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TEDESCHI FOOD SHOP 452 - ESTABLISHMENTSH TEDESCHI FOOD SHOP 9452 FORMERLY LIL PEACH 72 LORING.AVENUE Kimberley Driscoll Mayor City of Salem, Massachusetts lu Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978)-745-0343 P Iramdin@salem.com I1bi1CHP.�t11 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 Permit Number: FM -15-169 Permit Type: Retail Food 1000-10000 sgft Goods & Services: Retail Food: 1,000 -10,000 sq ft Name of License Holder: Tedeschi Food Shop #452 / Pervez Chowdhury Name of Food Establishment Address of Food Establishment Restrictions: Tedeschi Food Shop #452 72 Loring Avenue 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: $280.00 Issued: 1/1/2015 Kimberley Driscoll Mayor Permit # TO -15-39 Date of Print 1/29/2015 Permit Issued 1/112015 Permit Expires 12/31/2015 Permit Fee $135.00 Late Fee $0.00 City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 Iramdin@salem.com TOBACCO SALES PERMIT License For: Tobacco Granted To: Tedeschi Food Shop #452 / Pervez Chowdhury Address: 72 Loring Avenue Salem Location of Establishment: 72 Loring Avenue Restrictions: Notes: lu Public Health Larry Ramdin RS/RENS, CHO, CP -FS Health Agent MA 01970 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2015 , unless sooner revoked or suspended. e— Health Agent I M CITY OF SALEM, MASSACHUSETTS BOARD or Hi�ALTH 120 WASHINGTON S Inrmr, 411, FH,OOR KIMBERLEY DRISCOLL TizL. (978) 741-1800.Ft�x (978) 745-0343 LARRY RAMDIN, RS/RPTIS, CI 10, CP -FS MAYOR Iramdin@salem.com salem.com HEAT; L'FI AGI.%,N`1' Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: W34 Foo *45A 2) Establishment Address: q2 WING A UE A LIM M 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: qn- _ 13 5) Applicant Name & Title: PMET CH0U)0l41A(qPfeSI D EnT B) Applicant Address:13 TEA PARIN AL IDQJ HA 7) Applicant Telephone No: 24 Hour Emergency No:WMO-3181 Email: P- �(, 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: association or oration An individual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. - Name Title Home Address w N T is TMW AA i MA 12 Person Directly Res onsible For Daily Operations Owner, Person in Char e, Supervisor, Manager, etc. Name & Title: N i Address: 13 TPAFIVOEW Telephone No: Ln-%o.3ill Fax: Email: Emergency Telephone No: V1 NO . �1 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check M. zQKZ2J Date: r� ` � Amount: �// 1W Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one)/ 13Retail ( Sq. Ft) [3 Caterer Permanent Structure V/ ❑ Food Service —( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service — Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service — Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and RETAIL STORE Breakfast Estoblishments--------------„•,•,-- RESTAURANT 21) Length Of Permit: (check one) Annual ❑ Lass than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: 1000-10,000sq.ft. $280 ❑ More than 10,000sq.ft. $420 ❑ Residential Kitchens $140 ❑ 25-99 seats $280 - - -------- -------------- ---- ------ - -- ----------------------------------------------------------------- ❑ Bed & BreakfasUChildcare Services (Nursing ❑ More than 99 seats $420 Home $100 Temporary/DatesMme: ................................ ----------------------- -............. ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE ...................................... --- ....................... $25 ❑ PASTURIZATION $25 ❑ ALL NON-PROFIT' $25 *Including, church kitchens, state funded childcare & Rdvate club 23) Food Operations: Definitions: PHF- potentially hazardous food(time(temperature controls required) Non-PHFs - non -potentially hazardous food (no timettemperature controls required) (Check all that apply): RTE- read -to-eat foods Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PMI- to IiUIK uuamnle5 To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. n r A ^ 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: 4(.-108- 6095 KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"t FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 lramdin@salem.com 1P PablicHealth Prevent. Promote. Protect. LARRY R,IMDIN, RS/REHS, CI 10, CP HI.,At: fl f AGENT 201_ APPLICATION FORTERMIT FOR SALES OF TOBACCO & NICOTINE DELIVERY PRODUCT PERMIT FEE $1' NAME OF ESTABLISHMENT 'j'ONSW FOOD SHOP TEL# 978-7W-43/ ADDRESS OF ESTABLISHMENT '7.7 JJrult&_ FAX# DEPARTMENT OF REVENUE APPLICATION NUMBER: MAILING ADDRESS (if different) EMAIL - Business': OWNER'S - LhM Website: TEL # 617- SW199 ADDRESS e13 IL`N i'BB1t/ UIHY 17HW47JV INH STREET CITY STATE y' Qq ZIP EMERGENCY RESPONSE PERSON &ioo C Nb(U0mg HOMETEL# %I%87/� 3I6% Type of Products Sold: Cigarettes Cigars Chewing Tobacco_ Pipe/Cigarette Tobacco ✓ Nicotine Delivery Devices_ Other Tobacco Product (list on additional Sheet) I DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday I - Saturday Sunday HOURS OF OPERATION �de Please write in time of day. j (For awNe Ilam-llpm) A '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 locant in the Establishment In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns ang-paid all state taxes required under the law. yif Number Updated 723/12 TOBACCO.doc Check#&DateOSOA"Q'il 1.21111 Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of FOOD ESTABLISHMENT INSPECTION REPORT Address: Tel Name �' !L� G L I S I \ e ( Type of Operation(s) ❑ Food Service] Retail T pe of Inspection Routine ❑ Re -inspection Address Rik r Level ❑ Residential Kitchen ❑Mobile Previous Inspection Date: Telephone r El Temporary ❑ Caterer ❑ Bed R Breakfast [IPre-operationOwner ❑ Suspect Illness ❑ General Complaint rvez Ch c71 HACCP YIN Person -in -Charge (PIC) Time In: J.;qy- Out: C O 0 Permit No. ❑ HACCP ❑ Other Inspecto Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned/Knowledgeable/Duties 'EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/Segregation/Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices_ (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 -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 (FC5)(590.006) 27. Physical Facility (r -c-6)(590.007) 28. Poisonous or Toxic Materials (FC -7X590.008) 29. Special Requirements (590.009) 30. Other 5: o-awc Anti -Choking 590.009(E) ❑ Tobacco 590.009 (F) ❑ Allergen Awareness 590.009 (G) ❑ ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROWCHEMICALS ' ❑ 14. Approved Food or Color Additives JI 15. Toxic Chemicals TIMEREMPERATURE.CONTROLS.(Potentially Mazatdous Foods) El 16. Cooking Temperatures [117. Reheating [118. Cooling X19. Hot and old Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY.SUS,CEPTIBLE�POPULAT(ONS-.(HSP) ❑ 21. Food and Food Preparation for HSP CONSUMERADMSORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions Z 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 Wthin 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: - Print: - - PICs Signature: �7 , Print: ��� .G�,_ ,� 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) AssigumentofResponsibility* 5I 113( m B) Deonstration of Knowledge" 2-103.11 Person in char a -duties EMPLOYEE HEALTH 2 590 003(C) Responsibility of the person ht charge to Cant tliance with Fuod Iaw* 3-201.12 require reporting by food employees and 3-20'1..13 Fluid Milkand Milk, Products* a plirants* _ 590.003(F) Responsibility 01 A Food Employee Or An 3-202.16 Ice Made Froin Potable Drinking Water"' Applicant To.Report To The Person In Lainking Water from an A .roved S stem"' 590.006(A) Chry ge* 590.006(B) 590.003(03) Re orttn b I Person in Charge* 3 590.003(D) Excinsioas and Reeh9ctions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 C C FOOD FROM APPROVED SOURCE x Denotes critical item in the federal 1999 Fond Code or 105 CMR 590.000. S Food and Water From Regulated Sources 590.004(A-15) Cant tliance with Fuod Iaw* 3-201.12 Food in. a Hermetically Scaled Container* 3-20'1..13 Fluid Milkand Milk, Products* 3-202.13 3-202.14 Eggs and Milk Products, Pastcorimd° 3-202.16 Ice Made Froin Potable Drinking Water"' 5-101.11 Lainking Water from an A .roved S stem"' 590.006(A) Bottled Drinking Water, 590.006(B) Water Meets Sttutdards in 310 CMR 22.01` Washing ;Fruits and Vegetables Sheiffish and Fish From an Approved Source 3-201.14 Etsh and Recreationally Caught Molluscan Shellfish* _ 3-201.15 Molluscan Shellfish from NSSP l.t,9ted Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authorli 3-202.18 Shellstock Identification Present" 590.001(0) Wild Mushrooms* 3-201.17 Game Animals* 3-701.1.1 Receiving/Condition 3-202.11 PHFs Receiver) at Properr Temperatures* 3-202.15 - Package huetn'it * 3-101.11 Food Safe and Unadulterated TagslRecords: Shelistock 3-202.18 Shelistock Identification 3-203.12 ShOlstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(7) Labeling of Ingredients' Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Conformance with Approved Procedures j IHACCP Plans 3-502.11 specialized processing Methods* 3-502.12 Rethiced ox eu xeka -nom, criteria* 8-103.12 Conformance with Approved Procedures" x Denotes critical item in the federal 1999 Fond Code or 105 CMR 590.000. S Cross -contamination 3.302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.1t(A) Food Protection* 3-302.1.5 Washing ;Fruits and Vegetables 3-304.11 - hood Contact with Equipment and Utensils* - Contamination from the Consumer 3-306.14(A)(H) Returned Food and Reservice of Food* _ Disposition of Adulterated or Contaminated Food 3-701.1.1 Disc.urding or Reconditioning Unsafe Food* y Food Contact Surfaces 4-501.1I t Manual Warewasbing - Hot Water Sanitization 'remperat uses 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 and Utensils* 4-702.11. Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703-11 Methods of Sanitization- [lot Water and Chemical* 10 Proper, Adequate Handwashing 2. iv I I 1 Clean Condition -Hands and Arms* 2-301-12 Cleaning P.rocedurc* _ 2-301.14 When to Wash* 11 Good Hygienic Practices 2401-11 _ Eating, Drinkinor Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-30t12 PrevemingContamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11. Numbers and Capacities* 5-204.1.1 Location and Placement* 5-205-t1 Acces3ibilit , Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand: Drying Provision CITY OF SALEM _ BOARD OF HEALTH Establishment Name: og.,,� ,- <h� Date: '21 Page: c�2 of Nem No. Code Reference C - Critical Item R -Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date Verified PL ASE PRINT LEARLY - U JE7--JTI r d --- /Y- -OSC (2) Q�JJAXh — n s, lS ,✓ r 2a3.� v CSC 1/ tel, n Q O ti / !� AZ c i r5 r I( K)Pnof (C1Jul, mit . a )4,'K r Hb5 61 2 �-r 1 �a-+v� S 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: you ❑ No rF voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: r Violations Related to Foodborne Illness tnterventions and Risk Factors (Items I m (Cont.) PROTECTION FROM CHEMICALS 14 Food or Calor Additives An FE FE 17 m ..:. all - 3-202.12 Additives* _ 3-302.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) orToxic Substances 7-101.1. 1 _Poisonous identifyitsg information - Ori.ginal Containers* 7-10211. Common Name - Working Containers* - 7-201.11 Sep araixun-Stora e' 7-202,11 Restriction - Presence and Use* 7-202.12 Conditions of Usc* 7.203.11 Toxic Containers - Prohibitions* 7-204.11 Satirizers.Criteria- Chemicals° 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 OrvinQ Agents. Criteria* ` FC -7 Incidental Food Contact, Lathricants* 3-401.12 Restricted Use Pesticides, Criteria* R Rodent Bait Stations° 3-40111(A)(1)(b) Tracking Powders, Pest Control and Mortitoritt x. FE FE 17 m ..:. all - * thnotei critical item in the federal 1999 Foci Code or 163 CMR 590.0X m 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'FISw,-* 3-401,11(A)(2) - Comminuted Fish. Meats & Game 3-501.16(4) Animals -155'F 15 sec. * 3.401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 min" 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) sec. * 3.401.11(A)(3) Poultry, Wild Game, Stuffed PRFs, 27. Stuffing Containing Fish, Meat, FC - 6 Poultry or Ratites -165°F 15 sec. 3401..1.1(0)(3) Whole -muscle, Intact Beef Steaks ` FC -7 145°F a 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-40111(A)(1)(b) All {Ether PRFs -145°F 15 sec. Reheating for Hot Holding 3-403AI(A)&(D) ' PHFs I65'1` 15 sec. * 3-40111(B) Microwave- 1650 F 2 Minute Standing Tom* 3-403.11(C) Commercially Processed RTE Food - 140°F'* 3-A03.�--^ Il(E) Remaining Unsticed Portiims of Beef Roasts` _ Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 14WF to 70°F Within 2 Hams and From 70`F to 41013/45'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41`F/45oF Within 4 Hours* * thnotei critical item in the federal 1999 Foci Code or 163 CMR 590.0X m 3-501,14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45'F Within 4 Hours. 3-501.15 CcK)IinR Methods for PHFs 3-801.11(B) PHF Not and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 410/450 F* 3-501.16(A) Hot PRFs Maintained at or above 140`F. * 3-501.16(4) Roasts Heid at or above 130'F. 25. Time as a Public Health Control 3-501.19 Time as if Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSPI 21 3-801.11(A) Unpasteurised Pre-packaged Juices and [Beverages with Warning Labels* j 590.000 j 3-801.11(B) I Use of Pasteurized Eggs* IFC - 2 _ 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed S rts Not Served. * Food and Foal ProtectionFC 3-801. I i (C) I Unopened Food Pack e Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of j 590.000 j 23. Anhnal FoodsThatare Raw, Underrnoked or IFC - 2 _ : _� Not Otherwise Processed to Eliminate Food and Foal ProtectionFC - 3 Path ens.* Ohc� i &MI 25. 3-302.1.3 Pasteurized Eggs Substitute for Raw Shell .OG5 26. Eggs* - rrCBiVII'fGti1CBY 1 a7 Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited udder the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited trader #29 - Special Requirements. (Items 23-30) Crilical, 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 590.000. - Rem Good Retallpracttces --- - - - ) F'C j 590.000 j 23. 1 Manactament and Personnel _ IFC - 2 _ : _� 24. Food and Foal ProtectionFC - 3 .064 25. ' Equipment and Utensils FC_4 .OG5 26. 1 Water, Plumbing and Waste FC -5 .006 27. 1 Physical Facliity FC - 6 .667 1 2B. - PolsonousorToxicMaterials ` FC -7 .008 j 29. Special Re uirements .009 30 I Other 5:�'lMn�.vrc1L x�i c CITY OF SALEM _ L BOARD OF HEALTH r Establishment Name: � i F �� -5-KaDate: r9 � a.6 -r— Page: of Item No. Code Reference C - Critical Rem R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Dete- Verified PL E PRINTCLEARLY og I ro I ✓II _ S - F:�/ � IP MI/I I S., ,74 _eJj9 C/U i J- a - cI2 u/ �, () QOkel C xJ� Ch/CK cr �v 4 7:j t, , i ( !n% c A0AJIQ, a :SA_ l/ _ e- K ✓ C f 3 Iter/ cl 5�1D- 4 u A.O�"' CA C/- Ot 4e i t0 a ralADZzi Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct allVoluntary 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 Compliance ❑ Emplo ee Restriction I Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: iJ� Violations Related to Foodborne 111ness. Interventions and Risk Factor&(items '1-22) (Cant.) :. Z#17:54i l . :fat u 14 ( Food or Color Additives -- 3-202.12_ Additives* 3-302.14 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 7-101.1.1 Identifying Information - Original Containers* 7-102.11. Common Name - Working Conminers* 7-201.11 Se aradon-Stora * 7-202.11 Restriction - PresenceandUse 7-202.12 Conditions of Ilse* 7-203.11 Toxic Containers - Prohibitions* 7-204.11. Sanitizers. Criteria - Chemicals* 7-204.12 - Chemicals for Washing Produce, Ccitetia* 7-204,14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.12 Rodent ftt Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* 17 m 1u_tf' • '.s' * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.(M. 19 20 10 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.IIA(1)(2) Eggs- 155T 15 Sec. 3-501.16(B) 590.004(F) Eggs- immediate Service 145'F15sec* 3401.11(A)(2) - Comminuted Fish. Meats & Game 3-501.16(A) Animals -155'F 15 sec. * 3.401.11(3)(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. * , 3401.1 I(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Staffing Containing Fish, Meat, - Poultry or Ratites -165'F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks '.FC -7 145`F * 3-401.12 Raw Animal Foods Calked in a Microwave 165°F * 3401.11(A)(1)(b) All Other PHFs -145'F 15 sec. Reheating for Hot Holding 3.403.11(A)&(D) ` PHFs 165-F 15 sec. * 3403.1.1(B) Microwave- 165` F 2 MinuteStanding Time* 3-403.11(C) Commercially Processed RTE Food - 140'F 3-403-II(E) Remaining Unsticed Portions of Beef Roasts* - Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70'F Within 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/45'1` Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.(M. 19 20 10 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 Not and Cold Holding 3-501.16(B) 590.004(F) Culd PHFs Maintained at or below 41Q145° F* 3-501.16(A) Hot PHFs Maintained at above 14('R * 3-501.16(A) Roasts Held at or above 130'F. X25. Time as a Public Health Control 3-501.19 Time, as a Public Health Control* 590.004(H) Variance Re uirentent REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 21 3-801.11(.3) Unpasteurized Pre-packaged Juices and .Beverages with Warning labels* 580.00 i 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 * -1 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 580.00 i 21 Animal Foods That are Raw, Undercooked or FC -2 ! .003 1 Not Otherwise Processed to Eliminate -1 Food and Food Protection ! FC -3 Pathogens.* �'."0'01 X25. 3-302.13. Pasteurized Eggs Substitute for Raw Shell .005 X26. E * 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 (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. jd RefaltPractices- (.FC 580.00 i 21 1 Management and Personnel FC -2 ! .003 1 24. -1 Food and Food Protection ! FC -3 1 .004 X25. 1 Ecuioment and Utensils FC -4 .005 X26. 1 Water. Plumbing and Waste - FC -5 .008 27. Physical Facility !. FG - 6 .007 1 2B. Poisonous orTrncic Materials '.FC -7 .008 1 29. S ocial R irements .008 30 1 Omer so�r��.ceaz rx 4^l. TOBACCO VENE H u`$ x� ra' 4^l. TOBACCO VENE H u`$ , + .. Y +C�' Y TJ9r- 3M � Ex A n 4Y H u`$ , + .. KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 lramdin@salem.com L\RRY RAMDIN, RS/REI-IS, CHO, CP -PS HEAI..TF1 AGENT 201_ APPLICATION FOR PERMIT FOR SALES OF TOBACCO & NICOTINE DELIVERY PRODUCT PERMIT FEE $135 - NAME OF ESTABLISHMENT RDQSCH I FOOD SHOP TEL # 978 74N- y13 / ADDRESS OF ESTABLISHMENT -9 I L,ol N6 Ave SALEM FAX# DEPARTMENT OF REVENUE APPLICATION NUMBER: MAILING ADDRESS (if different) / EMAIL - Business': PPft/EZ &6 Q IAH"I- Co PI Website: OWNER'S NAME PfNr2 N0woHgjq TEL ADDRESS 7- H6, 3/87 STREETCITY STATE ZIP ((�� EMERGENCY RESPONSE PERSON RIVE -1 010WOHIA N HOME TEL# W -W-310 Type of Products Said: Cigarettes—,Z– Cigars ✓ Chewing Tobacco_ Pipe/Cigarette Tobacco ,`� Nicotine Delivery y Devices_ Other Tobacco Product (list on additional Sheet) `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. Signature MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax aid all state taxes requid;d under the law. Date —I o8-Log5 Social Security or Federal Identification Number Updated 723/12 TOBACCO.doc Check# & Date $ a k a j - •.eSi#. e4. � }� k YF�e cqd s f - j- r S �DAT+E4PRINTED.��-_ ` ESTABLISHMENT N .� 4t �j& File Number E a k a j - •.eSi#. e4. � }� k YF�e cqd F f - j- 4 d a 4_ j ef, PERIVIIT EXP: °ter f - j- 1 J-'17 f - a KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, lu MASSACHUSE xeetc>a BOARDOFHir)u tlf _, - 120 WnsHtNc�loN $"1R1 4'O^ FioUa .