TEE TIME GRILL - GOLF COURSE - ESTABLISHMENTS�
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Massachusetts Department of Public Health
Division of Food and Drugs
City/Town of S�LAE:k"
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:
Tel
Name -
Date
4 Ao-t
T pe of Operation(s)
Food Service
Retail
Type of Inspection
L] Routine
❑ Re -inspection
Address 7 j W I LI
Risk
Level
El Residential Kitchen
Previous Inspection
Telephone -7j4,) -
Ci -) 8, '7y q- ZV I
❑ Mobile
ElTemporary
❑ Caterer
❑ Bed & Breakfast
Date:
Pre-operation
a Suspect Illness
❑ General Complaint
Owner
PcaEv, T V-83Z>Ij
HACCP YIN
Person -in -Charge (PIC) 5���
Time
In:
❑ HACCP
Inspecto
Out:
Permit No.
❑. Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provis)on(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Ant -Choking 590.009 (E) E]IViolations
a 8 t ons marked may pose an imminent health hazard and require immediate Tobacco 590.009 (F) E]
Allergen Awareness 580.009 (G) ❑
corrective action as determined by the Board of Health.
„F006 PROTECTION MANAGEMENT,
❑ 1. PIC Assigned/Knowledgeable/Duties
�LEMPLOYEEHEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
r 1`70OURROMAPPROVEDSOURCE_-
0 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 CONTAADNAf16_N
❑ 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 (FCSX590.006)
27. Physical Facility (FCEX590.007)
28. Poisonous or Toxic Materials (FC -7X590.008)
9. Special Requirem is (590.009)
0. Other
jma..�0.
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
r -
IiPROTECTION FROM'Q-4 MICALS_
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
�TIMFJTEMPERATURE�CONTROLS (PoteMlalty Ha_¢erdaus Foods)-
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time as a Public Health Control
REQUIREMENTS FOR HIGHLYSUSCE= ONS.�;(
CEP718POPULATIH8P),,
El21. Food and Food Preparation for HSP
,CONSUMER_ADVISORY
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions i )
and Risk Factors (Red Items 1-22): (/
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE -INSPECTION:
Inspector's Sigoatur
Print: \ CL�6��p�
Page j of Pages
PICS Signature:
Print
N -
�n�tY\-� .+-.--r-.�. • -� s -_\v Yi ..rti-.. .. - ..^`rye r-r�.
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) AssiatmentofResponsibility-
590.003(B)
es onsibili[590.003(B) I 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 Faxl Employee Or An
3-202.16
ice Made From Potable Drmkinn Water*
Applicant To Report To The Person In
Driakin Water from an Approved System*_
590.006(A)
Charge*
590.006(B)
590.003(G) -
Reporting by Person in Charge*
3
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
C
C
C
C
FOOD FROM APPROVED SOURCE
'* Denotes cridad item inthe federal 1999 Food Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
S
Foci and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Rand in it Hermetically Scaled Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.14
Eggs and Milk Products. Pasteurized*
3-202.16
ice Made From Potable Drmkinn Water*
5-101..11
Driakin Water from an Approved System*_
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CNIR 22.0*
Washing Fruits and Vegetables
Shellfish and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201.15
_
Molluscan Shellfish from NSSP Listed
Sources*
Contamination from the Consumer
Game and Wild Mushroams Approved by
Regulatory Authority
3-202.13
SheilstoekIdentification Presem*
590.004(0
Wild Mushrooms"
3-201.17
Game Animals* -
3-901.11
Recelving/Condition
3-202.1.1
PHFs Received at Proper Tem raitues*
3-202.1.5
Package Irate, it *
3-101.11
Food Safe and Unadulterated
Tags/Records: Shelistock
3-202.13
Shellstock Identification
3-203.12
Shellstgckldentification Maintained*
Tags/Records: Fish Products
3402.11
Parasite Destruction* ^
3-402.12
Records, Creation and Retention"
590.004(n
Labeling of ingredients°
Cleaning Frequency of Equipment Food-'
Contact Sudfaoes and Utensils*
Conformance with Approved Procedures
/HACCP Plans
3-502.11.
Specialized Processing Methods*
3-502.12
Reduced oxygen packagin& criteria*
8-103.12
Conformance with Approved Procedures'
'* Denotes cridad item inthe federal 1999 Food Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
S
1 Cross -contamination
3-302.11(A)(1)
I 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
3-302.1I(A)
Food Protection*
3-302.15
Washing Fruits and Vegetables
3-304.11
FoodContactwith Equipment and
Utensils*'
Contamination from the Consumer
3-306.14(A)(B))
Retumed Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-901.11
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*4501.114
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 Sudfaoes 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*
30
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301..12
Cleaning Procedure*
2-301.14
When to Wash*
it
Good Hygienic Practices
2-401..11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges. From the Eyes, Nose and
Mouth*
3-30L12
Preventing Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(F,)
Preventing Contamination. from
Employees* I .
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities* -
5-204.11
Location and Placement*
5-205.11
Accessibili , 0 ration and Maintenance
Supplied with Soap and Hand Drying
Davices
6-301.11
Handwashing Cleanser, Availability
6-301.12
Hand Drying Provision
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: 777'rrZ- Cncu\i_ Date:41 ^ �1=1T Page: 2- of
Item
No.
Code
Reference
C - Critical nem
R - Red Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
-
PLEASE PRINT CLEARLY
Date
Verified
o ' aJi ,JSP; tr1b ql.` iQv �a�2cr�) `b t.�1 IdAvi�
f3�. S Frets .
t7^12 -
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
inspection, to observe all conditions described, and to
violations before the next ins P
comply with all mandates of the Mass/Federal Food Code. I u derstan at
noncompliance may result in daily i es five dollars o uspensi /revocation of
your food permit.
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal 13 Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors (items 1-22) (Cant.)
PROTECTION FROM CHEMICALS
14
Food or Color
15
16
18
TIMEITEMPERATURE CONTROLS
Additives
3-202.12
Additives*'
3-302.14
Protection from Una roved Additives*
'. FC -2
-FC-
Poisonous or Tattle Substances
7-101,11
Identifying Information - Original
Containers*
7-102.11.
