The URL can be used to link to this page

THE OLD SPOT - ESTABLISHMENTSTHEOLD SPOT \ 121. ESSEX STREET :i Milieea Oraibi-Crocker owner. - Phone 978-922-6868 Fax 97oreeGa e.co www.wiMhorsecafe.com � ^1 �B�r C'1oc�ti 392 Cabot Street - Rt. 1A W H10444 C4 Beverly, MA. 01915 - Exit 205 off Rt: 128 - 1.5 miles on the right .t, • KIM13ERLEY DRISCOLL MAYOR LARRY RAMDM, RS/REHS, CHO, CP -FS HEALTH AGENT Date: '7 Z.p Complaint Number: 0915 Complainant ,F -Ln) 4J & Address: CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4T" FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 LRAMDINQSALEM.COM COMPLAINT INTAKE FORM Time: 3'. -Ajr>r, Received By: P Phone: 9 -7 ? - S 4ko - 3S �k -AIL 47--n4*- oLOD SP6i oW -I-Mo 41 gaa0 ILL. g ptOALS )aa T46 pnm 44) eaT�& Gli \LiLEd-� F 1vJkA ti- Wfsr 1 Lt3a,-s v4 j ;U1, Uo►* ITi� . ID1nAY]iFSi 4 'P- s� Is [-x!NrV, 1-0 T)Y. D6L, A440 a\v`. 04'T„y \Js 617 - Investigated By:D 17- is is InvestigatedBy:D Date: Property Owner/Occupant Name Telephone #: 1- I►aY6S1111pirti0 "Tw)t Cea-*L4ZAaA� A110 a-b-jtD nI -* F4L1J1paektl 'J fAU-`Mr'.o Wei 's 60'a N �ilb eY� N%'Wwa A00ti�.uV�NC�- 2, A 5 'T14 N 'bs-1 p4q." 11e+'t4l� I Pt1.a�VlT 6aVP�tiPCA15a ., ? flgq� Tb NAvv rVi - Co6 s\, Cj art 'pa 0 Massachusetts Department of Public Health Division of Food and Drugs City/Town of FOOD ESTABLISHMENT INSPECTION '6NPORT Salem Board of Health 120 Washington Street, 4' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 AddrresssC/I 1 ,: (�, Tel. C- -) C 0 1 �S/J// Name 1 ( td D e Type of Operation fs) ❑ Food Service ❑ Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer E]Bed 8 Breakfast Permit No. Type of Inspection ❑ Routine E]Re-inspection Previous Inspection Date: ElPre-operation ❑ Suspect Illness ElElGeneral Complaint HACCP ❑ Other Address cz Telephone v Risk Level OwnerHACCP (FC5x590.006) YIN Person -in Charge (PIC Ti In•� Out:eVy\ Inspector Each violation checked requires an explIon on the narrative page(s) and a citation of specific provision(s) violated. Noncompliance with: Violations Related to Foodborne Illness rventions and Risk FactorsjRed Items) - Anti -Choking 590.008 (E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009 (F) ❑ Allergen Awareness 580.009 (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 LFOOD FROM APPROVED SOURCE _ ❑ 4. Food -and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans .PROTECTION FROM CONTAMINATION_ ❑ 8. Separation/Segregation/Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices -(Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Noncritical (N) violations must be corrected immediately or within 90 days as determined by the Board 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 (FC5x590.006) 27. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FC -7x590.008) 29. Special Requirements . rl/'�.(/ ,((590y.009) 14. Other a� � 4M dd ❑ 12. Prevention of Contamination from Hands NX3. Handwash Facilities ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals ITIMEREMPERATURE.CONTROLS (Potentlaltylia¢'ardous Foals)"� ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control IREOUIREME_NTSFOR_HIGHLY-SUSCEPTIBLE=POPULATIONS';(HSP): ❑ 21. Food and Food Preparation for HSP 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/� f , TE OF R`rE-InINS,PAECTI�ON: � �l Inspector's Signature: Print: PIC$ Signature: Print: - Page of Pages lr� Violations Related to Foodborne Illness Interventions and Risk Factors (Mems 1-22) FOOD PROTECTION MANAGEMENT I 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 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 Tee Made From Potable Driakiag Water* Applicant To Report To The Person In Dri Rking Water front an Approved System* 590.006(A) Charge* 5,90.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C 6 C FOOD FROM APPROVED SOURCE Denotes critical item in -the federal 1999 Foam Code or 105 CMR 590.000. C PROTECTION FROM cONTAmimA m Food and Water From Regulated Sources 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* 3-202.16 Tee Made From Potable Driakiag Water* 5-i01..1 I Dri Rking Water front an Approved System* 590.006(A) Bottled Drinking Water* 5,90.006(B) Water Meets Standards in 310 CMR 229* _ Shellfish and Fish From an Approved Source 3-201_,14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSF Lasted Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved Ey- yRe ulato Authorlt Regulatory 3-202.13 Shellshxk identification. Present` 590,004(0 Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 Receiving/Condition 3-20111 PHFs Received at Proper Tem ratures* 3-202.15 Package lute sit`* 3-101.11 _ Food Safe and Unadulterated TagsfRecords: Sheiistock 3-202.18 Shellstock Identification * 3-203.12 Shelistock Identification Maintained* 12 Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention"` 590.0040 Labeling of Ingredients* Handwash Facilities - - Conformance vAth Approved Procedures IHACCP Plans 3-502.11. Specialized Processing Metbods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* Denotes critical item in -the federal 1999 Foam Code or 105 CMR 590.000. C PROTECTION FROM cONTAmimA m 9 Cross -contamination 3-302.11(A)(1) I Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.1.1 i Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* Mechanical Warewashing- Hot Water . Sanitization Temperatures;*. Contamination from the Environment 3-302.11(A)Food Protection* 3-302,15 Washing Fruits and Ve etables 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* _ Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.1.1 i 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* 10 Proper, Adequate Handwashing 2-301..11 - Clean Condition - Hands and Anes* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or UsingTobacco* 2-401.1.2 Discharges FromtheEyes, Nose and Mouth* 3-30112 Preventiu ContazninationWhen Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em to ees* 13 Handwash Facilities - - Conveniently Located and Accessible 5-203.11 . Numbers and Capacities* - 5-204.11 Location and Placement* 5-205. Ll Accessibilit , 0 ration and Maintenance Supplied with Soap and Hand Drying Devices - 6-301.11 Handwashing Cleanser, Availability - 6-301..12 Hand -Drying Provision a#A Establishment Name Item Code C—Critical Ii No. Reference R — Red Item F SALEM OF HEALTH ae- Page:_ of —3 InIMEVA I= Discussion With Person in Charge: I have read this report, have had the opportunity to ask violations before the next inspection, to observe all c comply with all mandates of the Mass/Federal Foo noncompliance may result in daily fines of twenty ' your food permit. V j91ions and agree to correct all ,ns as described, and to I understand that rs or suspension/revocation of Corrective Action Required: I ❑ No I C9' Yes tf Voluntary Compliance ❑ Employee Restriction / / Exclusion MmatY spe icon Scheduled LI Emergency Suspension -inrgo �-Lv —/� ❑ Emergency Closure 0 Voluntary Disposal ❑ Other: Violations Related to Foodborne 111ness Interventions and Risk Factors (items 1-22) (Cont.) Itzr"110N 9 IN I5 16 17 _ - Food or ColorAdditives 3-20-2.12 - - - J Aditives*- _ Additives*- 3-302.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying information - Original Containers* 7-102.11, Common Name - Working Containers* 7-201.11 Se ation - Stn 7-202.11 . Restriction - Presence and Use* 7-202.I2 Conditions of Use* 7-203.11 Toric Containers - Prohibitions* 7-204.11 Sanidzers. 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* ,-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Momtorin * * Amies critical ivm in the federal 1999 Fwxl Code or 105 CMR 590.000. EN 3-501.14(0 Proper Cooking Temperatures for _ 3-501.15 PRFs 3-401AIA(1)(2) Eggs- 155`F 15 Sec. 3-501.16(B) 590.004(F) Eggs- Immediate Service 1450FL5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals -155'F 15 see. * 3-401.11(B)(1)(2) Pork and Beef Roast -130'F'121 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PIPs, 27, Staffing Containing Fish, Meat, FC-6 Poultry or Ratites -1650.F 15 sec 3-401:11(0)(3) Whole -muscle, intact Beef Steaks ` FC = 7 145'F * 3-401.12 Raw Animal Foals Cooked in a Microwave 165F * 3-40L)I(A)(1)(b) All Other PHFs -145'F 15 sec. _ Reheating for Hot Molding 3-403;11(A)&(D) PHFs 165'F 15 sec. * 3.403.11(B) Microwave -165' F 2 Minute Standing Tom,: 3--003,11(C) Commercially Processed RTE Food - 140'F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cociing of PHFe 3-501.14(A) Cooling Cooked PRFs from 140`F to 70'F Within 2 Hours and From 70'F to 41`F/45'F Within 4 Hours. * 3-501.14(.6) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 Hours* * Amies critical ivm in the federal 1999 Fwxl Code or 105 CMR 590.000. EN 3-501.14(0 PHFs Received at Temperatures According to taw Cooled to 41017/45'17 Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-801AUB) PHF Hot and Cold Molding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 410145' F* 3-501.16(A) - Hot PRFs Maintained at or above 3-501.16(A) Roasts Held at or above 130°F. 25. Thim as a Public Health Control 3-50L I9 Time as a Public Health Control* 590.004(H) Variance Requirement 21 3-801.11(A) Unpasteurized Pre-packaged luices and Beveranes with Warning Labels* 5190X00 3-801AUB) 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 3401.11 C Unopened Food Packa Not Re -served, CONSUMER ADVISORY 22 3 -6M -I I Consumer Advisory Pasted for Consumption of 5190X00 1 23. Animal Foods That are Raw. Undercooked or .- FC - 2 .00.3 Not Otherwise, Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* E*°'"* ""f1 25. 3-302.13 Pa zed Eggs Substitute for Raw Shell .005 ! 26. E 590.009(A) -(D) Violations of Section 590.009(A) -(D) .in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical. and coon -critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sec. tions of the Food Code and 105 OUR 590.000, Item _ Good Recall Practices .FC 5190X00 1 23. I Manailament and Personnel .- FC - 2 .00.3 1 24 Food and Food Protection FC - 3 .004 25. Equipment and Utensils !. FC -4 .005 ! 26. _ 1 Water. PlurnbiD2 and Waste j FC -5 .008 1 27, PhsisalFacili FC-6 .007 128. ' Poisonous or Toxic Materials ` FC = 7 .008 �29. Special Requirements 30. j Other _ ITY OF SALE BOARD OF HEALTH Establishment Name: S Date: �I � Page: 3 of 091i. _ va Up ff MWA MA . . . . - . - . - . . .. - . . • r . - . - . . . . . permit.. T -voluntary Compliance El Employee - . . - . - . .Emergency A gfko LI Voluntary Disposal Li Other: Violations Related to Foadborne Illness. Interventions and Risk Factors (Items 1-22) (Cant.) PROTECTION FROM CHEMICALS 14 Food or } 1 J 3 16 Im- 18 t r.0rt:♦ .91 Color Additives. 3-202,12 Additives*' 3-302.14 _ Protection from Unapproved Additives* 1 FC -2 Poisonous or Toxic Substances 7-10L1I Idemify ing Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-101.11 Separation - Storage* 7-202.11 Restriction - Presence and Use° 7-202,12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals fur Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205,11 Incidental Food Contact Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* - 7-206.12 Rodent Bait Stations' 7-206.13 Tracking Powders, Pest Control and Monitoring* t r.0rt:♦ .91 ' Drnc+tes crincat iv m in the L-der_l 1949 F�cd Care a' IU5 GN2 59U.0D0. 3-501,14(C) PHFs Received at Temperatures According to Law Cooled to 41 'F145'17 Within 4 Nnme Proper Gooidng Temperatures for .. 19 PHFs 340i.11A(i)(2) _ Eggs- 155°1715 Sec. 1 FC -2 E Immediate Service 145'Fl5see. 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-801_11(C) Animals - 155'F 15 sec. * 3.401.11(B)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratite% injected Meats - IWF 15 i 26. see. * 3-401.1.1(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC -S- Poultry or Ratites -165°F 15 sec, 3401.11(C)(3) Whole -muscle, intact Beef Steaks ! FC -7 145*F" 3-401,12 Raw Animal Foods Cooked in a - Microwave 165'F * 340'Ll1(A)(1)(b) All Other PHFs -145'F 15 see. L Reheating for Hot Holding 3-403A 1(A)&(D) PHFs 165'F 15 see. * 3-403.11(B) Microwave- 165` F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Foal - 140°F* 3-403.11(E) Remaining tinsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from I40`F to 70'F Within 2 Hours and From 70'F to 41`Fl45°F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41 OV450F Within 4 Hours* ' Drnc+tes crincat iv m in the L-der_l 1949 F�cd Care a' IU5 GN2 59U.0D0. 3-501,14(C) PHFs Received at Temperatures According to Law Cooled to 41 'F145'17 Within 4 Nnme 3-501.16(B) ( Cold PHFs Maintained at or below 3-501.16(A) Hot PHFs Maintained at or above 140'F. * 3-501,16(A) Roasts Held at or above 1300F. 20Time aS a Public Health Control .3-50IA9 Time as a Public Healtb Control* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONSIHSPI 21 3-501.15 Cooling Methods for PHFs 19 1 PHF Not and Cold Holding 3-501.16(B) ( Cold PHFs Maintained at or below 3-501.16(A) Hot PHFs Maintained at or above 140'F. * 3-501,16(A) Roasts Held at or above 1300F. 20Time aS a Public Health Control .3-50IA9 Time as a Public Healtb Control* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONSIHSPI 21 3-801.11(A) Unpasteurized Pre-packaged Juices and .BeYrrages with Warning Labels*.._..,_ 590.000 3-801,11(B) Use of Pasteurized Eggs* 1 FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * Food and Foci Protection 3-801_11(C) Unopened Foci Packs No Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 1 23. Annual Foods That are Raw. Undercooked or 1 FC -2 .003 .I Not Otherwise Processed to Eliminate Food and Foci Protection I FC -3 Pathogen.* a Bx il/,2N!I 1 25. 3-302A3 Pasteurized Eggs Substitute for Raw Shell _005 1 i 26. Eggs' 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating, to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical. and non-critical violations, which do not relateto the foodborne illness interaentians and risk facrors listed above, can be found in the following sections of the Food Code and 105 Cd1R 590.000. r Item I Good Retail Practices.FC 590.000 1 23. 1 Management and Personnel 1 FC -2 .003 .I 24., Food and Foci Protection I FC -3 .004 1 25. Equipment and Utensils r FC -4 _005 1 i 26. Water. Plumbinq and Waste I FC -5 .006 27. ( Physical Facility FC -S- 007 i 28. 1 Poisonous or Toric Materials ! FC -7 .008 r29. Special R uirements - ,009 t ' 30 1 other L s svrr.,.,msw c;. y DATE PRINTED f _ 12/30/2013 a, r ESTABLISHMENY_NAME. m File Number BHF Uvv-yv0052_ LOCATE FOOD SERVICE BHP 20140227 Jan 1, 2014 ° `Dec 31, 2014 $280 00t :� ESTABLISHMENT m , £ x}� r"`° a 'Total Fees =x ' $280 00 ,.0 .'�^.�,,.+,.c3` i 3• -�� J VIT clk �a 3'�� i 3a. `+& hr. +� ;':" .,a r�^ss-�`4 r.kti a �u '* t a �$ �: d as � %`� .s • i g & #k � i.:� i�� a � a,� � stx i� x� �fir>'nSe � X �'$ a '„ saw � ,PERMIT EXPIRES ecember 31; 2014 ;. BOardAi Healt4 •'s'w* i ... KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD or HPw: tv 120 WAS] IINGfON Si wirr, 4:- FLOOR TeL.(978)741-1800 FAX(978)745-0343 Iramdi a salem.com Pubficxealth LARRY RAMDIN, RS/RENS, CHO, CP -FS HIiAL:I'H AGG:N'r Food Establishment Permit Application (Application.must be submitted at least 30 days before the planned opening date) 1) Establishment Name: TKC ow D't 2) Establishment Address: l Z ( E 3) Establishment Mailing Address (If different): 4) Establishment Telephone No: 978- i45- 5Z,5 -(,o 5) Applicant Name & Title: M t 1 i S5 A Or& b; 8) Applicant Address: c) W0�5 tnl0✓fit, P I A C t Qt"VG/1 A4 A 7) Applicant Telephone No: 976 332, 441t9 24 Hour Emergency No: q7$ 332 445-0 Email: Crotk-gkd� 6c'o Crrr.c 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association Ve A corporation An individual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address MA Ja Pt 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Su ervisor, Manager, etc. Name & Title: Adtn C Vef praiAnkl alvnL--- '' Address: 15 5vjoy' Cvrvt mtq Telephone No: i Fax: NlAr Email: CrockC4- I r- (Z eor SF • Emergency Telephone No: 978. 332,• MK D 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: a (1/ / Check #: YS 2 �f Date: � 7 -� Amount: A l Food Establishment Information y14)' Water Source: CI'f if 15) Sewage Disposal: 4DEP Public Water Supply No: I applicable) C+ 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 13ren ten t-, ru*cr 19) Person Trained In Anti -Choking Procedures ( if 25 seats or more): Ass No 20) Location: 22) Establishment Type (check all that apply) (check one) ❑ Retail ( Sq. Ft) ❑ Caterer ✓Permanent Structure WFood Service - ( (c O Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service - Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and Establishments,,,,,,,,,,,,,,,,,,„- 21) Length Of Permit:,Breakfast (check one) RETAIL STORE RESTAURANT ✓Annual ❑ Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 Er25.99 seats $280 ❑ More than 99 seats $420 ----- -- -- ---------------- - ------ •--.. .......-- Bed & Breakfast/Childcare Seryices - /Nursing Home $1110 Temporary/DTemporary/Dates/Time:❑ ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ ALL NON-PROFIT' $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF- potentially hazardous food time/temperature controls required) that Non-PHFs - non -potentially hazardous food (no time/temperature controls required) (check all apply): RTE - rea to -sat foods Ex. sandwiches, salads, muffins which need no further processin Sale of Commercially P,HF Cooked to Orderblot PHF Cooked and Cooled or Hot Held ✓ Pre-packaged Non-PHFs ✓ for More Than a Single Meal Service Sale of Commercially Pr6paration of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs V Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Ogers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF In Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the hoard of Health on how to obtain copies of 105 CMR 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A,1 certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 20 19 Z(e 3 f' Z 26) Signature of Individual or Corporate Name: m CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4' FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 KIMBERLEY DRISCOLL Iramdin@c alem.com MAYOR 0 PablicHealt vrowne, vmac,. LARRY RAbIDIN, RS/RHI-IS, CHO, CP -FS . HF.AI:I I A(awr . . This Form will be collected during your next Board of Health inspection. QUESTIONAIRE - GREASE TRAPS 2012 1. NAME OF ESTABLISHMENT: DLd JC7�5 2. ADDRESS OF ESTABLISHMENT: 121 E55,c� 5vsc - 5nk/v,.6 XA 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? 465 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT- HAVE? CAPACITY IN GALLONS Ao, }- Icwvv• 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? Ot 5i e Clza i 5 tDMd 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? 11 I U I Z. a-1,2- Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division bf Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of FOOD ESTABLISHMENT INSPECTION REPORT Address: TAI_ Name - 40 Date Type of Operation(s) Type of Inspection U I yam- ood Service LI Retail ❑ Routine �ftc inspection -Address R k Level ❑Residential Kitchen Previous Inspection Telephone _ ❑Mobile ❑ Temporary Date: ❑ Pre-operatidn Owner CCPYM 62 SS a nI2QL ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person -in -Charge (PIC) Time In: �(,'�r ❑ HACCP Inspector Out: Permit No. ❑.Other each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. FOOD. PROTECTION MANAGEMENT, ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOODFROMAPPROVEDSOURCE _ ❑ 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) 8. Poisonous or Toxic Materials (FC -7X590.008) LB,29. special Requirements (590.009) 30. Other no Anti -Choking 590.009 (E) ❑ Tobacco 590.009(F) ❑. Allergen Awareness 590.009 (G) ❑ .' ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities -. .. _ �. .. � PROTEC-TION- FRO--M'CNEMICACS ❑ 14. Approved Food or Calor Additives ❑ 15. Toxic Chemicals TIMEftEMPERATURE: CONTROLS (PotentlellyMazaidousFoods)_ [116. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLYSUS.(:EP-nsLE=POPULAT10NSl(H8P).'._ ❑ 21. Food and Food Preparation for HSP CONSUMERAOVISORY ❑ 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, ruv �1�X Inspector's Signature: _ Print: Page oPages PLCs Signature:Print U I �.......-.w��, -. ..F .. ..- �-- •-•--wr.-... t. ...._-.- .. .. � ... .... ....�-✓'..w..a�. v �.�.14 .r+"P. • � � ..-'tirrl. -�X Violations Related to Foodborne Illness Interventions and Risk Factors (items 9-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(A) Assig ment of Responsibility* 590.01) I Demonstration of Knowledge" 2-103.11. I Person in charge -- duties EMPLOYEE HEALTH 2 590.003(C) - Responsibility of the person in charge to Com liamce 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 Dri r&i ng Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-20115 590.003(E) Removal of Exclusions and Restrictions C C C FOOD FROM APPROVED SOURCE Denofas catiad •,tem ui.the federal 19991="0 Code or 105 CMR 59( 000. -. Food' and Water From Regulated Sourc-e 590.004(A -B) Com liamce with Food Law* 3-201.12 Food in a Hermeticall • Scaled Container* 3=201.13 Fluid Milk and Milk Products" 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteuriz2d* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Dri r&i ng 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 Equipmene Shellfish and Fish From, an Approved Source 3-201.14 Fish and Recreadomafiy Caught Molluscan Shellfish* 3-20115 Molluscan Shellfish fromNSSP Tasted Sources* Proper, Adequate Handwashing Game and Wild PAushro . s Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 ReceivingtCondition 3-202.1.1 PHFs Received at Proper Temperatures* 3-202.15 Package 'Integrity* 3-i0iJ1 poral Safe and Unadulterated T agstR.ecords: Shel!stock 3-202.18 Shellstock Identification * 3-203.1.2 Shellstock Identification Maintained" - 1 TagslRecords: Fish Products I 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(() Labeling of Ingredients' Conformance with Approved Procedures /HACCP Plans 3-502.11. Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.!2 Conformance with Approved Procedures* Denofas catiad •,tem ui.the federal 19991="0 Code or 105 CMR 59( 000. -. Cross -contamination 3-302.11(A)(1) I Raw Animal Foods Separated from Cooked and RTE Foods* 4-501_ I.1 t Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* _ Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(A) - Food Protection* 3-30115 Washing Fruits and Vegetables 3-304.11. Food Contact with Equipment and Utensils* 4-602.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipmene Disposition of Adultorated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501_ I.1 t 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* 7702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipmene 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 2-401.11 Eating, Drinking or Usin= Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* -430112 Preventing Contamination When Tasting* 12 1 Prevention of Contaminatinn frnm Hand. 12 and CITY OF SALEM nn4Rn nF NGAI TW 7 Violations Related to Foodborne illness Interventions and Risk Factors ilterns1-22) (Cont.) PROTECTION FROM CHEMICALS 114 Food or Color 15 in m s �• Additives 3-202.12 Additives* 3-302.14 Protection from Una roved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101,11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Storage* - 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - 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* in m s �• ' Denotes critical Iran in the G -der tl 1999 Foal Code or 105 CMR 390.0110, 19 20 3-501.14(C) Proper Cooking Temperatures for 3-501..15 PRFs_ 3401AIA(1)(2) Eggs- 1551715 Sec. 3-501.16(B) 590.004(F) Eggs- Immediate Service 145'Fi5see- 3-401.1l(A)(2) Comminuted Fish. Meats & Game 3.501.16(A) Animals -155'F 15 sec. * 3.401.11(B)(1)(2) Pork and Beef Roast= 130'F 121. min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) set. * 3401.1i(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Staffing Containing Fish, Meat, i FC -6 - Poul or Ratites -165'17 15 sec, 3-401.11(0(3) Whole -muscle, Intact Beef Steaks FC -7 145'F * 3-401.12 Raw Anneal Foals Cooked in a Microwave 165F * 3-401:11(A)(1)(b) All Other PHFs - 145'F 15 sec. ° Reheating for Hot Holding 3-403AI(A)&(D) PHFs 165-F 15 sea' 3-403.11(B) Microwave- 165` F 2 Minute Standing Time" 3-403JI(C) 1(C) Commercially Processed RTE Food - 140'F* . 34t13.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 700F Within 2 Hours and From 70'F to 41'F145'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature ingredients to 4l'Ff45'F Within 4 Hours* ' Denotes critical Iran in the G -der tl 1999 Foal Code or 105 CMR 390.0110, 19 20 3-501.14(C) PHFe Received at Temperatures According to Law Cooled to 41''FJ45'F Within 4 Hours. 3-501..15 Cooling Methods for PHFs 3-801-11(B) PHF Not and Cold Harding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 410/45' F* 3-50LI(i(A) Hot PRFs 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 Contrui* 590.004(H) Variance Re oirement 21 3-801.1 ] (A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels* 690.000 3-801-11(B) _ Use of Pastem-izetl Eggs* FC -2 3-801.11(D) Raw or Partially Caked Animal Food and Raw Seed Sprouts Not Served. * 1 Food and Food Protection 3-801.11(C) Un ned Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Constamer Advisory Posted for Consumption of 690.000 Animal Foods That are Raw, Undercooked or 1 FC -2 .063 Not Otherwise Processed to Eliminate 1 Food and Food Protection 1 FC - 3 Patba ns.* Eh rw rn,2o r 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 1 005 I 26, E * ZiMLAAL KIZU V ttrMARVi l5 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 #t29 - Speciai Requirements. (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sectionsofthe Food Code and 105 CMR 590.000. ft Goad Retail Practices .FC 690.000 ;Management andPorsonrtel FC -2 .063 1 24. - 1 Food and Food Protection 1 FC - 3 TOQ4 25. i Equipment and utensils ( FC -4 1 005 I 26, 1 Water. Plumbing and Waste 1 FG -5 .006 27. Phystcal Facili i FC -6 - .007 j { 26. ' Poisonous or Toxic Materials FC -7 .008 I 29. Specie R uiremarns ,009 30. j Other _�__ £39CYdmwi42 he Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4ih Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 NameDa 90 Q a of Operation(s) Wood Service Retail T Ins ection Routine Re -inspection Address RI Level ❑ Residential Kitchen Previous Inspection Telephone � ❑Mobile Date: ElPre-opet�tion Owner HACCP YM ❑ Caterer El ❑ Bed &Breakfast ❑ Suspect Illness ❑ General Complaint Person In Charge (PIC) Time In:tInspector Out (n Permit No. El El OtherCP13 e Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) vlolated. 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 ERMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOODFRO_M-MPP ROVEOSOURCE-- 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C' N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Fa ' (FC -6)(590.007) 28. Poi, or To is Materials (FC -7)(590.008) 29. Special quire ants (590.009) 30. Other S. 5901nsy�-74. x / In ® / / ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMErrEMPERATURE CONTROLS (_Pots rtlally Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling L. dot 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): 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 Signator : Print: o PIC's Signature: Print: Page of�Pages �. .� � _..,-• .rte+ti�.,f - :.-' '.� � �- r ,� - >. Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION _ FOOD PROTECTION MANAGEMENT g1 590.003(A)Assignment of Responsibili * 590.003(B) Demonstration of Knowledge* 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 food employees and 3=201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved S stem* 590.006(A) Charge* 590.006(B) 590.003(0) ReportinE by Person in Charge' 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions IV in 6 FOOD FROM APPROVED SOURCE '* Denotes critical item in the federal 1999 Food Cale or 105 CMR 592000. 8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Scaled Container* 3=201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.1.1 Drinking Water from an Approved S stem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present'" 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701,11 Receiving/Condition 3-202.1.1. PHFs Received at Proper Temperatures* 3-202.15 Package integrity* 3-101.11 Food Safe and Unadulterated Tags/Records; Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(!) Labeling of Ingredients' Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Conformance with Approved Procedures lHACCP Plans 3-502.11. S ecialized Processin Metbrxis* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* '* Denotes critical item in the federal 1999 Food Cale or 105 CMR 592000. 8 Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from 'Cooked and RTE Foods* Contamination from Raw Ingredients 3302.11(A)(2) Raw Animal Foals Separated from Each Other* Contamination from the Environment 3-302,11(A) I Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and - Utensils*' ' Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservi,ce of Food* Disposition of Adulterated or Contaminated Food 3-701,11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- ,Hot Water , SaoitizationTem eratures* 4-501,114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601..11(A) - Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and . Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Arms* 2-301-12 Cleaning Procedure* 2-301.14 When to Wash* Il Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* - 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.1.1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301,11 Handwashin Cleanser,.Availability 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Coda C -Critical Item DESCRIPTION OF VIOLATION / PLAN O CORRECTION Date - No. Reference R - Red Item Verified --'----...__. _. _. .. !1 Discussion With Person in Charge: I have read this report, have had the viplations before the next inspection, comply with all mandates of the Mas: noncompliance may result in daily fir your food permit.- n Corrective Action Required: ❑ No ❑ Yes nity to ask questions and agree to correct all rve all conditions as described, and to ❑ Volu tary Compliance Re -inspection Scheduled ° ❑ ed i siriction Exclusion Emergency Suspension II Food Code. I understand that enty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure \ Q I ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne illness Interventions and Risk Factors (items 1-22) (Cont) 15 iIN im is TIMEITEMPERATURE CONTROLS Faetl or Color Additives_ 3-202.12 Additives*' 3-302.14 Protection from Un roved additives" 3-501,16(B) 590.004(F) Poisonous or Toxic Substances 7-101,11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Storage* - 7-202.11 Restriction - Presence and Use* 7-202-12 Conditions of list* 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 7-206.12 Restricted Use Pesticides; Criteria* Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIMEITEMPERATURE CONTROLS "Denote; aitieai ia:m in the federal 1999 Fu ,! Code or IV CMR: 90.0(10, 3-501.14(0 Proper Cooking Temperatures for _ 3-501.15 PHFs .3-401.IIA(i)(2) _ Eggs- 155°F 15 Sec. 3-501,16(B) 590.004(F) Eggs- immediate Service 145`Fl5sec* 3.401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(AI Animals -155'F 15 sec. * 3-401,11(B)(1)(2) Pork and Beef Roast - 130°F 121 mm* 3-401.I1(A)(2) Ratites, Injected Meats -155`F 15 590.004(Hj sec, * 3-401.11(A)(3) Poultry, Wild Game, Staffed PHFs, r27. Stuffing Containing Fish, bleat, FC -6007 Poultry or Ratites -1650.17 15 sec. 3-401.11(0)(3) Whole -muscle, Intact Beef Steaks FC - 7 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F 3401:11(A)(1)(b) All Other PHFs -145'F 15 sec. ° Reheating for Not Holding 3403.11(0)&(D) PHFs 165°F 15 sec. * 3-403,11(B) Microwave- 165° F 2 Minute Standing Time* 3-403, 11 (C) Coamaerciaily Processed RTE Foci - 140'F* 3403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PRFs 3-501.141 A) Cooling Cooked PHFs froin 140`F to 70'F Within 2 Hours and From 70`F to 41`F145'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature ingredient& to 41'F145'F Within 4 Hours* "Denote; aitieai ia:m in the federal 1999 Fu ,! Code or IV CMR: 90.0(10, 3-501.14(0 PHFs Received at Temperatures According to Law Cooled to 41'F/45'F Within 4 Hours. 3-501.15 Coolie 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 410145' F* 3-501.16(A) Hot PHFs Maintained at or above 140°P. * 3-501.16(AI Roasts Held at or above 130'F. 25. Time as a Public Health Control 3-50IA9 Time as if Public Health Control* 590.004(Hj Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801,11(A) Unpasteurized Pre-packaged Juices and :Beverages with Wartrina Labels* 590.400 1 3-801.11(B Use of Pasteurized E -n* .- FC -2 3-801.11(D) Raw or Partially Conked Animal Food and Raw Seed S its Not Served. * F4 Il�ood and Foots Protection 3-801.11(C) Un ed Food Package Not Re -served_ 22 3-603.11 Consumer Advisory Pasted for Consumption of 590.400 1 1 23. Animal Foods That are Raw, Undercooked or .- FC -2 .003 ; Not OtherwiseTroeessed to Eliminate F4 Il�ood and Foots Protection FC -3 Pathogens,' Els` ""Pour 25. 3-302,13 Pasteurized Eggs Substitute for Raw Shell .005 ! 26. Eggs* 590.009(A) -(D) 'Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Criticalmrd non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can: he found in the following sections of the Food Code and 105 CMR 5911,000. I Item 1 Good Retail Practices .FC 590.400 1 1 23. I Management and Personnel .- FC -2 .003 ; 1 2 F4 Il�ood and Foots Protection FC -3 .W4 25. Equipment and utensils I FG -4 .005 ! 26. Water. Plumbing and Waste FC -6 .006 r27. ( Physical Facility FC -6007 1 28. ' Poisonous or Toxic Materials FC - 7 008 29. Specie Requ remo rts ,003 30 Other 5:59�ra.�nwr„1 t:: yr J MA J \/ CITY OF SALEM BOARD OF HEALTH 7 Establishment Name: 1d,0 �� j 1 Date:—Z)—;a!2- Page:_S of _ T --_ �:.a� �11r��I�t�l� iir / _y I, I �r.GI � ►� moi WMAWIMM _ _1 �_ a� I.I. ��■�.. i. � Il _%� IffAM _,P� IF MA MMIN. UNW-11 If.J ._. 11 I s iweMI � ii.,-_ M�_ _/ _•• ri . :/i��}�C'%/fit •. ..., �'�. . Vol _'� _ _.1� _ _ _. CBS —12 f A"TIFIM'J l l '_ r l �`. IFIR rJWr..=FA'0MP&-I WPM OEM _ folly your permit. --- — qu tions an a conditioK as described, and to d Code. I understand that a dollars or suspension/revocation of l/PJ� - ® E] Voluntary Compliance ■Employee ��e-inspection Scheduled U C3 Embargo Q Exclusionask Emergency Suspension Emergency Closure T Violations Related to Foodborne illness Interventions and Risk Factors (iter 1-22) (Cont.) Im ra 18 Food or Gator 3-202.12 --_ E02,1 - I Additives* 3-302.14 Protection from Una roved ,Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101,11 Identifying information - Original Containers' 7-102,11, Common Name - Working Containers" 7-201.11 Separation - Storag& 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Samrizers, 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* 7-306.12 - .1 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* ra 18 ' Demtrs aiticat nein in the federal 1999 Foal Cale or IUB CMlt 590.000 ins 3-501.14(C) Proper Cooking Temperatures for 3-501..15 PHFs 3-401.IIA(I)(2) _ Eggs- 155`F 15 Sec. 3-501.16(B) 590.004(F) Eggs- Immediate Senice 145-Fl5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals - 155°F 15 sec. * 3.401.11(11)(1)(2) Port: and Beef Roast -130'F 121 mtn* 3-40131(A)(2) Ratites, Injected Meats - 155`F 15 590.004(H) see. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -165'F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145OF * 3-401,12 Raw Animal Foods Cooked in a Microwave 165'F * 3-40LII(A)(1)(b) All Other PHFs -- 145'F 15 sec. $ Reheating for Not Holding 3-11311 I(A)&(D) PHFs 165'F 15 sec. * 3-40311(B) Microwave -165= F 2 Minute Standing Tom* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403-II(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooped PHFs from 140`17 to 70*F Within 2 Hours and From 70`F to 41'F145'F Within 4 Hours. * 3-501.14(.6) Cooling PHR Made From Ambient Temperature ingredients to 41 0171450F Within 4 Hours* ' Demtrs aiticat nein in the federal 1999 Foal Cale or IUB CMlt 590.000 ins 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'Ft45'F Within 4 Hours. 3-501..15 CoolinE Methods for PHFs 3-801AI(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PIIN Maintained at or below 410145° F* 3-501.16(A) Hot PRFs Maintained at or above 140°17. 3-501.16(A) Rossm Held at or above 130'F. 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 .Bevem aes with Warning Labels* 3-801AI(B) Use of Pasteurized Bags* 3-801.1 l (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 Animal Foods That are Raw. Undercooked or Not Otherwise Processed to Eliminate Pathogens.* m .1' 1rz .r 3-30113 Pasteurized Eggs Substitute for Raw Shell E * twLUTAL HCtitnHCMCiV I Si 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 5ia111, _"..c ITY OF SALEM BOARD OF HEALTH Establishment Name: / hn C� lC� �1(. Date: :3 43 , � Page:_ of _ 11 a BIWA MAEFFIliff 001 WIN . ::.. W H� .-n- IRAN r■� ��.rr. ZMARM Discussion WiLth Person in Charge: pll conditions as described, and to .. - . - • .: 41iod Code. i -live dollars or your ... permit. IrTV_,T;II5Tj1I.� .. .. .