Washington Street, 4th floor, within
ten days of receipt of this notice.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A
request for such a hearing must be received in writing in this office of the Board of Health within seven(7)days of
receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and
documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an
attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or
investigation reports, orders, and other documentary information in the possession of this Board, and that any
adverse party has the right to be present at the hearing.
If you have any questions regarding this notification please call me at 978-741-1800.
Sincerely yours,
urrs �—
La Ram ill n
Health Agent
LR/hlp
CERTIFIED MAIL: 70121640 0002 3313 1246
cc: North Shore Tobacco Control Program
Dr. Shama Alam, Board of Health Chairperson and Members
.� Violation Notice
City Yown > Board of Health
PublicHealth
Prevent. Promote. Protect.
This notice is to inform you that your establishment violated the Board of Health Sale of Tobacco Products
&Nicotine Delivery Products and/or Environmental Tobacco Smoke(ETS)Regulation.
Nam'-of
Address
Date bf violation Time of violation Minor's age/gender Minor's ID#
(Ordtnpncg,Setction'Regulat�a
t _
(Act Constituting Violation)
Narrative information: ��t
liaffirm,under th pains and penalties'f perjury,that the above report is true to the best of my knowledge
and belief.)
Inspec16r N1 ignature) (Print name)
VENDOR STAQTMENT;II acknowledge I received this Violation Notice on 20A4—
a[ f� •�1 �M/i�and I am being given a carbon copy of this notice.I also,acknowledge that I
have been informed that the Peabody Board of Health will provide additional,follow-up information to
this violation notice.
wn�;er/Manager%Clerk(Signature) (Print name)
I
If-bendor refuses this Notice or if the inspector feels unsafe in delivering it,an explanation must be
written on a note attached hereto.Mailing of this Notice is thus required.
Contact the North Shore/Cape Ann Tobacco Alcohol Policy Program at 781.586-6821 with questions
Establishment-white NSTCP-yellow Board of Health-pink
SENDER: COMPLETE THIS SECTION COMPLETE THIS ON ON DELIVERY
■ complete it¢fia 1,2,and 3.Also complete A. ature
item 4 if Restricted Delivery is desired. 0 Agent
■ Print your name and address on the reverse X 0 Addressee
so that we can return the card to you. eived by(Footed Name) C. ate o:Deli ry
■ Attach this card to the back of the mailpiece, F'
or on the front if space permits. K�
t. Article Addressed to: D. Is delivery address different flnm item 1? 0 Yes
If YES,enter delivery address below: 0 No
6641.
�- s 3. Service Type
❑Certified Made Cl Priority Mall Express'
UQJ,/.N./ 7 v ❑Registered 0 Return Receipt for Merchandlse
_ P 4. 0 Insured Mail 0 Collect on Delivery
Restricted Delivery?F Xm Fee) 0 yes
2. Article Number 7012 1640 0002 3313 1246
(transfer from service lebeq
PS Form 3811,July 2013 Domestic Return Receipt
UNITED STN,',E>< M SERVICE First-Class Mail
., .� Postage S Fees Paid
USPS
:L +� Permit No.G-10
I � a.
• Sender: Please print your name, address, and ZIP+4®in this box*
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IjOO°� BOARD OF HEALTH
SALEM, MA 41970
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U.S. Postal Service,u
CERTIFIED MAIL,. RECEIPT
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Frn Postage $
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cerogaaFea
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O Return Receipt Fee Here
to (Endarsemerd Required)
O Restdetad1VV1 ty Fee
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(Endorsement Required)
Total Postage&Fees
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Sent To
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City of Salem, Massachusetts
Board of Health
e 120 Washington Street, 4th Floor, Salem, MA 01970
FP Tel. (978) 741-1800 Fax. (978) 745-0343 PublicHeaIth
Iramdin@salem.com Prevent. Promote. Protect.
Kimberley Driscoll Larry Ramdin RS/REHS, CHO, CP-FS
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2015
Permit Number: FM-15-235
Permit Type: Retail Food < 1000 sgft
Goods&Services: Retail Food: 0- 1,000 sq ft
Name of License Holder: Ban! Market/Francisco Pena
Name of Food Establishment Bani Market
Address of Food Establishment 73 Harbor Street Salem MA 01970
Restrictions:
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2015 unless sooner suspended or revoked.
Permit Fee: 70.00
Issued: 1/1/2015
/ City of Salem, Massachusetts
Board of Health 10 1
120 Washington Street, 4th Floor, Salem, MA 01970 Public Health
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin RS/RENS,CHO, CP-FS
Mayor Iramdin@salem.com Health Agent
TOBACCO SALES PERMIT
Permit#
TO-15-47 License For : Tobacco
Date of Print
2/26/2015 Granted To: Ban! Market/ Francisco Pena
Permit Issued
1/1/2015 Address: 73 Harbor Street Salem MA 01970
Permit Expires
12/31/2015 Location of Establishment: 32 Harbor Street
Permit Fee
$135.00 Restrictions:
Late Fee
$0.00 Notes: 73 Harbor Street
This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2015 , unless
sooner revoked or suspended.
Health Agent
f
t Q• CITY OF SALEM,
MASSACHUSETTS
rLbttcxeatth
BOARD or•HI,,v.�rl-r •,`.,",.`.,",`.��.`.
120 WASHINGTON SIREET,4TH FLOOR
KI114BERLEY DRISCOLL TI 1..(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/R51-IS,CI 10,CP-FS
Iramdin e Salem.Com
MAYORHI ;\1:1'11 ACIEN'I'
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: t. PA
2) Establishment Address: 39-,4-4bOAIS/-
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: ?7-7. TWL {fix
5) Applicant Name&Title: 6
6) Applicant Address:
7) Applicant Telephone No: 24 Hour Emergency No: 7#11.V1 Email: r4e
8) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
An individual
A partnership
Other legal entity
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge,Supervisor,Manager,etc.
Name&Title:
Address:' , S t4 SS W
Telephone No: 9.!k-7q#tg,?1Fax: M 7 Email: Q I MAI/.
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: f Date: o' Amounte 7,,Q Q
Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: (if applicable)
16) Days and Hours of Operation: 17) No.of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) At Retail( Sq.ft) ❑Caterer
Permanent Structure ❑ Food Service—( Seats) ❑ Frozen Dessert Manufacturer
Mobile ❑ Food Service—Takeout ❑ Residential Kitchen for Retail Sale
0 Food Service—Institution ❑ Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: _Breakfast Establishments---------------------•
(check one) RETAIL STORE RESTAURANT
Annual 0 Less than 1000sq.ft. $70 ❑Less than 25 seats $140
Seasonal/Dates: ❑ 1000-10,OOOsq.ft. $280 ❑Residential Kitchens $140
❑More than 10,OOOsq.ft. $420 1125-99 seats $280
O More than 99 seats $420
TemporarylDatesMme:
❑Bed&Brea kfast/-Chi[dcare Seryices(Nursing Home $100
------------------------------------------------------ ----------------------------------- ---------------- ------------------------------
ADDITIONAL PERMITS
O MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
❑ALL NON-PROFIT" $25
*Including, church kitchens, state funded childcare&private club
23) Food Operations: Definitions: PHF—potentially hazardous food(time/temperature controls required)
Non-PHFs—non-potentially hazardous food(no timattemperature controls required)
(check all that apply): RTE—ready-to-eat foods L6L.sandwiches,salads,muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs 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
Service Within 4 hours contact alternative,time as public health
control.
j Customer Self-Saraice of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
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:
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
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant: Ati� d v /J.6�r
Pursuant to MGL Ch.62C,sec.49�A,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: � —� ^
�/�pJ
26) Signature of Individual or Corporate Name:
e
CITY OF SALEM, MASSACHUSETTS
BOARD OF FIEALTH PublicHeaith
120 WASHINGTON STREET,4"'FLOOR
Prevent,Promote.Pmicel.
TEL. (978) 741-1800 Fax(978)745-0343
KIMBERLEY DRISCOLL Itamdin@salem.com
L,anxv aAnaD1N,as/luqls,cllo,c;r-Fs
MAYOR Hj;m rH AGi;Nf
201_APPLICATION FOR PERMIT FOR SALES OF
TOBACCO & NICOTINE DELIVERY PRODUCT
PERMIT FEE $135
NAME OF ESTABLISHMENT 1-30 All / 1L� rr TEL#
ADDRESS OFESfABLIS'HMENT— Fffl4l�bcr>� `nLdcP� FAX# Cf 7�/hf 3336
DEPARTMENT OF REVENUE APPLICATION NUMBER:
MAILING ADDRESS(if different)
EMAIL-,Business': Pe_N4b"i8S24MAdC°DAA Website:
OWNER'S NAME t—,9AAJQ1'rr // Al(4- TEL#���
ADDRESS Z ZA4• T/�2C2� ! � M A55 Ql F6 D
STREET CITY STATE ZIP
EMERGENCY RESPONSE PERSON f t� A MCS/SCO P-P— TA HOME TEL#
Type of Products Sold: Cigarettes LICigars el_� Chewing Tobacco Pipe/Cigarette Tobacco vNicotine Delivery
Devices_ Other Tobacco Product(list on additional Sheet)
DAYS OF OPERATION Monday . I Tuesday Wednesday . i Thursday ( Friday Saturday Sunday
i i
HOURS OF OPERATION RM 1 � AA �M ' i �T R M (p M
Please write in time of d r
(For example llam-11pm ! Jg nnPA /a�� p
*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. /
!l l4A=Cbfc� 62—az
Signattre V Date Social Security or Federal Identification Number
/y� ----------- -- yy - ----------------------
Updated 723/12 TOBACCO.doc Check#&Date / �`- �( �k`' $ jjr,(�
.Na
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978)741-1800 Fax(978) 745-0343
Citi /Town of � Address:
FOOD ESTA LISHME P CTION REPORT Tel.
