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TEMPLE SHALOM - ESTABLISHMENTSr,rX)OLE .S PA L401117 a8� ZA)r>nyz?,rE .� N� it J f- 1 ICN �aS'PS cG� pRas TV IMgssachusetts Department of Public Health Division of Food and Drugs City/Town of 22@�4 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:: Tet.- I Ili 14A NameD to Typ f Operation(s) Type of I pection �`%LrI Awt�mil ood Service ❑ Retail ❑ Routine ❑ Re -inspection Address isk Level ElResidential Kitchen ❑ Mobile Previous Inspection Date: Telephone [1 Temporary ❑ Caterer ❑ Bed 8 Breakfast Permit No. ElPre-operation ❑ Suspect Illness ❑ General Complaint El HACCP ❑.Other Owner HACCP YM Person -in -Charge (PIC) Inspector Time In�o(pjy�%� Out: Each violation checked requires an explan I n on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness In -ntions 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) F000, PROTECTION MANAGEMENT; _ [:11. 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 CPROTECTION.FROMCONTAMINATION _---`.j ❑ 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. 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 -2x590.003) 24. Food and Food Protection (FC -3x590.004) 25. Equipment and Utensils (FC -4x590.005) 26. Water, Plumbing and Waste (FCSx590.006) 27. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FC -7x590.008) 29. Special Requirements (590.009) 30. Other s: a,. LOW ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities --, {PROTECTION FROM'CHEMICALS_ ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals --...-.rdT- TIMEREMPERATURE_CONTROLS (P.otentlalty Ha¢ardous ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS TFOR ❑ 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 order. DATE OF RE -INSPECTION: r r® �`%LrI Awt�mil I Violations Related to Foodbome Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Resnsibilit * 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 Complitwee with Food Taw*_ 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 3-20216 Ice Made From Potable Drinking Wates* Applicant To Report To The Person In Drinking Water from an Approved System 590.006(A) Charge* 590.006(B) 590.003 Cr - 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 C C FOOD FROM APPROVED SOURCE "Denotes critical item in the federal 1999 Ford Code a 105 CMR 590.0ft In v -fi-,- - tin^ V. ".fes. rte-.,\._.. PROTECTION FROM CONTAMINATInN Food and Water From Regulated Sources 590A04(A-B) Complitwee with Food Taw*_ 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 .Eggs and Milk Products. Pasteim7ed* 3-20216 Ice Made From Potable Drinking Wates* 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 ui meat* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreadomily Caught Molluscan Shellfish* 3-201.15 _ Molluscan Shellfish from NSSP Tasted Sources* Proper, Adequate Handwashing Game and Wild DAushrooms Approved by Pegulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* - 2-301.14 ReceivingfCondition 3-202.11 PI -Ts Received at Proper Tem ratures* 3-202.15 Package hue it * 3-101.1 i Food Safe and Unadulterated Tags/Records: Shelistock 3-202.18 Shellstock Identification * 3-203.1.2 ShallstockIdentification Maintained* 12 _ Tags/Records:Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(n Labeling of Ingredients* Handwash Facilities Conformance with Approved Procedures /HACCP Plans 3-502.11. SE cialized Processing Methods* 3-502.1.2 Reduced osvgen acka'ng, criteria* 8-103A1 Conformance with Ap roved Procedures* "Denotes critical item in the federal 1999 Ford Code a 105 CMR 590.0ft In v -fi-,- - tin^ V. ".fes. rte-.,\._.. PROTECTION FROM CONTAMINATInN 9 Cross -contamination 3-302.1.1(A)(1.) I Raw Animal Foods Separated from Cooked and RTE Foods* 4-501..111 Contamination from Raw Ingredients 3-302.1 1(A)(2) Raw Animal Foods Separated from Each Other* Mechanical Warewashing- Hot Water Sanitization Tem eratures* - Contamination from the Environment 3-302.1.1(A) Food Protection* 3-30215 Washing Fruits and Vegetables 3-304.11. Food Contact with Equipment and Utensils* 4-602.11 Contamination from the Consumer 3-306A,I(A)(.B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces of ui meat* Disposition of Adulterated or Contaminated Food 3--701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501..111 Manual Warewashing - Hot Water - Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization 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 ui meat* 4-703.11 Methods of Sattitization - Hot Water and - Chemical* 30 Proper, Adequate Handwashing 2-30111 Clean Condition - Hands and Arms* 2-301.12 CleaninProcedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinkin£ or Using Tobacco* 27461.12 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 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 Hand Drying Provision . +. y .0 c -z s achusetts "Department of Division of Food and Drugs ..,City -/Town of 2�„ FOOD ESTABLISHMENTINS EC I N REPORT Putiic"Hili lth e6s4 Salem Board o�ealth 120 Washington Street, 0 Floor Salem, MAY, 01970-3523 ,Tel. (978),741-1800 Fax (978) 745-0343 Address: Tat _ai(i 91-71(_1 (�i/)� Name Date Type Operationf5) Type of fns ection PICS Si tore• --d�, Print: ood Service Retail El Routine ElRe-inspection Address " sk Level El Residential Kitchen El Mobile Previous Inspection Date: Telephone [I Temporary ❑ Caterer El Pre-operation ❑ Suspect Illness Owner }-2 JS ', HACCP YIN iPerson-in-Charge (PIC) "" Time,' ❑ Bed & Breakfast ❑ General Complaint In. �� /� ElHACCP Inspector -i O O W rV Permit No. I ❑. Other Each violation cNedked requires an explaZentions on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne 11loess / and Risk Factors_(Red Items) Anti -Choking 5910.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009 (F) Ely p q Allergen Awareness 590.009 (G) ❑ corrective action as determined by the Board of Health. POOp:PROTECTIONMANAGEMENT:. - ..- _ _-..I1 ❑ 1. PIC Assigned/Knov�ledgeable/Duties EMPLOYEEHEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑`t3. Personnel with Infections Restricted/Excluded T,F000'FROMAPPR0VED 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 t;PROTECTION FROM CONTAMINATION ❑ 8. Separation/Segregation/Protection d ❑ 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 -3x590.004) 25. Equipment and Utensils (FC -4x590.005) 26. Water, Plumbing and Waste (FC5)(590.006) 27. Physical Facility (FC -6x590.007) r 28. Poisonous or Toxic Materials (FCax590.008) 29. Special Requirements (590.009) 30. Other S &l/Yac ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROWCHEMICALS'_ ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE:CONTROLs(PoteiittattyHazardous_Fgods),. I ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control ,REQUIREMENTS FOR HIGHLY4USCEPTIBLE-POPULATIONS':(H!i ).,r ❑ 21. Food and Food Preparation for HSP �._ -DVISORY _ -_ _ ❑ 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 Signature: , n Print: - JA PICS Si tore• --d�, Print: Paxe of�esg Pa U Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATinN _ FOOD PROTECTION MANAGEMENT_ 1 590.003(0) Responsibility* 590.003otion 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* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System, 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 1 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions L C NE FOOD FROM APPROVED SOURCE Denote, critical item in the federal 1999 roma Code or 105 CMR 590.000. 8 Food and Water Flom Regulated Sources I 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* 3-202.14 Eggs and Milk Products. Pasteurzed* 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* Washing Fruits and Vegetables Shetllish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from'4SSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authorft 3-202.18 Shellstock i'dentifi"anon Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-703,1? ReceivingiCondition 3-202.11PHFs Received at Proper Temperatures* 3-202.15 Package lute it'` 3-101.11 Iiooi Safe and Unadulterated _ Togs/Records: Shellstock 3-702.18 Shellstock Identification * 3-203.1.2 Shellstock Identification Maintained* _ Tags/Records; Fish Products 3402.11 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 /HACCP Plans 3-502.11. Specialized Processing Methods* 3-502.1.2 Reduced Ox gen packaging, criteria* 8-103.!2 Conformance with Approved Procedures* Denote, critical item in the federal 1999 roma Code or 105 CMR 590.000. 8 Cross -contamination 3-302.11(A)(1.) Raw Animal Foals Separated from Cooked and RTE Foals* 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 3-304.1.1 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(0)(6) Returned Food and Reservice of Food* _ Disposition of Adulterated or Contaminated Food 3-703,1? Discarding or Reconditioning Unsafe Fes* t=1---- Food Contact, Surfaces 4-501.111 _- Manual Warewashing - Hot Water - Sanifization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem ratures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601..1 I (A) Equipment Ford Contact Surfaces and Utensils Clean* 4-602.1.1 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* 4-703.1.1 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301..1.1 Clean Condition -Hands and Arms* 2-301-12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eatin , Drinking or Using Tobacco* 2-401.12 Discharges. From the Eyes, Nose and Mouth* 3-301,12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from -Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and _Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashi ng Cleanser, Availability F6-301 Hand Drying Provision i - 2 CHURCH FOOD INSPECTIONS ------- -__— ------ --------_._-_._.— Date Name --------- ---- -- Address Office Hours AA- Uv-�- ate,- NOS Contact Person/Phone Number iServsafe Certificate Person in Charge Yes No Ilemen Certificate Yes No Aller en Al -- —ted Yes No Retail or Retail Food Staff Clothing/ Personal items Knowledge of Food Safety Hygiene Doesn't Apply Doesn't Apply Doesn't Apply )OM 0 Type of Product Approved Source Made on site Unpackaged Pre-packaged Dry (storage) Frozen (method of thawing) Fresh Type of Service/Events Self service Utensils - Serving utensils - Condiments - Counters - Dispensers Temperatures Fridge Freezer Cf.t 2Q�Q7o� - NL'�riI �W U .I, fil tem L I YJ�I Warming Units I C�&\ro LLJ3liA-4 Avg Food —Dry — Cold — Hot Products nVv Tampering - Torn packages — Dented cans — Sys 11 Expired Products i Hand Washing Sin Sign posted Clean�t� Hot water Soap Paper towels Warewashin Purpose 3 bay sink r dishwasher Sanitizer Sink Sanitizer Type Strips L�; Results— 3 bay sink IeA tj=d �Results — buckets or spray bottles C) S �Na cmles labeled Physical Floors C�— Walls Utility sink/Mop Rest Rooms Public Employees only Clean Hot water Lights( Multiple Use Soap Paper towels Employee sign for Hand — washing Comments ao,,- cash -H aw, CL -C) ,► S - A� Date Name Address Office Hours Contact Person/Phone Number Servsafe Certificate Person in Charge Yes No � All�ertificate Yes No Aller en AIsted Yes No Retail or Retail & Food Staff Clothing/ Personal items Knowledge of Food Safety Hygiene CHURCH FOOD INSPECTIONS Doesn't Apply Doesn't Apply Doesn't Apply r Type of Product Approved Source Made on site Unpackaged Pre-packaged Dry (storage) Frozen (method of thawing) Fresh Type of Service/Events Self service Utensils - Serving utensils - Condiments - Counters—Dispensers Temperatures Fridge y Freezer Warming Units Food –Dry – Cold – Hot Products Tampering -Torn packages – Dented cans– Expired Products I Ha d �Was in� Sign posted 00 Clean" Hot water Soap Paper towels Warewashin Purpose 4 3 bay sink 0 dishwasher j �Sarutizer Sink �Swn—itizer Type Strips Results -3 01 Results – buckets or spray bottles ----- ---- '��,e elk, Bottles labeled Physical Floors Walls Lights Utility sink/Mop — -------------------- Rest Rooms Public Employees only Multiple Use Clean Hot water Soap Paper towels Employee sign for Hand —washing Comments bc1Slezm V 0 e' + � (l� Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4"' Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of S610" FOOD ESTABLISHMENT INSPECTION REPORT Address: �r Tel_�1, I -1w lik)A Name Print: Type of Operation(s) Type of Inspection Print: r ,(z V Lr_. V. A K i ! d Service ❑ Retail Q�] Routine L4 a lrfspection Address01,� ❑ Residential Kitchen Previous Inspection Telephone p ❑ Mobile Date: lout: ❑ Temporary ❑ Pre-operation Owner P YIN ❑ Caterer ❑ Bed 8 Breakfast ❑ Suspect Illness ❑ General Complaint Person -in -Charge (PIC) d ❑ HACCPInspector IPermit No. I ❑.Other Each violatio" checked requires an explana�j on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti -Choking 590.009 (E) ❑ Items) Tobacco 590.009(F) ❑. Violations 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 FROIAAPPROVED SOURCE ❑ 4. Food and Water from Approved SourceT + ❑ 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 (FC5X590.00m) 27. Physical Facility (FC -6X590.007) 28. Poisonous or Toxic Materials (FC -7X590,008) 29. Special Requirements (590.009) 30. Other s: ar4d ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM'CHEMICALS, _ ❑ 14. Approved Food or Color Additives ^ ❑ 15. Toxic Chemicals _TIMEITEMPERATURE.CONTROLS(PoteiaiallyAsiaidousF..00s). _ ❑ 16. Cooking Temperatures [117 Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR-'H-IGHL-YIS 4CEPTIBLE=POPULATIONS IHSp` );. ❑ 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 (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 Signature- Print: Page_of Pages P[Cs Signature:GriVe Print: r ,(z V Lr_. V. A K i ! Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A)DemonstrAsia tment of Res onsibility* 590.003(6) ation 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* applicants* Shell Eggs* 590.003(F) _ Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Driak.ap 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 Char�e* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Rzntovul of Exclusions and Restrictions C C C FOOD FROM APPROVED SOURCE * Den(te, critical item inthe federal 1999 Fp)d Code or 105 CMR 590.000. in PROTECTION FROM Cr1NTAM1MaT1n1d Food and Water Fran 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* 3-202.13 Shell Eggs* 3-202.14 _ Eggs and Milk Products, Pasteurzed* 3-202.16 Ice Made From Potable Driak.ap Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Waterf 590.006(B) Water Meets Standards in 310 CMR 22.0* 2-301.12 Shetllish and Fish From an Approved Source 3-201.14 Fish and Recreatirnxaily Caught Molluscan Shellfish* 3-201.15 _ Molluscan Shellfish from `{SSP l st d Sources* Game and Wild Mushroom. s Approved by Regulatoty Authority _ 3-202.18 ShellstockIdentification Present* 590.004(C) Wild Mushrooms* r 3-201.17 Game Animals** -. Receiving/Condition 3-202.11 PRFs Received at PrpjLer Temperatures* 3-202.15 Package Inte grit * 3-!Oi.IF Food Safe and Unadulterated _ Tags/Records: Shelistock 3-202.18 Shellstock Identification' 3-203.12 Shetlstock Identification Maintained" Tags/Records: Fish Products 3-402.11 Parasite Destrucdon* 3-402.12 Rearrd;, Creation and Retention* 590.004(1) labeling of Ingredients' Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized ProcessingMethods* 3-502:1.2 Reduced oxygen packaging, criteria* 8-103.!2 Conformance with Approved Procedures* * Den(te, critical item inthe federal 1999 Fp)d Code or 105 CMR 590.000. in PROTECTION FROM Cr1NTAM1MaT1n1d 2-401.11 Cross -contamination 3-302.1.1(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.112 Contamination from Raw Ingredients 3-302A I(A,)(2) Raw Animal Foals Separated from Each Other* 4-60 L l 1(A) Contamination from the Environment 3-302.11(A) Food Protection* 3302.15 Washin Fruits and Vegetables 3-304.11. FoodContactwith Equipment and Utensils* 5-204.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 2-301.12 Disposition of Adulterated or Contaminated Food 3.70 1. 11 Discarding or Reconditioning Unsafe Food* 2-401.11 Food Contact Surfaces 4-501.1.11 Manual Warewashing - Hot Water Sanitization Temperaturw 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* em ratures*501.114. 501-114. Chemical Sanifization- temp., pH, concentration and hardness. * 4-60 L l 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 E ui ment7 4-703.11 Methods of Sanitization - HotWaterand Chemical* 5-204.11 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms*- 2-301.12 Cleaning Procedure* 2-301.14 1 _ When to Wash* 2-401.11 Eatin , Drinking or Using Tobacco* 2-401.12 Discharges: From the Eyes, Nose and Mouth* 3-30L12 Preventin Contamination WhenTastin Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* ryees* Handwash Facilities - Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 _ Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 _ Handwashin Cleanser, Availability 6-301.1.2 Hand Drving-Provision - -Massachusetts Department of Public Health Division of Food and Drugs City/Town of �A L" FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Address: nss: vl Tal 111;�,-7Li-( &i)/t Name /I_Q C �l Da Type of Operation(s) ❑._Food Service ❑ Retail Type of Inspection ❑ Routine E] -Re -inspection Address `� p - 1^ hill Risk -- Level ❑ Residential Kitchen Previous Inspection Telephone - V� W),$( ❑ Mobile Date: I ' J ❑ Temporary ❑ Caterer ❑ Bed 8 Breakfast ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint Owner I, HACCP YM Person -in -Charge (PIC) � Time �^ In: 1044ElHACCP Inspector Out: Permit No. ❑ Other Each violation\ checked requires an explanatffooh 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 Tobacco 590.009 (F) ❑ 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 ❑ S. Personnel with Infections RestrictedlExcluded _ FOOD'FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source _ ❑ 5. Receiving/Condition t ❑ 6. Tags/Records/Accuracyof Ingredient Statements a+ ❑ 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. 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 -2x590.003) 24. Food and Food Protection (FC -3x590.004) 25. Equipment and Utensils (FC -4x590.005) 26. Water, Plumbing and Waste (FC -5X590.006) 27. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FC -7x590.008) 29. Special Requirements (590.009) 30. Other s o -.a ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities . PROTECTION FROWCHEMICALS [114. Approved Food or Color Additives . ❑ 15. Toxic Chemicals t[MErrEMPEMT.URE:C.ONTROLS (Potentlalty karerdous F.00di) ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATIONS':(HSP)., ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY p [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 order. DATE OF RE -INSPECTION: Inspector's Signature:� Print: Lb ) PICS Signature: �i,,,� ( Print: ` a t 4. b. Page of Pages Violations Related to Foodbome Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) AssigttmentofResponsibility* 590.003(6) Dem a'tion 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 3-20L 13 Fluid Milk and Milk Pmducts`x 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 Dunkin Water from an Approved System" 590.006(A) Charge* 590.006(6)_ 590.003(Ci) 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 70 C FOOD FROM APPROVED SOURCE 4 Dmotes cruicat item in.the Federal 1999 rood Gime or 103 CMR 590_(X)(). C PROTECTION FROM CONTAMINATION Food and Water From, Regulated Sources 590,004(A -B) Compliance with Food Law* 3-201,12 Food in a Hermetically Sealed Container" 3-20L 13 Fluid Milk and Milk Pmducts`x 3-202.13 Shell Eggs* 3-202.14 Eg �s and PAi1k PnStiucts. PasteurzzcP' 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Dunkin Water from an Approved System" 590.006(A) Bottled Drinkin Water* 590.006(6)_ Water Meets Standards in 310 c,MR ^_20* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Shellfish and Fish From an Approved Source 3-201.14 _ Fish and Remauonai'iy CaagOk Molluscan Shellfish* 3-201.15 Ylolluscan Shellfish from uSSF Listed Sources* Proper, Adequate Handwashing Game and Wild Ttushrooms.4pproved by Re ulato Authorit _ 3-202.18 Shellstock Identification Present* 590,004(C) Wild Mushrooms* 3-201.It Game Animals* 2-301.74 Receiving/Condition 3-202.1.1 PHFs Received at Proper Ten eramres* 3-202.15 Package Inte , it 3-1(i l.7 i Food Safe and Unadulterated Tags/Records Shellstock 3-202.18 Shellstock Identification' 3-203.12 Shellstock Identification Maintained" 12 _ Tags/Records:-Fish Products 3.40211 Parasite Dentrucdoc* 3-40212 Records. Creation and Reientiun* 590.004(1) Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures /HACCP Plans 3-502.11. Specialized Processing Methods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures`" 4 Dmotes cruicat item in.the Federal 1999 rood Gime or 103 CMR 590_(X)(). C PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.11(A)(1.) Raw Animal Foods Separated from Cooked and RTE Foods* 4501.711 Contamination from Raw Ingredients 3-302.1 l(A)(2) Raw Animal Fails Separated from Each Other* Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.1.1(A) Food Protection* 3-302.15 Washing Fruits and Ve etables 3-304.11 Food Contact with Equipment and Utensils* 4-602.1.1 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_ 11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces - 4501.711 Manual Warewashing - Hot Water Sanitization Ten eralures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical. Sanifization- temp., pH, concentration and hardness. * 4-601,11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1 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* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301. 12 Cleanin Procedure* 2-301.74 When to Wash* 1.1 I Good Hygienic Practices 2-401..11. Eating, Drinking or Using Tobacco* 21101,12 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 6-301.11 Handwashing Cleanser,Availability 6-301.12 Hand -Drying Provision CHURCH FOOD INSPECTIONS mace Name Address saul-y,.. Office Hours C ntact Person Phone Number eu S t u e -a Ko Servsafe'Certificate Person in Charge Yes No Allergen Certificate Yes No Allergen Alert Posted Yes No Retail or Retail & Food Staff Clothing/ Personal items Knowledge of Food Safety hygiene Doesn't Apply I � � P ��s saA e yi I I CdYVj n ✓Yl � Doesn't Apply Doesn't Apply `6i,e- bv--K� — — ---- —------- - ---- J bb� i�jr-r Sin LaA c.Q��a�v, — �,viclan o coa� Type of Product Approved Source Made on site Unpackaged✓ Pre-packaged ✓ / Dry (storage) Frozen (method of thawing) L� Fresh / Type of Service/Events Q� _ r xW S his) Self service Utensils - Serving utensils - Condiments - Counters — Dispensers Temperatures Fridge Freezer Warming Units t V0 Food -Dry -Cold -Hot Products 1. . . .. - Dented I Tampering - Torn packages �entecl cans - eo{r�6 Expired Products Hand Washing Sin Sign 00 posted C.) --- �;� Clean --- Hot water Soap Paper towels ak, Warewashin Purpose 3 bay sink or dishwasher a S Sanitizer Sink Sanitizer-- - ---N `7 Type Strips CQe;" Results -3 bay sink Resultspray bottles Fottles labeled Physical Lights t4A O&e 60- Floors Walls SI. Utility sink/Mop — - -------- — ----- Rest Rooms Public Employees only Multiple Use `�vv W1 Clean Hot water Soap Paper towels Employee sign for Hand —washing 44ie- e- 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 FOOD ESTABLISHMENT INSPECTION REPORT Address: r IV �-1(1.1s::� (1 Tal- V't".:i Name DateType ofsperetion(s) Type of Inspection `( ❑fid Service ❑ Retail Routine e -inspection Address WO Risk 04A 0A Level ❑ Residential Kitchen ❑ Mobile Previous Inspection Date: Telephone ❑ Temporary ❑ Pre-operation Owner HACCP YIN ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person -in harge (PIC) Time ��q� In. I1:21 l Inspector Out: Permit No. ❑ Ot erC cacn vioracnon cnecRea requires arye�tpiananon on the narrative pagets) ana a citation of specific provision(s) violated. UNon-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Ant -Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009 (F) El Alleergen Awareness 590.009 (G) ❑ corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 2.4 Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOQ: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. 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 -3X590.004) 25. Equipment and Utensils (FC -4x590.005) 26. Water, Plumbing and Waste (FC -5X590.006) 27. Physical Facility (FC -6X590.007) 28. Poisonous or Toxic Materials (F(34X590.008) 29. Special Requirements (590.009) 30. Other j &,4d ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTIONPROM'CHEMICALSp ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEREMPERATURE:CONTROLS,(PotentlalryHaiardou F..poA )-'- -; ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control ._.. _- �.a ..._ -. _ _..._. REQUIREMENTS FOR,HIGHLY-$USC 11BLE- P-OPULATIONS':(HQP):,-' ❑ 21. Food and Food Preparation for HSP .CONSUMER ADVISORY _ __� E]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: spector's Signature: Print: Page of Pages PICS Signature: mN Print: 1'F'QlnC L V�G1S,?P\ at' td'visPrh--z, t Violations Related to Foodborne illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) tf Responsibilit * 590.00mon of Knowledge* 2-1.03.11. Person in charge - duties 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 Foots Employee Or An 3-202.16 Ice Made From Potable Drinkin„ 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 Char,e* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003{E) Removal of Exclusions and Residetinns C C 6 I FOOD FROM APPROVED SOURCE - Food and Water From, Regulated Sources 590.004(.A -B) Compliance with. Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and ;Milk Products. Pasteurzed* 3-202.16 Ice Made From Potable Drinkin„ Water* 5-101.11 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 - Fold Contact Surfaces of Equipment* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caug-Ju Tvloliuscan Shellfish* 3-201.15 Molluscan Shellfish fromNSSFlistM Sources* Proper, Adequate Handwashing Game and Wild ,Mushrooms Approved by Re ufato Autha2 - 3-202.18 Shellstock identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game. Animals* 2-301.14 Receiving/Condition 3-202.11: PHFs Received at Proper Tem alines* 3-202.1.5 Package Integrity* 3-10;.11 Food Safe and Unadulterated TaaslRacords; Shellstock 3-202.18 Shellstock identification * 3-203.1.2 Shellstock Identification Maintained* 12 Tags(Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(n Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures /HACCP Plans 3-502.11. Specialized Processing IvtetbWs* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 1 Conformance with An roved Procedures* Denotes critical item in the rederal 1999 Fard Code or 105 CMR 590.000. 8 PROTFCTION FROM CONTAMINATtnm Cross -contamination 3-302.1.1(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501..11. Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Anirnal Foods Separated from Each Other* Mechanical Warewashing- Hot Water , Sanitization Temperatures* 1 Contamination from the Environment 3-302.11(A) - Food Protection* 3-102,15 Washing Fruits and Ve etables 3-:304.11 FoodContactwith Equipment and Utensils* 4-602.1.1 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Foal* Frequency of Sanitization of Utensils and - Fold Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-701.31 Discarding or Reconditioning Unsafe Food* -. Food Contact Surfaces - 4-501..11. Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water , Sanitization Temperatures* 1 4501.114 Chemical Sanitization- temp., pH; concentration and hardness. * 4-601.A I(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1 Cleaning Frequency of Equipment Food- Comact Surfaces and Utensils* 4-702.11 - Frequency of Sanitization of Utensils and - Fold Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization -Hot Water and - Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* ii Good Hygienic Practices 2401.11. Eating, Drinking or Using Tobacco* 2-401.12 Discharges. From the Eyes, Nose and Mouth" 3-301.12 ..Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacifies* 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 Hand Drying Provision <1bAsachusetts Department of rPublic`Health Division of Food and Drugs City/Town of FOOD ESTABLISHMENT INSPFCTION REPORT Salem Board of Health 120 Washington Street, 4a' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Address: Tur t/I" 1 r, -Il J i Name�f�- V Date / Type of Opemtion(s) Type of Inspection M. �A GN -A ❑..Food Service ❑ Retail ❑ Routine [`]-Reinspection AddressRisk e c Level ❑ Residential Kitchen Previous Inspection Telephone f 64 ❑Mobile Date: X [ITemporary ElPre-operation Owner /� ' HACCP YIN ,i A ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness 0 General Complaint Person -in Charge (PIC) n Timet /QOM In: f( HACCP Inspector Out: Permit No. ❑. Other eacn violation cneckea requires ar► e>(planation on the narrative page(s) and a citation of specific provision(s) violated. nNon-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) ❑ q corrective action as determined by the Board of Health. Allergen Awareness 590.009 (G) El FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH y. _. '- ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded F000 FROM APPROVED SOURCE, F1 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 -2X590.003) 24. Food and Food Protection (FC -3X590.004) 25. Equipment and Utensils (FC -4X590.005) 26. Water, Plumbing and Waste (FC -5X590.006) 27. Physical Facility (FC -6X590.007) 28. Poisonous or Toxic Materials (FC -7X590.008) 29. Special Requirements (590.009) 30. Other s o-reaa V/ ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities ..-.. W_. _. W� : _._ .�....�.. _ .PROTECTION��FROM'CHEMICALS� ❑ 14. Approved Food or Color Additives` y ❑ 15. Toxic Chemicals :TIMHTEMPERATURECONTROLS(PotentlaltyHazerdousFoods) . ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling [119. Hot and Cold Holding ❑ 20. Time as a Public Health Control f REQUIREMENTS FOR.,HIGHLYSUSCEPTIBLE=POPULATIONS';(HSP) ❑ 21. Food and Food Preparation for HSP ,CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories _ Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (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: aspeetor's Signature: V Print: hlo( PLCs Signature: Print: // \ / - -. /�G r1'G /r1� J � Page of Pa es g g Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* 590.003(6) Demonstration of Knowledge* _ 2-103.11 I Person in charge - duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person i4 charge to Com xliaoce with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and iMilk.Products* applicants* Shell E -as* 590.003(F) Responsibility Of A Fail Employee Or An 3-202.16 lee Made From Potable Drinking Water* Applicant To Report To The Person In Drinkin Water from an A roved S• stent* 590.006(A) Charge* 590.006(,B) 590.003(G) Reporting by Person in Charge"` 3 590.003(D) Exclusions and Restrictions* 3.202.15 590.003(E) Removal of Exclusions and Restrictions 119 C C C FOOD FROM APPROVED SOURCE " Denotes critical ism in.the federal 1999 Food Code or 1105 CMR 590,000. 8 PROTECTION FROM CONTAMINATION Food and Water From, Regulated Sources 590.004(A -B) Com xliaoce with Food Law* 3-201.12 F<md in a Hermetically Sealed Container 3-201.13 Fluid Milk and iMilk.Products* 3-202.13 Shell E -as* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 lee Made From Potable Drinking Water* 5-101.11 Drinkin Water from an A roved S• stent* 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 Fub From an Approved Source 3-201.14 Fish and Recreationally Caught Mo?3uscan Shellfish* 3.202.15 _ Molluscan Shellfish from NSSP listed Sources* Proper, Adequate Handwashiog Game and Wild,Mt shroorris Approved by Ragulatcsy Authority 3-202.18 She'tlstock identification Present" 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 Receiving/Condition. 3-202.1.1 PIFs Received at Proper Tern ratures* 3-202.1.5 Package lnte,rit y 3-101.1 I Foodd Safe and Unadulterated Tags/Records: Shelistotk 3-202.18 Shellstock identification * 3-203,12 Shellstock Identification Maintained* 12 Tags/Records:'Fish Products 3-402.11 Parasite Destruction* 3-40312 Records, Creation and Retention* 590.004(1) Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures tHACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.!2 Conformance with Approved Procedures* " Denotes critical ism in.the federal 1999 Food Code or 1105 CMR 590,000. 8 PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.111 Contamination from Raw Ingredients 3-302A l(A)(2) Raw Animal Foals Separated from Each Other- Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(A) Foal Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* 4-602.1.1 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_i'i Discarding 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* 4-501.114 Chemical. Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1 Cleaning Frequency of Equipment 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 Handwashiog 2-301..1.1 Clean Condition - Hands and Arms* 2-301..12 Cleaning Procedure* 2-301.14 When to Wash* ii Good Hygienic Practices 2401.31. Eating, Drinking of 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 5-203.1.1 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,.Availabilit 7301.12 Hand Drying Provision CHURCH FOOD INSPECTIONS uate Name Address C�u --- rn Office Hours Person in Charge Yes No Doesn't Apply Allergen Certificate Yes No Doesn't Apply Allergen Alert Posted Yes No Doesn't Apply Retail or Retail i Food Staff ---- ----- -- Clothing/ Personal items Knowledge of Food Safety Hygiene --------- -- I[" V, Pe Z Wn sin Type of Product Approved Source Made on site Unpackaged Pre-packaged Dry (storage) Frozen (method of thawing) Fresh Type of Service/Events 41Z t� vrit e J_,W Self service U Utensils - Serving utensils - Condiments - Counters — Dispensers Temperatures t Fridge Freezer V c*^aA _y -- i -a° Warming Units %� A Food —Dry —Cold —Hot Products Tampering -Torn packages — Dented cans — Expired Products li Hand Washing Sin Sign posted Clean Hot water Soap Paper towels AWLarewashin Purpose urpose 3 bay sink or di It4w asher on" Sanitizer Sink Sanitizer OL4 Type Strips / O"\ Results — 3 bay sink sults —buckets or spray bottles Bottles labeled Physical Floors Walls Lights Utility sink/Mop Rest Rooms Public Employees only Multiple Use Clean Hot water Soap Paper towels Employee sign for Hand —washing Comments M ,,�- sh4,tv) 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 SaQo,,yy\ FOOD ESTABLISHMENT INSPFrTInN RFPnRT Address: /� f r 7..1 Q Name a Typ fOperation(s) lypSofinspectfon ` G V Food Service ❑ Retail LAIRoutine ❑ Re -inspection Address Risk Telephone /� 44 Level ❑ Residential Kitchen ElMobile Previous Inspection Date: If\ ❑ Temporary ❑ Caterer ❑ Bed 8 Breakfast Permit No. ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint ❑ HACCP El. Other Owner HACCP YIN Person -in -Charge (PIC Inspector Tim f,„,nn In: 1lWyY l Out: r=eran vnuranvnnecReu requires an expwparlon on the narrative pagets) and a citation of specific provision(s) violated. 7 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 Allergen . 590.009 (F) El n Awareness 590.009 (G) ❑ corrective action as determined by the Board of Health. _ FOODPROTECTIO.N MANAGEMENT,' ❑ 1. PIC Assigned/Knowledgeable/Duties - EMPLOYEE HEALTH - - - • - `- -' _ ._' _ _ ` 1 ❑ 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 ❑ 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 (FC -5X590.006) 27. Physical Facility (FC -6X590.007) 28. Poisonous or Toxic Materials (FC -7X590.008) 29. Special Requirements (590.009) 30. Other S[MEsurto [112. Prevention of Contamination from Hands ❑ 13. Handwash Facilities M_. PROTECTION FROM'CHEMICALS_^ ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals JimErrEMPERATURIE CONTROLS (Potentially liataidousFoods) ' [116. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control ,REQUIREMENTS FOR, HIGHLY4USCEPTISLE=POPULATIONS':(HSP); ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY._. ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (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 Signature: Print: P[Cs Signature:Print: ` G Page 0f Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 11 590.003(A) Assig tment of Responsibility* 590.003(6) 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,foW employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590003(F) Responsibility Of A Focxl 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) Charge* 590.006(1.') 590003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restr ct ons 4 C C L FOOD FROM APPROVED SOURCE s Denote -e criticalitem in -the federal 1999 Fa)i Code or 105 CMR 590.(0). C PROTECTION FROM CONT6MW6TInw Food and Water From Regulated Source3 590.004(A 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 Eggs and Milk Products. Pasteurized* 3-202.1,6 Ice Made From Potable Drinking Water* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water' 590.006(1.') 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 rvloliuscaa Shellfish* 3-201.15 Molluscan Shellfish from NSSF Lasted Sources* Proper; Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 ShellsteckIdentification Presenz" 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* - - 2-301.14 Receiving/Condition 3-202.11. PHFs Received at Proper Tem acmes* 3-202.15 Package Integrity* 3-10),I i Food Safe and Unadulterated _ Tags/Records: ahelistock 3-202.18 Shellstock Identification * 3-203.1.2 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" 13 Conformance with Approved Procedures IHACCP Plans 3-502.11. Specialized Processing Methods* 3-502:1.2 .Reduced oxygen packaging criteria* 8-103.12 Conformance with Approved Procedures* s Denote -e criticalitem in -the federal 1999 Fa)i Code or 105 CMR 590.(0). C PROTECTION FROM CONT6MW6TInw 9 Cross -contamination 3-301.11(A)(I,) Raw Animal Foods Separated from Cooked and RTE FoWs* 4-501..111. Contamination from Raw Ingredients 3-302.11(A)(2) Raw Antral 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* 4-602.1.1 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 3-701.11 LL Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501..111. Manual Warewasbing - Hot Water - Sanitization Temperatures* 4-501.1 t2 Mechanical Warewashing- Hot Water Sanitization Temperatures* - 4-502.113 Chemical. Sanitization- temp., pH, concentration and hardness. * 4-601.A 1(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1 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* 10 Proper; Adequate Handwashing 2-301..1.1 - Clean Condition - Hands and Arms* 2-301..1.2 Cleaning Procedure* 2-301.14 When to Wash* - 11 Good Hygienic Practices - 2401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges. From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 - Prevention of Contamination from Hands 590.0(9(E) Preventing Contamination from Em to es* - 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 - Accessibility, Operation and Maintenance SuppW with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser,.Availability - 6-301..1.2 Hand Drying Provision ,,Massachusetts Department of 'Public Health Division of Food and Drugs' City/Town of SaQr� f FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4s' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Address: T el" tines 1(LI (alYflt Name ❑ 12. Prevention of Contamination from Hands Date Typ "f Operetf (s) Food Service El Retail El Residential Kitchen ❑Mobile ❑Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. TTypey -Inspection Routine r]Re-inspection Previous Inspection Date: ❑Pre-operation ❑ Suspect Illness El General Complaint HACCP [j Other Address G i/ v) �n n _ _ ^ Telephone � Risk Level Owner ( HACCP YM Person -in -Charge (PICTim Inspectorr�1 U M.nn In: ��WYY °❑ Out: tacn violation c`n'ecKed requires an explapation on the narrative page(s) and a citation of specific provision(s) violated. \ v 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) ❑. Allergen Awareness 590.009 (G) ❑ corrective action as determined by the Board of Health. :- FOOD : PROTECTION MANAGEMENT' ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties • - El13. Handwash Facilities EMPLOYEE HEALTH- PROTECTfON FROWCHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC a "IE] 3. Personnel Infections ❑ 14. Approved Food or Color Additives with Restricted/Excluded r - El 15. Toxic Chemicals . -, •: . - .- - _ T- _ _._- FOOD'FROM APPROVED SOURCE ° - - - - i ❑ 4. Food and. Water from Approved Source - TIMEITEMPERATURE.CONTROLS. Potential Hazardous�F.00d%), (Potentially _ ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ' ❑ 6. Tags/Records/Accuracy. of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION - ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUSCEPTIBCE=PO - - '. ,, NS " 4 (. _P)`. J ❑ 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 -4)(590.005) 26. Water, Plumbing and Waste (FcsX590.006) 27. Physical Facility (FCEX590.007) 28. Poisonous or Toxic Materials (Fcax590.008) 29. Special Requirements (590.009) 30. Other ❑ 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 (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 16 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: V Print: r A. / / l PICS Signature:( Print: ` Page_ 0f Pages ` MMMPIP� I Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A)Asia invent of Res onsibili[ * 590.003(B) Demonstration of Knowledge 2-1.03.11 1 Person in charge -- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance nce with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* a licams* - Shell Eg-s* 590.003(F) Responsibility Of A Food Employee Or An 3-202.15 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from anA orovedS stem' 590.006(A) Charge* 590.006(13) 590.003 G Reporting by Person in Charge* 3 590.G03(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions IN C -10 C FOOD FROM APPROVED SOURCE * Denol'ex critical •,tem in-ttie f feral 1999 Fr )d Code ur 105 CMR 590.000. 10 12 PRnTFrTIn1d FRnee rnA1TAU1MAT1nm Food and Water From Regulated Sources 590.004(A -B) Compliance nce with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eg-s* 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.15 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from anA orovedS stem' 590.006(A) Bottled Drinking Water' 590.006(13) Water Meets Standards in 310 CMR 22.0* 4-702.11 Shelflish and Fish From an Approved Source 3-201.14 Fish and RecreaGanaliy Caught Molluscan Shellfish* 3-201.15 _ Molluscan Shellfisb from NSSP Listed Sources" Game and WlV Mushrooms Approved by Regulatory Authority 3-202.18 Sheilstock Identification present" 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* ReceivinSVConditlon 3-202.11 PRFs Received at Proger Temperatures* 3-202.15 Package hitegrity* 3-[OtJ I Food Safe and Unadulterated _ 'o aus/Rerords: Shelistock 3-202.18 Sheilstoek Identification 3-203.1.2 Sheistock Identification Maintained* --1 Tags/Records; Fish Prodmts I 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(1) Labeling of Ingredients' Conformance with Approved Procedures fHACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packagin& criteria* 8-103.12 Conformance with Approved Procedures* * Denol'ex critical •,tem in-ttie f feral 1999 Fr )d Code ur 105 CMR 590.000. 