Common Naive - Working Containers*
7-201.11
Separation - Storae" -
7-202.11
. Restriction - Presence and Use*
7-202.12
Conditions of Use'
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Sanidzem. Criteria - Chemicals*
7-204.12
Chemicals fm Washing Produce, Criteria*
7-204.14
Drying Agnm Criteria*
7-205.11
incidental Food Contact, Lubricants*
7-206.11
1 Restrict Use Pesticides, Criteria*
7-206.12
Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
monitoring*
TIMEITEMPERATURE CONTROLS
' Divorce cribcai lion in the federal 1999 Fond Cade or 105 CMR 590.000.
I
3-501.14(C) PHFs Received at Temperatures' -
According to Law Cooled to
41'9/45°F Within 4 Hous.
Proper Cooking Temperatures for
19
PHFa
3-401.11A(1)(2)
Eggs- 155°F 15 Sec.
'. FC -2
-FC-
Egos- Immediate Service 145'Fl5se&
3-401.11(A)(2) -
Comminuted Fish. Meats & Game
3-801.11(C)
4nimals - 155°F 15 sec. *
3-441.11(13)(1)(2)
Poi and Beef Roast -130'F121mio*
3-401.11(A)(2)
Ratites, Injected Meats -155°F 15
i 26-
See. *
3-401.1 I(A)(3)
Poultry, Wild Game, Stuffed PHFs,
Stuffing Containing Fish, Meat,
Poultry or Ratites -165'F 15 see.
3401.11(C)(3)
Whole -muscle, ihtact Beef Steaks
145°F "
3-401.12
Raw Animal Faxls Cooked in a
Microwave 165F *
3401:11(A)(1)(b)
A0 Other PHFs - 145'F 15 sec.
Reheating for Hot Holding
3-403.11(,A.)&(D)
PHFs 165-F 15 sec. *.
3403.11(B)
Microwave- 1650 F 2 Minute Standing
Tom*
3-403.11(C)
Coamtercially Processed RTE Food -
140°F*
3403.11(E)
Remaining Unsliced Portions of Beef
Roasts*
Proper Cooling of PRFs
3-50L14(A)
Coaling Cooked PHFs from 140`F to
700F Within 2 Hours and From 70`F
to 4FF/45°F Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature lngredicnts to 41°F/45°F
Within 4 Homs*
' Divorce cribcai lion in the federal 1999 Fond Cade or 105 CMR 590.000.
I
3-501.14(C) PHFs Received at Temperatures' -
According to Law Cooled to
41'9/45°F Within 4 Hous.
20
3-501.16(B) I Cold PIIFS Malaria ned at or below
3-501:19
Hot PRFs Maintained at or above
140°F. *
Roasts Held at or above, 130'F.
Time as a Public Health Coniroi
Time as a Public Health Control*
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-501.15501.15 CoolinEMethods for PHFSfor PHFs
19
PHF Hot and Coto Holding
20
3-501.16(B) I Cold PIIFS Malaria ned at or below
3-501:19
Hot PRFs Maintained at or above
140°F. *
Roasts Held at or above, 130'F.
Time as a Public Health Coniroi
Time as a Public Health Control*
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801.11(A)
Unpasteurized Pse -packaged Juices and
:Beverages with Warning Labels*
540.000
3-801A I(B)
Use of Pasteurized E&2*
'. FC -2
-FC-
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.I1
Consumer Advisory Pasted for Consumption of
540.000
23.
Animal Foods That are Raw. Undercooked or
'. FC -2
-FC-
.003 - j
Na Otherwise Processed to Eliminate
Food and Food Protection
7 3
Pathogens.*a° g'namr
25.
3-302.13.
Pasteurized Eggs Substitute for Raw Shell
.005 j
i 26-
Em.
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, mid non-critical violations, which do nor relate to the
foodborne illness interventions and risk.factors listed above, can be
found in the following sectionsofthe Food Code and 105 OUR
590.000.
'- Item
27.
Good R" Practices
I .FC
540.000
23.
! Man ent and Personnel
'. FC -2
-FC-
.003 - j
24.
Food and Food Protection
7 3
.004
25.
Equipment and Utensils
1 FC -4
.005 j
i 26-
Water. Plumbing and Waste
i FC -5
om
s ssero�,xw. e:.
Physical FaciliFC-8 .007
L 28.
Poisonous or Toxic Materials ' FC - 7 .008
' 29.
S ectal R uiremertls .009 1
30
I Other
s ssero�,xw. e:.
-m-19 �FW
uw-
)` N.: H5�'v-i�^
�Glty of Salem,Massachusetts 4TIT
r+ 3
{ r E
Board'of Healthy=�
k 120 Washington`Streeu!4th FloorSalem, MA 01970_ ` V
Tel (978) 741 1800 176k. ' 8) 7450343 PubliCHealth
t� .e "';'� Prevent Promote- Protect � °� � '
�. Iramdln@salemcom�
r z f
Kimberley Driscoll £,g y
Larry, Ramdin RS/RENS CHOCP FS��
Mayor. -
w Health Agent`
Ze
K-
FOOD ESTABLISHMENT PERMIT
s �'.��.+� L at` y t 3+ P, "� SxS. 5✓ bS «.,"n p
t e q' 3 yse. ru d s+a
A'no..a
(must be posted on the Premises oCt (hie Food 6661khment)
` NxP F K y, -`r
.qTa
_'4 r i 20
Permit Number: FM -14-382 tom' Ig'
$' ➢, r,
Aw
Z ` Permit Type £ FOOD SERVICE -ESTABLISHMENT 4€ A
A eW
4.1.r A'' b •S- �l+i^ P i L
P Goods & Services Food Service 0 24 seats
'glW'
Name of License Holder Peter M�kadis °
,��; ��.Name of Food Establishment ,� � S$dek$m LLC DBA Tee Time Gnll� �`Y� �, '�,� �� '
x 4ddress of:Food Establishment r75 Wilson Street SALEM MA 01970"{i
yp ,s rx *� x. s`:-.'y•r,y „ui a a" a -� 1 ,v, x i
i
t This License is granted inconformity with,the statutes, Regulations and or�dmances relating thereto and
t expires on
12l31/201a unless sooner suspended orrevoked s * fy
r ,x3x`. rbda` x- x 3 •F^� s�; ' 4 �'-�' '*- `�' c ac
...