Name a Date 7 Type of Operation(s) Type of Inspection
MIA& J ❑r-��Food Service El Roytine
Address Risk L*Retail I inspection
Telephone Level ❑ Residential Kitchen Previous Inspection
❑ Mobile Date:
Owner HACCP YM ❑ Temporary ❑ Pre-operation
❑ Caterer ❑Suspect Illness
Person-in-Charge(P Tim Bed& re ast ❑General Complaint
ElHACCP
Inspector - Out: , Permit No. El.Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti Choking 590.009(E) ❑
Violations marked may Tobacco 590.009(F) ❑.
y pose imminent health hazard and require immediate ❑
corcective action as determineedd by the Board of Health. Allergen Awareness 590.009(G)
r_FOOD PROTECTION MANAGEMENT _ __ _ ' ❑12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE
❑ 13. Handwash Facilities
.' - �. . _ _ . _
,PROTECTION FROfN'CHEMICACS
❑ 2. Reporting of Diseases by Food Employee and PIC [114.Approved Food or Color Additives _
E] 3. Personnel with Infections Restricted/Excluded
.__ _._ _ _ _ .- _ - ❑ 15.Toxic Chemicals
FOOD'FROM APPROVED SOURCE _
F14. Food and Water from Approved Source_ "TIMErrtMPERATURE.CONTROLS_ (Potentlalty Hax_ardous Fpods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling
PROTECTION FROM CONTAMINATION .__ _ , _ _ _ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20. Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
e REQUIREMENTS FOR HIGHLY4US..CEPTIBLE=POPULATION3'(HSP)',_
E]21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices ,CONSUMERADVISORY,
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices.(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical (N)violations must be corrected Official Order for Correction:Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel FC-3X 90.00 a) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-sXsso.00a) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (Fcs)(590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or oxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address
29. Special Re it me s (590.009) within 10 days of receipt of this order.
+30. Other DATE OF RE-INSPECTION:
$: �f94OC
Inspector's Signatu Print:
PICS Signature: -Print: L�✓ Page�. of
�,Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
* 3-302.11(A)(1) , Raw Animal Foods Separated from
1 590.003(,0) DemAsso meat of of Knowledge*
Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge"` Contamination from Raw Ingredients
2-103.11 Person in charge-duties 3-302.1l(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Omer"
Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-02.11(A) Food Protection* -
require reporting by food employees and 3-302.15 Washing Fruits and Ve etables
applicants*
590.003(1) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
*
Utensils
Applicant To Report The Person In Contamination from the Consumer
Charge*
590.003(Ci) Reporting by Person in Chavez* 3-306,14(A)(8) Returned Food and Reservice of Food*
31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
Food
590.003(E) Removal of Exclusions and Restrictions 3-70L I i Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE F1od* _
q Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance liance with Food Law* 4-5C)1.111 Manual Wazewashing-Hot Water
3-201.12 Ftwd in a Hermetically°Seated Container* Sanitisation Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water .
3-202.13 Shell Eggs* Sanitization Temper res*
3-202.14 Eggs and Milk Products.Pasteuriard* 4-501.114 Chemical.Sanitization-temp.,PH,
3-202.16 Ice Made From Potable Drinking W'ater* concentration and hardness. *
5-i ol.1I Drinking Water from an Approved S tem* 4-601_11(A) Equipment Food Contact Surfaces and
590.006(.',) Bottled Drink-ng Water* - Utensils Clean*
4-602.11 Cleaning Frequency of Equipment Fob
590.006(B) Water Meets Standards in CMR 22 e Surfaces and Utensils*
Food-
Shellfish and Fish Froman Approved
oved Source Contact Su
4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Mol,iuscan
Shellfish* Food Contact Surfaces of Equipment*
4-703.11 Methods of Sanitization-Hot Water and 7
3-201.15 Ntnlluscan Shell fish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wildority oms Approved by 2-301,11 - Clean Condition-Hands a=rms*
Regulatory Authority _
3-202.18 ShellstockIdentification Present* 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms*~ 2-301.14 When to Wash*
3-201.17 Game.Animals*- ll Good Hygienic Practices
-
5 Receiving/Condition 2-401.11. Eating,Drinking or Using Tobacco*
3-202.1.1 PHFs Received at Proper Temperatures* 2-401.12 Discharges.From the Eyes,Nose and
3-202.15 Package hue it'* - Mouth*
3-1;)1.11. _ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination.from
3-203.12 Shellstgckldentification Maintained" -� Employees*.
Tags/Records:Fish.Products 13 Handwash Facilities -
3-402.11 Parastte.Destructive!*
Conveniently Located and Accessible
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590,004(7) Labeling o1 Ingredients* 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11. Accessibilit , Operation and Maintenance
IHACCP Plans Suppled with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502.12 .Reduced oxygen packaging,criteria* - 6-301.11 Handwashin Cleanser,.Availabili
8-103.!2 ConfoimancewithA roved Procedures* tr301.12 Hand Drying Provision
Denotes critical item in-the.federal 1999 rood Cede or 105 CM:R 590.000,
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: J�QlDate: ; � Page: of
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,
No. Reference R-Red Item Varnled
P EASE Pr
IN LEARLV
r
r
Y
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
r noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
3-501.14(0 PHFs Received at Temperatures
Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to
Factors Memo 1-22) (Cant.) 41F/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS3-501.15 Cooluip Methods for PHFs
t 14 - Food or Color Additives 19 PHF Hof and Cold Holding
3-501.16(B) Cold PRFs Maintained at or below
3-202.12 Additives*- 590.004(()
3-302.14 Protection from Una roved Additives* 3-501,16(A)
F*
r - 3-SOl.lfi(A) H Hot PHFs Maintained stir above
15 Poisonous or Toxic Substances 140014. *
t 7-101,11 identifying Information-Original 3,501.16(A) Roasts Held at or above 1300F.
Containers*
7-102.11, Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* - 3-501,19 Time as a Public Health Control*
7-202.11 .Restriction-Presence and Use° 590•004(H) Variance Requirement
7-202.32 Conditions ofl se* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
s 7-203.11 Toxic Containers-Prohibitions*
7-204.11 Sanitizers.Criteria=Chemicals* POPULA7)ONS HSP
7-204.12 Chemicals for Washing Produce,Criteria' 21. 3-$01.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Agents.Criteria*
Beverages with Warning labels*
3-801.11(6 Use of Pasteurized Ea *
7-205.1 I Incidental Food Contact.Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served.
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring:* CONSUMER ADVISORY
22 3-603.11 Consumer Advisory Pasted for Consumption of
TIMEtfEMPERATURE CONTROLS
Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
16
PHFs Na OtherwiseProcressed to Eliminate
340i.IIA(1)(2) Eggs- 155F15See. Pathogens,'F'
Eggs-Immediate Service 145°F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shen
E
31401.11(A)(2) Comminuted Fish.Meats&Game
*
Animals-155°F 15 sec. *
t
3-401.11(B)(1)(2) Pork and Beef Rist- 130°14121 min* SPECIAL REQUIREMENTS
3401.]I(A)(2) Ratites,Injected Meats''-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
' see.* catering,mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Staffing Containing Fish,Meat, debited under the appropriate sections
? Poul or Ratites-165°F 15 sec. * above if related to foodborne 'illness
° 3-401:ll(C)(3) . Whole-muscle,intact Beef Steaks interventions and risk factors. Other
tl 145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#39-
t Microwave 165°F* , Special Requirements.
3-40LII(A)(1)(b) All Other PHFs- 145°F 15 sec.
17 Reheating for Hot Holding WOLA77ONS RELATED TO GOOD RETAIL PRACTICES
3-403A I(A)&(D) PRFs 165"F 15 sec.* (Items 73-30)
3-403.11(B) Microwave-'165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the -
Tunc* , Joodborne illness interventions and risk factors listed above, can be
3-403.11(0 - Commercially Processed RTE Food- found in the following sections-qf the Food Code and 105 CMR
140°F* 590.000.
tItem I Good Retail Practices .FC 07 00
3-403.11(E) Remaining tinslic�ed Portions of Beef i 590.r
i Roasts" 23, i Management and Personnel FC-2 .003
18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004
25. i Equipment and Utensils I FC-4 .005
i 3-501.14(A) Cowling Cooked PRFs front 140`F to 26. i Water.Plumbinq and Waste `: FC-5 .WB ,
70`F Within 2 Hours and From 70"F 27. Physical Facility 1 FC-6 .007
to 41`F/45°F Within 4 Hours.° 28. Poisonous or To)is Materials s FC 7 .008 '
3-501.14(11) Cooling PER Made Fmm Ambieni 29. S o cial Requirements ,009
Temperature,Ingredients to 41OF/45°F 30. Other
Within 4 Htaus* s:svnr,s,:o.•.c:
"Dinores criticat wm in the federal 1999 Food CMe or 105 CMR 590.000.
