Loading...
TAVERN ON THE SQUARE - ESTABLISHMENTSTAVERN ON THE SQUARE 163-189 Washington St. Kimberley Driscoll Mayor Permit Number: Restrictions: City of Salem, Massachusetts lu Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PublicHealth Iramdin@salem.eom Prevent. Promote. Protect. Larry Ramdin RS/REHS, CHO, CP -FS Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 FM -15-103 Permit Type: FOOD SERVICE ESTABLISHMENT Goods & Services: Food Service: >99 Name of License Holder: Tavern in the Square - Renato Valentim Name of Food Establishment Tavern in the Square Restaurant Address of Food Establishment 189 Washington Street SALEM MA 01970 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: $420.00 Issued: 1/1/2015 e KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD or• HuAI.•ni 120 Wmjimc ON SnEET, 0' Ft om 17:1. (978) 741-1800 FAX (978) 745-0343 lamdint@salem.eom O L%RRY IL%MDIN, RS/Alii IS, C1 10, CP -I3 HIiAL11I AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Esteldiahment Name r 2) Estatdial went Address: 3) Establishment Malting Address (if different: 4) Ed Wishment Telephone No., - 5) Applicant Name & Title: S 9) Applicant Address: S� 7) Applicant Telephone No: 1- So\- 5-73 24 Hour ergency No: FinaWaLeikeq 8) Owner Name & Tide pf different from applicant): 9) Owner Address Of different from applicant: 10) Estabfishmerd Owned by. An association V"—rsff An Other mitity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Tide Home Address \ 4im .G m- r 1 Parson Direedy Peqwmnelble For Daily Operations Owrrer person in Cha Supervisor, Manager, etc Name & Title: Address Ivy" l 3 ': ��N items C 54- G,^� I -e -4e. / . A D r 2 J Telephone Na �l �8-9iS-3S3 FaX:q- 0-9111 Email: A% Emergency Telephone Na 13) District or Regional Su am (if applicable) Name & Title: Address: Telephone No: Fax: Email: Amount ye . r Food Establishment Information 14) Water Source. 15) Sewage Disposal: DEP Public Water Supply No. (11' applicable) g JYn- k3-- k W*1 18) Days and Hours of Operation: to 17) f1m of Food Employees: 20 18) Name of Person In Charge Carfliled In Food Protection Management: Required as of 11UU21101 In sccavdance addt 105 CAIR 590.0WA) \ 19) Person Trained In Anti -Choking Procedures (if 25 seats or more): lit Yes No 20) Location: 22) Establishment Type (check all that apply) (check one) a petall ( Sq. Ft) D Caterer rmatteft FoodServloe-( 'LW Seats) 0FrownDessert Manufacturer o e 0 food Service -Takeout 0 Residential Kitchen for Retail Sale 0 Food Service- Institution 0 Residential Kitchen for Bed and ( Meals/Day) Breakfast Home 0 Food Delivery _........_ ......... -_......_.............. 0 Residential 10tchen for Bed and a�.gt. b(IshR!!ti!�$....... ___........ 21) Length Of Permit: (check one) RETAIL STORE �E11.9 NT Annual 0 Less than 1000sq.fL $ 70 0 Less than 25 seats $140 Seas°net 01000-10,000sq.ff. $280 0 Residential KKchens $140 ' 0 More than 10,000sq ft. $420 0 2599 seats $280 ,fibre than 99 seats $420 Tem poraryADatesf lime: ....._.__................dEff............................................................................. 0 Bei 8 &eaklasUChildcare Services IPgirsiti® Home $100 ....._.__.._............_..... _........ _.................... ADDITIONAL PEItiNIT3 .............................................. -............ 11 MAKE ICE CREAM, YOGURTISOFT SERVE $25 0 PASTUR17ATION $25 D ALL NON PROFM $25 1nduding, church kitchens, state funded chUdeare B private club 23) Food Operations: Defklkions. PHF-potenda9yharerdoustood(dmalempwatwecw*Wsmquk" Noo-PHFs—non-potentlaOyhazardous food (no domlempwature controlsrequlraQ (check 89 that apply): RTE—res /asst hmda . sanckwvkh salads, muffs wh/ch need no hn*ereWe Sale of Commerdafly PHF Cooked to Order Hot PHF Cooked and Cooled or Hot ald Prepackaged Non-PHFs for More Than a Sloe Meal Service Sale of Commercially Preparation of PRFs For Hot And PHF and RTE Foods Prepared For Highly Prspadaged PRFs 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 Valance Processed Foods for and/or HACCP Plan (including bare harp! 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- Raw 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 canmleted by the Board ofHealth Retell Safe of Salvage, Out of Date or Reconditioned FoodTotal Perak Fee: Payment Is due with application I, the undersigned, arrest to the accuracy of the Information provided in this appflcaeon and I affirm that the food establishment operation wfil comply with 108 CNR 680A00 and all oth 0 e law. 1 have been Instructed by the Board of Health on howto obtain copies of 106 CMR 590M and the Federal Food Code. 24) Signature of Appllcm* Pursuant to MGL Ch. 02C, sec. 49A, I certify undo the penalties of perjury that I, to my best knowledge and belief, Have foed a9 date tax returns and paid state taxes required undo law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: FOODSERVICE BHP 201, ESTABLISHMENT, �, ev fi �v S Y "61 $ 3v . � s STABMSHMEIN FOODSERVICE BHP 201, ESTABLISHMENT, �, ev fi �v S Y < $ 3v . � s STABMSHMEIN Ya � •,�£File Numl `YR l �F n > Cn K 3e FOODSERVICE BHP 201, ESTABLISHMENT, �, ev fi �v S �F M151 Yk �G.. ki 'd $ 3v . � s Ya .7♦P�,� _ S k `YR l �F n > Cn K 3e ''"� `Y...5`4' Y e `; s� k $� fair'- ✓ PERMIT EXPIItES'� st � M . �r �.,✓ �F M151 Yk �G.. ki 'd $ 3v . � s Ya r � � s ' CITY OF SALEM, r' .® MASSACHUSETTS GeV, �q BOARD o1; HEw:: I I �� ' ^oN J 120 WAS1 HNC'1'ON S'lumn', 401 FLOOR KIMBERLEY DRISCOLL O�C J L �Tqt.. (978) 741-1800 FAX (978) 745-0343 MAYOR JOSNN Ixamdinesalem.com PeblicIieatth LARRY RANH IN, RS/RHLIS, (11-I0, CP -FS HUAIILH AGENT °`food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: rgvc (-�' I x✓ - 1 e S r)✓q t c. 2) Establishment Address: l ecl WA> H 1 �JC- 'QJ St Sq .M ✓v✓'1 IDI 3) Establishment Mailing Address (if different): 1 4) Establishment Telephone No: � - 7 j 0- I9 5) Applicant Name & Title: S4ep kv J Pi' so Jy q 6) Applic ant Address: f00 5)g4jjnl 4e t 31O p)r AA, y� 0 7 Sj 7) Applicant Telephone No: 1�/7-SO/-}$)324HourEmergency No: Email: 1,4veA4tJ;-w5 , 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: A cor oration Sin ua ua A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address np KFS (/A�a��.- y2 fPlb�ur2t lWyl �/ ] rP 1 6p c Ar: 6L S �CS�✓>� /u-� 544✓ �9 IVtz r i 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Su ervisor, Manager, etc. Name &Title: RIC/I- A4p( C Gt ✓r 1_ Address: (,J4k-z F r-4 o 4 rzrO Telephone No: )) �l -.�Ii- 353 Fax:' J- Ili Email: Q,cke'!'qr^/,✓ Emergency Telephone No: `138-993- 35-}'j- 13) District or Regional Supervisor (if applicable) Name &Title: 5-,g/ GPS "J^ltla - OJ'(nR4JN) Mgvq�� Address: h Telephone No: 72)-all0-29 6 Fax: Email:s4Ie se'r✓r.� Im v^re-c Check#: ,Date: �� 3 Amount: J' 4 Food Establishment Information 14) Waxer Source: 15) Sewage Disposal: 1)EP Public Water Supply No: ( if applicable) J• IZM 16) Days and Hours of Operation: M- �Lii %I =3�-i 5�' I -I 17) No. of Food Employees: I c( 18) Name of Person in Charge Certified in Food Protection Management: S✓ � Required as of 101112001 in accordance with 105 CMR 590.003(A) \A co�o r e r,/ , 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): VYes No 20) Location: 22) Establishment Type (check all that apply) (check one) ✓ ❑ I etail ( Sq. Ft) ❑ Caterer Permanent Structure ood Service -( ZZg 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 .Breakfast Establishments ....................... 21) Length OF Permit: (check one) RETAIL STORE RESTAURANT Annual it ❑ Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: 81-000-10,O00sq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,O00sq.ft. $420 010�99 seats $280 IrMore than 99 seats $420 ...... .... .. . . . ........... --- --- ❑ Bed & Breakfast/Childcare Seryices /Nursing Home $100 Temporary/Dates/time: ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ ALL NON-PROFIT' $25 1ricludin , church kitchens, state funded childcare & private club 23) Food Operations: Definitions: PHF- potentially hazardous food (time/temperature controls required) that Non-PHFs — non -potentially hazardous food (no timellemperature controls required) (check all apply): RTE — ready -to -eat foods . sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to OrderHot PHF Cooked and Cooled or Hot Held / Pre-packaged Non-PHFs V, 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 1\41 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 V and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of V 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 ofHealth 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 h\1nrm i provide In this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other la ave bee nstructed by the Board of Health on how to obtain copies of 105 CMR 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: J 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 mql Address: FOOD E,$T*BLISHMEWT INSPECTION REPORT Tel. Name Print: D t Typ f Operations)) L�ype�+ nspectfon Page of ages Food Service ❑ Retail IL?Routine ❑ Re -inspection Address RI Level ❑ Residential Kitchen ❑ Mobile Previous Inspection Date: Telephone ❑ Temporary ❑ Pre-operation Owner HACCP YIN ❑ Caterer tied & Br aj�st ❑ Suspect Illness ❑ General Complaint Person -in -C a e I) Tim In. � Inspector Out: ermit No. ❑ Other Each violation ec a requl 6 s ah/exillanation on the narrative Oigii(tj and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk FactorsjRed Anti -Choking 590.009 (E) ❑ Items)�Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) E], Allergen Awareness 590.009 (G) ❑ corrective action as determined by the Board of Health. � OOgpROTECTION MANAGEMENT, _~ ❑ 1. PIC Assigned/Knowledgeable/Duties [ EMPLOYEE.HEALTH.�v ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded [FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy. of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PR TECTION FROM CONTAMINATION �� _ � _ _ '� _� eparabonlSegregahonlProtection 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing [111. Good Hygienic Practices Violations Related to Good Retail Practices- (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Noncritical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2x590.003) 24. Food and Food Protection (FC -3x590.004) 25. Equipment and Utensils (FC -4x590.005) 26. Water, Plumbing and Waste (FCsx590.006) 27. Physical Facility (Fc -6x590.007) 28. Poisonous or T is Materials (FC -7x590.006) 29. Special Re ui aants f (590.009) 30.0 Z 0.Othe 3: bfdtioc ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities i PROTECTION: FROM'CHEMICALS_- _ , I ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals T._9 =r TIMEfTEMPERATURE.CONTROLS (PoteMlallyHazardous Food;;),w; ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20 Time as a Public Health Control REQUIREMENTS FOR HIGHLY�SU$CEPTIBLE POPULATIQNS_(HSP).a ❑ 21. Food and Food Preparation for HSP ;C NONO SU_MERADVISORY ❑ 22. Posting of Consumer Advisories iTJ Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order.I DATE OF RE-INSPECTIO/q� 111 , 7 Inspector's Signature: Print: PICS Signature: Print: -L ✓ O a Page of ages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT _ 1 590.003(A)AssigtmentofRes onsibilit" 590.003(B) Demonstration of Knowledge 2-103. 1 1 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell --s* E QM 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 lee Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Char e* 590.006(_B) 590,003(G) Reporting by Person in Charce* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C 6 FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.0(1(). t` 1 PROTECTION FROM CONTAMINATinN S Food and Water From Regulated Sources 590A04('A-B) Compliance with Food law* 3-201.12 Food in a Hermetically Seated Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell --s* E QM 3-202.14 E * >s and iLlilk Products. Pasteurized* 3-202.16 lee Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(_B) Water Meets Standards in 310 CNIR 22.0* Washin Fruits and Vegetables Shaf(fish and Fish Froman Approved 7o,roe 3-201.14 Fish and Recreaticmally Caught Molluscan Shellfish* 3-201.15 _ Molluscan Shellfish from NSSPl1sfd Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Re ulator Authodty� _ 3-202.18 SheiistocL identification Present` 590.004(C) Wild Mushrooms* 3-20117 Game Animals* _ 3-70111 Receiving/Condition 3-202.11 PHFs Received at Proper TeuiErarures* 3-202.15 Package Integrity* 3.101.11 F xA Safe and Unadulterated Tags/Rocords: Shelistock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* _----I Tags/Records: Fish Products I 3=402_11 Parasite Destrucdon* 3-402.12 Records. Creation and Retention* 590.004(n Labeling of Ingredients' Cleaning Frequency of Equipment Fad -- Contact Surfaces and Utensils'r Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502x2 Reduced oxygen packaging, criteria* 8-103. t2 Conformance with Approved Procedures'.' * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.0(1(). t` 1 PROTECTION FROM CONTAMINATinN S Cross -contamination 3-302.11(A)0) Raw Animal Foods Separated from Cooked and RTE Foals* Contamination from Raw Ingredients 3-302.1I(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-30211(A) Food Protection* 3-302.15 Washin Fruits and Vegetables 3-30411 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservi,ce of Foal* FDisposition ofAdufterated or Contaminated Food 3-70111 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces - 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures*. 4-501.114 - Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1 Cleaning Frequency of Equipment Fad -- Contact Surfaces and Utensils'r 4-702.11 Frequency of Sanitization of Utensils and Fund Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Arms* 2-301.12 Cleaning Procedure* 730114 When to Wash* 11 Good Hygienic Practices 2-101.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination. from Em plo .es* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11. Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devkes 6-301.11 Handwashing Cleanser, Availability 6-301.1.2 Hand Drying Provision r M BOARD OF HEALTH I Establishment Name: I i I/V1 C �C Date: Wu I b Page:of _ 5 Zyb L6IL, C? R - Red Item • • . • • • NO 1"Me l ' ►r 1"I'll ISN MPG 11 I11��.119� �L :IM .11�Ilw,,,_. ,..._ 2k 09- MAN 2WWJVO I! "4111 WOMMA MINSAW107A 9, MM FMV, r. MI.�� -in. ®1ol 5 Zyb L6IL, C? Violations Related to Foodbarne 111ness Interventions and Risk Factors (items 1-22) (Cont.) Im " Dentes critical ivm in the federal 1999 Foal Code a 105 C31R 590.000. 20 3.501.14(C) Food or Color Additives 3-202.12 Additives* ---- 3-302.14 Protection from Unapproved Additives" 3-501,16(B) 590.004(0 Poisonous or Toxic Substances - 7-101,11 Identifying Information -Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Storage* - 7-202.11 ,Restriction - PresenceandUse* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce; Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.12 - Ralent:Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring' " Dentes critical ivm in the federal 1999 Foal Code a 105 C31R 590.000. 