-r a Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cant.) 15 IN 17 Food or Color Additives 3-202.12 Additive&* 3-302.14 _ Protection from Una roved Additives" FC - 2 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Se ation - 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 hicidental 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' IN 17 ' Denotes ceitica! nem in the L -doral 1999 Food Cale ur 105 CM11590.0W 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41T1454 within 4 Hours. * Proper Cooking Temperatures for 19 PHFs _ 3401.11A(l)(2) Eggs- l55`F 15 Seo. FC - 2 Eggs -Immediate Service 145'Fl5sec* 3401.II(A)(2) Comminuted Fish. Meats & Game 3-801.11 C Animals -155'F 15 sec. * 3 401.21(Jl)(i)<2) Pork and Beef Roast -130OF 121 min* 3.401.11(A)(2) Ratites, Injected Meats -155`F 15 25. sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat. 1 FC -9 Poultry or Ratites -165'F 15 sec. 3401..11(0)(3) Whole -muscle, Intact Beef Steaks s FC - 7 145OF * 3-401.12 Raw Animal Fowls Cooked in a Microwave 165OF * 3-401:11(A)(1)(b) Ail Other PHFs -145'F 15 sec. $ Reheating for Not Holding 3-403:1 i(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" 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFa 3501.34(A) Cooling Cooked PHFs from 140`F to 70*F Within 2 Hours and From 70'F to 4VF/450F Within 4 Hours. * 3-501.14(13) Cooling PRFs Made From Ambient Temperature Ingredients to 4l'F/45'F Within 4 Hours* ' Denotes ceitica! nem in the L -doral 1999 Food Cale ur 105 CM11590.0W 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41T1454 within 4 Hours. * Cold PHFs Maintained at or below 41'!45° F* Hot PHFs Maintained at or above 3-501.16(A) 1 Roasts Held at or above 1 20 1 1 Time as a Public Health Control I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 2Y 3-501.15 Cooling Methods for PHFs 19 i PHF Not and Cold Holding Cold PHFs Maintained at or below 41'!45° F* Hot PHFs Maintained at or above 3-501.16(A) 1 Roasts Held at or above 1 20 1 1 Time as a Public Health Control I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 2Y 3-801.11(A) Unpasteurized Pre-packaged Juices and :Beverages with Wanting Labels* 1.590.000 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801..1 l(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * i Food and Food Protection 3-801.11 C Unopened Food Pac39WNot Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 1.590.000 23, Animal Foods That are Raw. Undercooked or FC - 2 1 Not Otherwise Processed to Eliminate 1 i Food and Food Protection 1 FC -3 Pathogens.' '" "a rnna: r 1 25, 3-302.13. Pasteurized Eggs Substitute for Raw Shell .005 25. E SPECIAL RFOUIREMENTS 590.009(A) -(D) Violations of Section .490.009(A) -(D) in catering, mobile ford, 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 goad retail practices should be debited under #29 - jl1 Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and riskfactors listen above, can- be found in the follosdng sections of the Food Code and 105 CMR 590.000. t Item Goad Retail Practices:, .FC 1.590.000 23, Management and Personnel FC - 2 1 .003 i 1 214.. i Food and Food Protection 1 FC -3 .004 1 25, Equipment and Utensils IFC - 4 .005 25. Water. Plnmbino and Waste FC -5 .006 27. Physical Facit' 1 FC -9 .007 128. ' Poisonous or Toxic Materials s FC - 7 .008 29. Special Reguirements i 009 30 ( Other ' = Food(Retail`Establishment Permit � ",v �� ' LOCATED AT: 0121 ESSEX STREET DATE PRINTED: 12/18/2012 1 ' > ` SALEM, MA 01970 _ ,C �- 3 .. x � Permit Type Permit No. Permit Issued 'Permit -Expires = Fee Restrictio s / Notes FOOD SERVICE BHP -2013-0235 Jan 1 2013 .- Dec 31 2013 $280 00 ESTABLISHMENT a p ESTABLISHMENT NAME: The'Old Spot,,' `File Number -BHF -2006-000052 121 Essex`Street SALEM' ,� MA 01970' LOCATED AT: 0121 ESSEX STREET 1 ' > ` SALEM, MA 01970 3 � Permit Type Permit No. Permit Issued 'Permit -Expires = Fee Restrictio s / Notes FOOD SERVICE BHP -2013-0235 Jan 1 2013 .- Dec 31 2013 $280 00 ESTABLISHMENT a p K Total Fees: e� , a $280.00 a ?u �s 3` .. -t x 4 44-z`; 'Yx 'Y xr 3 4 t nP - � v _ p r r PERMIT EXPIRES December 31, 2013 ' x Board of Healthon i Y., > 5 F.a This Permit is transferable be reissued Iocation.,The permit be T. '- not and must upon change of ownership in a prominent location in the Establishment. or '` must_ g posted In accordance with the State Sanitary Code, beofre any revonations; improvements, orkquipment changes are made,„ all.plans for such must be submitted to and approved by the Salem Board of Health. Paget s ice_ ' a CITY OF SALEM, n /��®MAssACHusETTS PublicHealth B!orHLAI rI-r 4 2012 120 WASIQNGTON S'I'Rrcr'e, 41" FLOOR , IQMBERLEY DRISCOLtiTri.. (978) 741-1800 FAX (978) 745-0343• • LARRY RAMDIN, RS/REI-IS, C1 10, (I'. -FS MAYOR BOAh, '}.,_r_U Irnma.m dinsale.com HE,\j,'ni AG ENT -uF HEALTH Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: -rIt V I J 5 o+- 2) Establishment Address: I Z( t✓ 55 cX ivCLfi So, i-cen /A Pr r) I Cl 1.0 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: q`l5- 7H 5' S (o S(o .r'!) ApplicantName& Title: MiLi SfA OKA1131 OWN-er-- 6) Applicant Address: 5 W1Ao3WUtLPLA_C6 (3C-VML Mrj4t°Il 7) Applicant Telephone No: li$ L' 4440 24 Hour Emergency No: 915<'332'ti4.5'0 Email: CrDCI e/+4 is / Cpm cny nct 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association cor ora ion An individual A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address . 1 sse, 01Zi42'Jn i— S w✓kI9t. &V-C'L MA GS a Ola r� wti S ltd. w vf1 I c 1. M✓) 13rtn.<cn Cl?cke. v,'u res,ck4- Swl - ravl 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name & Title: errAjitn C✓n [ K e/ Address: W pal wU✓Vh I cac ✓Cvt 1'h Telephone No: 78.332-y4 S 0 Fax: MR Email: CroClGti�. Ccmcn)t ncf Emergency Telephone No: 9-7 Ifr 3 3 Z' qq9 13) District or Regional Supervisor (if applicable) Name & Title: Address: N/A Telephone No: Fax: Email: Check#: liq�l • Date: 'll . Z0 -7 Amount: 475;V Food Establishment Information Q't r'- 14) Water Source: Ct.4'1 15) Sewage Disposal: DEP Public Water Supply No. ( if applicable) a M-TH §'-1 M 16) Days and Hours of Operation: - SuN W- 30 - t6M 17) No. of Food Employees: (D 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) .(32nd to C✓rc� c r 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): eYes No 20) Location: 22) Establishment Type (check all that apply) (check one)0 Retail ( Sq. Ft) 0 Caterer Permanent Structure✓ GrFood Service - ( 70 Seats) 0 Frozen Dessert Manufacturer Mobile 0 Food Service - Takeout 0 Residential Kitchen for Retail Sale 0 Food Service- Institution 0 Residential Kitchen for Bed and ( Meals/Day) Breakfast Home 0 Food Delivery 0 Residential Kitchen for Bed and ----------------------------------------------------------------- ----- -Breakfast -Establishments 21) Length Of Permit: (ch ck one) RETAIL STORE RESTAURANT Annual ✓ 0 Less than 1000sq.ft. $ 70 0 Less than 25 seats $140 Seasonal/Dates: 0 1000-10,000sq.ft. $280 0 Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 t925-99 seats $280 0 More than 99 seats $420 --------------------------------- --------------------------------------------------------------------------------------- 0 Bed R Breakfast/Childcare Services /Nursing Home $100 Temporary/DateslTime: _.....- ---------- ---------------------------------------------------- ADDITIONAL PERMITS - ... ------------------------------ 0 MAKE ICE CREAM, YOGURT/SOFT SERVE $25 0 PASTURIZATION $25 0 TOBACCO VENDOR $135 0 ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare & private clubs) 23) Food Operations: Definitions: PHF -potentially hazardous food (time/temperature controls required) Non-PHFs - non -potentially hazardous food (no timeltemperature controls required) check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For. Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: ✓ v v Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 2-0'-kc(Z(P313 26) Signature of Individual or Corporate Name: ��J\_ , ` Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABLISHME"SPIEidTIO144 REPORT Tal Name Dat Type ofOperation(s) Type of Inspection Print: J C- ,� Z oo ervice ❑ Retail ❑ Routine Q4Re* pection Address Iflik.,V1Risk Level El Residential Kitchen Previous Inspection Telephone P _ ❑ Mobile Date: ❑ Temporary ❑ Pre-operation Owner HACCP YIN ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness 0 General Complaint Person -in -C arge (P C) Time !/ in: ,!�' HACCP Inspector Out: Permit No ❑ Other macn violate cnecxea requires -an explanation on the narrative )sage(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. - FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded EOOD:FROM APPROVEDSOU RCE _�-. ❑ 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 (FCsx590.006) 27. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FC -7x590.008) 29. Special Requirements (590.009) 30. Other Anti -Choking 590.009 (E) ❑ Tobacco 590.009(F) ❑ Allergen Awareness 590.009 (G) ❑ ❑ '12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM'CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEfTEMPERAT.um.CONTROLS (Doter ii6ity Hazardous F.00ds)- , ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLYSUS"CEP718LE=POPULATIONS':(HSP):., ❑ 21. Food and Food Preparation for HSP CONSUMERADVIS_ORY _ - ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): El 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: )Pve /Pjw,1 lrJ Inspector's Signa re: Print: Page_ of Pages PICS Signature: - Print: J C- Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 I 590,003(A)AssigumentofResponsibility* 590.003(6) Demonstration of Knowledge* 2-103.11. Person incharge- 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 Efs* - 590.003(F) Responsibility Of A Food Employee Or An 3-202.,16 lee Made From Potable Drinking Water* Applicant To Report'fo The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003 0 Reporting by Person in CharLe* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C L C FOOD FROM APPROVED SOURCE * Denotes critical hent in.the federal 1999 Find Code or 105 CMR 590.000. C PROTECTION FROM CONTAMINATtnN Food and Water From RaguWed 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 Efs* - 3-202.14 Eas and Milk Products, Pasteurized* 3-202.,16 lee Made From Potable Drinking Water* 5-101..11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water` 590.006(B) Water Meets Standards in 310 CMR 22.0* Frequency of Sanitization of Utensils and - Food Contact Surfaces of ui ment* She!!(ish and Fish From an Approved Scume 3-201.14 Fish and Recreationally Caught Meliusean Shell.rsh* 3-201.15 Molluscan Shellfish from NSSF Listed Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by Re ulato Authorlt 3-202.13 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 ratures* 3-202.15 Packaoe ince siL'* 3..!01.11 Food Safe and Unadulterated Tags/Records: ahelistock 3-202.18 Shellstock identification * 3-203.12 Shellstoek Identification Maintained* 12 __ Tags/Records: Fish Products 3-402.11 Parasite Destruction* - 3-402.12 Records. Creation and Reiemiun" 590.004(1) Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures /HACCP Plans 3-502.17. Specialized ProcessingMethods* 3-502:12 Reduced oxygen acka no criteria" 8-103.12 Conformance with A roved Procedures' * Denotes critical hent in.the federal 1999 Find Code or 105 CMR 590.000. C PROTECTION FROM CONTAMINATtnN 9 Cross -contamination 3-302-11(A)(1.) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501_ L 11. Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* _ Mechanical Warewashing- Hot Water Sanitization Tem eratures* Contamination from the Environment 3-302.11(A) Foal Protection* 3-302.15 Washing Fruits and Vegetables 3-301.11 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 ui ment* Disposition of Adulterated or Contaminated Food .3-7,01.11 Discarding or Reconditioning Unsafe l Food* 9 Food Contact Surfaces 4-501_ L 11. Manual Warewashing - Hot Water Sanitization Te rature0' 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* 4-602.1.1 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and - Food Contact Surfaces of ui ment* 4-703.11 Methods of Sanitization -Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301..1.1 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 1] Good Hygienic Practices 2-401.11 Eating, Drinking or Usin Tobacco* 2-401.12 Discharges. From the Eyes, Nose and Mouth* 3-301.'12 Preventin Contaznination When Tasting-* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Emto ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Ca acilies* - 5-204.11 Location and Placement* 5-205.11 - Acce ssibility. Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301..12 Hand Drying Provision 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 ! A -6n Address: FOOD ESTABLISHMEN"I S ECTION REPORT Tal. Namefil- Print: ✓ - Date 'trz Type f Operation(s) ood Service ❑ Retail El Residential Kitchen ❑ Mobile Type of spection outine ❑ Re -inspection Previous Inspection Date: Address Telephone Risk Level [I Temporary ❑ Caterer ❑ Bed & Bf��fnast r [IPre-operation [I Suspect Illness ❑ General Complaint ❑ HACCP Owner (� HACCP YM Person -in -Cha a (PILwwC) Tim In: ,`(X Inspector Out Permit N �( ❑Other Each violation checked requires an explanation on the narrative pages) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. FOOD: PROTECTION MANAGEMENT ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE _ 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 �,PROyECTION FROM CONTAMINATION- L✓-1/8�Sepa ration/Seg regation/Protection 9/9. 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- 590.005) _,3213t. Water, Plumbing and Waste cs 9o.0os) 27. Physical Facility (FC-sX 90.007) 28. Poisonous or is Mate als (FC -7 '590 .008) Ea�9.� Special Re 'Ants 590.009) Othe % S.000 I n Anti -Choking 590.009 (E) ❑ Tobacco 590.009 (F) ❑ Allergen Awareness 590.009 (G) ❑ ❑ 12. Prevention of Contamination from Hands 13. Handwash Facilities PROTECTIONFROWCHEMICAC5 ❑ 14. Approved Food or Color Additives `^ ❑ 15. Toxic Chemicals TIMET'EMPERATURE.C.ONTROLS.(Poiskia'llyHanitdousFootl_s) ❑ 16. Cooking Temperatures [117 Reheating [118. Cooling 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FORIHIGHLYSU§CEPTIBLE=POPULATIONS';(HSP)' ❑ 21. Food and Food Preparation for HSP fCONSUMERADVISORY. ❑ 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: off r I n Inspector's Signator . Print: ✓ - PICs Signature: APrint: Page I 0fages • �I .. � \ .� -+. ss � ii`.. -.m s - a .. s. .. +✓tiyfb ., e�4. n- `N• � r�+`ti.. -. -.. .. • Y • �.aa .+ .. Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 "A' Amment of Res onsibili[ * cost 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 I-aw* 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'ro The Person In Drinking Water from an Approved System* 590.006(A) Char. * 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C I FOOD FROM APPROVED SOURCE ' Denotr s critical Ami in -the federal 1999 rood Code or 105 CMR 590.0(X), C PROTECTION FROM (nMT1LW1NeT1nta Food and Water From, Regulated Sources 590.004(A -B) Compliance with Food I-aw* 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 Mill; 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 110 CMR 22.0* Frequency of Sanitization of Utensils and Shellfish and Fish From r an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from :NSSF Lis Sources* Chemical* Game and Wild Mushrooms Approved ;y- Regulatorl Authority - 3 -202.18 Shellstock identification Present` 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* - Receiving+Conditlon 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package late it-* 3-i0i-I1 _ Food Safe and Unadulterated TagsMer:ords: Shelistock 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(n Labeling o1 Ingredients' Conformance with Approved Procedures /"ACCP Plans 3-502.11. S ecialized Processing Methods* 3-502.12 Reduced ux en acka "ng, criteria* 8-103.12 Conformance with A roved procedures* ' Denotr s critical Ami in -the federal 1999 rood Code or 105 CMR 590.0(X), C PROTECTION FROM (nMT1LW1NeT1nta 4-501.. I I ---------------- Cross-coniaminatron 3-302.11(A)(I.) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.112 Contamination from Raw Ingredients 3-302A I(A)(2) Raw Animal Foods Separated from Each Other* 4-501.114 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* Cleaning Frequency of Equipment Food- Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 4-501.. I I Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* em ratures*4-501.114 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * Equipment Food Contact Surfaces and - 4-601.11(A) 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..1. t Clean Condition - Hands and Arms* 2-301..12 2-301.14 2-401.12 3-301.12 5-204.11 11 12 to Wash* Hygienic Practices , D(tnking or Using Tobac uges: From the Eyes, Nose CoL enation When ttion of Contamination fro CI Establishment BOARD OF HEALTH Date: MIL Page: Ze of _ •• • = • • • MIM 1670 11MITIMIM _ � � ,- : � �� ... �. ,.. VAIM ..A www�PM ��• LWJ%WLI I.1.1 ✓..� a. �.� • WA— M_ IL _ ,-lig WIT t�Ia17/':LVM WLi 01log NOR MIIWAMI _tC' i 1 I,O�'�,� �f!!si. .► s.1: A�1I. -AwrlIe..0 _ M 7..7 111. i ifriT:7, ...i_ ' ►��i.!��_�!7�QI�Iri1�'s1.�R� M6 oo permit. o vo-luntary Compliance El Employeer Exclusion o Re -inspection Scheduled LI Emergency Suspension Ej Embargo Li Emergency Closure Violations Related to Foodborne flings& Interventions and Risk Factors,(items 1-22) (Cont.) C 16 IM _.... Food or Gator Additives 3-202.12 Additives* 3-302-14 Protection .from Unapproved Additives" 3-50 L 16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11. Common Name - Working Container* 7-201.11 Separation - Storage* 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Tonic Containers - Prohibitions* 7-204.11 Sanitizes. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying A encs. 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* TIMEITEMPERATURE CONTROLS * Denottz critical teem in the federal 1999 Food Curie or 105 C.MR 390.000. 3-501.14(0) Proper Cooking Temperatures for 3-501.15 PHFe 3-401.11A(1)(2) Eggs- 1550F 15 Sec. 3-50 L 16(B) 590.004(F) Eggs- Immediate Service 1450F15sec* 3-401-II(A)k2) - Comminuted Fish. Meats & Game 3-501.16(A) .Animals -155°F 15 sec. * 3401.11(6)(1)(2) Pork and Beef Roast - 130°F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) Sec. * 3401.1.1W(3) Poultry, Wild Game, Stuffed PHFs, Staffing Containing Fish, Meat, Poultry or Ratites -165'F 15 sec, 3-401.11(C)(3) Wbole-muscle, Intact Beef Steaks 145'F * . 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F 3-401 401:11(A){1)(b) All Other PHFs - 145F 15 sec. l Reheating for Hot Holding 3403:11(1)&(D) PIIFs 165-F 15 sec. * 3-303.11(B) Microwave- 1650 F 2 Minute Standing Tom* 3403. i I (C) Commercially Processed RTE Food - 140'F* 3403.11(E) Remaining tinsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140`F to 70'F Within 2 Hours and From 70'F to 41`F/45'F Within 4 Hours. * 3-501.M(B) Cooling PHFsMade From, Ambient Tctnperamre Ingredients to 41'F/45°F Within 4 Hour" * Denottz critical teem in the federal 1999 Food Curie or 105 C.MR 390.000. 3-501.14(0) PHFs Received at Temperatures - According to Law Cooled to 41'F/45'F Within 4 Hours, 3-501.15 Coolutp Methods for PHFs 3-801.11(6 PHF Not and Cold Holding^ 3-50 L 16(B) 590.004(F) Cold PHPs Maintained at or below 41'/45° F* 3-50LI6(A) Hot PRFs Maintained at or above 140'F. * 3-501.16(A) Roasts Held at or above 130'F. Time as a Public Health Control 3501:19 little 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 Waring labels* 3-801.11(6 Use of Pasteurized Eggs* 3-801.11 (D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 3-801.11 C Unopened Food Package Not Re -served. ^` 22 3-603.11 Consumer Advistary Posted for Consumption of Animal Foods That are Raw. Undercooked or Not Otherwise Processed to Eliminate Patho *ens.* t�e'n;zaer 3-302.13. steuEggs Substitute for Raw Shell PE *ari=d 590.009(A)-(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary, and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk,factors listed above, can he found in the follawing sectionsof the Food Code and 105 CMR CITY OF SALE BOARD OF HEALTH Establishment Page:_ of Z DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRIN "WOMMMMA 0. �O..,,L��-.�►�� II �.W.!l! .1/►, t'ZII't��i%iLffld�IL .. _ ARM 6 too I 9 9 lie a your food permit. �/ bw ComplianceM Employee El Voluntary Exclusion Q Re -inspection Scheduled ci Emergency Suspension u Embargo Ll Emergency Closure Z Violations Related to Foodborne Illness interventions and Risk Factors (Items 1-22) (Cont.) 15 16 Im- Food or Color Additives 3-202.12 Ad�k .. 3-302.14 _ Protection from Unapproved Additives* I FC -2 I FC -3 Poisonous or Toxic Substances 7-101,11 identifying luformation - Original Containers* 7-102.11. Corrosion Name -- Working Containers* 7-201.11 Separation - Storage* 1 7-202.11 .Restriction - Presenceand 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, Crura* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-206.I1Restricted Use Pesticides, Criteria* 7-1_06.12 - Rodent Bait Stations* 7-206.I3 Tracking Powders, Pest Control and Monitoring* Im- Demxes cciticat ia:m in the L-deral 1999 Fwd Cate or 105 CMR 590.000. 3-501.14(C) PHFs Received at Tetnperntuses Accordin to Law Cooled to 41'0454 Within 4 Hans. Proper Cooking Temperaheres for 19 PHFs _ 3-40i.IIA(1)(2) Eggs- 155`F 15 Sec. I FC -2 I FC -3 Eggs- Immediate Service 145°F15sec* 3.401.11(A)(2) Comminuted Fish. Meats & Gane 3$01:11 C Admirals - 155°F 15 sec. * 3.401.11(13)(1)(2) Pori: and Beef Roast - 130°F 121 min* 3401.11(A)(2) Retires, Injected Meats -155°F 15 27. sea. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, L28. Stuffing Containing Fish, Meat, FC- 7 Poultry or Ratites -165'F 15 sec, 3401:11((2)(3) Whole -muscle, Intact Beef Steaks t 145°F * 3-401.12 Raw Animal Foods Cooked in a I Microwave 165`F * 3401 J I(A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3- 03AI(A)&(D) PHFs 165-F 15 sec. * 3-403.11(B) Microwave -165° F 2.Minnte Standing Ti=* 3403.11(C) Commercially Processed RTE Food - 140°F* 3-403.i1(E) Remaining UnslicedPortionsofBeef Roasts* Proper Cooling of PHFs 3-501:14(A) Cowling Cooked PHFs from 140`F to 70`F Within 2 Hours and From 70°F to 41 °F/450F Within 4 Hours. * 3-501.14(13) Cooling PHFs made From Ambient Temperature Ingredients to 41 °F/45°F Within 4 Hours* Demxes cciticat ia:m in the L-deral 1999 Fwd Cate or 105 CMR 590.000. 3-501.14(C) PHFs Received at Tetnperntuses Accordin to Law Cooled to 41'0454 Within 4 Hans. Cold PliFs tvlaintained at or below 41°145° F* Hot PRFs Maintained at or above Roasts Held at or above. Time as a Public Health REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-501.15 Coolie Methods for PHFs 19 PHF N t and Cold Holding Cold PliFs tvlaintained at or below 41°145° F* Hot PRFs Maintained at or above Roasts Held at or above. Time as a Public Health REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and Beverages with Warning Labels* 590.000 3-801.i1tB) _ Use of Pasteurized Eg * I FC -2 I FC -3 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.' 1 Equipment and Utensiis 3$01:11 C Unopened Food Package Not Re -served'" CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 j 23._ i 24.. Animal Foods That are Raw. Undercooked or I FC -2 I FC -3 .003 .004 Not Otherwise Processed to Eliminate 1 Equipment and Utensiis FC -4 Patho *ens.* Ex ..1e 'Mu ! 26. 3-302.1.3 Pasteurized Eggs Substitute for Raw Shed .006 I 27. 1 Eggs' SPECIAL REQUIREMENT5 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. VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Crifical,wid non-critical violations, which do not relate to the - foodborne illness interventions and risk factors listed above, can be found in the following sectionsof the Food Code and 105 CMR 590.000. -fret m "Gid Retail Practices IFC 590.000 j 23._ i 24.. 1 Management and Personn T Food and Food Protection I FC -2 I FC -3 .003 .004 1 25. 1 Equipment and Utensiis FC -4 .005 j ! 26. 1 Water. Plumbing and Waste _I i FC -5 .006 I 27. Ph sicai Facility FC -6 .007 L28. Poisonous or Toxic Materials FC- 7 .008 1 29. - §pecjaJ Requirernents009 t ' 30 1 Other - I 599Gfnmdrxcw'. be Commonwealth of Massachusetts s i• City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/28/2011 ESTABLISHMENT NAME: The Old Spot File Number: BHF -2006-000052 121 Essex Street SALEM MA 01970 LOCATED AT: 0121 ESSEX STREET SALEM,. MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2012-0147 Jan 1, 2012 Dec 31, 2012 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31, 2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment In ace ordance 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. Pagel KINIBERI.EY DRISCOLL MAYOR LARRY RAMDIN, RS/RHI IS, Ci R), CP-I•S IIIi.V:1iiA(tCN'P CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"' FLC)OR Tt,'i_ (978) 741-1800 FAx (978) 745-0343 Iramding>alem.com 201_ APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT__T TEL # 0 8. 744 -51P 51, _ ADDRESS OF ESTABLISHMENT t2A SA.Lfrek FAX# MIA MAILING ADDRESS (if different) EMAIL- Business': Crac*.E/di ) LO LJvaKLtBi e4— Website: -iKCo kj 5V&± • CoM OWNER'S NAME Ji/li (i55ot Q -aibi TEL# �l�fl' 33L �Jt \A ADDRESS 5 Wa STREET ;We;'411 'Fle STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) ,5'71 119 3 (Required in an establishment where potentially hazardous food is prepared) 9-4 -33Z- 4450 EMERGENCY RESPONSE PERSON 15rcyNlzr\ Cry cLel HOME TEL # °I%"?_ 1- LL41R-1 Please write in lime ofd p lFnr Pxmmnlp llam_l 1.1 5P(h'1�{MtI JPA7 1.�i!Itt.��^�'1'(�M (iY3oRM-1Am;t{:jpq•,•i RETAIL k0uftdcorStationary Food Crit $21 YES MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR• ALL NON-PROFIT (such as church kitchens) less than 1000sq.ft. 1000-10,000sq.ft. more than 10,000sq.ft. less than 25 seats more than 99 seats =$ 70 =$280 =$420 ------------ =$140 =$280 ✓ =$420 $100 YES $25 YES $135 YES 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 nd paid all st a taxes required under the law. Ind '� 7w Dec6li., . utt zv-la2t�3�z Signature _ Date Social lSecurity orFederal identification Nl Updated 5/23/11 FOODAP201 i.adm Chmk# & Date y U Joe Reale Salem Board of Health 120 Washington Street Salem, MA 01970 January 28, 2012 Re: The Old Spot Follow Up Dear Joe, 188 eog90 ops 9201, �® dp ti� 6 Please find enclosed a copy of the consultation report from A! Exterminators. At your request we hired Al, our monthly exterminating service to come out to our restaurant and do an in depth consultation on why we continue to have a mouse presence. I believe the report will show you that The Old Spot is compliant in trying new and effective ways to combat the mice that live in our area. In addition to our monthly service we have rebaited traps ourselves when necessary and had Al "foam fill' any cracks in our exterior that may allow entry. Additionally, we currently use Northside Carting who bought out our prior trash service company- Eric Z. The contract is the same as it has been since we opened six years ago, with our trash and cardboard being picked up everyday, Monday through Saturday. If there is something else you think we should be doing please let us know. The kitchen floor is being replaced February 6 -10th. I am sending a separate letter to Board concerning the floor issue. Sincerely, 4 ' Milissa Oraibi The Old Spot 121 Essex Street Salem, MA 01970 'Al A-1 Exterminators pest control professionals January 4, 2012 The Old Spot 121 Essex Street Salem, MA 01970 9ogRo 0 09'? zb opgj�M 6<ry The above account is currently being serviced once per month or whenever necessary. On December 23, 2011 the above listed was inspected and our findings are as follows: Main Kitchen: Floor tiles in need of repair Grease and debris found behind stove and fryolator area. No evidence of insects or rodents at the time of inspection. Main Lounge and Bar: All drains (sink and floor) working properly No evidence of Insects or rodents at the time of inspection Dining Room: Booths were inspected. Found neither evidence of rodents (mice) nor rodent harborage at the time of inspection. Basement: All drains were inspected and working properly No evidence of insect or rodent infestation at the time of inspection Proper controls were in place to prevent insects and rodents. I.e.: Bait stations, glue boards multi -catch traps If we can be of any further assistance, please do not hesitate to call me at 781424, 3248. Thank you, Scott Weisberg Inspector A-1 Exterminators 183 Shepard Street Lynn, MA 01902-4597 781-592-2731 800-525-4825 781-592-7641 Fax S ',( P ' r f l t f •� tE Ir`� I t 9� Y it x II yy t 1 * ,� - Masachusetts Department ofRPublicHea�#h Salen Boarclof°Hea)th 1` 1'20 Washington treet,,O Floor Division,of Food and Drugs ✓, Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORTt Tel. (978) 741-1800 Fax (978) 745-0343 Name i r1 I� "' - V 1 Date / Ups of Operation(s) Tvoe of Inspection Food Service ❑ Retail ❑Routine Re -inspection Address. Risk 25. Level t ElResidential Kitchen Pievious Inspeption Water, Plumbing and Waste Telephone _ -27. ❑ Mobile /., ❑Temporary .., '( ❑ Caterer ❑ Bed & Breakfast Date: 12_ �l moi. II / ❑Pre-operatlori/ El Suspect Illness ❑ en rel Complaint Owner 0 J HACCP YM Person In Charge (PIC) " y�., Time Spec' OR quirements In: y I � f 'ti HACCP Inspector1 (141 ILL: ��tl�.r Out% Permit No. Other Each violation checked requires an explanation Violations marked may pose an imminent action as determined by -the Board of Hes 1 ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3..Personnel with Infections Restricted/Excluded I, the narrative page(s) and a citation of specific Rrovision(s) violated. Non-compliance'with: ons and Risk Factors Ariti-Choking Tobacco trd,and,requireimmediate corrective "5e0.009( E) ❑ 590.00!D�(r7 ❑ ❑ 12. Prevention of Contamination from Hands �,❑ 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/ Protections' ✓- ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing -;. ❑ 11. Good Hygienic Practices ❑ 13. Handwash Facilities r PC ROTECTION FROM CHEMICALS�y • - _ _ El 14. 14. Approved Food or Color Additives 3" ❑ 15. Toxic Chemicals . IEEjt!!ttRATURE CONTROLS (Potentlally_Hazardous Fooda) - ❑ 16. Cooking Temperatures ❑ 17. Reheating 4❑ 18. Cooling a, ❑ 19. Hot and Cold Holding ❑ 20�,Time As a Public Health Control Violations Related to Good Retail Practices 1 Nun Critical (C) violations marked must ti corrected . To F immediately or within 10 days as determined by the Board and of Health: Non-critical (N) violations must be corrected Offi immediately or within 90 days as determined by the Board Offil +v iv lPersonnel a 23. Management and (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) • C 28. Poisonous or Toxic Materials (FC -7)(590.003) 29. Spec' OR quirements (590.009) 30.Othef S. Wlnapeol0m 14.tl n and Food,Preparation for HSP Posting of Consumer Advisories by a Bol order of cited in I the food of Violated"Provisions Related borne Illnesses Interventions : Factors (Items 1-22): )rder for Correction: Based on an inspection itemg-checked indicate violations of 105 CMR federal Food Code. This report, when signed below rd, of Health member or its agent constitutes an he Board of`Health. Failure to correct violations iisreport may result in suspension or revocation of establishment permit and cessation of food merit 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. W Inspector's Signature: Print:l a PIC's Signature: IgIA /I Print: 2 �I , - �. Page of LPages a Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Res ponsibility* 590.003(B) Demonstration of Ynowied e* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to - -a Com liance 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* tem* 590.006(A) Charm* 590.006(11) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restr ct ons 4 5 6 In FOOD FROM APPROVED SOURCE -Denotes cridad item in the federal 1999 Food Cale or 10 CMR 590.000. C PROTECTION FROM CONTAMINATION ' Food and Water From Regulated Sources 590.004(A -B) - -a Com liance with Food Law* 3-201.12 Food in a Hermetically Sealer{ Container* 3-201.13 Fluid Milk and Milk Products* 3-202.)3 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteurize* 3-202.16 Ice Made From Potable Drinking Water* 5-101A I Drinking Water from an Approved System* tem* 590.006(A) Bottled Drinking= Water* 590.006(11) Water Meets Standards in 310 CMR 22.0* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Sheillish and Fish From an Approved Source 3-201.1.4 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 _ ShellstockIdentification Present' 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* ----- 2-301.14 ReceivmgtConditlon 3-202.11 PIIFs Received at Pro er Tent eratures* 3-202.15 Package Irate rit 3-IOLl l Fcxd Safe and Unadulterated TagsMocords: Shelistock 3-202.18 Shelistock Identification 3-203.12 ShellstoekIdentification Maintained 'r 12 Tags/Records: Fish Producfs 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention` 590.004(1) Labeling of Ingredients" Handwash Facilities Conformance with Approved Procedures IHACCP Plans 3-502.11 Specialized Processirm Methods* 3-50212 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* - -Denotes cridad item in the federal 1999 Food Cale or 10 CMR 590.000. C PROTECTION FROM CONTAMINATION ' Cross -contamination 3-302.1.1(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.111 Contamination from Raw Ingredients 3-302.1.1(.A)(2) Raw Animal Funds Separated from Each Other* Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(A) I Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* 4-602.11. Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Rewnditioning Unsafe Food" 9_ __ Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water - Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.1 [(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11. Cleaning Frequency of FAuipment 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 Cleaning Procedure* 2-301.14 When to Wash* 1.1 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 Handwashing Cleanser, Availability 6-301..1.2 Hand -Dr i g Provision j BOARD OF HEALTH Establishment Name: I hP U(d Date: 1 Z(Zo�, Page: of Item No. Code Reference I C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PRIN PLEASE.T CLEARLY Date verified V Ste/ i i l e -, mss, �- ; I ., u A. r'j", l rc J 1 - / , (Jn (/ 4� ! 1 d e i vt o ��t G - I v c r,\ /, )` I_ /IYs �1 !-i CA_ N� � I / , Discussion With Person in Charge:/ I have read this report, have had the opportunity to ask qu stions and agree to correct all P � ons as described, and to comply with all mandates of the Mass/Federal Fo. I understand that violations before the next inspection, to observe aVars noncompliance may result in daily fines of twentyor suspension/revocation of your food permit. 6�n Corrective Action Required: ❑ No Yes ❑ voluntary Compliance ❑ ❑ Re -inspection Scheduled ❑ ❑ Embargo ❑ ❑ Voluntary Disposal ❑ Employee Restriction Exclusion Emergency Suspension Emergency Closure Other: Violations Related to Foodborne Illness lnterrenfhns and Risk Factors (Items; Y-72) (Cont.) C 136 17 Denotes critical a�ov in the L -doral 1999 Foal Cate or 105 C.MR 590.0(}0. IN FE 3.501.14(C) Color 3-202. 12 - 1 Additives*"' --•Additives 3-302.14 Protection from Unapproved Additives* 3-50L16(13) 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 Sanitize". Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying, Agents, Criteria* 7-205. i 1 Incidental Food Contact, Lubricants* 7-206.71_ Restricted Use Pesticides, Criteria* 7-206.12 .... Rodent 7-206.13_•- _Bait _Stattonsfi Tracking Powders, Pest Control and Monitoring* Denotes critical a�ov in the L -doral 1999 Foal Cate or 105 C.MR 590.0(}0. IN FE 3.501.14(C) Proper Cooling Temperatures for 3-501..15 PHFa _ 3401.IIA(1)(2) Eggs- I55`F 15 Sec. u 3-50L16(13) 590.004(F) E - immediate. Service 145'FiSsec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A7 Animals - 155'F 15 sec. * 3401.11(13)(1)(2) Port: and Beef Roast - 130'F 121 min* -40131(A)(2) Ratites, Injected Meats -155`F 15 530.004{Hj sec. * 3-40I.1 I(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC -6- Poultry or Ratites -165'F 15 sec 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 1 FC - 7.008 145°F ;` 3-201.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PIFs - 145'F 15 sec. Reheating for Hot Holding 3403A I(A)&(D) PHFs I65 -F 15 sec. * 3.403.11(B) Microwave- 165' F 2 Minnie Standing Time* 3-403.11(C) Commercially Processed RTE Food - MOP 3403.11(E) Remaining Unsliced Pardons of Beef Roastsl` 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 4I'F/45'F Within 4 Hours. * 3-501.14(B) Cooling PRFs Made From Ambient Temperature iagruicnta to 41'F/45°F Within 4 Hours* Denotes critical a�ov in the L -doral 1999 Foal Cate or 105 C.MR 590.0(}0. IN FE 3.501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'Ff45'F Within 4 Hunts. 3-501..15 Cooling Methods for PHFs _ PHF Hot and Coto Holding 3-50L16(13) 590.004(F) Cold PHFs Maintained at or below 43'1#5° F* 3-501.16(A) Hot PRFs Maintained at or above 140'P. * 3-501.16(A7 Roasts Held at or above 130'F. 1 25. Time as a Public Health Control 3-501:19 Time as a Public Health Control* 530.004{Hj Variance 1 -pi -ma, 21 3-801. 11 (A) Unpasteurized Pte -packaged Juices and BevcMees with Warning I abets* _ 530.000 ' 3-801.11CB 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 Protectionk 3-801.11(C) Unopened Food Package Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of 530.000 ' 23. Animal FoodsThat are Raw, Undercooked or FC - 2 ,003 Not Otherwise Processed to Eliminate Food and Food Protectionk FC - 3 Pathogens.* "nom 1 25. 3302.13. Pasteurized Eggs Substitute for Raw Shell .005 i ! 26. E 590.009(A){D) Violations of Section 590.009(A)-(D)in catering, mobile fwd, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to gaorl retail practices should be debited under #39 - Special Requirements. W4ralltl (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventianv and risk factors listed above, can be lrimnd in the folloxing sections of the Food Code and 105 CMR 590.000. item -- !Good Refect! Practices FC 530.000 ' 23. Managament and Personnel FC - 2 ,003 24. Food and Food Protectionk FC - 3 004 j 1 25. Equipment and Utensils i FCFC-4 .005 i ! 26. ! Water. Plumbino and Waste 1 FC -5 i .006 1 27. i Ph tcal Facility FC -6- .407 j L28. Poisonous or Toxic Materials 1 FC - 7.008 29. SpecialRequiremerds 005 7 30. i Other S: vvf'� a:. Massachusetts Department of .Public Healf6 Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 NameDat T e of O eration s Tvpe of Inspection Food Service Retail ❑ Residential Kitchen ElMobile El Temporary ❑ El & Breakfast Permit No. ❑ Routine Re -inspection Previous/ns action Date: /2/b/ 1 ❑Pre-operation Suspect ❑ GeneComplaint plaint ❑ Other ❑Other Address( _ Telephon NS � RIs Level Owner �y /197 t1 HACCP Y/N Person in Charge (PIC) .Time In:HACCP Out. Out. Inspector Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. . ��POOD PROTECTION.MANAGEMENT __. ❑ 1. PIC Assigned / Knowledgeable= / Dutie,_s J - -- EMPLOYEE HEALTH _ _ - _ _ _ _ °'--�.1 ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVEDSOURCE.__ _ _ - _ E]4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION r ❑ 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 ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS , ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals T_1diiEMPERATURE CONTROLS (Potentially Hazardous Fo_oda) ; ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling . Hot and Cold Holding ❑ 20. Time As a Public Health Control El 21. Food and Food Preparationlfr HSP POPULATIONS (HSP)! CONS44, UMER ❑ 22. Posting of Consumer Advisories 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. Poison9 su or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other/ 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: n Inspector's SignaturIe• Print: � PIC's Signature: Print. Page Aof Pages V `' Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assigmtment of Re�nsibility* 590.003(6) Demonstration of Knowledge* 2-103.1.1. Person in charge - duties EMPLOYEE HEALTH 2 590.003(,C)Responsibility of the person in charge to Compliance with Food Law* 3-201.1.2 require reporting by food employees rmd 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(.F) Responsibility Of A Fold 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* 590.0(x)(A) Charge* 590.006(B) 59().003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Resbictions'r 3-201.15 590.003(E) Removal of Exclusions and Restrictions Im 5 6 FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Fmd Code or I0i CMR 590.000. C PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590-004(A-6) Compliance with Food Law* 3-201.1.2 Foal 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* 5-101.1.1 Drinking Water from an Approved System* 590.0(x)(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" Frequency of Sanitivition of Utensils and Food Contact Surfaces of E ui ment* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Proper, Adequate Handwashing Game and WLid Mushrooms Approved by Figgufataty Authority 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 Temperatures* 3-202.15 Package late ,it 3-101.11. Food Safe and Unadulterated Tags/Records; Shellstock 3-202.18 Shellstc k Identification * 3-203.1.2 Shellstock Identification Maintained* 12 Tags/Records:Fish Products 3402.11 Parasite Destruction* 3402.12 1 Records. Creation and Retention* 590.004(7) Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures IHACCP Plans 3-502.11. Specialized Processing Methods* 3-502.12 Reduced oxygen packa 'ng. criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Fmd Code or I0i CMR 590.000. C PROTECTION FROM CONTAMINATION ') Cross -contamination _ 3-302.11(A)0) Raw Animal Foals Separated from Cooked and RTE Foods* 4-501..111 Contamination from Raw Ingredients 3-30211(A)(2) Raw Aulmal ,Foods Separated from Each Other" Mechanical Warewashing-Hot Water Sanitization Tem eratures* 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* 4-602.11. Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitivition of Utensils and Food Contact Surfaces of E ui ment* Disposition of Adulterated or Contaminated Food L370T11 • 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 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 Sanitivition of Utensils and Food Contact Surfaces of E ui ment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 - Clean Condition - Hands and Amens* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 - Prevention of Contamination from Hands 590.004(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 (i-301.1.2 Hand Drying Provision Establishment I T-ur 0HLC BOARD OF HEALTH Date I Page: --.2 Of Item No. Code Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Ca , Verified I / PLEASE PRINT CLEARLY . 1. l 4v' J/ A\ 1-e 1125� iAkOrnn e C VP (:-, �eI(AA.z�. t' - �n <s� L) 1 J- ' vPf-k-- i r✓ S (na lec // I K, t l I f ``^^ 1 I IG, 1-1649 x 4n (n�y ✓v(cc c (rZ d' �1 /,-7th ((V UA -I f-. ChM .i 36,�4 +- 37- O f ' A O F S vn JA10 Ole i J 7 I- ' c t cJn C' �•� ( Discussion With Person in Charge: / I have read this report, have had the opportunity'to ask estions and agree to correct all violations before the next inspection, to observe all co Itions as described, and to t_ comply with all mandates of the Mass/Federal Foo od I understand that noncompliance may result in daily fines of twe� f - - ollars or suspension/revocation of your food permit.` Corrective Action Required: b No Yes 1:1Voluntary Compliance ElEmployee Restriction / Exclusion Re -inspection Scheduled ❑ Emergency Suspension � ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: i Violations Related to Foodborne illness Interventions and Risk Factors{Rems 1-22) (Coni.) 15 16 18 " Deartac criticat vzra in the £edam 1999 Feed Cale or 103 CMR 590.090. 3-SOl.14(C) Pond or Color Additives 320212 Additives* 3-302.14 Protection from Unapproved Additives* 3-50L16(B) 590.004(F) Poisonous or Toxic Substances 7-107,11 rdentij}mgInformation- Original Cantamers* 7-102.11. Comanon Name - Working Containers* 7-201.11 Separation - Stora * 7-202.11 . Restriction -Presence and Use* 7-202.12 Conditions of Use* 7-203.11 'Toxic Containers - Prohibitions* 7-204.11 Sanitize". Criteria - Chemicals" 7-204.12 Chemicals for 1Trrashin Prodtux, Criteria* 7-204,14 Drying Agents. Criteria' 7-205.11 Incidental Foot Contam Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 - Rodent Batt Stations* 7-206.13 Tracking Powders, Pest Control and Monitnrin * " Deartac criticat vzra in the £edam 1999 Feed Cale or 103 CMR 590.090. 3-SOl.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3 4o1.uA{1)(z> Eggs- 155F 15 Sec. 3-50L16(B) 590.004(F) Eggs -Immediate Service 145'1`15sec4 3-401.11(A)(2) Comminuted Fish. Meats & Game 3.501.16(A) Animals - 155'F I5 sec. * 3.40LII(B)(IX2) Pork and Beef Roast -130'F121 min* 3-401.11(A)(2) Ratites, Ingected Meats -155`F 15 590.004{H) sec. * 3401.11(,A)(3) Poultry, Wild Game. Stuffed PHFs, Staffing Containing Fish, Meat, Poul!a or Ratites -165'F 15 sec. 3-401.11(0)(3) Whole -muscle, Intact Beef Steaks 145°F * 3401.12 Raw Animal Foods Cooked in a Microwave 165`F * 3401.11(A)(1)(b) .411 Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403.1 I(A)&(D) PHFs 165'F 15 sec. * 3-403-11(13) Microwave- 165°F 2 Maine Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-903.1 I(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70"F Within 2 Home 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* " Deartac criticat vzra in the £edam 1999 Feed Cale or 103 CMR 590.090. 3-SOl.14(C) PHFs Received at Temperatures According to Craw Cooled to 41'R457 Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-801.11 CB PHP Hot and Cold Holding 3-50L16(B) 590.004(F) Cold PRFs Maimained at or below 41°145°F* 3-501.76(A) Hot PRFs Maintained at or above 140°F. * 3.501.16(A) Roasts Held at or above 130'F. Time as a Public Health Control 3-501,19 Time as a Public Health Control* 590.004{H) Variance Re nirement 21 3-801. 11 (A) Unpasteurized Pre-packaged Iuices atad Beverages with Warning iabeIs* 3-801.11 CB Use of Pasteurized Ea * 3-801..11(D) Raw or Partially Cooked Annual Food and Raw Seed Sprains Not Served. * 3-801.11(C) Unopened Food Package Not Re served. ROMPUTRTWITO =111 22 3-603.11 Consumer Advisary Pasted for Consumption of Animal Foods That are Raw, Undercooked or Not Otherwise Processed to Eliminate Patho *ens:* sem ln?W I 3-302.13 Pasteur zed Eggs Substitute for Raw Shell E 590.D09(A)-(D) } Violations of. Section 590.009(A)-(D)in I{ catering, mobile flood, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, mrd non-criffcal violations, which do not relate,. to the foodborne itfness interventions and risk factors limd above, can be found in the following sections of the Food Code and 105 C32R Establishment Name ITY OF SALEM BOARD OF HEALTH Date: Page:_ of Item No. Code Reference C -Critical Item R - Rad Item DESCRIPTION OF VIOLATION / PLAN OFICORRECTION PLEASE PRINT CLEARLY ; Date, Verified IL� 4 P -r r� o t f A-( C4S 29- Vtf n S (Q-1 AP��ZYII 1tPnUAO G 1J1� S S e tJB^ ltlQW -L9uj 1 W 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 conditio s as described, and to P comply with all mandates of the Mass/Federal- l F d Code. understand that noncompliance may result in daily fines of twenty- fe II rs or suspension/revocation of your food permit. Corrective Action Required: ❑ No s ❑ Voluntary Compliance El Employee Restriction / Exclusion Re -inspection Scheduled ❑ Emergency Suspension 6 ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other. 'e Violations Related to Foodborno Illness. Interrenttons and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 Food or Color C LN TIMErrEMPERATURE CONTROLS Additives 3_202.12 Additives* 3-302.14 Protection from Un roved Addiuves' Poisonous or Toxic Substances 7-101.11 identifying Information - Original Containers* 7-102.11, Common Name - Working Containers* 7-201.1.1 Separation - Storage* - 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use+ 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washin 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* - LN TIMErrEMPERATURE CONTROLS 3 0.nctm aiticat ir,m in the federal 1999 Food Cade 01'105 CWMR 590.000. 3-501.14(C) PHFs Received at Tem According to Law Cooled to 41'17745°F Within 4 Hours. * Proper Cooking Temperatures for F3-501..15 iq PHFs 3-40i.IIA(1)(2) Eggs- 155F 15 See. Eggs- ImmediateService 145'Fl5see- 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-801.11 C Animals - 155'F 15 sec- * 3-401.11(B)(I)(2) Pork and Beef Rpt -13TF 121 min* 3-401.11(A)(2) Ratites, Injected Meats - 1550F 15 we. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -165'17 15 sec, 3401.11(C)(3) Whole -muscle, Intact Beef Steaks 145OF * 3-401.12 Raw Animal Fails Cooked in a Microwave 165°F* 3401AI(A)(1)(b) All Other PHFs - I45'F 15 sec, Reheating for Hot Holding 3-03.11(A)&(D) PHFs 165"F 15 see. * 3-403.11(B) Microwave- 165` F 2 Minute Standing Tittle" 3403.11(C) Commercially Processed RTE Fail - 140'17 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70`F Within 2 Hours and From 70'F to 41`F/45017 Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature ingredients to 41'17/45'F Within 4 Hours* 3 0.nctm aiticat ir,m in the federal 1999 Food Cade 01'105 CWMR 590.000. 3-501.14(C) PHFs Received at Tem According to Law Cooled to 41'17745°F Within 4 Hours. * 3-50L16(B) Cold PHFs Maintained at or below 590.004(17) 41'145' F- 3 -501,16(A) Hot PHFs Maintained at or above 3-501.16(A) 1 Roasts Held at or above 1.300F. * 120 1 1 Time as a Public Health Control I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 Coolm Methods for PHFs F3-501..15 iq ' PHF Hot and Cold Holding 3-50L16(B) Cold PHFs Maintained at or below 590.004(17) 41'145' F- 3 -501,16(A) Hot PHFs Maintained at or above 3-501.16(A) 1 Roasts Held at or above 1.300F. * 120 1 1 Time as a Public Health Control I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 1-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Wartime Labels* _ 3-801.11M Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and Rain Seed Sprouts Not Served. * 3-801.11 C Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Pasted for Consumption of Animal Fends That are Raw. UndercoDked or Not Othetwise,Processed to Eliminate Pathogens. * mins vronr 3-302.13. Pasteurized Eggs Substitute for Raw Shell E * WtUAL MUt9n'iC10111=1`4 1 b 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 goad retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sectionsaf the Food Code mad 105 CMR s svrr,�vs. m. � I I I Massachusetts Department oablip, Health Division of Food and Drugs. FOOD ESTABLISHMENT INSPECTION REPORT t- Salem Board of Health 120 Washington Street, 4'" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name 76 P� Print: I Da a of O orations Tvoe of Inspection V PIC's Signature. ,r- i Food Service ❑ Retail m Routine ❑ Re -inspection Address Ri Level ❑ Residential Kitchen Previous I sp ion Telephone �(1 El Mobile Date: //,�� mpo Caterer El Temporary ❑ Bed & Breakfast 1:1Prf6pe, .hon ❑ Suspect Illness El ❑ General Complaint Owner HACCP Y/N Person in Charge (PIC) Time '1 In: ^z�- Out Permit No. [I HACCP ❑ Other Inspector Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.DD9( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. , FOOD PROTECTI.ON MANAGEMENT ' ❑ 1. PIC Assigned / Knowledgeable / Duties [EMPLOYEE HEALTH [1 2. Reporting of Diseases by Food Employee and PIC E]3. PeIrsonnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source k, ❑ 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 n 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.fon-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)(59o.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. 5904,specffp 14.Ea . nn. ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM C_H_EMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEREMPERATURE CONTROLS (Potentially Haz_aM__ou_a Foods) ❑ 16. Cooking Temperatures W ❑ 17. Reheating ❑ 18. Cooling J� 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control ___. _.� r REOUIREMEMTS FOR HIGHLY SUSCEPTIBLE -POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP [122. Posting of Consumer Advisories r 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 GMR 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 REINSPECTION: a4CJl�1,a-1, i'5 a I 1 i Inspector's Signature: Print: I PIC's Signature. ,r- Print:/ Page o Pages N ' Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 7 590.003(A) Assiat�memofRes ponsibility* 590.003(B) Demonstration of Knowled�_ 2-1.03.11 Person in charge- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved S stem* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Char* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrict ons ME C C C FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Fond 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* 3-202.1.4 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved S stem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP listed Sources* Proper, Adequate Handwashing Game and Wild ,Mushrooms Approved by Regulatory Authort 3-202.18 Shellstock identification Present* 590M04(C) NVild Mushrooms* 3-201.17 Game Animals* 2-301.14 Receiving/Condition 3-202.11 PHFs Received at Proper Tem ratures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* 12 Tags/Records: Fish Products 3402.11. Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(7) Labeling of Ingredients' Handwash Facilities Conformance v✓lth Approved Procedures /HACCP Plans 3-502.11. Specialized ProeesSing,Metbods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Fond Code or 105 CMR 590.000. C PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302-1.1(A)(1) 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 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* 4-602.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-701,11 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 Equipment* 4-703.11 Methods of Sanitization - Hot Water and - Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Acids* 2-301.1.2 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2-40111 Eating, Drinking or Using Tobacco* 2-401.1.2 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 5W.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 Cieanser,.Availabilit y 6-301.1.2 Hand Drying Provision -CITY OF SALEM BOARD OF HEALTH Establishment Name: / o Id Date: Page: of Item No. Code Reference C - Critical Item R - Red Itemverified DESCRIPTION OF VIOLATION / PL N OF CORRECTION PLEASE PRINTI Date �l- 1 �p� [J✓ /^ /'CLEARLY l OC , 'l IS I N C )-Ice 0� CJS Gr rN I ! .I ^ G r CU '� / & C G It -71 -3--p. 4 D n.)4 k %3cAzx •-V fp. / rig a'.G Jc„ J aj ns. I s d 0 elk. 4 a ✓f .419. C — W.'/+tel I % �-ii iA O o i I Discussion With Person in Charge: 4-v fig JIM h,/' i-- 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- ve o suspension/revocation of your food permit. Corrective Ac Ion Required: ❑ No Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion inspectionScheduled ❑ Emergency Suspension o Embargo ❑ Emr:rgency Closure Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Hemg 1-22) (Cont.) 15 16 ,q Food or C otor Additives 3-202.12 Additives* 3-30214 Protection from Un roved Additivas* 3-501.16(6) 590.004(F) Poisonous or Toxic Substances 7-101,11 ldemi*ing 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 Sanidzers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Product, Criteria* 7-201.14 ents. 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 Monitnrin " C Demme crificid item in the federal 1999 FcaA Code or 10 C3iR 590.0X 19 3-501.14(C) Proper Cooking Temperatures 4or 3-501..15 PHFs 3-401.11A(1)(2) Eggs- 155'F 15 Sea 3-501.16(6) 590.004(F) Egos- immediate. Service 145'F15sec* 3-401.11(A)(2) - Comminuted Fish. Meats & Game 3-501.16(A) Animals - 155'F 15 see. * 3401.1I(B)(I)(2) Pork and Beef Roast -130'F 121 min* 3-401.11(A)(2) Ratites, injected Meats -155'F 15 590.004(H) Seo. * 3-401.11(A)(3) Poultry, Wild Game. Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -165'F 15 see. 3-401.11(0)(3) Whole -muscle, Intact Beef Steaks 145`F 4' 3-401.12 Raw Animal FtxAs Cooked in a Microwave 165'F 3-401.11(A)(1')(b) All Other PHFs - 145 F 15 sec. Reheating for Hot Holding 3-403A I(A)&(D) j PHFs 165'F 15 sec. * 3-403.11(B) Microwave- 165` F 2 Minute Standing Time* 3-403.11(C) Commercialjy Processed RTE Food - 140'F 3-403.I1(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 700F Within 2 Hours and From 70'F to 41'F/45'F Within 4 Hours. * 3-501.14($) Cooling PHFs Made From Ambient Temperature Ingredients tD 41'F/45'F Within 4 Hours* Demme crificid item in the federal 1999 FcaA Code or 10 C3iR 590.0X 19 3-501.14(C) PHFs Received at Temperatures - According to Law Cooled to 41'F/45'F Within 4 Hous, 3-501..15 Cooling Methods for PHFs PHF Hot and Cold Holding 3-501.16(6) 590.004(F) Cold Pl1Fs'Maintnined at cr below 410145' F* 3-501.16(A) Hot PHFs Maintained at or above 140'F. 3-501.16(A) Roasts Heid at or above 130'F. Time as a Public Health Control 3-501,19 Time as a Public Health Control* 590.004(H) VariancnRequirement of 2]. 3-801.11(A) Unpasteurized Pre-packaged Juices and :Beverages with Warding Labels* ConsumerAdvisory Posted for Consumption of 3-801.11(6} Use of Pasteurized Eggs* _ 3-801..1 I (D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 3-801.11(C) Unopened Food Package Not Re -served. C014SUMER ADVISORY 22 3-603.11 ConsumerAdvisory Posted for Consumption of Animal Foods That are Raw. Undercooked or Not Otherwise�Processed t0 Eliminate Pat1iD *ens.* E7teeivs anremr 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggst W'r-UAL Ht:UUIt1=Mt:N IA 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical. mid non-critical violations, which do not relate: to the foodborne illness interventions and risk factors listed above, can be 1aund in rhe fallowing sections. of the Food Code and 105 CMR C CITY OF SALEM 1> BOARD OF HEALTH - Establishment Name: QIJ �(� `Date:Page:-';�- of Ito No. Code Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN O CORRECTION Date Verified PLEASE PRIINTLEAFI ) ^ n (/ I,J / ro plc" r'11' 0n J 0 Id Si ✓/ k<' y n r f- GrPc<: r« e - rte c >♦- i OC c, b� r r11''L✓./ i c L .� } j uad ojc O—)tan -f'..L} C n✓ In V42r. - ual AQ -i i an c &1, CJs = Caw fir -5-S-U 1. li 0- ru c. / n C V Gc - /i, 4 -Ce C L/l CcYI 1�c V/ tkOCILVAShlry - t� A4 e Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to P `comply with all mandates of the Mass/Federal Foy d Code. I understand that noncompliance may result in daily fines of twenty -fl - ars or ension/revocation of your food permit. Corrective Action Required: d No I;;)—Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne fitness lntervendons and Risk Factors (Items -1-22) (Cont.) 16 Im Food or Gator Additives 3-202.12 i Additives - - ---�' 3-302.14 Protection from Una roved ,Akddiovas'% 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 - Stn * 7-202.11 . Restriction - Presence and Use* 7-202.72 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 Drvimr Aectits. Criteria" 7-205.11 incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.12 - Rodent Bair Starions* 7-206.73 Tracking Powders, Pest Control and Monitorin * * Dersau critical item in the fi detvl 1999 Fe A Code or 105 CMR 590.000. 20 3-5OI.14(C) gorm Proper Cooking Temperatures for 3-501.15 PHFs 3-401.11A(1)(2) Egg- 155F 15 Sec 3-501-16(B) 590.004(F) Eggs- rmmediste Service 145'F15sec- 3-401.11(A)(2) Comminuted Fish. Meats & Game 507. Y6(A3 Animals - 1550F 15 sec. * 3.401AI(B)(1)(2) Pork and Beef Roast -130°F 121 mitt* 3-40131(A)(2) Ratites, Injected Masts -155`F 15 590.004(11) sec. * 3-401.1I(A)(3) Poultry, Wild Game, Staffed PHFs, Stuffing Containing Fish, Meat, Poul or Ratites -1650F 1.5 sec 3401.11(C)(3) Whole -muscle, Intact Beef Steaks 145OF 4, 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-401:11(A)(1)(b) Ali Other PHFs - 145"F 15 sec. Reheating for Not Holding 3-403.4l(A)&(A) 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* 3403.11(E) Remaining Unsliced Purtions of Beef Roasts" Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140`F to 70'F Within 2 Hours and From 70`F to 41 `F/45°F Within 4 Hours. * 3-501.14(B) Cooling PRFs Made FromAmbient Temperature Ingredients to 41 °F/45'F Within 4 Hours* * Dersau critical item in the fi detvl 1999 Fe A Code or 105 CMR 590.000. 20 3-5OI.14(C) gorm PHFs Received at Temperatures - According to law Cooled to 4VN45°17 Within 4 Houm 3-501.15 Cooling Methods for PHFs 3-801.1 UE) PHF Not and Cold Holding 3-501-16(B) 590.004(F) Cold P11Fs Maintained at or below 4101450 F* 3-541.16(A) Ha PRFs Maintained at or above 140T. * 507. Y6(A3 Roasts Held at or above 130'F. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(11) e uirement Variance Requirement -s• s 27. 3-801.1 ] (A) unpasteurized Pte -packaged Juice& and .Bevrxaces with Warning Labels* 3-801.1 UE) � Use of Pasteuriued Eggs* 3-801.11(D) _...-..-...:....._ [taw or Partially Cooked Animal Food and Ran, Seed Sprouts Not Served, * 3-801.11(C) Unorsened Food EEkaE Not Re -served. 22 3-603.11 Consumer Advisory Pasted for Consumption of Animal Foods That are Raw, Undercooked or Not Otherwise Processed to Eliminate Pathogens.' e"mew "n 'f 3-302.13 Pasteurized Eggs Substitute for Raw Shell E 590.009(A)-(Pl) Violations of Section .590.009(A) -(D) in catering, mobile fwd, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above., can be found in the following sections of the Food Code and 105 CMR 4 BOARD OF HEALTH Establishment Name: :T1 A 6 Date: Pager of/ Item No. Code Reference I C - Critical Item R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEAS P INT CLEARLY Date 4 Verified �'^ 7 css- _ J e znj t1 a2 V EA J � - - ♦" r! X11 MG /tom- [A l 17�A✓�� / - aA, C4,rt rr.`� r e tv — V ,i �lze G¢ C 1. sie -� 2C ( 67Ltk-&-n 6 1 I c I en c"I i 77 -K501 -C C = {, (�CJ1ir�C GT M/JJ f 0 U - 12-t _SG A% C, Z G I SC Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all inspection, to observe all conditions as described, and to -violations before the next ins P comply with all mandates of the Ma /Fed I Food Code. I understand that noncompliance may result in daily fines ofve dEi rs or suspension/revocation of your food permit. -� i Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ EmployeeRestriction / Exclusion � Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness. Interventions and Risk Factors (items 1-22) (Conti 15 in * 'r Food or Color Additives 3-20_2.12 Additives* 3-302.14._ ^_. Protection from Additives* ; FC -2 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11, Common Nam - Working Containers* 7-101.11 5 ation-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 ResttiMed Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pert Control and Monitarina'�` in * 'r De'ncum aiticat acne in the L -demi 1999 Food C (ie or IV C.MR 590.000. 3.501.14(C) PHFs Received at Temperatures According in Law Conic to 4171454 Within 4 Hours. * I Proper Cooking Temperatures for 19 PHFs 3401.1YA(1)(2) Eggs- )55°F 15 Sec. ; FC -2 E g - immediate. Service; 145°Fl5sec* 3-401.11(A)(2) - Comminuted Fish. Meats & Game 3-801.11(C) Animals -155°F 15 see. * 3.401.11(B)(1)(2) Paris and Beef Roast -130-F 121miu* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 26. sec. * 3-401.1.1(A)(3) Poultry, Wild Game, Stuffed PHF's, 27. Stuffing Containing Fish, Meat. IFC -8 - Poultry or Ratites-165OF 15 sec. 3401.11(C)(3) Whole -muscle, Intact Beef Steaks ! FC -7 145°F 3-401.12 Raw Animal Faxls Cooked in a Microwave 1657 * 3-40'1:11(A)(1)(b) All Other PHFs - 145°F 15 sec. Reheating for Hot Holding 3-403AI(A)&(D) PRFs 165-F 15 sec. 3-403.11(B) Microwave- 165` F 2 Mature Standing Time* 3403.1. I(C) Commercially Processed RTE Food - 1400F* 3-40 1111(E) Remaining Unsliced Portions of Beef Roasts*' _ -- Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PBF% from 140`F to 70T Within 2 Hours and Front 70T to 41°F745°F Within 4 Hours. * 7501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°Fi456F Within 4 Hours* De'ncum aiticat acne in the L -demi 1999 Food C (ie or IV C.MR 590.000. 3.501.14(C) PHFs Received at Temperatures According in Law Conic to 4171454 Within 4 Hours. * I Cold PI-IFs Maintained at or below 3-501.16(X) 1 Hot PRFs Maintained at or above ME Control* 21 3-501-15 Ccolinp Methods for PHFs 19 PHF Hot and Cold Holding Cold PI-IFs Maintained at or below 3-501.16(X) 1 Hot PRFs Maintained at or above ME Control* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and ' .Bevernees with W`arnina Labels* 690-0XO 3-801.I1fM) Use of Pasteurized Ems` ; FC -2 3-801.11(6) _..., -..,..,.-- Raw or Partially Cooked Animal Food and Raw Seed $ uts Not Served. * Food and Food Protection 3-801.11(C) Unopened Food PackageNot Re -served. 22 3-603.11 Cousumer Advisory Posted for Consumption of 690-0XO 23. Animal Foods That are Raw, Undercooked or ; FC -2 .(103 Not Otherwise Processed w Eliminate Food and Food Protection FC -3 Pathogens.' 'n ° 1 25. 3-302.13. Pasteurized Eggs Substitute for Raw Shell ,005 26. E * SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile f loll, 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 - Speeiai Requirements. t • _ r r { s. ; s r r3FitleTr7r3r7:7xi?itif7 �fifif+J�'ti (Items 23-30) O*lcal mrd non-critical violations, which da not relate to the foadborne illness interventions and risk factors listed above, can be }'bund in the following sections of the Food Code and 105 CY1R 590.000. h Item i Good Retail Practices, .FC 690-0XO 23. ;Management and Personnel ; FC -2 .(103 124 Food and Food Protection FC -3 .004 j 1 25. I Equipment and Utensils I FC -4 ,005 26. + Water. Plumbim and Waste _ i FC - 5 .MS 27. I Physical Faci5ty IFC -8 - j .tSD7 28. Poisonous or Toxic Materials ! FC -7 008 29. Speaiat ft uirements .00B ) ,.... i. Other f Massachusetts Department of. Public Heilth Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT i Salem Board of Health 120 Washington Street, 40' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name kl I _ Print: 6NI _I r \ T e of O eration s Type of Inspection I T / !r -Food Service [1Retail ❑Routine &He -inspection Address 14SSPX C 0 t Risk Telephone G �l S Level E]Residential Kitchen El Mobile ❑ rTemporary Previous spe Ion Date: 5 /c`t[ ElPre-opera tion� OwnerHACCP '�J YM �, ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person In Charge (PIC) Time 1 In:3i ❑ HACCP Inspector I Ds4h I Ou w Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors 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_ 0 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N' 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water,. Plumbing and Waste (FC -5)(590.006) Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S. MnspacYFa 14.tl C-�n/m 117 ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/rEMPERA7URE CONTROLS(PotentiallyHazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control ---- REOUIREMENTSFOR,HIOHLYSUSCEPTIBLEPOPULAIIONS.(H P E121. Food and Food Preparation for HSP CONSUMERADVISORY_ _.. _ ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: �' A Inspector's Signature: t _ Print: l J PIC's Signature:/ Print: 6NI _I r \ Page of�Rages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(A)Assig-amentofResmnsibilaty* 590.003(B) Demunstr'tic, of Knowledge* 2-103.11 1 Person in charge - duties EMPLOYEE HEALTH 2 590.W3(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Focal 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 Char re" 3 590.0030 Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions L® C C I FOOD FROM APPROVED SOURCE '* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. $ 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* WashingFruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Mofluscan Shellfish from NSSP lasted Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authonl 3-202.18 Shellstock.ldentificathvr Present" 590.004(C) Wild Mushrooms` 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Pro er Tem eratures* 3-202.1.5 Package Inte rit 3-101.11 Food Safe and Unadulterated TagstRecords: Sheiisteck 3-202.18 Shellstock identification * 3-203.1.2 Shellstock Identification Maintained* TagslRecords:Flsh Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(1) Labeling of ingredients= Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Conformance with Approved Procedures /HACCP Plans 3-502.11. Specialized Processing- Methods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with A roved Procedures* '* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. $ _ Cross -contamination 3-302.11(A)n Raw Animal Foods Separated frum' Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Aninutl Foods Separated from Each Other* Contamination from the Environment 3-302.11 (A) Food Protection* 3-3 ) WashingFruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* ' Contamination from the Consumer 3-306.14 A)(B) Returned FcW and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.1.11 Manual Warewashing - Hot Water Sanitization Ten eratures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical. Sanitization- temp., pH; - concentration and hardness.. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of E- ui ment*' 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition =Hands and Anus* 2-301..12 Cleanin Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2401..11 Eating, Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting-* 12 Prevention of Contamination from Hands 590.0(9(F.) Preventing Contarmnation from Em to s* 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 Dr in Provision Establishment Name: 1 /t c0 -,i, -Item :Code, ,C„Critical Item `No Reference R'_` Red Item "` f �w TY OF SALEM BOARD OF HEALTH Date: 1/!/ DESCRIPTION OF VIOLATION / PLAN OF. Q r ; a I' PLEASE PRINT CLEARLY lnV7lfn 1-k-\fA,4 (IG(.(I*Je/. Page: 8 of _n_ Date ,. Verified L �ono��-.� h M 0 �t / i); /4-' J-V� 1-44— c ),�, 1'5 T, rJ �ihs�y�J Cs C < I -Cn Discussion With Person in Charge: Corrective Action Required: ❑ No - t Yes I have read this report, have had the opportunity to ask questions and agree to correct all g Voluntary Compliance ❑ Employee Restriction / violations before the next ins ection, to observe all conditions as described, and to ` Exclusion P ❑ d ❑ Re -inspection ScheduleEmergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollla s or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �` \` ❑ Voluntary Disposal ❑ Other:. Y , Violations Related to Foodborne fitness Interventions and Risk Factors (ttahrs1.22) tcont) 14 w Food or Ct Additives* Additives* Poisonous or Toxic Substances '.-tall �klentityinglnfotwion- Original ? Containers" Workinu Cx,nrainers* 7201.11 1 Sep iawat—Sarva tom__ 7-202.17 I Restriction —Pres co aInd Use* 3 10311 1 Toxic Cmitaincrs — R 704.11 Samtrrec'.Criteria -- Ctitolia4 7-204.14tar rink Aeente. Criteria" 7-205.11 incidental Fwd Contact.lnhnc<nis 7-206. i 1 [teStnviea l sc Pm:nctdes. Cytteria* 7-206.12 Rodent Bait Sradtonl _ ? 206-13 1 .7k+ng Prnrdom pe: i Control xnd _ TIMECCEMPERATURE CONTROLS 16—TI Proper cooking Temperatures _ PHFs 3110 1.1 i At L{2) }.ggs- N 3-4OI3l(A)(2,, Comminuted Fish, Meats&Uamc _ Anunals- t »' F 15 sec 3-401.1I(H)(I}{27 purkand BtefRoast-13€3t127mnx r 3-405.11(A)(2) �Ratitec, Injected Muds t55'B 15 3 �ICi f 11 {A)€3 j � Pouitry, WYId h anis. Stu t tuI piiFs, Stuffnig Containing Fish0.feu, Poultry orRauteg-] 65"T 15 vcc. C)( 3 -407.t7;3) tYhc3e-cons le bnn;ri3cefSteaks 3-40(.42 Animal Food,"'coked tie a �4firrowsve 765`F 3-401.f7.(A}(S)S}s) ' ,4I C.)tlier PEiF's�-.7K5`f�' 15 sec. - Reh eating for Hot Hotding 3-M)3.l1fA)F {Dl 1Hi 16 -F 75 sea. 403.1) (R) ticrov's" l65 [ Minute. Standing 3-403.11.(C) CComiaercially Pavessed Ri'F Kx d - 3-x03.1 I(F) j Remaining; ( 3-501, PI(A) ( Coling C(x)k--,d PTIFs ftom 14(ff to (j i 70'F Within 21(ours and From 70`E tc 41 7t45 F Within 4 Win,,. � 3-501.1}(l#) Coling PFI s Made Front Ambient Tamperatnre Ingredients €o4l`Ft45°F �....._____�.._ Within 4 1'h u 0 ..�..._...� ' llenoies crensit aIlin In the h. ii x i? 1990 Food C,xiE of 105 C141i 590000, I 3-50 1.1 d(C) PflFa Received at Temperatures According to Law Cooled to _:81 "1'!45`'F Within A How S- =1.75 -� Cvxilinv Mahod, for PHPs v.. 9 1 T.�+.�. PHF Hot and co€d Hewing 3-5()! .j ('(B) Cott' PH1 s Maintained at or bAvi 590.0041-1 45145' 1 3 -SQ i 16aA) flit RHT S S3aintafnec7 at or above 140'F. 3-5771, 16(,n) Roasts Held at or above 1301, 'v 20 _ Time as i Public Health Controi z-jQl l9 Time as a Public Health con trofr 30.O4Ai(H1 varianceReoairatneaC REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATl0NS (HSP 2'fl� 3 -SOI, t 1 FAJ Unp,menrlrcd Pre-peelaged Suictc aid 3-801 11{1)} jj' Rim or Pattiali cook"d Aminal Pexci and j H rn 5et�ci 5}�nau7 Not Served 3-8W I N:i 7.91 coned Fcxxi fackaae Not Rr-serv;eL v CONSUMER ADVISORY _ 22 3 03.11 Cousum„r Aevlsoi posted liar (Anuumption of iitn I F'axlThakarc Raw, Undercatked o: Not Oth reins Pr«ass�d to i3itrn#niue 3-3fj1111 3 P sreimr d f &n. Substitute for [taw Shet7 590.0090A) -t€3; vioF ttion; of Section 590 A)9(A)-(D) in caterrng, rnobilc, fxu3, temporarvand resiticw al kitchen operati,(ms .sI ovld be I debt ed ander Clic appropriate aLotiins altuve ii r ehveil to fi7odhorne dines, rntetvatiuons and risk kiclors, Other 590M9 violations relating to gaid rami practices Atauld be debited under #29 - Special Requirements. (items 23-30) Cf uirm` mad nota-r-rfut:ut viWalion,s, which do not relare in lite foodborne illness %naervettitoas and IIAjan tors Evieetabove, aur be found in rhea following st maims of'thn Food Code and 105 CMR Sv t:ev-vh!.2.W+. Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T of Operation(s) T Ins tion C ood Service Retail iefL Z-Fle-inspectionl Address SQ Risk Level ❑ Residential Kitchen Previous Inspection Telephon ` S - 5 ❑ Mobile ❑ Temporary Date: ❑ Pre-operation Owner HACCP YM 1114wra 114 ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) Time i)� El HACCP Inspecto Ou Permit No. El O herr 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 [EWNPLOYEE HEALTH _. ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded O FOOD FROM APPROVED - SOURCE. _ _ _ 0 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM 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: 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) 211. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S'501.p dFw 14.d. ' ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities )PROTECTION FROM CHEMICALS "' J ❑ 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 - REQ7U1UIREW9 MENTS FOR HIGHLY_SUSCEP_TIBLE 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): 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: PIC's Signature: Print: l V I pages Page of !7 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Respomibility* 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 focal 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) 590.0(13 G Reporting by Person in Char>e* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 C C I FOOD FROM APPROVED SOURCE * Dmmes critical item iu the Weral 1999 Faxi Code or IPS CMR 590..000_ $ Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3.201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.1.4 Eggs and Milk Produces, Pasteurized* 3-202.16 ice Made From Potable Drinking Water* 5401.11 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 Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Iisted SOurces* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Autho, ft 3-202.15 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.1.5 Package integrity* 3-101.11. Food Safe and Unadulterated Tagst9ecords: Shellstock 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 Retentions` 590.004(1) t.abeling of Ingredients' Cleaning Frequency of Equipment Food -- Contact Surfaces and Utensils* Conformance with Approved Procedures /HACCP Pians 3-502.11. Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Dmmes critical item iu the Weral 1999 Faxi Code or IPS CMR 590..000_ $ Cross -contamination 3-302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Aninatl Foods -Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(.B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501_111 Manual Warewashing- HotWater Sanitization Tem erannes* 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* 4-70211. Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ment* 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* 11 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2^401.12 Discharges. From the Eyes, Nose and Mouth* 3301.12 Preventing Contamination When Tasiin 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* 5-204.1.1 Location and Placement* 5-20511 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser,.Availabilit y 6-301.1.2 Hand -Drying provision CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: 2J li Page: 2 _ of Item Code C—Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date.. No. Reference R — Red Item __..._ _. _. _... , Verlfled S W 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- a dollars or suspension/revocation of your food permit t Corrective ❑ Volunt; J ❑ Emolovee Restriction Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Voluntary Disposal ❑ Emergency Closure ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors Mems 1-22) (Cont.) 1111121;1011 15 16 17 s Ftw_d_ or Gator Additives 3-202,12 Additives* __.. 3-302.14 Protection from Unapproved Additives* FG -2 Poisonous or Toxic Substances 7-101,11 Identifying Information - Original Containers* 7-102:11, Compton Name - Working Containers* 7-201.11_ Separation - Storage* 7-202.11 _ Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 'Tonic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Product, Criteria' 7-204.14 RDing Agents. Criteria* 7-205.11 Incidents] Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitorin *- s * Dmows critical hexa in the L&d 211999 Food Code w 103 CMR X90.000. 3-501,14(C) PHFs Received at Temperatures According to law Cooled to 41'r/45F Within 4 Hour& * Proper CooMng Temperatures for 14I PHFs 3-401.11A(i)(2) Eggs- 155°F 15 Sec. FG -2 Eggs- Immediate Service 145`Fl5sec* 3401.11(A)(2) Comminuted Fish. Meats & Game 3-801AI(C) Animals - 155"F 15 sec. * 3.401.11(11)(1)(2) Pork and Beef Roast =130°F 121 min* 3401.11(A)(2) Ratites, injected Meats - 155`F 15 ! 26. sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, 1 FC -6- Poultry or Ratites -165'F 15 sec, 3401.11(C)(3) Whole-muscle,ihtact Beef Steaks t FC -7,008 145`F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165F * 3-401:11(A){i)(b) All Other PHFs -145°F 15 sec, Reheatlng for Hot Holding 3-403AI(A)&(D) PHFs 165"F 15 see. * 3403.11(B) Microwave -165` F 2 Missile Standing Titer* 3-403.11(C) Commercially Processed RTE Food - 140`F 3-403.11(E) Remaining Unslic ed Portions of Beef Roasts* _ Proper Cooling of PHFs 3-501.14(A) Cooling Crooked PHFs front 140`F to 70°F Within 2 Hours and From 70`F to 41`F145'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41'Ff456F Within 4 Hours* * Dmows critical hexa in the L&d 211999 Food Code w 103 CMR X90.000. 3-501,14(C) PHFs Received at Temperatures According to law Cooled to 41'r/45F Within 4 Hour& * 3-50L16(B) Cold PHFs Maintained at or below 590.004(F) 410145' F* 3-501.16(A) Hot PHFs Maintained at or above Roasts Heid at or above 130'F. * 1 20 1 1 Time as a Public Health Control I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-501.15 1 Cooling Methods for PHFs 14I PHF Not and Cold Holding 3-50L16(B) Cold PHFs Maintained at or below 590.004(F) 410145' F* 3-501.16(A) Hot PHFs Maintained at or above Roasts Heid at or above 130'F. * 1 20 1 1 Time as a Public Health Control I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and :Beverages with Wattling Labels* . 590.000 3-801m(B) Use of Pasteurized Eggs. FG -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served * 1 Food and Food Protection 3-801AI(C) Unopened Food Package Not Re=served. 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 23. Animal Foods That are Raw. Undercooked or FG -2 .003 Not Otherwise Processed to Eliminate 1 Food and Food Protection FC -- 3 Pathogens.*e"° ""1 1 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 f ! 26. Eggs* W-LUAL N=UUlNt:Mrnl i 7 590.009(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 k29 - Special Requirements. (Items 23-30) Critical., and tion -critical violations, which do not relate to the foodborne illness interventions anti risk factors listed above, can be found in the following sectionsofthe Food Code and 105 CMR 590,000. ftem i Good Retail Practices I .FC 590.000 23. Management and Person- el FG -2 .003 i 24.. 1 Food and Food Protection FC -- 3 .004 1 25. 1 Equipment and Utensils 1 FC -4 .005 f ! 26. Water, Plumbin and Waste FC -5 _ 006 ; 27. PhysicalFaciHty 1 FC -6- .007 126. Poisonous or Toxic Materials t FC -7,008 ~29. Special Requirements .009 30 1 Other Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name 2 C)l8 Dat T of Operation(s) Food ServiceRoutine El Retail ❑ Residential Kitchen ❑ Mobile Type of Inspection Re -inspection Previous ns action Date: C Address a x e _ RIs Level Telephone _ Print: El Temporary ❑ Caterer Bed & Breakfast Permit No. ElPre-op ratQn ❑ Suspect Illness El General Complaint HACCP EllOherr- Owner A t 7� _ HACCP Y/N Person In Charge (PIC) DA y[1 Time In. y� Out• Inspector �' o Each vioiatidri 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'S - - ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded .FOOD FROM APPROVEDSOURCE ❑ 4. Food and Water from Approved Source ❑,-5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Pians PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) _26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) ej 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other 5,'5901nryxfFomb14.Ea n. /-� ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS _ ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEEEMPERATURE CONTROLS (Potentially Hazardous Foods) - [116. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control OUIR21. F Food and Food Preparation for HSP POPULATIONS -(HSP)' ❑. [CONSUMER -ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: /� 'n S^, Inspector's Signature: Print: _ I f PIC's Signature: Print: Page 06Pages, d LN ) Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(A)AssignmenIolEesponsibihty* 590.003(B) Demonstration of Knowledge* 2-103.11. 1 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3.201.13 Fluid Milk and Milk Products* applicants* _ Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinkin_r Water* Applicant To Report To The Person In Drinking Water from an Approved oved S stem* 590.006(A) Charge- hat e*590.003(G) 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Resffictiaas im in 6 in FOOD FROM APPROVED SOURCE * Denotes critiW item inthe federal 1999 Fond Code or I01 CA^.R 590.(100. 8 Food and Water From, Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Henneticall • Sealed Container* 3.201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.1.4 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinkin_r Water* 5-10,1.11 Drinking Water from an Approved oved S stem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 C .MR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreatiaoally Caught Molluscan Shelli isit* 3-201.15 Molluscan Shellfish from NSSP listed Sources* Contamination from the Consumer _ Game and Wild Mushrooms Approved by. Re ulatory Authonty 3-202.18 _ Shellstock Identification Present` 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 PackageIntegrity 3-101.11 Food Sate and Unadulterated Tags/Records: Shelistock 3-202.18 Shelistock Identification 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(1) Labeling of Ingredlents' C9eaning 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 oxygen packaging, criteria* 8-103.12 Conformance wi h A roved Procedures* * Denotes critiW item inthe federal 1999 Fond Code or I01 CA^.R 590.(100. 8 Cross -contamination 3-302.1l(A)(U 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* 9 _ Food Contact Surfaces 4-501.111. Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization -temp., pH, concentration and hardness. * 4-601,11(A) Equipment Food Contact Surfaces and - I hensils Clean* 4-602.1.1 C9eaning 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* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* i1 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* - 3-301.12 Preventing Contamination When Tastin * 12 Prevention of Contamination from Hands 59O.004(F) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.1.1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance - Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser,Availability 6-301.12 Hand Drying Provision Pager of 4e Item No. Code Reference C —Critical Item R — Red Item DESCRIPTION OF VIOLATION / PLAN F CORRECTION PLEASE PRINT CLEARLY Date verified { 7-)a , YI s, e let r /7 — L C-tO Lr i /1 ><— - sol c_ r n - aQ4 6�'C i /< �,- v.M G - c Cr % lo -T - A D411/ '- = 5d'-- (fi 1A gell t e t.)L r r ! in r Uzi O �1 0 / J t? r�P L/ z,-, CI 7 r 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 a co • Lon s described, and to P s�2� comply with all mandates of the Mass/Federal Food Co . I understaa d -f at noncompliance may result in daily fines of twenty-five do 1 rs or uspension ®cation of your food permit. Corrective Action Required: ❑ No Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other. Violaflons Related to Foodborne lltnesa interventions and Risk Factors Mems 1-22) (Cant) PROTECTION FROM CHEMICALS 14 Food or Color Im IN it 1,1151A14. • -. Additives 3-202.12 Additives* 3-302.14 Protection from Un roved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-I01Ai Identifying Information - Original Containers* 7-102.11. Cotmnon Name - Working Containers* 7-201.I1 Separation - Storage* - 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* - 7-204.11 Sardtizers. Criteria - Chemicals* 7-204.1.2 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.I2 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Morriumin * IN it 1,1151A14. • -. ' D nt)a% critical i�.m in the federal 1999 pori Cote" 105 CMR 590.000. 3-501.14(C) Proper Cooking Temperatures tar 3-501..15 PHFs 3-40i.IIA(I)(2) Eggs- i53,F 15 Sec 3-501.16(B) 590.004(F) Eggs -Immediate . Service 1450F15sec* 3401.41(A)(2) Comminuted Fish. Meats &. Game 3.501.16(A) Animals - 155'F 15 sec. * 3-461.11(B)(1)(2) Port: and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155`F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry-, Wild Game, Staffed PHFs, 27. Stuffing Containing Fish, Meat, + FC -8 Poultry or Ratites -165'F 15 sec. 3401.11(C)(3) Whole -muscle, Intact Beef Steaks FC - 7 1450F °' 3-401.12 Raw Animal Foods Cooked in a i Microwave 165°F * 3-401.11(A)(1)(b) All Other PRFs - 145°F 15 sec. Reheating for Not Holding 3-403AI(A)&(D) PHFs I65 -F 15 sec. * 3-403.11(B) Microwave -'165` F 2 Minute Standing Tom* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* - Proper Cooling of PHFs 3-501A,I(A) Cowling Cooked PHFs front 140`F to 70°F Within 2 Hours and From 70`F to 41`F145°F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature ingredients to 41'F145'F Within 4 Hours* ' D nt)a% critical i�.m in the federal 1999 pori Cote" 105 CMR 590.000. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled ro 41'F/45'F Within 4 Horns, 3-501..15 Coolinp Methods for PHFs 3 801.11CB? PHF Not and Cold Holding 3-501.16(B) 590.004(F) Cold Plff's ,Maintained at or below 41145' F* 3-501.16(A) Hot PHFs Maintained at or above 140'F. 3.501.16(A) Roasts Held at or above 1300F. ' t 25. Time as a Public Health Control 3-501,19 Time as a Public health Control' 590.004(H) Variance Requirement M1#1111.1 •' 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* i 540.0t80 3 801.11CB? Use of Pasteurized E ?s* FC -2 3-801.I 1(D) Raw or Partially Cooked Animal Food and Rau Seed Sproarts Not Served, * TFood 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 i 540.0t80 23. Animal Foods That are Raw-, Undercooked or FC -2 .00.3 Not Otherwise Processed to Eliminate TFood and Food Protection 4 FC - 3 Patho gens.* tm to ?^m 't t 25. 3-302.13. Pasteurized Eggs Substitute for Raw Sheil A05 ! 28. E SPECIAL REdiUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(P) in catering, mobile ford, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 59(J.000. --- i Item j Good Retail Practices i FC i 540.0t80 23. i Management and Personnel FC -2 .00.3 24. TFood and Food Protection 4 FC - 3 .004 t 25. 1 Equipment and Utensils FC -4 A05 ! 28. Water. Plumbing and Waste _� FC -5 .008 ; 27. I Ph aical Fadi + FC -8 .007 28. Poisonous or Toric Materials FC - 7 .008 29. - Special Requirements i 30 CCiber __ 1 CITY OF SALEM BOARD OF HEALTH / Establishment Name: 1 A;> O /A- SO Date: c( Page: 'a-- of Item Code C-Cdtical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R - Red Item _ Verified t SUI f` � ne- GA V- LM q-vj 4)t* )rK . O -7D z- v - I to i( -P - r r 1 I �- ri-k4 �n / C��nr�� h- CZ)M yak w.il rcS - �J: a - f 2! Cq'c✓J S (, /lin: c:r f l�iioneo , r- ____- I I I I J=VlordA tea' .n., 7 //' <A",.A an i fAI I lPAe 12 (-AS 5A4)r+7ZC/-LJ Discussion With Person in Charge: orrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ _ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to obse5W II conditions as described, and to Exclusion P -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Foo Code. derstand that noncompliance may result in daily fines of twent -fiv dollar's o us n/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness intementlons and Risk Factors (IMme 1-22) (Cont.) LIM 16 17 is : -r Food or Color Additives 3-202.12 Additives* 3-302.14 _ Protection from Una roved Additives" 3-501,16(B) 590.004(F) Poisonous or Toxic Substances 7-101,11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 . Restriction - Presence and Use° 7-202.12 Conditions of Llse* 7-20111 Toxic Containers - Prohibitions* 7-204.11, Sterilizers, Criteria - Chemicals* 7-204.12 Chemicals &n Washing Produce, Criteria* 7-204.14 Drying A encs. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Critetiaa 7-206.12 Rodent Bait Stations" 7-206.13 Tracking Powders, Pest Control and Monitoring' : -r Dint% critical iLLm in the ftderal i 999 Food Code or 105 0MR 590.000. 19 Im- 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3401,11A(l)(2) Eggs- 155eF 15 See. 3-501,16(B) 590.004(F) Eggs- Immediate Service 145'Fl5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3.501.16(A) Animals - 155'F 15 sec. * 3.401.I1(B)(1)(2) Pori, and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, injected Meats -155°F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Staffing Comaining Fish, Meat, -: FC -6- Poultry or Ratites -165'F 15 see,* 3401.11(C)(3) Whole -muscle, Intact Beef Steaks FC -7 145T * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs - 145'F 15 see. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165-F 15 see. * 3.403.11(B) Microwave -165` F 2 Minute Standing Time* 3403.11(C) CommerciailyProcessed RTE Food - 140'F* 3-403.1l(E) Remaining Unsliced Portim of Beef Roasts` Proper Cooling of PHFs 3501.14(A) Cooling Cooked Puffs from 140`F to 70`F Within 2 Hours and Front 70`F to 41'F145'F Within 4 Hours. * 3-501.14(6) Cooling FHFe blade From Ambient Temperature ingredients to 41017145°F Within 4 Hours* Dint% critical iLLm in the ftderal i 999 Food Code or 105 0MR 590.000. 19 Im- 3-501.14(C) PHFs Received at Temperatures According to law Cooled to 41'Ff45'17 Within 4 Hours, 3-501.15 Cooling Methods for PHFs 3-901AI(B) PHF Hot and Cold Holding 3-501,16(B) 590.004(F) Cold PHFs Maintained at or below 410145' F* 3-501.16(A) Hot PHFs Maintained at or above 140`P. * 3.501.16(A) Rests Held at or above 1300F. i 25, Time as a Public Health Control 3-501,19 Time as a Public Health Cantrot* 590.004(H) Variance Requirement 21 3-801.11(A) Unpasteurized Pre-packaged iuices and Wanting Beverages with Wang Labels* 690.000 3-901AI(B) Use of Pasteurized ESE* FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. I Food and Food Protection 3-801.11 (C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisary Posted tiro Consumption of 690.000 23. -Management Animal Foods That are Raw. Undercooked or 1 FC -2 .003 Not OtherwiseProcessedto Eliminate I Food and Food Protection I FC -- 3 ^tlxrs Pathogens.* ` inamr i 25, 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 1 !26 1 Eggsx -SPLUAL hl:UUlt t:Mt:N 1 b 590.009(A) -(D) Violations of Section .590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited udder the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements, (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness intenventions and risk factors listed above, can be found in the,/allowing sections of the Food Code and 105 CUR 590.000. foam 1 Good Retail Practices __..... _.... .FC 690.000 23. -Management and Personnel FC -2 .003 f 24.. I Food and Food Protection I FC -- 3 .004 ' i 25, E ui ment and Utensils I FC -4 .005 1 !26 Water. Plumbino and Waste ( FC -5 ( .006 27. { Physical Facility -: FC -6- .007 i 1 26. ' Poisonous or Toxic Materials FC -7 .008 i 1 29. S eoial Reauirements .009 J 30 Other svo,, wan c� CITY OF SALEM BOARD OF HEALTH _ Establishment Name: 01,1 �f�s)T"" Date: i,4 Pager of Item No. Code Reference C -Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION f I PLEASE PRINT CLEARLY 1 I Date Verified D. rl.f, leaS ZI v ¢P V t C� ,'Y � -1t J4 , ld - -)'V /A LZ 4-o ac l s rAl k) -13 Q v 47u- 1' - A --I c-1 G U-�S 1 f boa , l s c/I C/ -'s-4'y4a -L F'�(- n W• n I 91. c v a oc,4k 5�k ti - k - �(C o� KILd. W res iv IV/ Wo lam- l Pr Lir C 4�1� Discussion With Person in Charge: 1 have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to obsery a onditions as described, and to P comply with all mandates of the Mass/Federal Food ode. 1 understand that pY noncompliance may result in daily fines of twenty-five t ension/revocation of your food permit. Corrective Action Required: Cl No ❑ s ❑ Voluntary Compliance ❑ Employee Restriction Exclusion �. Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne tidnesa biterventdons and Risk Factors (/retest -22) (Cont1 46 18 #. s rr 15 Food or Color TIMEMEMPERATURE CONTROLS Additives 3-202.12 PHFs__ 3-302.14 _Additives* Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 IdentifgingInformation- Original Containers* I 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. Sanitiaers. Criteria - Chemicals* 7-204.12 Chemicals far Washing Produce, Criteria* 7-204.14 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* TIMEMEMPERATURE CONTROLS ' Denotes critical ism in The f- .doral 1999 Foal Coda ur" 105 C.MR 390.000. 20 3-50I.14(C) Proper Cooling Temperatures for 3-501.15 PHFs__ 3-401.11A(I)(2) _ Eg_e>s- 155`F 15 Sec. 3-501.16(B) 590.004(F) Eras- Immediate Service 1450F15sec4 3.401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animal's - 155'F 15 sec. * 3.401.11(8)(1)(2) Port: and Beef Roast -130'F 121 min* 3-401.1I(A)(2) Ratites, Injected Meats -155`F 15 590.004(H) see. 3-401.1.1(A)(3) Poultry, Wild Game, Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -165'F 15 see. 3.40L11('C)(3) Whole -muscle, latera Beef Steals 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-401.11(A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403.11(.A)&(D) PFIFs 165-F 15 sec. * 3403.11(B) Microwave -165' F 2 Minute Standing Time* 3103.1 I (C) Commercially Processed RTE Food - 140°F* 3403.11(E) Remaining Unsliced Portions of Beef Roasts* Prosper Cooling of PRFs 3-501.14(A) Coaling Cooked PHFs from 140'F to 70°F Within 2 Hours and From 70°F to 41`F/450F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambicnt Temperature Ingredients to 4f'F/45'F Within 4 Hours* ' Denotes critical ism in The f- .doral 1999 Foal Coda ur" 105 C.MR 390.000. 20 3-50I.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Ileum 3-501.15 (Cooling Methods for PHFs 3-80LII(B) S'SHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PILFs Maintained at or below 410145' F* 3-50L16(A) Hot PHFs Maintained at or above 140'F. * 3-501.16(A) Roasts Heid at or above 130'F. Time as Public Health Con a Public Health Control 3-501.14 _ Time as a Public Health Control* 590.004(H) Variance Requirement 21 3-80L 11(A) Unpasteurized Pre-packaged Juices and Beverages with VYarnin° Labels* 3-80LII(B) Use ofPasteurized Egg* 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 Animal Foods That are Raw, Undercooked or Not Otherwise Processed to Eliminate Pathogens.' srr ' "' f 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Violations of Section 590.009(A) -(D) in entering,. mobile frxxl, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne iciness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical. and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections. of the Food Code and 105 CMR .� Commonwealth of Massachusetts e City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: File Number: BHF -2006-000052 The Old Spot 121 Essex Street SALEM MA 01970 LOCATED AT: 0121 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2010-0090 Jan 4, 2010 Dec 31, 2010 $280.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $280.00 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page t KIMBERLEY DRISCOLL MAYOR DAVID GREENBALIAI, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"` FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGREENBAUM&AI:EM. COM 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT -TU�lAtlrtw i��S d Witt 11 e Otck SM TEL # e0k- 145-5(d%. ADDRESS OF ESTABLISHMENT t21 4�55<jx FAX# rV IAl- . MAILING ADDRESS (if different) EMAIL -Business': CrocktfA,`(e (Z CovwCA54 neY- Website: 4ktbld Se:j • C0rA OWNER'S NAME [W(i se, 0 M; -b TEL # 115(-4 9 -S0Ai`1 ADDRESS 15 VYwdSWorYh Qt 0.K STREET n CITY STATE - ZIP CERTIFIED FOOD MANAGER'SNAME(S) 13r�nden Qacl!-C/ CERTI FI CATE#(S) 57°f 111 (Required in an establishment where potentially hazadous food is prepared) EMERGENCY RESPONSE PERSON Ortnlee� biOMETEL# '115"'234"2iO4D F°Oi146' ay 9ntlay , _e_,a, ty SuSaaMAYO! HOURS OF OPERATION Please write in time of day. 1It30IlM— itIt3DAM^ I N:30 AM^ i j I 1 Por example Ilam -1t —1 5fM -tAM 5PM-IAM 5PM- IAMI IAM l .4M I AM TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTAURANT (Outdoor Stationary Food Cart NIA* FEE (check only) less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 less than 25 seats =$140 25-99 seats =$280 ✓ more than 99 seats =$420 ------------------------------------------------------------------------ ----------------------------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT (such as church kitchens) YES 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 belief, have filed all state tax returns and paid all state taxes required under the law. Signature 013 Date t ('t J 2 Vk p Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check# & DateZ"It� t(w(z0Lo• EXAM FORM NO. 4344 CERTIFICATE NO. 5791193 ServSafer Certification 0 0 #0655 National Restaurant Association /� EDUCATIONAL FOUNDATION for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafe® Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANS0—Conference for Food Protection (CFP). 3/11/2008 DATE OF EXAMINATION 3/11/2013 DATE OF EXPIRATION Local laws apply. Check with your local regulatory agency for recertification requirements. NATIONAL RESTAURANT Mary M. Adolf ASSOCIATION President & COO, Products and Services Division National Restaurant Association Solutions S 0 L U T 1 0 N S Tm ®2008 Natural Restaurant Association Educational Foundation. All rights reserved. ServSafe• and the ServSafe logo are registered trademarks of the National Restaurant Association Educational Foundation, 1, and used under license by National Restaurant Association Solutions, LLC, a wholly owned subsidiary of the National Restaurant Association. This document cannot be reproduced or altered. 07060701 - v.0803 0 EXAM FORM NO. 4289 CERTIFICATE NO. 5017397 =-� TD FMILISSA for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafe® Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). Presented by the National Restaurant Association Educational Foundation 8/29/2006 DATE OF EXAMINATION 8/29/2011 DATE OF EXPIRATION Local laws apply. Check with your local regulatory agency for recertification requirements. ' Mary M. Adolf President and Chief Operating Officer National Restaurant Association Educational Foundation \C UN National Restaurant Association EDUCATIONAL FOUNDATION www.nraef.org 02006 The National Restaurant Association Educational Foundation 05061402 v.0607 p Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 6aY�y� 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: File Number: BHF -2006-000052 The Old Spot 121 Essex Street SALEM MA 01970 LOCATED AT: 0121 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2011-0274 Jan 1, 2011 Dec 31, 2011 $280.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $280.00 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 KIMBERLEY DRISCOLL MAYOR DAVID GREENBAum, RS ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4". FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGREENBAl1NI&ALEM. COM 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTThr��- t JI LIA _rkt Ol i ADDRESS OF ESTABLISHMENT -124 165seX eArcr1 $Aleen. (► A MAILING ADDRESS (if different) TEL# 418-745.5456 FAX # EMAIL -Business': Crockt4ile. rQ cort colisi.At-r Website: 4he_dlJt_%py - - com OWNER'SNAME WlilisjA O✓a;b; TEL# ADDRESS 5WsLJ5 ro��h PWr r l3Lvt/luMA (7l°IIS STREET M 055h Qrrnlrl9; CITY STATE21P /� 5-01711-7ryto 1d.en l-,�%I1 CERTIFIED FOOD MANAGER'S NAME(S) 131 rackei---CERTIFICATE#(S) 5'7 °1 I 1 9 3 Lrn 3/l'3 (Required in an establishment where potentially �hazardous food is prepared) EMERGENCY RESPONSE PERSON BrWen CeacVer HOME TEL At DAYSOFOPERATION : • Monday 1" fThursday; HOURS OF OPERATION Please write in time of day. I5Pr*—tam SPrn-IAM; 5pn—lam I5em—laM 111 30 -- (0.M;II=ami tom W”(.Qrr► (For example 11 am -11 pm)own TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YESNO) less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 .... .............. .......... ......... ------ ---------------------------------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart $21 25-99 seats =$280 ✓ more than 99 seats =$420 BED/BREAKFAST/ YES kUO,) $100 CHILDCARE SERVICES/NURSING HOME ..... *------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES O $135 ALL NON-PROFIT (such as church kitchens) YES $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 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 {{��d��pa'd all slate taxes required under the law. ,V_X ' It kAIvAir� FIN $ �n-roor.zc� Date ' Social Security or Federal Identification Number Revised loA/l l FOODAP201 Ladm Check# & Date `S`#r J1,�4..+a`L!..i,•Mt,Ss�rr.T�:Nr'-.9g'Aw.�.!1r•.,.j�� YY"Ni4w=� .s :"i"�°'�1'A^.'.Fr�wt'- ""1,f,�✓,.r..�,.,, r, i�..-. Massachusetts Department of Public'Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Nam = e L �� Date 4' %(r, Tvoe of Operations) Type of Inspection lll� ,/7 �_i, Food Service R Routine M Address \ 1v S �� C Risk Retail Re -inspection o A Level ❑ Residential Kitchen Previous Inspection Telephone r ❑ Mobile [I Temporary El Caterer E] Bed & Breakfast Date: ElPre-operation)"� [I Suspect Illness El General Complaint Owner I S Cc tot/n HACCP Y/N Person in Charge (PIC) %1 Time r, ikf� O In�.�d00 I ElHACCP _ Inspector n o-, n I, V)i ti (�� . Out: Permit No. ❑ Other Each violation checked requires -art 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 _ _ I Gam oaM �ie afuuis.#kSL^rzfiifeipmadvWV Fn.}r ..e. +l� t� 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnerwith Infections Restricted/Excluded FOOD FROM ApPROVEO SOURCE„` -"`L'0 ,"BEV N k•y ❑ 4. Food and Peter from Approved Source -❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities �,YPROTECTION FROM CffEMIC ASS $ ��TM.,,�;wr�`�.. � n-r��psx i(��rnimd ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals b"TIMEITEMPERATURE CONTROLS (Potemially Hazardous Foods) T'`" tr ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling `PROTECTION FROM CONTAMINATION ` �i?'""""'�19. Hot and Cold Holding Pt •❑ 8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control O ' K 14 9. Food Contact Surfaces Cleaning and Sanitizing I ❑ 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. 23. Management and Personnel (FC -2)(590.003) 01 J 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: ssoin�Tomc-ia.� - `REQUIREMENT$ FOR HIGHLY SUSCEPTIBLE PQPULATIOM$ (HSP), ❑ 21. Food and Food Preparation for HSP y'rCONSUMER ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related ❑ 4 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. //gyp,, DATE OF RE -INSPECTION: �O _ (��v _( o O✓ /�.azt C --jg v�CO "4''T/(.GJ Inspector's Signature: Print: lll� ,/7 �_i, PIC's Signature: �, Print: \n _ )A_�fdx �A r dl\,,Pagelo� Pages tJ Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) 'FOOD PROTECTION MANAGEMENT 1 590.003(A) I Assignment of Responsibility* -_ 590.003(B) Demonstration of Knowledge* 2-103:11 Person in char e -duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-20113 Fluid Milk and Milk Products* applicants* Shell Eg s* 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 Drinkin Water from an A roved S stem* 590.006(A) Char 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(F..) Removal of Exclusions and Restrictions 4 6 $T#� •.a i• _ * Denotes critical item in the federal 1999 Foots Cade or 105 Cl lR 590.000. PROTECTION FROM CONTAMINATION 8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Henueticall Sealc-ti Container* 3-20113 Fluid Milk and Milk Products* 3-2.02.13 Shell Eg s* 3-202.14 E« >s and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101..11 Drinkin Water from an A roved S stem* 590.006(A) Bottled Drinking Watcr* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.1.7 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity 3-101,11 Food Safe and Unadulterated Tags/Records: Shelistock 3-202.18 Shellstock Identitication * 3-203.12 Shellstock Identification Maintained- Tags/Records: Fish Products 3-40131 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(1) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Pians 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxygen packagin.g. criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Foots Cade or 105 Cl lR 590.000. PROTECTION FROM CONTAMINATION 8 Gross -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 Fords 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 Fond* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food': 9 Food Contact Surfaces 4-501.111 Manual Warewashina - Hot Water Sanitization Temperatures* - 4-501.11.2 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4160E1 I(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of, Sanitization - 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* 1.1 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-30112 preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5 203. Ll Numbers and Capacities* 5-204.11. Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Haridwashing Cleanser, Availability 6-301.12 1 Hand Drvim , Provision Ck 5-3 - Establishment CITY OF SALEM BOARD OF HEALTH Date:... - 51- 0 -( o Page: a of Item No. Code Reference C - Critical Item R - Red item LODESCRIPTION.OF,VIOLATION PLAN OF CORRECTION ' 4' PLEASE PRINT CLEARLY Date V6,11led - -. L�v- _, e zi a ft __1 79 -N -L 4.Vt Vlq'y L P4 7 —�4'� "V /I V N 1A VIA A 0, (Lu ( 9-5 r-1 I 21600/1 _AJ 1 0 )rr�- 7 'st) k W A A Of A h0_Q -%r) Y3 e, S; O ' "A RnAlv��Iry 4, A " ---t- )V.0'Q - Ak�2'f 10 04 0..Ol1)r-1+1 Or, 71(;1C, 'A 11 A (&mA 1� AA 0 'J A JA 0„- f _h /) J,(, (,V - V--�) 47)_ '1'!XC_ X9 n 1-) 1-4 1f J'm -Y\ 0 1, 'ao. 6 url Liz _Vn Discussion With Person in rg 1. L) U 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.Lj Corrective Action Required: ❑ No Yes Voluntary Compliance El Employee Restriction Exclusion QZS, Re -inspection Scheduled Q Emergency Suspension k U'_� z) Embargo Ll Emergency Closure Voluntary Disposal Q Other: Violations Related to Foodborne Illness Interventions and Risk Factors (heirs 1-22) (Cont) PROTECTION FROM CHEMICALS 14 ?-)f11.14(C:) Food or Color Additives _ I I40'Fs 3-202.12 Addooves* —�---Proper 3-302.14 _ Protecoon front 1..IIia})PTO'�ed Addlh4eti�'_� is -501.i<kri,i Poisonous or Toxic Substances 1,9 �-101.11 identifying int'rimloon-Ur{ma! 1 If 4I"Fl-15`P' \Ytlldn 4 Hann,. ::-5UL1-44B7 iCommrn w-,rla 7-102.11 tiame !~Coot unr-� ti tthm = f-irx+t 7-201.11 1.11 -S w "w(fit Sin age 1 '-202,11 Re trlCon Pr s,mu wd L d Chi st:LlttA)_ t'n )dmon. of i?sd -203.11 1 Toxic Cnr.tainer- Profrbiuoos" 1 t 20411 Sams 7erti Crile in ChL n)ie h 7-204, 1 Clwnii tN for W n�ht k t )dn e < ntc a" 1 7104.14 U.gng At cntc Cvtetin 1 -1105,111 blctd ntai t fA ontnct l.ub Ian 06 ! j- lle " 6o t t sr pe r)cide . Clitet _ ') 206.12 1 RfXielll B 111 Sir,rtan, _66 '1 ¢ � 9ra. n rng ' cad -r;' } m Collo _i anti � TI?.yErrEMPERATURE CONTROLS _ Proper Cooking Temperatures for j PNFs 3=t-01 J.11U r2) 1 I Lg isj i' 175:.c. 3-dt?1.11.1.1);ix i CJ.rt11c i-41}1.1 1;t3)i 1 ,f2l tr.} ... t fWl 2tsa5tt i. 1"4" siE)1.1 �(h1 )) tt Litt,.- indu .l `shuts - L,5 r 1S r40tli!A)?3i LD3.ittt!&(11)1 E' uirr - Wd Ci int sit l { lli!;4, E Siufit a? C''n*t nu m, 5is!i, h� j i t t t R� •- Rehea Lrig mr hat I olQi?y t 103A If h) Vuun=,11o�e- in 1 2ggaw� 5=an,aiind I REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 21 3-801 '1 I l t? Unr t teunzcd Pr I adl a t ed Juices and 1 131 Fet i es with wan nng habuk' &bl 11(13 11 of Pn te.uri cd hirl I I(I)) 2 w orl",1111,11N C ookd Aaunal Food and _ R;'w Si )inn . Ne! srrvvd ` 3-8ci 1 1eC i ! Ud. )i~..,r.d Nxxi Pilclw, Not Rr sen=e-l. 22 3-(!63 t o. snt ac is M soi 4 r' St f3 for {Int unptistn <,i v r.)3 1 sxi hat � c i. v .Under .x)Red ;;r � 4 i Cltl F tdt Prkxvc :; U ) F'. SPECIAL FiEQUiREMENTS _ eaterust, nu;i)ik fn).,te11nPananiastd 1 1 nsic;r n� ut kitclic 11 �Pulttinot i11,t;id i)t: debited ill"Crtltc appropriatens i)th? t.8[cJC s r,„ia€nit; Sr). n,x_ rCi ke? tr O ATIONS RELA TED TO GOOD RETAIL PRACTICES (a errs 23-30t t r dhr v'1tc ill cd"" IN ti, !incl I'W' pl' tore fisted r; i:r)rr, (on I .n' i+i ti:;: r 7 )aL; .,; , »r PooA £'osis tt1 d 14 t`atlk vti.(YiU ?-)f11.14(C:) PFiFa� :ivied at'remperawres I I40'Fs 3-0{J3.i 1(I'1 �—nun u)i.npT Losuceb Pot az ,nf f4cef —�---Proper 41 "F/45'F Within 4 Homs. Cooling of PHFs -501.i<kri,i jCiar6neL'�)hedPHFsfmroI<V'I'I 1,9 7;)01.- Within 2 flow: and From PHF Hot and Cold Holding 1 If 4I"Fl-15`P' \Ytlldn 4 Hann,. ::-5UL1-44B7 I CL.ct)t-� PHEL ki do Frrm ai &Ii'ol I rwnl tatart iu redxai:u to •,i i -145`F 410/4511 F ti tthm = f-irx+t REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 21 3-801 '1 I l t? Unr t teunzcd Pr I adl a t ed Juices and 1 131 Fet i es with wan nng habuk' &bl 11(13 11 of Pn te.uri cd hirl I I(I)) 2 w orl",1111,11N C ookd Aaunal Food and _ R;'w Si )inn . Ne! srrvvd ` 3-8ci 1 1eC i ! Ud. )i~..,r.d Nxxi Pilclw, Not Rr sen=e-l. 22 3-(!63 t o. snt ac is M soi 4 r' St f3 for {Int unptistn <,i v r.)3 1 sxi hat � c i. v .Under .x)Red ;;r � 4 i Cltl F tdt Prkxvc :; U ) F'. SPECIAL FiEQUiREMENTS _ eaterust, nu;i)ik fn).,te11nPananiastd 1 1 nsic;r n� ut kitclic 11 �Pulttinot i11,t;id i)t: debited ill"Crtltc appropriatens i)th? t.8[cJC s r,„ia€nit; Sr). n,x_ rCi ke? tr O ATIONS RELA TED TO GOOD RETAIL PRACTICES (a errs 23-30t t r dhr v'1tc ill cd"" IN ti, !incl I'W' pl' tore fisted r; i:r)rr, (on I .n' i+i ti:;: r 7 )aL; .,; , »r PooA £'osis tt1 d 14 t`atlk vti.(YiU ?-)f11.14(C:) PFiFa� :ivied at'remperawres Al ording to Law Cowled to 41 "F/45'F Within 4 Homs. —C3-5111.15 N Cooling Medtois for PHFs 1,9 PHF Hot and Cold Holding 3-561.16(B) Cold PH1 t Maintained at or below 590,004P) 410/4511 F > Jt) l i NA) f lot PI -11's INIattimmed at or above 140'F. Chi st:LlttA)_ Held w above 130'f * t tmsts al _ Time as a Public Health Controf a io t I t as t Public t seat th Control' _ Rc�aniamedt REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 21 3-801 '1 I l t? Unr t teunzcd Pr I adl a t ed Juices and 1 131 Fet i es with wan nng habuk' &bl 11(13 11 of Pn te.uri cd hirl I I(I)) 2 w orl",1111,11N C ookd Aaunal Food and _ R;'w Si )inn . Ne! srrvvd ` 3-8ci 1 1eC i ! Ud. )i~..,r.d Nxxi Pilclw, Not Rr sen=e-l. 22 3-(!63 t o. snt ac is M soi 4 r' St f3 for {Int unptistn <,i v r.)3 1 sxi hat � c i. v .Under .x)Red ;;r � 4 i Cltl F tdt Prkxvc :; U ) F'. SPECIAL FiEQUiREMENTS _ eaterust, nu;i)ik fn).,te11nPananiastd 1 1 nsic;r n� ut kitclic 11 �Pulttinot i11,t;id i)t: debited ill"Crtltc appropriatens i)th? t.8[cJC s r,„ia€nit; Sr). n,x_ rCi ke? tr O ATIONS RELA TED TO GOOD RETAIL PRACTICES (a errs 23-30t t r dhr v'1tc ill cd"" IN ti, !incl I'W' pl' tore fisted r; i:r)rr, (on I .n' i+i ti:;: r 7 )aL; .,; , »r PooA £'osis tt1 d 14 t`atlk vti.(YiU I CITY OF SALEM /� BOARD OF HEALTH Establishment Name: p l J 0'� S ac' Date: S<�_ I., --f Ti Page: 3 of Item No. Code Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Vermed / �.,.a/y� ` A A_7) ` \ _ _ �_ l n n MMA? — A a r ` .Q1 n ii) t /VVI ,AM 0 c!, Iro 0A A n .S 0 I P LO V ALr— % Q n -t /A 1�j en n Jil' P Of . . CAO L A ('1.4 - . - /1 I t , !Gt tag.: .(IZ! _ 0 V Discussion With Person in Charge: have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: ❑ No )19 Yes A Voluntary Compliance ❑ Employee Restriction / Exclusion pr,Re-inspection Scheduled L) Emergency Suspension C3Embarg` god ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors ((tams 1-22) (Cant.) PROTECTION FROM CHEMICALS 14 15 16 17 18 71MEI EMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-50116(B) 590.004(17) Polsonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11, Common Name - Working Containers* 7-201. 11 1 Separation - Storage* - 7-202.11 . Restriction -Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Saintizers.