'1
r
` City of Lynn BOOK 8 PAGE 29W "45
Business Certificate
RECEIVED
OFdOMMARCH 7r 2011
Date of Issue: MARCH 7. 2011 MI MAIL -1 A IQ. 3b
-This Car"cate Expires: MARCH T. 2015 (171 NEW FILING t.YIIN, fq�FENEWAL
Under the provisions of Chapter One Hundred Ten. Section Five of the General Laws, as amended, the
undersigned hereby declares that a business under the title at:
LA SABROSONA is being conducted at: 141 CHATHAM ST.. L fNN. MA
BY THE FOLLOWING-NAMED CORPORATION OR
PERSONS OR CORPORATION RESIDENCE ADDRESS
FULL NAME
ADALBERTO BATISTA 85 ESSEX ST., LYNN, MA 01902
SIGNED:
IMPORTANT NOTICE: This Certificate expires four years from the date of issue. If you cease conducting
business before that time,the law requires that you contact the City+.lark and withdraw this Certificate.
Contact Telephone Number. 781-24&7345 Type of Business: ESE TAURANT
BUSINESS CERTIFICATE FILINGS ARE NOT A LICENSE TO CONDUCT BUSINESS, ANY PERSON
WISHING TO CONDUCT BUSINESS MUST, IN ADDITION TO THE ABOVE, CONTACT THE ZONING
ENFORCEMENT OFFICE TO ENSURE THAT THE BUSINESS LOCATION IS IN COMPLIANCE WITH CITY
ZONING LAWS.
THE COMMONWEALTH OF MASSACHUSETTS
Essex, ss. Date: MARCIJ 72011
Personally appegred before me,the above-named AVASERTO 8fXISTA on this date and made oath the the
foregoing statement is true.
Jus01
of I otary Public
My Cornmissior expires:
`�• ealariaaus
A TRUE COPY ATrt'EBTt d4 uxuanr: to15
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4"'Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
City/Town of fern _ Address:
FOOD ESTABLISHMENT IN511EPTION REPORT Tel.
Name D Type of Operation(s) T pe spection
t�lj ❑ Fo d Service MU-01-Ing
Address Ri etail Re inspection
Telephone Le el El Residential Kitchen Previous�l p�ction
❑ Mobile Date: '� ''
Owner �' HACCP YIN ❑ Temporary ❑Pre op ration
❑ Caterer ❑Suspect Illness
Person-in-Charg (PIC) Tim ❑ Bed& eakfast ❑General Complaint
In: �oI ❑ HACCP
Inspector Out: Permit No. ❑.Other
ZOW
Each violation h requi s an-explanation on the narrative pages)and a citatio f pecific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors-(Red
Items) _ Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
❑
corrective action as determined by the Board of Health. Allergen Awareness 590.009(G)
FOOD PROTECTION MANAGEMENT _ _. -_ _ _ _ _ _ , ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH - _ 1 - _. �_- -. _
. - - -- - - - - ._ _• _-- . .
;PROTECTION FROM`CHEMICALS__
❑ 2. Reporting of Diseases by Food Employee and PIC - u
[114.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted[Excluded
_. . . . .____ ...1 ❑ 15.Toxic Chemicals
,.1 0005*RAP
OM H_ROVEDSOURCE_ _ - ti� ,
" - -�- - TIMEREMPERATURE"QONTROLS.(t?otentlallyHaxardo.usF Food
E] e) i
4. Food and Water from Approved Source _- - - -.
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling
PROTEMON FROM CONTAMINATION. __ - - _ - ❑19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection L ❑20.Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUS_.CEPTIBLE=POPULATIONSf(HSP): -1
❑ 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY_ _ -_
El 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2x order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3xe90.003)0.00a) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-axsso.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (FC5)(590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address
29. Special Requir (sso.00s) within 10 days receipt this prd r
30.Other . DATE OF RE-INSPEC ION::Ji]VI C
Inspector's Signature: Print: 1
PICS Signature: .-�,,,�,L Print: 1 - Page I of�ages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003(A) Assignment of Responsibility* 3-302.1.1(A)(1) Raw Animal Foods Separated from
- Cooked and RTE Foods*
590.003(6) I Demonstration of Knowledge" - Contamination from Raw Ingredients
2-103.11 Person in charge-duties 3-302.1 I(A)(2) Raw Arumal Foals Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection*
require reporting by food employees and 3-302.15 Washin Fruits and Ve etables
a licants* - 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Fool Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge* - 3-306.14(A)(B) Returned Food and Reservice of Fund*
590.003(G) Re ottin b Person m Charm* ReturnedDispositiieof Adulterated ryc�r Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3MI.I I Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE F0 d*
d Food and Water From Regulated Sources F9 Food Contact Surfaces
590.004(A-B.) Compliance with Food law* 4-501..111. Manual Wazewashing-Hot Water
3-201.12 Food in a Hermetically Seated Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water .
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 ice Made From Potable D mkiag Water* concentration and hardness. *
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Fold Contact Surfaces and-
590.006(A) Bottied Drinkinv Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR.220* 4-602.1 Cleaning Frequency of Equipment Food-
Shellfish and Fish From an Approved Source Contact Surfaces and Utensils*
PPr 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreational'iy Caught Molluscan Food Contact Surfaces of Equipment*
SItclLish* _ 4-703.11 Methods of Sanitization-Hot Water and
3-207.15 Molluscan Shellfish from NSSP listed 4-70111
Sources* 10 Proper,Adequate Handwashing
Regulatory Game and Authority
Mushrooms Approved by 2.301.11 Clean Condition-Hands and Arms*
�Authoritut
3-20218 Shellstac:kiden2iticationPresenO 2301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* it Good Hygienic Practices -
Receiving/Condition 2-401.11 Eating,Drinking or UsiE&Tobacco*
3-202.11 PHFs Received at Proper Temoeramres* 2-401.12. Discharges.From the Eyes,Nose and
3-202.15 Package rote. it y - Mouth*
3-101.11 _ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shelistock L12 Prevention of Contamination from Hands
3-202.18 -Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.1.2 Shellstock Identification Maintained* Em plo es*
Tags/Records;Fish Products 13 Handwash Facilities
3-402.1 t Parasite Destruction'
--- Conveniently Located and Accessible
3-402.12 Records,Creation and Retention" 5-203.11 Numbers and Capacities*
590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement*
� Conformance with Approved Procedures
5-205.1.1 Accessibility,Operation and Maintenance
/HACCP Plans Stipplled with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices-
3-502.12 Reduced ox en packaLfing,criteria* 6-301.11 Hardwashing Cleans Availability
8-103.12 Conformance with A roved Procedures" 6-301.1.2 Hand Drying:Provision
Denotes critical iteat inthe federal 1999 food Code or 105 CMR 590,000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Pager Of
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Rem
EAS PRINT CLEARLY Verified
,
Inj
' � J t
Discussion With Person in Charge: Corre ve 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 i
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. i
❑ Voluntary Disposal 0 Other:
r I
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne illness.Interventions and Risk According to Law Cooled to
Factors(ltemst-?2) (Cont.) 41'F145'F Within Hours,
PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Not and Cold Holding
3-202.12 _ Additives_*' 3-501..16(B) Cold P2JFs Maintained at or below
rotection from Unapproved Additives* 3-50L16( H°145'F*
3-302.14 P _-..._ 3-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances
140°P. *
7-101 A I identifying information-Original 3-501.16(A) Roasts Held at or above 130'F.
Containers*
7-102.11, Compton Name-WorkingConminerO 20 Tuna as s Public Health Control
ontrool*
7-201.11 Separation-Storage* 3-501:19 Time as a Public Health Co
7-202.11 .Restriction-Presence and Use* - 090.004(H) Variance Requirement
i 7-202:12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS NSP
7-204.11 Sanitizers,Criteria-Chemicals* 21 1-801AI(A) Unpasteurized Pre-packaged Juices and
i 7-204.1.2 Chemicals for Washing Produce,Critcria* .Bovero>es with Wartnn�Labels*
7-204,74 opts,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact,Lubricants* 3-801.1 I(D) Raw or Partially Cooked Animal Fond and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served
7-206.12 - Rodent Bait Stat"ms* 3-801.11(C) Unopened Food Packs Not Re-served.
7-206.13 Tracking Powders, Pest Control and
Mtx itoris � CONSUMER ADVISORY
TiMEIFEMPERATURE CONTROLS 22 3.503.11 Consumer Advisory Pasted for Consumption of
16 Proper Cooling Temperatures for Aotmal Otherwise
Foods Thar are Raw,Undercooked or
PHFs - Not Otherwise-Processed to Eliminate
Pathogens.* tnamr
t 3401,I1A(1)(2) Eggs- 155F 15 Sec. o 3-302.13 Pasteurized Eggs Substitute for Raw Sheil
Eggs-Immediate Service 145Fl5secrt Eggs*
3-401.11(A)(2) Comminuted Fisb.Meats&Game
Animals-155'F 15 sec.