20 3.501.14(C) Proper Cooking Temperatures for 3-501,.15 PHFs 3401.IIA(1)(2) Eggs- 155`F 15 Sec. 3-501,16(B) 590.004(0 E as- Immediate Senice 145'F15sec- 31401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals- 155'F 15 sec. * 3.401.11(8)(1)(2) Pork and Beef Roast -130°F 121, min* 3-401.11(A)(2) Ratites, Injected Meats -'155'F 15 590."X14 H1 Ler * 3-403.11(A)(3) Poultry, Wild Game, Staffed PRFs, 27. Stuffing Containing Fish, Meat, Poultry or Ratites -165'F 15 sec, 3-401.11(C)(3) Wh6le-muscle, Intact Beef Steaks ! FC- 7 145'F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165`F * 3.40131(A)(1)(b) All Other PHFs -145°F 15 sec. * . Reheating for Hot bolding 3403.11(A)&(D) P.HFs 165-F 15 see. * 3-403.11(B) Microwave -'165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140"F* 3403.11(E) . Remaining Unsliced Portions of Beef .Roastsi` Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PRFs from 140`F to 70'F Within 2 Hours and From 70'F to 410141450F Within 4 Hours. * 3-501.)4(B) Cooling PRFs Made From Ambient Temperature ingredients to 41'F/45'F Within 4 Hours* " Dentes critical ivm in the federal 1999 Foal Code a 105 C31R 590.000. 20 3.501.14(C) PHFs Received at Temperatures According to law Cooled to 41'F/45'F Within 4 Hours. 3-501,.15 CoohnE Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501,16(B) 590.004(0 Cold PHFs Maintained at or below 1 4101450 F* 3-501.16(A) Hot PHFs Maintained at or above 140T. * 3-501.16(A) Roasts Held at or above 130'F. 1 25. Time as a Public Health Control 3-501,19 Time as a Public Health Contr(A' 590."X14 H1 Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.1)(A) Unpasteurized Pre-packaged Juices and :Beverages with Warning iabels* 590.6110 3-801.11(B) Use of Past_euriz_ed_B *s* - !- FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served i Food and Food Protection 3-801AI C Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 "Consumer Advisory Posted for Consumption of 590.6110 L 23_ Animal Foods That are Raw, Undercooked or !- FC - 2 .003 Not Otherwise Processed to Eliminate i Food and Food Protection FC - 3 Patbo-ears" 'a cl,�'c 1 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 ! 26. 1 E ° 590.009(A) -(D) Violations,of Section 590.009(A) -(D) in catering,. mobile fwd, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illuess interventions and risk factors. Other 590.009 violations relating to gold retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, acrd non -M ical violations, which elo not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000, 'r item 1 Good Refat7 Pracdces FC 590.6110 L 23_ 1 Management and Personnel !- FC - 2 .003 1 24. i Food and Food Protection FC - 3 .004 j 1 25. 1 Equipment and Utensils FC - 4 .005 ! 26. 3 Water. Plumbing and Waste FC - 5 _ 006 1 27. Physical Facility i 28. ' Poisonous or Toxic Materials ! FC- 7 .QOB 29. - Special Requirements .009 11 ' 30 1 Other s.sverm„�ru.zc: CITY OF SALEM BOARD OF HEALTH J Establishment Name: Date: Page: of Item No. Code Reference C - Critical Item R -Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date verified � I 5 ) A IN t T Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to P comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: ❑ No Yes 0,46tary Compliance ❑ Employee Restriction / Exclusion le' Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne Illness. Interventions and Risk Factors fiterns 1-22) (Cont,) Lim IN 17 18 Food Of Color Additives 3-20112 Additives*' 3-302.14 Protection from Unapproved Additives" 3-501.16(B) 590.004(M Poisonous or Toxic Substances 7-10111 - Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Stora * - 7-202.11 ,Restriction - Presenceand rise* 7-202.12 Conditions of Use* 7-203.11 Toxic Cattainers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Crivaia' 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Foal Contact Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* - 7-3(16.12 - Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring! IN 17 18 " Drnetes rritieal i+nm in the i-Qeral 1999 P�1 Cate w' ith C:1NR �9n.t)p0. `ry 3-501.14(0 Proper Cooking Temperatures for 3-501.15 PHFs 3-401.1IA(1)(2) Eggs- 155'F IS Sec. 3-501.16(B) 590.004(M Eggs- Immediate Service 145'F15sec+ 3-441.11(A)(2) Comminuted Fish. Meats & Game 3•SO1.16(A) Animals - 155'F 15 sec. * 3-40111(11)(1)(2) Pork and Beef Roast - 130'F 121 min* 3401.1 I(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) sec. 3-401.1 t(A)(3) Poultry, Wild Game, Stuffed PHFs, r2_7 Stuffing Containing Fish, Meat, FC -6 Poultry or Ratites -1650F 15 sec, 3401AI(C)(3) Whole -muscle, law Beef Steaks 1 FC -7 145V 3-40L12 Raw Animal Foods Cooked in a Microwave 165F * 3441:11(A)(i)(b) All Other PHFs - 145'F 15 sec. " Reheating for Hot Holding 3- W3.I I(A)&(D) PHFs 1653' 15 see. * 3-403.11(B) Microwave- 165' F 2 Minute Standing Tlrtu* 3-403.11(C) Commercially Processed RTE Food - 140'Fx 3403.11(B) Remaining Unsliced Portions of Beef Roasu': Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140`F to 70'F Within 2 Hours and From 70'F to 41'F/45'F Within 4 Hours. * 3-50114(6) Cooling PHFs Made From Ambient Temperature ingredients to 41'F/45'F Within 4 Hours* " Drnetes rritieal i+nm in the i-Qeral 1999 P�1 Cate w' ith C:1NR �9n.t)p0. `ry 3-501.14(0 PRFs Received at Temperatures According to Law Cooled to Within 4 Hixns. 3-501.15 _41=F/45`17 Cooling Methods for PHFs 3-801.11(B) PHF Not and Cold Holding 3-501.16(B) 590.004(M Cold PI -117s Maintained at or below 41'/45° F* 3-501.16(A) Hot PIVs Maintained at or above 140°F. * 3•SO1.16(A) Roasts Held at or above 130°F. 1 25. Time as a Public Health Control 3-501:19 Time as a Public Health Control* 590.004(H) Variance R u rement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.1](A) Unpasteurized Pre-packaged Juices and .Beverages with 41'uning Labels*,.__ 590.000 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801.1 I (D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Pasted for Consumption of 590.000 L23. Anima] Foods That are Raw, Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC -3 Patbugans.* smxe,* v,2onr 1 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .605 26. E 590.009(A) -(D) Violations of Section .590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590,009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical mrd non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and JOS CMR S90.000. Hem I Good Retail Practices .FC 590.000 L23. i Management and Personnel FC - 2 .003 1 24.-? Food and Food Protection FC -3 .004 ! 1 25. E ui ment and Utensils .__ FC - 4 .605 26. Water. Plumbing and Waste FC -5 .066 r2_7 Physical Facility FC -6 .007�� i 28. Poisonous or Toxic Materials 1 FC -7 .008 29. Sial Requirements 30 Other 53Q'I�f c< HARBOUR FOOD SERVICE EQUIP. PICK TICKET 229 MARGINAL STREET PO BOX 6009 CHELSEA, MA 02150-0006 Harbom Phone: (617) 884-3900 WWI', 19741 Guiding The Food Service Industry Fax: (617) 884-1935 11/25/13 5:04 PM Since 1929 email: info@harbourfood.com Website: www.harbourfood.com 1 TAVERN-SALEMTAVERNrN THE SQUARE- SALEM .3 -189 C/O TAVERN IN THE SQ MGMT CO 163 WASHINGTON ST SALEM, MA 0070 22 MCGRATH HIGHWAY, SUITE 201 ON SOMERVILLE, MA 02143 - 5. J. . ........... 30 BO'PRE NET .11125/13.. ............. ltem D Weight L . .. ... . . WNCCDP1P CONDIMENT DISPENSER IPT 1 12 V' EA .0 SHOW WNCCBRDIS24 CUT BD 18x24 RED I ✓ EA; .0 IN02S3 WNCCBGRI824 CUT BD 18x24 GREEN 2 ✓ EA! .0 1NO2S3 WNCCBYL1824 CUT BD 18x24 YELLOW I ✓ EA .0 IN02S3 WNCCBWT1824 CUT ED 18x24 WHITE I V EA' .0 IN02S3 WNCCBBUIS24 CUT BD 1844 BLUE I ✓ EA .0 IN02S3 II V Total Weight: .0 Delilah Castro From: rick <rick@taverninthesquare.com> Sent: Tuesday, November 26, 2013 4:00 PM To: Delilah Castro Subject: Tavern in the Square Attachments: Harbour Order.pdf Hello Delilah, Rick Naples from Tavern in the Square. It was a pleasure meeting you today. I have attached the invoice for the cutting boards that were purchased to replace the existing ones in the kitchen. If you have any questions please do not hesitate to call me at 978-740-2337. Thank you and have a great Holiday Rick Naples General Manager Tavern in the Square Salem 978-740-2337 IIJ� CITY OF SALEM 11� BOARD OF HEALTH Establishment Name: M 12 Date: Page: of Item No. Code I Reference C -Critical Rem R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date - Verified y,., u 1 i moi, Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Feder d Code. I unjdMtand that noncompliance may result in daily fines of w - veollars r s spension/revocation of your food permit. Corrective Action Required: o ❑ Yes voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne 111ness lntervenNons and Risk Factors (Hems 1-22) (Cont.) 15 U 17 _..----^ Food or Color Additives 3-20-- ...._..-. ---2.12___ Addi.-.... 3-302.14 Protection from Unapproved Additives* ISOL11B Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Sto 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toric Containers - Prohibitions* 7-204.11. Sanitizers. Criteria - Chemicals* - 7-204.12 Chemicals for WashiM Produce, Criteria' 7-204.14 Drying Agnts. Criteria* 7-205.I1 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides,' Criteria* - 7-206.12 - .1 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitorme* 1u..7 t1' *it -.e - Proper Cooking Temperatures for 19 PHFS _ 3-401.1IA(t)(2) Eggs- 155'F 15 Sec ISOL11B E Immediate Service 145°F15sec" 3-401.1I(A)(2) Comminuted Fish. Meats & Game Raw or Partially Cooked Animal Fad and Raw Seed Sprouts Not Served. * Animals - 155'F 15 sec. * 3-401.11(11)(1)(2) Port: and Beef Roast -130°F 221 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 ! 26. sec. * 3401.1I(A)(3) Poultry, Wild game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, i FC -6 Poultry or Ratites -165°F 15 sec, 3.401.11(0)(3) Whole -muscle, Intact Beef Steaks FC- 7 145'F * 3-401.12 Raw Animal Fads Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs - 145'F 15 sec. i Reheating for Hot Holding 3403Al(A)&(D) PHFs 165°F 15 sec. * 3-503.11(B) Microwave- 165` F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE FoW - 140oF* 3-403.11(E) - Remaining Unsliced Portions of Beef Roasts* .. Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140`F to 70'F Within 2 Hours and From 70-F to 41`F/45'F Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'F - Within 4 Hours* '.Denotes entiad icm in The fideral 1999 Food Cate ur I05 CNV 590.000. 3-501.14(C) PHFs Received at Temperatures According to Law Gaoled to 41'P145°F Within 4 U'vtre * 3-501.16(13) 590.004(M 3-501..15 Cooling Methods for PHFs 19 1 PHF Not and Cold Holding 3-501.16(13) 590.004(M Cold PHFs Maintained at or below 411450 F* 3-501.16(A) Hot PHFs Maintained at or above 140'F. * 3-501.16(A) Roasts Heid at or above 1.300F. ISOL11B Time as a Public Health Control 3-501.19 Time as a Public Health Control* FOR HIGHLY SUSCEPTIBLE POPULAYIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beveratzes with Warning Labels* Animal Foods That are Raw, Undercooked or ISOL11B Use of Pasteurimi Eggs* Not Otherwise Processed to Eliminate 3-801.11(D) Raw or Partially Cooked Animal Fad and Raw Seed Sprouts Not Served. * Pathogens.* �` x 1 3-801.11(C) Unopened Ford Packa Not Re -served. Ne. ,, 1r1-111 22 3-603.11 Cousumer Advisory Posted for Consumption of 590.ow 1 23 Animal Foods That are Raw, Undercooked or ' FC - 2 .403 Not Otherwise Processed to Eliminate - Food and Food Protection FC -3 Pathogens.* �` x 1 1 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 I ! 26. Eggs* ZiFrUtAL tiCt.R IM114CAM I7 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering,, mobile fwd, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good. retail practices should be debited under #29 - Special Requirements. (items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.400. .item i Good Retail Practices FC 590.ow 1 23 Management and Personnel ' FC - 2 .403 24.- - Food and Food Protection FC -3 .004 1 25. Equipment and Utensils i FC - 4. .005 I ! 26. Water. Plumbing and Waste i FC -5 .008 27. ' Physical Facility i FC -6 .007 28. 1 Poisonous or Toxic Materials FC- 7 008 j 29. ;eciai R uiremeMs .009 ' 30 i Other i rm.iu I, Commonwealth of Massachusetts " fr . �. ` r City of Salem - Board of Health Klmbefley A DnSaoil 4y120 Washington Street 4th Floor Mayor SALEM, MA-` 01970' , F, Food/Retail Establlshlnent Permit DATE PRINTED. 12/10/2012 71 V ESTABLISHMENT NAME:`_ Tavern to the Square Restaurant s l FileNumbe BUF2009-000007 163-189 Washington Street T— P SALEM' M MA 01970At,2 tv ;- LOCATED AT:: ' z SALEM, MA .01970 <Permit Type Permit No. Permit Issued ;Permit Expires .` : Fee Restrictions /Notes' ' FOOD SERVICE BHP 2013-0090 Jan 1, 2013 Dec 31, 2013 Y ,:ESTABLISHMENTIR - xt x .;.. "Total Fees -$420.00" i S � % 41 a.0 a ¢ 3 N, 50, PERMIT EXPIRES x December 31, 2013 yam. . Board of Health F , -x This Permit is not transferable and must be'reissued upon change of ownership or location. The permit must be posted" in a prominent location in the Establishment. ' e In accordance with the State Sanitary Code; beofm any revonations, improvements, t or equipment changes-are_ made, all plans for such must be submitted to and approved by the Salem Board of Health Page tnre x y � � F�% [. KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEM -TIT 120 WASIiINC, CON S"IRlsl:'It', 411' FLOOR Tess. (978) 741-1800 Fns (978) 745-0343 r lcamdin(u�salem.com PutrficHeaIth LARRY RAiW)IN, RS/RGI-IS, CIIO, CP -FS H@:,\un I A(iF,N'P Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: r! 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: _ Z33 5) Applicant Name &Title: 6) Applicant Address: nd eAkxcpQ 7) Applicant Telephone No: % 3,24 Hour Emergency No: It Email: 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: A ssociation corp at' An m tvidual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address G � 1 12 Person Directly Responsiblee� For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title: /51 t k A40") Cfr e'n ^'19M en - Address: t '91 4✓95 ,v A✓ St- Telephone No: 5a9 �'y�-Z3 S Fax: Email: A. ,k -+P Emergency Telephone No: `'y 71 — ??T--3 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #: Date: Amount: OIXAMn Im �I S)1009 )1:)Inb Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: _ } n No. of Food Employees: 18) Name of Person in Charge Certified in Food rotection Mana e Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): wyes No 20) Location: 22) Establishment Type (check all that apply) (check one) 0 Retail ( Sq. Ft) 0 Caterer Permanent Structure N.Food Service - ( 2 yb Seats) ❑ Frozen Dessert Manufacturer Mobile n Food Service - Takeout ❑ Residential Kitchen for Retail Sale 0 Food Service - Institution 0 Residential Kitchen for Bed and ( Meals/Day) Breakfast Home 0 Food Delivery ❑ Residential Kitchen for Bed and ----- ------------------------------------------------------- Establishments------------------------ 21) Length Of Permit:Breakfast (check one) RETAIL STORE RESTAURANT Annual 0 Less than 1000sq.ft. $ 70 D Less than 25 seats $140 Seasonal/Dates: 0 1000-10,000sq.ft. $280 D Residential Kitchens $140 0 More than 10,000sq.ft. $420 015-99 seats $280 More than 99 seats $420 - ------ --- -------- -- --- --- - -- - - ❑ Bed 8 Breakfast/Chitdcare Seryices /Nursing Home $100 TemporarylDateslTime: ---------------------------------------------------------------- ADDITIONAL PERMITS - D MAKE ICE CREAM, YOGURT/SOFT SERVE $25 0 PASTURIZATION $25 0 TOBACCO VENDOR $135 D ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare & private clubs) 23) Food Operations: Definitions: PHF— potentially hazardous food(time/temperature controls required) Non-PHFs — non -potentially hazardous food (no time/temperature controls required) check all that apply): RTE— ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held 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 V/ Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for V and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of V 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 V 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 comply with 105 CMR 590.000 e 590.000 and the Federal Food C 24) Signature of Applicant: �`LL ation provided in this application and I affirm that the food establishment operation will law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 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 ste 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate N CITY OF SALEM BOARD OF HEALTH Establishment Name:'f-7)vi3 SLa`i t� `i �� a qo q N3 Date: 6 Page: of Item No. Code Reference C -Critical Item R -Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Verified 1 �vl» rT r�—W Sim �-r-4— W \ aN: Li q r Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all inspection, to observe all conditions as described, and to violations before the next ins p comply with all mandates of the Mass/Federal Food Code. I underAnd that noncompliance may result in daily fines of tw e d liars or s ension/revocation of your food permit. Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion Ll Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne titness Intervent/ons and Risk Factors {teems 1-22) (Cont.) •i 1.' +!1 F... r Food or Color XX Additives 3-202.12 -. Additives*' 3-302.14 Protection from Unapproved Additives* 3-50L16(B) 590.004(F) Poisonous or Toxic Substances 7-101,11 Identifying Information-Ori&inal Containers* 7-102.11, Compton Name - Working Containers* 7-101.11 Separation - Storage* - 7-202.11 . Restriction - Presence and -Use° 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 3401.11(C)(3) Drying entS. Criteria' 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bair Stauons* 7-206.13 Tracking Powders, Pest Control and Monitoring* XX * Denotes critical item in the federal 1999 Food Cale w 1115 C&tR 590.000. 19 20 3-507. t4(C) Proper Cooking Temperatures for 3-501.15 PHFe 3-401.IIA(1)(2) _ Eggs- 1557 15 Sec. 3-50L16(B) 590.004(F) Eggs- Immediate Service 145'FISsec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals - 1550F 15 sec. * 3-401.11(11)(1)(2) Port: and Beef Roast -130°F 121 min* 3-40IA I(A)(2) Ratites Injected Meats -155`F 15 590.004(H) sec. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Staffing Containing Fish, Meat, Poul or Ratites -165'F 15 sec. 3401.11(C)(3) Whole -muscle, intact Beef Steaks 145°F * 3-401.12 Raw Animal Faxls Cooked in a Microwave 165T * 3-401.11(A)(1)(b) All Other PHFs -145'F 15 sec. _ Reheating for Hot Holding 3403A I(A)&(D) PHFs 165'1715 see. * 3-403.11(B) Microwave- 165` F 2 Minute Standing Time* 3403. 11 (C) Commercially Processed RTE Food - 140°F* 3403-II(E) Remaining Unsiiced Portions of Beef Roasts" Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140`F to 70`F Within 2 Hours and From 70'F to 41`F/45'F Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* * Denotes critical item in the federal 1999 Food Cale w 1115 C&tR 590.000. 19 20 3-507. t4(C) PHFs Received at Temperatures '.. According to Law Cooled w 41TV45017 Within 4 Hours. 3-501.15 Coolina Methods for PHFs _ PHF Not and Cold Holding 3-50L16(B) 590.004(F) Cold PIIFs Maintained at or below 4101450 F* 3-501.16(A) Hot PRFs Maintained at or above 140'F. 3-501.16(A) Roasts Held at or above 130'F. ' Time as a Public Health Cotdrol 3-501:19 Time as a Public Health Control' 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 2I 3-801.11(A) Unpasteurized Pre-packaged Iuices and :Bevernees withVv_arning Labels* 3-80LI I(B) _ Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served * 3-801.11(C) Unopened Food Package Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked or Not Otherwiae Processed to Eliminate Path o*ens.*`''°°'°°"1 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggsrt Violations of Section 590.009(A)-()) in catering,, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can he found in the foltawing sections of the Food Code and 105 CMR 50t) 1)[10 5-�roc'+me^sc:-: cc Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4t' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name _ c, Date T f O eration s T e f Irts Non 2 J Pagel0 Pages Food Service ❑ Retail outme ❑ Re -inspection Address . Risk Level ❑ Residential Kitchen Previous Inspection Telephone (� El Mobile Date: ❑ Temporary ❑ Pre-operation Owns HACCP YM w6w_ ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person In Charg PIC) Time In Out.. Permit No. El HACCP ❑ Other Inspector Each violation checked requires an expltion-on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: n Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco v Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑l action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT , --------- ❑ 1. PIC Assigned / Knowledgeable / Duties [112. Prevention of Contamination from Hands ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE - e Eloo 4. Fd and Water from Approved Source TIMErrEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION yw+' ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing Z11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) V 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE_POPULATIONS.(HSP). ❑ 21. Food and Food Preparation for HSP CONSUMER.AOVISORY nka: ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions rl and Risk Factors (Items 1-22): oC Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: G C /y 0 a -L Inspector's Signature: Print:' PIC's Signature: Print: Vii% e- /%-CP Pagel0 Pages ePt3 C"40 -e -to --fie vo 'a/L 5 "kAza --t o 'Be VV\ }� -�rowdo' "AVj ON_yJ Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) PROTFCT1nN FRnU nriNTAuivaTlnN _. FOOD PROTECTION MANAGEMENT 1 590.003(A) tf Rs onsibilit * 590.003(=anon of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.W3(C) . Responsibility of the.person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Foul Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C 6 I FOOD FROM APPROVED SOURCE - Food and Water From Regulated Sources . 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* - 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.1.4 EMs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables. Shellfish and Fish From an Approved Soume 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Lasted Sources* Contamination from the Consumer. Game and Wild Mushrooms Approved by Regulatory Authority 3-202.1.8 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving(Conditlon 3-202.1.1. PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated TagstRecords: Shellstock 3-202.18 Shellstock Identification 3-203.12 Shellstock Identification Maintained* Tags/Records:'Fish Products 3402.1 f Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(7) Labeling of Ingredients' Cleaning Frequency of Equipment Food - Contact Surfaces mid Utensils* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria' 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Folxi Code or 105 CMR 590.000. 3 Cross -contamination 3-302.11('A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302A I(A)(2) Raw Anitnal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) - Food Protection* 3-302.15 Washing Fruits and Vegetables. 3-304.1 t Food Contact with Equipment and Utensils* Contamination from the Consumer. 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Foody° 9 Food Contact surfaces 4-501.111. Manual Warewashing - Hot Water Sanitization Temperatures* . 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH; concentration and hardness. 4-601.11(A) Equipment Food Contact, Surfaces and - Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces mid Utensils* 4-702.11 - - Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and. Chemical* 10 Proper, Adequate Handwasning 2-301.1.1 - Clean Condition - Hands and Arms* 2-30112Cleamn Procedure* 2-301.14 When to ;Was 11 Good Hygienic Practices 2401.11. Eating, Drinking or Using Tobacco* 2-401.12 Discharges.From the Eyes, Nose and . - Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(&) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 - Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-3(11.11 Handwashin Cleanser, Availability 6-301.1.2 Hand Drying Provision CITY OF SALEM n BOARD OF HEALTH Establishment Name LL (%ASL -M.4 A 9 Date: H q -�� Pager of _ R — Red Item AM _� MR F ... MEMO S. 0 OPINION W.9. .. .. .. . food permit. , .... .- Violations Related to Foodbarne Illness Interventions and Risk Factors films 1-22) (Cont.) m .16 Im is TIME/TEMPERATURE CONTROLS Food or Color Ad di4ivess 202.12 Additives* 3-30114 Protection from Unapproved Additives* Poisonous or Toxic Substances 7-101,11 7dentifyingInformation -Original Containers* 7-102.11, Comoton Name - Working Containers* 7-201..11 Separation - Storage* - 7-202.11 . Restriction - Presence and Uses' 7-202.12 Conditions of Use* 7-203-11 Toxic Containers - Prohibitions* 7-204.11 Sarmizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Trackirig Powders, Pest Control and Monitorin Im is TIME/TEMPERATURE CONTROLS Denotes critical vzm in the federal 1999 Foci Cate a' 103 CMR 590.000. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 4t'F/45°F Within 4 Hours. * Proper Cooking Temperatures for 14 PHFs 3-401.IIA(1)(2) Eggs- 155°F 15 Sec. E , -,s- Immediate Service 145'FiSsec* 3-40Ll l(A)(2) Comminuted Fish. Meats & Game 3-801.11(C) P.nimals - 155'F 15 see. * 3401.11(13)(1)(2) Pork and Beef Roast - 130'F '121 min* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 sec. * 3401.1 l(A)(3) Poultry, Wild Game, Stuffed PHFs, Stuffing Containing Fish, Most, - Poultry or Ratites -165'F 15 sec 3401_11(C)(3) Whole -muscle, Intact Beef Steaks 145°F * 3401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401A I(A)(1)(b) All Other PHFs - 145'F 15 sea Reheating for Not Holding 3403.11(A)&(D) PHFs 16S'F 15 sec. * 3403.11(B) Microwave -'165` F 2 Minute Standing Time* 3403.I1(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cowling Cooked PHFs from 140'F to 70°F Within 2 Homs and From 70°F to 41 `F/45'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/456F Within 4 Howx* Denotes critical vzm in the federal 1999 Foci Cate a' 103 CMR 590.000. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 4t'F/45°F Within 4 Hours. * 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 410145° F* 3-501.16(A) Hot PHFs Maintained at or above at I L$111i3 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-507,15 CoolingMethods for PHFs 14 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 410145° F* 3-501.16(A) Hot PHFs Maintained at or above at I L$111i3 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and Beverages with Warning labels*_ 3-501.11(9 Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and Rain Seed Sprouts Not Served, * 3-801.11(C) Unopened Food PackageNot Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw, Undercooked or Not Otherwise Processed to Eliminate Pathogens.' Eft' "t 3-302.13. Pasteurized Eggs Substitute for Raw Shell E a Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical., and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections -of the Food Codc and 105 CMR son nfm 'Establishment N2 00 oakt1 CITY OF SALEM }�� BOARD OF HEALTH t VSA , , Date: :l— 10 – 02 Pager of _ �as MAZUR ME= 033 =112 V Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. — ❑ Voluntary Compliance ❑ Re -inspection Scheduled ❑ Embargo ❑ Voluntary Disposal ❑ No 1.0 Yes ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Hems -f-22) (Cont.) ..tr t Mtsy Ii F im 16 17 18. he.,. r. :TA9I 5* Food or Calor Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic SubsUnces 7-101,11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Stn * - 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 'toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7.206_ I2 Rodent Bait Statitms* 7-206.73 Trar k ng Powders, Pest Control and Monitorine* he.,. r. :TA9I 5* ' Denotes critical i> nv in the L -doral 1999 Fwd Code a 105 C:MR 590.000. NO 20 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHF$ _ 3-401.11A(i)(2) Eggs- 155F 15 Sec 3-501.16(B) 590.004(F) E - immediate Service 145'Fl5sec* 3.401.11(A)(2) Comminuted Fish. Meats & Came 3-501.16(A) Animals - 155'F 15 sec. * 3401.11(B)(1)(2) Pork and Beef Roast -130'F 121 min* 3-401.1I(A)(2) Ratites, injected Meats -155`F 15 590.004(H) sec. * 3-401.1,1(A)(3) Poultry, Wild Game, Stuffed PHFs, i 27. Ph sisal Faci' (_28. j Poisonous or Toxic Materials Stuffing Containing Fish, Meat, .007 .008 Poultry or Ratites -165'F 15 sec. 3401.11(C)(3) Whole -muscle, Intact Beef Steaks .009 145OF' 3-401.12 Raw Animal Faris Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs - I450F 15 sec. * Reheating for Hot Holding 3-103.11(A)MD) PRFs 165'F 15 sec. * 3-403.11(B) Microwave- 165` F 2 Minute Standing Time* 3403. 11 (C) Commercially Processed RTE Food - 140'F 3-303.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PIFs from 140'F to 70'F Within 2 Hours and From 70'F to 410F/45011 Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* ' Denotes critical i> nv in the L -doral 1999 Fwd Code a 105 C:MR 590.000. NO 20 3-501.14(C) PHFs Received at Temperatures According to taw Cooled to 41'F/45*F_Within 4 Hours. 3-501.15 Cooluip Methods for PHFs 3-901AI(B) PHF Not and Cold Holding 3-501.16(B) 590.004(F) Cold P33Fs Maintained at or below 41'115° F* 3-501,16(A) Hot PHFs Maintained atorabove 140'F. * 3-501.16(A) Roasts Held at or above; 130'F. " 1 25. Time as a Public Health Control 3-501:19 - Time as a Public Health Control* 590.004(H) Variance Recicurement t •• IrIeW I I wit ra 21 3-801.11(A) Unpasteurized Pre-packaged Juices and .Beverages with Warning Labels* 59a000 3-901AI(B) Use of Pasteurized Eggs _ -t FO -2 3-801-II(D) _ Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served, * �, Food and Food PrcteeiionFC 3-301.11 C UnoDened Food Package Not Re=served. CONSUMER ADVISORY 22 3-603.11 Consumer Adiiisory Posted for Consumption of 59a000 1 23. Animal Foods That are Raw. Undercooked or _ -t FO -2 .003 Not Otherwise Processed to Eliminate �, Food and Food PrcteeiionFC - 3 Patho=ens.* te ` nom" 1 25. 3-302.13. Pasteuriwd Eggs Substitute for Raw Shell .005 ! 26. E * L rxca,rVIrUZW=J% I= Violations of Section 590.009(A) -(D) in catering, mobile £acrd, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #2.9 - Special Requirements. ka[ru= (Items 23-30) Critical.. and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the follewing sectionsof the Food Code and 105 CMR 590.000. item Gael Retail Practices j .FC 59a000 1 23. 1 Management and Personnel _ -t FO -2 .003 ! 24.. �, Food and Food PrcteeiionFC - 3 .004 .`.! 1 25. i ERuipmetn and L tensiis 1 FC - 4 .005 ! 