r �
Permit Feef$140.00' b r
Issued 3/25f2014 F y_
'.t ✓ qy,t
77
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$
PW
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d
KIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM,
MASSACHUSETrs
BOARD OI' Hu ACT I -I
120 WASHINGTON S'mFi;T, 4''" FLOOR
T111.. (978) 741-1800 FAx (978) 745-0343
Iramdingi salem.com
LARRY RAMDIN, RS/R73FIS, CHO, CP -FS
H14AI.xi-i AGI7,NT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: iGG' (eine 6�-,fle
2) Establishment Address: 7 G/ II T m
3) Establishment Mailing Address (if different):tga SgRd.GISc✓>
5�t(,r Q 40q, Ql cd
4) Establishment Telephone No: y7 gFja
5) Applicant Name &Title:
6) Applicant Address:
G G
7) Applicant Telephone No: f 3(4 24 Hour Emergency No:6 (
/ Email: /' kpa([J ® 5 twt
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
C rAkIL4 ) C ip
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,
Manager, etc.
Name &Title:
Address:
Telephone No:
^�
` O;S �p6J Fax:
Email:
Emergency Telephone No:
13) District or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
Fax:
Email:
Check #: 10119 9 Date:
Food Establishment Information
14) Water.Source:
15) Sewage Disposal:
DEP Public Water Supply No:
( if applicable)
t'b �j L
16) Days and Hours of Operation: -7:Lli — t"(Z Acv`^
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)
❑ Retail ( Sq. Ft)
❑ Caterer
Permanent Structure
OTy od Service - ( z0 Seats)
11 Frozen Dessert Manufacturer
Mobile
Wood 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
..............................................................................Breakfas(
Establishments......................
21) Length Of Permit:
(check one)
RETAIL STORE
RESTAURANT
A
❑ Less than 1000sq.ft. $ 70
B'1_ess than 25 seats $140
asonal/Dates:
❑ 1000-10,000sq.ft. $280
❑ Residential Kitchens $140
°(!
11More than 10,000sq.ft. $420
1325-99 seats $280
❑ More
— 1-1131
than 99 seats $420
---- -- ------------------- ----- ------------ ------------- ---------------------------------------------------------------- .......
❑ Bed 8 Breakfast/Childcare Services (Nursing Home $100
Temporary/bates/Time:
-----------------------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
❑ MAKE ICE CREAM, YOGURT/SOFT SERVE
$25
❑ PASTURIZATION
$25
❑ ALL NON-PROFIT*
$25
*Including, church kitchens, state funded childcare & private club
23) Food Operations:
Definitions: PHF-potentially hazardous food(time/temperature controls required)
Non-PHFs- non -potentially hazardous
food (no time/temperature controls required)
(check all that apply):
RTE- ready -to -eat foods Ex. sandwiches, salads, muffins which need no further processing
Sale of Commercially
PHF Cooked to Order
Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs
V00-
L.,4or 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
V Events or Institutional Food Service
I, the undersigned, attest to the
comply with 105 CMR 590.000 a
590.000 and the Federal Food C
24) Signature of Applicant:
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
racy of the information provided in this application and I affirm that the food establishment operation will
1- t applicjble jpw. I have bW instructed by the Board of Health on how to obtain copies of 105 CMR
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: A
26) Signature of Individual or Corporate Name: _ I (Nk—Im LJ_
Massachusetts Department of Public Health
Division of Food and Drugs
City/Town of
FOOD ESTABLISHMENINSPECTION REPORT
Salem Board of Health
120 Washington Street, 0 Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Address:
Tel
Name
Da I
TYpe Operatlon(s)
oad Service
Retail
El Residential Kitchen
❑ Mobile
Type of nspection
utine
El Re -inspection
Previous Inspection
Date:
Addres
Telephone
Risk
Level
[ITemporary
❑ Caterer
❑ Bed & Bree
1�/
ermit Noffyl2r AN,El.
ElPre-operationOwner
❑ Suspect Illness
El General Complaint
El HACCP
Other
)
HACCP YM
Person -in -Charge (PIC)
' 1
Inspector
Time
In: I
Out:
Each vioIatioV_9fiAfked requires'an explanation on the narrative ba§e(s) and a citatidn 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 Tobacco 590.009 (F) ❑
corrective action as determined by the Board of Health. Allergen Awareness 590.009 (G)
[.FOO ROTECTION MANAGE_MENT�
PIC Assigned/Knowledgeable/Duties
i EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
�_.FOODFROM: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__-_ --�
❑ 88. Separation/Segregation/Protection -
Z�< 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)
5. Equipment and Utensils (Fc -4x590.005)
26 Water, Plumbing and Waste (FCSx590.006)
7. Physical Facility (FC -6x590.007)
fPoisonous or Toxic Materials (FC -7x590.000)'
29. Special Requm is (590.009)
30.Other
S: &Lala
(
❑ 12. Prevention of Contamination from Hands
W-,'< Handwash Facilities
),PROTECTION FROM`CHEMICACS____`_
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIME/TEMPERATURE CONTROLS_.(PotentlallyHa ardous Fo_o_ds)�]
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time as a Public Health Control
--W - -__ -- -„tea.-
REGUIREMENTs FOR,HIGHLY-SUSCEFTBLE-P6P-u- IONS';(4iSP);'3
❑ 21. Food and Food Preparation for HSP
-�-
rCONSUMER'ADVI$ORY �„--- - -
❑ 22. 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 order )'
DATffEOFRE-INSP CTION: / Il
(
, -, JL_.....,.....-+..:Yr..+^'l '..--.'.- ( -1 iF.-. i.... --
Violations Related to Foodborne Illness
Interventions and Risk Factors (Mems 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assig mentofResponsibility*
590.003(6) 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 Focal Employee Or An
3-202.1,6
ice Made From Potable Drinking Water*
Applicant To Report To The Person In
DrinkingWater from an A roved S stem*
590.006(A)
Charge*
590.006(E)
590.003(G)
Reporting by Person in Charge*
3
590.003(D)
Exclusions and Restrictions*
3-201.15
990.003(E)
Removal of Exclusions and Restrictions
C
C
6
C
FOOD FROM APPROVED SOURCE
*Devotes critical item in the federal 1999 Food Cade or 105 CMR 59(100).