3.441.11(3)(1)(2) Pork mi
and Beef Roast- 130'F 121 n* SPECIAL REQUIREMENTS
l 3-441.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.()09{A}-(D)in
sec. * catering,mobile fod,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Staffing Containing Fish,Meat, debited under the appropriate sections
i
Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness
1 3401.11(C}(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
( 1450F* 590.009 violations relating to good retail
3-401.12 Raw Animal Fads Cooked in a practices should be debited under#29-
1Microwave 165F* Special Requirements.
3-401:11(A)(1)(b) All Other PHFs-- 145'F 15 sec.
1T Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.41(A)&(D) PHFs I6ST 15 see.* (Iteins 23-30)
3-403.11(B) Microwave-'165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the
Tithe* foodborne illness interventions and risk factors listen above, can be
{ 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMIR
1400F* 590.000.
3403.11(E) Remaining Unsliced Portions of Beef pert+ 1 Good Retail Practices FC 590.000 i
Roasts* 23. I_Nana omen and Personnel :, FC-2 .003 - !
18 Proper Coaling of PHFs
24. 1 Food and Food Protection - FC-3
.004
25. E ui teem and Utensils I FG-4 .005 i
3-501.14(A) Cooling Cooked PHFs from 140'F to 26, Water.Plumbing and Waste FC-5 .006 '
70'F Within 2 Hours and From 70`F 27. Physical Facility i FC-6 007
to 41'F1450F Within 4 Hours. * 1 28. Poisonous or Toxic Materials 1 FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient �29. Special Requirements 009
Temperature Ingredients to 410F145°F 30 1 Other
Within 4 Hours*
*Denotes critieat item in the federal 1999 Foal Cade a'105 CMR 590.D00.
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
City/Town of----C � Address:
FOOD ESTABLISHMEM('-I SPECTIO REPORT Tel.
Name [RIslrl
e Type of Operation(s) Type of Inspection
jjr�6k-,t VflJf,?4 ❑ F d Service ®�utine
Address etail ❑Re-inspection
Telephone el ❑ Residential Kitchen Previous Inspection
❑ Mobile Date:
Owner CCP YIN ❑ Temporary ❑ Preoperation
�- ❑ Caterer ❑Suspect Illness
Person-in-Charg (PIC) Tim , 4�4� ❑ Bed e�fast 0 HACCP General Complaint
Inspector In. Permit N ❑.Other
Out:.
Each violation ecke req i s exp anation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking 590.009(E) ❑
Items)
marked may pose an imminent health hazard and require immediate Tobacco 9 590.009(F) ❑
❑
corrective action as determined by the Board of Health. Allergen Awareness 590.009(G)
FF OD PROTECTION MANAGEMENT -� 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties - ` _ Handwash Facilities
`EMPLOYEE HEALTH
- - - "-" ' LPROTECTIONFROM'CHEMICACS_ �
❑ 2. Reporting of Diseases by Food Employee and PIC
[114.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
DS _ ��
,FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals
� _ ; _�___,
F14. Food and Water from Approved Source _ [TIMEREMPERATURE:CONTROLS(PoteWlelty iazardous F.ggds)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
[V,e TTags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling
PROTECTION FROM CONTAMINATION _? P1<Hot and Cold Holding
❑ 8. eparation/Segregation/Protection El20.Time as a Public Health Control
Food Contact Surfaces Cleaning and Sanitizing IREQUIREMENTS FOR,HIGHLYSUSCEPTIBLE_POPULAT(ONS'':(HSP):
❑2
El 10. Proper Adequate Handwashing 1. Food and Food Preparation for HSP
El11. Good Hygienic Practices f-CONSUMER
[122. Posting of Consumer Advisories
Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Red Items 1-22):
of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2X590.003) by
of the Board of Health. Failure to correct violations
24. Food and Food Protection (Fc-3X590.004) cited in this report may result in suspension or revocation of
5. Equipment and Utensils (FC-aX5so.0o5) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (FC5X590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing
28._,Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address
Special Requir nts (590.009) within 10 days of receiptof this ord
30. O DATE OF RE-INSPECTION::
s: o-adac
Inspector's Signature: Print: ' f t
PLCs Signature: n Print: C '-- Page oages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 ICrass-contamination
3-302.11(A)(1) Raw Animal Foods Separated from
1 590.003(A) Assignmenttrat of Responsibility*- Cooked and RTE Foods*
2-103.11 Demonstration of Knowledge" Contamination from Raw Ingredients
2-103.11 Person in charge-duties 3-302 l l(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH
Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-3011.1(A) - Food Protection*
require reporting by food employees and 3-302,15 Washing Fruits and Vegetables
applicants* 3-304..11 Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An Utensils*
To Report To The Person In Contamination from the Consumer
Charge*
590.003 G Re tin b Person in Charee* 3-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
Food
590.003(E) Removal of Exclusions and Restrictions 3-701..I t Discarding or Reconditioning Unsafe
_FOOD FROM APPROVED SOURCE rood*
4 Food and Water From,Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law`" 4-501..1.11 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Scaled Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 MechanicalWarewashing-Hot Water
3-202.13 Shell Eggs* - Sanitization Temperatures*.
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 - Chemical Sanitization-temp.,pH,
3-202.16 lee Made From Potable Drinking Water* concentration and badness.*
5-101.11 Drinking Water from an Approved System* 4-60 1 A I(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinkine Water* - Utensils Clean*
590.006(B) Water Meets Standards in 310 CIviR 22.0* 4-602.i l Cleaning Frequency of Equipment Food
-
Shellfish and Fish From an Approved Source Contact Surfaces and Utensils*
4-702.11 Frequency of Sanitization of Utensils-and
3-201.14 Fish and Recreadonaily CaupJ t Molluscan Food Contact Surfaces of Equipment*
3-201.15 Molluscan Shellfish from A?SSF listed
Shell-fish" 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical*
10 Proper,Adequate Handwashing
Fie MatoAuttrorH
Game and Wild Mushrooms Approved try 2-301.1.1 Clean Condition-Hands and Arms*
-
3-202.18 Shellstock Identification Present* 2-301.12 Cleanin Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
5 Receiving/Condition 2401.11. Eating,Drinking or Using Tobacco*
3-202.1.1 PHFs Received at Proper Tem natures* 2401.12 . Discharges.From the Eyes,Nose and
3-202.1.5 Package Integrity* Mouth*
3-1()1.11 Food Safe and Unadulterated* 3-301.12 Preventin Contazrunation When Tasting*
6 Tags/Rerords:Shelistock 12 Prevention of Contamination from Hands
3-202.18 -Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.1.2 Shellstock Identification lvlaintained* Employees*
Tags/Records;Fish Products 13 Handwash Facilities -
3-402.11 Parasite Destruction*
Conveniently Located and Accessible
3-402.12 . Records,Creation and Retention* 5-203.11 . Numbers and Capacities*
590.004(n Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Pians Supplied with Soap and Hand Drying
3-502.11. S' cfalfzed Prucessin Methods* Devices
3-502:12 Reduced ox gen acka"ng,triter a* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Confoimance with A roved Procedures" 6-301.1.2 Hand Drying Provision
Denotes critical item inthe federal 1999 Paid Code or 105 CMR 590.(X)0.
SPIN MEMO ME IF,
AAA
�i1II __ t�_ _ �.�. .S,i' ,s,..►a ,.: .-: v i►. . 'jig. .. � =�
LSI .I OHIO
3-501.14(C) PHFs Received at Temperatures
} Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors Otems 1-22) (Cont.) 41T-,145°F Within 4 Hours,
PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PHFs
19 PHF
14 - Foal or Cotor Additives Slot and Cottl Holding
3-50136(B) Cold PHFs Maintained at or below
3-202.12 Additives*
4(() 41
3-302.14 Protection from Una 3-50L
Unapproved Additives* ld5°F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained of or above
1400F.
7-101.11 Identifying Information-Original 3-501.1 (A) Roasts Heid at or above 130'F.*
Containers*
Time as a Public Health
7-102.11. Cotmnon Name-Working Containers* 20 Co 3-501:19 Tirtte as a Public Health Control*of
nal*
7-201.11 Separation-Sm +'
7-202.11 .Restriction-Presenceand Use* X5'0.004{H} Varianceuiremem
7-202.12 Conditions of Use"
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sardtizers.Criteria-Chemicals* POPULATIONS H.*'sP
7-204.1.2 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14ants,Criteria' :Beverages with Warning Labels*
ling
7-205.11 Incidental Food Contact Lubricants* 3 801.i 1(B Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
7-206.12 - Rodent:Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIME(i EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of
16
Proper Cooking Temperatures far Amr
Animal Foods That are Raw,Undercooked o
PNot Otherwise Processed to Eliminate
3-401.I1A(1)(2) Eggs- 155°F 15 Sec.
Pathogens,'
Eggs-Immediate Service 145°F15sec* 3-302.13, Pasteurized Eggs Substitute for Raw Shell
3.401.11(A)(2) Comminuted Fish.Meats&Game Eggs*
Animals-155°F 15 sec. " SPECIAL REQUIREMENTS
3-401.11(B)(1)(2) Pork and Beef Roast-130°F'121min*
3-461.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
see.* catering,mobile food,temporary and
3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
t Stuffing Containing Fish,Nieat, debited under the appropriate sections
Poultry or Ratites-165°F 15 see. * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other
,r 145OF 4' 590,009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
r Microwave 165°F* Special Requirements.
3-40LI I(A)(1)(b) All Other PIFs-145°(15 sec.