26. I Water. Plumbing and Waste i FC -5 .006 i 27. Ph sisal Faci' (_28. j Poisonous or Toxic Materials FC -6 E FC = 7 .007 .008 i 29. Special Requirements .009 30. j Other Y' fvligsachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMN NIT SPECTION REPORT Salem Board of Health 120 Washington Street, 4t" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Nam tnAkPA AA �� ov,n Date Tvpe of 0 eration(s) Food Service Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary 1❑ Caterer ❑Bed & Breakfast peroit No. 8,10 of Inspection ❑Routine CS.Re-inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint ElHACCP ❑ Other Address- 3 Xq I Q )'WA .nn . " isk Level I Telephone Owner HACCP YM _ Person in Charge(!�IC) \ Inspector 4 \ Time Ou��� , Each violation checked requires violations marxea may pose an imminem-nei action as determined by the Board of Health. n on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: fentions and Risk Factors Anti -Choking Tobacco hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ FOOD_PROTECTION MANAGEMENL_ _ . E]1. PIC Assigned / Knowledgeable / Duties [EMPLOYEE HEALTH ❑ 2. Reporting of Diseases' by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded r -FOOD FROM APPROVED SOURCE- - , , ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROOM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection �) 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) O 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.006) 29. Special Requirements (590.009) ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Fooda) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control kEdUIREMENTS FOR [❑ 21. Food and FF odlPreparation for HSP POPULATiONS_(HSP)I CONSUMER ADVISORym,• - u - ❑ 22. Posting of Consumer Advisories ,,Number of Violated Provisions Related 1 Tc Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. 30. Other DATE OF RE -INSPECTION: oV 1 61n v Inspector's Signature:A.-P. L_"L- Print: h PIC's Signature: l-- - Print: C, �,, Page of?,Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(A) AssiDem tient of of Knowled&e*� 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 - 590.003(C) Responsibility of the person in charge to Compliance with f=ood lav:* 3-201.12 require repotting by foot employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Fraployee Or An 3-202.16 ice Made From Potable Drinking Waren* Applicant To Report To The Person In Drinking Water from an Approved System' 590.006(A) Charge* 590.(H)6(B) 590.003(6) Rgor6ng by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 5 FEN FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Fwd Codc or 105 CMR 590.000. 8 Food and Water From Regulated Sources 590.004(A -B) Compliance with f=ood lav:* 3-201.12 Food in a Hermetically Scaled Container* 3-201.13 Fluid Milk and Milk Products* 3-202.-13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 ice Made From Potable Drinking Waren* 5-101.'1 Drinking Water from an Approved System' 590.006(A) Bottled Drinking Water* 590.(H)6(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreatiwally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSF Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Re ulato Authort 3-202.18 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 ReceivingrConditkon 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Inte rity* 3-101.1 i Food Safe and Unadulterated Togs/Records: Shellstockc 3-202.18 Shellstock Identification 3-203.12 ShelistockIdentification Maintained* TagsfRecords: Fish Products 3-402.11 Parasite Destruction.* 3-402.12 Records. Creation and Retention* 590.004(1) Labeling of Ingredients` Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Conformance with Approved Procedures lHACCP Pians -502.1- [3_502 Specialized ProcessingMetbcxis* .12 Reduced ox gen acka 'ng, criteria* -103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Fwd Codc or 105 CMR 590.000. 8 Cross -contamination 3-302.11(A)(]) Raw Animal Foals Separated from Cooked and RTE Foods* Contamination from Raw ingredients 3-3011l(A)(2) Raw Animal Foods Separated from Each Other` - Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe , Food* 9 Food Contact Surfaces 4-501.111. Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. 'k 4-601.11(A) Equipment Food Contact Surfaces and ' Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and - Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Arms*. . 2301..12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-40112 Discharges From the Eyes, Nose and , Mouth* - 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Ent to ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11. Numbers and Capacities* _ 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Haridwashing Cleanser, .Availability 6-301..1.2 FHandD 'n ,Provision CITY OF SALEM BOARD OF HEALTH Establishment Name n Paae: r-), of Item No. Code Reference Reference C -Critical Rem R - Red Item V DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - PLEASE PRINT CLEARLY verified i 5 //J „ matin / - Pi1N�l l u D O IJ, nen �n 6 " - �C;. a - x, F-� lk l ✓i A n y V 4--��AIPI�U An-r/l r,1AA -sol •Ids �u / On �C ,7 -t rte -kb 16 - a Q �erl�- i"n-0 A�h oy ,, ,A . �vtca tiv � V�6� � .�E' oaY - o �r Discussion With Person in Charge: Corrective Action Required: ❑ No yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to Exclusion 6--"Re-in ctjAn Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that \ �,t, or s spension/revocation of your food permit. noncompliance may result in daily fines of tweet -five dZcw/ ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne I tnes , Interventions and Risk Rectors; (item 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 15 17 18 TIMEITEMPERATURE CONTROLS Food or Color Addi Ives 37202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-501-16(B) 590.004(F) Poisonous or Toxic Substances 7-101..11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7 201.11 Separation - Storage* 7-202.11 .Restriction -Presence and Use* 7-20212 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Satdtizers.Criteria- Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contaa, Lztbricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring' TIMEITEMPERATURE CONTROLS * Denotes critical ram in the federal 1999 Fuad Cale or 105 CMR 590.000. C 20 3-501.14(C) Proper Cooidng Temperatures for 3-501.15 PHFs 3401.I1A(1)(2) Eggs- 155°17 15 Sec. 3-501-16(B) 590.004(F) E Immediate Service 145'F15sec- 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals - 155*F 15 sec. * 3401.11(B)(1)(2) Pork and Beef Roast - 1.30°F 121 min* 3-401.11(A)(2) Raffles, Injected Meats -155°F 15 590%4(11) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, Poultry or Ratites -165°F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks i FC = 7 145°F * 3401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-401:11(A)(1)(6) All Other PHPs - 145°F 15 sec. Retreating for Hot Holding 3-403.t1(A)&(D) PHFs 165-F 15 sec. * 3-403.11(B) Microwave -165° F2 Minute Standing Time* 3-403.11(0 Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PRFs 3-501.14(A) Cooling Cooked PHFs from 140*F to 70°F Within 2 Hours and From 707 to 41°F/45=F Within 4 Hours. * 3-501.14(B) Cooling P11Fs Made From Ambient Temperature Ingredients to 4PF/45°F Within 4 Hours* * Denotes critical ram in the federal 1999 Fuad Cale or 105 CMR 590.000. C 20 3-501.14(C) PHFs Received at Temperatures According to Caw Cooled to 41°F/45°F Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501-16(B) 590.004(F) Cold PHFs Maintained at or below 410/450 F* 3-501.16(A) Hot PHFs Maintained at or above 140T. 3-501.16(A) Roasts Held at or above 130°F. 25. Time as a Public Health Control 3-501,19 Time as a Public Health Control* 590%4(11) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and .Beverages with Wanting Labels* 590.0W 3-801.11(B) Use of Pasteurized Eggs* FC -2 3-801..11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11. Consumer Advisory Posted for Consumption of 590.0W 23. Animal Foods That are Raw. Undercooked or FC -2 .003 Not Otherwise Processed to Eliminate Food and Food Protection I FC -3 Pathogen,.' 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. E Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. TIONS RELATED TO (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Cade and 105 CMR 590.000. - Item Good Retail Practices .FC 590.0W 23. Management and Personnel FC -2 .003 _ 24 Food and Food Protection I FC -3 .004 25. Equipment and Utensils �1-FG-4 .005 26. Water. Plumbing and Waste I FC -5 .006 27. Physical FacilityFC-6 .007 28. Poisonous or Toxic Materials i FC = 7 .008 29. Special Requirements ,009 30. Other S:iW�:mMaxl426x Massachusetts Department of Public Health Division of Food and Drugs . FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name c Date Type of Operation(s) Tf Inspection PageAof�_97 Food Service Retail n l PJINL� t�L�� �e zc ms. o s}?ri .. l Routine. Re -inspection _ Address'In Risk Telephone _ Level ❑ Residential Kitchen Previous Inspection I7k -7 ❑ ❑ Mobile Temporary Date: [3Pre-operation Owner. _ HACCP YM p n�D-aL _ ❑ ElBed Caterer & Breakfast ❑ Suspect Illness ElGeneral Complaint Person in Charge (PIC)Time ` In. El HACCP Inspector �� A Out: Permit No. ❑ Other Each violation, checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Ii* v Non-compliance with: Violations Related to . oodborne Illness Interventions and Risk Factors Anti -Choking ,Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) p- 590.009(F)ID-11 action as determined by the Board of Health. .FOOD PROTECTION MANAGEMENT .,.......x _, ❑ 1. PIC Assigned / Knowledgeable / Duties rEMPLOYEE HEALTH , ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded .FOOD FROM APPROVED SOURCE ❑ 4 Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION _,%•, ❑ 8. Separation/ Segregation/ Protection 9�9. Food Contact Surfaces Cleaning and Sanitizing [110. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) V 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S. 5WMA enFw 14.e A- U LU��� [112. Prevention of Contamination from Hands ❑ 13. Handwash Facilities I PROTECTION FROM CHEMICALS 1, 71 ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMFJTEMPERATURECONTROLS (Poteralaliy Hazardous Foodsj ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control _4 4 REOUIREM.ENTS FOR HIGHLY SUSCEPTIBLE PO PULATIONS.(HSP)! ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY QK22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): F71 Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. -�- oDATE OF RE -INSPECTION: Inspector's Signature: 1 Print: / PIC'sSignature: I( Print: `� C� PageAof�_97 ��� Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(Aj AssigamentofResponsibility* 590.003(B) Demonstration of Knowled e* El 2^103.11 Person in charge- duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to Compliance with Food Law" 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinkin Water* Applicant To Report To The Person In Drinking Water from an Approved S stem` 590.000(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restri'etions LE IBJ C I FOOD FROM APPROVED SOURCE ° Denotes crniad item in the federal 1999 Food Cale or 105 CNIR 590.000. 8 Food and Water From Regulated Sources 590.004 -A -B) Compliance with Food Law" 3-201.1.2 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteurized'* 3-202.16 Ice Made From Potable Drinkin Water* 5-101.1.1 Drinking Water from an Approved S stem` 590.000(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authorlt 3-202.18 Shellstock identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.1.1 PHFs Received at Proper Temperatures* 3-202.15 Package late try* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.1.2 Records, Creation and Retention* 590.004(1) I Labeling of Ingredients" Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils' Conformance with Approved Procedures /HACCP Pians 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packa'ng, criteria* 8-103.12 Conformance with Approved Procedures* ° Denotes crniad item in the federal 1999 Food Cale or 105 CNIR 590.000. 8 Cross -contamination 3-302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Focxls* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Anitnal Fonds Separated from Each Other* Contamination from the Environment 3-302.11(A) I Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Faod and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Fes* 9 Food Contact Surfaces 4-501..1.11. Manual Warewashing - Hot Water Sanifization Te eratures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601A (A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils' 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Arms* 2-301..1.2 Cleaning Pru-edure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11. Eatin , Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(Fi) Preventing Contamination from Employees* - 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacifies* -204.11 Location and Placement* -205.11 Accessibility, Operation and Maintenance [6-30). Supplied with Soap and Hand Drying Devices -301.11 Handwashin Clcansor,.Availabilit 12 Hand -D in Provision BOARD OF HEALTH 101 Establishment Name: \011U AA.F+ AA r �/r z ��F Date: °t—� - 1() Page: of _ Item No. Code C- Critical item Reference R -Red Item DESCRIPTION OF VIOLATION !PLAN OF CORRECTION ` " `` - - "� PLEASE�PRIW CLEARLY v a'. +lr. n" Date Verified O n PA /"l ( I I I ! 9 t rl J, n I -h �!?// �L _ - _ ._ r. �I A An 19 A NA I C'; r 1 91? -r;a,n,. C% (')APl,,. i ul� !Y J�, 0, " �) I n Discussion With Person in Charge: Corrective Action Required: ❑ No Yes Voluntary Compliance ❑ Employee Restriction / Exclusion �d— Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other Sc� 3a-sa 1Uorv?��+- �. FORM 7348 (REV. 7/2000) HOBBS & WARREN, -BOSTON This Form Approved by the Department of Public Health S IJ Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 Food or Color Additives 3-202.12 Cooling Methods for PHFs 3-202.14 _Additives* _ Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name -Working Containers* 7-201.11 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* - 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME(fEMPERATURE CONTROLS 16 PHFs Received at Temperatures According to Law Cooled to 41 'F/45'F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.11(B) PRFs 3-501.16(6) 590.004(F) 3-401.IIA(1)(2) Eggs -155°F15Sec. Hol PHFs Maintained at or above 140°F* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* FC 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155°F Sec.* - 4 3-401.11(B)(1)(2) Pork and Beef Roast - 130°F 121 Min.* Water, Plumbing and Waste 3-401.11(A)(2) Ratites, Injected Meats - 155°F 15 Sec.* .006 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, FC - _ Stuffing Containing Fish, Meat, 28. Poisonous or Toxic Materials Poultry or Ratites - 165°F 15 Sec.* - 7 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks Special Requirements 145°F* .009 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.1 I(A)(1)(b) All Other PHFs - 145°F 15 Sec.