10 12 PRnTFrTIn1d FRnee rnA1TAU1MAT1nm 4-5(}1..111 Cross -contamination 3-302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501_1 t2 Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* 4-501.114 Contamination from the Environment 3-302.11(A) Fiord 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* 4-702.11 Disposition of Adulterated or Contaminated Food 3--'01.11 Discarding or Reconditioning Unsafe Fond' 4-5(}1..111 Manual Warewashing - Hot Water 7 2-401.12 Sanifization Temperatures* 4-501_1 t2 Mechanical Warewashing- Hot Water Sanitization Tem eratures* - 4-501.114 Chemical. Sanitization- temp., pH, concentration and hardness. 4-601.1) ( A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces mid Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-70311 Methods of Sanifization - Hot Water and 2-301..11 - 1 Clean Condition - When 2-401.11 Eatin , Drinking or Using Tobacco* 2-401.12 Discharges. From the Eyes, Nose and Mouth* 3-301.12 Preventin Contamination When Tasting Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities 5-203.11 5-204.11 5-205.11 6-301.11 CHURCH FOOD INSPECTIONS Date ------ Name ----------- -�_^ Haaress Office Hours M �W -p _ Contact Pers1oonn)/Phone Numbe�(r �/ Servsate Certificate Person in Charge Yes No Allergen Certificate Yes No Allergen Alert Posted Yes No Retail or Retail & F Staff Clothing/ Personal items Knowledge of Food Safety Hygiene Not @awe^C 1'. . Doesn't Apply I ^ L4 Doesn't Apply ' Doesn't Apply 'O3e-Dc/n �� _ M Type of Produc Approved Source Made on site Unpackaged repackaged- fsJL�on- Dr (storage) G&OWkA. Frozen ethod of thawing) q es O.. _-QTi . n ^, OAAA A. G" v Type of Service/Events ,w GOO CQ O t Self service Utensils - Serving utensils - Condiments - Counters - Dispensers Temperatures Fridge Freezer Ury4s� &r So t" 52 SkiYAZYs _ i A - OA.L.St vy3ll�, \--t �a e Food -Dry - Cold - Hot Products O 0w Tampering Torn - - - ---- - ------------ -------- n , ^K � Q �G - packages - Dented cans -l Expired Products � G� - --- -- - ---- -- ---- — - I Hand Was Sink I - -- -- e ----- Sign posted N0 Clean Hot water —.. — - - - Soap Paper towels Warew Purpose v `tel Qit�,� 3 bay sink or dishwash r San,t,zer Sink I v - - - - - . -- --- Sanitizer ---1 ----- --- — ry D n- TYpeW, Strips ✓v d Q ...-- Results-3bay sink - - .. - -- -• ------- --- Results- buckets or spray bottles Bottles labeled Physical. / v Floors / Walls t/ Lights Utility sin Mop Rest Rooms Public Employees only Multiple Use Clean Hot water ✓ Soap Paper towels Employee sign for Hand — washing Comments V . kr:2t.P,v, p. "6 R Commonwealth of Massachusetts ` b City of Salem Board of Health lQmberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/18/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000288 LOCATED AT: Temple Shalom 287 Lafayette Street Salem MA 01970 0287 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2009-0056 Dec 18, 2008 Dec 31, 2009 $25.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $25.00 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 14 KIIABERLEY DRISCOLL MAYOR JANET DIONNE, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4T" FLOO TEL. (978) 741-1800 vptl FAx (978) 745-0343 IDIONNFJ ALENI. CONI DEC 1 �,7 82009 2009 APPLICATION FOR PERMIT )TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT le -n 10 I C rS h" lay) TEL # 13& —? I%l —4 �*o ADDRESS OF ESTABLISHMENT 287 LaUA-le S4' FAX# 90'6-7142-42-92— MAILING 0k"%14L—y2-9L MAILING ADDRESS (if different) _ EMAIL -Business': C `44 OWNER'S NAME ADDRESS STREET CITY STATE CERTIFIED FOODMANAGERS NAME(S).W-elT`-Y.I>h 'rh'.' nt="r :"�A' T I« CERTIFICAT (Required in aneslablishment where potentially hazardous food is prepared) A= t'."i"a . .r:.r .,fi` u�- $,, , ;Ba., h`,xk •' _Y.f " ^!! =' ,r,,�s " ;Fa'+ rarE rk�N- , 1'. EMERGENCY RESPONSE PERSON HOME TEL # .0 ZIP :DAYSOFAPERATION 1 :r.Monda Tuesday- c°Wednesday- �,Thursda 1,1,' Friday,-, 1 Saturday -,-'I:, Sunda HOURS OF OPERATION Please write in time of day. I j (For example 11 am -11 pm) i TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 - ---------------------------------------------------- --------------------------------------- RESTAURANT YES NO less than 25 seats _ $140 (Ou door Stationary Food Cart ,`"-.210; 25.09 sears =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES ------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES$25 TOBACCO VENDOR YE NO $135 DtALL NON-PROFIT (such as church kitchens) EES O $25 'Please pay total with one check payable to the City of Salem. ' This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. OVai(19-b01 Signature U Date Social Security or Federal Identification Number ----------------------------�------------------------------------------------ Revised 424/07 FOODAP2008.adm Check# & Date y 16 / .g $ 021' h 0287 LAFAYETTE STREET Telephone: 741-4880 Owner: Temple Shalom PIC: Dorothy Halber Inspector: David Greenbaum 'Date Inspected: Correct By: 14/3/2008 Risk Level Permit Number: BHP -2008-0150 Status: SIGNED OFF fl# of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations i must be corrected immediately or within 90 days) HACCP: City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection El Temple Shalom Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) - Equipment and Utensils FAIL Non -Critical Comment: The GE dairy unit in the down stairs kitchen needs a general cleaning. GENERAL COMMENTS: No other health code violations cited at this time. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800 BLUE GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 04,2008 ) Page 1 oft ;RED: Violations Related to !Foodborne Illness Interventions and Risk Factors (Require . immediate'corrective action) Item Status Violation Critical Urgency N14`1 LUIQA- City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 04,2008 ) Page 2 oft V; Co onwealth Of MaimCiWui Commonwealth City of Salern Board of Health lGmberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000288 Temple Shalom 287 Lafayette Street Salem MA 01970 LOCATED AT: 0287 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2008-0150 Jan 3,2008 Dec 31, 2008 $25.00 ESTABLISHMENT Total Fees: $25.00 PERMIT EXPIRES December 31,2008, Board of Health v This Permit is not transferable and must be reissued upon change of ownershipLor locatiom The permit must be posted in a prominent location in the Establishment. - In accordance with the State Sanitary Code, beofre any revonations; improvements, or -equipment changes are made; all plans for such must be submitted to and approved by the Salem Board. of Health. Page 33 of 37 ' o QTY OF SALEM, MASSACHUSET5 a yr f`�i• o BOARD OF HEALTH �o 120 WASHINGTON STREET, 4'H FLOOR TEL. (978) 741-1800 KIMBERLEYDRISCOLL FAX(978)745-0343 RECEIVED MAYOR Iscurf a� sAL2M. OOM Y7 JOANNE SCOTT, DEC 3 -2007 HEALTH AGENT CETY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT IG11Iyk�_ 5Id V I TEL # 17? --A-118-0 ADDRESS OF ESTABLISHMENT Ri-I FAX# MAILING ADDRESS (if different) EMAIL - Business': +/h - OWNER'S NAME /VGA TEL # ADDRESS STREET CITY STATE CERTIFIED FOOD MANAGER'S NAME(S) IV I CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) ':•*'".y '� ts. _cst.: � �`>£.r>�'i +F..�: i"' ""Xe :F:iv ^".r4" tw+A'„�'�1-° rt.. .. r�, s�.1t. xfSe✓"'?°v. ..... �.::.� Please We in time of day. TYPE OF ESTABLISHMENT RETAIL STORE FEE (check only) YES � less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 ------------------------------- -------------------- BED/BREAKFASTI YES NO CHILDCARE SERVICES -------------------------------- -------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) $100 YES $25 YES $135 E'S NO $25 ZIP *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 fled all state tax returns and paid all state taxes required under the law. - A" 14 k&VaA"-c— fhb)vi Date Social Security or Federal Identification Number ---------------------------'--------------------------- ------- ------ -------- Revised 4/24/07 4/24/07 FOODAP2008.adm Check# & Date 0287 LAFAYETTE STREET City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Temple Shalom Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-4880 Equipment and Utensils FAIL Non -Critical BLUE Owner: Comment: Both freezers in the basement kitchen need a general cleaning. Temple Shalom PIC: Physical Facility FAIL Non -Critical Milton Davis Comment: The ceiling in the restrooms have chipping/peeling paint. Scrape and repaint all chipping/peeling paint. Inspector: David Greenbaum Date Inspected: Correct By: 2/13/2007 Risk Level: Permit Number: BHP -2007-0278 Status: SIGNED OFF # of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 BLUE GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 13,2007 ) Page I oft RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 13,2007 ) Page 2 oft sBaa dof Health IGmberleyDnscoli ' " ° 120 Washington Street' 4th Floor, av'w 1 Mayor �k 4�.... i ...-s. S • S .may -^Y•..r.� e p < p t ` �.Aa+'T�^t Y�'L ..x � i:`„ Y SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2007 ESTABLISHMENT NAME: File Number: BHF -2004-000288 Temple Shalom 287 Lafayette Street MA 01970 LOCATED AT: 0287 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2007-0278 Jan 4, 2007 Dec 31, 2007 $25.00 ESTABLISHMENT Total Fees: $25.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 9 of 12 MAILING ADDRESS (if different) 11 0'-t"t't - EiviAIL -- Business': OWNER'S ADDRESS STREET Owner's: TEL # CITY STATE CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE Please write in time of day. TYPE OF ESTABLISHMENT RETAIL STORE YES NO ---------------- RESTAURANT YES NO BED/BREAKFAST YES NO ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) HOME TEL FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 YES NO YES NO YES NO $5 $50 $25 ZIP `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 slate tax returns and paid all state taxes requiredunderthe law. Yl.. •./. . itniAai - I1J91 in( hAni � __ Signature Date Social Security or Federal Identification Number ------------------------------------------ - r Revised 11/13/06 FOODAP2007.adm Check# 8 Date -!i-2A L.9. $ 2,5°Qo CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH RECEIVED s 120 WASHINGTON STREET, 4TH FLOOR lJM 3 SALEM, MA 01970 -_ 2007 TEL. 978-741-1800 FAX 978-745-0343 r CITY OF SALEM WWW.SALEM.COM BOARD OF HEALTH Kimberley Driscoll ,JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT -T eM pl e S/64O1mTEL #. a -7g -�q (- y F� ADDRESS OF ESTABLISHMENT o[ s i 1- aq�p Si- FAX # qU —1gL -ii MAILING ADDRESS (if different) 11 0'-t"t't - EiviAIL -- Business': OWNER'S ADDRESS STREET Owner's: TEL # CITY STATE CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE Please write in time of day. TYPE OF ESTABLISHMENT RETAIL STORE YES NO ---------------- RESTAURANT YES NO BED/BREAKFAST YES NO ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) HOME TEL FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 YES NO YES NO YES NO $5 $50 $25 ZIP `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 slate tax returns and paid all state taxes requiredunderthe law. Yl.. •./. . itniAai - I1J91 in( hAni � __ Signature Date Social Security or Federal Identification Number ------------------------------------------ - r Revised 11/13/06 FOODAP2007.adm Check# 8 Date -!i-2A L.9. $ 2,5°Qo - a�o(zq Commonwealth of Massachusetts s r City of Salem Board of Health g� 120 Washington Street, 4th Floor "�Yn� 0 SALEMMA 01970 , Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: File Number: BHF -2004-0288 Temple Shalom 287 Lafayette Street Salem MA 01970 LOCATED AT: 0287 LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2006-0236 Jan 3, 2006 Dec 31, 2006 $25.00 ESTABLISHMENT Total Fees: $25.00 PERMIT EXPIRES December 31, 2006 Board of Health 44— This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 7 of 13 CITY OF SALEM, MASSACHUSETTS v BOARD OF HEALTH ulv R� O m. (s 120 WASHINGTON STREET, 4TH FLOOR I1� SALEM, MA 01970 V DEC 12 2005 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAX 978-745-0343 CITY OF SALEM MAYOR WCOTT, PH, FI BOARD OF HEALTH JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEMPLE SHALOM TEL # 978-741-4880 ADDRESS OF ESTABLISHMENT 287 LAFAYETTE ST - MAILING ADDRESS (if different) OWNER'S NAME NSA TEL # CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun.— on.Tue.Wed.Thu.Fri.Sat.Sun.TYPE TYPEOF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO/,� less than 25 seats =$100 V 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES......Nb -------------------- ----------------------------------------$100----.---------- ----------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDORS NO $50 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 paid all state taxes required under the law. oya1693 30leo Date Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------- Revised11/03/05 FOODAP2.adm Check#&Date / 9 f�/os� 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/� _ ��� 2 1 !� / /7rTL�fZ�1• Date %-�% T e' of O eration s Type of Inspection Food Service ❑ Retail ❑ Residential Kitchen El Mobile ❑ Temporary ❑ Caterer El Bed 8 Breakfast Permit No. [Er Routine ❑ Re -inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint [I HACCP ElOther Address / r f X¢ J Telephone �/ /��� Y Risk Level Owner /� // (_Qrt Q2 rn T71� HACCP Y/N Person in Charge(PIC)y� /_ el -e �� ! Time In: Out: Inspector ✓•/�G,C�t'rt�i'%C 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 .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. 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 S. 590nre fFor &14,dc MA ❑ 12. Prevention of Contamination from Hands © 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures = ❑ 17. Reheating ❑ 18: Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ` - - _ ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): 1 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: .✓�J Print: A PIC's Signature: �� - /"-, Print: ��, r� ���, Page of JPages -�,�, Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) � FOOD PROTECTION MANAGEMENT I I 590.003(A) Assignment of Responsibility* 590.003(B) I Demonstrailon of K'nowled'oe* 2-_103.1.1 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 fbcxl employees and 3-20113 Fluid Milk and Milk Pioducts* applicants' Sheri Egos: 590-003 Responsibility Of A Food Employee Or An 3-202.'16 Ice Made From Potable Drinking Water'^ Applicant To Repots To The Person In Drinking Water roman roved System* 590.006(A) Cbm g"e 590.006(B) 590.003(G) Re Quina b Person in Char e" 3 590.0030) Exclusions and Restrictions* 3-201.,15 590.003tE) Removal of Exclusions and ResuiMions 4 5 a * Denotes critical item in tate federal 1999 Food Code or 105 CNIR 590,000, g Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law*. 