�„ ^� TEL. (978) 741-1800 17)1-\'(9i8) 7�5=0343 44 4DRRY RAM1)1N, RS/REHS, CHH, CP -PS e 1ramdi salem.`ccom o5HEA1. LH A(ifN'C :S Food Establishment Permit lication (Application .must be submitted at least 30 days before 6 planned opening date) 1) Establishment Name: QD FOO SAW J1 �`I0 2) Establishment Address: r►ES e 11 LO n N s v -E A l*vl c� IQ -m r A 3) Establishment Mailing Address (if different)):] r/ rI 4) Establishment Telephone No: 978 7VV d3 5) Applicant Name & Title: Avar . Cwawow/ pfesldenj- 6) Applicant Address: 3 7'� UVJQV r ^P HA MW 7) Applicant Telephone No: yQ. �/ 24 Hour Emergency No:617 WQ 3jf7 Email: fd 7 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: association A torpor on An individual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address —Tryc PfweinT 13 TeA Nirq LON M ALD%1 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name&Title: Pervel OW Address: (C�� la f 4 gMALMIM Telephone No:I O -3I4 Fax: Email: Emergency Telephone No: (�1 `— qQ--, m 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #: 7`I7 33 Date: - Amount: Ud Food Establishment Information 14) Water Source: 15) Sewage Disposal: MP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 In accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures (if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one)/ 13Retail ( Sq. Ft) ❑ Caterer Permanent Structure✓ ❑ Food Service - ( Seats) ❑ Frozen Dessert Manufacturer Mobile . ❑ Food Service - Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and -Breakfast Establishments----------------„--• 21) Length Of Permit: (check one) RETAIL STORE RESTAURANT Annual ❑ s than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: 000-10,OOOsg1t. $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑ 25-99 seats $280 ❑ More than 99 seats $420 -----------------------------------------------------------------------------------------------------.......... 13 Bed & Breakfast/Childcare Services (Nursing Home $100 Temporary/Dates/Time: A ITIONAL PERMITS MAKE ICE CREAM, YOGURT/SOFT SERVE $25, ❑ PASTURIZATION $25 ❑ ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF- potentially hazardous lood (timeltemperature controls required) (check all that Non-PHFs — non -potentially hazardous food (no time/temperature controls required) apply): pp y): RTE — ready -to -eat foods Far. 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 PackaginglCook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares FoodlSingle Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be comu[eted by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been Instructed by the Board of Health on how to obtain copies of 105 CMR 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. I - 25) Social Security Number or Federal ID:. 110- 26) a- 26) Signature of Individual or Corporate Massachusetts Department of Public Health Division of Food and Drugs City/Town of 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 Address: Tal Name � Q D Type of Operation(s) Food Service Retail T pe of Inspection Routine Re -inspection Address 1 �rl� Rsk TelephoneI V q H _ Level Residential Kitchen El Mobile ❑ Temporary El C] Bed & Breakfast Previous I spe n Date: '3 f i 31w( El Pre-operation? El Suspect Illness E] General Complaint Owner Q y0Z HACCP YIN Person -in -Charge (PIC) Tirpq !1 Oa !i Permit No. ElHACCP ❑.Other Inspector eacn violation cnecxea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti -Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate To590.009 (F) El q Allergen Awareness 580.009 (G) ❑ corrective action as determined by the Board of Health. _ - - --s..:. - FOOQPROTECTION MANAGEMENTS- ❑ 1. PIC Assigned/Knowledgeable/Duties _ EMPLOYEE HEALTH...- ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded -• ---- _...-.. _ - F.00D�FROM�APPROVED SOURCE ❑ 4. Food and Water from Approved Source rt ❑ 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_ (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 (FC5)(590.006) 27. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FC -7x590.008) 29. Special Requirements (590.009) 30.Other ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities 1PROTECTIONFROWCHEMICALS ❑ 14. Approved Food or Color Additives _ ❑ 15. Toxic Chemicals TIME/TEMPERATURE: CONTROLS (PotentiattyHaisrdousFoods) ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATIONSt(HSP)' ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY [122. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (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 orders DATE OF RE -INSPECTION: n' Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 I 590.003(A) Assia tment of Responsibility* 590.003(B) Demonstration of 1{nowledge* 2-103.11. Person incharge -- duties EMPLOYEE HEALTH 2 590A03(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Char * 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 IE L C FOOD FROM APPROVED SOURCE Denotes critical item inthe federal 1999 Food Code or 105 CMR 590.000, C PRATPCT1nN PRnM CnNTAUuu A-nnra Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Scaled Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Pwducts. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-1.01..11 Drinking Water from an Approved System* 590.006(A) Bolded Drinking Water* 590.006(B) Water Meets Standards in 31.0 CMR 22 0* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molinscan Shellfish* 3-201.15 _ _ Molluscan She(Ifish from `1SSP lasted Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by .4e Mato Authorit 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* . 2-301.14 Receiving/Condition 3-202.1.1 PHFs Received at Proper Temperatures* 3-202.1.5 Package tette grit y 3-! 01.11. Food Safe and Unadulterated _ _ Tagsf9ecords: Shelistock 3-202.18 Shellstock Identification * 3-20312 ShellstockIdentification ly?aintained* -tI Tags/Records:Fish Products I 3-402.11 Parasite Destruction` 3-40112 Records. Creation and Retention*_ 590.004(1) Labeling of Ingredients' 13 Conformance with Approved Procedures /HACCP Plans 3-502.11. Specialized Processing Methods* 3-502.1.2 Reduced oxygen acka&g, criteria* 8-103.!2 Conformance with Approved Procedures* Denotes critical item inthe federal 1999 Food Code or 105 CMR 590.000, C PRATPCT1nN PRnM CnNTAUuu A-nnra 9 Cross -contamination 3-302.11(A)(1) I Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.1.11. Contamination from Raw Ingredients 3-302.11(A)(2) Raw Ammtd Foods Separated from Each Other* _ Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(A) Food Protection* 3-302,15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* 4-602.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-701.i1 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.1.11. Manual Ware -washing - 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 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 2301.11 Clean Condition - Hands and Arms* 2-301..12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 - Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2401.12 - Discharges. From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(F) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 - Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6301.11 ar"washing Cleanser,Availability 6-301.12 Hand Drying Provision ITY OF SALEM ((`� ((� BOARD OF HEALTH Establishment Name: ry/d)c l!t — -q-p f ©� Nb / i�"c Date: ci �� Page:_ of Rem Code No. Reference C — Critical Item R -Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date, - Verifed PLEASE PRINT CLEARLY J I,l, y Dzpri,N o- is M1 s, c, —UwPs - CRr e Uld6da�- ar I" ` p Q, [ Lw CnZ4&�L r itK -AJ cru + 1 a_ — • t6 r .rine CW31—IL/ McrJ - 3 c> - a 13 o tk O� v Ir Vi t r rJ Can .T. n✓ M ✓ eG IJ YISi S 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 Fo d Code. I understand that noncompliance may result in daily fines of tWE My a dollars or sus n/revocation of your food permit. Corrective Action Required: ❑ No Yes Voluntary Compliance El Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension o Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: an Vichttions Related to Foodborne fitness interventions and Risk Factors Mems 1-22) (Cont.) 15 17 Ft uT II a ^' • t'. Food or Cotes Additives - - -- ...- 3 2 --- vee,*. e02.12 Additiv_ 3-302.14 Protection from Una moved Additives'r 3-50LI(i(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11. Common Name - Working Containers* 7-201.II 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 fru Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food CoataM Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* - 7-206.12 - Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring., - Ft uT II a ^' • t'. * 0.natac cn icai 1 e-ni in the f doral 1999 FwA Cale or 105 CNIR 590.090. 19 Es w, 3-501,14(C) Proper Cooking Temperatures for 3-501.15 PHFs _ 3-40i.IIA(1)(2) Eggs- 155'F 15 Sec. 3-50LI(i(B) 590.004(F) E gs- Immediate, Service 145*F15sec* 3-401 A I(A)(2) - Comminuted Fish. Meats & Game 3-501.16(A) Animal's -155'P 15 sec. * 3401.11(13)(1)(2) Pork and Beef Roast - 1309F 121 min* 3401.11(A)(2) Ratites, Injected Meats -'155°F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Facility Stuffing Containing Fish, Meat, Poultry or Ratites -165'F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks .008 145T * 3401.12 Raw Animal FomLs Cooked in a .009 Microwave 165'F * 3-401:11(A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165" F 15 sec. * _ 3-403.11(B) Microwave 165` F 2 Minute Standing Time* 3403.11(C) Conunerciaily 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 PRFs from 14 -r to 70'F Within 2 Hours and From 70'F to 41`F/45'F Within 4 Hours. 3-501. 4(B) Cooling PHFs Made FromAmbient Temperature Ingredients to 41 OF1456F Within 4 Hours* * 0.natac cn icai 1 e-ni in the f doral 1999 FwA Cale or 105 CNIR 590.090. 