17 Reheating for Hot Holding VIOLATIOiYS RELATED TO GOOD RETAIL PRACTICES
3-403.11044(D) PHFs 165F 15 sec.* (Items 23-30)
3-403.11(B) Microwave-'165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk,factors listed above, can be
3-903.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000.
3403.11(E) Remaining Unsliced Portions of Beef - , Item I Good Retail Practices J .FC 540.000 i
Roasts* 23. 1 Management and Personae! 1 FG-2 .003
1S Proper Cooling of PHFs 24.. Foal and Food Protection I FG-3 .004
1 25, 1 Equipment and Utensils 1 FC-4 .005 I
3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbing and Waste i FC-5 .006 ;
70°F Within 2 Hours and From 70"F 27. Ph sicai FacirrtvFC-8 007
to 41°F145OF Within 4 Hours. * X28. ' Poisonous or Toxic Materials ' FC-7008. '
3-501.14(6) Cooling PRFs Made From Ambient 29_ �Special Requirements � .609
Temperature Ingredients to 41°F/456F 30 i Other L_
Within 4 Hours* s:.saor,. ss.x c:
'Dinotex critical iuzm in the federal 1999 Ford Cale a1V C14IR 190.0()0.
t
CITY OF SALEM
n_ � BOARD OF HEALTH of
� Pa
Establishment Name: nl U r' I/�V Date: ge: '
Nem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
a
v
Discussion With Person in Charge: Corrective Action Required: ❑ No es
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
Re-inspection Scheduled ❑
violations before the next inspection, to observe all conditions as described, and to 6' Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
j your food permit.
❑ Voluntary Disposal ❑ Other.
- 3-501.14(C) PHFs Received at Temperatures
�1 Violations Related to Foodborne illness Interventions and Risk According to Law Cooled to
Factors{Kerns 1-22) (Cant.) 41'F/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-50LI5 CoolingMethods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3--501..t6(B) Cold PI3FsMaintained atorbelow
_02,12 Additives*
3-302.14 - Protection from Unapproved
vee 595004{F? Hot P °F*
_ _ ver*
t 1r rLaved Adtiitives'k 3-501.16(0) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances -
140°17.
7-101,11 Identifying Information-Original 3.501.16(A) Roasts Held at or above 130'F.
Containers* 20 Time as n Public Health Control
7-102.11. Common Nature-WorkingContainers*
7-201.11 5 ation-St e* 3-50L I9 Time as a Public Health Control*
590.004(H) Variance Requirement
7-202.11 ,Restriction-Presenceand Use*
1 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY-SUSCEPTIBLE
` 7-203.11 Toxic Containers-Prohibitions* POPUt ATIONS HSP
720411 Sanitizets.Criteria-Chemicals*
21 3-80111(A) Bes Pre-packaged Juices and
7-204.12 Chemicals far WashingProduce,Criteria* evcrzewt labels*
7-20414 n ents.Criteria* 3-801.11(6 Use of Pasteurized Eggs*
7-205.11 Incidents]Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Rax Seed Sprouts Not Served.,
7-206A2 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and _
Mtmitcrin * CONSUMER ADVISORY
TIMEfi EMPERATURE CONTROLS 22 3-603,11 Consumer Advisory Posted fur Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
- - Not Otherwise,Processed to Eliminate
PHFs
f Patbogens.*`oyes,n .I
3401.]IA(t)(2) Eggs- 155°F 15 Sec.
E -Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute forRaw Shell
3401.11(A)(2) Comminuted Fish.Meats&Game E
Animals-155'F 15 sec.
,r 3-401.116)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS
590.009(0)-(D) Violations of Section
3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(0)-(IJ)in
4 sec. * catering,,mobile ford,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
;t
Poultry or Ratites-165°F 15 sec, * above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145'F^ 590.009 violations relating to good retail
3.401.12 Raw Animal Fords Cooked in a practices should be debited under#29-
Microwave 165F* Special Requirements.
3-40LI I(A)(1)(b) All Other PHFs-145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.41(A)&(D) PHFs 165°F 15 sec. * (Items 23-30)
l 3403.11(B) Microwave- 165`F 2 Minute Standing Critical,and non-critical violations, which do not relate to the
Time* i foodborne illness interventions and risk factors listen above, can be
3-03.t 1(C) Commercially Processed RTE Food- found in the fallowing sections of the Riod Code and 105 CMR
140°F* 590.000.
3403AI(E) Remaining Unsliced Portions of Beef ttern j Good Retail Practices FC 590.000 i
Roasts* i 23. 1 Manamment and Personnel FG-2 .am
1S Proper Cooling of PHFs24.I Food and Food Protection j FC-3 .004
1 2- 6,-1 Equipment and Utensils I FC-4 .005
3-50L M(A) Cooling Cooked PHFs from W'F to ! 28, Water.Plumbipq and Waste 1 FC-5 .006
70`17 Within 2 Hours and From 70'F 27. ' Phvsical Facility
to 41`F/45°F Within 4 Horns.* L28. Poisonous or Toxic Materials F0 7 .008
3-501.14(6) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41°F/45°F 30i Other _
1l
Within 4 Hours*
Denotas critical tum in the federal 1999 Food Cale or 105 CN(t 590.000.
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4s'Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTABLISHM 1 PE TION REPORT Tel.
Name Da Type of Operation(s) T e of Inspection
❑❑� Fyyod Service utine
Address Risk WooRetail Re-inspection
Level ❑ Residential Kitchen Previous Inspection
TelephoneElMobile Date:
[ITemporary ElPre-operationOwner HACCP YIN
(r' ❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) Tim ❑ Bed a st El General Complaint
I'm ❑ HACCP
Inspector Out: Permit No. E],Other
Each viotati• n ecked requi es a xplanation on the narrative ages)and a citation of'specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may Tobacco 590.009(F) ❑.
y pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
;,FOOD PROTECTION MANAGEMENT' _ . _ T] ❑ 12. revention of Contamination from Hands
F11 PIC Assigned/Knowledgeable/Duties
13. Handwash Facilities
EMPLOYEE HEALTH -` .`.. -11 .
__ _ __. _._ _ ;PRQTECTIONFROM4CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC
El 14.Approved Food or Calor Additives
❑ 3. Personnel with Infections Restricted/Excluded '
..1 . ❑
IF000 FROMAPPROVED SOURCE 15.Toxic Chemicals__ _ _ -
❑ 4. Food and Water from Approved Source !TIMEREMPERATURE'CONTROLS.(Potentlalty Ma¢ardotis Foods)
❑ 5. ReceivinglCondition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
- - - -.- M --
,PROTEC- TION FROM CONTAMIN- ATION _ , _ __ � Y2119. Hot and Cold Holding
❑ 8iSeparation/Segregation/Protection E]20. Time as a Public Health Control
Il-X/9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR,HIGHLYSUSCE!rflki=PULATIONS
0Pi(HSP);',.�I
El21.Food and Food Preparation for HSP
❑10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices !_0ONSUMERADVISORY
❑22. Posting of Consumer Advisories-
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical(N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C N
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
2 Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations
5. Equipment and Utensils cited in this report may result in suspension or revocation of
(FC-aXsso.00s) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC5X590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing
Poisonous or xic Materials (FC-7X590.008) and submitted to the Board of Health at the abova4ddressi
29. Special Re ire ent (590.009) within 10 days of receipt of this ofder.
30. Other DATE OFRE-INSPECT( N:
i s: &iaiac w
Inspector's Sig - < Print:
i
P[Cs Signature: Prim - �. Page o ages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Hems 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination
3-302.1.](A)(]) Raw Animal Foals Separated from
1 590.) B) Ansi meat of Responsibility*Knowledge"
Cooked and RTE Fo(xis*
590.003(B) Demonstration of Knowled a"` Contamination from Raw ingredients
2-103.11. Person in char a-duties 3-302.1.1(A)(2) Raw Anima]Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection*
require reporting by food employees and 3-302,-15 WashingFruits and Vegetables
applicants* 3-304. 1. 'Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Charge*
590.003 G Reporting by Person in Charee* 3-306.14(A)(B) Returned Food and Reservice of Food*
Disposdion of Adulterated or Contaminated
-
3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and:Restrictions 3-701..1.1 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501..111 Manual Warewashing-Hot Water
3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Tentperaturesii,
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Ware-washing-Hot Water
3-202.13 Shell Eggs* - Sanitization Temperatures*.
3-202.14 Eggs mid Milk Products,Pasteurizcd* 4-501.114 Chemical Sanitization-temp.,pH, .
3-202.16 lee Made From Potable Drinking Water* concentration and hardness.*
5-101.1.1 Drinking Water from an Approved Stem.* 4-60 LI I(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinkine Water' Utensils Clean*
590.006(B) Water Meets Standards in 31.0 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food
Shellfish and Fish From an Approved Source Contact Surfaces and Utensils*
4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationaiiy Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* _
-- 4-703.11 Methods of Sanitization-Hof Water and
3-201.15 Molluscan Shellfish from NSSF bested � -
Sources* Chemical.