3-201.12 Food in a Hertnetieti0v Sealed Container` 3-20113 Fluid Milk and Milk Pioducts* 3-202.13 Sheri Egos: 3-202.14 H * *s and Milk Pralucts. Pasteurized* 3-202.'16 Ice Made From Potable Drinking Water'^ 5-1.01.11 Drinking Water roman roved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" Washing Fruit and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.,15 Molluscan Shellfish'from NSSP Listed Sources` Contamination from the Consumer Game and Wild Mushrooms Approved by Re ufato Author 3-202-18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Oame Animals* 3-70L11 Receiving/Condition 3-202.11 PI-tFs Received at Pro rer Tem ep ratvres* 3-202.15- 3-101.11 Food Safe and Unadulterated 'w Tags/Records: Shellstock 3-202.18 Shellsttxk Identification * 3-203.12 Shellstock Identification Maintained* TagsfRecords: Fish Products 3--402.,11. Parasite Destruction* 3-402.12 Records. Creation and Retention* 590-0040) Labeling of Ingredients' Frequency of Sanitization of Utensils tmd Food Contact Surfaces ofF �ui ment* Conformance with Approved Procedures tHACCP Plans 3-502.11 Specialized Processing Methods* 3-50212 Reduced oxygen packaging, criteria" 8-103.12 Conformance with A roved Procedures* * Denotes critical item in tate federal 1999 Food Code or 105 CNIR 590,000, g Cross-contaminafia R tw animal F<xxls Separated from Cooked and R I t Foods* Contamination from Raw in 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-30211(A) Food Protection* 3-302.15 Washing Fruit and Vegetables 3-304.11 Food Contact with Equipmem and Utensils* Contamination from the Consumer 3-306.14(A)(1d) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-70L11 Discarding Reconditioning unsafe Food" 9 Food Contact Surfaces 4-501.111. Manual Warewashing - Hot Water San itization'I'em. eratmes* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem eratuves* 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 tmd Food Contact Surfaces ofF �ui ment* 4-703.11 Methods of Sanitization Her Water and Chemical* 1p Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms"` 2-301.12 Clearand Procedure* 2-301_14 When to Wash" 1.1 Good Hygienic Practices 2-401.11 Ealing, Drinking, or Using Tobacco* 2-401.12 Discharges From the Eyes, =Nose and Mouth* 3-301.12 Preventing Contamination When Taxiing* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* t3 Handwash Facilities Conveniently Located and Accessible 5-203,11 Numbers and Ca acities* 5-204.11 Location and Placement* 5-205.11 Accessibility, O eration and Maintenance Supplied with Soap and Nand Drying Devices 6-301.11 flandwashing Cleanser. Availability 6-30112 Hand Drying,Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: h/_E sllcs/etm Date: Page: a of CZ Item No. Code Reference c -Critical Item R —Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - -PLEASE PRINT CLEARLY Date Verified tom. o� P v5 6 7 ALL u� /A/9_ Sy4/les / �r ee2.P .eds Vis l)96e c . rev (ptie 1'�)Pko'e / / .o /3 857- k 6e oi2 lVllef 0 5 /F Z Src% A6Z Ati /Doti P cveP c le e .ter 911 'F� /0/11. iiv47 �7' �,2flC' �P 'u hm7 Oe?q/)6- A/� LPd, P /�aU/✓%P ,PST /!J /f rW t -/a EXT - /✓� 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,nd t0 comply with all mandates of the Mass/Federal Food Code. I understand tY� noncompliance may result in daily fines of ent�v�o1 ars or suspe�ion/revocation of your food permit. /` v � Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled El Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: V Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 15 , Denotes critical item in the fMcral 1999 Food Code or 105 CMR 590-000, F3-501-15 Food or Color Additives 3-202-12 Additives" 3-302.14 Protection front Una) roved Additives* FC -2 Poisonous or Toxic Substances 7-101.11 Identifying Irlormanon - Orinnal Containers'1 7-102.11 Common Natne- Workin.* Containers - 7 -201.11 Separation - Strait age - 7 -20111 Restriction - Presence and Use* 7-202.12 1 Conditions of Use* 7-20311 Toxic Containers -Prohibitions* 7-204.11. Sanidzers, Criteria - Chemicals* 7-204112 Chemicals for Wasinq Produce, Criteria" 7-204.14 Dn. in . ents, Criteria - riteria*7-205.(1 7 -205 11 Incidental Food Contact. Lubricants - 7 -206.11 Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stations* 7-246.13 T nicking Powders, Pest Control and Monitorinn* , Denotes critical item in the fMcral 1999 Food Code or 105 CMR 590-000, F3-501-15 Proper Cooking Temperatures for 14 PHFs 3-401.1.1 All )(2) Eggs- 1.55'F 15 Sec. FC -2 E g,s-Immediate Service 145'F'15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 24 Animals - 155'F 15 sec. 3-401.1l(B)(1)(2) Pork and Beef Roast - 134'1, 121 rain* 3-401.11(A)(2) Ratites, Injected Meats- 155'F 1.5 27. sec. 3401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 28. Stuffing Containing Fish, Meat, FC -- 7 Poultr , or Ratites -165`F 15 sec. a` 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145'F * 3401.12 Raw Animal Foods Crooked in a __.009 .- Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs -- 145'F 15 sec- Reheating for Hot Holding 3-403.1] (A)&(D) PHFs 165'F 15 sec. * 3-403.11 (B) Microwave -165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed R'rE. Fond - t40'F* 3-403.li(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501. W(A) Cooling Cooked PFIFs from 140'F to 701 -'Within 2 Hours and From 70'F to 41"F/45'le Within 4 Hours. 3-501.14(13) Cooling PElFs Made .From Ambient Temperature ingredients to 41'F/45°F Within 4I3ours* , Denotes critical item in the fMcral 1999 Food Code or 105 CMR 590-000, F3-501-15 3-501.14(0) PHFs Received at Temperatures According to Law Cooled to 41"F145" F Within 4 Homs. * Cooling Methods for PHFs 14 PHF Hot and Cold Holding 3-901.31(B) 3-501, IO(B) Cold PHFs Maintained at or below, 590.004(F) 41'145° F* FC -2 1-501.16(A) Hot PHFs Maintained at or above 140°7. Raw or:PaitialIv Cooked Antmal Food and Raw Seed S routs Not Served. " 3-501,16(A) Roasts Held atornbove 130°F. 24 Time as a Public Health Control _25._ 26. 3-541-19 Time as a Public Health Connnl* FC - 4 FC -5 594.004(It) Varianceuirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 2'1 3-801.11(A) Unpasteurized Pre-packaged Juices and Beveows with Warning Labels* Animal Foods 'that are Raw. Undercooked or 3-901.31(B) Ilse of Pasteurized Eggs* FC -2 3-801.11(D) Raw or:PaitialIv Cooked Antmal Food and Raw Seed S routs Not Served. " 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-80'1.1 ] (C) Uno xned Food Packa =e Not Re -served. r 1171-103 11 Consumer Advisory Posted for Consumption of FC Animal Foods 'that are Raw. Undercooked or 23. Not Otherwise Processed to Eliminate FC -2 pathogcns * e", :-asnor 24. 3-302.13 Pasteurized Eggs Substitute for Raw Shell FC -3 E gs" 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 tisk factors. Other 590.009 violations relating to good retail practices should be debited under 1#29 - Special Requirements. VIDLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Criaical and non-critical violations, nhieh do not relate to the foodborne illness interventions and riskjuciors listed above, can be found in the following sections of the Food Code and 10.5 CMR 590.000. Item __-_-- -------......, 'Good Retail Practices FC 590--.0-00-- 23. _ Manacientent and Pe-rsonn-e-l--- ----------- FC -2 .003 24. _ --- - Food and Food Protection FC -3 .004 _25._ 26. _ -Equipment and Utensiis Water. Plumbin and Wasie FC - 4 FC -5 .005 .006__ 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC -- 7 .008 29 Silecial R ulrements 30 - --------- _ - Other __.009 .- >:S &Br nb,411d1 p� CITY OF SALEM, MASSACHUSETTS - BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741.1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Church Kitchen Name of Establishment: Temple Shalom Address of Establishment: 287 Lafayette Street Owner's Name: Dorothy Halber Restrictions: Application Date: 12/8/2004 Permit for Food Establishment 220-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSET BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR T� SALEM, MA 01970 v,1 4 TEL. 978-741-1800 OCC �� ?0p4 FAX 978-745-0343 C/ B STANLEY J. USOVICZ, JR. JOANNE SCOTT, MI RS, CHO eOq rO)r MAYOR TT AGENT 2005 APPLICATION FOR PERMIT TO OPERATE'/'A FOOD ESTABLISHMENT/ a NAME OF ESTABLISHMENT TEMPLE SHALOM TEL # 978-741-4880 H ADDRESS OF ESTABLISHMENT 287 LAFAYETT& ST., SALEM, MA 01970 MAILING ADDRESS (if different) OWNER'S NAME TEL # CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(SL CERTIFICATE#(s)' (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON FnFFN TALKOWSKY HOME TEL #9785745-5029 HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun. TYPE OF ESTABLISHMENT . RETAIL STORE YES NO RESTAURANT YES NO /40� 00 BED/BREAKFAST YES NO FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT (such as church kitchens) YES NO CED 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. IC Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my �+t best knowledge and belief, have filed all state ty xieturns and vaid qll state taxes required under the law. Date Social Security or Federal Identificatidfi Number a -----W--�(------------- ------------------ Revised 11/03/03 FOODAP2.adm Check# & Dale Z 0287 LAFAYETTE STREET Temple Shalom City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: _ Item Status Violation Critical Urgency Nature of problem or correction Non-compliance with: Not Done 741-4880 - r Owner Anti -Choking PASS ❑ _Temple Shalom _ Tobacco PASS ❑ PIC: FOOD PROTECTION MANAGEMENT Not Done PIC Assigned / Knowledgeable / Duties PASS RED Inspector:_ EMPLOYEE HEALTH Not Done David Greenbaum Date Inspected: Correct By. x Reporting of Diseases by Food Employee and PIC PASS RED 3/21/2005 Personnel with Infections Restricted/Excluded PASS RED Risk Level: FOOD FROM APPROVED SOURCE Not Done and Water from Approved Source PASS RED Permit Number:Food BHP -2005-0323 Receiving/Condition Tags/Records/Accuracy of Ingredient Statements PASS PASS ❑ RED RED } Status' SIGNED OFF Conformance with Approved Procedures/HACCP PASS RED At of Critical Violations:Plans PROTECTION FROM CONTAMINATION Not Done - :Time IN: '. Time OUT qtr Separation/ Segregation/ Protection PASS RED "Notes:" Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED 37 .. Proper Adequate HandwashingPASS ❑� RED Urgency Description(s): Good Hygienic Practices PASS RED BLUE: Violations Related to Good Prevention of Contamination from Hands PASS RED Retail Practices (Critical Handwash Facilities PASSd❑ RED violations must be corrected immediately or within 10 days)(Non-critical violations GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 23,2005) Pate 1 oft 0287 LAFAYETTE STREET must be Corrected Immediately PROTECTION FROM CHEMICALS or Within 90 days) Approved Food or Color Additives RED. _ RED Violations Related to w Toxic Chemicals FOOdIJome Illness Interventions: RED TIMEITEMPERATURE CONTROLS and Risk Factors (Require 3 ;..( Cooking Temperatures immediate corrective action) RED PASS Reheating RED Cooling PASS Hot and Cold Holding Shalom Not Done Not Done PASS Q RED RED PASS Not Done RED Haz Not Done PASS RED PASS ❑d RED PASS ❑D RED BLUE PASS ❑D RED BLUE PASS PASS RED Freezer in upstairs kitchen had a Water, Plumbing and Waste PASS ❑ temperature of 38°F. Adjust unit to Physical Facility PASS ❑ maintain a temperature of 0°F or below. Time As a Public Health Control PASS W RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other- See Notes PASS ❑ BLUE GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 23,2005 ) PaQe 2 oft STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Church Kitchen Name of Establishment: Temple Shalom Address of Establishment: 287 Lafayette Street Owner's Name: Dorothy Halber Restrictions: Application Date: 12/1/2003 Permit for Food Establishment 47-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT t CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3 • 120 WASHINGTON STREET, 4TH FLOOR NOV 2 4 2003 SALEM, MA 01970 TEL. 978-741-1800 CI Il Or- SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEMPLE SHALOM TEL# 978_741_48RO ADDRESS OF ESTABLISHMENT 2877LAFAYETTE" ST. . SALEM, MA n1470 MAILING ADDRESS (if different) OWNER'S NAME TEL # CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # HOURS OF OPERATION: Mon.`G,30 "ue. —Wed.—Thu.—Fri.—Sat. Sun. RET=AICSTORE•fd` RESTAURANT BED/BREAKFAST FEE-checkionly x , ,r, lessban`1000sq ft6,; "-$'50'd" r,k1000=10,,000sq.ft:...Ys,.,�=$100 more than 10,000sq.ft. =$250 YES NO ��/ less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT (such as church kitchens) YER NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and be ief, have filed all st to tax r turns and aid all tate taxes re wired under law. , �a gl�O��i?o�o9 p �©S�a/!o3 0/(0 ��� Signature Date Social Security or Federal Identification Number -----------------------------------------------------------------}-- - - - -- - - - -- -- ----------------------------------------- Revised 11/03/03 FOODAP2.adm Check# 8 Date :.763 //-,776 ' �S' s Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4t' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name Tim 0LN- Date D2-,2,5_-0 oae ion(s) e otInspection Roufne 1-1Re-inspection Previous Inspection Date:,? -d6-03 ❑ Pre-operation ❑ Suspect Illness El General Complaint ❑HACCP ❑Other El Retail 7D�PCe K Residernlal Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address /,/e 'O _ Risk Level Telephone y4//,- yWG Owner HACCP WN Person in Charge (PIC)00,0r,Time i�`ri3'�Il� In: Out: Inspector�� P�"76,57, Z._/,jL .�� s rztF s t:acn violation cnecKea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. ._FOOD PROTECTION MANAGEMENT ❑ 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 ❑ 6. 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) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S: 5XInsp clFo m6 10 Eoc ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION'. FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMErrEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY 1 ❑ 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: ect ds S ature 7 �CC�.La� f Print: PIC's ignature _Zatof Print: �` J Page 2 Pages V / Violations Related to Foodborne Illness tnterventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 5P0.003(A) I Assignrnent of RespatsibilFeE 590003(Bm) Dmnonsti mn of Knowied 2-103.11. Pcrson in citarie - chrtles EMPLOYEE HEALTH 2 590.003(0) Responsibility of. the person in charge to 590.004(.4-B) require reporting by food employees and 3-201.13 a �licants"' _ 590.003(F) Responsibility Of A Food Employee Or An 3-202.13 Applicant Ta Report'Fo The Person In 3-202.14 Char *eF 590.003{G) Re ortina by Person in Char Le' 3 I 590.003(D) Exclusions and Restrictions* 590.003(Et Removal of Exclusions and Restrictions C Fe C • •r *Denotes emical item in the fedend 1999 Fond Code or M CMR 590.006. 