PROTECTION FROM CONTAIMMATlnN
8
Food and Water From Regulated,
590.004(A -B)
Compliance with Food Law*
3-201.12
Fwd in a Hernreticail - Sealed Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.14
Eggs and Milk Products. Pasteurized*
3-202.1,6
ice Made From Potable Drinking Water*
5-101.11
DrinkingWater from an A roved S stem*
590.006(A)
Bottled Drinking Water'
590.006(E)
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
_
Patolluscan Shell fish from NSSP lzstcd
Sources*
Contamination from the Consumer
Game and Wild Mushrooms Approved by
Regulatory Authority
-
3-202.18
Shellstock identification Present"
590.004(C)
Wild Mushrooms*
3-201.17
Game. Animals* -
x
ReceivingrCondition
'3-202.11
PHFs Received at Proper Tem era uses*
3-202.15
Package lnte,rit *
3-10i. 11
Food Safe and Unadulterated
_
TogsfRecords: Shellstock
3-202.18
Shellstock identification *
3-203.12
Shellstock Identification Maintained*
Tags/Records:-Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records. Creation and Retention*
590.004(1)
_
Labeling of Ingredients'
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*
Conformance with Approved Procedures -
/HACCP Plans
3-502.II
Specialized Processing Methods*
3-502:12
Reduced oxygen packaging criteria*
8-103.12
Conformance with Approved Procedures*
*Devotes critical item in the federal 1999 Food Cade or 105 CMR 59(100).
PROTECTION FROM CONTAIMMATlnN
8
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
3-302.11(A)
Food Protection*
3-302.15
Washing Fruits and Vegetables
3-304.11.
Food Contact with Equipment and
- Utensils*
Contamination from the Consumer
3306.14(A)(B)
Returned Food and Reservice of Food'*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Foal*
9
Food Contact Surfaces
4-501..111.
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.1 t2
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 - Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301.12
Cleanina Procedure*
2-301_14
When to Wash*
1..1
Good Hygienic Practices
2401.11
Eating; Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth)`
3-301.12
Preventing Contamination When Tastin
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 Ca acities*
5-204.1.1
Location and Placement*
5-205.11.
Accessibility. Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-30L11
Handwashing Cleanser, Availability
6301.1.2
Hand Drying Provision
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: v6 -1 I Pager of
Item code c-crlticat Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date,
No. Reference R -Red Item ,,,,,� ,,,,,,� ,,, �,,,, _ Verified
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
violations before the next inspection, to observe all conditions as described, and to
comply with all mandates of the Mass/Feder ode. I understand at
noncompliance may result in daily fines o f' dollars or suspen on/revocation of
your food permit. PA A f n p ---
Required:
e Re -inspection Scheduled
❑ Embargo
0 Voluntary Disposal
❑ No
I U--Tes
❑ Employee Restriction /
Exclusion
❑ Emergency Suspension
❑ Emergency Closure
❑ Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors (RemsY-22) (Cont.)
15
16
17
18
r.r •3.1 :Tt..
Food w Color Additives
3-202.12
Additives*-
3-302A4
_
Protection from Unapproved Additives"
FC - 2
Poisonous or Toxic Substances
7-101,11.
identifying Information -Original
Containers*
7-102.11.
Common Name - Working Containers*
7-201.11
Separation - Stara * -
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 AtIents, Criteria*
7-205.11
Incidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria* -
7-206.12
Rodent Batt Stations*
7-206.13
Tracking Powders, Pest Control and
Momtmin *
r.r •3.1 :Tt..
* Dmores enficat item in the federal 1999 Food Cain wIV CNIR 590.000.
3-501.1.4(C) PRFs Received at Temperatures
According to Law Cooled to
41'131450F Within 41 urs. *
Proper Cooking Temperatures for _
19
PHFs
3-401.11A(l)(2)
Eggs- 155'F 15 Sec.
FC - 2
Eggs- Immediate Service 145'F15sec*
3-401.11(A)(2)
Comminuted Fish. Meats & Game
590.004(H)
Animals - 155'F 15 sec. *
1.401.I1(B)(1)(2)
Pant and Beef Roast - 130'F 121 min*
3-401.11(A)(2)
Ratites, Injected Meats -155*F 15
! 26,
sec. *
3401.1.1(A)(3)
Poultry, Wild Game. Stuffed PHFs,
27.
Stuffing Containing Fish, Meat,
IFC -B
Poultry or Ratites-I65'F 15 sec
3-401.11(0)(3)
Whole -muscle, Intact Beef Steaks
FC - 7
145T *
3-401.12
Raw Animal Fouls Cooked in a
1
Microwave 165°F *
3-401:11(A)(1)(b)
All Other PHFs - 145'F 15 sec.
Reheating for Hot Holding
3.403A I(A)&(D)
PHFs I65 -F 15 sec. *
3403.11(B)
Microwave -'165` F 2 Minute Standing
Time*
3-103.11(C)
Contntercially Processed RTE Food -
140'F*
34WAI(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.)4(B)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/456F
Within 4 Hours*
* Dmores enficat item in the federal 1999 Food Cain wIV CNIR 590.000.
3-501.1.4(C) PRFs Received at Temperatures
According to Law Cooled to
41'131450F Within 41 urs. *
3-501.16(B)
590.004(F)
3-501.15 Cooling Methods for PHFs
19
1 PHF Not and Cold Holding
3-501.16(B)
590.004(F)
Cold PRFs Maintained at or below
410/45' F*
3-501.16(A)
Hot PRFs Maintained at or above
140`P.
3.501.16(A)
Roasts field at or above 1.30'F.