Game and Wi)d Mushrooms Approved by 10 Proper,Adequate Handwashing
_
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*
3-202.18 Shellstock Identification Present' 2-301.12 Cleanin Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
5 Receiving/Condition 2-401.11 Eating,Dri ng or Using Tobacco*
3-202.11 PRFs Received at Proper Tem ratures* 2-401.12. Discharges.From the Eyes,Nose and
3-202.15 Parka,"Integrity* Mouth*
3-10i.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 -Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.1.2 Shellstock Identification Maintained* Employees*
Tags/Records;Fish Products 13 1 Handwash Facilities
302.11 Parasite Destruction`
Conveniently Located and Accessible
3-402.12 Records,Creation and Retentiun* 5-203.11 Numbers and Ca acities*
590.004(1) Labeling of Ingredients' 5-204.11 locution and Placement*
7 Conformance with Approved Procedures 5-205.11. Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.11. Specialized Processing Methods* Devices
3-502.1.2 Reduced oxy gen acka 'ng,criteria* 6-301.11 Handwashtn Cleanser,Availability
8-103.!2 Conformance with Approved Procedures* - 6-301.12 HandProvision
*Denotes critical item in the federal 1999 Fa)d Cale of 105 CMR 590.000.
r
Aw
ff
Mt MAR-1111.' ,a.tll�==
�11�MERIANV/TIM
I►:�u�� 1R1�'�!�Jt,�L � _
F 41L
AG F MWJWM�M IRAs
MANWAORMAR
rall 1910
3-501.14(C) PHFs Received at Temperatures
I Vlotedons Related to Foodborne illness interventions and Risk According to law Cooled to
Factors fftems 1-22) (Cont.) 41F145°F Within 4 Hairs.
PROTECTION FROM CHEMICALS *• 3-501.15 CoolingMethods for PHFs
J F), 19 PHP Not and Cold Holding
14 - Food or Color Additives - 3-501.16(B) Cold PIIFs fvlaintamed at or below
3-202.12 Additives*' 590.004(M 41°/45'F*
3-342.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above
" 15 Poisonous or Toxic Substances
144°F.
7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1.30'F.
Containers*
7-102.11. Common Name-WorkingContainers* Time as a Public Health Control
- - 3-501.14 - Time as a Public Health Control*
7-201.11 Separation-Stora *
7-202.11 .Restriction-Presence and Use* - 590.404(H) Variance Requirement
7-242.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions*
7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.1](A) Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
7-204.14 n encs.Criteria* 3 801.11(B) Use of Pasteurized Eggs*
r 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(0,) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Nor Served.
7-206.12 Rodent Bait Stations* 3-801.11 C Unopened Food Package Not Re-served.
7-206.13 Tracking Powders, Pest Control and _
Monitoring* CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
f
Animal Foods That are Raw.Undercooked or
16 Proper Cooling Temperatures for Not Otherwise.Processed to Eliminate
PHFs FR4c>w rr+rmw
Pathogens,'
'3-401.11A(1)(2) Eggs- 155° Pasteurized
13
3-342
F 15 Sec. Pat
tE *s-Immediate Service 145'Fl5see- . . Eggs* Eggs Substitute for Raw Shell
3-401.11(A)(2) - Comminuted Fish.Meats&Game
Animals-155'F 15 sec.
3-401.11(11)(1)(2) Pork and Beef Roast- 1309F 121 min* SPECIAL REQUIREMENTS
of Section
\4 3-401.]I(A)(2) Ratites, Injected Meats-155cF 15 594.009(A}-(D) Violations of Section temporary
and in
i see.
* catering,.mobile food,temporary and
G 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
k Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
I 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and Tisk factors. Other
145°F* 590.009 violations relating to gaol retail
t 3401.72 Raw Animal Foals Cooked in a practices should be debited trader#29-
y Microwave 165'F* Special Requirements.
340LII(A)(f)(b) All Other PHFs- 145'F 15 sec.*
19 Reheating for Hot Holding VIOLA770N3 RELATED TO GOOD RETAIL PRAC77CES
i 3403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-36)
j 3-403.11(B) Microwave 165'F 2 Minute Standing Critical,aid non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
! 140°F* 590.000.
3403.11(E) Remaining Unsliced Portions of Beef i /tam I Good Retail Practices I FC 590,,400
Roasts*
L21 1 Management and Personnel FC-2 .003
IS - Proper Cooling of PHFs i 24.- 1 Food and Food Protection FC-3 .004__a
128. 1 Equipment and Utensils FC-4 .005_
3-501.14(A) Cooling Cooked PHFs from 140`F to 26, 1 Water.Plumbing and waste FC-5 .MS i
70°F Within 2 Hours and From 70°P 27. Ph s cal Favi R FC-8 C07
to 41°F/45'F Within 4 Hours. * 28. ' Poisonous or Tabc Materials i FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. Specie R uirelents .009
Temperature Ingredients to 41'F/45°fi i 30. i Oma -- -
Within 4 Hours*
1
` °Denotes critical ae-min the federal 1999 Food Cate of 105 CMR 590.000.
IIFA
FIti�� .11tl►�l� IWAV
,MnM k AM.I n SAVA"Vp�.
lCi � P,AM
LiL�iill0l��I�(�11�l► . . �_. .. , � r� J�'?1. �. , , _ �► . �r;, �. !!��_
I�i7� :��Ul�l�'L/■I PWG_"!lll I..r e _
ril �V �Fl.'F-Nice- .il�'ri►c.1�9aWI .0 7101 wm
ME i�►7 ''!l.►d' 11�i�IR��-. .. /l!,�i'I�:,� wi�1► �!LI .MI�'�ll�!;�=
f(G®SLI TII�II�IIil�i1G'*ta!1 ! i ! :1 �. - , " .• .L;,,... .. .�. NITI
•
3-i01.14(C) PHFs Received at Temperatures 4
t Violations Related to Foodborne Illness tntementlons and Risk According to Law Cooled to
Factors(gems Y-22) (Cont) 41°FY45°F Within 4 Haus.
PROTECTION FROM CHEMICALS 3-501.15 Coolie -Methods for PHFs
14 Food of Color Additives 19 PHF Hot and Cold tioidfng.
3-20212 Additives* 3-501.16(B) Cld PHFs Maintained at or below
3-302.14 Protection from Una roved Additives" 3-50 16( 410145 F
15 Poisonous or Toxic Substances 3-501,16(A} HotPHFs Maintained slot above
7-101,11 Identifying Information-Original - I4pF. *'
Containers* 3.501.16(A) Roasts field at or above i30°F.*
7-202.11. Common Name-Working Containers* 20 Time as a Public Health Control
* 3-501:19 Time as a Public Health Control*
7-201.11 Separation-Stora
7-202.11 .Restriction-Presenceand Use* - 590.004(H) Varianceairemrnt
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals for Washin Produce,Criteria° 21 3-801.17(A) Unpasteurized Pre-packaged Juices and
7-204.14 Agents.Criteria* Beverages with Warning Libels'
3 801.11(B) Use of Pasteurized Eggs*
7-205.11 incidental Food Contact.Lubticams* 3-801..11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served-*
7-206.12 - Rodent Bait Stations* 3-801,11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders, Pest Control and
Monitoring* I CONSUMER ADVISORY _
71MEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of
16 - Proper Cooking Temperatures far Animal Foods Tbat are Raw.Undercooked or
PHFs Not Otherwise.Processed to Eliminate
3401.11A(1)(2) Eggs- i55T 15 Sec. patbo,ens,*�xr a rn„urn
Eggs-Immediate Service 145°FL5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-441.11(A)(2) Comminuted Fish.Meats&Game
Eggs*
Animals-155°F 15 sec. *
i
3401.11(B)(1)(2) Port and Beef Roast- 130°F 221 mio* SPECIAL REQUIREMENTS
C 3-401.]t(A)(2) Ratites,injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.f)09(A)-{D}in
sec.* catering,mobile fbod,ternporary and
3-401.11(A)(3) Poultry,Wild Game,Staffed PtfR, residential kitchen operations should be
t
Stuffing Containing Fish.Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec * above if related to foodborne illness
3-40J A1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Qther
145°F* 590.009 violations relating to good retail
' 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
} Microwave 165°F* Special Requirements.
r 3-40'1:11(A)(1)(b) All Other PHFs- 145°F 15 sec.
i7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403,41(A)&(D) PHFs 165°F 15 sec.* (Items 23-30)
3403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relax to the
Timc* - foodborne illness interventions and risk factors listed above, can he
3403.i 1(C) Commercially Processed RTE Foal- found in the following sections of the Food Code and 105 CY,R
140°F* 590.000.
3-103:11(E) Remaining Unsliced Portions of Beef Item i Good RefaR FracNees FC $90.000
Ronk: 3 23. 1 Ma Ment and Personnel -FC-2 .003
18 Proper Cooling of PHFs i 24.. ! Food and Food Protection FC 3 .004
1 25. I Equipment I and Utensils ( FC-4 _005_,
3-501.14(A) Cooling Cooked PHFs from 140°F m I Water,Plumbing and waste j FC-5 .066
70°F Within 2 Hours and From 70°F 27. ( PhVsical Facitit FC-6 .007--
, to4t`F/45°F Within 4 Hours. * 26. Poisonous or Tmic Materials ! FC-7 .008
3-501.14(11) Looting PHFs Made From Ambient 20. S ecia Requirements 009
Temperature ingredients to 41°F/45°F ' ! Other i___
Within 4 Hours*
1 *Dewres critical ir<'..m in the federal 1999 Foal Cade a'105 CNIR 590.000.