19 Es w, 3-501,14(C) PHFs Received at Temperatures -. According to law Cooled to '♦ 41'F/45'F Within 4 Hours, 3-501.15 Colin Methods for PHFs _ PHF Hot and Cold Holding 3-50LI(i(B) 590.004(F) Cold PRFs Maintained at or below 41'1#5' F* 3-50L16(A) Hot PHFs Maintained at or above 140°F. * 3-501.16(A) Roasts Held at or above 130'F. " Equitiment and utensils Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPUi ATIDNS HSP 21 3-801.11(A) Unpasteurized Pre-packaged Juices and ..Beverages with Warning Labels" -� 5gatim -, 3-801.11(B) Use of Pasteurized Eggs* (.003 ! 3-801..11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served * TFC -3 3-8Q1.11(C) Unopened Food PackageNot Re -served. 22 3-603.11 ConsumerAdvisoryPosted for Consumption of 5gatim -, 23. I Man in and Personnel Animal Foods That are Raw. Undercooked or (.003 ! 24.. Not Otherwise -Processed to Eliminate TFC -3 r.004 Patho *7rxe,o vnncei Equitiment and utensils 3-302.13 Pasteurized Eggs Substitute for Raw Shell ! 26. Water. Plumbing and Waste E SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section .590.009(A) -(D) do 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. VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Critical.. mid non-critical violations, which do not relate: to the foodbonte illness interventions and risk factors listed above, can he found lit the following sections. of the Food Code and 145 CMR 590.000. t item j Goad Retell Practices i .FC 5gatim -, 23. I Man in and Personnel F7 C - P (.003 ! 24.. Foodand Food Protection TFC -3 r.004 125. Equitiment and utensils i FC -4 .005 i ! 26. Water. Plumbing and Waste j FC -5 .906 rlPhysical Facility i FC -6 i-28. Poisonous or Toxic Materials '. FC = 7 .008 X29. _ Special Requirements .009 30 i Omer s:saae�-�s6.x m: f a n - - ,,, Commonwealth of Massachusettsii Rev c �_ ,.�., `. �..ft. City Salem of J 1 Board of Health= Kimberley Dnscoll R A20 Washington Street 4th Floor.hMayOr' it c yl y SA LEMMA 01970 =� s4.Y-`g „ = FOO /Retail Establishment Permltz .,_ e. :} � DATE PRINTED e $'_11/29/2012 's5w T, 3`7 "'3#' Al ESTABLISHMENT NAME: _Tedi" # escht Food Shop #452. File Number BHF 2004-000011 72 Loring Avenue7, Salem MAg01970'" RR L g ..LOCATED AT 0072xLORING AVENUE. '-'SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expilres Fee Restrictions / Notes FROZEN DESSERTS 6HP-20129664* Jan 1; 2013- Dec 31, 2013 $25 00 u. RETAIL FOOD Ic BHP 2013,0025 Jan:1, 2013,- Dee 31, 2013 �t $280 00 F TOBACCO VENDOR _BHP2 013-0039 Jan 1, 2013 Dec 31, 200 $135 004 o * ' ' � e t t 2 Total Fees $440 00 r -Sx.. #fa R, �` [�kl'ye "< 64±s`1.� '�' �' r =N+6rs +5 i t z : a xd- - .ac..: s' PERMIT EXPIRES December 31 2013v^�N I p pA I " " '� b Board�of Health 1 nz L zk Ji g This Permit is not transferable and must be reissued upon change of ownership or location' The permit must tie posted in a prominent location in the Establishment. In accordance with the State Sanitaiy Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must`be submitted 4o and'approved by the3Salem Board of Health. `aPage"�'` ., - 1 +mss CITY OF SALEM, % RECEIVEDMASSACHUSETTS by 29212 KIMBERLEY DRISCOT� MAYOR CITY CF sp',-ELTVA BOARD OF H BOARD OF HEN; T1 -I 120 WAstnNc TON Smi--uI e, 4111 FLOOR Tia.. (978) 741,1800 Fns (978) 745-0343 Iramdin(a� saleln.com lu th LARRY RAbIDIN, RS/RI IIS, CI -IO, CP -FS HF,AI:PI-I A('ENI' Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: e�Q I Ib SN 451 2) Establishment Address: la Lorin& A&a Jl kll f iN 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: 976—M -431'I' 5) Applicant Name &Title: err[2 O&WONut04VAIr-l2 6) Applicant Address: 730o������ ®� q MOEN 7) Applicant Telephone No: � Iy X Oy�-XV 24 Hour Emergency No: 611-ky4-31 %% Email: Pipfil,4t 6 , 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: .An association A corporation An individual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 'f I G Priest 3 Te es f wlq N 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name &Title: tU62 CHOWIDIA01 Address: 16 Te4AVLAM MALDyn Telephone No: (0 -940-3 181 Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check 11lagha—s%() . Date: k10 qzl Amount: Vo 70 7 0) Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) - 5 16) Days and Hours of Operation: p f 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) E ablishment Type (check all that apply) (check one) ✓ L-4^etail ( Sq. Ft) 0 Caterer Permanent Structure ❑ Food Service - ( Seats) ❑ Frozen Dessert Manufacturer Mobile 0 Food Service - Takeout 0 Residential Kitchen for Retail Sale ❑ Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home 0 Food Delivery - - - 0 Residential Kitchen for Bed and -Breakfast Establishments - 21) Length Of Permit: (check one) RETAIL STORE RESTAURANT Annual 0L��ss than 1000sq.ft. $ 70 0 Less than 25 seats $140 Seasonal/Dates: 9'1000-10,000sq.ft. $280' 0 Residential Kitchens $140 0 More than 10,000sq.ft. $420 0 25-99 seats $280 0 More than 99 seats $420 ---------- ------ --- - ------------------Vic--- ------- - -- ----------------------- -------------- ❑ Bed & Breakfast/Childcare Sees /Nursing Home $100 Temporary/Dates/Time: v q ADDI ONAL PERMITS AKE ICE CREAM, YOGURT/SOFT SERVE $25 .. 0 PS�rT�URIZATION $25 13TOBACCO VENDOR $135 0 ALL NON-PROFIT $25 Including, church kitchens, state funded childcare 6 private clubs) 23) Food Operations: Definitions: PHF- potentially hazardous food-(time/temperature controls required) Non-PHFs -non-potentially hazardous food (no timeltemperature 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 Saleof Commercially Preparation of PHFs For Hot And ,. PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal.Origin Perishable Foods Only - Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. /1 4 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 -108 6095 S 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 ofonN� FOOD ESTABLISHMENT INSPEr_TInN RFPnRT Address: Ter�n� n/rl Ii�,/)A NameIWO a (FC -2x590.003) Date Type of peration(sl Type of spection SCne Equipment and Utensils (FC -4x590.005) 26. ❑ Feta lService ffRe-inspection Address Risk (FC -6x590.007) Level ❑ Residential Kitchen Previous Inspection Telephone !1 Special Requirements ❑ Mobile Date: Other I [I Temporary [I Pre-operation OwnerP VPA(J YIN ❑ Caterer ❑ Bed 8 Breakfast ❑ Suspect Illness E] General Complaint Person -in -Charge (PIC) Ti In: ❑.OtheCP Inspector_pk Out: Permit No. ❑ r=acn vwranu� cneciteu require5tan expiarlaTion on the narrative pagets) ane a citation of specific provision(s) violated. VNoir-compriance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti -Choking 590.009 (E) ❑ ViTobacco 590.009 (F) El marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009 (G) ❑ corrective action as determined by the Board of Health. FOOD: PROTECTION MANAGEMENT._ ❑ 1. PIC Assigned/Knowledgeable/Duties _ EMPLOYEE HEALTH ­ _- ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded - FOOD -FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy. of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans _.-EC _-.- - PR_OTTION FROM CONTAA MINATION- . - ❑ 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- (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. 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 (FC -5)(590.006) 27. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FC -7x590.006) 29. Special Requirements (590.009) 30. Other I ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities ;PROTECTION FROM'CHEMICALSi, ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals �TIMEREMPERATURE'CONTROIS.(Po_ teMlatly Hazardous Foods) T._ ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR,NIGHLYSUS.CEP,TREE=POPULATIONS''fHSP),_y ❑ 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 (Red Items 1-22): Official Order for Conecdon: 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 S receipt of this order. \ DATE OF RE-INSPECTION:VI /t n .i- 04 i ii�/�.,i t Y Y IQ)Cb l n _ ^_ Y Y/M�I�C'V!/1 7� �_ i�.e� Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590,003(A) AssigttmentofResponsibility* 590.003(B) Demonstration of Knowledge* _ 2-103.11. Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food 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 Fax! 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(0) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201-15 590.003(E) Removal of Exclusions and Restrictions C C C LN FOOD FROM APPROVED SOURCE ' Denote -c critical ;tem in.the Wer il 1999 fund Code or 105 CM:R 590,000, C PROTECTION FROM COWTAM1MAT1ntd Food and Water From Regulated Sources 590.004(A -B) Compliance with Food 3-201.12 _Law* Food in a Hermetically Seated Container* 3=201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.,16 ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Shellfish and Fish From an Approved Source 3-201.14 Fish and Reaeationatiy Caught Mollascaa Shellfish* 3-201-15 Molluscan Shellfish from NSSP lasted Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by F.e ulatio Authorlt 3-202.1.8 Shellstock Identifcation Present" 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 Receiving/Condition 3-202.11 PHFs Received at Proper Tent sures* 3-202.1.5 Package Lite , it * 3-10LII Food Safe and Unadulterated _ Tags/Records: Shellstock 3-202.18 Shellstock Identification 3-203.12 Shellstock Identification tvlaintained* 12 Tags/Records:Fish Products -� 3-402.11 Parasite Destruction* 3-402.12 1 Records, Creation and Retention* 590.004(.1) Labeling of Ingredients* Handwash Facilities - - Conformance with Approved Procedures /HACCP Pians 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.!2 ConfomancewithA ;ovedPcxedures* ' Denote -c critical ;tem in.the Wer il 1999 fund Code or 105 CM:R 590,000, C PROTECTION FROM COWTAM1MAT1ntd -Cross-contamination 3-302.1.1(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.1.11. Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foals Separated from Each Other* Mechanical Warewashmg- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(A) -I Food Protection* - 3-302.15 WashmR Fruits and Ve etables 3-304.11 Food Contact with Equiputent and Utensils* 4-60_1.1.1 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Fund* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-70111 Discarding or Reconditioning Unsafe FoW* Food Contact Surfaces 4-501.1.11. Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashmg- Hot Water Sanitization Temperatures* 4-501.11.4 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-60_1.1.1 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* IO Proper, Adequate Handwashing 2-3,01.11 Clean Condition - Hands and Arms* 2-301..12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2401.11. Eating, Drialdrig 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 590.0(A(F) Preventing Contamination from Employees* 13 Handwash Facilities - - Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 - Accessibility, Operation and Maintenance Supp" with Soap and Hand Drying Devices - 6-301.11 Handw•ashfn Cleanser,Availabilit HandDrying Provision CITY OF BOARD OF HEALTH Establishment .: _-z__ �11 � •. MIN,�� ._! u..•. -_�/E.w ...:. _ Alii. -. • _ WIM NO- M��CIJINmatt NOW-��, v !71/I�I�iI �•i� :.� `.. �fli� � .fit .i .a../ �_ ��� . . MI 0 I. I?A, . A l i .,♦ u.., .ter k�, , _ ,*01307012/� l ■ •. . ■ .. i Violations Related to Foodborne fitness Interventions and Risk Faetomfliems 1-22) (Cont.) 17 IM * Denocca exiticai iwni in the federal 1999 Fwd Calc a' 105 CMR 590.000. 3-501.14(C) Poon or Color tidditives 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 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 fru Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.12Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitorin * * Denocca exiticai iwni in the federal 1999 Fwd Calc a' 105 CMR 590.000. 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3.401.1IA(1)(2) _ Eggs- 155F 15 Sec 3-501..16(B) 590.004(F) Eggs- Immediate Serviw145'Fl5sec* 3.401.1I(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animal's - 155'F 15 sec. * 3.401JI(B)(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. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -165017 15 sec.* 3-401.11(C)(3) Whole-muscle,Imact Beef Steaks 1450F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165F * 3-401.11(A)(1)(b) AD Other PIRs - 145°F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165-F 15 sec. * 3-403.11(B) Microwave- I65` F 2 Minute Standing Time* 3403. H(C) Commercially Processed RTE Food - 140°F* - 3-4012-II(E) Remaining Unsticed Portions of Beef Roasts* Proper Cooling of PHFs 3S0I.14(A) Coating Cooked PRFs from 140°F to 70'F Within 2 Hours and From 70`F to 4I'F/45'F Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 4l*F/456F Within 4 Hems* * Denocca exiticai iwni in the federal 1999 Fwd Calc a' 105 CMR 590.000. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F145'F Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-901.11(B) PHF Piot and Cold bolding 3-501..16(B) 590.004(F) Cold PHFs Maintained at at below 41'145' Ft- *3-501.16(A) 3-501.16(A) Hot PRFs Maintained at or above 140`F. * 3-501.16(A) Roasts Held at or above 1300F. 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 Pte -packaged Juices and Bevera>es with W"arnina labels* 3-901.11(B) Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sproms Not Served. * 3-801.11(g) Uno ned Food Pa Not Reserved. CONSUMER ADVISORY 22 3 b03.I1 Consumer Advisory Posted for Consumption of Animal Foals That are Rau'. Undercooked or Not Otherwise Processed to Eliminate Pathogens"� t" 0'� f 3-302.13. Pasteurized Eggs Substitute for Raw Shell E 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile fold, 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 }'bund in the fallowing sections.bf the Food Cade and 105 CMR Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T of Ooeration(s) LJFood Service LZRetaii T e Ins ction 0 outine ❑ Re -inspection Address Risk Level ❑ Residential Kitchen Previous Inspection Telephone u ❑ Mobile El Temporary ` Date: ElPre-operation Owner h HACCP YM r� p ❑ Caterer [IBed & Breakfast ❑ Suspect Illness ❑ General Complaint Person In Charge (PITime In:Id: ❑ HACCP Inspector Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. QNon-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. FOODPROTECTION MANAGEMENT ❑ 1 PIC Assigned/ Knowledgeable/ Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other [112. Prevention of Contamination from Hands ❑ 13. Handwash Facilities ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Fooda) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control _ __ - REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS_(NSP)I E121. Food and Food Preparation for HSP qC NONO SUMERADVI$ORy _ ���,,,, •n +o ❑ 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. n DATE OF RE -INSPECTION: _ V � _ zr . k_-e� Signature:��(V ,/A� I Print:�h lure:77/7eh /hn�^7�c f l Print: /incl/ of,,,,, >ages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) _FOOD PROTECTION MANAGEMENT 1 590.003(A)Asia tment of Res ronsibilit * 590.003(B) Demonstration of Knowledge* 2-103.11. Person in charge - duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants,* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant 1b Report To The Person In Drinking Water l'icmt an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) - Reporting by Person in Chat e* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 C C C FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Foal Code or 105 C.MR 590.000. 8 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(.4 B) Compliance with Food Law* 3-201.12 Food in a Hermeticall • Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Egs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.'11 Drinking Water l'icmt an Approved System* 590.006(A) Bottled Drinking Watcr* 590.006(B) Water Meets Standards in 310 CMR 22.0* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* ' Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP lasted Sources* 1 Proper, Adequate Handwashing Game and Wild Mushrooms Approved by Re g ulato Authont 3-202-18 Shellstock Identification Present" 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 RecelvinglCondltion 3-202.11. PHFs Received at Proper Tem rataxes* 3-202.1.5 Package Irate ity* 3-101.11 Food Safe.and Unadulterated Tags/Records; Shellstock 3-202.18 Shellstock Identification 3-203.1.2 Shellstock Identification Maintained* 12 Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(1) Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures 7HACCP Plans 3-502.11. Specialized Processing Methods* 3-502.12 Reduced oxygen nen acka ing, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Foal Code or 105 C.MR 590.000. 8 PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.1](A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* - Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other^` Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.1.5 Washing Fruits and Vegetables 3-:304.11 - Food Contact with Equipment and Utensils* 4-602.11 Come enation from the Consumer 3-306.14(A)(B) Returned Food and Reservi,ce of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* ' Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or RecondiG<ming Unsafe Food - 9 Food Contact Surfaces 4-501..111 Manual Warewashing - Hot Water Sanitization Te eratures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4501.114 Chemical Sanitization -temp., pH; concentration and hardness. * 4-601..1:1(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* ' 4-703.11 Methods of Sanitization- Hot Water and , Chemical* 10 1 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Anus* - 2-301..12 - CleaningProcedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eatin , Drinkingor UsingTobacco* 2401 12 Discharges From the Eyes, Nose and Mouthy 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) _ Preventing Contamination from Ent loyees* - 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 Mand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.1.2 Hand Dr ii Provision CITY OF SALEM BOARD OF HEALTH EstablishmentName L,c�� r)n 1 L4� Date: �{— i Page: of Rem Code C - Crmcal nem DESCRIPTION OF VIOLATION / PLAN OF CORRECTION © Date - No. Reference R - Red Item verified P EASE PRINT CLEARLY _O n ?. U, �'P nn ,(, a ; rale "� �1 oL, l 027�� {� �b.,n✓� c _ I gypp- - A l 1 G /1 ( f / \ ., I � l A �J Discussion With Person in Charge: Corrective Action Required: o No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-fivellars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. \^-�� I !?,� ❑ Voluntary Disposal ❑ Other: I_ d Violations Related to Foodborne fitness Interventions and Risk Factors Mems 1-22) (Cont.) . .. �....yf c.� 15 Food m Color Additives -u 3,202.12 - i Additives* - 3-302.14 Protection from Unapproved Additives'" Poisonous or Toxic Substances 7-101.11 Identi6ing 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 Sanitize". Criteria - Chemicals'* 7-2(13.12 Chemicals for is* 7-204.14 Drying Agent& 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 Monittxin * IM SIT] :11 ITr' -. •.. ..• * Denotw critical herr in the federal 1999 Fwd CWe w 103 CMR 590.000. 20 21 3-501.14(0) Proper Cooking Temperatures for 3-501.15 PRFs _ 3-401.11A(1)(2) Eggs- 255`14 15 Sec. 3-501.16(B) 590.004(F) Eggs- Immediate Service 145`Fl5sec* 3401.I1(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* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Staffed PHFs, 27. Stuffing Containing Fish. Meat, Poultry or Ratites -165'F 15 sec. 3-401.11(C)(3) Whole -muscle, lnw Beef Steaks ! FC= 7 145`F * 3401.12 Raw Animal Foods Cooked in a i - Microwave 165`F * 3-401:11(A)(1)(b) All Other PHFs - 145 F 15 sec. Reheating for Hot Holding 3403.1.1(A)&(D) PHFs 165-F 15 see. * 3403.11(13) 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 3501.14(A) Cooling Cooked PRFs from 140`F to 700F Within 2 Hours and From 70`F to 4I'F/45'F Within 4 Hours. * 3-501.14(B) Cooling PRFs Made From Ambiens Temperature ingredients to 41°F/456F Within 4 Hours` * Denotw critical herr in the federal 1999 Fwd CWe w 103 CMR 590.000. 