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* 71MEI EMPERATURE CONTROLS * Denotes critical item in the federal 1999 Foal Cale" 105 CMR 590.000. C m m 3-501.14(0) Proper Cooking Temperatures for 7501.15 PHFS 3-401.11A(1)(2) _ Eggs- 155°F 15 Sea 3-50116(B) 590.004(17) Eggs- Immediate Service 145'Fl5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals - 155'F 15 sec. * 3401.11(8)(1)(2) Pork and Beef Roast -130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) sec. * 3401.11(A)(3) Poultry, Wild Game, Stuffed PHFS, 27. Stuffing Containing Fish, Meat, FC - 6 Poultry or Ratites -165'F 15 sec. 3-101.11(C)(3) Whole -muscle, Intact Beef Steaks FC- 7 145'F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-40L I I(A)(1)(b) All Other PHFS - 145'F 15 sec. Reheating for Hot Holding 3-403AI(A)&(D) PHFS 165F 15 sec. * 3-403.11(B) Microwave- 1650 F 2 Minute Standing Time* 3403.11(C) Commercially Processed RTE Food - 140'F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFS 3-501.14(A) Cooling Cooked PHFS from 140'F to 70'F Within 2 Hours and From 70'F to 41*F/45'F Within 4 Hours. * 3-501.14(B) Cooling PHFS Made From Ambient Temperature Ingredients to 41'F/456F Within 4 Hours* * Denotes critical item in the federal 1999 Foal Cale" 105 CMR 590.000. C m m 3-501.14(0) PHFS Received at Temperatures According to law Cooled to - 41'F/45'F Within 4 Hours. * - 7501.15 Cooling Methods for PHFS 3-801.11(B) PHF Hot and Cold Holding 3-50116(B) 590.004(17) Cold PRFs Maintained at or below 410/45' F* 3-501.16(A) Hot PRFs 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. L4 Time as a Public Health Control* 590.004(H) Variance Requirement REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-80.1.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels* 590,000 3-801.11(B) Use of Pasteurized Ems* .FC - 2 3-801A I (D) Raw or Partially Cooked Animal Food and Raw Seed S outs Not Served. * Food and Food Protection 3-801. l i (C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590,000 j 23. Animal Foods That are Raw. Undercooked or .FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Patho ens.* e`r*`` 1'1 m` 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. Eggs* 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 - Specia) Requirements. (Items 23-30) Criticalacrd non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000. t Item I Good Retail Practices .FC 590,000 j 23. 1 Management and Personnel .FC - 2 .003 24. Food and Food Protection FC - 3 .004 I 25. Equipment and Utensils 1 FC - 4 .005 26. Water. Plumbing and Waste I FC -5 .006 { 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC- 7 .008 29. - Special Requirements .009 30. other c sw�tMmwr,.z bx F Massachusetts Department of Public Health Division of Food and Drugs / FOOD ESTABLISHMENT INSPECTIONG�EPORT' Salem Board of Health 120 Washington Street, 4`" Floor Salem, MA 01970.3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name4, 1) � S Tvve of ODeration(s) Food Service LJ Retail El Residential Kitchen ❑ Mobile El Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Type of Inspection ]Routine [] Re -inspection Previous Inspection Date: ElPre-operation ❑ Suspect Illness El General Complaint E] HACCP ❑Other Address �o �'C�� -�{ �/'E' Risk Level Telephone G (]c� C� Owner / JR�)� / ' I HACCP YM Person in Charge (PIC) ^^ll V lIJ (1 Pl1S Inspector Ne, Time In �; (i /y✓/ Out: )YYv Each violation checked requires -ail 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)59o.009 (F) action as determined by the Board of Health. FOOD PROTECTION OANAGEMENT,:-= . 4 "�;--, , • �i" ❑ 1. PIC Assigned / Knowledgeable / Duties 'EMPLOYEE WEALTH -ifi�"" V"rr'� .-ws1. nvtM$Eld..ababFkun Sh'Mrn:'a12$49nv'mtrniNM�9 I ? iAfl prty ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded g -FOOD FROM APPR6YEd SOURCE a� tai w F _ , .,' ii Xtra ❑ 4. Food and Water from Approved Source tom❑ 5. Receiving/Condition x.0 6 Tags/Records/Accuracy of Ingredient Statements ti ❑ 7. Conformance with Approved Procedures/HACCP Plans 9. Food Contact Surfaces Cleaning and Sanitizing L'J 10. Proper Adequate Handwashing ❑ 111."tood Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C 7W7 V`, 23. Management and Personnel (FC -2)(590.003) - 24. Food and Food Protection (FC -3)(590.004) 0� 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) J) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590,009) 30. Other ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities °'-PROTECTiI)N ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals 1= 77MEtfEMPERA,TURE CONTA61sIII) otentIally WaYs i retoua floods) °-i'€ g.±,,d.�w.FS't3a,.m...,�i�:a.�r.."a„";siws.-Rhn ❑ 16. Cooking Temperatures '/ [117. Reheating O�L7U 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control �;REOUfREMENTS FOR F1GHLY SUSCEPTIBLE POPULATIONS (tisP}; �:. ❑ 21. Food and Food Preparation for HSP .,CONSUMER ADY($JO Y=` -cam 1 , am'mQ , dfia+Qsi" �,a„..�' ❑ 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 r 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: 5 -1 5-01 sssoi/nepecfcorm�sia ep'i� 11 J_Q _ V i Inspector's Signature: /�Print:. - C._Pr7 cG , `- ``�� N on PIC's Signature:(� Print: ,S CAS 1(� Page of� Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1--590.003(A) ' Assi„nment of Responsibility* 1590.003(B) Den�onstsation of Knowledge" 2-103.11 Person in charge -duties EMPLOYEE HEALTH 2 59(ww(_C) Responsibility of the person in charge to Cam tliance 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 - Applicant To Report Tonic Person In Drinking Water from an Approved System* 590.006(A) Char e* 590.006(,B) 590.(X)3(0) Reportingg by Person in Charge* 3 1 590.003(D) Exclusions and Restrictions* 3-201.15 L90 003(1-,)__i Removal of Exclusions and Restrictions 4 FOOD FROM APPROVED SOURCE -Denotes critical item in the federat 1999 Food Code or 105 CNIR 590.000- PROTECTION FROM CONTAMINATION 8 Food and Water From Regulated Sources 590.004(A -B) Cam tliance with Food Law* 3-201.12 Food in a Henneticail l 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* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(,B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables SheiNish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201.1.7 Game Animals* 3-701.1.1 Receiving/Condition 3-202.11. PHFs Received at Proper Temperatures* 3-202.15 Package Inte it y* 3-101.11 Food Safe and Unadulterated Tags/Records: Sheilstock 3-202.18 Shellstock Identification * 3-203.12 Shelistock Identification Maintained" Tags/Records: Fish Products 3402.11 Parasite Destmcfion* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans - 3-502.11 S ecialiuti Processin Methods* 3-502.12 Reduced ox en tacka 'ng, criteria* 8-103.12 Conformance with Approved Proeednres* -Denotes critical item in the federat 1999 Food Code or 105 CNIR 590.000- PROTECTION FROM CONTAMINATION 8 Crpss-contamination 3-302.11(A)(1) Raw Animal Foods Separated front Cooked and RTE Focxis* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Aniund 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(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.1.1 Discarding or Reconditioning Unsafe Food* y Food Contact Surfaces 4-501.111 Mannas Warewashing - Hot Water Sanitization'rem eratures* - 4-501.112 Mechanical Warewashina 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 - Hat Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arens" 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-40112 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590A04(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.1.1. Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.(2 Hand Drving Provision CITY OF SALEM BOARD OF HEALTH Establishment Name -Q �_,_S'V�� Date: bPage: ___0 of Item N 0 '�V Code Reference C - Critical Item R ±Red Item I - 44) 44, DESCRIPTION OF VIOLATION PLAN OF CORRECTION '10 ",-F- 'Ar ae, - 4� PRINT 4�_ "Z jll� t ::.Verified '�LEA4i�� T "'cLEACLY Date,, Aa J 0,o�o 7 0 Avi AAA OK P" f'. T�-VU.4- lc Y -r) A L/ ) 0 A A A 0 nn iX PACAA OA 10 -KI) 1-0 1 (X /1i'1 5r_� (A'� 0 R� I- not p/Nk.6� '�A MA" LJh '0 C'_ r'��A Jk 6'Mj (/V-\ �rp A, I nv- VM("0,1-,A '11AAA P O VfrrI4 IA. V -y-\ Zf AA.,Q Z k A I 'A I L/ Discussion With Person in Charge: I have read this report, have had the opportunity tod questions and agree to correct all violations before the next inspection, to observe/al/l`conditions as described, and to comply with all mandates of the Mass/Federall(ood Code. I understand that noncompliance may result in daily fines of tvVentV-five dollars or suspension/revocation of your food permit. Corrective Action Required: Ei No U Yes u Voluntary Compliance L) Employee Restriction Exclusion Ll Re -inspection Scheduled L) Emergency Suspension c3 Embargo 0 Emergency Closure ZI Voluntary Disposal J Other: Violations Related to Foodborne Illness Interventions and frisk Factors (11olhis 1-22) (Cont) 14 r Food of Ek 3-30114 protection &onr Unapproved AddntvCSIO cus or Toxic Substances Chj'nta, I canaairlers* 71iii-11 Coulation Name - Workilml Copulincr,* ;-5€)7.)4(0`• PPF{ Reimed af Temperate Accordizql, to Law Cooled to " FFi45"T' Millie,, Hours, 1, 3 50 ! . j 6(B) Cold PHN Mainunned at or bolow I 590,004(F} V'/45° FA 3-501 16(A) Not PFIFc Mairnained at of atxzve W),V. * -A l —1i 6(A) t N-i-sts —Hel If -at o -T above _130'F �jTime as a Public Health Control 7."02.1! Reqhcokal - Pielsence. and Ue* 7- 2M. 12 —Condifion, of Use" REGUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203. foxic Container,- Prohdatlow`l� POPULATIONS HISP ?04.31 )amtirers TT - 7 -2C4.12 Chenlicads for [2177, 14A) npaaeurized Pro-pae"aged Joices ard — ------ 13r razes wah Wen me 7-204, 14 Drlinx Avcnts. Critcria' I —I- —Incitiental —NNA (" ln-I act . Ea -b- i -i antsy 1k1i-SWAI(B! (It' pIcuallized, Eno'* M I i I (D) R6W,T I"aluAl', OlUk"d 4n oriel f"(Xd 311d 7-206-11 1 Re�nriuied UNe, Pe�Eicides, Cl-innia' - R�w SL'd SurOIIU NUt StrVCd. 7-206.12 Roden! Bell Sm6oc,' [�-W I (Cl T�rvl erred Food Packagc Not Re -served, 720617 _p _Ej, I Trocking, Powderi. Pst Control and 0 3-401.111(1)(2) I Fggl,- 155F 15 Slc, I Pq.tlftnmtdiatcScrvicc 145'F-15scc, 1. 11 (A)(2) r cnmolijlwed Fisb, Meats &, Glow Ain([ la - 154 14 sec. 3 4 'Ft. V1 (IT)( It( loil, and l3i,t Roast - I 30'F 121 min* 3-40 L! I (A)f 2) 155+15 .3 401.11{A)(3) Si,c, Pouln), Wild Gidrnw_ Stutfed 11tiFs, stuffilig, CrInniming Fish- Nlleu, Pouhry orkafitr�- 165'1` 15 stc, ' 3_4 07-1 ! I Q(3) 'Nhole-mucle, Intact Becfsicak", 1 1-401J2 I uxl� jUd in a Raw Amend FC(N lm Mics.,)wave 16 , -401.21(A)(10) All Othim NVs - 1 151 15 ge(- _TliiiT Reheating for Hot Holding -I _sec, I THF, 165° f 5 I 403.111B) Microwavc- 165, F 2 Minnie Standing Tinle" 1(C) Commercially Pt(wessod RTE Ked T�CT5 c al, Unsficed Forticlas Of her, Roask* Proper Cooling of PHFs 3-501,14(A} Coohng Cooked PHFs film 140'F to j 70"F within 2 Hours and From 79"T to 41 F745 F Within 4 Houm * Cooling PHR Made N lan Ambient f,' Tarnpranae Ingredients to 411 °F/45`14 Within -1 Hours'' 1)"ll"ies malcal ilon in ih�, ioleral N�,) i.(im 165 CkIR 590 000 22 3 b)O, I I j Consumer Advisory Posted ',")r Consumption of AnitnJ lm, Raw. Under"xlked or Nix othrm ow F'rucelised m E'limmane -*-iO7 —1i II'd Epe!; Substitute fo Itaw Shell Vidalims ol'Sectioti 5901X)9(A)-(D)Jn catering. neofalc f(fixi, temporary and i rcsidtaival kitchen operations shcafld be. debit under the appropriate 1"IlAVIIS above if related to foodborne illness interventions and risk factors_ Other 5901.009 violahons relatin,, to good retail practices should 1v debited under #29 - { Special Requirements. (Items 23-30) Crag ¢t gra n< di'n, Inical Vioami'l, Which do nazi reolte to Me kaldh ,I orne i1bless and ri�kJ4ticiry hued above. (an be Ifinmal et iiu-fin H1ntmg.ter tions of the Foad Code and 105 Cafilt _590,110a CITY OF SALEM BOARD OF HEALTH ame:�:� A_ �� Date: Pager of Item 9 No. Code c ti Reference C - Critical Item Item'"'_ I CTIOI, DESCRIPTION OF VIOLAT 4 PLEA PRINT CLEARLY :Datele� Verif P �1 )r) QA A /-\A0-VNA o A 1 I 0 o^A .14!1_.0 QAAAf-1Q VI f �t () A IVA /,il 0 r1l." //A/ I ak V)I-,PA 0 V .64 — - =11A 10 n_ - Cyt, "P IV 41) ��U 1 �-Pj A mtz, O�A J A OA 11A,)1A,)A r0/1 Al/ll V)0 f _ ��A 1 O./ni OAn (Al\ inn 4A (2A 0 1/� r) --A.1).A 14. 0_)' rf P2 I K)A1_0,42__ AnI /17D _015617-rJ r, . A Q-', -A v _j _W 0 V_ ld\ I _ f) iA -JA V, I 111C a ( � Q ---,C)-K e7+ 0,1 .fin 0 /1 FZU (0-1 IhAIA i' Do Q(A Discussion With Person in Charge: I have read this report, have had the opportunity to a/Sk quelsf�lonLand agree to correct all violations before the next inspection, to observe tillconditions asand to with all mandates of the Mass/Federal ode. I understand that noncompliance may result in daily fines of twee y,-TlVe dollars or suspension/revocation of your food permit. Corrective Ej No Lj Yes ij Voluntary Compliance 0 Employee Restriction Exclusion c�n�vdescribed, U Re -inspection Scheduled u Emergency Suspensicomply 0 Embargo Li Emergency Closure U Voluntary Disposal U Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-221 (Cont) I® IC tai 14 -1t11.11 t Ide:ntlfying tnfonnazinn - f3ti;inal ! C'ntztainers=' 102.11 Common Name tti,1rF..i+t C. ?utai ?01.33 �-�—Sem---tSaon-Sttaag� 7-2D3.t' f Restriction-Pvuctauauk] 1,1c 7--203 t 1 I Toxic Containers - Prohibitions" 7 -?t)4.1 d Samrues. Crltetria t,"}attuic ts: Criteria* 7204.14 6izart� t.gents.£rttcrtl"`_ a L03 11� � hzctd ntal 1 rid Contact. mace, l T 2(3fi t i Reatreel d t Sa Pesticides. 7-206.12 1 Rak,nt 13attstation,* _ i :00'[3 Track nb Plnvdcrs P�St Cmnrol and MoaStarm� �� TIMEITEMPERATURE CONTROLS _ j�—Praper Cooking Temperatures 3-401A l - 11E i i(z} 1 bp; -..l 55 r 15 Sec. 3-401.1 IrA)(2) I Curmaiinnted F-izh, Ivbaicti &' Game 3-;03,11 (A)&, f D) PHF, 165'I' 15 sea' 3-403.1,1(B) Microwave- 165° F 2 Warr, Standing Time, _ _ 3-d03.1.1tC) C,t}mtnereial(y i'rrnecsed R' if ex+d - 3-803.11(E)Remaininn Unsticod Portions of Beef 4 i0l 14(A) Coaling Cooked PHI -',s frun, 14014to 70'F Within 2 ,hours and From 70`1' tori 1'F,45°F Within 4 Hours. 350114(B) Cooling; PHFs Made From Ambient Temperature ingredients u, 41'F145`F ',t;eiioCt� critical ileo: ie the (xlerd 1991) Fo(ke Code or 10 ('MM 590 nidi. 4(C} PHFs Received at Temperatures; ,•t',cording to Lain Cooked to wam.., 4w,��., s I Animals- i 5'F 0 gec. -401.I1(B}{I)(27 nuts: andBoa Roast -150 F 121 m 3 401.11(A)(2) Ratites, fnjccied McAts 15 F 15. _acc._ 46EII(A)53 i'ncdtry.)Wild i5imc.StuffeadKfFs, 4 44u fni8 Cunt bine Nish ht at, 3-5ol' 16(rk) I potilu v or Ratn s 163"i l5 sec. $- ,3401,11(C)(3) oLhole-muxh Intact Buf Steaks ->01.391 t45 1 _ 401.12 _._. 3-40 1 1 Raw Atoned F<,xk Cooked in a "llorotvsve ib5'F * _ _- _ ____ i-401-I'IGAi(l)(h) I.V1Other 141FS-14TF 5scc. 3-;03,11 (A)&, f D) PHF, 165'I' 15 sea' 3-403.1,1(B) Microwave- 165° F 2 Warr, Standing Time, _ _ 3-d03.1.1tC) C,t}mtnereial(y i'rrnecsed R' if ex+d - 3-803.11(E)Remaininn Unsticod Portions of Beef 4 i0l 14(A) Coaling Cooked PHI -',s frun, 14014to 70'F Within 2 ,hours and From 70`1' tori 1'F,45°F Within 4 Hours. 350114(B) Cooling; PHFs Made From Ambient Temperature ingredients u, 41'F145`F ',t;eiioCt� critical ileo: ie the (xlerd 1991) Fo(ke Code or 10 ('MM 590 nidi. 4(C} PHFs Received at Temperatures; ,•t',cording to Lain Cooked to wam.., 4w,��., s REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HS_P} 3f77Alii ;Intiln};sseurizedPre Izacr..tficdTtticesaizt3� ?-501 ! i (t1) R tw or PatYtall Cex)ked Anumtl Food and _ R tx '3e d yEroutc the t served, u 861 1 i (C, t t uuened Food Pa kaec Not Re served, ' CONSUMER ADVISORY �22.;C'onsurMt Att.isory 3'r ted fez) L:cna,rangtion of ' vnimM Foo& FootThat are Raw. Undercooked or Not Otherwise Precose n to 131iminaie i .302 3 1 Y ate tr}r r1 hags 5 <bsutule los Raw Shell SPECIAL REQUIREMENTS 590. k D) Viola) -ie ne of Se tion 59t caternle mobile fixe, teniporany and reside nt al kitchen operations should be debt ed under the appropri tic sections above if ,elated to fx)itx>rne illness interventions and risk factors, CRher S90.009 violations relating to good retail prat aces shattld be debited under 1129 - a' spacial Reiluirenionts. VIOI ATIONS RELATED TO GOOD RETAIL PRACTICES (items 23-30;t Ctiue-af utak] non, ruu:at viufaliuns, which do root relive za rill, faodburne illness inc,rverdions rntd rsxk foo. tors L. wd above_ earn be found in ?he,fo=`r nn&ag se,•rinrs of the rood £brie and 105 CCR S -asee.r.a'_ Cclolin:> M,effi & for f'iiFs t.g PHF Hot and Cold Holding _ 3 5tli Fft3; Cold PHFs Main aimxi at or belch 41"145° F` Roo004(F) i 16iA) Ilot PHf s Maintained at or above 140'F.* _ 3-5ol' 16(rk) Roasts Heid at or above 130'T. 20 _ _ — ( Time as a Public Health Control ->01.391 Time as a ['utzticlfeaitIz Connvl-r 196.q(WH) i Variance. Reauir ores REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HS_P} 3f77Alii ;Intiln};sseurizedPre Izacr..tficdTtticesaizt3� ?-501 ! i (t1) R tw or PatYtall Cex)ked Anumtl Food and _ R tx '3e d yEroutc the t served, u 861 1 i (C, t t uuened Food Pa kaec Not Re served, ' CONSUMER ADVISORY �22.;C'onsurMt Att.isory 3'r ted fez) L:cna,rangtion of ' vnimM Foo& FootThat are Raw. Undercooked or Not Otherwise Precose n to 131iminaie i .302 3 1 Y ate tr}r r1 hags 5 <bsutule los Raw Shell SPECIAL REQUIREMENTS 590. k D) Viola) -ie ne of Se tion 59t caternle mobile fixe, teniporany and reside nt al kitchen operations should be debt ed under the appropri tic sections above if ,elated to fx)itx>rne illness interventions and risk factors, CRher S90.009 violations relating to good retail prat aces shattld be debited under 1129 - a' spacial Reiluirenionts. VIOI ATIONS RELATED TO GOOD RETAIL PRACTICES (items 23-30;t Ctiue-af utak] non, ruu:at viufaliuns, which do root relive za rill, faodburne illness inc,rverdions rntd rsxk foo. tors L. wd above_ earn be found in ?he,fo=`r nn&ag se,•rinrs of the rood £brie and 105 CCR S -asee.r.a'_ (((� Establishment Name:- Item Code ,; C = Criti ti }' No. Reference R -Red eir I r CITY OF BOARD OF DESCRIPTION OF V A7L11 C< —4 1LTH Date: 11TION / PLAN OF C M E PRINT CLEARLY Page: "t of s Date verified Discussion With Person in Charge: I have read this report, have had the op violations before the next inspection, to comply with all mandates of the Mass/F noncompliance may result in daily fines your food permit. Corrective Action Required: ❑ No ❑ Yes ask questions and agree to correct all :3 Voluntary Compliance ❑ Employee Restriction / I as described, and to ❑ Re -inspection Scheduled U Exclusion Emergency Suspension Code. I understand that /e dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure U Voluntary Disposal ❑ Other: Violations Regaled to Foodborne ittrress Interventions and Risk Factors (ttehis 1.22) (Cont) PROTECTION FROM CHEMICALS 14 I 1 Food or Color Additives le 720314 Toxic Comahaw,.—Prohibi'.mrsa Poisonous or Toxic Substances 7-I(0 C.12 Identifying lnforurt'tion -. ongina; Chemic aft for V.ashuis_ t'rU(1uc.e f mora* -- ContainersA 7 102 1 I Common Name Working Criumi ? Ot'11 Se uoacton--51'otlgc ° 202.12 Restriction - Pr senc0 and Ise* 720314 Toxic Comahaw,.—Prohibi'.mrsa 7--04. 17 Sanhizets, Criteria - C'hcroicsiW _ 20412 Chemic aft for V.ashuis_ t'rU(1uc.e f mora* -- 1204.14 DrvinxAmente.Criteriar 205-1 i Lnxd ntat FaxJ t certaa2. Laihr iem�is' 7 206.f 1 Ressrioed l se Pu nudes. Castettal' ?-206.12 '�f2ocic�n B"Istatctwts- - 7-206.13 1Tracking Pomlerr. Pest Control and 401.11A(l)(2) f {.g.:- 355 c 11 5,,C __ _ if t- Sntruc dt etc Our Ica l e5 lr3 JSac° T-401.11f�1(2) Comrrunateef 1 tsh hteii s k C,tane Commercially Praessed RTF. Ksid - Animals - 155'4 15 sec. -401.,1I(3)(1)(2) -Park and b(.0RoRoata - I 3W!" 121 nsin" .3-401.11 (A)U) � i R titres, Injected bleats 155'F 1.5 �. Within_4I-iotus } ac. — T -46111(A)(3) (Poultry,Wild Game,Stuffed PHFs, swing Ctrntaming 1''IsI thein, Pouitry l2atnes 165`1 15 sec. ' 3-401.I I (C)(3) 'Whole-nntcle- Intact Beet Stinks 1451; *. _ 3-4101.12 Faxfs Conked in it Mier lwa" 1651` _ '461.f2(A 1(I)(b) ,MR Other PHF -. 145'F 15 sec." 3-4,03..1(A)&(13) plfks 155°2F 15 sec. ^- _ i -403.11(B) mittom1w- 16 ' F 2 minute standing i 70`F Within 2llours 2nd From 701' Time, 3-403. f I(C) Commercially Praessed RTF. Ksid - t oolhtg PFii s Made Front Ambient 14('IFs 403.11(13) �) Remaining Ctsliced Portions o€Beef 3 S01 A I(A) I Cmduill Cooked PUFF from 14)°F to i 70`F Within 2llours 2nd From 701' __------{{--to-42"FI45 Y W thin 4 Hoots 1 4 501.14 Sj t oolhtg PFii s Made Front Ambient craperawre Itgrediertis to ;i'B"45°F �. Within_4I-iotus ' DenvteS critical i ern a the e lc r e l s>)') Food C'Kie cr. 105 CNia 590 [300. 14((') PI{ps Received at T'erinNratures Ace l -ding to €uta. C(x71ed to t 41'F#451r Within d Hotos. * 3-501.15 C.00tin<. 4lethesdt for PHFs 19 PHF Hot and Cold Holding 3s 7.I iIi) Coad PHFs Mitintained at or below 41`145° Fx 3-503-26(A}_____ IhaPRFsMaintainedatcvabove 3-Stil.'16{A) { Rnasts Heid at or above 1309, T 2g Time as a Public Heafth Control s .SOI 10T-- Latsus as a Nuhn Health Control'` _ iO.ilOdOi)�� Vat tansel egatrenlent� — REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULA`TTIONS (HSPS 21 3-801 II(A) i Unp Meurtzrd Pr pact egcd Jokes and � i3cvet i es WithbS arming I,ab,.is' Bic tit Paswurirzd �3-W111(D) Raw orPauiallv0sikedAvunalF(xdand (_,, R nv S d S �namis rot Sertsd I n xr i c rt r „tea rc-4 no, t ,— ? n ---A CONSUMER ADVISORY 22T-!t'onsnmet Adv3sort Plssted�fstr ("otlsannp6oa o,f Annual FKKriK That are Raw, Cnderounked or Nol Oth rwisc pm eeved to Niunnate Patho'e s' Pgg:< Subirmuie fa+" Raw S31cit 594.UO9tot'i-t 17) Violations of Section 590.(X59(A)-(D) in catering. mobile faro, temporary and t resideut_il 4iiehen operations i hould be debited under the appropriate se, Lions atxwa if related to f<_xxlborne illness interventions and risk €ac€ors. Offer 590.009 violations relating to good retail j practices uhouid be debited under ##29 — spet-ial Rec)uirernents. (Items 23-301 Gtitiral and nota-eriaic:at vtcintiom, rich do trot =elate in the ,focae,'bornet ilines.s inletrvstttians and riskjoclors 11wedabove, cnn be found in ; he boli )axng sec'ioris of the Food Cade rand 105 C,1't R IhMz',""V Z , , Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/30/2008 ESTABLISHMENT NAME: File Number: BHF -2006-000052 LOCATED AT: IGmberiey Driscoll Mayor The Old Spot 121 Essex Street SALEM MA 01970 0121 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2009-0318 Dec 30, 2008 . Dec 31, 2009 $280.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $280.00 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR JANET DIONNE, ACTING HEALTH AGENT M CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4n' FLOOR 'ISL. (978) 741-1800 FAX (978) 745-0343 ]DIONNE&AMM. COM 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT IVIC (31 r '500t- TEL # 978 - 14 5 - 5-U51(0 ADDRESS OF ESTABLISHMENT 1-2-k ES5C; _'CA,C-a*_ FAX# IJIfF MAILING ADDRESS (if different) EMAIL - Business': C r0 C 1G2 /a J I C 0 c omcuo¢ . ne+ Website: 4-h2 0US poi' - C 0 M OWNER'S NAME hj I j SSA t(3ia(lo ( + &Ce-4ert Ca C14-er TEL # 910 -239- 504 'A ce kt ADDRESS 101 STREET 5rG(4#, CYV0j,e�_ CITY V STATE�? H 11-13 AR 1(3 CERTIFIED FOOD MANAGER'SNAME(S) M'liSS, oa,,%; CERTIFICATE#(S) 5017301'1 xx &IVI (� (Required in an establishment where potentially hazardous food is prepared) 'z /l C17ir-92�-�`'lg1 EMERGENCY RESPONSE PERSON Drca Len l _✓OC�ILer HOME TEL# al k -Z39- Lg 40 cell DAYS OF OPERATION ' _, , :r Monda r L . 7ufbsd9 �' i'-Wednesd Thursd { ' `• Edda "'Saturda "' Sunda- HOURS OFOPERfday. in day. i;5PM-1AM rjPM-IA/IISPM-IAM U:30AM— 11:3aArn— 1%,3o AM- IOAX- Please write time of (For example llam-11pm) I IAM I • M ) AM I �M TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YESVO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 RESTAURANT (Outdoor Stationary Food Cart $21 less than 25 seats =S140 25-99 seats =$280 more than 99'seats 420 --------------------------------------------------------ES ------ --------------------------------------------------------------------------------------- --------- BED/BREAKFAST/ YNO $0-1--0- 100 CHILDCARESERVICES ---------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES O $135 ALL NON-PROFIT (such as church kitchens) YES 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. ( A— 17-1111 01 2-0 -19Z(P-3 Date or Number -------------------------------T— 7 ---- ------------------------- Revised 424/07 FOODAP2008.adm CheckN &Date %yb3-/d� $ . THE OLD SPOT 121 Essex Street Salem, MA 01970 978.745-5656 Janet Dionne Board of Health 121 Washington Street Fourth Floor Salem, Massachusetts 01970 December 12, 2008 Dear Miss/Mrs:Dionne, Please find enclosed out application for our Food Permit renewal. I have also included current copies of our menu from THE OLD SPOT. Most items are the same "pub" food, we have been serving since opening. In addition to ourregular menu we offer 4.6 nightly specials. We may be. changing it u a bit in the next few weeks. I will forward you a menu P with any changes we make. As Y always if you have an u,estions of need to reach me I'am Y4 available by telephone at 978.239-5044. Thank you in advance for your consideration. Sincerely, Milissa Oraibi c �. Appetizers & Salads 4 Onion Soup Pumpernickel crouton and melting Swiss $6.00 Old Spot Clam Chowder Potatoes, bacon, thyme and cream with chipotle oil & scallions $6.00. Wings or Fingers Hog or Chicken, plain or fiery buffalo sauce, celery & house made blue cheese dressing. $7.50 Green Green Salad Field greens, green apple, spiced walnuts, shaved parmesan and balsamic vinaigrette $7,00. Blue Cheese Wedge Iceberg wedge ,apple wood smoked bacon, house dressing; tomatoes and red onion $7.00 Mushroom Salad Sauteed portobellos, crimini, and buttons, over arugula, truffle vinaigrette & shaved parmesan $8.00 *All Salads available with grilled Chicken. Sirloin Tips, Grilled Shrimp or Portobellos - add $5.00 Toad in the Hole* Pork bangers baked in Yorkshire pudding with onion gravy $ 8.00 ` Ploughman's lunch Bread, hardboiled Eggs, three cheeses, branston pickle, tomato, pate, green apple, cornichons, mustard and ham $12.00 Curried Chips With melted English cheddar and onion gravy $ 6.00 Sweet Potato Sizzler Crinkle cuts with cheddar, bacon, sour and scallions $ 9.00 * Consuming raw or undercooked food may cause food borne illness. * 18% Gratuity may be added to parties of 6 or more Sandwiches and Entrees Deluxe Cheese Burger* Lettuce, tomato, onion, bacon and sauce with chips & a pickle $9.00 Grilled Chicken Sandwich* Marinated breast, portobello, cheddar and chips $9.00 Slow Roasted Pork Sammie* Pulled and pressed with Dijonaisse, pickles and Swiss $8.00 Fried Haddock Sandwich. Cheese,, lettuce, tomato, pickle, tartar and fries $8.50 Old Spot meat Pie Guiness Stewed beef and Iamb layered with toasted corn and onion gravy, baked with mashed potatoes $14.00 Very Slow Roasted Pork Seasoned with sage & bay, bubble and squeak, house apple sauce $16.00 Fish & Chips Old Speckled Hen battered fresh haddock with chips, tartar, fresh lemon & malt vinegar $16.00 Grilled Stuff Grilled Garlic Sausage* $12.00 Grilled Sirloin Tips * $15.00 Grilled Turkey Tips $13.00 Grilled Lamb Tips * $16.00 All Grilled Stuff get a choice: of Mashed Potato, fries, Sweet Potato Fries or Salad and Pick a sauce: Chipotle BBQ or Wow Wow Sauce Dinner Specials Nightly - Brunch Specials on Sundays — Gl,p nfu Breakfasty EntreesSane Hot Oatmeal -With apples, brown sugar, cinnamon maple syrup and cold crea 5.00 I 3 j Organic Granola and Vanilla Yogurt- With fresh berries, honey and mint $ 5.00 Toad in the Hole* - Pork bangers baked in Yorkshire pudding with onion gravy $800 Scottish Smoked Salmon* - Bagel with whipped cream cheese, dill, tomatoes, onions and capers $'9.00 Bananas Foster Fried Dough Sauteed bananas, rum and brown sugar with whipped cream and powdered sugar $ 7.00 Eggs Benny - Two poached eggs, grilled black forest ham, hollandaise and English muffin $11.00 Big Omelet of the Day ; With toast and home fries or cheddar floddie $10.00 Stuffed French Toast- With cream cheese, brown sugar and pecans with blueberry maple glaze and side bacon $ 9.00' Traditional French Toast - With cinnamon maple syrup and side bacon $ 7.00 Steak and Eggs"- Sirloin tips with a petite cheddar omelet, toast and home fries $15.00 LunchyEntrees 4 Onion Soup - Pumpernickel crouton and melting Swiss $6.00 Old Spot Gam Chowder - Potatoes, bacon, thyme and cream with chipotle oil & scallions $ 6.00 Lamb Lollipops* - With minted pepper jelly $ 8.00 Deluxe Cheese Burger* - Lettuce; tomato, onion,'bacon and sauce with chips & a pickle $ 9.00 Beer Battered Fish Sandwich' - Cheese, LTO, tartar sauce and lemon on a roll served with fries $ 8.50 Slow Roosted Pork Sammie- Pulled and pressed with Dijonaisse, pickles and Swiss, on marble rye with fries $8.00 Warm Turkey Breast Sandwich - Cranberry glaze and melting brie on 7 grain bread $ 8.00 Grilled Marinated Sirloin Tips'- Fries and wow wow sauce $15.00 "Consuming raw or Undercooked seafood may cause food borne illness r Desserts Chocolate layer Cake With rum fudge sauce.and whipped cream $ 7.00 Brownie Sundae Caramel and fudge sauce and vanilla ice cream, whipped cream and walnuts. $ 6.00 Lemon Bars With raspberry coulis fresh berries and dusted with powder sugar $ 6.00. Spotted Dick Bread pudding with whiskey sauce and vanilla ice cream $ 6.00 Cheese Cake "Of the day" ask your server for details $ 6.00 0 - WATER METER ELECTRIC PANEL METER IST FLOOR LIQUOR CAGE HEATSOURCE H2O WIFINI f M HEATSOURCE ELECTRIC PANEL STAIRS HEAT/AC BASEMENT SPACE UNDER . DINING ROOM USED FOR 2ND FLOOR ELECTRIC FEEDS FLOOR PLAN FOR BASEMENTS AT 121 ESSEX STREET SALEM, MA BACK DOOR EXIT IT WALK IN ', r � r 1 1 FSTAIRI HANDICAP BATH— ROOM P 32 KITCHEN a i a 1 1 BACK HALL WALLED OFF NO ACCESS FLOOR PLAN FOR FIRST FLOOR AT 121 ESSEX STREET SALEM, MA 35 ' BAR STAIR LADIES 1 r — 31 ! r ;ROOM j MEN'S r ROOM ; 39 BAR ENTRANCE f'b u.;,.,. ., ,. w �-�A` .. ... ..M c '.• ... ... .4 Massachusetts Department .of Public Health Salem Board of Health Division of Food and Dru S 120 Washington Street, 41' Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Q 1j Dat P Nod a of Operation(s) `Food Service ❑ Retail ❑ Residential Kitchen ❑ Mobile El Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Type of Insoection ®tine Lj Re -inspection Previous Inspection Date: ElPre-operationOwner ❑ Suspect Illness ❑ General Complaint ElHACCP ❑ Other Address ^ I J of Risk Level Telephone _f4�-- ,5as-Z 9 Jl $5G (o ( �/� �� HA CCP Y/N Person in Charge (PIC) Time In: 3.41 Out:S � Inspector T Each violation checked refluires 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 ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH -i ;'`. ' R M 1 3�� ❑�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. El 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. 23. Management and Personnel (FC -2)(590.003) -24. Food and Food Protection (FC -3)(590.004) 5. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.067)' 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S:5001nsp OFw 14.Ua � /9 n ❑ 1� Prevention of Contamination from Hands ❑ 13. Handwash Facilities �n PROTECTION FROM CHEMICALS''"a a § ""'� '"x """"'gxg,. a i...e, ❑ 14. Approved Food or ColorAd A45. Toxic Chemicals r TIME(TEMPERATURE CONTROLS (Potentially Hazardous Foodsj 1•=, a «m `. a.., ,'., at ..t4e;t�.� .�F.e,-,. z-.�.... ai.m war "aasa.ml ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control 3 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULA11ONS (HSP);` J4 ❑ 21. Food and Food Preparation for HSP CONSUMERAbVISORY, 51'�t-_. ,'!'"1 .; V=A_ru�,:A i ❑ 22. Posting of Consumer Advisories J 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: I uj,.�cPa.o2cl�✓. Inspector's Signature:( Print: I PIC's Signature: Print: M t c v\ o_'9 S c,S 5 0 __d 1�"" Page p Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* _ 590.003(B) Demonstration of Knowledge" 2-103.11 Person incharge- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law" 3-201.12 require reporting by food employees and 3-201,13 Fluid Milk and Milk Products* a ilicants* Shell E --Rs* 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(6) Re orcin b Person in Charge* 3 1 590.003(D) Exclusions and Restrictions* 3-201.15 59Q003(E) Removal of Exclusions and Restrictions C C C C *Denotes criduil item in the federal 1999 Fwaf Cate or 105 C14R 590,000. PROTECTION FROM CONTAMINATION $ Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law" 3-201.12 Food ins Hermetically Sealed Container* 3-201,13 Fluid Milk and Milk Products* 3-202.13 Shell E --Rs* 3-202.14 Fg =s 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* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Re u �21ory Authority 3-202.1& Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701,11 Receiving/Condition 3-202.11. PffFs Received at Proper Temperatures* 3-202.15 Package Inteity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shelistock Identification Maintained* - Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(J) Labeling of Ingredients* Frequency of Sanitization of Utensils and Food Contact Surfaces of E ai ment* Conformance with Approved Procedures /HACCP Pians 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced ox 'aen packaging, criteria* 8-103.12 Conformance wiUt A. roved Procedures* *Denotes criduil item in the federal 1999 Fwaf Cate or 105 C14R 590,000. PROTECTION FROM CONTAMINATION $ Cross -contamination 3-302.1.1(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(.4)(2) Raw Animal Fads Separated from Each Other* Contamination from the Environment 3302.1. t(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701,11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.1.11 Manual Warewashing- Hot Water Sanitization Tem eratures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chenncal Sanitization- temp., pH, concentration and hardness,'" 4-601.11(A) Equipment Fors] Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-7x2.11. Frequency of Sanitization of Utensils and Food Contact Surfaces of E ai ment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* IQ Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11. ..Eating, Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-30112 Preventing Contamination When Tastin 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 Nand Drying Devices 6-301.11 Handwashi ng Cleanser, Avail abiI't 6-301.12Hand Drvin,* Provision �4 r CITY OF SALEM /� BOARD OF HEALTH Establishment Name: Inn o (J � 1L 1' Date: 17 /3w -J Page: of iT No. Code 'Refer e ce== '4a,� C Item 'R=Redttelm 41 ,O.�F,CORRECTION € ,"Xya;�, rz�" 11 DESCRIPTION OFVIOLATION/PLAN 4:,t.�', °'gk `" `"-01 „PLEASE 16 raY `, .�+` r '.y:, - � +;G: Date V¢rlfled PRINT EAR V^n "Xi .. K fin „� ,S�.fr,`, 1 rx Qr i i U Itf-rn >>60- A Je I JWrrA, n A 4 r 17 f n_ Uv2r•_ A :5_6 _, l/ haro(j_6 .4., Afi,,, A,,,- rQ. Gr r, <„ oq.,� C�00 SR n . f M ✓e.( .j � 3(J Case 0 � A-fnr It r t (if 1-4 L , 0/13 C/4 � n..h : r- GCr r'.I CL H7nt �. ,b /(�GOI ��%Y , �.1 ✓ U &6, f'h !" :<s+�r 7`i/�'� c n•- /Ire 00,Y;l 1 j `0 V -e / 10'1 v dc'ti 4io XI 60c n, n , . l%, 5 '��I+ '1-1 f 7 I" A- � r G A 1( n Discussion With Person in Charge: Corrective Action Required: ❑ No gfjl'as I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction Exclusion inspection, to observe all conditions as described, and to violations before the next ins p L.13 Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. .- �� ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne illness IntervenficifIs end Risk Factors (Ifernal 1-22) (Cont) 14 1 1 Food or Color Mounts$ I 3-202AT-7 3-302,14 Protocirrs) trom 1"a to Poisonous at Toxic Substances 7101 11 i,GE^ntiiyzglnfAlnutzon-{lc� tea, 3-501 Is Coolin, Merhotl, fi)r PHFs 7-102,11 Ckgamoil Name - ',Av ork;ti, 3-501.16(81 lien - Sl LwaE— 590,00-Iff') R(�m iction - Pr�,w�o and L HrePFl I, %L infe'lled 'It "I 81,11w, 11 Tmic Conaameo, - Probitiviom* 204 sanili7ek,cote"mt -- chemicck, -27 F�" CheirliertiI, far W'ash z�jxltcc� clito�j 104 �4 Criteria' 1--7i05.5 Incid"mal L2-20ie I I ResiricotdTs, rici}zs.Cttretta, - ! 7-206A2 R(sicol fl�llt Statiow 1-7 - 1 7-3()6,I3 j Tracking Poiwler;, olurol and 16 .3 401 11 A(l )(2,11 Fggf- 15i, F S 5, 5, c. 71 1 (A)() Conawnwed Fe,1c, Meats & C1,11310 AniuILIN 73-4 7)111(13)t 1 )i2l Poik and Bcci hoist -1'f1 121 min" 3-401.11(A)(2} Raim" lrnecte6 Menu I "4'F I sec. I 3-401.11(A}<3) -4110t0ir", M]d Stuffed t"IFs, sloffin" ConlIoning Fish, Mea, lloultrt of katii�s- J 65"T 15s,�c. V1, le-'oaselu, himla Beef StcaKs 1451t '- —Arntytal —K�xJ—,,Calked -w —a Mlccowave All Other NIFI -- 149'1 15 see 9 for Not Holding PJIF, 165'F I7 sec. 11 Nlicrowavc- 165' F 2 Mmwe, Stancliq 1403. 11 (C) 3-4031 1 (E) R".'Inainiag (�Ilsoced portions of jloas!,:* Proper Cooling a9 PHFs _, i PRFs h m !,Vl- to -75 A WA) iok� -x 70F Widkes 2 iiourc acrd From ?(YF to I Within 4 Hoam ' 3-503.-1 4(B) Ci,oliiig MR; )vfe& From rkinbiew Tcatlwatme 1%imdicrit,; to 41 `F/45T Dwioes awcli gon in tl� Iouxal 1 I)Qq Nml 165 CMic REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS —(tSEL---- 2ii-71.ti -S0111](A) Juices wai ff0171!(—D) I Raw or fiaalmll,, C(Aed Animal Food and 5-g0 1-1 1,f) I rinoneried Fcxxi Flackw,,c Not pr-�,crved. 22 3 1iO' , i I i C(ait um(a ALI , i soi 4 Pawil for Calmnoption of Animal foJ, Dist 'are Raw. Undemx"ked I,. N, (it Od I -,I w iw PT m.e,scd t o F1 i mi mat pai hoiteL; & ec., I SkJ �elmle fo-1 Raw S101 'IT A'j-(f)) i Violet tis of Section 590.(4,)1)(A) -(D) in catering molal- fixid, temportuy and remd-mt at nitchev; ojanraiitsis liould be. debited under the iproltriaf< ac ens above, if related to fexAborne qlncss inteiventioio; and dsk factors- Other ,;90.()09 violations r0ative, to ,ow retail jpracticeo Acold Ix debited tcoder #29 - (fterms 23-30) cliwai and non -t rwcol vwfalion, which do to ?elate I,) file foodborne iflnf,'Sr inw,venlioav and riA-fiat turs lioed above, con be folma, in owI tolorwog.wz amens of the hnid Cade and 205 ("I'll? 90, 00u, S Y I ,r a V 2 1, In Lav, 00e�d to I! -N5 F sviihill � Horns, 3-501 Is Coolin, Merhotl, fi)r PHFs 1Y !PFIF M*t and Gold Holding 3-501.16(81 COW PlfFs 'Maintainto, at or below 590,00-Iff') HrePFl I, %L infe'lled 'It "I 81,11w, 3-50 H-161{A2—.+,R—"I,al RcId a, or �)bovc B01% Time as 3 Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS —(tSEL---- 2ii-71.ti -S0111](A) Juices wai ff0171!(—D) I Raw or fiaalmll,, C(Aed Animal Food and 5-g0 1-1 1,f) I rinoneried Fcxxi Flackw,,c Not pr-�,crved. 22 3 1iO' , i I i C(ait um(a ALI , i soi 4 Pawil for Calmnoption of Animal foJ, Dist 'are Raw. Undemx"ked I,. N, (it Od I -,I w iw PT m.e,scd t o F1 i mi mat pai hoiteL; & ec., I SkJ �elmle fo-1 Raw S101 'IT A'j-(f)) i Violet tis of Section 590.