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IPA 6111 MI
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3-501.14(C) PHFs Received at Temperatures
Violations Related to Faodborne Illness Interventions and Risk According to Law Cooled to
( Factors(Itelrts7-22) (Cont.) 41'F/45`F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501-15 Cooling Methods for PHFs
19 PHF Hot and Cold Holding
g4 Food w Color Additives - 3-50L16(B) Cold PHFs Maintained at or below
3-202.12 Additives* 590.004(F) 410145'F*
i 3-302.14 Protection from Unapproved Addiiives'r
3-501.16(A) Hot PHFs Maintained at or above
55 Poisonous or Toxic Substances
' 140 .
7-101.11 Identifying Information-Original
3-501.16(A) Roasts Held at or above 1300F.Containers* *
20 rimea Public Health Control
7-102.11. Common Name-Working Containers* 3-501:19 Tune as s a Public Health Control*
7-201.11 Separation-Storage* - .
7-202.11 .Restriction-Presence and Use*
- 590.004{Hj Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Conuuners-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
"f 7-204.12 Chemicals for WashingProduce,Criteria" 2g 3-841.1](A) Unpasteurized Pre-packaged Juices and
't 7-204.14 m ears.Criteria" :Beverages with Warning Labels*
k 7-205.11 Incidental Food Contact,Lubticants* 3-801.11(8 Use of Pasttially i Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.1 I(D} Raw or Partially Cooked Animal Food and
7-206.12 RadenY Bait Stations* Raw Seed S Its Not Served
3-801.11(C) Unopened Fond Package Not Re=served.
7-206.13 Tracking Powders, Pest Control and -
S Monitorin * CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS
22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Rads That are Raw.Undercooked or
F6 Proper Conking Temperatures for
PHFs Not Otherwise Processed to Eliminate
Pad10 ells.*mxrre Wn .r
3-401.11A(l)(2) Eggs- 155'F15 sec:
r
Eggs-Immediate Service 145'F15=- 3-302.13. Pasteurized Eggs Substitute for Raw Shell
E *
f 3-401._11(A)(2) Comminuted Fish.Meats&Game _
Animals-155'F 15 sec.
3-401.11(11)(1X2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTSof Section
3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A}-{D) Violationnssof Seon 590.09{A)-tDin
)
see.* catering,.mobile food,temporary and
3-401.1.t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. ' above if related to foodborne illness
3-401.11(0(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3401.12 Raw Animal Foals Cooked in a practices should be debited under#29-
t Microwave 165°F* Special Requirements.
340LI I(A)(1)(b) All Other PHFs- 145°F 15 sec.
17 Reheating for Hot Holding VIOLATRO RELATED TO GOOD RETAIL PRACTICES
7 3403.11(A)&(D) PHFs 165T 15 sec.* (Items 23-30)
? 3-403.11(B) Microwave 165°F 2 Minute Standing Critical,mrd non-critical violations, which do not relate to the
Tithe* foodborne illness interventions and ris&factors listed above, can be
3-103,11(C) Commercially Processed RTE Food- found in the following sectionsof the Food.Codc and 105 CMR
' 140°F* 590.000.
3-403.11(E) Remaining Unsliced Portions of Beef 1 Goad Retail Practices , .FC 540.000
'Roasts* 23. 1 Management and Personnel FG-2 .003
gig Proper Cooling of PHFs 1 24. I Food and Food Protection FC-3 .004
125. Equipment and Utensils _ FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140`F to 2�6, Water.Plumbino and Waste I FC-5 .008
r 70'F Within 2 Hours and From 70'F 27. Physical Facility FC-6 007
to 41°F/45'F Within 4 Homs. * -28. Poisonous or Tc)jc Materials ' FC-7 .008
7501.14(8) Cooling PHFs Made From Ambient 29. Special Requirements i ' .003
Temperature Ingredients to 41'F/45°F 30 i Other - i-
Within 4 Hours* - s:+vnr,m Marx c:
.w ^Derma,critical!rem in the federal 1999 Foal Code or 105 CMR 590.000.
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CITY OF SALEM, MASSACHUSETTS
BOARD OF'FIEALTH
120 WASHINGTON STREET,4..FLOOR PabIlCHieB Ith
Prevent.Promote.Protect.
TFI... (978) 741-1800 FAX(978) 745-0343
KIMBERLEY DRISCOLL Itamdin@salem.com salem.com
LARRY Rs\MDIN,[LS/RI31-T5,CI-IO,CP-1'S
MAYOR Hl'.AI.1'fI ACFNT
201 APPLICATION FOR PERMIT FOR TOBACCO SALES
p PERMIT FEE $135
NAME OF ESTABLISHMENT ( A 17i )Ct� y TEL#
ADDRESS OF ESTABLISHMENT 1yal��b S / FAx# 7 -333 6
DEPARTMENT OF REVENUE APPLICATION NUMBER:
MAILING ADDRESS(if different)
EMAIL- Business': Website:
OWNER'S NAME:Fk,4 AJP—I S cD S_ ��v� a TEL# 9� 7 5 LI - 2ro7d
ADDRESS '?- El s4 - S -/- /tee A-60JP M4 0 , o
STREET I nn n CITY �e STATE ZIP
EMERGENCY RESPONSE PERSON S �G ✓1//� HOME TEL#�7X� � x/75
Type of Products Sold: Cigarettes C/ Cigars ��Chewing Tobacco C�Pipe/Cigarette Tobacco (/Nicotine Delivery
Devices_ Other Tobacco Product(list in additional Sheet)
DAYS OF OPERATION ! Monday Tuesday Wednesday Thursday Friday Saturday Sunday
HOURS OF OPERATION _ l/ Q-DITTb !lb /� S Tb l —rD fQ
Please write in time of day.
(For example IIam-11 pm)
i
*Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code,before any renovations, improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns and paid all state taxes required under the law.
Signature Date Social Security or Federal Identification Number
---------------------------------------------------�-- ------.a-------------------------------------------- ----------
Updated 7/23/12 TOBACCO.doc Check#&Date "7'--5
.�- MINI III1-
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�l•;Ity of Salem M'' r=" ' ,K
IGmberfe Dnscoll
Board of Health „ . Y
tI 7W , X120 Washington Street,4th Floor Y
Sw y R � .rn i^ a•-'r• „l'c{t:-s .ice - fiVex.-a �4,aa 1 r ¥ f-s�
F00d/RetailEstabbshmentPermlt � � kl
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DATE PRINTED a � * 12/20/2013
ANY ESTABLISHMENT NAME` : Bani l4Iarket "Rr +��
:�..zE @- aa''
y `File Numbee BHF 2004-000006 �73 11arbo. ```� "" �' x
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_ LOCATED AT `X0073 HARBOR#STREETS
SALEM MAS 01970 ,� a t
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Permit Type Pernut Nod Per►mt Issued; Permit Espires� Fee Restrictions/Notes r �
RETAIL FOOD F' BHP2ot4o2ot Jan1 2014 %%:Dec31 2014 F, z
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PERMIT-EXPIRES ecember 313 2014 '
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,T)us Perini[is nottransferable,I . and must be reissued upon change of ownership or location The permit must be posted
in a romiueat location m the Establishment " 14
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g � Ia accordancer nth the State Sanitary Code;beo�fre any revonations lunprovements,or equipment changes are made, ' �
mow,
all plans for such must be subnutted to an approved b the Salem Board of Ilealth page t p
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CITY OF SALEM, 10
r • , �` MASSACHUSETTS
G
_ Bonan or Hent:n1
120 WASHINGTON S'MrTT,41'11 F1,OOR
KIMBERLEY DRISCOLL Tial.(978)741-1800 FAx(978)745-0343 LARRY RAMDIN,RS/RENS,C1 10,CP-F5
MAYOR Iramdin@salem.com salem.com HEALTH A(',ICNT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
2) Establishment Address: t H,48 OQ. 5
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: 7` 7 3
5) Applicant Name&Title: `F N A
6) Applicant Address:
7) Applicant Telephone No: 7!�? •6,5/q 707024 Hour Emergency No: rf.74*5331 Email:
8) Owner Name&Title(if different from applicant): ^F 9AW 60 -Q uv fc
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
An individual
A partnership
Other legal entity
.12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title: 6a"vt trn 4n J C i S c Q Q N fl
p
Address: L M aA,(70 d 455 Q /q60
Telephone No: -(fid/—ID 7a Fax: 7' 7/411Y Email: I 2Salgt C�D�K
Emergency Telephone No: y 33 3
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
7�
Check#: , Date: I 'oZ ' 16 — Amount: �V
Food Establishment Information
-,4) Water Source: 15) Sewage Disposal:
wDEP Public Water Supply No: (if applicable)
16) Days and Hours of Operation: 17) No. of Food Employees:
98) Name of Person in Charge Certified in Food Protection Management: -
Required as of 101112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures( if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) O'Retail ( Sq. Ft) ❑Caterer
Permanent Structure ❑ 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 ❑ Residential Kitchen for Bed and
21) Length Of Permit: -Breakfast Establishments•
RETAIL STORE RESTAURANT
Annual (check one) OR Less than 1000sq.ft. $70 ❑Less than 25 seats $140
Seasonal/Dates: ❑1000-10,OOOsq.ft. $280 ❑Residential Kitchens $140
❑More than 10,OOOsq.ft. $420 ❑25.99 seats $280
❑More than 99 seats $420
Temporary/DatesMme: -- ---- -------- -------------- -- ---------------------------------------------------------------------
❑Bed&BreakfastlChildcare Services(Nursing Home $100
--------------------------------------------------------- ----------------------------------------------------------------
ADDITIONAL PERMITS
❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
❑ALL NON-PROFIT' $25
*Including, church kitchens, state funded childcare&private club
23) Food Operations: Definitions: PHF—potentially hazardous food(timeltemperature controls required)
Non-PHFs—non-potentially hazardous food(no time/temperature controls required)
(check all that apply): RTE—read -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
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs 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
Service Within 4 hours 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
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:
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
the
with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant: �! L9—
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: 6L J q &Z ?