20 21 3-501.14(0) PHFs Received at Temperatures According to law Cooled to 41'F/45°F Within 4 Hours. 3-501.15 Coohng Methods for PRFs 1 23. PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold Pi1Fs Maintained at or below 4101+5' F* 3-501.16(A) Hot PHFs Maintained at or above 140`P. * 3.501.16(A) Roasts Held at or above 1300F. 1 25. Time as a Public Health Central 3-501A9 - Time as a Public Health Control* 590.004(H) Variance Requirement II(A) i Unpasteufved Use of Pastetaued E&-.* - Raw or Partially Cooked Animal Food and Raw Seed Streets Not Served. * 13-801._ I i(C) I Unnnened Food Paekaee Not &--served. * I [OKOR I ,. : s . y. 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 ;. 1 23. Animal Foods That are Raw. Undercooked or ! FC -2 .003 - I Not Otherwise Processed to Eliminate 1 Food and Food Protection FC -3 Path o mens.* `""`"* tar 1 25. 3-302.13. Pasteurized Eggs Substitute for Raw Shell .005 26. Eggs* 6'1;13yt'1■ Violations of Section 590.009(A) -(D) in catering, mobile £ood, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne it Iness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Speeiai 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 1015 CMR 590.00. I Hem 1 Good Retail Practices .FC 590.000 ;. 1 23. i Man�gamant and Personnel ! FC -2 .003 - I _ i 24. 1 Food and Food Protection FC -3 .004 1 25. 1 Equipment and Utensils i FC -4 .005 26. Water. Plumbing and Waste j FCFC 5 5i 006 27. P� Facility 007 I 28. Poisonous or Toxic Materials ! FC= 7 .008 j 29. - Special RegLilremerns i - .009 i 30. 1 Other s:�voram� -x c: Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 74:1-1800 Fax (978) 745-0343 Name Date Type of Ooeration(s) T f Ins action Print: ass, -C ❑ Food Service U Retail Routine ti Re -inspection Address Risk w p Level Residential Kitchen El Mobile Previous Inspection Telephone ✓1 I r q I + [I Temporary Date: ElPre-operation Owner A HACCP YM t�,%n v)Un � ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness El General Complaint Person in Charge (PIC) 1 ) Time t l / l na0,�f In: ODt!' Permit No. ElHACCP C1 Other Inspector t Each violation cnecke0 requires a"TT nation 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)19 590.009 (F) t2 action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT_ _ _ _ - - - -_1 ❑ 1. PIC Assigned / Knowledgeable / Duties - - --------- EMPLOYEE -HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE�_ ❑ 4. Food and Water from Approved Source ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTIONFROM CHEMICALS - ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMErrEMPERATURE CONTROLS (Potentially Hazardou87F 8) Q 5. Receiving/Condition &r r e J e, -Q o-5(,)07 M ❑ 16. Cooking Temperatures E]6. Tags/Records/Accuracy of Ingredient Statements JlU1 [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ., r m ,) ❑ 19. Hot and Cold Holding ❑ 8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control ❑ 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) x 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other s: SHolnwa�orm8-ta.Ea �. J, ! REQUIREMENTS FOR HIGHLY -SUSCEPTIBLE POPULATIONS -(HSP); ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY _ *- m •: ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions L,�J and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature:u. A Print: PIC's Signature: ; / Print: ass, 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) Le15onsibility* 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 applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved S tem* 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 Re-stri'ctions 6 FOOD FROM APPROVED SOURCE '' Denotes critical item in the federal 1999 Food Code or 1 t15 CMR 590.000. g 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. W Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-'[01AI Drinking Water from an Approved S tem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables Shel!£sh and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* ( Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock.Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.1.1 PHFs Received at Prolter Temperatures* 3-202.1.5 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shelistoch 3-202.18 Shelishxik [dent ficatinn 3-203.1.2 Shellstock Identification Maintained* --� Tags/Records:Fish Products 3=40211 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 /HACCP Pians 3-502..11 Specialized Processing Methods* 03 Reduced oxyeen packaging, criteria* 103 res*12 Conformance with Approved P rocedu '' Denotes critical item in the federal 1999 Food Code or 1 t15 CMR 590.000. g Cross -contamination 3-302.11 (An]) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302A I (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 Reserviee of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* _ 9 Food Contact Surfaces _ 4-501,111 Manual Warewasbing - Hot Water - Sanitization Tem eratures* _ 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem eratures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. 4-601..11(A) Equipment Food Contact Surfaces and - Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* - 4-702.11 Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Her Water and - Chemical* to Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating. Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-30112 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacifies* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashin Cleanser, Availability 6-301.12 HandDrn Provision CITY OF SALEM _ BOARD OF HEALTH �. EstablishmentName:�C�C� f� ` ��.�- \"i)� r �� Date: �' - 5� �xPage: hof a Item I Code I C -Critical Item I DESCRIPTION OF VIOLATION / PLAN OF CORRECTION I Date No. Reference R -Red item -t`„n, N� I Verified v o- 0 �r,Y�7 "X;L 111�/irn t. -'1'!.r _ire Ci ' O'Y V"6�} 'vt 1'9M'A (b l Q�lt 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 sup Anse ion/revocation of your food permit. \/J 1: A^ r / // Ny,/ ❑ voluntary aompnance ❑ Re -inspection Scheduled ❑ Embargo ❑ Voluntary Disposal I%L:t'wo—say ' ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: Vloistfons Related to Foodborne Illness Pnter'rentions and Risk Factors (tents 1-22) (Cont.) Egg, 111174415171701711M� I * Denotes critical runt in the £.-decal 099 Foal Code or 105 CMR 59000. 3-501.14(C) Proper Cooking Temperatures for 3-202,12 Additives*,Food 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* 7-202.12 Conditions of Use* 7-2033.11 Toxic Cattamers - Prohibitions* 7-204.11 Sanidzem- Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Dryipj A encs. 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 Momtmin * * Denotes critical runt in the £.-decal 099 Foal Code or 105 CMR 59000. 3-501.14(C) Proper Cooking Temperatures for 3-501,15 PHIes 3401I1A(1)(2) Eggs- 155'F 15 Sec. 3-501.16(B) 590.004(F) Eggs- Immediate Service 145'Ft5sec* 3-40LI l(A)(2) - Comminuted Fish. Meats & Game 3-501.16(A) Animals -155'F 15 sec. * 3401.11(B)(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. * 3-401.1.t(A)(3) Poultry, Wild Game, Stuffed PHK 27. Stuffing Containing Fish, Meat, IFC -5 Poultry or Ratites-I65°F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks " FO - 7 145'F * 3-101.12 Raw Animal Foods Cooked in a '009 � Microwave 165'F * 3-401AI(A)(1)(b) Ali Other PIFs - 145'F 15 sec. Reheating for Not Holding 3 443A I(A)&(D) PHFs 165-F 15 sec. * 3403.11(B) Microwave= 165-F 2 Minute Standing Time* 3-403. t 1(C) Commercially Processed RTE Fond - 140'F* 3403.11(E) Remaining Unsliced Portions of Beef Rcasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PIFs from 140"F to 700F Within 2 Hours and From 70'F to 4 VF145°F Within 4 Hours. * 3-501.14(!3) Cooling PHFs Made From Ambient Temperature Ingredients to 41°2145'F Within 4 Hours* * Denotes critical runt in the £.-decal 099 Foal Code or 105 CMR 59000. 3-501.14(C) PHFs Res, ived at Temperatures According to Law Cooled to 41'F145'F Within 4 Horns. 3-501,15 Cooline Methods for PHFs 3-80LI I(B) PHF Not and Cold Holding 3-501.16(B) 590.004(F) Cold PiTFs Maintained at or below 41'!45° F* 3-50L 16(A) Her PHFs Maintained at or above 140'2. * 3-501.16(A) Roasts Held at or above. 130'F. - Time as a Public Health Control 3-501: i4 entire as a Public Health Control* 590.004(H) Variance Requirement t r- 21 3-80i.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warningbels* 590.000 3-80LI I(B) Use of Pasteurized E *_..-.._.... :, FC -2 3-801..I I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served- * ,Food and Food Protection 3-801.11(C) Un ned Food Package Not Rove ned. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 123. Animal Foods That are Raw, Undercooked or :, FC -2 .043 Not Otherwise Processed to Eliminate ,Food and Food Protection I FC -3 Pathogens.* Vf.C" V'�'t 1 25, 3-302.13. Pasteurized Eggs Substitute for Raw Shell .445 j i 28. Eggsv SPECIAL REQUIREMENTS 590.W9(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. r ♦ f-e..ter� (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 590.000. Itaen i Good Retail Prtcdcas (.FC 590.000 123. Management and Personnel :, FC -2 .043 i 24.. ,Food and Food Protection I FC -3 .044 1 25, I Equipment and Utensils I FC -4 .445 j i 28. _ Water. Plumbing and Waste M _ t FC - 5 .406 _ 27. �Physital Facility IFC -5 .97 i 28. Poisonous or Trace Materials " FO - 7 .048 291, Special Requirements 30. 