FC - 2
Time as a Public Health Control
3-501,19
Time as a Public Health Control*
590.004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONSfHSP1
21
3-801.11(A)
Unpasteurized Pre-packaged Juices and
Beverages with Warming Labels*
540.000
3-801.11(B)
Use of Pasteurize(, Eggs*
FC - 2
3.801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served- * '
I Food and Food Protection
3-801.11(C)
UnopenedFood Package Net Re -served. *
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for Consumption of
540.000
Animal Foods That are Raw. Undercooked or
FC - 2
.003 !
Not Otherwise Processed to Eliminate
I Food and Food Protection
I FC- 8
Pathogens, *FJ `1ii`l
1 25.
3-302.13.
Pasteurized Eggs Substitute for Raw Shell
.005
! 26,
EggO
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 it Iness
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
(Itertts 23-30)
Critical. and non-critical violations, which do not relate to the
foodborne illness interventioat and risk factors listed above, can be
found in the following sectionsofthe Food Code and 105 CMR
59(.000.
' item
Good Aetall Practices
FC
540.000
i Manaoament and Personnel
FC - 2
.003 !
223.
4
I Food and Food Protection
I FC- 8
.004
1 25.
Equipmentand Utensils
I FC -4
.005
! 26,
._
Water. Plumbing and Waste
1 FC -5
,006 1
27.
1 Ph sical Facility
IFC -B
L28_
Poisonous or Toxic Materials
FC - 7
.008
29.
Special RegLilrements
1
.009
30
1 Omer
CITY OF SALEM
g � /�� / j BOARD OF HEALT
D Date: Page:__ of
Establishment Name: � I ti"(�C_, L�liii^� C�"►i✓i/t•-
C —Critical Item--- • . • I OF . •
R - Red Item
LEASE PRCLEARLY
NJ
low
WOW M UK
EMISSION
SIMMONS
r�j���=�11r■r_���
_
:��,.IIL
���.
/... IM
Ori
,/�Il�l,l
INS 0=1
MM
LOW
01011
'i
INS
--_
'�/JIS�i! �t�.i GL%4�i GI _i7ti��%7•/0Ma /.Wi'�4 6, �,.i�u� �_
Al.
_--�
_
INS
SWAIN, 110111110
INS
INS
11111 10111
01111111 _
LIM
.. -.. .. - .... . . . 0.6 - .
your ... permit.
i
T. ..
Violations Related to Foodborne illness Interventions and Risk
Factors (ftents'1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
15
16
17
It I IT 1:1114 u'_ .. �
Food or Color Additives
3-202.I2
Additives*
3-302.14
Protection from Unapproved Additives"
3-501.16(B)
590.004(F)
Poisonous or Toxic Substances
7-101,11
identifying Informaation- Original
Containers*
7-102.11.
Common Name - Working Containers*
7-201.11
Separation - Stora e*
7-202.11
. Restriction - Presence and Use*
7-202.12
Conditions of Use*
7-20111
Toric Containers - Prohibitions*
7-204.11
Sterilizers. 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
Raiem:Bait Stations*
7-206.13
Tracking Powders, Pest. Control and
monitoring*
It I IT 1:1114 u'_ .. �
' Denotes critical heat in the fedeml 1999 Foal Cale cc IUB CMR X90.000.
19
3.501.14(C)
Proper Cooldng Temperatures for
3-501.15
PHFs
3401.11A(1)(2)
Eggs- 15517 15 Sec
3-501.16(B)
590.004(F)
Ee Immediate Service 1450F15see-
3-401.11(A)(2)
Comminuted Fish. Meats & Game
3-501.16(A)
Animals - 155F 15 sec. *
3-401.11(6)(1)(2)
Pork and Beef Roast -130OF 121 min*
3-401.11(A)(2)
Ratites, Injected Meats -155'F 15
590.004(H)
Ste.
3-401.11(A)(3)
Poultry, Wild Game, Stuffed PHFs,
27.
Stuffing Containing Fish, Meat,
. FC -8
Poultry or Ratitea-165OF 15 sec
3-401.11(C)(3)
Whole -muscle, Intact Beef Steaks
FC 7
145°F *
3401.12
Raw Animal Foods Cooked in a
�'
Microwave 165'F *
3-401.11(A)(1)(b)
All Other PHFs - 145'F 15 sec.
Reheating for Not Holding
3-403A l(A)&(D)
Pf1Fs 165T 15 sec. *
3-403.11(B)
Microwave- I65' F 2 Minute Standing
Time*
3403.11(C)
Commercially Processed RTE Food -
140aF
3-4012A I(E)
Remaining Unsliced Portions of Beef
Roasts"
Proper Cooling of PRFs
3-501.14(A)
Cooling Cooked PHFs from 140'F to
70'F Within 2 Hours and From 70'F
to 4VF(450F Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature ingredients to 41 aF1456F
Within 4 Hours*
' Denotes critical heat in the fedeml 1999 Foal Cale cc IUB CMR X90.000.
19
3.501.14(C)
PHFs Received at Temperatures
According to law Caroled to
41'F145`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)
Cold PHFs hfaimained at or below
41'145° F*
3-50L16(A)
Her PHFs Maintained at or above
140`F. *
3-501.16(A)
Roasts Held at or above 130'F.
1 25.
Time as a Public Health Control
3-501:19
Time as a Public Health Central*
590.004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPT16LE
POPULATIONS (HSP)
2]
3-801.11(A)
Unpasteurized Pre-packaged Juices and
.Bevera es with Warning Labels*
590.400
3-801.11(B)
Use of Pasteuriml Baas*
'- FC -2
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts is Not Served, *
; Food and Food Protection
3-801.11(C)
Unopened Food PackaNotRe-served.*
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for Consumption of
590.400
23.
Animal Foods That are Raw. Undercooked or
'- FC -2
.00333
Not Otherwise -Processed to Eliminate
; Food and Food Protection
FC -3
Pathogens.* ``b ` '
1 25.
3-302.13.
Pasteurized Eggs Substitute for Raw Shell
.005 i
!
E
590.009(A) -(D)
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 #t29 -
Special Requirements.
(Iters 23-30)
C?*ical,and non-critical violations, which do nor relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following sectionsof the Food Code and 105 CMR
590.000.
t item
I Good Retail Practices
.FC
590.400
23.
1 Management and Personnel
'- FC -2
.00333
24.