26) Signature of Individual or Corporate Name:
ffit . �
Ulm • • e • . • . - - ..
M PM
ww��w■w MOM- OWN A 0 rf Old C OR MS,re Iffillw
MPAIM"MR(Mle ARA
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!J�!6��'lhl� I�i'�la�l. _.'�11;�:���11, . .. ,�.ti�. .'� 'tr ;i-� ',...:►����.'►�i � _ . ►A
JOS
CITY OF SALEM, MASSACHUSETTS 1P
_ BOARD OF HEALTH
120 WASHINGTON STREET 4"t FLOOR PabliCHea Ith
STREET, Prevent.Promote.Protect.
TEL. (978) 741-1800 FAX(978) 745-0343
KIMBERLEY DRISCOLL lxamdin@salem.com
" LARRY RAbfUIN,RS/12[CIiS,C1 10,CP-VS
MAYOR Hl_tAMI r Aoe:Nr
March 6, 2013
Francisco Pena, Owner
Bani Market
73 Harbor Street
Salem, MA 01970
Dear Mr. Pena:
During a routine inspection of your establishment conducted by Board of Health Sanitarian
Delilah Castro on February 20, 2013, it was noted that you are purchasing large quantities of
meat, poultry, fish, vegetables and dairy products and cutting and re-packaging these items into
smaller containers. During your plan review on January 16, 2008 it was noted and agreed by you
that there would be no food preparation at this establishment. (See Attached)
Your establishment does not have the required facilities to conduct these types of processes.
Additionally, you do not have the necessary certifications required to conduct this type of
business
Pursuant to Board of Health authority under MGL 111 and 105 CMR 590.014(B)(h)you are
hereby ordered to immediately cease and desist all operations related to the preparing,
packaging and handling of all meat, poultry,fish,vegetables and dairy products.
Failure to comply with this order will result in the immediate suspension or revocation of
your permit to operate a retail food establishment.
Should you be aggrieved by this Order, you have the right to request a hearing before the Board
of Health. A request for such a hearing must be received in writing in this office of the Board of
Health within ten (10) days of receipt of this Order. At said hearing, you will be given the
opportunity to be heard and to present witness and documentary evidence as to why this Order
should be modified or withdrawn. An attorney may represent you. Please also be informed that
you have the right to inspect and obtain copies of all relevant inspection or investigation reports,
orders, and other documentary information in the possession of this Board, and that any adverse
party has the right to be present at the hearing.
Orders of the Board of Health may be enforced by an application to Superior Court.
Sincerely yours,
Larry Ramdin
Health Agent
CITY OF SALEM
BOARD OF HEALTH
r
Name of Establishment: Bani Market
Address: 73 Harbor Street
Owner(s): Francisco Pena
Phone:
The proposed new owner of this establishment presented plans for this
establishment for review in accordance with the State Sanitary Code.
Mr. Pena will work in this establishment full time.
ITEMS FOR SALE
All food items displayed and offered to the public must be fromgha source
permitted as a Wholesaler from the Mass Department of Public Health.
There will be no food preparation at this establishment.
Any change in size or items for sale must be approved by the Board of Health.
FLOOR PLAN
All surfaces must be intact, impervious and easily cleanable. This includes any
areas in the basement used for storage.
All refrigeration units must have accurate internal thermometers. Refrigerated
food must be held at 41 degrees Fahrenheit or lower, freezers at 0 degrees
Fahrenheit or lower.
EXPIRATION DATES
All expiration dates on products must be clearly visible. Out dated items must be
promptly removed from display.
HAND WASHING
The hand sink must have a wall hung soap and paper towel dispenser, stocked
at all times.
TRASH
The owner will determine how trash will be handled.
EXTERMINATION
Monthly services of a Licensed Pest Control Operator are required.
Please keep receipts for inspections.
Outside area of premises must be kept clean and sanitary.
An opening inspection is scheduled for January 17, 2008.
anne Scott Date
Health Agent
IL
Francisco Pena Date
1
41
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Commonwealth of Massachusetts
x c a E City of Salem
Board of Health Klrrlbed1 y Driscoll
120 Washington Street,4th Floor.
Mayor
SALEM,MA 01970
3,�'Food/Retail Establishment Permit
DATE PRINTED: 12/17/2012 ,.
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r ESTABLISHMENT NAME. _ # Bani Market'
.File Number:BHF-2004-000006 1"v 73 Harbor Street
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Salem $ .>. MA 01970 ,
LOCATED AT . ` 0073 HARBOR STREET x g -
SALEM,MA _01970 4y
Permit Type Permit No Permit Issued Permit Expires Fee Restrictions/Notes -
BHP-2013-0217 ` '� 2 0 $70-00
•,='RETAIL FOOD r Jan 1,2013 Dec 31,2013
TOBACCO VENDOR' BHP-2013-0225" Jan 1,2013 Dec 31,2013n $135 00
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Total Fees: $205.00 "- -
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PERMIT EXPIRES
December 31 2013
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This Permit is not transferable,and must be reissued upon change of ownership or location.The permit must be posted r' y
in a prominent location in the Establishment. . e
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 ^
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4 CITY OF SALEM,
MASSACHUSETTS
BOARDOI'HI?AtariPubliceatfh
H
120 WASHING"roN S1 at L'r,411,F1,0olt
KIMBERLEY DRISCOLL Tia..(978)741-1800 FAt(978)745-03,DEC 2Q 1. titin,RANIDIN,RS/REI-IS,CHO,CT-FS
MAYOR IramdiLi@salem.com BQCITY t;F SALEM HI�,�V:;I'.hIAGENT'
ARD OF HEALTH
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: eaAlL
2) Establishment Address: 73 . HAR hej4 . ,5'
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: q78 ) 71-1 3
5) Applicant Name&Title: C ` C&) Toa-;VA
6) Applicant Address: El A4 , B44455<- 010760
7) Applicant Telephone No: C17g.65-4 - O7 4 Hour Emergency No:779?.Lf06" �Fb Email: e#j *65V 04,&4
8) Owner Name&Title(if different from applicant): ! o
9) Owner Address(if different from applicant): a
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
A corporation
An individual t 9�
A partnership
Other legal entity
12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title:
Address:
Telephone No: / Fax: ;7j- 7/{*3336 Email:
Emergency Telephone No: GS •a
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: '� _ Dater Amount o
Food Establishment Information '
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable)
16) Days and Hours of Operation: 17) No.of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) la Retail( sec.°' Sq. Ft) ❑ Caterer
Permanent Structure ❑ 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 ❑ Residential Kitchen for Bed and
21) Length Of Permit: Breakfast Establishments
(check one) RETAIL STORE RESTAURANT
Annual 91 Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140
Seasonal/Dates: 0 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140
❑ More than I0,000sq.ft. $420 ❑25-99 seats $280
❑ More than 99 seats $420
Temporary/DateslTime: -- - - --- -------il-- ----- - - ----- -- ----- -m--------------------------------------- - -------------------
❑ Bed&Breakfast/Childcare Services/Nursing Home $100
----------------------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
❑ MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
IF TOBACCO VENDOR $135
❑ALL NON-PROFIT $25
(Including, church kitchens, state funded childcare 8 private clubs)
23) Food Operations: Definitions: PHF-potentially hazardous food(timeltemperature controls required)
Non-PHFs-non-potentially hazardous food(no timeltemperature controls required)
check all that a / : 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
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs 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
Service Within 4 hours 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 SaleAnimal Origin
_ _ _
Perishable Foods Only I
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:
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
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24)' Signature of Applicant: .a'&e 0'_Q4
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: (�6/_
26) Signature of Individual or Corporate Name:
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CITY OF SALEM, MASSACHUSETTS
/ BOARD OF HEALTH
120 WASHINGTON STREET 4`"FLOOR p11b�1CHC81th
> rr.one.r.amm�.v....
'FEL. (978) 741-1800 FAX(978) 745-0343
IQMBERLEY DRISCOLL " kamdin e Salemxom - -- -
L,\IatY R\AmtN,Rs/Iu IIs,c,HO,cr-rs
MAYOR `' HF',\unl AGENT
This Form will be collected during your next Board of Health inspection.
QUESTIONAIRE — GREASE TRAPS 2012
0
1. NAME OF ESTABLISHMENT: N/ M A- `6P7f RPr f S&&02yV-
2. ADDRESS OF ESTABLISHMENT: /J i og , S�
_3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP?
4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?
CAPACITY IN GALLONS
5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR
BY AN OUTSIDE CLEANING SERVICE?
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
YOUR ESTABLISHMENT?
S. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?