(4,)1)(A) -(D) in catering molal- fixid, temportuy and remd-mt at nitchev; ojanraiitsis liould be. debited under the iproltriaf< ac ens above, if related to fexAborne qlncss inteiventioio; and dsk factors- Other ,;90.()09 violations r0ative, to ,ow retail jpracticeo Acold Ix debited tcoder #29 - (fterms 23-30) cliwai and non -t rwcol vwfalion, which do to ?elate I,) file foodborne iflnf,'Sr inw,venlioav and riA-fiat turs lioed above, con be folma, in owI tolorwog.wz amens of the hnid Cade and 205 ("I'll? 90, 00u, S Y I ,r a V 2 1, ITY OF SALEM BOARD OF HEALTH 4 Establishment Name: � 01,-D &7,r -r Date: 1;;l/vat � Pager of Item No. Code ro M Reference C -Critical Item T" R - Red ItemVerified DESCRIPTION OF VIOLATION / PLAN OF CORRECTION %,A ',NY j, f� k - PLEASE PRINT CLEARLY Date ff V(21 101G ♦ 01) rrcec fc_� 13(-", pjc� 4V /2� 1, r, r C' Q/' cd %;Pf' f1l M-c"A fj� CIO( ^,/M I V Fr1)0m . A,, L\ OZ -0l ��e L,el?-L A 71— 0A �J..9 .SACIV.'A C"49o%'n i- -7 ,rA�OA 4 NA LF C( &g i iJA n r� r (1\S f \0 A ALO, fJsfi zC, 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: L3 No o Volunttiry Compliance 0 Employee Restriction Exclusion ❑Re inspection Scheduled 0 Emergency Suspension C] Embargo Q Emergency Closure Ll Voluntary Disposal U Other: Violations Related to Foodborne illness Interventions and Risk Factors (Iterns I-2?) {Cont.} PROTECTION FROM CHEMICALS to 1 � Food or Color Additives 3-302.14 1 protection fron Poisonous or Toxic Substances W.If Identifying Intonnation -- 000rad 7 ,-102,11 Common Name'- Worlon" Contf 7-201 11St �)ra --- 7-20111 Restricoon - Presence and Use* 7-202.12 Conditions of 0 7-201,11 Toxic Coivainets - fltofiibvions# 7-204.12 Cheirlicak for to w�jll 1 t 7-204.14 Criteria'" 7-206,11 Rcstricld U,Stl ReAicids s. Criteital 7 206.F - -T -f -f,7,- 7-206,13 �Ckuqg Powders, 0,1SL Control and "nMErrEMPERATURE CONTROLS 16 Proper Cooking Temperatures for PHFs 7iu5i—1 I A(I Egg��- 155'F 15 5,"(% -7' IJ((A)G) Comminuted Fish, Meats & Game Anirnais 15Flsec- -T'--�7 orT aerlB,,ei Roast 13) F 121 rn 3-401.1I(A)f2) Ratite" Injecied Idciits -- I -WF 15 'se* Stoffing, Containing Fisl), Mein, Poultry 01 Rath"- 1651, 15iiec. 14514 4 -E,;% una�[ I oods E,,,k,,l in a Miclowave lbs 'F --F 3-401,11(A)(1)(b) All 1 1 IF ,-- 145°F 15 3-193111 A)&( ii PIJF 16"'F 17 wc. 4 _3 -4031 1 (B) -- -"�-dic"ro-wavc - 165" kI i mae sumiling 3-403 . I I (C) COMMOMativ Pia esled R11t.Foosi 140T 3-iiii I(F) Remaining of Bee, Roasis* 0 1J,RA) --T 1 Proper Coaling of PHFS ('oofirtg C(,,,k,.,41 PflFs femi 140'F to WASI� F* -1-50L10"A) i 70'1- Within 2 flours and From -10F !40'F. * w4l'FAYF Within 4 Hones, c --- ittsists Hold at or above 1301i, Cooling PHFt Made From Ambu.-tu Tcmpeouarr fulicsfieras it, 41°F/45'F 1. 19 Fina as a Punficltealtb Within 4 Hours' - Devoleb mucal heir m the fol'ral N99 Food ('Vle of 105 CMR .59i 100( - -1I50ijilO PitWs Rec,Mel atl`cmperatmo� Ac�adins to Lac Cooled to 'I ,F/45' -F Wiflan,l Houis, 3-58 r '5 coolin. ?ylt-dux]t for PHFs 3-1;0!' 16(B) Cold PHF'q lylainetiflerl at or belc�sv 396 Owl-) WASI� F* -1-50L10"A) e flot PHE;Nfauktained at or above !40'F. * --- ittsists Hold at or above 1301i, Time as a Public Health Control 1. 19 Fina as a Punficltealtb 1-801-t!(A) Unpaqtcurizsd Pre-packagcd Juices and Bevyraoei; with `�'ami o .` 3 -801, 11 iB i U cot Panba 16 red Eggs 3-801.1i(D) Raw or Partially Cooked Aniard Food and R , St 9i Surows fol Sei ved - r'71 22 13-00-iAl Coaonocr Ativisory Posted for Conountition of Anim �l F,.xxlThat arc Raw. Undercooked o; t rot &lsem ise VroceqS'edw l-,lienruais Ila og sm 3 I -30113 Pastezlrfzd fol Raw Shell SPECIAL REQUIREMENTS catering. molulc ftx)ct temporary and remdenual kitchen operationshould be debited under the appropriate qeowns above, if related to to(Aborne i [Incss inter veafions and risk faclors. ORiff .590.W9 violations r0tuntu) to ,okxf retail practices,ibould 1-v debited under #29 - Speend Rcquheme�,nR. --'7RELTE AD TO GOOD RETAIL PRACTICES VICLAT16NS (Items 23-30) criir'.al ezvd niai-(rilwol viOlarons, which do nm relar, 1,; Ike filodborne dhw" eief V,1nh0nS ond ri,.kfirctors lisieda ove(an lit, faun in ihe jocF >arxy sutmr a of the Food Cade and 10-5 (WR 590.0W, Establishment Name CITY OF SALEM BOARD OF HEALTH Date: (0- /0, d) Page -4— of Rem , • No Codet� Reference . .... '4121 C - Critical Itervilp "'DESCRIPTION OF VIOLATION/ PLANO FCORRECTI ON IEA��PRINTCLEA �A Pt CLEARLY -Date Verified IM, -A -">-)T L4 r �)vpA A '1 .4 TAI'cio t A � 6 (_A )S -5 ✓�g0n-)L� - .- F S V L TO dYJC,.-),t4fA&� Pf, +YY), MA1,4-4-r. r tJ, A /o n L V1 C I /Y - C_:�Tj f IF - T /{j4 /I Cj" eoe!c I C- apt WLI le4 0 in i he L 4 - 0 %�e 01 Xf 'L3 I e'* i i J A ri --�AAJ Pce—AL A /Mangyl J- NiaoiN44 -R- e7 0AA)0A 9� r -d- !��Ijvbuolj 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.`724 --Corrective Action Required: Yes u Voluntary Compliance 0 Employee Restriction Exclusion */Ra -inspection Scheduled L3 Emergency Suspension o Embargo, Ll Emergency Closure u Voluntary Disposal El Other: 64otanons Related to Foodborne fitness Interventions and Risk Factors (Itedur 1-22) (Cont) PROTECTION FROM CHEMICALS _ 4 FFood or Color Additives -i-202.i2 Additives'" ?-301It Protection #rant Una" roved Adtlikives" 1g Poisonous or Toxic Substances 7-(01.11 € itientifvinefr Donation-Origulie, M 7-102,11 1 Grateon same W >rki na C cmpz 7201.11 separation—Stoia�a' _ 7-21 i tte,trzcaon - Pr sena' "wd 1 se* 7-202.12 Cordnion, of Uso, 7-343.11 Paxtc t' ontainet - Psobibitiana 204.12 1 Cheuucals for 2-206.1 !.e,ziuted t;e Peeftczdes- Criteria'. 7.2(}6.12 Rotten #3 ztStatnn4. _�.. 06.13 Tracking Powders.) est Control and Igs-15.4"-15:5;c. F s,z,�-3inm_r.iz ttu 4cntiicc 145'1=155ec= 3-40LItfi3f2J Comminuted tush, Meats & Cietnc Anttnais-1>5�F.SSsec. " -40L1 tfii}(1}t2) E Park and (tool Koxst - 130°t' 121 mink 3-A0'l.ii(A)C Rutter, SnJcet d Nlcats 1555-F IS _ 3-4t?i.ti{A)r3} f'nnztry-,4atidt^zme,.Stni}e"I1''Nis, Stuffing Coni nzuRnF Fish, Meat, Poultry or Rantes.165°J" 14 sea 3-A01,1!(C)(3) 1Vbde-mus fe, Entactl3t<f5teais 3 - -OT I2 Raw ?utiaut[ 1rot>ris Ccxrketl in a� N4zcruu�ave 165'F1.fAt(1}ib) Ali OtherPt{t�t-FS`�E" IS sec. Reheating for Hot Holding 3_�#03,tlfA}K(13} Pl3}r; 165°F 15 sec. d-A03.1,t(k1) Microwave- 105' F 2 ;tlinute Standing _ `fimc" 3-403. i J (O;) Commterrialty Pz cxess:,ti RT'E €vxx# - _ G ldtl'>F:z 3-4f➢3.3 t(i:) Remainingt!nsti,ced Portions of Beef Roasts _ -� Proper Coaling of PHFs _ 3-501. f4(A) Cooling Cooked PffPs from 140`F to '0 t Within 2 (fours and prom 7Q`F i=t45 -'A'vd itt 3-5flt,idiBj Ctmlzt.gPHfsMadeFrotzrArttbient Temperature ingredicnts to41°E/44`F Peaates critical ile , ^t ih. re era, Not Folio (;<;Ja or 105 t:Afill 59i} e30{1. PHFs Received at Temperatures Accordirig to Law Coded to 4 FFAS°F 1Tz hhia d Houi_c_ 19 PHF Had and Cold Holding Calot Pf ii ? mLliued at of below 590.0*4f) 41°145°F`_ 3-501.16(A) Ihx PfOrg Maintained at cr above 140'F. :i-Sit1.15[A) Roasts Held at or above 136°F- is Time as a Public Health Control 3-i01 � 9 � � i T' imc as a €'ahlic. i-lealth C`antsnl' 21 3-801,11i,10 Unp meurizcd I've -packaged Juices raid lit eca>ec ivittz lraz tii� labdls�. �i SOI i if13J L c csf PAsteusnrcd { Raw or Patiaile Ux>ked Anitnal Food wid _ 4e ed Sparotzts'JuE Ses vc tt 3 801 1 I E L, t: e ne d B�ad Palace Not Re -served. `. CONSUMER ADVISORY _ 22 1.6 11 Coesumrr A Js isoiv Posted for Consumption of 7iucal 1 o'that are R tw. Undercooked or Not (uteri •iso I'res i,tve,f to Elirunate 330.1 £ este to �d gds F Suhsotul atty far R5het1 � ! ' . 590.009oA)-(D) Violeflows os Secttou 59(i.00')i ,)-('D)in cawriog mobile foul, tenpurary and resid ni al f:i(chea operations should be 1 aebzted raider the appropriate sections ttrveezIrrefined ill "o dborneillness inlet ventions; and tisk facirns. Other 590.(A)9 violations rotating to good retail pia tic c should be debited tinder #129- I Sp,cial Rc>quircmonts. (Rens 23-30) coast and non, ritual vio4itionc which de no; reiate to Me ftwdhornc (anew imeroentiorts and rkskjirerors tisied nGave. (an Orr foluid ire the fvtlnsz fg see ions of the food Cotte caul 105 CUR 3 Roasts _ -� Proper Coaling of PHFs _ 3-501. f4(A) Cooling Cooked PffPs from 140`F to '0 t Within 2 (fours and prom 7Q`F i=t45 -'A'vd itt 3-5flt,idiBj Ctmlzt.gPHfsMadeFrotzrArttbient Temperature ingredicnts to41°E/44`F Peaates critical ile , ^t ih. re era, Not Folio (;<;Ja or 105 t:Afill 59i} e30{1. PHFs Received at Temperatures Accordirig to Law Coded to 4 FFAS°F 1Tz hhia d Houi_c_ 19 PHF Had and Cold Holding Calot Pf ii ? mLliued at of below 590.0*4f) 41°145°F`_ 3-501.16(A) Ihx PfOrg Maintained at cr above 140'F. :i-Sit1.15[A) Roasts Held at or above 136°F- is Time as a Public Health Control 3-i01 � 9 � � i T' imc as a €'ahlic. i-lealth C`antsnl' 21 3-801,11i,10 Unp meurizcd I've -packaged Juices raid lit eca>ec ivittz lraz tii� labdls�. �i SOI i if13J L c csf PAsteusnrcd { Raw or Patiaile Ux>ked Anitnal Food wid _ 4e ed Sparotzts'JuE Ses vc tt 3 801 1 I E L, t: e ne d B�ad Palace Not Re -served. `. CONSUMER ADVISORY _ 22 1.6 11 Coesumrr A Js isoiv Posted for Consumption of 7iucal 1 o'that are R tw. Undercooked or Not (uteri •iso I'res i,tve,f to Elirunate 330.1 £ este to �d gds F Suhsotul atty far R5het1 � ! ' . 590.009oA)-(D) Violeflows os Secttou 59(i.00')i ,)-('D)in cawriog mobile foul, tenpurary and resid ni al f:i(chea operations should be 1 aebzted raider the appropriate sections ttrveezIrrefined ill "o dborneillness inlet ventions; and tisk facirns. Other 590.(A)9 violations rotating to good retail pia tic c should be debited tinder #129- I Sp,cial Rc>quircmonts. (Rens 23-30) coast and non, ritual vio4itionc which de no; reiate to Me ftwdhornc (anew imeroentiorts and rkskjirerors tisied nGave. (an Orr foluid ire the fvtlnsz fg see ions of the food Cotte caul 105 CUR 3 .+w ., rry«;-;qui. �,.ti.ry .�+7'=Fti.� •.a..7 � 6rv+«�.. �..>, rvwr,l,;'n •": �^ k.r'iry.r� Y' .�.. Massachusetts Department of Public Health Salem Board of Health 120 Washington Sreet, Division of Food and Drugs Salem, MA 01970-t35234 th 190-35234'" Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Mc 'a �� y T e of O eration s ood Service Retail Type of Inspection Routine Re -inspection Address - Ris Page4 of Pages Level ❑ Residential Kitchen ❑ Mobile Previous Inspg§ction Date:'/ 309 Telephone M_ �/� f/� ` f T� 1 m El Temporary ElCaterer ❑ Pre-oper tion ElSuspect Illness Owner �` �U� HACCP Y/N Q k M Pn en ❑ Bed & Breakfast ❑ General Complaint Person in Cha►ge (PIC) Time 1-0ElHACCP Inspector I ou, Off. Permit No. ❑Other Each violation checked fequires 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 MANAdEMENT, -„�, ❑ 1. PIC Assigned/ Knowledgeable/ Duties EMPLOYEE HEALTH =, Moa `7 ❑ M2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded q4 3 P $ ice`^�]i FOOD FROM APPROVED SOURCE „„,,,;,,,�s ,w,.m;;,.,,��,.,�� ❑ 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 ,t s ' ;L P', .❑ 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. 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 4--,25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) -27. Phsical Facility (FC -6)(590.007) 28. onous or Toxic Materials (Fc -7)(990.009) 29.cial Requirements (590.009) 30. ttet 5: 5901nspeclPom rlC.tla ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities 4 PROTECTION FROM CHEMICALS ��Im �y lir r _ --6, _ ❑ 14. Approved Food or Color Additivesy, ❑ 15. Toxic Chemicals ''TIM&EMPERATORE CONTROLS (PPtemlafly Nazardous F064)i �1�701 m1Im.... ❑ 16. Cooking Temperatures [117. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control 'REQUIREMENTS FOR HIGHLY $U$GEPTIBL,E POPULATIONS (HSPi,2 ❑ 21. Food and Food Preparation for HSP �''-CONSUMER ADVISORYW, `•' °°" ' �o„g.'"" `�' """"":' r"`�" ❑ 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: 0� h?"46 rZ,;Zo:)g Inspector's Signlure. ` Print: , PIC's Signature: Print: p ^ co ( Page4 of Pages „S 4 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11. Person in charge- duties EMPLOYEE HEALTH 2 590:003(0) Responsibility ofthepersonincharge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-20'1.13 Fluid Milk and Milk Products* applicants* Shell Elias* 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) C� 590.006(B) 590.003(G) Ra or6n b Person n Charee* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Rennovai of Exclusions and Restrictions 4 La C I FOOD FROM APPROVED SOURCE ° Denotes critical heat in the tetleral 1999 Foal Code or 105 CMR 590.000. 8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-20'1.13 Fluid Milk and Milk Products* 3-202.13 Shell Elias* 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 Drinkin Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish" 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity - tte it y*3-101.11. 3 -101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.0040) Labeling of ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ment* Conformance with Approved Procedures /HACCP Plans 3-502.11 S ecialized Processin McOxxis* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* ° Denotes critical heat in the tetleral 1999 Foal Code or 105 CMR 590.000. 8 Gross -contamination 3-30211(A)(]) 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 3-3041 11 Food Contac' 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* 4 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* - 4-501.112 Mechanical Warewashin;- Hot Water Saniti zatian Tem etatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surf=aces 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 ment* 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 Cleanine Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 240t.it Eating, Drinkinor 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 ConvenismAl 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 [6-301.11Handwashin y Cleanser, Availabilit-301.1.2 Hand Drying Provision m a` CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: a (a Page: of SRem Code C-Criticalltem V,�V � DESCRIPTION OF VIOLATION / PLAN OF.CORRECTION ',� �� .ice, Dates LnNo. Reference R -Red Rems 1. a '> k e Verified s ...,.� Al$ .+z'l a. &.4...: ma$ ,v m ,dnxr. „ff',\, A �sv.., .✓re ,f„ PLEASE PRINT CLEARLY as . h _ I- , , (V I / IY/\N.,, 1ti L mak- ..1 O _ F7 .,.--4-� e`..., 6- I- 1-) 1wnn c J]oi1T.u0 / I I Discussion With Person in Charge: have read this report, have had the opp rtunity o 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 MassRederal Food Code. I understand that noncompliance may result in daily fines nty- I doliars or suspe sq for/r evocation of your food permit. (/f yl , 2 1IIINNN""" Corrective Action Required: Ll No es El voluntary Compliance Re -inspection Scheduled ElEmbargo ❑ Voluntary Disposal ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: J Violations Related to Foodborne fitness Interventions and Risk Factors (item 1-22} {Cont) M I Food or U(Nor MICHVVes 3-20,112 Addaive," 3-3{2.14 Proteetioll frotInIlL111i di2rw mi .Additives`Poisonous lsi of PustelnETJ �Eo or Toxic Substances 0 1 . I IIdentifying Inforoalelon Original ars I. 111C) 7-102.11 CouamooName , 7-201.11 Se2aijkft': 7-202.21 Petra tion -Pro 'riewa:. and Use* 7 1-02.12 Conditiom of Usa* r-303.11 1 oxic Containen, - Prollilonoo"! 7-204A Chemici& for Washo4 PawltocC'I 7204,14 Drliu,�Vmm. Critev lucid nis' tal Fool] (Aaolat, I,UhMaMS _, --- 7 236.11_ko�ariljd U t, Pesticides, Criteria* -20(1.12 —_ L . ..... .... .. --- I Rotical B44 Slauoos� 1-111cfing Powders, Pest Control aw ,72061, TIMENEMPERATURE CONTROLS Proper Choking Tomperatures Proper "q Tor _t �PHFs 1, 1,55'F 15 5,, _370THArl)(2) F� 155 F 15, �&� Sx. i Fx,gs- lalloediaw Servicc 145"Fl5se, I (A) '2) CornjoinulrW Fith, Nlcje,s & Gama 3-401.11(13) 1a21 Pork and Btef Roost 1301-' 12.1 alin 3-40 1.11 Rgites, b0cfol Mlc,a - 155T 15 Poultry, Wild Garm, Stuffed PRFs, StuffingContainiq, Fish, Meat, Poultry or kjdlesl 65`1 15 sec. 3-401,11(C)(1) intact Be Stew, 145T * 5-4-5 1, 12 Raw Anoy;�, 11cld"Tiloked it a NA, ......... IM'14 * I ��-401,11(A)(I)(b) All Odxr I'liFs - 145"ll 15 w Reheating for Hot Holding 73 40_ Pips 1657 15 sec. �40111(w) Nficrlexavc- lf,"' R Know SlaudirrIg Tinier' CornmoJally triocassed RTL'Food 140'F" 3-403.1 i(El t Rcoilojun, Unsficvd Ponions of ft�[' Roasle Proper Cooling of PHFS 501 J,4fA) Cooling Cooked PHFs frota 140°€o to I 7WT within 2 lfours and From Tfl' io 41 T/45� F Within 4 Houm 3-501,14(13)_Coot 1UL, pffs Made FrotnMnbietit 'reatfiv r ature ho,reditoas 144PF/45'F Within 4 1+"f,* Denotes caecal Item is th" fo'kal'l 1999 Fo(xi (A'Ae "� 10 CMR 590 000 22 i 3-00, 11 Cofizlvo,i Ait4 isory Posted for Consompticar of Aiokti A 1xN Mai arc Raw, Underolokcd or Oljrera tee Processed to 'Flinkinare, 70�7_3 pf�qeitnl�d Ep'. Sobwtut< foi Raw Shelf 590'009M)-(t)� 1 Viokitow, of Section 590,009(A) -(D) in catcring. lnobik. "xi, temporary load te%idemial Kitchen operations should he debited under the appropri.de, sections ala ve if rehned to fioodborne ilincis 5108tions and risk factori. Other ()"01) violations relating to Pod retail praakes :,horrid be debited under #29 - Special ReAluiremomts_ (Items 23-30) Critics; and eve, nvwl voeoflons' which do nor relate jo the foodborne, illness infel ven0ay and risk firclors F'o'd above, cin be found in dwJ61hia-mg sections of Me Food Code and Io-,, CUR S I h � Mf2 " ticwva2ea With Warninp. Ubeh'* lsi of PustelnETJ �Eo Raw or Pirliady OyAcd Animal Food and h-801 ars I. 111C) ("notened FulA Packaize hotRe 22 i 3-00, 11 Cofizlvo,i Ait4 isory Posted for Consompticar of Aiokti A 1xN Mai arc Raw, Underolokcd or Oljrera tee Processed to 'Flinkinare, 70�7_3 pf�qeitnl�d Ep'. Sobwtut< foi Raw Shelf 590'009M)-(t)� 1 Viokitow, of Section 590,009(A) -(D) in catcring. lnobik. "xi, temporary load te%idemial Kitchen operations should he debited under the appropri.de, sections ala ve if rehned to fioodborne ilincis 5108tions and risk factori. Other ()"01) violations relating to Pod retail praakes :,horrid be debited under #29 - Special ReAluiremomts_ (Items 23-30) Critics; and eve, nvwl voeoflons' which do nor relate jo the foodborne, illness infel ven0ay and risk firclors F'o'd above, cin be found in dwJ61hia-mg sections of Me Food Code and Io-,, CUR S I h � Mf2 " '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: NameTyp Management and Personnel Dat e of Operationfs) Tvoe�of Inspection ❑ Food Service ❑ Retail 25. Equipment and Utensils (FC -4)(590.005) ❑ Routine ❑ Re -inspection Address 1\ Risk Iv Level ❑ Residential Kitchen ❑ Mobile Previous Inspection Date: Telephone - ❑ Temporary ❑ Pre-operation Owner HACCP Y/N ❑ Caterer ❑ Bed 8 Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) Time In: ,�j O2-, Permit No. ❑ HACCP ❑ Other Inspector Each violation checked requires an explanation on the narrative pagb(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, �� El 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/ Knowledgeable / Duties ❑ 13 Handwash Facilities 'EMPLOYEE HEALTfi1'v:t's„"G'�'�-q:x ,ri '-a�'"rv= `PROTECTIO4nomc'HEMICALS 11iH -r' �.' ❑ 2. Reporting of Diseases by Food Employee and PIC S=aaw.r u-t.�` 3 -� 1 �• �E = �_, s1 f aiM • .w � 1E a�.x ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ,FOODFROMAPROUE4 G'� �2i _tu E] 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans r PROTECTION FROM CONTAMINATION` TV" ❑ 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. 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) 29 -Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) FR 30. Other S: ss Mi tFa m 144m ❑ 15. Toxic Chemicals r71M&EMPERATURE CONTROLS (PofehtkaNytl"azardoue Foods) 3�,gj cF t94,i, s ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control rAEG IAEMENTSFOR1{IGHLYSUSCEPTtBL�EPOPULATIfiNS{HSP)��, L121. Food and�Food Preparation for HSP Y".CONMYIro,_ ",..��..m�.,aUEFSOR�.jnyrsy^mw a�w ❑ 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: 1 Inspector's Signature: 1 Print: PIC's Signature: r Print: l (I , /( Page of ages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 596.003(A) I Assignment of Responsibility* 590.003(B) Demonstration ofKnowledge* 2-103.11 Person in charge duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Fiord 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 Chase* 3 1 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 • � � : t „ s • : +Pl�r�'Ta1T1L�l x Denotes critical item in the federal 1999 Food Code or 105 CMR 590.060. PROTECTION FROM CONTAMINATION S 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* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 31.0 CMR 22.0" Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Reerearionally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms- -3-201.17 Game Animals* - RaceivinglCondition 3-202.1'( PHFe Received at Pro er Tem eratures* 3-202.15 Paeka e lute it 3-101.11. Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* gstRecords: Fish Products 3-40211 -rasite Destruction* 3-402.12 Creation and Retention* 590.004(J)beling of Ingredients" Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ment* $Records. nformance with Approved Procedures ACCP Pians 3-502.11ecialized Processin Methods* 3-502.12duced ox en acka ing, criteria* 8-103.12nformance with Approved Procedures* x Denotes critical item in the federal 1999 Food Code or 105 CMR 590.060. PROTECTION FROM CONTAMINATION S Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 7302.11(A)(2) Raw Anand Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-3(4.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(,X)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.1.1 Discarding or Reconditioning Unsafe Food* q Food Contact Surfaces 4-501.111. Manual Warewashing - Hot Water Sanitization Tem eratures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Samfizatlon- temp., pH, concentration and hardness. 'k 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Foo ContactSurfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ment* 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* 1.1 Good Hygienic Practices 2-401..11 Eating, Drinking or UsiEE Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em to ees* F-13-1 Handwash Facilities Conveniently Located and Accessible 5-203. Lt 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 Hindwashing Cleanser, Availability L.6-301.12 Hand Drying Provision ALEM BOARD OF HEALTH I Violations Related to Foodborne fitness Interventions and Risk Factors ((terns 1-22) (Cant) 14 Food or Color Arlditives �-Zt - 12 Mdifivu"t 3734)2,14 PE�oAcctioa 206.13 Poisonous in Toxic Substances ig (ltennt3 ... g It(,i mal'on )'7""'1 590 Wiidiiti 4-11kfrats_ 7-102,11 COM14011 NInee -- WOrkim, CoinanitW 7-201.11 I aLIQ —n- 5I -- tat L -S�u R'ntfictksl - po'sencc and usr* 0 Coadaionb of Llso* 7 103 11 Toxic Crnitainelprollihn;omml 20 �11 --C—hctoiClfs* r7204 12 h,:ntn-.& M 3 401, 11 A(1)(2) Eg!"- 155' IS 5""u. '2111111117ahatc coninnnuied Nlc Meats & Glitic Anlwak- 1,5 1' IS Sec. 3-401.1l(fknl1a2) Pork lkod kof Roast . 11110'F 121 illit) 7�f—MlIcRiz—)- 'R'T'it-c—s I—ujcc'�d —155 —T 1-5 sec. * 3 ZI, I I (A)i 3 l poifltr�' ',it Came t it k, IT sinfling Cowan 'int Fish, Isle flouitry Or Raines -1 65A,' 15 scc, Whille-min"Cle, [niact fivel"Sicitirg I Fs. 11 —I 145`1 3� -40 M 1. 12 kao Animal Flds CookA in a 'Miclewavr 165'F 1-401 O(A)(Iab) All Other 14T'F 15 sec. i7 Reheating for Hot Holding PHF, 165' P I -403A1(8) Microv avt- 165° F2 Nlinti Standing d 403 1 ittC) onenevcialNvlProces" p,,Z_ 4 1 3-409).11(1-1 1,'11 Renaunhe, Unshced Portions of fim" 13- 01 14(A) Ccilling Colikd (IFIFs fftan 140'F it, 7-106.11 Re�irlct-" Lse Pis 'tnaje�. 0iterel* 7-<06.l2 F3 et 206.13 -!patent ��a Control and 1 Tracking Nwilers, Pe M 3 401, 11 A(1)(2) Eg!"- 155' IS 5""u. '2111111117ahatc coninnnuied Nlc Meats & Glitic Anlwak- 1,5 1' IS Sec. 3-401.1l(fknl1a2) Pork lkod kof Roast . 11110'F 121 illit) 7�f—MlIcRiz—)- 'R'T'it-c—s I—ujcc'�d —155 —T 1-5 sec. * 3 ZI, I I (A)i 3 l poifltr�' ',it Came t it k, IT sinfling Cowan 'int Fish, Isle flouitry Or Raines -1 65A,' 15 scc, Whille-min"Cle, [niact fivel"Sicitirg I Fs. 11 —I 145`1 3� -40 M 1. 12 kao Animal Flds CookA in a 'Miclewavr 165'F 1-401 O(A)(Iab) All Other 14T'F 15 sec. i7 Reheating for Hot Holding PHF, 165' P I -403A1(8) Microv avt- 165° F2 Nlinti Standing d 403 1 ittC) onenevcialNvlProces" p,,Z_ 4 1 3-409).11(1-1 1,'11 Renaunhe, Unshced Portions of fim" 13- 01 14(A) Ccilling Colikd (IFIFs fftan 140'F it, VF Within 2 fttiurs and From 701= __._()I___._. IV 4) 1^/45 f` Wiffin 4 Hiiio s-501.14(11) Cooling IIHFMekle Fo)m Ambient ig Temperature ljigredienls k) 41 OF/45'F 590 Wiidiiti 4-11kfrats_ Den'qeN alulml ite'll ill !AC itie'eat 1909 F`o(w'! ( lxle,' litS C"Ok 590 OW REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS {HSR) 3,01.11(A) Uripstem'Qed Pl`C-paC1'aged Juices anjill S -J-111(13) -T-�T(- _8d, 1)) or Pal mik; Ox*d Aminal Fix)d dad Not Served.;' P-11 1-1- k- R. ---1 22 l 3-60"Al 1(:onsnEne r Advisory Prated for (Ascaullption of Anus Fs& 'Ifas, ire Raw, Undsroxokcd oi -31)il.. I x T Ew ,z,,A Fgs subsuiary fol Rriv, Shelf SPECIAL REOUIREMENTS Vio!uiinl7 of Soctmn 5`)O, W(A)-(Il} in cafcrinsi. mobilc flxxL tenipi tat y and rulodent'al kitchen operations; shoklld be 1 (whined under tile apropriale, neclloriS aBove if relateid to fi-sodhorne illness intcavztltions and risk factors, Other I 590,(V) violations relatmL) f(i 000xi rctld! practices Aicaild he debited under #29 - splxjal IteOuirealent (Iterus 23-39) critfcal'Ied non, 'oval viol mwns, which do neo l rebate to the foodborne iliness ififo vew;vlcs and fiskjactors lisiod (,oi be fulf"d in OleP i(oilon � i , serlioro o Me Food Code and 105 (14R LOW, __._()I___._. 4 1 "F[45'F Within .' Hours, 3 Cclolin, Method,, for 111417s ig PHF Hot and Cold Holding Cl�ddl�Tifl , S Mnint,(Med at Of IXAOW 590 3-59)1 t flt A.) fill PH} � Maintained at or above 14("T" Roasts 1 -told at or above 130°FC 0 1 Time ne a Public Health Control I II3-X61.19'fin'19 x as a Public Health Control' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS {HSR) 3,01.11(A) Uripstem'Qed Pl`C-paC1'aged Juices anjill S -J-111(13) -T-�T(- _8d, 1)) or Pal mik; Ox*d Aminal Fix)d dad Not Served.;' P-11 1-1- k- R. ---1 22 l 3-60"Al 1(:onsnEne r Advisory Prated for (Ascaullption of Anus Fs& 'Ifas, ire Raw, Undsroxokcd oi -31)il.. I x T Ew ,z,,A Fgs subsuiary fol Rriv, Shelf SPECIAL REOUIREMENTS Vio!uiinl7 of Soctmn 5`)O, W(A)-(Il} in cafcrinsi. mobilc flxxL tenipi tat y and rulodent'al kitchen operations; shoklld be 1 (whined under tile apropriale, neclloriS aBove if relateid to fi-sodhorne illness intcavztltions and risk factors, Other I 590,(V) violations relatmL) f(i 000xi rctld! practices Aicaild he debited under #29 - splxjal IteOuirealent (Iterus 23-39) critfcal'Ied non, 'oval viol mwns, which do neo l rebate to the foodborne iliness ififo vew;vlcs and fiskjactors lisiod (,oi be fulf"d in OleP i(oilon � i , serlioro o Me Food Code and 105 (14R LOW, Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name II e ©�C �. Date i Tvoe of Operations) Tvpe of Inspection ❑Routine ❑t Re -inspection Previous Inspection Date: ❑ Pre- Aeration ❑ Suspect Illness ❑ General Complaint HACCP El Other ©- Food Service ❑ Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address SSFxI Risk r Level TelephoneS 6 S Owner M (2i (( SSG C ra%, -r 4-e,,641 Cl -b HACCP V7/ -N- Person in Charge (PIC) Inspector `) 4septl ) Time InEl . �'r� ay 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 MANAGEMENTa.�,„, „, ,- E]1. PIC Assigned / Knowledgeable / Duties 'EMPLOYEE HEALTH ❑2. Reporting of Diseases by Food Employee and PIC ❑ 3.. Personnel with Infections Restricted/Excluded to FOOD FROM APPROVED SOURCE „„�....,' ?^,„,a, ❑ 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: " ci is x( ❑ 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. CL'N1 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: 5901nspecfFom,E i4 Ox >✓1 � n ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities °'PROTECTIpN fROM L`HEMICALS "'"' �°` f [114. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEifEMPCRATURE CONTROLS (Potemialty Hazardous Foods) 1,� " ak ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control rREOUIREMENTSFORHIGHLY SUSCEPTIBLE POPULATIONS(HS0j "--,`s ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY"-,�- ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: n Inspector's Signature: ,\ / / / Print: PIC's Signature: �.� Print: bA ' A I \ 4vl 5 Page oO-�� Pages of Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT '1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of 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 feral 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 Drmkin Water* Applicant To Report To The Person In Drinking Water from an A roved S stem* 590.006(A) Charge' 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(F,) Removal of Exclusions and Restrictions in in FOOD FROM APPROVED SOURCE w Denotes, critical item in the federal 1999 Fond Code or 105 CMR 590.000. rOTOTTOTIMOM17"MM "0 $ Food and Water From Regulated Sources '.. 590.004(A -B) Compliance with Food Law*' 3-201.12 Food in a Hermetically Scaled Container* 3-201.13 Fluid Milk and Milk Products* 3-202.1.3 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drmkin Water* 5-101.11 Drinking Water from an A roved S stem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.04` Washin Fruits and Vegetables ShelBish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authodt 3-202.18 Shellstock Identification Present* 590,004(0) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11. - PHFs Received at Proper Temperatures* 3-202.'15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records; Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(1) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxygen packa 'ng, criteria* 8-103.12 Conformance with A roved I§ocedures* w Denotes, critical item in the federal 1999 Fond Code or 105 CMR 590.000. rOTOTTOTIMOM17"MM "0 $ Cross -contamination 3-302.11(A)(]) - Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients - 3-302.11(A)(2) Raw Amnud Foods Separated from Each Other* Contamination from the Environment 3-302.1.1(A) - Food Protection* 3-302.15 Washin Fruits and Vegetables 3-304.11. Food Contac with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111. Manual Warewashing - Hot Water Sanitization'rem eratures* - 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem eratures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. '� 4-601.1 [(A) Equipment Foal Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11. Clean Condition - Hands and Arms* 2-301-12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-40LI 1 Eatin , Drinking or Usin Tobacco"' 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting' 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em to ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacifies* 5-204.1.1 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 CITY OF SALEM BOARD OF HEALTH Establishment Name:_ Date: S&IJ,>v L9 Page:_ of :Z) Item Code `Reference C - Critical Item R-RedItem ,rf .N. n DESCRIPTION OF VIOLATION ! KLAN OF CORRECTION 3.r,/�. ,..= 4' ""ts�" `:w* �.,3;r ., �,,.. -,. . ,-_ r ,g„ +#1-0;Ns a Xi$ �z aAd�ii,.,.,. .VIlPLEASE. PRINT CLEARLY''t;�„ Date Verrfied .Rt IvXv.n:�: nN �.f ..I i -1A Sb) I [Y D ofcr O/-er� ^l4—(cl; + !� gni A. 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/FedeRl Food Code. I understand that noncompliance may result in daily fines of tw my five -d liars 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 0 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cant.) PROTECTION FROM CHEM 14 F '. Food or 3-10114 Protection from Unapprmed Additive,* —7 -poisonous or Toxic Substances .7 1() 1 . I I ldcwhong Infornialion - Original olnaiircls" 102.1'1 CorrmastNarne Wkwkir.,,Convunqrs' 772h, FPce and Lkt' x Sim tz, - 202.11 Re'striction - llre 7,20111 1 Toxic 7-204,14 ?-205. I I UNITeII, — V Criteria 7e, a- Criteria" Caoict. I ura;cans" 7-200.12 Rodent Bot sroions* 7 206,13 1 Tracking Powderi, Pest Control ond TIME/TEMPERATURE CONTROLS I Proper Cooking Temperatures 3-10LI1 k(l)(2) I F.gtpi- 155'F 15 Sac. 3-40IJUA7(12) Contolinuted Fisle Mews & Game Amraak - l-5,I`F Is sec. 3.401A I(B)d n2) Pork and Ii ed Roast - I 30T 12-1-r, 3-401A Ratites, laiecrea Meats IS 71 -ZFI i TIAY Pourlry. W"MTanx, Stntied Ptifs Sniffing Cortramov Fish, Meat, Pouhry tar Rotacs. 1651 15 sec. 711�1 —11� Intact BeIl Steaks 145f'T I' -1�a, ArvW Frx,& Cooked In a 3 Z01 12 Miewwavc T401 llt,�)(17)b) Other 1�[jF, 3-103A I f,k),ND) IIHI-N 16511-- 1-fI sec. * -;M171 ow-aw 1 —0 1 F -nu-11 Stand ng T-403. �i 3-403.1 )(C) COnUreftlatlY RTF Frxet - 3-403.1 Kit I Rcinawire, Unt4ired Portions, of Beef 3-501.14(A Ctviiag Cooked PHrs from 14)'f- to 70'T' Within 2 Hours and f"I"Offt 7W1 [o 4 J'J�/45`F Within I Hours, e 37-5)1 146) . adint; IIHFN Made From Ambient Temperature lng;cdicnts to 41`F/45` F TNT,V'1111'M1t111'�1i n 4 flmra r Den(Aff criticli Jann in If,,, I , "dMO lI,'1)QJ`oIxICode w 105 CM14i2 54t) U£i9. 1 3-501 INCj PffFs Received at Temperatures According to Law Cooled III 715 � 5fin, Melh;sdS for I'llf's PRF Plot and Cold Holding Cold PHFs Maintained at or below 41—ids" F- I& A) 11111Mainnuned at or above 140'F 3-5011h(A) Roasts Hod at or above 130,F. as a Public Health Control Variance REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATiONS, (HS iL�-- 21 ad pre-pactaged juices and 3-80 1. 11 (B) I tis of Pastela T—17- — lj)I Ram or Paitialb, CIK)ked Amaral rood and Raw Sr(td Sproat,% Not Sei vcl 3 -WI I J(Co noocned Foxi Packafx Not Re -served. CONSUMER ADVISORY T J—Ptirn 12 F k of 1 onsumer Affvisory Posted for Cowen Ainuml FoodThat are Raw. Underotxilred oi Not Otlwm ise Processed III I-In"Ineve 1, "M), 3-302.13 Pzs,eupved FgttsSubsInole lot Raw Shelf SPECIAL REQUIREMENTS 590.009(A) -,DI Violafirw)� cif Section 590.0054A) -fl)) in ealcrvlgmobile fix)d, telyllaraly and reridennat kitchen operations should be I del-Ined undrei the appropriatew�:, ions above it' related to foodborne illness niter ventions and risk factors. Wer 5Q0.009 violations relatink, to good retail practiccs Aiould be debited under #29 - spCe"mi RtajnhvTuCI&, VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Ctlzirwl on,w! I101'alldn,5, which do not relate ;o Me ,foodborne, rs!roev< iIu,1rveftI;&ns and risk frictors hot.d above, can be found in!hefiolfm ingsertiom oft w Food Gore and 10 C44R 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 NameDate, f Tvpa of 0 eration(s) Tvpe of Inspection ( _ 0 [/]Food Service Routine H`Re-inspection Address Rik (❑'Retail 2 Level ❑ Residential Kitchen ❑ Mobile Previous Inspection Date: / Telephone _ El Temporary �� ❑Pre-operatlon� Owner HACCP YM ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ElGeneral Complaint Person in Chbirge (PIC) Time In: El Inspector Out; , ��- Permit No. El Other Each violatibfii checked requires an bxplanation on the narrative pa6ejs) 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 �, .,�„i.��„-',y�..,eZM„.� !„ „°, ❑ 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 c . C 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. . G, :, 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.o07) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 41 30. Other S. 5801nspxtFam6-14.do n -n n t2. Prevention of Contamination from Hands 3. Handwash Facilities PROTECTION FROM CHEMICALS , ❑ 14. Approved Food or Color Additives yl 5. Toxic Chemicals r �TtMElTEMPERATURE CONTROLS (Pbientially Hazardous Footle) p �' . __z w;�,e El 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling E) 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control (REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)T1 ❑ 21. Food and Food Preparation for HSP 1: CONSUMER,ADVISORY„"`F'a ,,. _� ,,`•:'"�o�,�,.,;�vx�, �. ,,:.�,;u° E .IiF ❑ 22. Posting of Consumer Advisories Ii 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: MCA/ dA/ -00q Inspector's Signature: I / Print: PIC's Signature: Print: I Page of Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) I Assignment of Resonsibility* 590.003(Bl Demonstration of Knowledge* 2-103.1-1 Person in charge - duties EMPLOYEE HEALTH 2 590kW(C) Responsibility of the person in charge to Com rliance with Food Law* 3-201.1,2 require reporting by food employees and 3-20113 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Foud Employee Or An 3-202.16 ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an A roved S stem* 590.006(A) Charge* 590.006(33) 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 Restrictions 4 in C FOOD FROM APPROVED SOURCE *' Denotes critical item in the federal 1999 Food Code or 105 CNIR 590A00. �y PROTECTION FROM CONTAMINATION 8 Food and Water From Regulated Sources' 590.004(A -B) Com rliance with Food Law* 3-201.1,2 Food in a Hermetically Sealed Container* 3-20113 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* 5-101.1.1 Drinking Water from an A roved S stem* 590.006(A) Bottled Drinking Water* 590.006(33) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreaponally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201..1.7 Game Animate 3-701,11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-40111 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(J) Labeling of ingredients' Frequency of Sanifization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialize Processin Methods* 3-502.12 Reduced ax en sacka 'ng. criteria* 8-103.12 Conformance with A. roved Procedures* *' Denotes critical item in the federal 1999 Food Code or 105 CNIR 590A00. �y PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.1](A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1l(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.1.1(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 Confaminated Food 3-701,11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitisation Temperatures, - 4-501.112 Mechanical Warewashing- Hot Water Sutitization Tem eratutes* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601,11(A) Equipment Food Contact Surfaces and Utensils Cleats* 4-602.11 Cleaning Frequency of Equipment Foad- Contact Surfaces and Utensils* 4-7021 1. Frequency of Sanifization 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 Anus* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eahn , Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* i2 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* acities* 5-2(AAl Location and Piaeernent* 5-205.11 Accessibility, O oration and Maintenance Supplied with Soap and Rand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.1.2 Hand Drving Provision Establishment Name: the V CITY OF SALEM BOARD OF HEALTH Page: oZ of _— Date:"5 1t-7 (1)a Item t ;No Code _ '�' .. Reference C - Critical Item ..,,. R—RedItemze. �" DESCRIPTION OF VIOLATION /PLAN OF CORRECTION .' ,, x h ':�.. „rq.:.. ,. s. •r,.