8 Food and Water From Regulated Sources 590.004(.4-B) Coniance with Food Law" 3-201.13 Focxi in a Hermetically Sealed Confniner* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shcli F -es* 3-202.14 Eras and Milk ProduUs. Pasteurized* 3-202.16 Ice Made From Potable Drinkin- Water* 5-101..11 Drinking Water from an Approved System* 590.006(A) Bottled DrinkinR Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" Contamination from the Environment Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed 3-304.11 Sources` Game and Wild Mushrooms Approved by Utensils` Re utatot Autharit 3-202,18 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Game Animals* Receiving/Condition 3-202.11. PHFs Received at Proper Temperatures 3-202.15 Package late rit y"` 3-101.11 Food Safe and Unadulterated Tags/Records: Shellefock 3-202.18 Shellstock Identification 3203.12 Shellsfock Tdeutificaiion Maintained" Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients' Mechanical Warewashing-Hot Water Conformance with Approved Procedures /HACCP Plans 3-5{Y2.11 S ecialized Proeessin� Methoils* 3-502.'13 Reduced os "en lacka ring- criteria' 8-1 Y3.12 Canfrnrnance with A cored Procedures` *Denotes emical item in the fedend 1999 Fond Code or M CMR 590.006. 8 Cross -contamination 3-302.11(A)(]) Raw Amia'd Foo Separated from Cooked and RTE Foods* _ Contamination from Raw ingredients 7 3-302,1 I(A)(2) Raw Animal Folds Separated from Each Other* Contamination from the Environment 3-302.11(4) Food Protection, 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils` Contamination from the Consumer 3-306 14(A)(.B) Returned Food and Reservice of Food" Disposition of Adulterated or Contaminated Food 1 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501,111 Manua Wartiwashing - Hot Water Sanitization 'Cam �erattnes* 4-501.112 Mechanical Warewashing-Hot Water Sanitization Tem eratures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. 'r 0-601.11(A) Equipment Food Contact Surfaces and Utensils Clean" 4-602.11 Cleaning Frequency of Equipment Focxl- Contact Surfaces and Utensils'' 4-702.1 t 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 Amis* 2-301.12 Clennin,2 Procedure* 2-301.14 When to Wash* F-11 Good Hygienic Practices 2401.11 Batin ,Drinking rn' Using Tobacco` 2401.12 Discharges From the Eyes, Nose and Mouth` 3-301.12 Prcventine Contamination When Tastin " 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em k> ccs* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Ca acities* 5-204.11 1 Location and Placement* 5-205.11 Accecsibiht. O reration and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing, Cleanser, Availabdit b-301.12 Hand Dr vino Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: 7G/rLA<e SiJrrlryn Date: o?5- l] �{ Page: `z of Item No. Code Reference C - Critical item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION .. PLEASE PRINT CLEARLY Date Verified u flame p2viCe 11L1, 1)6T a ,z `eI/Q,LIt ! l/I e" /✓O 'l Z'- re We (�/O(Fi Y/"s /I/G 6L /1/0 //1/0GP G ix+ rcl � 61 e La 7 /0--t15 //_/0/ D /� c/� 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 ins 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 ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal 11 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) • 14 3 -501.14(C) Food or Color Additives Use of Pasteurized E-,* 3-202.12 Additives" 3-801.11(0) 3-302.14 Protection froth. Una roved Additives* 1.5 3-501.15 Poisonous or Toxic Substances Ica 7-101.11 Identifying information -Original Containers" 7-102.11 Common Ntarne - Working Containers* 7-201. t 1 Separation - Stora e" 7-202.11 Restriction- Presence and Use* 7-202.12 Conditions of Use - se*7203.'11 720, 11 'Toxic Containers - Prohibitions" 20 7-204.11 7-204.12 Sanitizers. Criteria - Chemicals* Chemicals for Washing Produce Criteria* . 7-204.14 Dryin , Alo-enm Criteria* 7-205,11 Incidental Food Contact, Lubricants" 7-206.11 Restricted Use Pesucides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 TrackinIg Powders, Pest Control and Monitoring' r ,.y 1Cr 3 -501.14(C) Proper Cooking Temperatures for Use of Pasteurized E-,* 3-801.11(D) PHFs 3-801.11(0) 3-401.11A(1)(2) Eggs- 155'F 15 Sec 3-501.15 Eggs- Immediate Service 145"Fl5sec* Ica 3-401,11(A)(2) Comminuted Fish. Meals &Game 3-501.16(B) Animals - 155'F 15 sec. * 3-40LII(B)(1)(2) Pork and Beef Roast -130El2l min" 3-401Al(A)(2) Ratites, hjected Meats- 1.55'F 15 sec. * 3-401.11.(A)(3) Poultry, Wild Game. Stuffed PHFs, 20 Stuffing Containing Fish, Meat. 3-501,19 Poultry oRatites-165°F 15 sec 3-401.11(0(3) Whole -muscle, Intact Beef Steaks 145"1` 4' 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PLEB -- 145"F 15 sec. .,L7 Reheating for Hot Holding 3-403.11(A)&(D) PF1Fs 165'F 15 sec. * 3-103.11(,B) Microwave- 165' F 2 Minute Starabro, ']'lite* 3-403.11(C) Commercially Processed RTE Food 14017- 3-403.11(b) Remaining Unsliced Portions of ,Beef Roasts" 18 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70'F Within 2 Hours and From 70'F to 41'F(45'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 411`t45'17 R ithin 4 Hours - * Denoie.s diticaI item in the federal N99 Ford Code or 10i CMR 590.000. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 3-801.11(A) 3 -501.14(C) PHFs Received at Temperatures Use of Pasteurized E-,* 3-801.11(D) _ Accordim.* to lawv Cooled to 3-801.11(0) UnoenedFoodPacka>eNotRe-served."' 41'F(45'F Within 4 Hours. 3-501.15 Cooling Methods for PHFs Ica 3-302.13 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 41.'145° F* 3-501.16(A) Hot PRFs Maintained at or' above 140"F.x 3--501.16(A7I Roasts Held at or above '130°F. K 20 1 Time as a Public Health Control 3-501,19 Time .is a Public Health Control* 590.004(H) Variance Recuirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 3-801.11(A) Unpasteurized Pre-packaged Iuiees and Beverages with \4arnim, Iabcls* 3-901.11(B) Use of Pasteurized E-,* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 3-801.11(0) UnoenedFoodPacka>eNotRe-served."' CONSUMER ADVISORY �2 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked or Not Otherwise Processed to Elhninate Pathogens.": crre4e,E rrvaoo� 3-302.13 Pasteurized Eggs Substitute for Raw Shelf Eggs* Violations of Section 590.009(4)-(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 factos, Other 590.009 violations relating to good retail practices should be debited under 1129 - Speeial Requirements. (Items 23.30) Critical and non-critical violations, which do not reloie to the frrodborne ithiess inten,enrions and risk facwts fisted aboee, can be found in the follooing sections of the Food Code and 105 CMR 590.000. corva CITY OF SALEM, MASSACHUSETTS �y BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR `� 11 SALEM, MA 01970 ��syBa TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: Dorothy Halber Name of Establishment: Temple Shalom Address of Establishment: 287 Lafayette Street Type of Establishment: Church Kitchen Application Date: 12/11/2002 Restrictions: Permit for Food Establishment 65-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT e ,i CITY OF SALEM, MASSACHUSETTS IRo �1,�JhI �OONUITA� Sy O! BOARD OF HEALTH V 120 W4SHIN310N STREFF..aiH F1.001: DEC 0..2002 SAL =m, MA 01970 s� �gq��rllN6 TEL, 978-74 I - i 800 L{ 1 Y �..Ji SHL�NI FAI 978-745-0343 gOARE) OF HEALTH STANLEY USOVICZ. JR, JO -NNE SCOTT MPH, RS, CHO MAYOR HEALTH P.6HNl 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEMPLE SHALOM TEL #_978-741-4880 ADDRESS OF ESTABLISHMENT 287 LAFAYETTE ST. SALEM MA 01970 MAILING ADDRESS (if different) OWNER'S NAME TEL # ADDRESS CITY_ __ STATE_ ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # HOURS OF OPERATION: Mon.Tue.Wed._Thu. Fri.—Sat.—Sun.— TYPE ri._Sat.Sun.TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT (such as church kitchens) e N06 -t;-013 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 b lief, have filed all state tax retufns and paid all state taxes required under the law. _'4;zAak. ��w / /�5/a 03;--- 96- 3o'7�j Signature U Date Social Security or Federal Identification Number Revised it/25/02 FOODAP2.adm Check#&Date �� ZgE— 5 "�1 �' THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name _ t PIC's Signature: /!l� j �� / Date / zfp (, T f r i n p Food Service LJ Retail El Residential Kitchen El Mobile El Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Type of Inspection ❑ Routine ❑ Re -inspection Previous Inspection Date: ElPre-operation ❑ Suspect Illness ❑ General Complaint ❑ HACCP ❑ Other Address - -�) 'J/ - Risk Level Telephone 7� _ / - / �l c /�f Owner (HACCP {l7l�G+'� �b{ Y/N Person in Chaige (PIC) / . //l n. Time In: Out: Inspector Cr/ Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking 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. Local Law ❑ 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 .0,- ❑ 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. 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 ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (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 Signature: I Print�_�/�. PIC's Signature: /!l� j �� / Print: Pageof-ages FORM 734A HOBBS & WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION MANAGEMENT 590.003(A)Assi nment of Responsibility* H590.003(B) Demonstration of Knowledge* 2-103.1 I 1 Person in Charge - Duties EMPLOYEE HEALTH C 5 C FOOD FROM APPROVED SOURCE 590.003(C) Responsibility of the Person in Charge to x: 3-201.12 require reporting by Food Employees and 3-201.13 Fluid Milk and Milk Products* Applicants* Shell Eggs* 590.003(F) Responsibility of a Food Employee or an 3-202.16 Ice Made from Potable Drinking Water* Applicant to Report to the Person in Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* ,�3'1 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C 5 C FOOD FROM APPROVED SOURCE * Dentes critical item in the federal 1999 Food Code or 105 CMR 590.000. .8 9 IL 13 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 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* 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* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(7) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* * Dentes critical item in the federal 1999 Food Code or 105 CMR 590.000. .8 9 IL 13 PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces 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* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY of SALEM BOARD OF HEALTH Establishment Name: V -/-N Date: 01?611C3 Page: G of item No. Code Referenc C—Criticalftern 9 —,Red Itern_, DESCRIPTION OF VIOLATION PLAN OF,C?�RIECTIOW, PLEASE PRIW CLEARLY Date Verified Z5 A-9 -)1; 6"-//�) Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: 0 No U Yes Q Voluntary Compliance U Employee Restriction Exclusion U Re -inspection Scheduled Q Emergency Suspension U Embargo U Emergency Closure U Voluntary Disposal Q Other i FORM 734B HOBBS&WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) (Cont.) PROTECTION FROM CHEMICALS Em f Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous orToxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS 16 PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.11(D) PHFs 3-501.16(B) 590.004(F) 3-401.11A(1)(2) Eggs - 155*F 15 Sec. Hot PHFs Maintained at or above 140°F* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155°F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 Min.* Physical Facility 3-401.11(A)(2) Ratites, Injected Meats- 155°F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165*F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* 17 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) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 18., Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140*F to 70°F Within 2 Hours and from 70*F to 41°F/45*F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. '20 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(D) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/450F* 3-501.16(A) Hot PHFs Maintained at or above 140°F* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21; 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 3-801.1l(B) Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* Ellecwv 11112001 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* MAAMrLl• 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relote to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Sp ecial Requirements .009 30. Other co n CITY OF SALEM, MASSACHUSETTS # BOARD OF HEALTH -- 3 120 WASHINGTON .STREET, 4TH FLOOR a _ SALEM, MA 01970 - TEL. 978-741-1800 - FAX 978-745-0343 STANLEY USOVICZ, JR. _JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATEA.FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter. 94, Section 305A and Chapter III, Section 5 of the General Laws,'to.operate a Food Establishment in the. City of Salem is.hereby granted to: Owner's Name: Dorothy Halber Name of Establishment: Temple Shalom Address of Establishment: 287 Lafayette Street Type of Establishment: Church Kitchen I: Applicatioii'Date: 11/28/2001 Restrictions:; ' Permit for Foo& Establishment - 53-02:1 Frozen Desserts/Ice Cream Permit.for:.the Sale of Tobacco Products These'Permits Expire .Decembercg31, 2002: This permit'is not transferable and musttbe reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. I HEALTH AGENT j 0 E s These'Permits Expire .Decembercg31, 2002: This permit'is not transferable and musttbe reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. I HEALTH AGENT j 0 e CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH ® d 120 WASHINGTON STREET, 4TH FLOOR TTTAAA (�'�� SALEM, MA 01 970 D 1C��, j� mfr TEL. 978-741-1800 111'tNNyVVVI11I777i FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO I*VY 2 3 LVUI MAYOR HEALTH AGENT LEM HEEAOTjH DE ALEPT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEMPLE SHALOM TEL # 978-741-48800 ADDRESS OF ESTABLISHMENT 287 LAFAYETTE ST. MAILING ADDRESS (if different) OWNER'S NAME TEL # ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # DAYS/ HOURS OF OPERATION: Mon.- Tue.-Wed.-Thu.-Fri.-Sat.-Sun.-TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO �, 3 Qp�- $40 RESTAURANT YES NO y $40 BED & BREAKFAST YES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO NO CHARGE FOR NON-PROFIT (such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Revised 11/1/01 foodapZadm Check#& Date Social Security .�,.:w,:h+,r..n,,,'k+M.ti..s...,x+.. rtLa.r.s�'„'"..�V"'-M•^"i+r'.'^`^,r..-...P..:9^�wKw..m.-mar www-......�.�-^F .:_ _: THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street Board Of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 740-9705 Name I/ / 1 Date T of O eration s T of Iey� ns�ection / //fn X- I ,r77eS ! -D ❑ Food Service Retail J Routine ❑ Re -inspection Address Risk 1G eA S Level ❑ 1-1Mobile Residential Kitchen Previous Inspection Date: a -,R3 -WW 1 Telephone7 _ U8%0 ❑ El ❑ Temporary Caterer Bed & Breakfast ❑ Pre-operation Suspect Illness ❑ General Complaint Owner / 7Z�1A t� O fp0 `Yl HACCP Y/N Person in Charge (PIC )Q� Time P ❑ HACCP Inspector In: ❑ Other yy� S Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with; RED Violations (1-22) 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. Local Law ❑ 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 IngrediehhStatements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION I8. Separation / Segregation / Protection V9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing t ❑ 11. Good Hygienic Practices BLUE Violations (23-301 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. Ca 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 SSWliupttFam610 tloc - ❑ 2. Prevention of Contamination from Hands (13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (RED Items 1-22): Official Order of 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 mustbe 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: Z //Print: Print: PIC's Signature: a,0(tom N Page � of S Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION AND MANAGEMENT l_ 8.„ L_1"590.003(A) I Assignment of Responsibility* 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 Law* 3-201.12 require reporting by food employees and xi Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Re ortin b Person in Charge* Shellfish and Fish From an Approved Source 590.003(D Exclusions and Restrictions* 3-201.15 590.003E Removal of Exclusions and Restrictions i5 7 FOOD FROM APPROVED SOURCE *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C } PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 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* 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* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Inte rit 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* -T-4-0 Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records Creation and Retention* 590.004(J) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C } PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1 l(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, concentration and hardness* 4-601.11(A) Equipment Food Contact Surfaces and - Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces 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* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* - 2-301.14 When to Wash* -T-4-0 Good Hygienic Practices 1.11 Eating, Drinking or Using Tobacco* 2-401..12 Discharges from the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6 301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: Z22Up,/P S//nl�m 1/-f/14- e,-7 �eiL, i�e,S ) Date: R- ` 00-- Page: I of 3 Item Code C- Critical Item, > DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No „ Reference R'— Red Items s- PLEASE PRINT CLEARLY Verified'' e,, 4 -hew G/L/fiPs /.Se � /(X 4/ JY / 0erC/t A-10 / w 9? dl r, / 47S 44,es /3 AAS i,1/e. v.7 P S i S .Q e, 107 -4AeVl N f 7P/jSi marId/ -Vex c Aod-n /]/P�-Jz 9 ,/e/l e d Iw -e, o !/ e4 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 i violations before the next inspection, to observe all conditions as described, and to comply Exclusion ❑ ❑ Emergency with all mandates of the Mass/Federal Food Code. I understand that noncompliance may Re -inspection Scheduled Suspension result in daily fines of'twenty-five dollars or suspension/revoca%n of our food permit. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 734B � HOBBS & WARREN - BOSTON t- Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 'A 15! TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 3-50L16(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 e* 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 Food Code or 105 CMR 590.000. 20,, 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.11(D) PRFs 3-50L16(B) 590.004(F) 3-401.11A(1)(2) Eggs - 155*F 15 Sec. Hot PHFs Maintained at or above 140°* F 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155°F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 Min.* Physical Facility 3-401.11(A)(2) Ratites, Injected Meats- 155°F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165°F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All OtherPHFs- 145°F 15 Sec.* 17,, 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) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 18 ` Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Within 2 Hours and from 70°F to 41*F/45*F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 20,, 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(D) PHF Hot and Cold Holding 3-50L16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/450F* 3-501.16(A) Hot PHFs Maintained at or above 140°* F 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) '21-: 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 3-801.1l(B) Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* 3-801.11(C) Unopened Food Package Not Re-serv* ed. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* E1/ective 1/'12001 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* rt CllU1Hr MtN 1 J 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other CITY OF SALEM BOARD OF HEALTH Establishment Name: 2tz22 1,,. . (fe/J n, Date: a- ra --/ut Page: 3 of _ 9 Item , No. Code f Reference,,, CF— Critical Item'. Red R"6 �', DESCRIPTION OF VIOLATION / PLAN OF CORRECTION � � '11 yz. < PLASg INCLEARLY Date -.. Verified, .. lCe a e. , c ` 7 R -p all � �G - .cYxr,Nl)�irto /J P e J eeJe0 C IL'At e -v ry 141r r:,r ff A1dQ'S1PIy A/a . rJ - I' m /ur Ax r° i a e22t a5Lva /v c ✓ � 7'�n i o � d° S til `L/ /LO O A / Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions ar d 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/rev" catio f your food permit. L 9 t r of o fa A,/C� a L�rr t Corrective Action Required: ' ❑ No r"y ` ;❑yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 7348 HOBBS a WARREN - BOSTON I J Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14f , Food or Color 15 TIME/TEMPERATURE CONTROLS 16 Additives 3-202.12 Additives* 3-202.14 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* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers,Criteria- Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drving 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 16 PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.11(B) PHFs 3-501.16(B) 590.004(F) 3-401.11A(1)(2) Eggs - 155°F 15 Sec. Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155°F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast -130°F 121 Min.* Physical Facility . 3-401.11(A)(2) Ratites, Injected Meats - 155*F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165°F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs - 145°F 15 Sec.* 17;i 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* 3-403.1 l(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 185 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140*F to 70°F Within 2 Hours and from 70*F to 41°F/45°F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 19 720;. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/45°F* 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) -.21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.00 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* Effective 11112001 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* 1a 1_1R 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility . FC -6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other ..4 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT NINE NORTH STREET Tel: (978) 741-1800 Fax: (978) 740-9705 In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: Dorothy Halber Name of Establishment: Temple, Shalom Address of Establishment: 287 Lafayette Street Type of Establishment: Church Kitchen Application Date: 11/30/2000 Restrictions: Permit for Food Establishment 16-01 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2001 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT NOV 3 0 2000 CITY OF SALEM HEALTH DEPT. CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel: (978) 741-1800 Fax: (978) 740-9705 2001 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S TEMPLE SHALOM 287 LAFAYETTE ST. TEL# 978-741-4880 TEL # ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON- HOME TEL # TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTAURANT YES NO # seats_ # nonsmoking_ BED & BREAKFAST YES NO ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO TOBACCO VENDOR YES NO FEE check only $40 $40 $40 $5 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. c' Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge'and belief, have filed;all state tax returns and paid all state taxes required under the lava: 633 - 36 3a77 Signature V Date Social Security or Federal Identification Number ------------------------------ ---•----------------- -'-------------------- -------------------------- Revised 11/21/00 foodap2.adm Check#& Sanaa Form ST -2 Certificate of Exemption Massachusetts Department of Revenue Certification is hereby made that the organization herein named is an exempt purchaser under General Laws, Chapter 64H, sections 6(d) and (e). All purchases of tangible personal property by this organization are exempt from taxation under said chap- ter to the extent that such property is used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation. Willful misuse of this Certificate of Exemption Is subject to criminal sanctions of up to one year In prison and $10,000 ($50,000 for corporations) In fines. (See reverse side.) TEMPLE SHALOM SONS OF JACOB TEMPLE SHALOM 287 LAFAYETTE SALEM OF CONGREGATION OF CONGREGATION \\ ST MA 01970 NvI AJDNONACLC VH IKANSFEHABLE FA EXEMPTION NUMBER E 042-163-016 ISSUE DATE 09/05/96 CERTIFICATE EXPIRES ON 09/05/01 COMMISSIONER OF REVENUE MITCHELL ADAMS THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Board of Health FOOD ESTABLISHMENT INSPECTION REPORT Address: 9 North Street Salem, MA 01970-3928 Tel: (978) 741-1800 Fax: (978) 740-9705 Name // Date T e of O eration s Tvoe of Inspection ❑ Food Service Retail /3 {I=C!y a? -,92 -Root CRRoutine ❑ Re -inspection Address 1Risk Qa d u / S f Level ❑ ❑ Residential Kitchen Mobile Previous Inspection Dater -.23_ ;R000 Telephone / -7L//- ❑ ❑ Temporary Caterer ❑ Pre-operation ❑ Suspect Illness Owner HACCP Y/N ❑ Bed & Breakfast El General Complaint Person in Charge (PIC) Time In: ❑ HACCP ❑ Other Inspector / l/ ✓%n�i/S�///%iv' %moi//� `% Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) Violated. Non-compliance with: RED Violations ti -22) 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) ❑ s9o.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ 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 r ❑ 8. Separation / Segregation / Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing E110. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices BLUE Violations (23-30) 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 5: 50IFm 614.Joc ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY 1-122. Posting of Consumer Advisories Number of rotated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (RED Items 1-22): Official Order of Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or -its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: Print: PIC's Signtore: ._j Print: Page of Pages n Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION AND MANAGEMENT C 1 590.003(A) Assignment of Responsibility* 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 •'r. 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003 G Re ortin b Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003E Removal of Exclusions and Restrictions 4 I5 LIE 741 FOOD FROM APPROVED SOURCE *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C F10 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 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* 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* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records; Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Ta s/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records Creation and Retention* 590.004(J) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C F10 PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.1 t4 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* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges from the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision ^ - - THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name Date a -a 3-G0/ Address Page -�—' of z rig ///Ga liv Item No. In thespacebelow describe all violations checked on front page. A(n) Ale. ,lr.rr/ L(; Exm/CN inspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments, Chapter X, 105 CMR 590.000. The following violations were observed: .t7Ce A l./ ayw 4 ® ' Discussion with Management 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 Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT NINE NORTH STREET Tel: (978) 741-1800 Fax: (978) 740-9705 In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: Dorothy Halber Name of Establishment: Temple Address of Establishment: 287 Type of Establishment: Church Application Date: 03/14/2000 Restrictions: Permit for Food Establishment Frozen Deserts/Ice Cream Shalom Lafayette Street Kitchen Permit for the Sale of Tobacco Products These Permits Expire December 31, 2000 1E This permit is not transferable and must be reissued upon change of ownership or location. In accordance with the State Sanitary Code, all plans of renovations, improvements, equipment changes must be approved by the Health Department. - V//' HEALTH=AGENT, =� CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 MAR 1 3 9000 CITY OF SALEM HEALTH DEPT. JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel: (978) 741-1800 Fax: (978) 740-9705 2000 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEMPLE Shalom TEL 978-741-4880 ADDRESS OF ESTABLISHMENT 287 LAFAYETTE ST., SALEM, MA 01970 MAILING ADDRESS (if different) OWNER'S NAME TEL # CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON TEL ESTABLISHMENTS DAYS & HOURS OF OPERATION NON-PROFIT ORGANIZATION /NO FEE TYPE OF ESTABLISHMENTr FEE check only RETAIL STORE YES NO t $40 ��rt'�'� RESTAURANT YES NO # seats_ # nonsmoking_ $40 n ADDITIONAL PERMITS MAKE FROZEN DESSERTS YES NO TOBACCO VENDOR YES NO $5 $10 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. 