1 Other '009 � Massachusetts Department of Public Health 'Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name Date TVDO of Ooeration(s) Type of Inspection t] Re -inspection Previous Inspection Date: E3Pre-operation ❑ Suspect Illness El General Complaint El HACCP ❑Other ❑ Food Service®Routine � Retail Residential Kitchen ❑ Mobile E3Temporary ❑ Caterer ElBed 8 Breakfast El Permit No. Addres Risk Level Telephoneqo� Owner HACCP YM Person in Charge (PIC Time Int Out: Inspector Each violation checked requires ap nation 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-Chokin Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E)IM 590.009 (F) action as determined by the Board of Health. - - �F000 PROTECTION MANAGEMENT_ ❑ 12. Prevention of Contamination from Hands I] 1. PIC Assigned / Knowledgeable / Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH _ "f" � _ ' �' "' • PROTECTION FROM CHEMICALS r.r a k "�". ° ❑ 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 ❑ 4. Food and Water from Approved Source ITIMEITEMPERATURE CONTROLS (Potentially Hazardous_ Foods) JA 5. Receiving/Condition Nt (Q Q,,QJyL H 6 ❑ 16. Cooking Temperatures El 6. Tags/Records/Accuracy of Ingredient Statements '� ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 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. IC 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 f s: svornspeaFormsa eoo ,p.�� l�V•"� n1. [118. Cooling ❑ 19. Hot and Cold Holding [120. Time As a Public Health Control - REM - -- - REOUIENTS FOR HIGHLY SUSCEPTIBLE _PO PULATION$(HSP)! El 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowted ek. 2-103.1.1 I Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law'I 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 Fad Employee Or An 3-202.16 Tee Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved S tem* 590.006(A) Char * 590.006(B) 590.003(G)) Reporting by Person in Charge* 3 590.003(D) Ezclusians and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C is FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 food Cade or 105 CMR 590A00. In a. PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law'I 3-201.12 Food in a Hermeticall • Scaled Container* 3-201.13 Fluid Milk and Milk Products* 3-202.1.3 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Tee Made From Potable Drinking Water* 5401.11 Drinking Water from an Approved S tem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" Frequency of Sanitization of Utensils and Food Contact Surfaces of Equi�merit* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreatitwally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Proper, Adequate Handwashing Came and Wild Mushrooms Approved by Re ulato Authord 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 Receiving/Condition 3--202. 1 t PHFs Received at Proper Temperatures* 3-202.1.5 Packa e lnte t * 3-101.11. Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* 12 TagslRecords: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.0040) Labeling of Ingredients' Handwash Facilities - Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen paclkagrigg, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 food Cade or 105 CMR 590A00. In a. PROTECTION FROM CONTAMINATION 9 Cross -contamination ' 3-302.1,1(A)(1) Raw Animal Foods Separated from Cooked and RTE Foals* 4-501..1.11. Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Aminal Foods Separated from Each Other* Mechanical Warewashing- Hot Water , Sanitization Temperatures* em eratures*4-501.114 Contamination from the Environment 3-302.11(A) I Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11. Food Contact with Equipment and Utensils* ' 4-602.11 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 Equi�merit* Disposition of Adulterated or Contaminated Food 3-701..11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces - 4-501..1.11. Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water , Sanitization Temperatures* em eratures*4-501.114 4-501.114 Chemical. Sanitization- temp., PH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food-" Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and Food Contact Surfaces of Equi�merit* 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 Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12. Discharges. FromtheEyes, Nose and Mouth* - 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(F,) Preventing Contamination from Employees* 13 Handwash Facilities - Conveniently Located and Accessible 5-203.11 1 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, .Availability 6-301.1.2 HandD 'n Provision CITY OF SALEM BOARD OF HEALTH Violations Relaters to Foodborne tttness. Interventions and Risk Factors {(terns I-=) (cont.) PROTECTION FROM CHEMICALS 14 Food or Color C Additives 3-202.12 Additives*� 3-302.14 Protection from Un roved Additives'" 3-501.16(6) 590.004(M Poisonous or Toxic Substances 7-101.11 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 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, CTiteTia* 7-204.14 Drying Agents. Criteria* 7-245.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-245.12 Rodent Bait Stations;° 7-206.13 Tracking Powders, Pest Control and Monitoring* C ' Denotes aitical wra in the fe&ra1 1999 Fmd Cate or 105 CMR 590.000. 19 C 3-501,14(0) Proper Cooldng Temperatures for 3-501.15 PHFs _ 3-401AIA(1)(2) Eggs- 155°F IS Sec. 3-501.16(6) 590.004(M Eggs -Immediate Service 145*FI5.wzo 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals - 155F 15 sec. * 340IAI(B)(1X2) Pork and Beef Roast -130'F 121 mm* 3401.11(A)(2) Ratites, Injected Meats- 155'F 15 590.004(H? sec.* 3-401.1.1(A)(3) Poultry, Wild Game, Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -165°F 15 sec. 3-301..11(C)(3) Whole -muscle, Intact Beef Steaks 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-40hll(,A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403AI(AWD) P1fFs 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 Unsticed Porrirnu of Beef Roasts* 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 41`FI45'F Within 4 Hours. 3-501.14(B) Cooling PRFs Made From Ambient Temperature Ingredients to 41'F145'F Within 4 Hours* ' Denotes aitical wra in the fe&ra1 1999 Fmd Cate or 105 CMR 590.000. 19 C 3-501,14(0) PHFs Received at Temperatures According to Law Cooled to 41'Ft45`F_Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-801.11(6 PHF Hot and Cold Holding 3-501.16(6) 590.004(M Cold PHFs Maintained at or below 410145" F* 3-501.16(A) Hot PHFs Maintained at or above 140'F. * 3-501.16(A) Roasts Held at or above 1300F. Tame as a Public Health Control 3-50IA9 Time as a Public Health Control* 590.004(H? Variance Requirement REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and .Bewra ges with Warning Labels* 3-801.11(6 Use of Pasteurized Eggs* 3-801A I (D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 3-801.11(C) Unopened Fcxx1 Package Not Re served. 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw, Undercooked or Not Otherwise Processed to Eliminate Patbogens.* EXe `ink( 3-302.13. Pasteurized Eggs Substitute for Raw Shell 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 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 Massachusetts Department of Public Health bivision of Food and Drugs F00®'ESTABLISHMENT INSPECTION REPORT �. Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name i &-e Print: ZZ PIC's Signature: +� Dat ¢ TVDe of Ooeration(s) Tie of Inspection Q sr Z7 / ( ❑ Food Service [$'Retail IN Routine ❑ Re Address Risk I -inspection _ ` ( Level ❑ Residential Kitchen Previous Inspection Telephone E3 Mobile El Temporary .Date: ElPre-operation Owner C HACCP Y/N / IC ( iv ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) j Time In: Out p Permit No. El ElOtherC- Inspector Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. " FOOD PROTECTION MANAGEMENT, - ❑ 1. PIC Assigned / Knowledgeable / Duties �-E MPLOYEE HEALTH .❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED ❑ 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 [111. 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) 6. 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 m- S S9JlnspetYFomi614.tla n„A, ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities I PROTECTION FROM CHEMICALS _ _ j ❑ 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 . RH EQUIREMENTS FOR OHLY _SUSCEPTIBLE POPULATION$.(HSP) ❑ 21. Food and Food Preparation for HSP ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: Print: ZZ PIC's Signature: +� Print: „ Page -1 of Pages U Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION _ FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* _ 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge -- duties EMPLOYEE HEALTH 2 59R003(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 E20 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 Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* - 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 C C FOOD FROM APPROVED SOURCE * Denotes critical item in the Wer:d 1999 Food Code or 10 CDiR 590-000, $ Food and Water From Regulated ,Sources 590.004(A B) Compliance with Food Law* 3-201.12 Fcxxi in a Hermetical) Sealed CouLziner* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell E20 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water" 590.006(B) Water Meets Standards in 31.0 CMR 22.0_* Washing Fruits and Vegetables Shei ish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and V Od Mushrooms Approved by Ra Mato Authorit 3-202.18 Shellstock Identification Present`^ 590.004(C) Wild Mushrooms* 3-201..17 Game Animals* 3-701.1 I Receiving/Condition 3-202.1.1. PHFs Received at Proper Temperatures* 3-202.1.5 Package hate rit V* 3-101.I1 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* 3402.12 1 Records. Creation and Retention* 590.004(J) Labeling of Ingredients° Cleaning Frequency of Equipment Fes- Contact Surfaces and Utensils* Conformance with Approved Procedures /HACCP Plans 3-502.11. ed Processing Methods* 3-502.12 Rox packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the Wer:d 1999 Food Code or 10 CDiR 590-000, $ Cross -contamination ' 3-302-11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.1 I(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-30411 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reserviee of Food* Disposition of Adulterated or Contaminated Food 3-701.1 I 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 Fes- 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* 2-301.12 Clearting Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 240111 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from ._Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11. Numbers and Caparities* 5-204.11 Location and Placement* 5-205.11. Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices (7301.11 Haralwashing Cleanser, Availability 6-301..1.2 Hand Drying Provision j Establishment Name:__LQ CITY OF SALEM 'BOARD OF, HEALTH Date: Pace- Q of Rem.* Code No. RM ence C - Critical Item R — Red Item DESCRIPTION OF VIOLATION)/ PLAN OF CORRECTION Date-, � r Ve�� PLEASE PLvEAScE./PT.R�INT CLEARLY _ �v t cfol e ;mss � C/ / e ' �2 G cep 6 pr✓ av r (4)� y ji= v r s S45, n �., ouyeE m azp euj Wit UcYG cec r r A f, , —11 p Ff irccd, ✓ Je_ cv r «� a II CI c_ he sr n O ft, , 131 cr b v N r=5 c,4- L 1 u-dZ46k,A I AA a 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 ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. Voluntary Disposal 0 Other: Violations Related to Foodborne, Illness. Intervention$ and Risk Factors (Items -1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 17 18 TIMEMEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-501-I6(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 1 Separation - Storage* 7-202.11 ,Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Wishing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 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 * lhnotes critical item in the &&ral 1999 Food Code or 105 CMR 590.000. 20 3-541.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3401.11A(1)(2) _ Eggs- 155F 15 Sec. 3-501-I6(B) 590.004(F) Eggs- humediate Service 145°Fi5sec* 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 - 130°F 121 min* 3401.11(A)(2) Ratites, Injected Meats --155°F 15 590.004(H) sec. 3401A I(A)(3) Poultry, Wild Game, Stuffed PHFs, -27. Stuffing Containing Fish, Meat, FC -6 Poultry or Ratites-I65'F 15 sec.* 3401.11(0)(3) Whole -muscle, Intact Beef Steaks FC -7 145°F * 3401.12 Raw Animal Foods Cooked in a i Microwave 165°F * 3401;11(A)(1)(b) All Other PHFs -145°F 15 sec. j Reheating for Hot Holding 3403.11(A)&(D) PHFs 165F 15 sec. 3403.11(B) Microwave- 1659 F 2 Minute Standing Time* 3403.11(C) Commercially Processed RTE Food - 140°F" 3403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 1409" to 700F 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* * lhnotes critical item in the &&ral 1999 Food Code or 105 CMR 590.000. 20 3-541.14(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-I6(B) 590.004(F) Cold PHFs Maintained at or below 410/450 F* 3-501.16(A) Hot PRFs Maintained at or above 140°F. * 3-501.16(A) Roams Held at or above 130°F. 25. Time as a Public Health Control 3-501-19 Time as a Public Health Control* 590.004(H) Variance Re airement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and .Beverages with Warning labels* 590.600 3-801.11(B) Use of Pasteurized Eggs* FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprcarts 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 590.600 23. _, Animal Foods That are Raw. Undercooked or FC -2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Patho ens. 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell 26. E s* 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, (items23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and riskfactors listed above, carr be found in the following sections of the Food Code and 105 CMR 590.000. t Item I Good Retail Practices (-FC 590.600 23. _, i Management and Personnel --- FC -2 .003 i 24. Food and Food Protection FC - 3 .004 25. E ui rnem and Utensils i FC -4.005 26. e Water. Plumand Waste' FC -5 .006 -27. Physical Facili FC -6 .007 28_ Poisonous or Tonic Materials FC -7 .008 29. Special Requirements i ,009 30. Other j S:SVLtw -26 CITY OF SALEM nQ BOARD OF HEALTH Establishment Name: l QUan c1 Date: c _ Pacie�-3 of Item No. Code Reference C - Critical Hem R — Red Hem DESCRIPTION OF VIOLATION / PLAN 6F CORRECTION PLEA E PRINTCLEARLY Date Verified -► G ec a r � i R / _ 4 l Discussion With Person in Charge: 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 fond permit. Corrective Action Required: ❑ . No Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion �rl��'nspection Scheduled El Emergency Suspension ❑ Embargo ❑ Emergency Closure Ll Voluntary Disposal Volunta ❑ Other: s i d Violations Related to Foodborne Illness Interventions and Risk Factors (items I-V) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 17 18 TIME/TEMPERATURE CONTROLS 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 Containers* t. 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 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/TEMPERATURE CONTROLS * Denotes critical item in the federal 1999 Fwd Cade m 105 CMR 590.000. RN 70 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3401.11A(1)(2) Eggs- 155°F 15 See. 3-501,16(B) 590.004(F) Eggs- Immediate Service 145'FlSsec* 3-401.11(A)(2) - Comminuted Fish. Meats & Game 3-501.16(0) Animals - 155'F 15 sec. * 3.401.11(3)(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, - 6 Poultry or Ratites -165'F 15 sec. 340LIl('C)(3) Whole -muscle, Intact Beef Steaks 1 FC -7 145'F * 3401.12 Raw Animal Foods Cooked in a Microwave 165`F * 3.401:11(A)(1)(6) All Other PHFs - 145'F 15 sec. _ 1- _. Reheating for tot Holding 3403.11(A)&(D) PRFs 165-' 15 sec. * 3403.11(B) Microwave -965' F 2 Minute Standing Time* 3403.11(C) Commercially Processed RTE Food - 140'F* 3403.11(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/45'F Within 4 Hours* * Denotes critical item in the federal 1999 Fwd Cade m 105 CMR 590.000. RN 70 3-501.14(C) PHFs Received at Temperatures ' . According to Law Cooled to N' 41'F/45F Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-801.11(8) 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(0) Roasts Held at or above 1300F. 25. Time as a Public Health Control 3-501. L9 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 2I 3-801.11(A) Unpasteurimd Pre-packaged Iuices and .Beverages with Wazningubets* 590.000 i 3-801.11(8) Use of Pasteurized Eg„es* 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 590.000 i 23. Animal Foods That are Raw. Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection , FC -3 Patho ens.* E'W"1.01 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 I 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. (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 following sections of the Food Code and 105 C.VR 590.000. ttem I Good Retail Practices 1 FC 590.000 i 23. Mana ement and Personnel FC - 2 .003 24. Food and Food Protection , FC -3 .004 i 25. Equipment and Utensils -_ -i FC -4 .005 I 26. Water. Pidmbi and Waste -' FC -5 .006 27. Physical FacilityFC - 6 .007 28. Poisonous or Toxic Materials 1 FC -7 .008 29. - Special Requiremaritsi ,009 30. Other _ 1- _. I 5:5Mimmtrst426x Commonwealth of Massachusetts ` City of Salem Board of Health Kimberley Driscoll 'l 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/14/2011 _ ESTABLISHMENT NAME: Tedeschi Food Shop #452 File Number: BHF -2004-000011 72 Loring Avenue Salem MA 01970 LOCATED AT: 0072 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD . BHP -2012-0020 Jan 1, 2012 Dec 31, 2012 $280.00 TOBACCO VENDOR BHP -2012-0028 Jan 1, 2012 Dec 31,2012 $135.00 Total Fees: $415.00 PERMIT EXPIRESecember 31, 2012 . Board of Health This Permit is not transferable and must be reissued upon change of ownership or -location. The permit must be posted in a prominent location in the Establishment. . In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health.. Page 1 r7?�I KJNI13ERLEY DRISCOLL N AYOR L.A It IWRANIIAN, RS/IWI IS, Cl [O, CP -I S H E,V:II I AGICN•I' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASI-TLNGTON STREET, 4". FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 I rauxhna salcm corn 201_ APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TeDeSCRI TEL# 97F7yy-V3/ ADDRESS OF ESTABLISHMENT_ 72 A0f/N6 t VE FAX # MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'S NAME PefVEZ Cgowy ay _ TEL# 4/9-8YO3191 ADDRESS 511 CABot S Reyxfta PfR 01915 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) / C EMERGENCY RESPONSE PERSON Penn m C lowb Hu+y HOME TEL # 978 23? 936✓ DAYS OF OPERATION.,Monda �' , I ° Juesday Wednesday <Thursday- ' : j =. Fdday I Saturday - 1. Sunday HOURS OF OPERATION ` p/ E I j Please wi to in time of day. (Forexamplellam-llpm) I 12.101111 d!0 TYPE OF ESTABLISHMENTFEE RETAIL STORE YES NO (check only) less than 1000sq.ft. 70 1000-10,000sq.ft. $28 more than 10,000sq.ft. -------------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 - -- ----------------------------------------------------------- BED/BREAKFAST/ YES NO ---------- $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVEYES NO C9 --- TOBACCO VENDOR NO $135! ALL NON-PROFIT (such as church kitchens) YES NO *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and pairt all state taxes requirediunder the law. Date Updated 523/11 FOODAP201 Ladm Check# & I or Federal Identification. Number