= :� a „..�� o,... ,� m .�r '<i '`"�c y"q,w ...r �K ,.., ?`; �%', %,;, ,k-.'"` e, a I `� Date .; Verified ,,, �5' - whyr� s , +r,= ..PLEASE PRINT CLEARLY �r - 4 • ,.` L�1, /Ntt , ? o(o/l r -I Ilt cz" Y\ C \ t � ig 4A y- .1—(. Juo Qs GeL t-rn �i ;�S �( ✓ ,C' M t ( , ( if r i r. ^ r c,D l G oxe %.n f; eLP �ta—r Cv.n J :Z�. —4 r v wr ll n 4s % I (or to cG o rf r f , 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 ❑ oluntary Compliance ❑ Employee Restriction Exclusion violations before the next insll to observe all conditions as described, and to P Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty -fie dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: \ � Li, -501 W(C) NiFs Received at'remperatures Violations Relaud to Foodborne illness interventions and Risk ACCOI(fiag to Lain Cooled to Factors (Items 1-22) (Cont.) I T/45" F Within I Hours, 3-501 15 Colllia,, t4ellrods for PffFs PROTECTION FROM CHEMICALS PHF Hot and Coid Holding 14 00 or Color I yes old Fiffs Maintained ator b -low, 3-20212 Addiam-,,* 4P/45"F' 2222 I bli VlfF" Marnalumal at or above- 30114 Plotection —3�0 1, 16(A) '15 Poisonous or Toxic Substances 7 10111 1 1 identifying t"tolunoon tlu n d is Held a, or Rabove 13W`F. coruallleo,- .. . ..... — Time as a Public Health Control 7-102,11 Common Naala--- IL 20 ---- 3,501 19 1 7-201. 11 S P-20111 Rc,qriculip - Pre circe and Use" 7210111'2 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7,203,11 Toxic coluaftatiir — Prollifsuions� POPULATIONS (HSfl 72204 11 Sanur/tv,,Tri'i n., - fenarca's — 21_,-811 lA) Unpaniturued Pie-pacfaged Juice,%, ,nd 7 �041 2 Chemicals for Wwfulal, tlo)ducc, Croio-W 14 viulz Axuitl�. Criteria'f 204 -PL— L— 80l 11(lx* lax 1st Pastas !zed I s' i-201,11 hiciricautil Flaxi Contact, I urricants' 1-� — 7-2200 11 Remoedt,'w Pe�boule�', Critenn' 2, -1-406.12 1 ReKlisto bad Station" --- L3 I l'(Lj,) -1 �Ioane(—'T atc€ Packapr� fiat Re served_ ". ? �206 1 Tracking Poaderi, P-'st Control and TIME(TEMPERATURE CONTROLS I Proper Cooking Temperatures for 3-40111 A(l)(1,i Iy- 15"5"F i 5 SX. �mwediatc Scrvrce 15'Fl5secl Comicinuarl Fisfk,.Mltiau & Uamc Animals- 151"F 15 sec.'s Poik aDd Bt�ef Roast - 130'F 121 minT4,T) :ITC�) 27) ftatites, lmecl^d NRAvs - 155'F 15 461.11(A)(3) Poultry, Wild Came, Stu fedFiriir�s Stuffing CoulainuiL I , Fish. I&T.-ai, poultry or katites- 165"F , IS wa. 3-401.11 f Whok-muscre, Intact beef Steaks (451; 340 1. 12CookedImunal Fo,,dr Cooked in a -- — -- I Nlicn,)wave 16.S'F - 3-401 5(T��I)(Jra ki! other PRE 14,517 15 sec. Reheating for Hot Holding TTOTI I (A) &-if)) Pfll-i 165'T IJ wc, 3-4}3.1J(B) Microwave 165' F 11 Nlinure Skandin.,, 140'P 3-403.1 Remaijurr, unsficed Portions of fleet. Proper Cooling of PHFS TW 14(A) Coaling Cookcit PHI -',s [ram 140-F to 70`F Within 2 Hours and From 70 17 n, 41'F/45'P Within 4 Honm � 501.14(B) Cooliag, PHP,, Made Front Ambient Templtratkire Ingredients to 41 °F/45"F Within 4 ll<cmr I Den"tea craical u0m ill 6h" fo'llaal 1999 Foal Ggle or 105 0MR 590 00(L CONSUMER ADVISORY 2222 C(,nsuinet Animal FIKA, Thar ale Raw, Under")kod vi %!la Odler� i. -W it) Ellminate Paifira'cus'4 - - ---Fge S — l s—uWe I'll —Raw S --lb nL* SPECIAL REQUIREMENTS —590,0-09(A)Tr))--r1 —vi-01all-i—on, CT-S'e—ctlon -(D) in carcring, mobile foval, temporary and resider al kitchen Operations Should 1%-, calluted wider the appropriate sections above if ichued to foodhorne illness interventions and -isk factors, Offier 590.009 violations relaerri� to good retail pstroices should he debited under #29 - Special Requirements, VIOLATIONS RELATED TO GOOD RETAIL PRACTICES {iters 23-30) C' zilral "ut"I non-, riii'ac viol"&ort'r, alrich do nii; rebore to lite fioodborne ilinelsi ilaery rations and riA-jacrors livildabove (vrl be troutuf in thefollortntl ze, tiom oulte Fleal Code ewd 105 ('MR 'a)0,000, Establishment Name: CITY OF SALEM BOARD OF HEALTH Date: L-4- /,0 Page: � of 14 Item Code C 7 Critical Item 114�;, " ��'M - "DESCRIPTION OF VIOLATION/PLAN OF CORRECTION 4 n,�� 6 '4 _i? �O' 'Date - �Verlfied N Reference f! Red Item PLEASE PRINT CLEARLXY"x ...... --n AJc5rKiqeA Ckmilrs=,5 f4,!40,0 A)n 0 Ai. be/ C71 c9T 14,0,n .2 1 �7 �n 1) A &/ W7, A, 4 F 7 j',^ \tp� Jil J fA )iof� 4 sin11 7 Discussion With Person in Charge: Corrective Action Required: L:l No Yes I have read this report, have had the opportunity to ask questions and agree to correct all 0 Voluntary Compliance 0 Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to Re -inspection Scheduled L) Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I uhder�ta'nd that noncompliance may result in daily fines of t\w" t y- iv dollars, suspension/revocation of Lj Embargo U Emergency Closure your food permit. U VoluntaryDisposal U Other, F llfiFs �Recviv,�Ta17r"'W'iuureT Violations Related to Foodborne fitness Interventions son Risk Acca dint to Law Cooled ul lio L Is Ce0u), Mefluo& for Ill fF, PROTECTION FROM CHEMICALS f--- j-47�e;od W®r Color Additntes I9 PHF Hot and Cold Holding 1i SIL16FB) void PHI s Maintained at cir below itic) 0(Wf41!45` F* —3O2t4— rotectiOn 3 501 t(7, A) I I(A VIIFa Maintained at or above IT Poisonous or Toxic Substances 7 101.1-1 identitykriginfiinnalion Orilclla' 40F. 13o F. Containers, (A) Held at or abov, L20 I Time as a Public Health Control 771 T2 I 1 1 Common 'th ,Dtl'ifav as a Public lie2 L7.20 L I I auLtion - Slo�lwel _ _E11-- a um� �olrcnlel 590�00`4(li) Varian 7-202.11 Reqtiction - aud ljel 7 2:172 Condo (if ljso� REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 -?03 . [I Toxic Cillairloo, - f1mbibi:iou POPULATIONS -F204 11 Saiin,7ers' crocria - chelnic'ls�-7- 204.12 --ftHp�— IF-Ti —11-80 —1 (Ai klnpo�urif�d —julctswid 20T 12 Chelilicali, for Wast , Criteria, t U'' -L' L)q-, 7-104 14L of Pil,temized LL-v,* 7-205J1W, hicidlaal I-kiod Contici, I'luircants, ---- T- '!- I i I (D) RalvoR rumill,,Crx)kc d, Rio iriidandl 7-206 11 -- ZlvT,0oi I se Pe iteala- tRav, )r,) I amNot Sove& 1 Rodent Bait Starwq,�' E1�8011 -j(( _rrer d F tnet Not Re sry eed, 720611 rracktns, PoivdPestri� P�Conti of and 1�orutlii`in-' CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 11 22 3 1 11 onsuuler ldy;Sor% Posied fiwColloillaptiern of Aahnni Ficsis'llge are Raw. Lhlder"x)1wd or 16 Proper Cooking Temperatures for PHFs Net "-nhtru ise Prcwessed to Elinin-liac 3-4#}1.7 1 Aq 1)( F.g&s- 155 = 15 lrnn)ediaw 4erviuc I "'T'Iff 5clec Sahsfitot= for Raw sii'-11-1 7— 3-40ITI iA7(21 0yunintatcl Fi,* Nleal', & Ccime Anineds - 155,17 1 scc. - SPECIAL REQUIREMENTS 3-101 J Pcliti and Patel Roast -13011 130111- 121 lfti!j*j I - 590.009(A) -j)) Vioiiiyiins (it Section 590A09(A)-(D) in 1-401.11' ,A)t 2) Raiiee � hijeciod Ndvals 155 3F I sec..caY, rine, nlobik fixid, tempuras v a lid T461-IFA)(1) llolflfry' Wild Fiuw, $h tomdvio:al kitchen operations should be sluffillf, Cont tion Fish. Meal, f debited under the appropriate sectiorh; -L'ou Ltr�Lyl! Ratites 5"F t5 sec. I above if related to fixAborne illness 3-401 11 t —C) i 1) 'Whole-aill"de. orao ovof Sleaks, inteiventiong and risk factors Met 145'T 590.009 violations relating to good r(,,1aJ1 3--,l0JJ2 Raw Animal I"oid% CtK&W in a prat rices ,should be debited under #29 - Miclowave W5 T j Requireiwmts' 3 -ZT I I �A (�b) AliChhei7P111--y - 14 Y' F 15 sec. 17 Rebemmg for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 7-- I(A)&-fD) PHF, 165`r i ,CG. 1 ----4 (Items 23-30) 403.I1(B) Miciowave- 165 F 2 NlbauStanding i CiW-wlat?ci noli-c ramal viotvwm, which do nal cehire lo;he Itnle" i foodborne i1filers mlcev,nlioirsand rikjnewrs Imed ahove, con be cominelcially Piwessed RIE, F'Xid - 'found in Me Food Code mud 105 CUR 3-40:3.1 I(E) I Renaaming Unshced Portions Fg{I Proper Cooling at PHFs Coolext PHFs from 140'F it) 7W1 Within 2 Hours and From 70q' 1-1 T(BT-- to, to 4PF/45' F Within 4 Hours, - (1 -ooliva PHFs Made From Ambicat I I Terrf)a f aLkna! Gagredients to 4101,/45'-F Within 44 llouf,0 mural herr,-5n the folk-lral 1994 Ford Cr�e,r 105 CXIR 596 000 11 CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: 7 c-'J(Page: A of Item No 7 Reference 4; `Reference, C —Critical itemDate I R —Red d Item 0A A DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION '4 k CLEARLY t PLEA CL f SE PRINT Verified r ap 17, J C � 4, Hy /4-. C�nf�4or ,;7 _610r� 1. 0Pi k LZ ro 4 la! rj L *ok M A X I - I I lAekPI-1 Ca, I)C 4- 4iA7,a,-, e5 J), tAp" 61 A 4-)kAna,7JZ��o J(c, 4Ar, ffA, ^_,p e, 4-- _,?-Afk b0o a(31-1 S///' fzu I C' Q40 jz ied ,1 C)V,))" 6 yz-- '�tA A r, lk�z iAt4�7.: VCKWP�'�'� A)O,CLj 64:: 71, 1 11 r 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 t�five-dollars or susp.. ension/revocatioof noncompliance may result in daily fines of twen, your food permit. Corrective Action Required: u No b Yes El Voluntary Compliance El Employee Restriction Exclusion d Re -inspection Scheduled Lj Emergency Suspension Embargo o Emergency Closure Li Voluntary Disposal El Other: r/� Violations Related to Foodborne fitness Interventions end Risk Factors (Ifenks 1-22) (Cont) 14 9M 3-302,14 Identifying hifokaunon - Original colletiller"', Common Cifte6a" 7-204,14 7-205.31_ 72312.11 Restriction - Presence: and 7-202.12 CQUAMOM Of USC' 7-20111 Toxic Contameil, - Probib -17-204.11 satudzers. criterw - Chcu Cifte6a" 7-204,14 7-205.31_ incidental FlxNJ Coninct, 7-20& 11 Rostric(ed L,w Ileticidel, Critei ia, 7-206.12 R(xiew Fait Snaiou�- 7-206, 13 Vnicking Pts[ Control atic 3-401.11 Eggs- 155 F 15 &,C. Proper Cooling of PHI's h,15'Fi5sec, 3.401.:1 Pu - Gana, ikocil I , h, Meats I Animals 15'51' I� st,. 3-401.11 (3)(I)i2) Pori, and Bect Ptsist 1301' 12 1 atin 3-401.11(A)(,) Ratites, lnnno,�dl Nicam - 155'F IS 4-61.1 ITA)(:T) tlktidtry, Wild Game, Stuffed PRFs, Sulffula Fish� Nfeat� :rkul2l liell ill polutry ol. Rattles 165-`1 Sec. T4071 (C)(3) Whole--mosde, Invialicef Steaks 1450F Z iiz 3-191.12 I R 6d, Foilkk CkKikcd iv a on 1651' I k 1� h, A 11 , ul—, 139-15- __ I jil,P I ter 3-403.11 (A), -i DI PHI-, 165' 1, 15 swi;, -4033 1 47 1 )3.11 Micro""", ln5�l r" 2 Mumno standing, 3-M3.1 I (C) Commercially Processed RTE FixPf ;-403,11 (E) I Rcinamin, I Proper Cooling of PHI's �1t4(A) Cooling CwkiA PRFs �(un 140'F to 70017 Within 2 Hour, and From ?iFF �T5701 14E) to 4 1`F/45'F Within 4 fhau,,, Ciloluiv PfIfr Made Front Ambient Temprawre bnjrinfieres to 41 -F/45`F Within 4 IhkkkrNs :rkul2l liell ill the ro,ik�,ml i9gk) F'ood C,Xle C�r 10-) ('MM 591) O(Xl M 1,)4(c) PHFs Received ,it Temperatures A(xordiag to LaH Cooled to I 41'1'/4.5-F Wifliml H(qus. * 3-501.16(b) Cold pliFs tilturitilifled at or Mow 590,00AW) 41�450F� Clot PHFs Maintained at or above 46T', 2-501 . it(A) Rwlai Held at or above 13001% Time as a Public Health Control S07 19 'fiMf.a 5100J)W(fi) var;M REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 21 3-801,11(1'i L,5)JIactcu!';aedI'ic-p;WI,,Igcd3i)ictsallci Revera�ms with Wakid;w Likba[;,* Raw Std Ui iop7eaed Fkxkd Paclalae Not Re -served. 22 360311 1 Aninol i lNid, Dial are Raw. Undenalikktd in Not Offivq v ise Pr(xoqsed is) Efirninaw PFi5teinri/ d F)7g, Sobstinliv for Raw ShOl 590.fH)9tA3 :O) Viokjwni; of Section 590.(X)9(A)-(17)Jo cateringmobilc itiml, unfriporwy and i rosidetWial kitchen operations Aiould be debited wider the appropriate 'rations xlxwe if related ill ftxx1bonw illness itutei: veil t;onl; and tisk filclors, Other 540.009 violatkinq relating to food retail arni shtkidd be debited under #29 - Spccial Rquirenlmts. {perils 23-30) Criri,wi and Pon-, rilPad rw!alioao ulTith do Pin rehin, to Me foodhorrie dinest intel, venliow and ri,%kJiu: lors lilled above. Can Go finind iki ukkejr,Ilokwng, se, tions n; rhe Fount Code and 10-5 CNIR Legend of the Pig.."....or as many of you have'asked, "Where did the name come from?" In Gloucestershire England, "The Old Spot" refers to the oldest pedigree of spotted pig in the world. Raised on mall family farms throughout England, they were fed mostly "whey" and apples dropped from trees, giving them the nicknames "cottage pig" or orchard pig". Truth be told - We just like the idea of a spotted pig! The Old Spot is chef Brenden Crocker's second restaurant. Taking over where the former McSwiggans left off you will still find that funky neighborhood vibe. Our staff and regulars are the friendliest in Salem, the beer is still cold and we think the food is better than ever. September marked our one year anniversary.. Thank you for a. great year. Stop in for lunch Wednesdaym Saturday or Dinner. 7 nights,a.week. We also serve Sunday Brunch with a smallburvery cool menu .....: everything from eggs benny, fried dough, fish.cakes & beans, scones and' clotted cream" to curry rice with veggies. Check out our window boards ,and Menu page for upcoming events, movies & live music schedule including Acoustic Sunday, House BandMondaysand BLUES on Thursdays! See you at the Pig........... the spotted Pigl li Nli X10 NQ NJ, No/ yi \li If/ �V %►i Ali �1> �1� Ali Ali �1_ Ali >1� Ali NI/ 'J/, I/ 71T il� i14 il� il� 7IC AN 71-* VIN it At i1, A� / t iA "R rh ilk il� /1� ilk i1C Ili Ali zli Ali. h Ali Nli Ali Ali Ali Nle �Ii N1i Ali Ali \11,' Ali Ali tele- \1i Ali "li Ali "IN il� il� ilA il*4 il% /IN. il� /IN 71N i1\ il\ ilN il. i1�.!1' 711 ilk 71r 711Z il. lam' Spotted Pig Stuff, \� Adult tee shirts 516.00 \� Kid tee shirts 512.00" ii'c Baseball caps 515.00 Bucket hats 515.00 Ili Ali zli Ali. h Ali Nli Ali Ali Ali Nle �Ii N1i Ali Ali \11,' Ali Ali tele- \1i Ali "li Ali "IN il� il� ilA il*4 il% /IN. il� /IN 71N i1\ il\ ilN il. i1�.!1' 711 ilk 71r 711Z il. lam' Appetizers & Salads 4 Onion Soup Pumpernickel crouton and melting Swiss $6.00 Old Spot Gam Chowder Potatoes, bacon, thyme and cream with chipotle oil & scallions $6.00 Pork and Black Bean Chili * Poblanos, tomatoes and beer, topped with, cheese, sour cream, scallions $6.50 Wings or Fingers * Hog or Chicken, plain or fiery buffalo sauce, celery & house made blue cheese dressing $7.50 Green Green Salad Field greens, green apple, spiced walnuts, shaved parmesan and balsamic vinaigrette $7.00 Blue Cheese Wedge Iceberg wedge draped with apple wood smoked bacon, house dressing, tomatoes and red onion $7.00 Mushroom Salad Sauteed portobellos, crimini, and buttons, over arugula, truffle vinaigrette & shaved parmesan $8.00 *All Salads available with grilled Chicken, Sirloin Tips, Grilled Shrimp or Portobellos — add $5.00 Toad in the Hole* Pork bangers baked in Yorkshire pudding with onion gravy $ 8.00 Ploughman's Lunch Bread, hardboiled Eggs, three cheeses, branston pickle, tomato, pate, green apple, cornichons, mustard and ham $12.00 Curried Chips With melted English cheddar and onion gravy $ 6.00 Sweet Potato Sizzler Crinkle cuts with cheddar, bacon, sour and scallions $ 9.00 * Consuming raw or undercooked food may cause food borne illness. * 18% Gratuity may be added to parties of 6 or more Sandwiches and Entrees Deluxe Cheese Burger* Lettuce, tomato, onion, bacon and sauce with chips & a pickle $9.00 Grilled Chicken Sandwich* Marinated breast, portobello, cheddar and chips $9.00 Slow Roasted Pork Sammie* Pulled and pressed with Dijonaisse, pickles and Swiss $8.00 Fried Haddock Sandwich Cheese, lettuce, tomato, pickle, tartar and fries $8.50 Old Spot meat Pie Guiness Stewed beef and Iamb layered with toasted corn and onion gravy, baked with mashed potatoes $14.00 Very Slow Roasted Pork Seasoned with sage & bay, bubble and squeak, house apple sauce $16.00 Fish & Chips Old Speckled Hen battered fresh haddock with chips, tartar, fresh lemon & malt vinegar $16.00 Breaded and Pan Fried Pork Chop* Homef ries and wow wow sauce $16.00 Grilled Stuff Grilled Garlic Sausage* $12.00 Grilled Sirloin Tips * $15.00 Grilled Turkey Tips * $13.00 Grilled Lamb Tips * $16.00 All Grilled Stuff get a choice: of Mashed Potato, Fries, Sweet Potato Fries or Salad and Pick a sauce: Chipotle BBO or Wow Wow Sauce Four Onion Soup - Nestled under a pumpernickel and Swiss sandwich 06.00 Gam Chowder -'Creamy clam broth with Potatoes. Bacon and thyme with crackers 06.00 Pork s Black Bean Chili - Poblanog, tomatoes s beer, topped w/cheese, sour cream s scallions 06.50 Grilled Sausage Dufour - Sweet s sour cabbage, coarse grained mustard and English cheddar. 07.00 Sweet Potato Sizzler - With bacon, sour cream and melting cheddar 09.00 Curried Chips - Regular fries with curry; cheddar, scallions 07.00 Mushroom Salad - SautCed mixed mushrooms, over baby arpgula and sweet truffle vinaigrette 08.00 Hog Wings Pork "wings" tossed in fiery buffalo sauce with celery s house made blue choose dressing 07.00 . Chicken Fingers or Chicken Wings - "Plain" or "Buffalo" With celery, carrots and house made blue cheese dressing 0 7.00 Ploughman's Lunch Bread, boiled eggs. 3 cheeses; pickled veggies, tomato, green apple and country pate 011.00 Blue Cheese Salad Iceberg wedge. apple wood smoked bacon: tomato and red onion 07.00 Add sirloin tips, grilled chicken, buffalo grilled chicken: or portobellos 05.00 Old Spot Green Green -Salad Field, greens, green apple, spiced walnuts, shaved parmosan and balsamic vinaigrette 07.00 .. Add sirloin tips, grilled chicken, buffalo grilled chicken, or portobellos.05.00 Deluxe Cheese Burger - Bacon, lettuce, tomato, onion, pickle, cheese, sauce and fries 08.50 Grilled Chicken Sandwich Marinated breast, ma9o. lettuce, tomato, onion and fries 08.50 Curry Chicken Salad Wrap - Greens. red onion; raisins and. English cheddar, in a flour tortilla 08.50 Fried Haddock Sandwich - Cheese, lettuce. tomato, onion, tartar and fries 08.50 Fish `n` Chips - Beer battered haddock with fries. tartar and mail vinegar 013.00 • Consuming raw or undercooked moats or fish may result in food borne illness • .78% Gratuity will bo addod to padios of six or Moro Breakfasty Entrees Hot Oatmeal - With apples, brown sugar, cinnamon maple syrup and cold cream $ 5.00 Organic Granola and Vanilla Yogurt- With fresh berries, honey and mint $ 5.00 Toad in the Hole*.- Pork bangers baked in Yorkshire pudding with onion gravy $8.00 Scottish Smoked Salmon* - Bagel with whipped cream cheese, dill, tomatoes, onions and capers $ 9.00 , Banonas.Foster Fried Dough - Sauteed bananas, rum and brown sugar with whipped cream and powdered. sugar $ 7.00 Eggs Benny Two poached eggs; grilled black forest ham, hollandaise. and English muffin $17.00 Big Omelet of the Day - With toast and home fries or cheddar floddie $10.00 Stuffed French Toast -With cream cheese, brown sugar and pecans with blueberry maple glaze and side bacon $ 9.00 Traditional French Toast With cinnamon maple syrup and side bacon $ 7.00 Steak and Eggs*- Sirloin tips with a petite cheddar omelet, toast and home fries $15.00 " Lunchy Entrees 4 Onion Soup - Pumpernickel crouton and melting Swiss $6.00 Old Spot Clam Chowder- Potatoes, bacon, thyme and cream with chipotle oil & scallions $ 6.00 Lamb Lollipops* - With minted pepper jelly $ 8.00 Deluxe Cheese Burger* - Lettuce, tomato, onion, bacon and sauce with chips & a pickle $ 9.00 Beer Battered Fish Sandwich* - Cheese, LTO, tartar sauce and lemon on droll served with fries $ 8.50 Slow Roasted Pork Sammie*- Pulled and pressed with Dijonaisse, pickles and Swiss, on marble rye with fries $ 8.00 . Warm Turkey Breast Sandwich - Cranberry glaze and melting brie on 7 grain bread $ 81.00 Grilled Marinated Sirloin Tips*- Fries and wow wow sauce $15.00 . ** Consuming, raw or undercooked seafood may cause food borne illness' Desserts Chocolate layer Cake With rum fudge sauce and whipped cream $ 7.00 Brownie Sundae Caramel and fudge sauce and vanilla ice cream, whipped cream and walnuts $ 6;00 Lemon Bars With raspberry coulis and fresh berries and dusted with powder sugar $ 6.00 Spotted Dick Bread pudding with whiskey sauce and vanilla ice cream $ 6.00 Cheese Cake 00f the day' ask your server for details $ 6.00 Alcohol Service Begins at, Noon Draft Beer, Sierra Nevada Pale Ale Harviestoun's Bitter &Twisted Anchor Liberty Ale I -PA Sam Adams Boston Ale Paulaner Hefeweizen Old Speckled Hen. Guinness Stout Bass Ale . Pabst Blue Ribbon Smithwick's Irish Ale - La Chouffe Saison Wachusetf Blueberry Berkshire Brewing Coffee Haus Harpoon Selection Stella Artois Black & Tan Shandie Bottle Beer Corona Amstel Lite Miller Lite' Miller High Life Mike's Hard Lemonade Strongbow English Cider Samuel Smith's Nut Brown Ale Samuel Smith's Old Pale Ale Left Hand Brewery's JuJu Ginger - Rogue Dead Guy Ale Saison Du Pont Farm Ale Orval Trappist Ale, Non Alcoholic Captain Eli's Root Beer Ginger Beer Sunday Specialties Bloody Mary - "the works" with our house made mary mix and celery stalk 7.00 Mimosa— what better way to,get get rid of the fuzzies, champagne& CIJ 8.50 Hot Toddy- we make ours with Jcimeson's, tea and honey with lemon 8.00 Hot Minty Chocolate - Swiss Miss and peppermint topped with whipped cream"8.50 Gobsmacked Cocktail— Brandy, triple.Sec and sour mix straight up with asugar rim 8.00 Thickety Boo— Crown Royal and Butterscotch Liquor shaken serve "up"8.50 Nancy Boy- Stoli Vanilla Vodka and White cacao with a drop of Bailey 8.50 Peach Knickers— Vodka, Peach Liquer, splash orange, splash cranberry on the rocks 7.00 Leaping Horse Cabernet Sauvignon, $6.50 Red Truck Cabernet Sauvignon $7.00-$27.00 Leaping Horse Merlot $6.50 Andrew Peace. Shiraz $7.00-$27.00 Grao Pascal Dao, Portugal $6.00-$23.00 Les Salices Pinot Noir $7.50-$29.00 White Wine . R Collection Chardonnay - $7.00-$27.00 Crane Lake Chardonnay $6.50-$25.00 Sterling Vineyards Sauvignon $6.50-$25.00 " Salvalai Pinot Grigio $6.00-$23.00 Casal Garcia Vihno Verde $6.00-$23.00 Leaping Horse White Zinfandel $6.00423.00 Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4'" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name[` y 1;1n Da e' Type of Operations) Type of Inspection Food Service ❑ Retail ❑ Routine 2 -Re -inspection . 1 %- /, Y1 i4- Address Q ' Risk (� Level ❑ Residential Kitchen ❑ Mobile Previous Inspection Date: Id (I 10-1 Telephone -%/ !f _ v ❑ Temporary ❑ Caterer ❑ Pre-operation ❑ Suspect Illness Owner } ( ' 1 'Q �� HACCP YM t/ 5 i) a , k I nnr Ke ( ❑ Bed & Breakfast ❑ General Complaint Person in Charge (PIC) Time In*, , ?� E]HACCP Inspector i7 f Out: l 2). Permit No. ❑Other Each violation chediedlrequi('es 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. �FOOb PROTECTION MANAGEMENT1„."` ❑ 1. PIC Assigned/ Knowledgeable / Duties 9°EMPLOYEE HEALTH r ❑�2 Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded tFOOD FROM APPROV,EOSOURCE 'y ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. aConformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION i ��1,pP i -U, .m ❑ u8. 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. 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) 1 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S, seaIrup Wom 14.6 n/)t--)/l ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities Food -, ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals s= TIMEfrEMPERATURE CONTROLS (Potentlally Haardous Fcwds} g ❑ 16. Cooking Temperatures ❑ 17. Reheating E118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control }; REQUIREMENTS FOR mdf iLY SOSCEPTIaL,E PQPULATtINJS (NSP) ❑ 21. Food and Food Preparation for HSP [CONSUMER AbVISORY]F' El 22. Posting of Consumer Advisories Y 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: � 3 � it z ' / n Inspector's Signature: \ u/ I / Print: PIC's Signature: l %� `�� -t:1"n (! C��I J()),? %IJV Paged of J Pages ✓ v V l Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility' 590.003(B) Demonstration of 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* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* _ Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In .Drinking Water from an A roved S stem* 590.006(A) Charge's 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 4 LN C I FOOD FROM APPROVED SOURCE .x Denotes critical item in the federal 1999 Food Cale or 105 CbIR 590.000. S Food and Water From Regulated Sources 590.004(A -B) Compliance with Food law* 3-201.1.2 Food in it Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.1.3 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 .Drinking Water from an A roved S stem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* WashinZ Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Iisted Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201..17 Game Animals* 3-701.11 Receiving/Condition 3-202.11, PIFs Received at Proper Temperatures* 3-202,15 Package Inteit'* 3-101.11 Food Safe and Unadulterated Tags/Records: Shelistoek 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(J) Labeling of ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures lHACCP Plans 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced ojjaen acka 'm�, eriteria* 8-103.12 1 Conformance with Approved Procedures* .x Denotes critical item in the federal 1999 Food Cale or 105 CbIR 590.000. S Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE FaAs* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Foci Protection* 3-302.15 WashinZ 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* F9- Food Contact Surfaces 4-501..1.11 Manual Warewashing - Hot Water Sanitization "rem ratures` - 4-501.112 Mechanical Warewashing- Hot Water SanitizadonTemperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601-11(A) Equipment Food Contact Surfaces and Utensils Clean - 4 -602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition- Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and - Mouth* 3-301.12 Preventin> Contamination When Tasting' 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Ent loyees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and 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 6-301.12 Hand Drying Provision CITY OF SALEM / BOARD OF HEALTH _/ I Establishment Name: 1 V h r) td�0 I T Date: Id- /I S I T Page: of Item No. Code Reference C — Critical Item R — Red Item s' "- DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - - l PLEASE PRINT CLEARLY. Date Verified L,i.. I to / f� ��.!nn 0.G � � ✓'P i -.�i ,rr,J rltl/ C 1/701- at 1--4 /,n 4? -E-J ^ IG . 14 C(00 n 014 l i Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all p pp Y 9 9 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. X -1� /i, �� / J r� ) �f X V (/ l (1 v Corrective Action Required: ,.'a ❑ No ltl Yes ❑ voluntary Compliance ❑ Employee(Restriction / �� Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: y Violations Related! to Foodbarrur Illness Interventions and Risk Factors (Itchts I -Zi) (Cont) PROTECTION FROM CHEMICALS i4 Food or Color Additives 3-2712 12 Addsme, 3_-30114Protection fvaa_j��- 15 7 f(IL11 WenofyinL Intoi, mat;loi - Originall 7-162.11 cournion'Nanw atJort -Storm 7-20111 Rr,,iqc ion - Presc 7-202,1=2 �,i ition", of Us,;* 7-203 [1 Toxic Cowforiei� - 7-204.11 ;,111117W•Toicml 7-204,12 Chingicais for Was 7 -245.1 1 Incidental Foi'A ("orract, Lubricants' -i-206.11 f6sf rc f�ad UL, I e s fi " des, C, ri to fvi 7-206J2 Rotlent Boa sfaloons� 72+06.13 'I lacking pctelder.�� Pts, Control and CONTROLS Cooking Temperatures for 3-401.).1 A(l)(2) Fgg.,- ,401.110a,)(2 Conamnuw t�t� & t7arn, Animals - 15,�'T' 15 st�c. 3 -4-01.1 1 1,B)( 13(2) lorTand BcTR ast ("1304, 121 nein' 3-410 1 11 (A)(2) Ratim,, hij . ceid Cleats - 1 55 F 15 Sec l' 461 11 (A), Ti Poultry, Wild Garife, SWred Pl-fFs', f sluffiliv C"filaming Hlsh. Meat, i,cmhrr�(Ir RatiteS-j65"T' ffi sec. 3-40 1.1 If C)(3) Intact f3l"cl' Storks '3-40E.32 za,ac --;�I Flxlrk, C co&,d ane Raw Nlicfo�.SSVC 165�f` 1-401 11 (A)(1)(b) Ali Othes PIJFs -- 145'F 15 see, Reheating for Hot Holding T -T- — -- TO - I I F)) PKFs Ifi- 5TTF Microwave- 165' F 2 lalmule &areiin Time'. T403 11 Commercirdly Processed RTE Huai - 140'F� 0� Rominin UaQrced Portions of lica�f R"ast"t 3-501,14(A) Crating PHF� from 14WF To ?W17 Within 2 Hours and From T)"I' 41'I'14YF Within 4 Hoots, Made Moot Ambient I s -561.14{B3 Coaling Temperature Ingredients to 41�F/45'F + Denotes critical item is the l,teral l4O9 Fotxl Code or 105 CNIR 596 EfOti 3-nklLll(fo Raw Or Partialiv Ctx)ked Animal Ford and LRtm sr(,d,SxtauLs Nut serwd 4701 IW,. -t...... p-,-1 22 Animal Focifis That art: Raw. Undercooked of Not Othefw ise Vrocegsed to Elimmulf. t 30 2 "t N Url/ed Fgjat 4tzbs6tulr fra PUV shell SPECIAL REQUIREMENTS HD) C Vittkincins of Section 54)0.(109(A) -(D) in catering, mohiLe "A, tempilroulp and icsidential kitchen operations should he debited under the appropriaresections abcve if related to foodborne ith)css interventions and risk factors. Olber 590.009 violations relating to 000d retail practices should be debited under .#29 - Specilal Requirements, (Items 23-30) clai,11 and non-"imcal vkitalioo, which (IV 'un relate fo the foodborne Illness unai'ventions tial KS4 Pews tivied al"olle, con be foutu" in the ft:,iloeing sVrfiorlv of the Food Code curd 105 041? Massachusetts Department of Public Health Div'sion of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name ._ .O j o h Date 1JR4 .' T of Ooeration(s) T e of Inspection /, M^Food Service ❑ Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast 'Permit No. ,- Routine Lu Re -inspection Previous Inspection Date�l/ ❑ Pre,operation ❑ Suspect Illness ❑ General Complaint ❑ Other Address Risk Level jQ0Telephone Owner %� p t �7 HACCP Y/N Person in Charge (PIC) Time In:[IHACCP Out:, �( Inspector Each violation checked'requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. rFOOD PROTECTION MANAGEMENT �'""" 7K` -j ❑ 1. PIC Assigned / Knowledgeable / Duties _ EMPLOYEE HEALTH _ a ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3.. Personnel with Infections Restricted/Excluded �`F06DFROMAPPRUVEDSOU PCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans 4 PROTECTION FROM CONTAPi11NiA N ; 0 - ❑ 8. Separation/ Segregation/ Protection , ❑ 9. Food Contact Surfaces Cleaning and Sanitizing � E] 90. 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. 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)(590.067) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S. sXIFa�,a.� n i 4 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECT10fi FROM CHEMICALS !; T ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals LTIMEiTEMPERATURE CONTROLS (Potentialiy Hazardous Ptstids) � ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ®a 9. Hot and Cold Holding ❑ 20. Time As a Public Health Control f._REOUIREMENT ' FOR t 1GHLY SUSCEP1.TI6LE -- LAMONS {HSP) [3 21. Food and Food Preparation for HSP ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions if _ and Risk Factors (Items 1-22): // I, 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: 1 Inspector's Signature: \ ( j o h PIC'sSignature: Print: fnncrn/ Jo)1 C Page\ of Pages, Violations Related to Foodborne Illness interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Rcsponsibili!L 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 3-20113 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(0) Reporting by Person in Charge* 3 1 590.(N)3(D) Exclusions and Restrictions* 3-201.15 590.003(F) Removal of Exclusions and Restrictions 4 C ''.V FOOD FROM APPROVED SOURCE * Denotas cri6ced hem in the federal 1999 Foal Code or 105 CM R 590.000. $ Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-20113 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Ea�s and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 3 10 CMR 22.0* WashinE Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock. Identification Present* -590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.1.1 Receiving/Condition 3-202.1.1 PIIFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated - Tags/Records: Shellstock 3-20118 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(1) Labeling of Ingredients` Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 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* * Denotas cri6ced hem in the federal 1999 Foal Code or 105 CM R 590.000. $ Cross -contamination 3-302.1.l(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) - Food Protection"` 3-30215 WashinE 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 3-701.1.1 Discarding or Reconditioning Unsafe Food' 9 Food Contact Surfaces 4-501.1.11. Manual Warewashing - Hot Water Sanifization Temperatures?' 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.11.4 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 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 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 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 Handwashing Cleanser, Availability 6-301.1.2 Hand D 'n Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: � I "' oo (=^30 Date: ti) �, /")� Page: 77'A_ of eem Code C - Critical nem x DESCRIPTION OF VIOLATION / PLAN OF CORRECTION �; Date No. Reference R Red Item z.✓,.. �. * (,"� . "� -» f PEASE Paiwr CL ARLY*_ `-' +--�. �_ f .„;�. `; Verified _qv. 1) 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. (� /I r_11'U z _11 Corrective �❑/ voluntary compliance \ Re -inspection Scheduled ❑ Embargo ❑ Voluntary Disposal Ic Yes ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: �"t�j viofatiana Refaced to Foodborne fitness Interventions and Risk Factors (item 1.22) (Cont) 14 Food or Color Additives 32012.12 A,16%e,,k T401.t1((-,)(3j _ 3-,30114 Protection from La rPproced Addrfzses",_ SS P� oisonous or Toxic Substances 3-404401.12 i-101.11 ;Identifying infortr tion--f3riginal :3-501. WA) �iaitt3i11e[5'r _ _ _1-4f1.11.(A.)([ab) 7-102.11 Campion Name - 1Vorkin £,untainers' 7-20111 Separation - r' 7.202.11 Restriction - Presence% and UNca - 3-403.11{A}k {ll} 7-202.12 -'ondilions(if Use' 3-403.13(B) 7-203.11 Toxic Containers -Prohibitions°` 7-2{14.11 -- Santuzcr G, C'Etter7!C`neiaicilti 7.204. d2 Chc.aut ids for W uhn�? #imdncc E aitznas, 7-2111.14 Dr ten cnte. Csats i t" _ 205.11 Incidental ! xx1 Contin �dubruants* j 11 7-1 ve Petrides- Crttett<t'' 726.12 Roden ft tt StauouO _ 7 206 13Tclekmb Prnvder5_ Pest Control and �I Monrtoain� �� TIME/TEMPERATURE CONTROLS 16 - --� Proper Cooking Temperatures for ,.. PHFs i<10LISAtt {'? l gg. 3>5`n 15 Sc. Inuued atc'Sxvicx. 1 45 l"]Ssec° 3-4-01.11.(>1)(2f Cttmelinuted f trh, Meats k Okun Arthritis- 155`F IS sec. 3-401.12 {B)o l j(2) Pork and B of lftmm 1304`121 mip' 3-401.11(4)(2) PKmteti In(ce_dMe.ats 155 3F15 3-401-11(A)(3) I Poultry, Wild Game, Stuffed PI -117s, i Sprffilu�cortaining f=ish, Meat. Poultry' Ratites -165'1^ 15 sec. T401.t1((-,)(3j 7bole-muscle, intaccl;cef steaks 590.004(Y) 145°P * 3-404401.12 Raw Anirrtal ho+xds Cooked it, a :3-501. WA) Mioowaw 165'Fx _ _ _1-4f1.11.(A.)([ab) All Other PHf"s-145°Pi5see _"� Reheating for Hot Holding 3-403.11{A}k {ll} PHFs 165'P 15 sec,." 3-403.13(B) 165" F2 Mnu;e. Standing; 3-403.11(0) Commercially Processed RTE Fex,6 - 140'F* .3-403.11 (E) _ Remaining Gnsliced Portions of Beef 590.004(Y) Roact�x 1-50 1 16(A) Proper Cooling of PHFS� :3-501. WA) Ccx>hng Cooked PHFs Eram 140"P to 7001: Within 2 ]iotas and From 70"T to 411745'F Within d Hews- 350t.t4{B} Cooling PHFsMideFromAmbiew femperamre ingredients to 41`F745'F `Benates c66CAl Itern in, rhe 12deml 1999 Food (`Ade or I Ofi CM 59() 900. I 3-501-14(G) PHFsReurved it Temperatures According to Lew Cooled to 2 t"GidR r, iF. H v, I W—.. c * 3-501. i 7 ' Coohn- Methods for PIFs �. PHF Hot and Gold Holding 2 401 16(S) void PHFs Manit,tiued at or bdow 590.004(Y) W/45" F* 1-50 1 16(A) fiot PHI s %faintateed at or above {AWP r Roosts Held at or above 130°F. Time as a Public Health Control Variance REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _ POPULATIONS {HSPS _ 3-801,11(A) i;nFa'teutir:,dPrcItat.i.agedJuicesand e-ROt 1-, nf.e, of Pa*teured s' 3-801. f I;L3) Raw or Partially Cooked Animal fool and _ _ ( Raw S d itris W'ot Set'yvd 3-ROl ! i lCi Furtooened Food Packaste Not. Re -served, CONSUMER ADVISORY t 2'' 3-6(}7 11 Cons-msr Ad Noac Pentad f'or Consninp nn of vtietrrl t xrd<'lhat tri Raw. Ende txx>kedo: Not Olherwise rw,,cessed to Eliminate I'=thorn c a��a :o' 3-303 13 1 ,stat rrrud F99, Subsottue lot Raw Sbell _ SPECIAL REQUIREMENTS _ 59WitC)90A) (D)—Tvtioi au rns oi`Sertion 590JW)9(A)-(D) in catering . mobile Lard, temporary and residetWat kitchen operations shotdd be debited under the appropriate sect above if related to fc>ndborne illness interventions and risk fags. Other 59{).009 violations relating to cxxi retail practices should be debited under #29 - Special Retlnirements, VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (items 23-30) Griwwi and non-critical v,ul rftaus. which do mu redatc ;o the Iocdborne tlInese in¢en+rntiorrs and nst-fasters li etcd Shove, earn irr fvund in the foifondrtg ser ions fft the Food Code mut )('5 CV,R 59(1.000, AS"o,e -2.0-e CITY OF SALEM BOARD OF HEALTH Establishment Name: )�C_ 01j Date: Page: 3, of -;!z Item i Code C -Critical Item -.4 1 �"'7�'— �V, DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date .No. Reference R - Red Item I & V Mid PLEASE PRINT CLEARLY - "I 7�� 6 f Yr 3Dd —49(-J"t 3 -9 Sys �4) k<p M,-. A 7)C -JJ( -,L, j 1 Discussion With Person in Charge: Corrective Action Required: LI No �b Yes I have read this report, have had the opportunity to ask questions and agree to correct all El Voluntary Compliance 0 Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to Re -inspection Scheduled Lj Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of Ll Embargo Ll Emergency Closure your foo permit. /' I L, voluntary Disposal Ll Other: Violations Related to Foodborne fitness Interventions and Risk Factors (list" 1-22) (Cont) 14 is M filiFs Received According, to Lav, Cooled to —.