; Food and Food Protection
FC -3
.004 j
1 25.
1 Equipment and Utensils
I FC -4
.005 i
!
Water. Plumbing and Waste
! FC - 5
.006 1
27.
i Ptiyatcal Faciflty
. FC -8
:.007
i28.
Poisonous or Toxic Materials
FC 7
008 '
~29.
a
�ecial Ro�uirements
�'
! 30.
1 other
1 i
ssw:r�2n_
Certificate of Achievement
I
townFICATE ISSUER
#0655
A
NATIONAL?
RESTAURANT
ASSOCIATION.
175 W Jackson Blvd; Ste 1500
Chicago IL 60604-2814
1.800.765.2122
www.restaurant,org I www.ServSafe.coni
This certificate is awarded to
Congratulations! You have completed
ServSaf k) Food Handler
Employee Food Safety Online Course and txam
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Massachusetts Department of Public Health Salem Board of Health
120 Washington Street, 0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
City/Town of SAI.�.r•,
FOOD ESTABLISHMENT INSPECTION REPORT
Address:
TAI
Name
'TL' --:?6--1 L C �il�
Date
-b-I'
Type of Operation(s)
Food Service
Retail
Type of Inspection
[I Routine
❑ Re -inspection
Address 75 id i LS ouJ �'
Risk
Page ) of -- Pages
Level
F-1ResidentialKitchen
Previous Inspection
Telephone
81 ., Q _
❑ Mobile
11Temporary
❑ Caterer
❑ Bed & Breakfast
Date:
Pre-operation
ii Suspect Illness
❑ General Complaint
Owner
PeTtk rn I kjv:)l &
HACCP YIN
Person -in -Charge (PIC)
Time
'Sn
In:
El HACCP
Inspector'v
Out:
Permit No.
❑.Other
racn violation cnecltea 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
[111. Good Hygienic Practices
Violations Related to Good Retail Practices- (Blue
Items) Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Noncritical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C N
23. Management and Personnel (FC -2)[590.003)
24. Food and Food Protection (FC -3X590.004)
25. Equipment and Utensils (FC -4X590.005)
26. Water, Plumbing and Waste (Fc5X590.006)
27. Physical Facility (FC -6X590.007)
28. Poisonous or Toxic Materials (FC -7X590.008)
29. Special Require men s (590.009)
30. Other
S b"d
n ,/
Anti -Choking 590.009 (E) ❑
Tobacco 590.009(F) ❑.
Allergen Awareness 590.009 (G) ❑
[112. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROWCHEMICALS-
❑ 14. Approved Food or Color Additives ' L
❑ 15. Toxic Chemicals
TIMEITEMPERATURE:CONTROLS .(PoteMWItj HaaaidousF.oatS)
❑ 16. Cooking Temperatures
❑ 17. Reheating
[118. Cooling
[119. Hot and Cold Holding
❑ 20. Time as a Public Health Control
REQUIREMENTS FOR HIGHLYSUSCEPTIBLE-POPULATIONS,(HSPI-
❑ 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 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 Si
Print:'
0) M�i�ea�tiJ
PICS Signature:
Print:
Page ) of -- Pages
Violations Related to Foodbome Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.0031A) Assignment of Responsibility*
590.003(6) 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 Law*
3-201.12
require reporting by food employees and
3-201.13
Fluid Milk and Milk Products't
applicants*
Shell Eggs*
590.003(F)
Responsibility Of A Fad Employee Or An
3-202.1.6
Ice Made From Potable Drinking Water*
Applicant To Report To The Person In
Drinking Water from an Approved System
590.006(A)
Chaff
590.006(B)
590.003(G)
Re 'n by Person in Chane*
3
.59,0.003(')
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restr ctioas
4
C
10-
I I
FOOD FROM APPROVED SOURCE
' Denotes critical hent in the federal 1999 Fatd Code or 105 CMR 590.01.
PROTFt^.TInN F12nRA CnNTAuru AT nm
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Food in a Hermetically Seated Container*
3-201.13
Fluid Milk and Milk Products't
3-202.13
Shell Eggs*
3-202.14
EaEs and Milk Products. Pasteurized*
3-202.1.6
Ice Made From Potable Drinking Water*
5-101.1 I
Drinking Water from an Approved System
590.006(A)
Bolded 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 Recreationally Caught Moldu-can
Shellfish*
3-201.15
_
Molluscan Shellfish from NSSP Usted
Sources*
Proper, Adequate Handwashing
Game and Wild Mushrooms Approved by
Ragulatory Authority
3-202.13
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals* -
2-301.14
Receiving/Condition
3-202.1 f
PHFs Received at Proper Tem ahaes*
3-202.1.5
Package lute sit *
3-IOt.1 I
Frx. i Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shetlstock Identification lvlaintamn d*
12
Tags/Records: -Fi h Products
3402.11
Parasite. De struct on' -
3-402.12
Record. 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 packaLfing, criteria*
8-103.!2
Conformance with Approved Procedures*
' Denotes critical hent in the federal 1999 Fatd Code or 105 CMR 590.01.
PROTFt^.TInN F12nRA CnNTAuru AT nm
9
Cio, -contamination
3-302.11 (A)(])
Raw Animal Foods Separated from
Cooked and RTE Foods*
4-501.111.
Contamination from Raw lngredrents
3302.1.1(A)(2)
Raw ,Anitmtl Foods Separated from Each
Other*
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
Contamination from the Environment
3-302.1.1(,A)
Food Protection*
3-102.15
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..1�11)
iscardmg or Reconditioning Unsafe
Food*
9
Food Contact Surfaces
4-501.111.
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.1 t2
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-710 1.114
Chemical, Sanitization- temp., pH,
concentration and hardness. *
4-601. t I (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-HotWaterand-
Chemical*
1g
Proper, Adequate Handwashing
2-301.1.1
Clean Condition - Hands and Arms*
2301-12
Cleaning Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices "
2-401.11
Eating, Drinking or Using Tobacco*
2-401.12
Discharges. From the Eyes, Nose and
Mouth*
3-301.12
Preventia 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
t.ocation and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11
Handwashing Cleanser,.Availabilit
- 6-301.12
Hand DrvinR Provision
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: 'int✓ 7-)M& C� Cl L� Date: S-i� i 3 Page: '2 of Z
Item Code C — Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTIONI Date
No. Reference R -Red Rom - Verified
W i
I I I I - SitaAn Jt' tJdT tGsc'C%V- I _ _ I
is
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 d ribed, and to
comply with all mandates of the Mass/Federal Food d . I un lers d that
noncompliance may result in daily fines wenty- o rs or su nsion/revocation of
your food permit.