* 17 Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(8) Microwave - 165°F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 18 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Within 2 Hours and from 70°F to 41 °F/45°F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 19 20 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41 'F/45'F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(6) 590.004(F) Cold PHFs Maintained at or below 41°F/45°F* 3-501.16(A) Hol PHFs Maintained at or above 140°F* 3-501.16(A) Roasts Held at or above 130°E* FC Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 3-801.11(B) Use of Pasteurized Eggs* Management and Personnel 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* .003 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 Animal Foods that are Raw, Undercooked or Management and Personnel FC not Otherwise Processed to Eliminate .003 24. Pathogens.* H/ecfiv 1/1/2001 FC 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other 1 Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: File Number: BHF -2009-000007 LOCATED AT: Tavern in the Square Restaurant 163-189 Washington Street SALEM MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2010-0103 Jan 4, 2010 Dec 31, 2010 $420.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $420.00 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR Ij AVID GREENBAuNi, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4' FLOOR TEL. (978) 741-1800 �Ipw•FAX (978) 745-0343 V t: DGREENBAUN12SALEM. COM �O U, 15?009 17-I 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1 U� e, n �v� `�tl� SG TEL # q1 5k, ADDRESS OF ESTABLISHMENT FAX # MAILING ADDRESS (if different) EMAIL -Business': G "un,�At qe {Op1(Vebsite: G)WW, �0.�crn\r \�� OOfr.Con l OWNER'S NAME_2)"c_n :J�e SC G TEL# ADDRESS STREET ZIP CERTIFIED FOOD MANAGER'S NAMES) MCN'! Qet7,\ C CERTIFICATE#(S) i,1LO3s" 1 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON_M(,:``\HOME TEL# X11 -Z -)q -3R (o(o ®A;SOF©PFERATION'��' _,_.. Tues�yur_ Wed'n'esda a� .. Y ,. Fntla ¢aLMay r Su`n""day HOURS OF OPERATIONj 11 fid_' \ -'-� (Arml \\.b0 Ari\ 1\ �lot-`'1 I \O •3ah+� )O; Ant Please write in time of day. pm `�-•gyp ,(�-v- — I ! (Forexample I1am-11pm) 1 I NYy\ i. \ NM t -l\ ) A;cM TYPE OF ESTABLISHMENT�''* FEE (check only) RETAIL STORE YES pv^ less than 1000sq.ft. =$ 70 It 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT (YES' NO (Outdoor Stationary Food Cart $210 less than 25 seats =$140 25-99 seats =$280 more than 99 seats 1-x$429 BED/BREAKFAST/ YES NO) $100 CHILDCARE SERVICES/NURSING HOME - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT (such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuao MG hapter 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 return4 aid abate taxes required under the law. SignatuTE MN -J- Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check# & Date $ �� KIMBERLEY DRISCOLL MAYOR J)AVID GRLi.I:')NBAUM ACTING HEALTH A(3I3N,r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 41" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGRI3HN13AUM@,SAL E,M COM MEMORANDUM Date: November -24,2009 To: Food Establishment Owners From: David Greenbaum, Acting Health Agent RE: 2010 Food Permit (application enclosed) DUEDECEMBER2Bft Enclosed is the 2010 Food Permit application. A check and the completed application must be received in this office by DECEMBER 28, 2009. You will be issued a $100 ticket for late submission of application and/or fee. Partially completed applications will be considered late and subject to ticketing.' A few reminders: • All City taxes and water bills must be paid in order to receive a 2010 permit. You may not operate after December 31, 2009 without a valid 2010 permit. • Food preparation employees must cover body hair with hats, hair coverings nets, beard restraints or clothing that covers body hair. There is no bare hand contact of ready to eat foods. Gloves must be changed when they become contaminated, such as when the face or hair is touched. Then hands must be washed, and new gloves put on. • Exterior openings must be screened or protected from entrance by insects or rodents. • The 2009 Food Permit is valid. only for the owner listed on the application. Change in ownership, requires a new application and a review of the floor plan and menu of the establishment by the Health Agent. • Any change in the establishment including a change in the menu or renovation must receive prior approval by the Board of Health. • The Food Code requires that each establishment having a seating capacity of 25 persons or more shall have on the premises someonetrained and certified to remove food lodged in the throat, and to have insurance adequate to cover such employees. Please see the enclosed flyer for convenient, local choke -saving classes. 0 Thank you for your cooperation. ttBUGrb BURGER BUG KILLERS, INC® CONFIDENTIAL MONTHLY SANITATION AND PEST ELIMINATION REPORT P: 3�5.E65.3611 R 305.865.0740 TOLL FREE866.928.4766 Account �,,r� Loc t cr# Address „y Ci tya 'State/Zip _f'`._ /r$'!,'.-'nC,i�r Efrea a PPioae _ ' ° Timeylf;service -Da - NOTE TO CUSTOMER: This report is confidential, and is designed to be a benefit to you as part of yaw 'Bugg Burger service. It. is intended to prevent repeat violations of Sanitary Codes. by bringing: them to your attention. Quite often, serious or repeat violations: noted by your Health Inspector during his inspection could cause him to request suspension or revocation of your license or operating permit. - L. OUTSIDE. PREMISES YES 'NO YES No . 1. Are sit parts ofoutsidepremises free of Litter and Rubbish? O' ❑ 18. Are Storage Shelves Cabinets Racks and Pot Hangers ,r 2. Are Garbage Areas, Cordamers dean and containers dean? ,.. ® ❑ Covered ? ❑ - 19. Are Stove Hoodsan Filters clean and free of grease or soil 3. Are doors leading to the outside m Good. Repair and - - build -up? -•F' - `r —} _❑ Self -Closing? - - ❑ 20. Are Sinks and Dishwashing Areas clean and leak free? hr 4. Are all areas Vermin Proofed as required by local Health - r" - 21. Is Food preparation equipment dean? Mixers Grinders Codes? : - QQQ' ❑ Slicers, Can Openers, tee Machine, Coffee Urn 'Proof 5. Is area free of Rodent Harborage, Burrows? ❑ Cabinets, Meat Saws, Chopper, other Equipment? ❑ 6. Are all outside storage areas Clean and Accessible for treatment? - - ❑ V. STORAGE ROOMS - IL DINING ROOM AND LOUNGE - - - 22 Are rooms free of Litter and Rubbish? ):] ❑ :' 23. Are all food products stored Off The Ron and away from 7. Are Side Stands, Utensil Drawers and Lowerators clean and v Toxic Materials? - - - ❑ orderly? ❑ 24. Are Floors, Shelves and Racks dean? . ❑.: 8. Are all Tabes Booths and Chairs dean? Iff ❑ - - - 9. Are Walis.- FloorsDrains Getting A/C Vents and Lights VI. VERMIN CONTROL - - clean and in good repair?.: ` - ❑ 0 25. Is account using Monday Night Is Fly Night.? ❑ -10. Is Drink Equipment clew? Mixers Blenders ace Bins_ .26. Were any. Roaches found? ❑ �s IceScoops, Ice Tea Dispenser. Coffee Makers. Milk 9 ,..� - 27. Any evidence of Rodents? ❑ ri .Dispenser, Beverage Dispenser, Sinks other Equipment? - ®� _ 2g, Vermin Control Report made? ❑ COV 11. Are Storage Shelves and Cabinets clean? Id 29. Was customer notified prior to serviceregarding - III. RESTROOMS preparation? - ' 12. Are Public Restrooms and Employee Resfrooms CIIew -.30- With whom did you speak? '�- 0 doors Self -Closing, Fixtures in Good Repair and free of Odor 961• ❑ 31. Will you call the customer the mod day about any ❑ 13. Are employee Lockers and Locker Area Clean? ,C" ❑ problems noted? Or IV. KITCHEN -BAKERY -BUTCHER -SHOP - 32. Do you want one of our Sanitartans from "Bugs" Burger's Environmental Control Division to call this > 14. Are Stainless Steel aid Hardwood Tables Clean? . ❑ customer' - CdH 15. Are Walls, Floo DPams)Ceiling, A/C Vents and U.ghts dean - ❑ and in good repair?-- - - ❑ 33. Is account properly prepped for services? ❑ ❑ 16. Are Ranges, broilers er 'Ovens itnlls and Stoves clean r Products used and free of baked on foodsan. reale? ❑ D' �`^>-`Y +'yamj '.. t r 'fi ,r' ay 17. Are all parts of Itchen free of Liber? : ❑ � 9i R`� �°�"iSE r fi` dez �, r . 4__.:y=t,3' 4 Comments:I zs"`z 1go�E Fv''.�zaeefSrs - f X-1 custom& Siiyffture - Title - Service pecialist (required except when V service rendered) - _.n. _., NOTE TO CUSTOMER: AFTER EACH SERVICE ALL FOODCONTACT' SURFACES MUST BE WASHED.-:' `WERMIN PROOFING REPAIRS ARE NOT INCLUDED IN YOUR MONTHLY CHARGES. IF B4 IS CIRCLED, SERVICE SPECIALIST WILL PREPARE A VERMIN - CONTROL REPORT TO POINT OUT WHAT REPAIRS ARE NECESSARY IN ORDER -TO PREVENT INFESTATION. I 86 MY BUGS NOW (1-.866.92&4766)' bugsburgercom . • • 0 0 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH KIMBERLEY DRISCOLL 120 WASHINGTON STREET, e FLOOR MAYOR - TEL. (978) 741-1800 FAX (978) 745-0343 LARRY RAMDM, RS/REHS, CHO, CP -FS LRAMDINPSALEM.COM HEALTH AGENT COMPLAINT INTAKE FORM Date: Time: �j (� Gt w� Received By: [PaLd Complaint Number: 0318 Complainant l'/L) SbQ j� Pi 1� Address: Phone: MM Investigated By: -D. (3 $40d"� f\vr— Date: 6— %z Property Owner/Occupant Name Telephone #: rA cr 1q7i�> a(NCK- 10113 T\1lz-� 56'\NPS Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Temporary Food Permit DATE PRINTED: 03/23/2012 ESTABLISHMENT NAME: File Number: BHF -2009-000007 LOCATED AT: Tavern in the Square Restaurant 163-189 Washington Street SALEM NIA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes TEMPORARY FOOD BHP -2012-0397 Mar 24, 2012 Mar 25, 2012 Permit for Salem's Spring Fling - Food to be served: Pulled pork sliders & Buffolo chicken mac n cheese. Total Fees: PERMIT EXPIRES IMarch25,2012 Board of Health Page 1 I JIMBERLEY DRISCOLL. 11.AYOR DAVID GREENBAUNI, RS ACTING HE-VLTH ;1GENT P.1 CITY OF SALENI, MASSACHUSETTS BOARD OFHEALTfi LO WASHINGTON STR);E?T, 4"' 17LOOR Tim. (978) 741-1800 r� 1;,%x (973) 745-0343 DGlRl FSR unl a e.%I.Fm. COM APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT FEE: 1-3DAYS= NON -PROFIT --S2&- 4-7 DAYS = 4"&_ OVER 7 DAYS = >7 DIVIDED Bx7.x.8M = THE AMOUNT DU (EXAMPLE:14 DAYS DIVIDED BY 7= 2 X 6DO =$120' CHECK PAYABLE TO THECITYOF SALEM, NO CASH 1 1 NAME OF EVENT �VL� I LOCATION DATE(S)OFEVENT NAME OF APPLICANT -7 1 JTELEPHONE# _M-'�io ADDRESS IRSk S&i4 --{ Ply} 01577 - NAME OF BUSINESS %gV54`i-✓ I��� SQk/Alt TELEPHONE#S��`�`/�'233} ADDRESS K°5 _ xiti: ,�3}„ _ C I- • 1/SA' 7e^ A n I y }O- CERTIFIED FOOD MANAGER'S NAME Cn r1 V`_np1,. tJ CERTIFICATION#Tf3' `L4S f3 A PLAN OF THE ESTABLISHMENT IS: ENCLOSED DRAWN ON THE BACK TYPE OF REFRIGERATION: _GAS 1�!< ICE DRY ICE _OTHER METHOD FOR COOKING/HOT HOLDING: 2C' GAS OTHER METHOD FOR SANITIZING: /_CHEMICAL _07HER SOURCE OF FOOD: NAME: 1 &lcl . - S ADDRESS I p 1 w ✓�'T1'^� �r-" g'P' yd'} "t i "' �% �' I % �O FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: / \ J',lleci �0/� Si`[Atd: - ?ullm.) AI:^L- 2gSjQ �iG- 3=:oCLe1ZcNs C61e31'- �3 c„'Je40 _ Lly eh.3- n.A.0 li cL¢w - f4]aakx <.-enr I HAVE READ THE BOARD OF HEALTH, 'REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS:' I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARD ING THOSE REQUIREMENTS. I UNDERSTAND THEM. AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATK OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PURSUANT TO MGL C62C, S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, TO MY BEST KNOWLEDGE AND BELIEF, HAVE FILED ALL STATE TAX RETURNS AND PAID ALL E TA XES.REOUIRED UNDER LAW SIGNATURE DATE SOCIAL SECURITY OR FEDERAL ID# 41b TEMPAPPLIO-11.WOREVISEOIGIVIO PEFlMR II ' CHECOa FAX TRANSMITTAL DATE: S FROM: Tavern in the Square TO: FAX: 978-740-9111 FAX: TEL: 978-740-2337 TEL: PAGES: �d "BUGS" BURGER IS UG KILLERSr INC. CONFIDENTIAL MONTHLY SANITATION AND ;PEST ELIMINATION REPORT P: 305.865.3611 F: 305.865.0740 TOLL FREE: 866.928.4766 "•�f' Giv ::g' ....% L'r.�f3.a -� _ I!"•r:l %.. -rr -,_�,! r,r.^,�.i"�. Account • + Loczfyiouft` Address 4- jf7.- City - .. ;. - --5 f• __ :.tet-�? :�., rJ;`�•f, Stair r7.ip Arou vdvr Phand -into of :cervica I)nte NOTH, TU CUSTOMER: This roport is confidential, end is designed to Iran hnychit to you as part of your 'Bugs' Burger serviu- 11. i. wiv."dcd to prevent repeat violations of Sardtnry Codaa by bringmg Thom m wnr " n . Qlrite often, nonan or repast viola one noted by your Health Inspector during his inspection could cause him to requrst auSpeneion or revocation of yvur Hcense r!opel'ating permit. I. OUTSIDE PREMISES 1. Are an pads of outside premises free of Litter and Rubbish_? 2. Are Garbage Areas, Containers clmn and corvalnom - Covered 9 3. Are doors leading to'he outside in Good Repair and Self-Cbslna? 4. Are all areas Vermin Pleated as required by local Health Codes? 5. Is area free of Rodent Harborage. Burrows? 6. Are all outside storage areas Clean and Accessible for treatment? H. DWING ROOM AND LOUNGE T Are Side Stands, Utensil Drawersand Lowerat❑rs clean and omer.y? 8. Am all Tables, Boot_ his nQ.Dhairs clean? 9. Are Wit Is Flo -gMT1 ' 10eilina. A/CVeofs and Lights _ clean and in gdidrl repay? 10. Is Drink Equipment dean? Mirers. Blende-m Ice Bins. Ice 5c000s, Ice Tea, Discenser Coffee Makro, Wl Dispenser, Beverage Dispenser, Sinks, other Equipment? 11. Are SLorage_Shelves and Cabinets dean? III. RESTROOMS 12. Are Public Rostreoms and Emolovee Restrooms Clean, -- doors Sel-Olosina, Fixtures In Good Repair and free of Qagf? 13. Ara employee Lockersand Locker Area Clean? IV. KITCHEN-BAKERY-BUTCHP IIOP 14. Are Stainless Step d Hardwood Tables Clean? 15, Are Walls, .Floor ,'6r) Gi Ceiling. AIC Ven<s and Lights clean and in good repai. 16.Am Ranges, Broilers Frears, Ovens,rills and SiF�clean and free at baked an foods and grease? 17. Are all parts of Kitchen free of Later? f N-W'NO .. 111 16. Ara Storage Shelves, CabJets Hacks and Pot Hanaore ..❑ - . clean? L3 1 ❑ 19.Am SIDV Hoods and SLurs clean and free of grease or soil -- - .. bund -up? p` 'U 20.Are Sinks anc Dishvrashino Areas dean and leak free? Y* "- - '•21. Is,[0Dd preparation equipment clean? M� Grinders ... ' V. ❑ S I[`cers; Cance Op9ners, Ice Machine: Coffee Urn, Profit ILI ❑' Cabinets, Meat Saws, Chopper, other Equipment? - fir". ❑ Y STORAGE BOOMS Ii / !' X . �ti Customer ibnature .. 7iflle v,/,// P - .' nice Sprvrahsl (required except when key acniec rorrdored) NOTE TO CUSTOMER: AFTER EACH SERVICE ALL FOOD CONTACT SURFACES MUST BE W.U11ED. 'VERMIN PROOFING REPAIRS ARE NOT INCLUDED IN YOUR MONTHLY CHARGES. IF I7EN144 IS 01FICILED, SFRVICE SMIL WILL PREPARE A VERMIN CONTROL REPORT TO POINT OUT WHAT REPAIRS ARE NECESSARY IN ORDER TO PREVENT INFESTATION. I �d 86 MY BUGS NOW (1.866.928.47661 bugsburgercom 22. AT rooms free of Litter and Rubbish? 23. Are all food�pmdocts stored Off The Floor aid away from Toxic Materials? ❑`,* ❑', 24.Are Floors, Shelves and Racks clean? �❑ VI. VERMIN CONTROL �. Monday Night Is Fly Night.? �r ❑ Q= 25. Is accountusing ?& Were any Roaches found? . ❑ 27. Any evidence of Rodents? fir". ❑ 28. Vermin Co01rol Report made? _ 29. Was customer notified prior to service_ regarding .. 4... preparation? -- 30. With whom did you speak? _- 31. Will you call the customer the next day about any problems noted?Or 32- Do you walIint one d our sanitarians from "Bugs' Burger's ervironmemal Control Division to call Ibis ❑ 7 y "" customer, ". f ❑ .. 33. Is accaunf proper.epped Por services? / o Products p''"� ',- �<'�':r % -fry E3 >:2"•'�`.''r- .{ : s Ir! Ii / !' X . �ti Customer ibnature .. 7iflle v,/,// P - .' nice Sprvrahsl (required except when key acniec rorrdored) NOTE TO CUSTOMER: AFTER EACH SERVICE ALL FOOD CONTACT SURFACES MUST BE W.U11ED. 