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. - -_ - Pu-rsuaht=ttd€MOI_ C-hapter=620; Sechom49A 1 certlfy=uhderthe�pains and penaltles=6f=pddwTthat4,�to my `=3 best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Revised 10/20/98 foodap2.adm Check# & 311610 333-30' -307` Date Social Security or Federal Identification Number • THE COMMONWEALTH OF MASSACHUSETTS City of Salem BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT Establishment Name Date a n Address f `7 Time: In Out Telephone r Type of Establishment: Food Service Retail Food Purpose: Routine tom% Owner's Name lz2weP Residential Kitchen o�low up jy/ (r�l S. Person in Charge Mobile Unit Temporary Food Service Complaint• Investigation 10. Inspector's Name Catering U Other Based on an Inspection today, the Items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column "N" and critical violations are marked under column "C". Descriptions of each Item appear on the back of this form. Each violation checked requires an explanation on the narrative page(s). This report serves as official notice of violated provisions and official notice to correct said violations. Food 1. Food Supply 2. Food Containers Food Protection 3. PHF Temperatures 4. Facilities. Hot iS Cold Storage 5. PHF Re -service 6. Spoiled/Damaged Foods' ,20. Food Protected (r�l S. Food Thermometers 9. Cross Contamination 10. PHFs thawed, cooked d cooled 11. Food Handling 12. Dispensing Utensils Personnel 13. Employee Infections 14. Employee Hygiene 15. Employee Clothing Equipment A Utensils 16. Equipment/Utensil Clean 8 Sanitized 17. Food Contact Surfaces 18. Non -Food Contact Surfaces 19. Food Contact Surfaces Clean ,20. Non -Food Contact Surfaces Clean 21. Wiping Cloths 22. Dish/Warewashing Facilities 23, Pre -Scraped, Soaked 24. Wash/Rinse Water 25. Thermometers/Test Kits 26. Equipment/Utensil Storage 27, Single Service Articles 28. Single Service Re -Use N C .0021F .002 .008 .009 .010 .013 .013 .013 .013 .013 .013 .013 .013 .013 .013 .014 .01`4 0112 Sanitary Facilities 29. Water Source 30. Sewage 31. Cross -Connections 32. Toilets/Handwashing 33. Insects/Rodents 34. Plumbing 52. Toilet Rooms Handwashing Areas 37. Garbage/Refuse 38. Outside Disposal 39. Outer Openings 40. Pesticide/Rodenticide Application Physical Facilities 41. Floors 42. Walls, Ceiling 43. Lighting 44. Ventilation 45. Dressing Rooms Other 46. Toxics 47. Premises 48. Living Areas 49. Linen 50. Pets 51. Bulk Foods 52. Salad Bars .015 .016 .017 .018 8 .019 021 .017 .018 .019 .020 .020 .021 021 .022 .022 .023 .024 .025 .026 .027 .027 .027 .027 .031 .032 LN of 13 Critical Items Violated _ se items require immediate attention. t ^'•="�''�'Received y Inspected by SMOKING LAW COMPLIANCEYESNO_NA Reinspection of Critical Items FORM 734A r1&w H09R5 a WARREN 'M CHOKE SAVER COMPLIANCEYES_NONA Reinspection of Noncritical Items - W Establishment Name Date Address Page 0 of Item No. In the space below describe all violations checked on front page. (n) eg,;�g me- p4&A AIIIC4f�g inspection of this establishment was conducted in accordance with the State Cpde for Food Establishment Ch t r X, 105 CMR 4 590.000. The following violations were observed: • -A-M-40OWUR151190 i NO,! 00-1.5 Will! IN 11PNINNAM t �i r MEN "101175N. 11111111 L/ opportunityDiscussion with Management /V6 2A,( 74 "1 I have read this report, have had the all conditions as described, and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. •` �,rw�.,y{"Fw.d'�ivt�`�.rF�1/'/`h"nS`�+-•ws,�+�:M/�rnrv{�r'�kkrxr«*+�.T�+9nirAti}n�v.,,.,:�.f-I-•,�,.�li.�,j�'�.:,F/'n.h,,,»t. .�_,. THE COMMONWEALTH OF MASSACHUSETTS City of Salem JOANNE SCOTT. MPH, RS, CHO HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT NINE NORTH STREET Tel: (978) 741-1800 Fax: (978) 740-9705 In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: Dorothy Halber Name of Establishment: Temple Address of Establishment: 287 Type of Establishment: Church Application Date: 12/21/98 Restrictions: Permit for Establishment Frozen Desserts/Ice Cream Shalom Lafayette Street Kitchen Permit for the Sale of Tobacco Products These Permits Expire December 31, 1999 118-99 This permit is not transferable and must be reissued upon change of ownership or location. In accordance with the State Sanitary Code, all plans of renovations, improvements, equipment changes must be approved by the Health Department. HES ALTH AGEN CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 DEC 1 1 1998 CITY OF SALEM HEALTH DEPT. JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel: (978) 741-1800 Fax: (978) 740-9705 1999 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEMPLE SHALOM TEL# 978-741-4880 ADDRESS OF ESTABLISHMENT 287 LAFAYETTE ST. MAILING ADDRESS (if different) OWNER'S NAME TEL # ADDRESS _ CERTIFIED FOOD MANAGER'S NAME(S)_ CERTIFICATE#(s)___ (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON _TEL # .. ESTABLISHMENT'S DAYS & HOURS OF OPERATION NON—PROFIT ORGANIZAT ioN� Cep �9TYPE OF ESTABLISHMENT _ I. FEE check only RETAIL STORE YES NO $40 RESTAURANT YES NO # seats_ # nonsmoking_ $40 ADDITIONAL PERMITS MAKE FROZEN DESSERTS YES NO $5 TOBACCO VENDOR YES NO $10 Please pay totai with one check payable to the City of Salem This permit is not transferable and must be reissued upon change of ownership. 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 !, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature ,-,_ ,, Date - Social Security or Federal Identification,Number / � — --------------------------- Revised 10/20/98 foodap2.adm Check# & Massachusetts �. `I Form ST -2 Department of 91~ Certificate of Exemption Revenue Certification is hereby made that the organization herein named is an exempt purchaser under General Laws, Chapter 641 sections 6(d) and (e). All purchases of tangible personal property by this organization are exempt from taxation under said chap - e' to the extent that such property is used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation. Willful misuse of this Certificate of Exemption is subject to criminal sanctions of up to one year in prison and $10,000 ($50,000 for corporations) in fines. (See reverse side.) TEMPLE SHALOM SONS OF JACOB TEMPLE SHALOM 287 LAFAYETTE SALEM OF CONGREGATION OF CONGREGATION ST MA 01970 NOT ASSIGNABLE OR TRANSFERABLE EXEMPTION NUMBER E 042-163-016 ISSUE DATE 09/05/96 CERTIFICATE EXPIRES ON 09/05/01 COMMISSIONER OF REVENUE MITCHELL ADAMS F IkV O, DEC 1 1 1998 CITY OF SALEM HEALTH DEPT. THE COMMONWEALTH OF MASSACHUSETTS TOWN OR CITY OF FOOD ESTABLISHMENT INSPECTION REPORT A Establishment Name _ Date Address Time: In Out N C 1. Telephone _ L _. / Type of Establishment: Food Service k Retail Food Purpose: �I Routine Owner's Name 2. Residential Kitchen Follow-up 30. Sewage Person in Charge Mobile Unit Complaint Temporary Food Service Investigation Food Inspector's Name I Catering Other .019 3. PHF Temperatures Based on an Inspection today, the Items checked below indicate the violated provisions of 105 CMR 590.000. Each item is followed by the applicable section of the Massachusetts regulation. Non-critical violations are marked under column"N" and critical violations are marked under column "C". Descriptions of each item appear on the back of this form. Each violation checked requires an explanation on the narrative page(s).. This report serves as official notice of violated provisions and official notice to correct said violations. Food N C Sanitary Facilities N C 1. Food Supply .00229. Water Source .015 2. Food Containers .002 30. Sewage .016 31. Cross -Connections .017 Food Protection 32. Toilets/ Handwashing .018 8 .019 3. PHF Temperatures .004 33, Insects/Rodents .021 4. Facilities. Hot b Cold Storage .004 34, Plumbing .017 S. PHF Re -service .006 35. Toilet Rooms .018 6. Spoiled/Damaged Foods .003 36. Handwashing Areas019 7. Food Protected .003 37. Garbage/Refuse .020 8. Food Thermometers •004 38. Outside Disposal .020 9. Cross Contamination .005 39. Outer Openings .021 10. PHFs thawed, cooked d cooled .005 40. pesticide/Rodenticide Application .021 11. Food Handling .005 12. Dispensing Utensils .006 Physical Facilities 41. Floors .022 Personnel 42. Walls, Ceiling .022 13. Employee Infections .008 43. Lighting .023 14. Employee Hygiene .009 44. Ventilation .024 15. Employee Clothing .010 45. Dressing Rooms .025 Equipment i Utensils Other 16. Equipment/Utensil Clean 8 Sanitized .013 46. Toxics .026 17. Food Contact Surfaces .013 47. Premises .027 18. Non -Food Contact Surfaces .013 48. Living Areas .027 19. Food Contact Surfaces Clean .013 49. Linen .027 20. Non -Food Contact Surfaces Clean .013 50. Pets .027 21. Wiping Cloths .013 51. Bulk Foods .031 22. Dish/Warewashing Facilities .013 52. Salad Bars .032 23. Pre -Scraped, Soaked .013 24. Wash/Rinse Water .013 No. of 13 Critical Items Violated 25. Thermometers/Test Kits .013 These items require immediate attention. _ 26: Equipment/Utensil Storage .014 27. Single Service Articles .014 Re ewed y' Inspected by �_ ��°�^ 28. Single Service Re -Use .012 �+a�^-- •� SMOKING LAW COMPLIANCE -YES -NO -NA Reinspection of Critical Items FORM 734A ti& HOBBS 8 WARREN CHOKE SAVER COMPLIANCE -YES -NO -NA Reinspection of Noncritical Items FOOD C1 Food Source, approved, wholesale 2 Containers, property labelled Full Item Descriptions FOOD PROTECTION C3 Potentially hazardous foods at proper temperatures: 140°F or above, 45°F or below, O°F; rapid cooling of cooked foods within 4 fours C4 Facilities to maintain product temperature C5 Unwrapped and potentially hazardous foods not re -served 6. Damaged, spoiled, returned foods segregated 7 Food protected during storage, preparation, display, dispensing, service, transportation 8 Thermometers provided, conspicuous, accurate 9 No cross -contamination 10 Potentially hazardous foods properly thawed, cooked, and cooled 11 Food handling minimized 12 Dispensing utensils stored PERSONNEL C13 Employees with infections restricted C14 Hands washed and clean; good hygienic practices 15 Clean clothes, hair restraints EQUIPMENT & UTENSILS C16 Equipment, utensils sanitized (automatic and manual methods) 17 Food contact surfaces: designed, constructed, installed, maintained, located 18 Non-food contact surfaces: designed, constructed, installed, maintained, located 19 Food contact surfaces clean, free of all cleansers 20 Nonfood contact surfaces clean, free of all cleansers 21 Wiping cloths; clean, use restricted 22 Dish/Warewashing facilities: designed, constructed, maintained, installed, located, operated 23 Pre -flushed, scraped, soaked 24 Wash/Rinse water clean, temperature 25 Accurate thermometers, chemical test kits provided; instructions posted 211 Storage, handling of clean equipment/utensils 27 Single service articles, storage, dispensing 28 No re -use of single service articles SANITARY FACIUTIES Water source; approved, hot 8 cold under pressure C30 Sewage and waste water disposal C31 No cross -connections, back siphonage, backflow C32 Toilets 8 Handwashing: number, accessible, design, Installed C33 No insects or rodents; harborage prevented 34 Plumbing; installed, maintained 35 Toilet rooms enclosed, self-closing doors, fixtures good repair, clean, signs 36 Handwashing areas supplied with soap and towel dispensers, proper waste receptacles 37 Garbage and refuse: containers covered, adequate number, insect/rodent resistant, frequency, clean 38 Outside area: dumpster covered, construction, clean 39 Outer openings protected 40 Pesticides and rodenticides, proper application PHYSICAL FACILITIES 41 Floors constructed, maintained, clean 42 Walls, ceiling attached equipment constructed, maintained, clean 43 Ughting provided as required, fixtures shielded 44 Rooms and equipment vented as required 45 Dressing, locker areas provided, clean OTHER C46 Toxics properly stored, labelled, used 47 Premises litter -free, unnecessary articles, cleaning maintenance equipment properly stored. Authorized personnel 48 Uving/sleeping quarters and laundry separate 49 Linen properly stored 50 No pets or other large animals except guide dogs 51 Bulk foods stored, labelled, dispensed 52 Salad bar operations prepared, refrigerated, displayed, protected . rT.. .. v�..:-A4✓r'.r a,. we'+ �" �-. .r✓`r :•'rd a,.•,��F«.r.r, ,l.r mw.�. ,. ,�.._p., THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name Date Address Page _? of Item No. In the space below describe all violations checked on front page. Ain) ,A,,,, w,. ,e,-„/ q.,,,,)„ inspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments, Chapter X, 105 CMR 590.000. The following violations were observed: A r. Y l.v Discussion with Management 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 Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. U wwasacnusecis Form ST -2 Department m Certificate of Exemption Revenue Certification is hereby made that the organization herein named is an exempt -purchaser under General Laws, Chapter 64H, sections 6(d) and (e). All purchases of tangible personal property by this organization are exempt from taxation under said chap. ter to the extent that such property is used in the conduct of the business of the purchaser. Any abuse or misuse of this certificate by any tax-exempt organization or any unauthorized use of this certificate by any individual constitutes a serious violation and will lead to revocation. Willful misuse of this Certificate of Exemption Is subject to criminal sanctions of up to one year In prison and $10,000 ($50,000 for corporations) In fines. (See reverse side.) TEMPLE SHALOM SONS OF JACOB TEMPLE SHALOM 287 LAFAYETTE SALEM OF CONGREGATION OF CONGREGATION ST MA .01970 NOT ASSIGNABLE OR TRANSFERABLE FEB 5 .1990 CITY OF SALEM HEA! T`-1 DEPT. EXEMPTION NUMBER E 042-163-016 ISSUE DATE 09405/96 CER IFICATE EXPIRES ON 09/05/01 COMMISSIONER OF REVENUE MITCHELL ADAMS