❑ voluntary compliance
❑ Re -inspection Scheduled
❑ Embargo
❑ Voluntary Disposal
❑ No I.❑ Yes
❑ Employee Restriction /
Exclusion
❑ Emergency Suspension
❑ Emergency Closure
❑ Other:
Violations Related to Foodborne Rtness Interventions and Risk
Factors (items 1.22) (Cont.)
PROTECTION FROM CHEMICALS
14
Food or Color
im
16
17
TIMEMEMPERATURE CONTROLS
Additives
3-202.12
Additives*'
3-302.14
Protection from Una roved 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*
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Sanitizers. Criteria - Chemicais*
7-204.12
Chemicals for Washing Produce, Criteria*
7-204.14
Drying AErus. Criteria"
7-205.11
Incidental Food Contact, Lubricants*
7-206.11Restricted
Use Pesticides; Criteria$
7-206.12
- Rodent'Bait Station.**
7-20fi.13
Tracking Powders, Pest Control and
Momtarin *
TIMEMEMPERATURE CONTROLS
* Denotes critical icer in the federal 099 Ford Code or 105 CMR 390.000.
19
20
3-501,14(C)
Proper Cooking Temperatures for
3-501..15
PHFs
.3.40i.IIMI)(2)
_
Eggs- 155F 15 Sec
3-501.16(B)
590.004(F)
-E os- Immediate Service 145`Fl5sec*
3401.11(A)(2)
Comminuted Fish. Meats & Game
3-S01.16(A)
Animals -155'F 15 sec. *
3.401.11(8)(1)(2)
Pork and Beef Roast - 13TF 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 PHFs,
Stuffing Containing Fish, Meat,
Poultry or Ratites-I65'F 15 sec.
3-401.11(C)(3)
Whole -muscle, intact Beef Steaks
145'F *
3-401.12
Raw Animal Foods Cooked in a
Microwave 165F *
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. *
3-403.11(B)
Microwave- 165` F 2 Minute Standing
Time*
3-403.11(C)
Commnerda]ly Processed RTE Food -
140°F*
3403AI(E)
Remaining Unslic:edP"donsofBeef
Roasts*
Proper Coaling of PHFs
3-501.14(A)
Cooling Cooked PHFs front 140`F to
70`F Within 2 Hours and From 70'F
to 4I'F/45'F Within 4 Hours. '
3-501.74(B)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41*F/45'F
Within 4 Hours*
* Denotes critical icer in the federal 099 Ford Code or 105 CMR 390.000.
19
20
3-501,14(C)
PHFs Received at Temperatures
According to Law Cooled to
41'F/45'F Within 4 Hours.
3-501..15
Cooling Methods for PHFs
3 ii0l.li(6)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold PHFs Maintained at or below
4101450 F*
3-501.16(A) -
Hot PHFs Maintained at or above
140`F. *
3-S01.16(A)
Roasts Field at or above 130'F.
Time as a Public Health Control
3-50IA9
Time as a Public Health Control*
590.004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULAYiOHS (HSP)
21
3-60111(A)
Unpasteurized Pre-packaged lances and
Beverages with Warning Labels*
3 ii0l.li(6)
Use of Pasteurized Eggs*
3-901.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
3-801.11(C)
Unopened Food Package Not Re -served.
CONSUMER ADVISORY
22
3-603.11
Consumes .Advisory Posted for Consumption of
Animal Foods That are Raw. Undercooked or
Not Otherwise Processed to Eliminate
Pathogens.' s"'n smt
3-302.13
Pasteurized Eggs Substitute for Raw Shell
Eggs
catering,, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if retated 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 facrors listed above, can be
found in the following sections -of the Food Code and 105 CMR
590.000,
QTY OF SALEM,
a MASSACHUSETTS
®��® BOARD OF HEALTH
ill '� "' 120 WASHINGTON STREET, 4-' FLOOR
10
Public Health
KINMERLEY DRISCOLL ���� TFL. (978) 741-1800 FAX (978) 745-0343 LARRY RAMDIN, RS/RENS, CHO, CP -FS
Iramdinasalem.com
MAYOR MP% � HEALTH AGENT
BoAP"' good Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: Sidekim LLC d.b.a Tee Time Grill
2) Establishment Address: 75 Wilson Street, Salem, MA 01970
3) Establishment Mailing Address (if different): 82 Sanderson Ave, Suite 112, Lynn, MA 01902
4) Establishment Telephone No:
5) Applicant Name & Title: Peter Mikedis President
6) Applicant Address: 82 Sanderson Ave, Sutie 112, Lynn, MA 01902
7) Applicant Telephone No:781.595.3663 24 Hour Emergency No: 617.839.4117 Email:pmikedis@sidekimfoods.com
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 LLC
11) If a corporation or partnership, give name, title and home address of
officers or partner.
Name Title Home Address
Peter Mikedis President 21 Cheever Ave Saugus, MA
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc.
Name & Title:
Address:
82 Sanderson Ave, Lynn, MA
Telephone No:
781.595.3663 Fax:781.596.3663 Email:
Emergency Telephone No:
13) District or Regional Supervisor (if applicable)
Name & Title:
NICK SIDERI OPERATIONS MANAGER
Address:
82 SANDERSON AVE, SUITE 112, LYNN, MA
Telephone No:
781.595.3663 Fax:781.596.3663 Email:NSIDERI@SIDEKIMFOODS.COM
Check #:: Date:__ Amount:
Food Establishment Information
14) Water Source: public
15) Sewage Disposal: public
DEP Public Water Supply No: ( if
applicable)
16) Days and Hours of Operation:
6:OOam-12:OOpm
17) No. of Food Employees: 7
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)
❑ Retail ( Sq. Ft)
0 Caterer
Permanent Structure
10Food Service - ( 24 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
RETAIL STORE
RESTAURANT
❑ Less than 1000sq.ft. $ 70
Q Less than 25 seats $140
21) Length Of Permit:
❑ 1000-10,OOOsq.ft. $280
❑ Residential Kitchens $140
(check one)
❑ More than 10,OOOsq.ft. $420
❑ 25-99 seats $280
Annual
❑ More than 99 seats $420
Seasonal/Dates:
.............................................................................