'VERMIN PROOFING REPAIRS ARE NOT INCLUDED IN YOUR MONTHLY CHARGES. IF I7EN144 IS 01FICILED, SFRVICE SMIL WILL PREPARE A VERMIN CONTROL REPORT TO POINT OUT WHAT REPAIRS ARE NECESSARY IN ORDER TO PREVENT INFESTATION. I �d 86 MY BUGS NOW (1.866.928.47661 bugsburgercom Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: File Number: BHF -2009-000007 LOCATED AT: Kimberley Driscoll Mayor Tavern in the Square Restaurant 163-189 Washington Street SALEM MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2011-0311 Jan 1, 2011 Dec 31, 2011 $420.00 ESTABLISHMENT FROZEN DESSERTS BHP -2011-0312 Jan 1, 2011 Dec 31, 2011 $25.00 Total Fees: $445.00 PERMIT EXPIRES December 31, 2011 Board of Health � pm IF This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL 1N1AYOR DAVID GREENBAuM, RS ACTING HEALTH AGENT CITY SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET. 4" FLOOR TEL. (978) 741-1800 FAa (978) 745-0343 DG EENnAU,NI&ALI.N. CONI 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT t %jey-(/1 3h 4Ire TEL # 9 -Ag -440 2331 ADDRESS OF ESTABLISHMENT J201 \, a 6 FAX # 9-+8-440 Q11 -L MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'S NAME' KeNOctO V(5G1-eV1-tlWti TEL ADDRESS '-A J, STREETIL I CITY 'STATE / ZIP CERTIFIED FOOD MANAGER'S NAME,7S) Key",4O 1/Cn �✓)�I �� CERTIFICATE#(S)`/ G/' I 1 OZI (Required in an establishment where potentially hazardous food is prepared) � EMERGENCY RESPONSE PERSON Ma-�'-(- Rem Ls HOME TEL #6 f7 2:7q2390 DAYS OF; OPERATION±.:Tuesday:; ; >'i 4`Wednesda ,�; :,:.Thursday..; ' - Friday.= . ;;Saturday ; i , °,:Sunday HOURS OF OPERATION 3p/�wvL dtA dj; 3oAmdl 3oA (/:3oF}�rn 9o'3oRvr" o:3�A, Please write in time of day. (For example l lam-11pm) 1%i/'✓+�] ;.1 a.�,-,, ��r,->-, �a JAyyl, t"'r- TYPE OF ESTABLISHMENT ` / FEE (check only) RETAIL STORE YES 199 less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 --------------------------------------------------------------------- ------- --n-"2----•----------------------140 RESTAURANT E NO less tha5 seats =$140 (Outdoor Stationary Food Cart $210) 25-99 seats 80 more than 99 seats$420 --------------- -------------------- YES NO $100 CHILDCARESERVICESINURSING HOME--------•-••----------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE (S�) NO P25 TOBACCO VENDOR YES �I� ALL NON-PROFIT (such as church kitchens) YES1�I`6 $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishme In accordance wit a State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be subm tt d to an pproved by the Salem Board of Health. Pursuant to L Cha 62 ection 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax retumvan pai Its s required under the law. 10 V Revised 10/7/11 FOODAP201 Ladm Check# & Date _ • y or Federal Identification Number P.1 "BUGS" BURGER BUG KILLERS, INC. CONFIDENTIAL MONTHLY SANITATION AND PEST ELIMINATION REPORT P: 395.865.3611 F: 305.865.0740. TOLL FREE: 866.928.4766 �Acco, F/Sf tate/ ip -' AL a' a PfiooE '" '•"' � !'me of'ervice Do& f NOTE TO CUSTOMER:.This report is confidential, and is designed W be a benefit to you as part of your Bugs" Burger service. It is intended to prevent repeat violations of Sanitary Codes by bringing them to Your attention. Quite often, setious or repeat violations noted by your Health Inspector during his inspection could cause him to request suspension or revocation of your license or operating permit. 1. OUTSIDE PREMISES 1. Are all parts of outside premises free of liber and Rubbish? 2. Are Gar3l� SII qe Areas, Containers dean and containers Covered ? 3. Are doors leading to the outside in Good Repeu and Self -Closing? 4. Are all areas Vermin Proofed as required by local Health Codes? . - - .. -. 5. Is area free of Rodent Harborage Burrows? 6: Are all outside storage areas Clean and Accessible for treatment? II. DINING ROOM AND LOUNGE 7. Are Side Stands, Utensil Drawers and Lowerators clean and orderly? 6. Are all T of d Chairs clean? 9. Are Na to rs rain gilt A/ Vents and Lights N and in g o 10. Is Drink Equipment clean? Mixers, Blenders. Ice Bins Ice Scoops, Ice Tea Dispenser Coffee Makers, Milk Dispenser, Beverage Dispenser, Sinks other Equipment? 11. Are Starac a Shelves and C ba inets clean? UI. RESTROOMS 12. Are Public Restrooms and Employee Reslrooms Clean, doors Sell-Closinq, Fixtures in Good Repair end free of Odom 13. Are employee Lockers and Locker Area Clean? IV. RITCHEN-BAKERY-BUTCHERSHOP 14. Are StainlessSte Hardwood Tables Clean? 15. Aro Walls. Flop mi Ceilino, A1C Vents and Lights clean and in good repair? 16. Are Ranges, Broilers Fryers, Ovens, Grills and Stoves clean and tree of baked on foods and grease? 17. Are all parts of Kitchen free of Utter? - ■ ■ ■ ■ 1 B.Are Storage Shelves, Cabinets Racks and Pot Hangers dean? 19.Are Stove Hoods and Filters clean and free of grease or soil build-up? 20. Are Sinks and Dishwashing Are dean and leak free? 7y1. is Food preparation equipment dean? Mixers Grinclers, -'ci' Slloers Can Operlars, Ica Machine, Coffee Urn, Pmet Cabinets, Meat Saws, Chopper, other Eouipmenl7 V. STORAGE ROOMS 22. Are rooms free of Litter and Ru blush? 23. Are all food products stored Off The Floor and away from Toxic Materials? 24.Are Floors, Shelves and Racks dean? VI. VERMIN CONTROL 25. Is account using Monday Night Is Fly Night-? 26. Were any Roaches found? 27. Any evidence of Bedevils? 23.Vermin Control Report made? 29. Was customer notified prior to service regarding .preparation? 30. With whom did you speak? 31. Will you call the customer the rued day about any problems noted? Or 32. Do you want one of our Sanitariums from "Bugs" Burger's Environmental Control Division to call this customer? YE,SS NO Xlc ❑ J ■ ■ ■ ■ J,❑ 33. Is account proper) topped for�S7ervices? a, ❑ Products used �p �rs,r,1, tLf/�'�trzS lot Co a is 0AIIIIof C-�.rL� .F`7 �✓� JV'�lirj�,� i� 9�iC.ISi41 C it£ A .Ow..,V ] a 0 r d I stumer Signature Title 's Sce Specj 5st e (required except when key service re v eyed) NOTE TO CUSTOMER: AFTER EACH SERVICE ALL FOOD CONTACT SURFACES MUST BE WASHED. 'VERMIN PROOFING REPAIRS ARE NOT INCLUDED IN YOUR MONTHLY CHARGES. IF ITEM H4 IS CIRCLED, SERVICE SPECIALIST WILL PREPARE VERMIN .: CONTROL REPORT TO POINT OUT WHAT REPAIRS ARE NECESSARY IN ORDER TO PREVENT INFESTATION. 86 MY BUGS NOW (1.866.928.4766) bugsburgercom P.1 "BUGS" BURGER BUG KILLERS, INC. CONFIDENTIAL MONTHLY SANITATION AND PEST ELIMINATION REPORT P: 305 86561 1 F: 305.865.0740 TOLL FREE: 866.928.4766 ! . _ SQA= e7.4. "P 4 Late NOTE TO CUSTOMER: This report is confidential, and is designed to be a benefit to you as part of your 'Bugs" Burger service. It is intended to prevent repeat violations of Sanitary Codes by bringing them to your attention. Quite often, serious or repeat violations noted by your Health Inspector during his inspection could cause him to request suspension or revocation of your license or operating permit. 1. OUTSIDE PREMISES 1. Are all parts of outside premises free of Litter and Rubbish? 2. Are Garbage Areas, Conirs clean and containers Covere 2 3. Are doors leading to the outside in Good Repair and Self -Closing? 4. Are all areas Vermin Proofed as required by local Health Codes? 5. Is area free of Rodent Harborage, Bumaws? 6. Are all outside storage areas Clean and Accessible for treatment? II. DINING ROOM AND LOUNGE ?.Are Side Stands, Utensil Drawers and Low rrators clean and orderly? 8. Are all TabIBS So Chairs dean? 9. Are Wa is F[% m, r 'n ilio AQ Vents and Lichts clean and in good repair? 10. Is Drink Equipment clean? Mixers @lenders Ice Sins, Ice Sccoos, toe Tea, Dispenser Coffee Makers, Mill Discenser, Beverage Dispenser, Silks other Equipment 11. Are Storage Shelves and Cabin dean? III. RESTROOMS 12. Are Public Reshooms and Employee Restrooms Clean, doors Seff-Closing, Fixtures in Good Repair and free of Odor? 13. Are employee Lockers and Locker Area Clean? rV. IUTCHEN-BAKERY-BUTCHERS HOP 14.Are Stainless Steel ardwood Tales Clean? 15.Are Walls, Floors rains ailing, ASC Vents and Lig Ms clean and in good repairY- 16.Are Ranges, Broilers Fryers Ovem, Grills and Stoves dean and free of baked on foods and grease? 17. Are all parts of Kitchen free of Litter? YES 1N0 Iffy,❑ EEY ❑ ❑,� In 3J ❑ Lr ❑ �A ❑ Q ❑,/ ❑ f7 • Z/ f7 ❑ 15 ■ ►. ■ 18 -Are Storage Shelves, Cabinets Racks and Pot Hangers clean? 19.Are Stove Hoods and Filters clean and free of grease or soil build-up? 20. Are Sinks and Dishwashing Area clean and leak free? 21. Is Food prepwdon equipment clean? Mixers Grinders Slicers, Can Openers, Ice Machine, Coffee Urn, Proof Cabinets, Meat Saws, Chopper, other Equipment? V. STORAGE ROOMS 22. Are rooms free of Litter and Rubbish? 23. Are all food products stored Off The Floor and away from Toxic Materials? 24. Are Floors, Shelves and Racks clean? VI, VERMIN CONTROL 25. Is account using Monday Night Is Fly Night.? 26. Were any Roaches found? 27- Any evidence of Rodents? 28. Vermin Control Report made? 29. Was customer notified prior to service regarding preparation? 30. With whom did you speak? 31. Will you tall the customer the next day about any problems noted? Or 32. Do you want one of our Sanitarians from "Bugs" Burger's Environmental Control Division to call this customer? 33. Is account properllyj fed forspites? Products used.- f.^s.' "r°_...a . '�r' ":' •, r r `' YES NO X �/ •���-'c��,r---! -ate<-�^f <'�' , --- Customer Signature,: Title ' - Service Specialist (required except when key service rexdered) NOTE .TO CUSTOMER: AFTER EACH SERVICE ALL FOOD CONTACT SURFACES MUST BE WASHED. VERMIN PROOFING REPAIRS ARE NOT INCLUDED IN YOUR MONTHLY CHARGES. IF ITEM 04 IS CIRCLED, SERVICE SPECIALIST WILL PREPARE A VERMIN CONTROL REPORT TO POINT OUT WHAT REPAIRS ARE NECESSARY IN ORDER TO PREVENT INFESTATION. 86 MY BUGS NOW (1.866.928.4766) bugsburgercom I Massachusetts Department of, Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name _ Dat T e of Operation(s) Tvpa of Inspection bod Service Retail v? FJ Orz, I ❑ Routine RHe-inspection Address t f, /� Rik l w ^ Level ❑ Residential Kitchen Previous Inspe tion Telephone P a� ❑ Mobile Date: 7 `- El Temporary ❑ Pre-operation Owner Ip { HACCP Y/N _w % 9 �' ❑ Caterer ElBed & Breakfast ❑Suspect Illness ElGeneral Complaint Person in Chargb (PIC) Timlej� OO ut: 1" - Permit No. El HACCP ❑Other Inspector ) Each violati ch cked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT_„_ ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOU_RC_E _ ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION - -� ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 7. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other 5: 5801ns�ecfFamSl4.tloc n / ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS I [114. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardou_s_F_oo_d_s) „ ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling �7 .919. Hot an Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE_POP_ULATIONS.(HSP), ❑ 21. Food and Food Preparation for HSP {CONSUMERADVISORY'-"- ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: 4 Inspector's Signature: Print: PIC's Signator : Print: �e Page of ages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590,003(A) Assi moment of Res tonsibility* 590.003(B) Demonstration of Knowledge* 2-1.03.11. Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food law* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Foal Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person in -Drinking ater from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.I5 590.003(F) Removal of Exclusions and Resttictions JM in FOOD FROM APPROVED SOURCE " Denotes critical item in the federal 1999 rand Cade or I W CM R 590.000. 8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food law* 3-201.1.2 Foci in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5 -101.11 -Drinking ater from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* WashmE Fruits and. Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.I5 Moguscan Shellfish from NSSP Listed Sources* - ' Game and Wild Mushrooms Approved by Re Nato Autnorit 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-70111 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.1.5 Package hul: it 3-101.11 Foci Safe and Unadulterated Tags/Records: Sheilstock 3-20218 Shellstock Identification * 3-203.1.2 ShellstockIdentification Maintained Tags/Records: Fish Products 3-4021.1 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(1) Labeling of Ingredients" Cleaning Frequency of Equipment Folill- - Contact Surfaces and Utensils*:, Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized ProcessingMeth(ds* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* " Denotes critical item in the federal 1999 rand Cade or I W CM R 590.000. 8 Cross -contamination 3-302.11(A)0) Raw Animal Foods Separated Prom Cooked and RTE Foods* Contamination from Raw Ingredients 3-302,11(A)(2) Raw Animal Foods Separated from Each Other' Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 WashmE Fruits and. Vegetables 3-304.11 Food Contact with Equipment and _Utensils* Contamination from the Consumer 3-306.14(A)(,) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-70111 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501..111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness.* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Folill- - Contact Surfaces and Utensils*:, 4-70111 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4=703.1 I Methods of Sanitization -.Hot Water and . Chemical* 16 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301..1.2 Cleaning Procedure* 2-301.14 When to Wash* -- Il Good Hygienic Practices 2401_11 Eating, Drinkinor Using Tobacco* 2401.12 Discharges From the Eyes, Nosoand . Mouth* ... 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.0(14(F;) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11. Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibilit , Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.L2 HandD 'n Provision CITY OF SALEM _ BOARD OF HEALTH Establishment Name: Date:'` ., _Page: ,.';Z of Item Code C -Critical nem DESCRIPTION OF VIOLATION / PLAN OF CORRECTION No. Reference R — Red Item t r �I - PLEASE PRINT CLEARLY / S� 0111 I / I ).,c,./ r pt n f l �Pl GT 4 ('fw (11) ,4 1\Inm7- 7.rp/J .S nim Verified Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Re$triction / violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Feder od Code. I understand that noncompliance may result in daily fines o we >t - ve ollar or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit./1 / 71 ❑ Voluntary Disposal ❑ Other: Viciarlons Related to Foodborne fitness. fnterrendons and Risk Factors(ftenrs 1-221) (Cont.) go t '• Food or Color AddKives 3,202.12 Additives*_ 3-302.14 Protectionfrom Unapproved Additives" FC - 2 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 on - Stora + - 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 'Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals fur Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent :Bait Stations" 7-206.13 Tracking Powders, Pest Control and Monitorin ' t '• 3 D novas critical item in the L-deral 1999 Fox J Coiie 01 105 CMR 390.000. 