........ . .........................................
April 1.2013 -November 30, 2013
13 Bed & Breakfast/Childcare Services /Nursing
ADDITIONAL PERMITS
Home $100
Temporary/Dates/Time:
❑ MAKE ICE CREAM, YOGURT/SOFT SERVE
❑ PASTURIZATION
$25
$25
❑ ALL NON-PROFIT*
$25
*Including, church kitchens, state funded childcare 8 private club
23) Food Operations:
Definitions: PHF- potentially hazardous food (time/temperature controls required)
Non-PHFs - non -potentially hazardous
food (no 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
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
andlor 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
I, the undersigned, attest to the ac
comply with 105 CMR 590.000 and
590.000 and the Federal Food Cqd
24) Signature of Applicant:
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
provided i application and I affirm that the food establishment operation will
I have beeetffistructed by the Board of Health on how to obtain copies of 105 CMR
Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties
Have filed all state tax returns and paid state taxes regyicedund
25) Social Security Number or Federal ID: 26-0247311
26) 26) Signature of Individual or Corporate Name: —
that I, to my best knowledge and belief,
ServSafe
EXAM FORM NO. 10269
CERTIFICATE NO. 9341951 `..'.
ServSafe@ Certiricatimonti
�z
-
Overall Point Score
Overall % Score
Passing % Score
Status
78
97
75
PASSED
Perfect
Your
Point
Point
Score
Score
80
78
Domain Names
Implement Food Safety SOPS
16
16
I Employee Hygiene and Health
12
10
Receipt. Storage, Transport
13
13
Food Prep. Display and Service
28
28
Compliance with Regulatory
11
11
0
#0655
for successfully completing the standards set forth for the ServSafe® Food Protection Manager Certification Examination,
which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP)_
08/24/2012
DATE OF EXAMINATION
08/24/2017
DATE OF EXPIRATION
Local laws apply. Check with your local regulatory agency for recertification requirements.
Paul Hineman
Executive Director, National Restaurant Association Solutions
02010 National Restaurant Association Educational Foundermn. All rights reserved ServSafe and the ServSafe logo are registered trademarks of the National Restaurant Association Educational Foundation.
and used under license by National Restaurant Association Solutions, U.C. a wholly..ad subsidiary of the National Resteumnt Association.
This document cannot be reproduced or altered
NATIONAL l
RESTAURANT
ASSOCIATION
CERTIFICATE OF
ALLERGEN AWARENESS TRAINING
Name of Recipient: Nicholas L Sideri
Certificate Number: CW1066
Date of Completion: 01/13/2011
Date of Expiration: 01/12/2016
the above-named person is hereby issued this cert�ficate
for completing an allergen awareness training program
recognized by the Massachusetts Department of Public Health
in accordance with 105 CMR 590.009(G)(3)(a).
This cert�ficate will be valid for five (5) years from date of completion.
Issued By:
CompuWorks
CompuWorks Systems, Inc.
591 North Avenue, Door 2
Wikefield,NIA 01.880
P: 781-224-1113
F:781-224-0504
we v.compuworks.com
- -._ - -- _ _r_ �_�_._ _ � __,�
1 � � 'S^
w. � , �
yr `
10TH TEE BURGER
50Z BURGER, CHOICE OF AMERICAN OR CHEDDAR
BIRDIE
MARINATED GRILLED CHICKEN BREAST
DOG LEG
JUMBO CIDER MARINATED HOT DOG
HACKER
GRILL ITALIAN SAUSAGE WITH ONION & PEPPERS
MULLIGAN
GRILLED HAM & CHEDDAR
WATER HAZARD
TUNA MELT
SERVED WITH LETTUCE, TOMATO, PICKLE &
ADD FRIES FOR 4-1.50 MORE
HIPS
BASKETS
CHICKEN FINGER BASKET
CHICKEN.WING BASKET
FISH &CHIPS
OLD SALEM GREEN BURGER
10TH TEE BURGER WITH BACON, CHOICE OF CHEESE,
LETTUCE, TOMATO, SAUTEED ONIONS, PICKLES
BBQ SAUCE, FRIES
9.00
PICKLE & CHIPS
MIXED GREEN SALAD
CAESAR SALAD
GREEK SALAD
ADD CHICKEN *3. ADD STEAK TIPS *4
GRILL
7.5 TEE TIME GRILL STEAK TIP 14.
75 3/4 L55 MARINATED SIRLOIN.
TWIN GRILLED BBQ CHICKEN BREAST 12.
7.50 g.. TERIYAKI TOP SIRLOIN STEAK 14.
100Z TOP SIRLOIN MARINATED
SERVED WITH CHOICE OF 2 Y:
FRENCH FRIES, COLE SLAW, ONION RINGS, BAKED BEAN &SALAD
s.5o BREAKFAST
Tee Time Grille at Ole Salem Green overview:
There have been several vendors over the years with no consistency. They have run limited menus and full liquor. We have
spoken to many members and staff of the course expressing disappointment of service and variety over the years.
Especially last year.
We need to build back the clientele base.
Our objective is to serve quality affordable sandwiches, meals and appetizers to golfers and to bring in outside clientele. In
order to sustain expenses we have to market Tee Time Grill outside of the golf course. We are running a marketing
campaign with Salem News and social media.
We have a limited menu with a nice variety of appetizers, sandwiches, burgers and entrees.
We will be offering 4 varieties of beer on tap as well as bottled beer, soda, sports drinks, water & coffee
Wine & Mixed cocktails
We plan on kee
Thank you,
Peter Mikedis
Manager
Sidekim LLC dba Tee Time Grill
variety to the basics.