3-501,14(C) PHFs Received at Temperatures According to law Cooled to 41'17145°F Within 4 Hours. * Proper Cooking Tenperidures far 19 PHFs 3.401.11A(I)(2) _ Eggs- 155'F 15 Sec. FC - 2 Eggs- immediate Service 145°Fl5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-801.11(C) Animals -155°F 15 sec. * 340LI I(B)(I)(2) Pork and Beef Roast -130OF 121 min* 3-401.I1(A)(2) Ratites, Injected Meats -155°F 15 26 . see. * 3-401.11(A)(3) Poultry, Wild Game. Stuffed PHFs, 27. Stuffing Containing Fish, Meat, - Poultry or Ratites -165'1715 sec, 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks '- FC -7 145E * 3-401.12 Raw Animal Foods Cooked in a .009 Microwave 165°F * 340LI I(A)(1)(b) All Other PHFs -145*F 15 sec. Reheating for Not Holding 3-103.11 A)&{D} ( 15 sec. * PIFs 16565"F l5. 3403.11(B) ..---'T. _ Microwave- 165` F 2 Minute Standing Tits* 3-40111(C) Commercially Processed RTE Food - 140°l 3403.1 I(E) Remaining Unsliced Portions of Beef Roasts" Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PRFs from 141-F to 70`F Within 2 Hours and From 70F to 41`F145OF Within 4 Hours. * 3-501.14(8) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45°F Within 4 Hours* 3 D novas critical item in the L-deral 1999 Fox J Coiie 01 105 CMR 390.000. 3-501,14(C) PHFs Received at Temperatures According to law Cooled to 41'17145°F Within 4 Hours. * 3-501.16(B) { Cold PIIFs Maintained at or below 3-501.16(A) Hot PHFs Maintained at or above 14017. Time a3 a Putnic 3-501.14 Time as a Public REQUIREMENTS FOR HIGHLY SUSCEFTTBi E POPULATIONS (HSP) 21 3-501.,15Caolin Methods for PRFs 19 PHF Haf and Cold Holding 3-501.16(B) { Cold PIIFs Maintained at or below 3-501.16(A) Hot PHFs Maintained at or above 14017. Time a3 a Putnic 3-501.14 Time as a Public REQUIREMENTS FOR HIGHLY SUSCEFTTBi E POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and .Beverages with Warning labels* 530.000 i 3-801.1l(B) Use of Pasteurized Em* FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 1 Food and Food Protection 3-801.11(C) Unopened Food Package Not Rc: served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Pasted for Consumption of 530.000 i 1 23. Animal Foods That are Raw. Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate 1 1 Food and Food Protection Patlro tens * erx"e rnrzxr 1 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26 . 1 Eggs*. 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, ternporuv and msidenual kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, mrd non-criRcal violations, which do not relate to the foodborne illness interventions and risk factors listed above.,can be found in the following sections. of the Food Crule and 105 CMR 590.000. 1 Min i Good Retail Practices ; .FC 530.000 i 1 23. i Manaaemern and Personnel FC - 2 .003 24. 1 Food and Food Protection 1 25. Equipment and Utensils1 FG -4 .005 26 . Water. Plumbin4 and Waste �i FC -5 1 .006 27. ! Physical FacilityFG-6 - .Q07 1 28. Poisonous or Toxic Materials '- FC -7 I008 ' 29.Spaciai Regviremerrts FRl other - .009 s:ocr,.Tffi:e.z c� N (D 9l Ol J N W ? 1 OF cn CD m D Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT au �1 Salem Board of Health 120 Washington Street, 4" Floor = Salem, MA 01970-3523 g Tel. (978) 741-1800 Fax (978) 745-0343 Name e� G�(P( Date T e of O eration s T f Ins ection Food Service ❑Retail , j r rip I Routine Re -inspection Address (q Risk , UU Telephone Level El Residential Kitchen ❑Mobile Previous Inspection 4 t/ j J ❑ Temporary Date: ❑ Pre-operation Owner r `- HACCP YM Km l ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) Time In. . Ya) ElHACCP Inspector Out Permit No. ❑ Other Each violation checked quires an explanation on the narrative page(s) and a citation of specific provision(s) violated. �� Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action a§'determined by the Board of Health. CFOOD PROTECTION MANAGEMENT _ _ W El 1. PIC Assigned / Knowledgeable / Duties EEMPLOYEE HEALTH'S ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded ___-- FOO_ D FROMAPPROVED SOURCE E]4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 8. Separation/ Segregation/ Protection A 9..Food Contact Surfaces Cleaning and Sanitizing 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S. SOlna IFOm 14.tl A K2. Prevention of Contamination from Hands 13. Handwash Facilities PROTECTION FROM CHEMICALS : " •i;+ `: ;w -;,. j ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods)® ❑ 16. Cooking Temperatures [117. Reheating (] 18, Cooling Hot and Cold Holding 20. Time As a Public Health Control .REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY, I _. _ - ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. � DATE OF RE-INSPECTION:gJ� aq-1 ��7L Inspector's Signature: Print:- "/ PIC's Signature: / rlJ-//. Print: Page orb o Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) I Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11. 1 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law` 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* a licants* Shell Eggs* 590.003(F) Responsibility Of A Foul Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Change* 590.006(B) 590,003(G) Relicirting by Person in Charge* 3 1 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restr ct ons C I® 6 V FOOD FROM APPROVED SOURCE * Denotes critical item in the tederal 1999 Food Code or 105 CA4R 590.000. FT PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law` 3-201.12 Food in a Hermetically . Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.73 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* ' 5=101..1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 220* Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by Regu0tory Authority 3-202.18 Shellstock Identification Present* 590,004(C) Wild Mushrcotns* 3-201.17 Game Animals* 2-301.14 Receiving/Condition 3-202.11 PHFs Received at Proper Tem eratures* 3-202.15 Package Integrity* 3-101.11. Foci Safe and Unadulterated Tags/Records; Shellstock 3-202.18 ' Shellstock Identification_* 3-203.1.2 Shellstock Identification Maintained'" 12 TaWRecords: Fish Products 3-40211 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590L040) Labeling of Ingredients` Handwash Facilities Conformance with Approved Procedures IHACCP Plans 3-502.11. S ecialized Processing Metbtxis* 3-502.12 Reduced 6x gen acka "ng. criteria* 8-103.12 Conformance with A. roved Procedures* * Denotes critical item in the tederal 1999 Food Code or 105 CA4R 590.000. FT PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-5011.11. Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Anirmtl Foods Separated from Each Other* Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(_A) Foci Protection* 3-30215 1 Washing Fruits and Vegetables 3-304.11. Food Contact with Equipment and Utensils* 4-602.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-70111 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-5011.11. Manual Warewashing - Hot Water Sanitization Temperatures?, 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * _ 4-60L11(A) Equipment Food Contact_ Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization -Hot Water and Chetnical* 10 Proper, Adequate Handwashing 2-30111 Clean Condition - Hands and Arms* 2-301..12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2-401.12 ,Discharges From the Eyes,. Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.0(A(E) Preventing Contamination from Employees* - - 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashi ng Clean Sol" .AvniInhiIit 6-301.12 Hand Drying Provis on CITY OF SALEM BOARD OF HEALTH Establishment Name: G lof, / .,) a/2 sc,'C c Date: a Paae: i of nem No. Code Reference C - Critical Rem R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION T— gate Verified PLEASE PRINT CLEARLY (i S J, OJi GZ c� rl 7 J m r r G �l c7 cr JXi I`P(< s l G d CJS n/ i _MLS. I - a a -1 - 1 - v (Ce— 4 .l C!N f flack (Le I 6j t ✓ �� Discussion With Person in C erge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily finessuspension/revocation of your food permit. oft . e Corrective Action Required: ❑ . No as ❑ Voluntary Compliance ❑ Employee Restriction / � � Exclusion - Re -inspection Scheduled ❑ Emergency Suspension 13Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: i Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 16 17 18 TIMEMEMPERATURE CONTROLS Food or Color Atlditives 3-202.12 Additives* 3-302.14 Protection froEUnapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101 A I Identifying Information - Original Containers* 7-102.11, Common Name - Working Containers* 7-201.11 Separation - Stnrae* 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Wishing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 1 Incidental Food Contact, Lubricants* 7-206.11Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIMEMEMPERATURE CONTROLS * Denares crifieal itear in the federal 1999 Food Code n 105 CMR 590.000. IRS 3-501.14(C) Proper Cooking Temperatures for _ 3-501.15 PHFs 3401.1IA(l)(2) Eggs- 155°F 15 Sec. 3-501.16(B) 590.004(F) Eggs- immediate Service 145'F15see* 31401.11(A)(2) Comminuted Fish. Meats & Game 3.501,16(A) Animals - 155'F 15 sec. 3.401.11(B)(1)(2) Pork and Beef Roast - 130°F 121 min* 3401.11(A)(2) Ratites, Injected Meats -155-F 15 590.004(H) sec. 3401AI(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC - 6 Poultry or Ratites -165°F 15 sec. 3401.11(C)(3) Whole -muscle, Intact Beef Steaks FC- 7 145°F 4` 3401.12 Raw Animal Foods Cooked in a Microwave 165'F * 340111(A)(1)(b) All Other PHFs -145'F 15 sec. ' Reheating for Hot Holding 340311(A)&(D) PHFs 165°F 15 sec. * 3403.11(B) Microwave- 165` F 2 Minute Standing Time* 3403.11(C) Commercial lyProcessed RTE Food - 140°F* 3-403.11(E) - Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70°F Within 2 Hours and From 70'F to 41'F/45'F Within 4 Hours. * 3-50IJ4(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 Hours* * Denares crifieal itear in the federal 1999 Food Code n 105 CMR 590.000. IRS 3-501.14(C) PHFs Received at Temperatures According to law Cooled to 41'Ff45'F Within 4 Hours. 3-501.15 Cooling Methods for PHFs Unpasteurized Pre-packaged Juices and .Beverages with R'artrin4, Labels* PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 410/45' F* 3-501.16(A) Hot PHFs Maintained at or above 140°F. * 3.501,16(A) Roasts Held at or above 130°F. 3-801.1 I (C) Time as a Public Health Control 3-50119 Time as a Public Health Control* 590.004(H) Variance Requirement FOR HIGHLY SUSCEPTIBLE POPULATIDNS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and .Beverages with R'artrin4, Labels* Animal Foods That are Raw. Undercooked or 3-801.11(B) Use of Pasteurized Eggs* Not Otherwise Processed to Eliminate 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served * Pathogens.* E" `/1nw' 3-801.1 I (C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 5� 000000 23. Animal Foods That are Raw. Undercooked or FC -2 .003 Not Otherwise Processed to Eliminate _ Food and Food Protection FC - 3 Pathogens.* E" `/1nw' 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. Eggs* SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne ilhtess interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Critical: mrd non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sectionsofthe Food Code and 105 CMR 590.000. t Item I Good Retail Practices I FC 5� 000000 23. 1 Management and Personnel FC -2 .003 24. _ Food and Food Protection FC - 3 .004 25. Equipment and Utensils G 4 .005 26. Water. Plumbing and Waste _ ' FC -5 006 27. Ph sical Facili FC - 6 .007 ' 26. Poisonous or Toxic Materials FC- 7 .008 29. S ecid Requirements ,009 30. 1 Other ' s:'Wc 2z CITY OF SALEM BOARD OF HEALTH / Establishment Name: � .I e nL. (A) 16 BSc; jcaAo Y Date: '/ )1" �i.4 Page: 3 _ of Item Code No. Reference C - Critical Item R - Red Rem DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date.. Verified ,PLEASE PRINT CLEARLY S�,>1, /-S. ✓1 — �l ` - t,r / moi, 57-0 n J 47f c r Cn ✓ f- r r�.A✓ CIV '-6- GJ s c OM GJII - 4 G /b c. l�x�a%� / 1 �.a A,f"X0 G .2 -3 Ajoe ILI cd r yr < < r" rpl-, Sh ir eea nr o /N /1 �r Ili y- C G moi- n 1!9 rs a SL r S�. J ,ua(( S. ( —f wo ctog ne0<Sin A Sal Com' I I Lr L A is cc Un 4-- AqG% -Q I - n Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of wenty- iye do lars or suspension/revocation of your food permit. �� --" JJJ Corrective Action Required:❑ . No yes ❑ Voluntary Compliance ❑ Employee estr� fiction / Exclusion Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure Voluntary Disposal ❑ Other: i a i Violations Related to foodborne Illness, Interventions and Risk Factors (hems;1-22)(Cont.) PROTECTION FROM CHEMICALS 14 i� 17 18 111TT'I:1/-0!1SxT_ m: 4"Ilk111T4773 Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101..11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Comamers* 7-201.11 1 Separation - Storae* 7-202.11 ,Restriction - PresenceandUse* 7-202.12 Conditions of Use* 7-203.11 Toric Containers - Prohibitions* 7-204.11 Saniriurs. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.22 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and MoWtmin * 111TT'I:1/-0!1SxT_ m: 4"Ilk111T4773 * Ihnotes critical item in the federal 1999 Foot Code at 105 CMR 590.000. Fm t 0 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.IIA(1)(2) Eggs- 155°F 15 Sec. 3-501.16(B) 590.004(F) Eggs- immediate Service 145'F15sec* 3401.11(A)(2) Comminuted Fish. Meats & Game 3501.16(A) Animals - 155°F 15 sec. * 3'401.11(13)(1)(2) Pork and Beef Roast - 130'F 121. min* 3.401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) sec. * 3401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, 1 FC -6 Poultry or Ratites -165017 15 sec. 3-101AW)(3) Whole -muscle, intact Beef Steaks 145'F " 3-401.12 Raw Animal Foods Cooked in a Microwave 165`F * 3401:11(A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403AI(A)<&(D) PHFs 165-F 15 sec. * 3-403.11(B) Microwave- 165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403-.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70'F Within 2 Hours and From 70'F to 41°F/45'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient . Temperature Ingredients to 41°F/4.5'F Within 4 Hours* * Ihnotes critical item in the federal 1999 Foot Code at 105 CMR 590.000. Fm t 0 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to . 41 °F/45'F Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-801.11(13) PHF Hot and Cold Holding . 3-501.16(B) 590.004(F) Cold PRFs Maintained at or below 410/45' F* 3-50L16(A) Hot PHFs Maintained at or above 3501.16(A) Roasts Held at or above 130'F. 25. Tithe as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS fHSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and .Beverages with Wanting Labels* 590590 3-801.11(13) Use of Pasteurized Eggs* 'FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590590 i 23. Animal Foods That are Raw. Undercooked or 'FC -2 .I Not Otherwise Processed to Eliminate Food and Food Protection FC -3 Pathogens.* EA '. f &wf 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. Eggs* Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can'be found in the following sectionsof the Food Code and 105 CMR 590.000. ( Item Good Retail Practices .FC 590590 i 23. Management and Personnel 'FC -2 .I 24 _ _ Food and Food Protection FC -3 _004 25. 1 Equipment and Utensils FC -4 .005 26. Water. Plumbing and Waste 1 FC -5 .006--) 27. Ph ical Faclti 1 FC -6 .007 28. Poisonous or Toxic Materials 29. - Special Requirements .009 30. 1 Other s:,Ma,m .2e Establishment No, 4eference 1 R - Red Item r( CITY OF SALEM BOARD OF HEALTH DESCRIPTION OF VIOLATION / PLAN OF CORRECTION I Discussion With Person in Charge: /�vtGii J� l f r JrLe I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe ail conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. /< / wi- . (%t C4'5:�� ( Corrective Action Required ❑ Voluntary Compliance Vie -inspection Scheduled ❑ Embargo ❑ Voluntary Disposal q V C-o---�UQd -�-- c'�L�d of Verified rtta'W%®7:Tm ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: Violations Related to Foodborne Itineas. Interventions and Risk Factors {items 1-22) (Cont.) 15 16 C is t m: LI ..e... Additives W Food w CColor. 3-202.12 ......�- Additives* 3-302.14 Protection from Unapproved Additives* 3-501.16(13) 590.004(17) Poisonous or Toxic Substances 7-101.11 identifying Information - Original Containers* 7-102.11. Comamn Name - Working Containersx 7-201.11 Separation - Storage* 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sardtizers. Criteria- Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.12-- - Rodent Bait Stations*_ 7-206.73_---- Tracking Powders, Pest Control and Monitoring* C is t m: LI ..e... Denotes criti:ai iu,m in the Edaal 1999 Fc A Cade w 105 CMR 590.000. IKE 3-501.i4(C) Proper Cooking Temperatures for i-501..15 PRFs 3-401AIA(1)(2) Eggs- 155'F 15 Sec. 3-501.16(13) 590.004(17) Eggs- immediate Service 145°Fl5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals -155'F 15 sec. * 3-401.I1(B)(I)(2) Pork and Beef Roost - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 590.004(H) see. * 3-401.11(A)(3) Poultry, Wild Game. Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC-$ Poultry or Ratites -165'F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks FG -7 145'F * 3-401.12 Raw Animal Foods Cooked in a - Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs - 145'F 15 sec. ` Reheating for Not Holding 3403AI(.A)&(D) PFIFs 16ST 15 sec. * 3-403.11(B) Microwave- 165` F 2 Minute Standing Time* 3-401.11(C) Commercially Processed RTE Food - 140'17 3403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140`F to 700F Within 2 I{ours and From 70'F to 41`F(45'F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°Fi45'F Within 4 Hours* Denotes criti:ai iu,m in the Edaal 1999 Fc A Cade w 105 CMR 590.000. IKE 3-501.i4(C) PHFc Received at Temperatures According to Law Cooled to 41'F145`F Within 4 Hours. i-501..15 Coolinz Methods for PHFS 3-801-11(B) PHF Not and Cold Holding 3-501.16(13) 590.004(17) Cold PILFs Maintained at or below 41'145° F* 3-501.16(A) Hot PHFs Maintained at or above 140'F. 3-501.16(A) Roasts Field at or above 130'17. 25. Time as a Public Health Central 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement 21 3-801.1 ] (A) Unpasteurized Pre-packaged Iuices and .Beveraees with Waning Labels* 590.000 3-801-11(B) Use of Pasteurized Eggs* _ ! FO -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 1 23. Animal Foods That are Raw, Undercooked or ! FO -2 .063 Not Otherwise Processed to Eliminate 1 Food and Food Protection FC -3 Pathogens.' `"r°'"* vi.' 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 ! 26. EggO Violations of Section .590.009(A) -(D) in catering,, mobile fleet, temporary and residential kitchen operations should be debited udder Site appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to gaol retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical. and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of'the Food Code and 105 OUR 590.000. I item ;Good Retail Practices .FC 590.000 1 23. 1 Maneqsment and Personnel ! FO -2 .063 1 24. - Food and Food Protection FC -3 .004 25. Equipment and Utensils I FG -4 .005 ! 26. Water, Rumbing and Waste j FC -5 .006 27. I Phlricai FaciVity FC-$ .007 1 128. ' Ptzsanous or Toxic Materials FG -7 .W8 29. - Special Requirements - .009 30. I other ` o_ CITY OF SALEM BOARD OF HEALTH Establishment Name: !�alfa?fti Date: `�/- Page: S� of Item Code No. Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date - Verified I q X i t(2e cC Lt r rA .�fA e - n11 ' c c _// A i /LO I V / n ! CY4c G o al -d cz68j c AA A -7 A?� 1, -k A)OOJ colyt4>lj C o 0 )a D Cr Q� I r A/ '-�Th 1 2 • II - t ' - c j 4v sz- J=a'(2"l Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to P comply with all mandates of the Mass/Feder I Food Code. I understand that noncompliance may result in daily fines o wenty five dollars or suspension/revocation of your food permit. , // /' ��s - �"�•e Corrective Action Required: El No ❑ Voluntary Compliance ❑ Employee R friction Exclusion Inspection Scheduled ❑ Emergency Suspension � Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 11 Violations Related to Foodborne Illness Interventions and Risk Factors (Item 1-22) (Cont.) ♦ tt " FT1707#77W97704M 14 rFood or Coior Additives 3-20112 I Additives* 3-302.14 _ Protection from Un_P'`1.a roved Additives* 15 _ __.._. Poisonous or Toxic Substances 7-101,21 identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Stora * 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitize". Criteria - Chemicals' 7-204.12 Chemicals for Washing Produce, Criteria° 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, lubricants* 7-206.11 Restricted Use Pesticides, Criteria* i Rodent Bait Stations* 7-206.13Tracking Powders, Pest Control and Monittxin 16 17 18 ' Dm tee aiiieal isa'.m in the federal 1999 Fond Cate "'105 CNIR 590.000. 19 20 3-501,14(C) Proper Cooking Temperatures for 3-501.15 PHFs _ u 3-40f.11A(1)(2) Eggs- i55`F 15 Sec. 3-50116(B) 590.004(F) Eggs- Immediate Service 1450F15sec* 3401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals - 155'F 15 sec. * 3401.11(13)(1)(2) Pork and Beef Roast- 130'F 121 min* 3-401.1I(A)(2) Ratites, Injected Meats - 155`F 15 590.004(H) See. * 3-401.11(A)(3) Poulty, Wild Game, Stuffed PHFs, 27. Staffing Containing Fish, Meat, FC -8 Poultry or Ratites-I65'F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steals FC -7 145°F * 3401.12 Raw Animal Ft Aq Cooked in a i Microwave 165'F * 340LI I(A)(1)(b) All Other PHFs --145F 15 sec. Reheating for Not Holding 3-403.11(A)&(D) PHFs 165'F 15 sec.' _ 3-403.11B) landing Microwave -16S F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140'F* 3-403AI(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PRFs from 140'F to 70°F Within 2 Hours and Front 70F to 41°F145'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature ingredients to 41*F/456F Within 4 hours* ' Dm tee aiiieal isa'.m in the federal 1999 Fond Cate "'105 CNIR 590.000. 19 20 3-501,14(C) PHFs Received at Temperatures According to Law Cooled to 41'F145F Within 4 Hatt&. 3-501.15 Cooling Methods for PHFs _ PHF Hot and Cold Holding 3-50116(B) 590.004(F) Cold PHFs Maintained at or below 41'/d5° F* 3-501.16(A) Hat PRFs Maintained at or above l40°F. * 3-501.16(A) Roasts Held at or above 130'F. 125. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement 21 3-801.11(A) Unpasteurized Pte -packaged Juices and :Beverages with Warning labels* _ 590.000 i 3-801.11(B) Use of Pasteurized Bias* FC -2 3-801.11(D) - Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 1 Food and Foal Protection 3-801.11(g Unopened Food Paclatile Not Re -served. C014SUMER ADVISORY 22 3-60111 Consumer Advisory Posted for Consumption of 590.000 i 23._ Anhnal Fuods That are Raw, Undercooked or FC -2 .003 I Not OtherwiseProcessedto Eliminate 1 Food and Foal Protection 1 FC -3 Patbo*ens.*�0 'uzoor 125. 3-302.) 3 . Pasteurized Eggs Substitute for Raw Shell .005 26. Eggs' Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to aaoel retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, cart be found in she following .sections of the Food Code and 105 CMR 590.000. Rel- err i Good Retail Practices i FC 590.000 i 23._ 1 fefanaoement and Personnel FC -2 .003 I FR. 1 Food and Foal Protection 1 FC -3 .044 125. E ui meet and Utensils i FC -4 .005 26. Water. Plumbino and Waste 1 FC -5 .006 27. I Ph alcal Facilityi FC -8 .007 1 28. Poisonous or Toxic Materials _ FC -7 .008 29. §pecial Requirements i .009 ; 30 Other CITY OF SALEM BOARD OF HEALTH Establishment Name: >_/ rn i%. Date: Page:( of Item I No. Code Reference C -Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTIONe Verified r PLEASE PRINT CLEARLY /� s, ,u 12 ,u J rA)A6,L r.1, �--- ✓s _ T-4 fl s l( S ) L)f - _C 6h Qon. l aL A4 D (n J n c, G� J Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of tl enty-ffflve dollars or suspe Ion/revocation of your food permit. �C ��`�8 Corrective Action Required: ❑ No p Yes ❑ Voluntary Compliance ❑ Employee Restriction i Exclusion e -inspection Scheduled El Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne 111nesa Interventions and Risk Factors (hems I -W) (Cont.) 15 16 17 C 1170#111115771M= * llcm ,, aincat 1c m in the L-&rji 1999 Fo A Cade or 105 C -MR 590.000. Food or Gator Additives - - -.. 20 3-202,12 _.�_. roees*. . - Additives* 3-302.14 Protection .frorn Unapproved Additives* 19 Poisonous or Toxic Substances 7-101.11 identifyingInformation - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Stn z' - 7-202.11 . Restriction - Presence and Use* 7.202.12 Conditions of Use* 7-203-11 'Toxic Containers - Prohibitions* 7-204.11, Sanitizes. Criteria - Chemicals" 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.12 - 1 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitorm * * llcm ,, aincat 1c m in the L-&rji 1999 Fo A Cade or 105 C -MR 590.000. Proper Cooking Temperatures for PHFs Received at Temperatures According to Law Cooled to 41'r/45'F Within 4 Hours. PHFs 3-401.11A(t)(2) Eggs- 155'F 15 Sec. 19 Eg - Immediate Service 145'Fl5sec* 3401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(B) 590.004(F) Animals - 155'F 15 sec. * 3.441.11(11)(1)(2) Part, and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 3-501.16(A) sec. * 3-401.1.1(A)(3) Poultry, Wild Game, Stuffed PRFs, Tame as a Public Health Control Stuffing Containing Fish, Meat, 3-501,19 Poultry or Ratites -165°F 15 sec. 3401.11(C)(3) Whole -muscle, Intact Beef Steaks Variance Re uirement 145°F 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3 40I,l I(A)(1)(b) All Other PRFs - 145°F 15 sec. Reheating for Hot Holding 3403A I(A)&(D) i PHFs 165"17 15 sec. * 3-403.11(B) Microwave -'165' F 2 Minute Standing Time* 3-403.11(C) ConmrerrdAy Processed RTE Food - 140'F* 3-402A I(E) Remaining Unsticed Portions of Beef Roasts" Proper Coaling of PHFs 3-501.14(A) Coaling Cooked PRFs from 140`F to 70'F Within 2 Hours and From 70`F to 41°F/450F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Abient Temperature Ingredients to 41'F/45°F Within 4 Hours* * llcm ,, aincat 1c m in the L-&rji 1999 Fo A Cade or 105 C -MR 590.000. f ;1-J*' 0 1!4110 11 21 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'r/45'F Within 4 Hours. 3-501. i5 Cooling Methods for PHFs 19 3-801.11(D) PHF Not and Cold Holding 3-501.16(B) 590.004(F) Cold PIiFs Maintained at or below 41'145° F* 3-50LI6(A) Hot P1iFsMaintained atorabove Ido'F. * 3-501.16(A) Roasts Held at or above 130'F. 20 Tame as a Public Health Control 3-501,19 Time as a Public Health Control* 590.004(H) Variance Re uirement f ;1-J*' 0 1!4110 11 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with V 'a- ninesbels* 3-80LIA(B) Use of Pasteurized E 2* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 3-801.11(C) Unopened Food Package Not Re -served, 22 3-603.11 Consumer Adv nary Posted for Consumption of Animal Foods That arc Raw, Undercooked or Not Otherwise Processed to Eliminate 1 Pathogens.* 3-302.13. Pasteurized Eggs Substitute fa Raw shell E 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile ftmd, temmporary, and" residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Speeial Requirements. (Items 23-30) Critical.. and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following ,sections -of the Food Code and 105 CMR 'u �92amirovei:. be `NtlCRO BREW2.13 IN 305TCN NUMBER NAME -71 v LENW.-MMARTELL 89 Heath Street Boston. MA 02130-1402 Telephane (617) 442-7777, ext. 5 Fax (617)522-9455 ,, ww-RealcitySoda.com UA 77yG 5t) ('14 ERVTYPE r STATE ZIP t ACT TEL REOUESTED 97� 7yd �tlr r�ttSll�l �� a ra 2 ♦ ,,AP, ,l COMPLETION WORK ORDER 77-72-Z7-1� 2-- - - Real City Soda - Equipment Leasing - Draft Operations ) _ SERIAL NO- I DISPATCH NUMBER I III-SERVICE B - DELIVERY C - INSTALL -7I OTY 1 PARTS DESGFI PON UNIT PRICE AMOUNT I ,-ela Z-30 12 TOTAL PARTS HOURS RATE AINOUHT J Z OT APPLI YES TOTAL LABOR TRAVEL NRLEAGE TRAVEL TIME OTHER OTHER FREIGHT TAX YES NO IRE ABOVE CONST TUTES ACCEPTANCE OF WORK DFSW ED ABOVE. TOTAL -► TEC'INICI AN NMAE AND NUMBER S/I�v�s% lD/✓S �C�ifS� Y YO C -f 2,- / % X Z'd CFRVICF C)FRl1lan 99V6ZZ9L19 Ilalieyo-xoual BIC L£OZLLOBNV UNUA-MAKIRL COMPLETION WORK ORDER 89 Heath Street Bosto n, MA 02130-1402 Telephdrvi(617) 442-7777, ext. 5 a Y-6 P - Fax (617) 522-9455 www.RealcitySoda.Gom R at City Soda - Fquipindrd Leasing - Draft Operations 'MCPO BREWED IN BOSTON' I �NUMBER ADDRESS 17 �w ADUH, D r rTny 16 LPJAIIAn, V, kld� I--,' STATEIZIP c, I P, J 11 A CONTACT TEL Affil WORK QUESTED -d v JV A-V r", �-*4( r-l;,- Lo,,- ypkll 1.0ea z2L G S k* - .77) MTYPE MFG MODEL, /2 4' 7A SERIAL NO., DISPATCHPUMBER, OTHER - A- SERVICE B - DELIVERY C - INSTALL ITY, PARTS;Iit§CRIPTPON:Z- UNIT, PRICE MOUNT TAX 1 YES NO 2 YES NO TOTAL TECHNICIAN NAME AND NUMBER SIGNATURE ABOVE CONSTITUTES ACCEPTANCE OF WORK (v, TOTAL PARTS ` R ---------_01.16TME COPY TOTAL LABOR TRAVEL MILEAGE 7A TRAVEL TIME if F &Z ,ke OTHER - OTHER TAX 1 YES NO 2 YES NO TOTAL TECHNICIAN NAME AND NUMBER SIGNATURE ABOVE CONSTITUTES ACCEPTANCE OF WORK DESCRIBED ABOVE. ` R ---------_01.16TME COPY FAX TRANSMITTAL DATE: July 26, 2012 FROM: Tavern in the Square TO: Joe Reale FAX: 978-740-9111 FAX: 978.745.0343 TEL: 978-740-2337 TEL: PAGES: 1 La . LENW`--MARTELL COMPLETION WORK ORDER 89 Heath Street I Boston, MA D2130-1402 _ Telephone (617) 442-7777, ext. 5 Fax (617) 522-9455 ty •—-'--._." www.RealciiySoda.com.771CItySoda • Equipment Leasing • Draft Operations 'MICRO BRCUIED IN BOSTON' NUMBER NMSERV-TYPEMFG MODEL 1 ADDRESS SERIAL NO. DISPATCH NUMBER • CITY STAT% ZIP CONTA:T - - TEL. A - SERVICE B - DELIVERY C - INSTALL WORK 4CUESTED CITY PARTS DESCRIPTION UNIT PRICE AMOUNT is CORRECTIVE ACTION TOTAL PARTS HOURS RATE AMOUNT i 1. TOTAL LABOR '_ ��"-` .:�-`✓ /i`, TRAVEL MILEAGE TRAVEL TIME OTHER OTHER •' • OTAPPLIES FREIGHT TAX 1.'� .:• YES NO 1/ 2YES 11 NO TOTAL —► SIGNATURETECHNICIAN NAME AND NU IABEH SIGNATURE ABOVE CONSTITUTES ACCEPTANCE OF WORK DESCRIBEDABOVE. ['d FAX TRANSMITTAL DATE: 7 ,) -� o / FROM: Tavern in the Square TO: Toe, 6'(e- FAX: 978-740-9111 FAX: TEL: 978-740-2337 TEL: PAGES: �d as rleam arreeT , t 1 Boston, MA 021 3 0-1 402 Telephone (617) 442-7777, ext. 5 6, -" Fax (617) 522-9455 V �_ w•ww.Rea citySOda.com - Real City Soda • Equipment Leasing • Draft Operations NCRO CREWED IN BOSTON" aEH NAME l'd _ SEBW.'TYPE MFG TRAVEL MILEAGE MODEL "; h. �_ ��' TRAVEL TIME i -✓ '�V/ `�a;'�..*-✓.- OTHER SERIAL NO. OTHER DISPATCH NUMBER JADDRIESS v OT APPLIES NO STATE21PTACT TAX 2 SIGNATURETECHNICIAN D TOTAL —► NAME AND NUME - i ./ A -SERVICE B - DELIVERY C -INSTALL WORKTiEOUESTED vv CORRECTIVE OTV PARTS DESCRIPTION UNIT PRICE AMOUNT 'V� ✓'� >-� mob.. :"✓f •'K /�i. "' / ; i Gy ✓' TOTAL PARTS ✓y/� - / HOURS RATE AMOUNT .vYr Vit.. l'd TOTAL LABOR /�-- TRAVEL MILEAGE 7'' .r -•y'[ j' "; h. �_ ��' TRAVEL TIME i -✓ '�V/ OTHER OTHER IF • OT APPLIES NO FREIGHT TAX 2 SIGNATURETECHNICIAN D TOTAL —► NAME AND NUME i ./ SIGNATURE ABOVE CONSTITUTES ACCEPTANCE OF WORK -� DESCRIBED ABOVE. l'd