— 1— .......... 1 PHF Not and Gold Holding s0l Food or Color Additivesmeqo1 Itielit Cold PHF Maintained at or below 3-202,12 �5�lw)*)4('F)' 411/45�� F, i:5E 14 1"oteplion from UniL)-L)rl),ed �XddjlL�SsL 3 -50 L I 6(A) Hot PHF Madiraineel at or above Poisonous at Toxic Substances 1400F, '-101.1t Identifying latoslyallion - Original 3-561 j6(A) kolims Held at of above 130OF --- 0--l--- Time as a Public Health Control 7-102, 11 Couraron Name -- Workir, Containers* L Time as a Public Health Conos)V 19 7-1-01.11 S�piaauon - 7-202.11 Ragriction - Pi-eia:ncc and Le* 590,004(13) Valiance 7-202-t2 Condiu(n of t2 of Use REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-°03.11 Toxic Container,, - Probibvions* POPULA IONS (HSP /-204AT satl7p Chlawcak for Wash 21 1-80111(A) Uafemei rrizcd Pry -paclaged Juices and -1 7204,14 D LsirvAceLirs.. Criteria d 7-205,11 Incidental ofl`a,tourlz� 7-20(r IT— 70-11rided usv—lpeqicides. Gait -iia * 3-h()1. !I(f) ttov, or Cooked Amaral Rxid and m,Sood 1(2 `vat Served. S' 7,1'06.1i Rodent Bmt Stations __�p TIEK- 21a"P-lied 12-1d 7-206, 13 Flecking p"-st conlrol and CONSUMER ADVISORY TIMErrEMPERATURE CONTROLS 22 334)6:11 C(Asuirwr Ad�isi:ey Posted filrCdirt rulption of ��,tlliimll F-(4� llca lirc Raw. undercoulod errProper Cooking Temperatures for Proper PHFs N(A 01hem-i'se rlo,,cegsed!o Eliminate Eggs- 15-5'F 15 11 E Slihsinine ioi Rac, Shell Esas, muneiiaw Scivmr 145c"If l5see, —%leats & Gallic, -antro als - 1-55"F 15 Sec. Pc')(k and I'leol Roast - 130"F 123 rnin* 7,40 SPECIAL REQUIREMENTS 3-40 1. 11 (A)(Pi 590,00f)(A)-(D) Violulions of Section 590.009(A)-(7)Jn Svc. catering, mobilc. foiKl, ternpixary and 3-4(;Tfl(A)i3) po"Itr) , Wild Game, Sturfed PRFs, lr"WcuVal kitchen operations should be Solffina Containing Fish, Main, debited wider the appropriate sections llowiry or Pilvies-105'F I5,v,%. above if related to fk)odhk)rnc illness 7 inutaventions laid risk factors. Othff 401 11 (47)1_3, s/hoic mo,�ic, Innact Fleef Steaks 1 145'F—r590,009 violations relatingrelatingto 'good retail 401 i2ii—,,,5mrw i—,,Z —c,,,k7,d —m piawficcs 11mai3d be debited under/129- --- ____j Miciowave lo.S'F Spacial Requirements, 3-401 1 H�i(lsbi I All OffiLiTilF, -- t,7T I, I--, sec. .1 3-103,11(A)&it)) I PHF, 165'F 15 set:. '° 4403.11(B) Microwave- 165 F 2 Minut, Standing 13rae, allv provessed RTE Food 103 11 (C) coroverci 14WI-il fleamillia" I"lislaed Portions of Beef I 3-501,14(A Coaling, C(iolied 1"Iffs from 140°F to 70"F Within 2 Ifourg and From '10'1' to 41'F/45`F Within 4 Roam, I b501.14W Cooling PHRMade Front Ambient Temperature Ingrc(ficiaq to 4?F/45'F Within 4 HElirrs Denotes critical imin in lh: lederai N(a) Food ClAe c,r 165 CMR 590 (JO(L (items 23-30) Cii&,sa fmd non, rigicai tin tai;cilia, which do last relao, in the l'oodborne iib is ini&i vcnrions-and r kjca fors 1led above, (on be 1[vand ill ihcfoll.)iwpig ser oklris sf fhe Food Code and 10,5 (.,WR 41 . Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/08/2008 ESTABLISHMENT NAME: File Number: BHF -2006-000052 IGmbefley Driscoll Mayor The Old Spot 121 Essex Street SALEM MA 01970 LOCATED AT: 0121 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2008-0320 Jan 7, 2008 Dec 31, 2008 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31, 2008 Board of Health -b 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 13 of 14 KIMBERLEY DRISCOLL MAYOR JOANNE SOOTT, HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"' FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 ISCOTT(@SALEM. COM R CFQVED DEC 3 - 2007 CITY OF SALEM BOARS OF HATH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1 kL 014 6SIL64- TEL # g7fs- 7` c;- 570.S-ZP ADDRESS OF ESTABLISHMENT l7 I asfX ShZC SLI /_ m FAX # MAILING ADDRESS (if different) EMAIL -Business': (,r-OGVe/Jule D COmc&s+ —I e%— Website:-W-e0)J,�V64-- Cowl OWNER'S NAME Mi lA 5561 QrrL('b i TEL# G2fs 92-7- ADDRESS STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) I V I J (n 55 L orr✓i 1 h t CERTIFICATE#(S) 50 1'-7 391 (Required in an establishment where potentially hazardous food is prepared) W1 /� EMERGENCY RESPONSE PERSON 3fty,J.e., ( tZlOk er HGME-TEL # 97 231 - 28 `L0 DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunda Please write in time of day. 1 5-1 AM 5-1,9 (For example 11 am-11pm) TYPE OF ESTABLISHMENT RETAIL STORE YES Nd --- - ----- - - ..... RESTAURANT YE NO ,Outdoor Stationary Food Cart $21 - - ..--... BED/BREAKFAST/ YES NO CHILDCARE SERVICES --------------------------------------- ADDITIONAL PERMITS II4b-IAM 1f'30—[Am 111,36— 14M, ,IO -161'1 MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) FEE (check onl less than I000sq.ft. =$ 70 1000-10,000scift =$280 more than 10,000scift =$420 ------------------------------- less than 25 seats ...--....--- =$140 25-99 seats 280 more than 99 seats =$420 .........._._--------------------- $100 . ........................... ..........- YES $25 YES $1313 5 YES 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 fled all state tax returns aP paid all sta a taxes regwred under the law. t t [2`I /0.1 Social Security or Federal Identification -------------------------------------------------------- -----� --- -- ---------- --- ------------------------------- Revised 4/24/07 FOODAP2008.adm Check# & Datc — $ 0121 Essex Street Telephone: (978) 745-5656 Owner: Milissa Oraibi & Brenden Cr j PIC: Camie Murphy Inspector: John Gehan Date Inspected: Correct By: 2/28/2007 Risk Level: l Permit Number: BHP -2007-0215 Status: # of Critical Violations: Time IN: 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) N The Old Spot City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact "Surfaces Cleaning and Sanitizing -Comment: No sanitizer available at time of inspection. FAIL Critical RED Sanitizer with proper ppm to be readily available at each work station. utting boards stained and scored. Resurface or replace cutting boards. Handwash F cilities FAIL Critical RED Coommm�ent: Mens restroom missing handwash sign. Provide sign. Han di missing handwash sign. Provide signs. it_f( then hand wash sinks are reading over 150°F. Sink temperatures to be between 110°-130°F. Adjust sinks accordingly. 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 28,2007 ) Page 1 oft ,r Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection- FAIL Critical Foodborne Illness Interventions /' and Risk Factors (Require immediate corrective action) /moment: Refrigerator across from fryolator has uncovered foods. All foods must be covered. +!White refrigerator has uncovered foods. All foods must be covered. ✓White freezer has uncovered foods. All foods must be covered. i alk in refrigerator has uncovered foods. All foods must be covered. Equipment an tensils FAIL omment: White freezer in kitchen requires general cleaning. erial oven requires general cleaning. here is no sanitizing log available at time of inspection. Log to be maintained daily. o sanitizing testystrips available at time of inspection. Provide test strips. ot�6 h downstairs feezers require general cleaning. . Same units have no visible thermometer. Provide visibleb and accurate thermometers. GENERAL COMMENTS: Owner to fax over past three months of extermination reports to the BOH. u City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800 BLUE BLUE GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 28,2007 ) Page 2 oft 0121 Essex Street Telephone: (978) 745-5656 Owner: Milissa Oraibi & Brenden Cr PIC: Milissa Oraibi Inspector: John Gehan Date Inspected: Correct By: 3/7/2007 Risk Level: Permit Number: I BHP -2007-0215 J 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) The Old Spot City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing PASS Critical 0 RED Comments: No sanitizer available at time of inspection. Sanitizer with proper ppm to be readily available at each work station. Cutting boards stained and scored. Resurface or replace cutting boards. Handwash Facilities PASS Critical ❑ RED Comments: Mens restroom missing handwash sign. Provide sign. Handicap restroom missing handwash sign. Provide signs. Kitchen hand wash sinks are reading over 150"F. Sink temperatures to be between 110°-130°F. Adjust sinks accordingly. 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. Mar 08,2007 ) Page 1 oft RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS Critical BLUE Comments: Refrigerator across from fryolator has uncovered foods. All foods must be covered. White refrigerator has uncovered foods. All foods must be covered. White freezer has uncovered foods. All foods must be covered. Walk in refrigerator has uncovered foods. All foods must be covered. Equipment and Utensils PASS BLUE Comments: White freezer in kitchen requires general cleaning. Imperial oven requires general cleaning. There is no sanitizing log available at time of inspection. Log to be maintained daily. No sanitizing testvstrips available at time of inspection. Provide test strips. Both downstairs feezers require general cleaning. Same units have no visible thermometer. Provide visibleb and accurate thermometers. GENERAL COMMENTS: Owner to fax over past three months of extermination reports to the BOH. All violations from 2/28/07 have been corrected. 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. Mar 08,2007) Page 2 oft Mar 08 07 02:49p P.1 To: Salem Board of Health Fronr Milissa Ofaibi Attn: John Gehan 4 pages includes the cover Fax 978-745-0343 Date: March 8, 2007 Re: Extermination Reports CC: From The Old Spot 121 Essex Street Salem, MA urgent For Review O Please Comment ❑ Please Reply Dear John, Please find our extermination Reports from A-1 Exterminators. If you require any additional documents, please call me at the numbers below. Thank You, MilisseOraibi Hungry Pig, Inc. D/bla The Old Spot 978-745-5656 97B-239-5044 Cell Mar 08 07 02:48p p.2 03/0912007 10:53 7915927641 AlEXTERMINATDR5 44", ., r4 P 'Alttr upw 9d so ohys VITCH E Nj pgEp/,qSMT,BAR AREA/3 REST RK CONT: CRAWLSPACC PIS NEEDED BRENDEN OR MELISSA ANY PROBLEMS CALL LAURA AT 978-774-62-28 D,Apj, a 0,t� C-DnVPVft INFORMATION EXP OAllE SALES TAX C.oz Cl o4b Nvcc TWALOUE JOTALAMDURTOD HERE 9AM OPENS 11:30AM OWNERS/WILD HORSE IN BEVERLY AMMOMALCOMN0ENTS 6 OWCLUNO TYPE MqRMTY YES O �- L M lj.F:mC�nlV0 3 Fvm*i 0 20 osp 0 Cl60 045 2 raff* ❑ 0 Fw* 0 90 Days ❑ 6m... 0 REASON FOR NO WAFIRA"TY .ftrWsGrAC0m*ti*ded ... . .. .......... ... Mow wwfllw—bm..... .............. ........... I .. ..... . ..... ........ ....... I not pmpared. �.: . ...... ...... p —:771 ........ . . ........ ...... 0 L-m-Rodeot prWV — :2LK��.�. TM OUT� I AWNu—Onhe Coes. CnnuY�Cwtarior Cavy wma E YES 140 Floom — gem ........ coumctsurk-o—C."a ..... I . I a ..... 0 0 Drain Areas—Clean ............ ........... 0 ... .... ❑ n FW Ftom — C1030 - I - - I . ... ❑ 13 Dinim AmS — 00am ....... Empl . 6ywATM—gW 13 Ll Locker AMOS — CAW ..... stm9c AMp, — OrgonlZed ........ .. . . ..... .... o ... ..... o 13 C-DnVPVft INFORMATION EXP OAllE SALES TAX C.oz Cl o4b Nvcc TWALOUE JOTALAMDURTOD HERE 9AM OPENS 11:30AM OWNERS/WILD HORSE IN BEVERLY AMMOMALCOMN0ENTS 6 OWCLUNO TYPE MqRMTY YES O �- L M lj.F:mC�nlV0 3 Fvm*i 0 20 osp 0 Cl60 045 2 raff* ❑ 0 Fw* 0 90 Days ❑ 6m... 0 REASON FOR NO WAFIRA"TY .ftrWsGrAC0m*ti*ded ... . .. .......... ... Mow wwfllw—bm..... .............. ........... I .. ..... . ..... ........ ....... I not pmpared. �.: . ...... ...... p —:771 ........ . . ........ ...... 0 L-m-Rodeot prWV — :2LK��.�. TM OUT� I AWNu—Onhe Coes. CnnuY�Cwtarior Cavy wma E Mar 08 07 02:48p AA-1 Uterrilinators 193 SHEPAM STRM. MINI. MA01902-4597 ® 781.%2.2731 1800.525.4825 FAX 781-592-764111 pest and Termite control Professionals frr DAM DAY P.3 F – — PI -F A SE! REM 17 pA:Vj�r,,7_17 r.o. Zox i0! rm, IIIA !C_23.C.31 CURRENT I 30 DAYS- WDAYS' . I 90 DAYS TM DATE ACTEND, CONTROL FOR SERVICE 9HAW COMMENTS YES NO Floors — Clean ............. ............ * , 0 0 - f 0 0 Drain Areas — Clean ........................ 0 Q Rest Rooms — Clean ........................ 0 0 DINng Areas — Clean ....................... Li Employee Areas — Clean .... ........ ...... C] ❑ LockerAteas — CAean ....................... 0 0 Storage Areas— Organized .................. [3 0 Comments OR ENTITIES NUMBER UNITPRIGE MOUSEGLBD muLn.CT TRAP DATE PRDTEGTA PROTECTA LIP CHECK NO. ATU SAIT STA OMC C)VISA OVISCOVER RAT GLUE 8D ACCT. # - EXP DATE c,= 0 "I ADDITIONAL COMMENTS wco _DV NG TYPE i Family 13 3 Family 11 2 Family 13 6 Family 0 SALES TAX TOTAL DUE 'tOrALAMOUNTPD REASON FOR NO WARRANTY I INFORMATION AMOUNT WARRANTY YES [3 NO 0 30 Days El 60 Days 0 90 Days C1 6 Mos. 0 -Partial service recruested ........ . ... ............................... ............. . ....... ...... .Poor sanitation....:...._ ................ . ....... ---—.1 ............ . ........................ -.0 Witchen/bathroom cabinets not Prepared ............. . ..... I ... .......................... EL .Closets/furniture not Prepared........._ ............................ - ...........................❑0 -Rocierrt proofing needed_ ........................ ... . ....... .... .................... . .......... 0 -Other OFFOOD&AGRIVULTURE'SPESTICM TIME IN WAtl AGREED TO NOTIFY TENANTS 2-7 1 YES NO Floors — Clean ............. ............ * , 0 0 - Counter Suftces — Clean ................... 0 0 Drain Areas — Clean ........................ 0 Q Rest Rooms — Clean ........................ 0 0 DINng Areas — Clean ....................... Li Employee Areas — Clean .... ........ ...... C] ❑ LockerAteas — CAean ....................... 0 0 Storage Areas— Organized .................. [3 0 Comments OR ENTITIES NUMBER UNITPRIGE MOUSEGLBD muLn.CT TRAP DATE PRDTEGTA PROTECTA LIP CHECK NO. ATU SAIT STA OMC C)VISA OVISCOVER RAT GLUE 8D ACCT. # - EXP DATE c,= 0 "I ADDITIONAL COMMENTS wco _DV NG TYPE i Family 13 3 Family 11 2 Family 13 6 Family 0 SALES TAX TOTAL DUE 'tOrALAMOUNTPD REASON FOR NO WARRANTY I INFORMATION AMOUNT WARRANTY YES [3 NO 0 30 Days El 60 Days 0 90 Days C1 6 Mos. 0 -Partial service recruested ........ . ... ............................... ............. . ....... ...... .Poor sanitation....:...._ ................ . ....... ---—.1 ............ . ........................ -.0 Witchen/bathroom cabinets not Prepared ............. . ..... I ... .......................... EL .Closets/furniture not Prepared........._ ............................ - ...........................❑0 -Rocierrt proofing needed_ ........................ ... . ....... .... .................... . .......... 0 -Other OFFOOD&AGRIVULTURE'SPESTICM TIME IN WAtl AGREED TO NOTIFY TENANTS 2-7 1 Mar 08 07 02:49p 414.1 Exterminators - te3HF.xtPARD STRLLYNN. MA 01=4W® Tat -m-2731 I-=425.6825 FARM -M-7661 Past and Termite Control Prote5SIOnSIS R7 DATE RM1'r TIPt - COHTROLFOR ACr.Z M. -- p.4 ^r: R9 CURRENT 30 DAYS l 6D DAYS I 90 DAYS - - - SEWCECHARGE " NUMBER UNIT PRICE AMOUNT MOUSEGLBD =`.. MULTI -CT TRAP DATE; �% - :.� PROTECTA - PROTECTA LP. CHECK NO. RIUBAITSTA ❑ MC []VISA ❑ DISCOVER RAT GLUE BO ACCT. a EXP DATE C.Oo.0 cHc❑ ADDITIONAL COMMENTS SALES TAX NCO TOTAL DUE DWELLING TYPE I Family ❑ 3 Famlry ❑ 2 Family ❑ 6 Family ❑ REASON FOR NO WARRANTY WARRANTY YES ❑ NO ❑ 30 Days ❑ 60 Days C 90 Days ❑ 6 Nos. ❑ OUSTOMER SICiwllUBE Lip. 0. • YES NO Floors—Clean ............................. ❑ ❑ Counter Surfaces—Clean ................... ❑ ❑ Drain Areas—Clean ........................ ❑ ❑ Rest Roome—Clem ......................... ❑ ❑ Dining Areas—Clean ....................... ❑ ❑ Employee Areas — Cleen .................... ❑ ❑ Locker Areas—Clean ....................... ❑ ❑ Storage Areas — Organized .................. ❑ ❑ Comments DWELLING TYPE I Family ❑ 3 Famlry ❑ 2 Family ❑ 6 Family ❑ REASON FOR NO WARRANTY WARRANTY YES ❑ NO ❑ 30 Days ❑ 60 Days C 90 Days ❑ 6 Nos. ❑ OUSTOMER SICiwllUBE Lip. 0. • -partial service requested .... ........................ ...._....... ...._._.............._...... ... 0 -Poor sanitation ...................... ................ ...... ....................._.......................... �Kitchen/Dathroom cabinets not Prepared.........-._ .....................................❑ ❑ POST APPLICATION REQUIREMENTS OCCUPIED AREAS MUST BE VACATED FOR HOURS. .CkmtsftUrniture not prepared ........................ ......................:......._..... ... Q THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE REOCCUPIED. DO NOT ALLOW ADULTS. CHILDREN, OR PETS ON _ '----- -Rodent Proofing needed""""'-"""'""'""""'""""" "-'--'-'-' --^......... ..... .❑ TREATED SURFACES UNTIL DRY. -Other :ONTRACTING ENTRIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD$ AGRICUL7URE'S PESTICIDE TIME IN IUREAU CONSUMER SHEETS. WRITTEN STATEMENTS, POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 en�no m.noor rnennelnMc. TNEAROW SERVICE HAS BEEN SATISFACTORILY COMPLETER.. must TECH SIGNATURE ; TECH NO. IMPORTANT MESSAGE FOR A. M. DAT{E�/� TIME M OF PHONE AREA CODE NUMBER EXTENSION �❑ FAX ® MOBILE °lam Z- 5 AREA CODE NUMBER TIME TO CA TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH. RETURNED YOUR CALL WILL FAX TO YOU NOTES NOTES f �t ;i w tlb.'4 -•i THE OLD SPOT 121 Essex Street Salem, MA O 1970 978-745-5656 Board Of Health 120 Washington Street Salem, MA 01970 RE: Menus for The Old Spot Dear Joanne Scott, a 'JAN v 4 2001 CITY OF SALEM BOARD OF HEALTH Please find enclosed copies of our current menus. I apologize for not getting them to you sooner. We expect to run these as well as two to three nightly dinner specials through February. I will send out new menus as we change them. Thank you in advance, -",k A- Milissa Oraibi The old Spot Lunch Menu Four Onion Soup Nestled under a pumpernickel and Swiss sandwich $5.50 'JAN v 4 2001 CITY OF SALEM BOARD OF HEALTH Pork and Black Bean Chili Poblanos, tomatoes and beer, topped with cheese, sour cream and scallions $6.50 Grilled Sausage Du Jour Sweet & sour cabbage, coarse grained mustard and English cheddar $6.00 Mushroom Salad Sauteed mixed mushrooms, over baby arugula and sweet truffle vinaigrette $8.00 Hog wings Chicken or Pork "wings" tossed in fiery buffalo sauce with celery sticks, and . house made blue cheese dressing $7.00 Ploughman's Lunch Crusty bread, hard boiled egg, 3 cheeses, pickled veggies, tomato, green apple and country pate $9.00 Blue Cheese Salad Iceberg wedge, apple wood smoked bacon, tomato and red onion $7.00 Add sirloin tips, grilled chicken, buffalo grilled chicken, or portobellos $9.50 Old Spot Green Green Salad Field greens, green apple, spiced walnuts, shaved parmesan and balsamic vinaigrette $7.00 Add sirloin tips, grilled chicken, buffalo grilled chicken, or portobellos $9.50 Deluxe Cheese Burger Bacon, lettuce, tomato, onion, pickle, sauce and fries $8.50 Grilled Chicken Sandwich Marinated breast, mayo, lettuce, tomato, onion and fries $8.50 Curry Chicken Salad wrap Greens, red onion, raisins and English cheddar, in a flour tortilla $8.50 Fish --n- Chips Beer battered haddock with fries, tartar and malt vinegar $12.00 Fried Haddock Sandwich Cheese, lettuce, tomato, onion, tartar and fries $8.50 • consuming raw or undercooked meats or fish may result in food bome illness •18% Gratuity may be added to parties of six or more The Old Spot Brunch Fresh Scones With Clotted cream and fruit preserves -7 - Ploughman's. Lunch Three English cheeses, tomato, green apple, Branston pickle, country pate, hard boiled eggs and crusty bread -9- Scottish Smoked Salmon Bagel, whipped cream cheese, capers, red onion and tomato dill relish -1 I - Green Green Salad Greens, balsamic vinaigrette, spiced walnuts, shaved parmesan and green apple -9.50- Toad in the Hole English Bangers baked in Yorkshire pudding with onion gravy -8- Fried Dough Chambord macerated strawberries, whipped cream and powdered sugar -7- Big Red's Big Breakfast Crawfish cake, rosemary and molasses baked beans, hangers, bacon, grilled tomato, floddies toast and two fried eggs - 12 - Eggs Benny Two poached eggs, shaved Black Forest ham, crumpets, floddies and hollandaise -1 I - The Old Spot Cheddar Omelette Bacon, carmelized onions, tomato and mushroom Or any combination, with toast and floddies -10 - Stuffed French Toast Roasted apple, marscapone, sugared pecans, cinnamon maple syrup - 8 - Slow Roasted Pork Sandwich Pulled and pressed with Swiss, Dijonaisse and Steve's Sweet Frites -8 - Curried Basmati Rice With toasted cashews, butternut squash, green apple and red peppers - 9 - -- Sides Available -- Crumpets or Toast -2.50- Bagel 2.54Bagel & Cream Cheese, Floddies or a Scone -3.50 - Bacon, Bangers or Ham Steak 4.50 - Baked Beans or Sweet Frites - 3.50 - Organic Yogurt with Berries and Granola - 5 - After I:OOPM Steak Tips with Fries and Onion Rings -14 - Deluxe Cheese Burger and Fries -9 - Beer Batter Fried Haddock Sandwich and Fries - 12 - IT'S 'PALL M&NO (under 1") I .4 ch!ekeD F*tagers grad Fries ...................6.00 Kid larger grad F -ries ..................6.50 'Pemut Tatter grad gutT (or 141y) ..................3.50 yotdogs and Fries..............................6.00 xvevroni end cheese............................6.00 MAW$ I)vsty Wnh Tatter, or Tomato Ssuce .....6.00 Gabes o� juice, `Milk, m so% `mak Appetizers 4 Onion Soup Pumpernickel Crouton and melting Swiss $5.50 Pork and Black Bean Chili Poblanos, Tomatoes and Beer, topped with, Cheese, Sour Cream, Scallions $6.50 Buffalo wings Hog or Chicken, fiery Buffalo sauce, Celery and house made Blue Cheese dressing $7.00 Ploughman's Lunch Crusty Bread, hardboiled Eggs, three Cheeses, pickled vegetables, sliced Tomato, Pate and Green Apple $9.00 Pan Fried Crawfish Cake House baked Molasses and rosemary Beans, Chipolte Aioli and Lemon $8.00 Grilled Sausage Du Jour Grained Mustard, English Cheddar and sweet and sour Cabbage $6.50 Salads Green Green Salad Field Greens, Green Apple, Spiced Walnuts, shaved Parmesan and Balsamic vinaigrette $7.00 Blue Cheese wedge Iceberg wedge draped with apple wood smoked Bacon, House dressing, Tomatoes and Red Onion $7.00 Mushroom Salad Sauteed Portobellos, Crimini, and Buttons, over baby Arugula, sweet Truffle vinaigrette & shaved Parmesan $8.00 * Consuming raw or undercooked meats & fish may result in a Food borne illness * Please let us know if you have any food allergies 18% Gratuity will be added to parties of six or more Entrees Slow Roasted Pork Shoulder Apples and sage, Cheddar Floddies and Onion gravy $16.00 Grilled Atlantic Salmon Truffled Mashed Potatoes & creamy sauteed Mushrooms $17.00 Hand Cut Mafalda Pasta Sausage, Black Olives, Tomatoes, Cream, Cilantro and Feta $14.00, Grilled Hanger Steak Bubble and Squeak, Wow Wow sauce $17.00 Pan - Roasted Statler Breast Cranberry cream, English Peas and Cheddar Mashed Potatoes $16.00 Seared Jumbo Sea Scallops Wild Rice Pilaf, Apple wood smoked Bacon and aged Balsamic $17.00 Garlic Roasted Portobellos Baby Arugula, wild Rice Pilaf, Red Pepper coulis and Chevre with Balsamic drizzle and Frites $15.00 Pan Roasted Lamb Indian Curry cream, Cashews, Red Peppers, Onions and Basmati Rice $18.00 Pub Stuff Deluxe Cheeseburger Bacon, Lettuce, Tomato, Onion, Pickle and sauce, with Fries $9.00 Grilled Chicken Sandwich Marinated Breast, Portobellos, Cheddar and Fries $9.00 Slow Roasted Pork Sandwich Pulled and Pressed, with Pickles, Dijonnaisse and Swiss $8.00 Toad In The Hole Pork Sausage baked in Yorkshire Pudding, with Onion gravy $7.00 Beer Battered Fish - n - Chips English Ale battered fresh Haddock with Fries and Malt vinegar wrapped in paper $13.00 Old Spot Meat Pie Ground Lamb and Beef, toasted Com and Onion gravy baked under Mashed Potatoes $12.00 Grilled Sirloin Tips Fries, thick cut Onion Rings, home made sweet ketchup $14.00 Executive Chef- Brenden Crocker Executive SOUS Chef- Steve Feiven Late Night Menu 4 Onion Soup pumpernickel crouton and melting Swiss $5.50 Pork and Black Bean Chili poblanos, tomatoes and beer, topped with, cheese, sour cream, scallions $6.50 Buffalo Wings hog or chicken, fiery buffalo sauce, celery and house made blue cheese dressing $7.00 Ploughman's Lunch crusty bread, hardboiled eggs, three cheeses, pickled vegetables, sliced tomato, pate and green apple $9.00 Blue Cheese Salad iceberg wedge, apple wood smoked bacon, tomato and red onion $7.00 Deluxe Cheese Burger bacon, lettuce, tomato, onion and sauce $9.00 Grilled Chicken and Portobello Sandwich cheddar and fries $9.00 Curry Chicken Salad Wrap greens, red onion, raisins and English cheddar, in a flour tortilla $8.50 Basket Of Fries $3.00 add chili, cheese and sour cream $6.00 * Got a sweet tooth? Ask for the dessert menu! * Consuming raw or undercooked meats & fish may result in Food borne illness- *18% Gratuity added to parties of six or more gm4w. Jim Beam 5.50 D"044 Chocolate Laver Cake 7.00 Basil Hayden 8.00 With rum fudge sauce & whipped cream Makers Mark 7.50 Baked Granny Smith 6.00 Caramel sauce and ginger ice cream Dewars 5.50 Lemon Bars 6.00 Chivas Regal 6.50 With raspberry coulis and fresh berries Johnnie Walker Red 6.50 Spotted Dick 6.00 Johnnie Walker Black 7.00 With whiskey sauce & vanilla ice cream Glenfiddich 6.50 Vanilla Ice Cream 6.00 With rum fudge sauce and whip cream Courvoisier VSOP 8.00 Hennesey VSOP 8.00 Cote 6.50 PO4 Spanish Coffee- Kahlua, Brandy & Gran Fonseca Bin 27 Ruby 6.00 Marnier Dow's 10 yr Old Tawny 6.50 Mexican Coffee- Kahlua Taylor Fladgate 20yr Tawny 12.00 Dow's Colheita 1992 9.50 Irish Coffee- Jameson Nutty Irish- Frangelico & Baileys 014" Italian Coffee- Sambuca Amaretto Di Saronno 6.00 B & B 6.00 Keoki Coffee- Brandy, Kahlua & Dark Cacao Baileys 6.00 Spotted Pig- Hennessey & Annisette Frangelico 6.00 Gran Marnier 6.00 Irish Mist 6.00 Sambuca 6.00 05corla za We proudly serve Fair Trade Certified Coffee Fresh Roasted locally by The Atomic Cafe In Beverly Drafts Sierra Nevada Pale Ale Harviestoun's Bitter&Twisted Anchor Liberty Ale I.P.A Magic Hat #9 Tucher Hefeweizen Belhaven Scottish Ale Guinness Stout Bass Ale Newcastle Brown Ale Pabst Blue Ribbon Smithwick's La Chouffe Saison Geary's London Porter Double Decker Ale Woodchuck Hard Cider Blue Point Toasted Lager Black & Tan Shandie *Bottle Selection Samuel Smith's Nut Brown Ale Orval Trappist Ale Samuel Smith's Old Pale Ale Corona Left Hand Brewery's JuJu Ginger Amstel Light. Rogue Dead Guy Ale Miller Lite Saison Du Pont Farm Ale Mike's Hard Lemonade Stone Cat Blueberry Ale O"Doul's Red Wines Estrella Cabernet Sauvignon $5.50 Geyser Peak Cabernet Sauvignon $6.50-$25.00 Estrella Merlot $5.50 Andrew Peace Shiraz $6.50-$25.00 Oakley Five Reds $5.75-$22.00 Grao Pascal Dao, Portugal $5.00$20.00 Les Salices Pinot Noir $7.50-$29.00 White Wines Hacienda Chardonnay $6.25-$24.00 Geyser Peak Chardonnay $6.50-$25.00 Sterling Vineyards Sauvignon $6.00$23.00 Salvalai Pinot Grigio $5.75-$22.00 Casal Garcia Vihno Verde $5.25-$20.00 Forestville White Zinfandel $5.00 CITY OF SALEM, MASSACHUSETTS 6 BOARD OF HEALTH a 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741 -1800 FAx 978-745-0343 W W W.SALEM.COM Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT T�t 0141ST_t TEL# �-1`15-5IoSj ADDRESS OF ESTABLISHMENT 121 �.SSlix /7 t" ` FAX # MAILING ADDRESS (if different) EMAIL -- Business': Owner's: G✓uckt rd 1 t 'c-) C0 a%cCt5 f ✓l c -' OWNER'S NAME MAA-556 QVAt%91 TEL# 978 gZ7"cicl�ll ADDRESS CITY STATE CERTIFIED FOOD MANAGER'S NAME(S) Mt, U5 °i (A D✓AI b r CERTIFICATE#(S) '50 1139-1 (Required in an establishment where potentially hazardous food is prepared) C.6I t C116 - 231 - Z$LA D EMERGENCY RESPONSE PERSON !7Yt1'Id.e,Cwle- HOME TEL #AlS-cl21/-WO OAYSRFOPERATION Monday Tuestlay Wednesday Thursday Friday Saturday Sunday HOURS OfRPERATIRN(130A�_ ir,3oAM 1P3oAM 11,36AM IC3oAM Il �j6AM 10 •DaAlvl Please write indmeofday' O AM ! 1` -FOAM '•. o I'pofjM .,. It(k1fiM ItUO tint '.. isvDAm tiooAM (for examplettam-ttpm] 1� = more than 99 seats TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTAUIFMW BEMBREAKFAST --(9-------- YES NO YES O FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ----------------------------------------- Mess than 25 seats --- 100 25-99 seats = more than 99 seats =$200 --------- - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) $100 YES 1 $5 YES $50 YES 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. 20 - 112, (P 3 8 7 - Social Security or Federal Identification Number ----------------------------------------------------- Revised ----------------------Revised 11/13/06 FOODAP2007. adm ✓Check# 8 Date t0 12jqvii, $ 1� — Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: File Number: BHF -2006-000052 LOCATED AT: The Old Spot 121 Essex Street SALEM MA 01970 0121 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2007-0215 Dec 20, 2006 Dec 31, 2007 $150.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $150.00 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 11 lCorporate Offices Cape Cod New Hampshire 183 Shepard Street 72 Main Street, Suite 522 South Broadway e-mail Lynn, MA 01902 W. Harwich, MA 026711 Salem, NH 03079 A11nfo@ (781) 592-2731 (508) 432-5866 (603) 893-8099 (800) 525-4825 (800) 499-5866 (800) 525-4825 At Exterminators.com A't Exterminators Fax (781) 592-7641 Fax (508) 432-5299 Fax (603) 890-3761 l\Commercial, Industrial Pest Control Service Agreetp�nt Date: Customer Tel. Tel.# Address k, L Fax e-mail City State Zip Code Service Information and Location'' 1t,� `�?;— 7yj --s�j6 Customer � of J S()/Tf" Tel. # Address /Z/ %SSP X .ST Fax e-mail City S � to State Zip Code Orl 76 Multiple Locations (see attachment) Co trot: This agreeme Is for the control of the folio ing pests: / ( 7Roaches ( Ants ( Rats (�) Mice ( ) "Other 'Does not include Carpenter Ants, Pharoah Ants. " Does not include Termites, Wood Boring Insects or Flying Insects unless specifically mentioned. Special Instructions: Service Schedule: A-1 Exterminators will prr9vide intensive service and will also provide Regular Pest Control Services: Exterior Rodent Control: Exterior Insect Control: Bird Control: 1x month ( ) 2x month 1x month ( ) 2x month ( ) 1x month ( ) 2x month ( ) 1x month ( ) 2x month Payment: In consideration of the service provided by A-1 assigns the following sums: $ %7S for each intensive service fi �J/cC•OGF $_%r for each regular service. $ 11,14- for each exterior rodent service. $ N4 for each exterior insect control service. $ ifV 14 for each exterior bird control service. ( ) weekly. ( ) weekly. ( ) weekly. ( ) weekly. Exterminators, the customer agrees to pay A-1 Exterminators, its successors or wee, -I-; /QQ�9ck-7 .3 !1 � 6CGln s Payment Terms: ( ) COD ( ) Charge. Payment due upon receipt of invoice. ( ) Total Annual payment in Advance $ less % discount Customer Obligation: The customer agrees to cooperate fully with A-1 Exterminators. Whenever conditions conducive to the breeding and harborage of pests covered by this contract are reported in writing by A-1 Exterminators to the customer, the customer shall take the necessary steps to correct such conditions. Pest Damage: The customer agrees that A-1 Exterminators is not responsible for any business disruption or damage caused by insects and/or rodents, on, or to the customer's premises or its contents, and the customer specifically releases A-1 Exterminators from liability for any such claims. Additional No Cost Service: A-1 Exterminators shall promptly provide additional service between regularly scheduled visits as deemed necessary by A-1 Exterminators. Services: Service is the inspection and/or application of pesticides for the control of the above mentioned pests. All services shall be performed in accordance with Federal and State requirements, and EPA and USDA standards. Materials: All materials used to control pests shall conform to Federal, State and local laws and regulations. A-1 Exterminators reserves the right to re-enter the customers premises and remove any chemicals including rodent and insect baits upon termination of this agreement. Equipment and Products: The customer agrees to pay A-1 Exterminators for any equipment installed or placed on the customer's property necessary for the control of the above mentioned pests. Insurance: Upon Request, A-1 Exterminators will furnish to the customer a certificate of insurance showing coverage in effect. Terms of Contract: • This contract shall be effective for an original period of one year. Thereafter, this contract shall renew itself from month to month until terminated by either parry upon thirty days written notice. Rate subject to periodic review and increase by A-1 Exterminators after initial 12 month period. • The customer further agrees to additionally pay for any equipment or products ordered or installed on the customer's premises as determined to be necessary by A-1 Exterminators for the control of the above mentioned pests. Such items may include, but not be limited to the following: Bait Stations, Glue Traps, Multiple Ketch Traps, Fly Spray, etc. n , By E �e��inatprg ( Accepted Date: _ C�t� / Print Name Print Title Tide �oRc �V - By White - Office Copy Yellow -customer copy Sign me INS, It 0121 Essex Street The Old Spot City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency FOOD PROTECTION MANAGEMENT PASS RED PIC Assigned / Knowledgeable / Duties PASS ❑J RED Noncompliance with: Anti -Choking PASS Tobacco PASS EMPLOYEE HEALTH Reporting of Diseases by Food Employee and PIC PASS ❑d RED Personnel with Infections Restricted/Excluded PASS ❑d RED FOOD FROM APPROVED SOURCE Food and Water from Approved Source PASS RED Receiving/Condition PASS ❑d RED Tags/Records/Accuracy of Ingredient Statements PASS ❑J RED Conformance with Approved Procedures/HACCP Plans PASS RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 18,2006) Page 1 of Good Hygienic Practices Prevention of Contamination from Hands Handwash Facilities PROTECTION FROM CHEMICALS Approved Food or Color Additives Toxic Chemicals PASS Item Status Violation Critical Urgency RED: ; 'S' t ;� x a'o PROTECTION FROM CONTAMINATION RED RED PASS Violations. Related to,, Separation/ Segregation/ Protection PASS PASS RED Foodborne Illness Interventions and Risk Factors (Require ,., ;$r Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED irilmediate Corrective action) Proper Adequate Handwashing PASS RED Good Hygienic Practices Prevention of Contamination from Hands Handwash Facilities PROTECTION FROM CHEMICALS Approved Food or Color Additives Toxic Chemicals PASS ❑D RED PASS D RED PASS RED RED PASS LJ RED PASS RED TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS ❑J -RED Cooling PASS 0 RED Hot and Cold Holding PASS ❑J RED Time As a Public Health Control PASS ❑J RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS Q RED City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeOTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 18,2006) Page 2 of ' ;1 Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other- See Notes PASS BLUE GENERAL COMMENTS: 832:- Provide sanitizing solution of proper concentration at all work stations at all times. - Stock all wall hung soap and paper towel dispensers at all times. - Please fax a contract with a licensed pest control operator to the Board of Health by 9122106. In accordance with the Federal Food Code and the State Sanitary Code this establishment has met all requirements to operate a food establishment. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 18,2006) Page 3 of Commonwealth of Massachusetts City of Salem » Board of Health lGmbedey Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 09/18/2006 WHO'S PLACE OF BUSINESS IS: File Number: BHF -2006-0052 The Old Spot 121 Essex Street SALEM MA 01970 LOCATED AT: 0121 ESSEX STREET SALEM, MA 01970 Permit Type Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE ESTABLISHMENT Sep 18, 2006 Dec 31, 2006 $150.00 Total Fees: $150.00 PERMIT EXPIRES ,December 31, 2006 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. M1 d ♦ L 1`M' A Y'f F;? 4.T Y lj(' ti i ..ifr`\' v,{."ki-�.� �f 1'T 1 i 4 � '�[ k4" L _.'v.t. 9. 4't� T 4-�`'w Y +k'�' Commonwealth of Massachusetts City of Salem » Board of Health lGmbedey Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 09/18/2006 WHO'S PLACE OF BUSINESS IS: File Number: BHF -2006-0052 The Old Spot 121 Essex Street SALEM MA 01970 LOCATED AT: 0121 ESSEX STREET SALEM, MA 01970 Permit Type Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE ESTABLISHMENT Sep 18, 2006 Dec 31, 2006 $150.00 Total Fees: $150.00 PERMIT EXPIRES ,December 31, 2006 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. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH j s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll www.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE -A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT The OUS170I TEL# 476-146 -15(051,9 will IA"ave. J ADDRESS OF ESTABLISHMENT Ili �S5CX 5 KGS- SG ICM . MA w971) MAILING ADDRESS (if different) OWNER'S NAME AIMC& Ora16i + gr"et\ C✓ ckl- TEL# 918-941-4491 ADDRESS 5 WaJSWOI k\ PlacC- CITY STATE MA ZIP Otells CERTIFIED FOd5 MANA'GER'S NAME(S) ( ^,4Cn Lead.[,- CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON IVIS �1 S,SA O/A� b� HOME TEL # ql5. 921- Lt l HOURS OF OPERATION: Mon. 311 °' l Tue.00-t Wed.0I Thu.u;`- I Fri.t(3'-I Sat. I ;i °- I Sun. 10 - 1 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. 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 (not just serve) ICE CREAM, YOGURT, SOFT SERVE YESVO $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT (such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 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. 0 1_ n r W -99-9o31 Signature Date V 101146 Social Security or Federal Identi Revised 11/03/05 FOODAP2.adm Check#& �� S Aril- w�ew 12t ,x -556-K SA- �5'� , An , q -n --►11's -51st Appetizers 4 Onion Soup Pumpernickel Crouton and melting Swiss $5.00 Pork and Black Bean Chili Poblanos, Tomatoes and Beer, topped with, Cheese, Sour Cream, Scallions $6.00 Buffalo Wings Hog or Chicken, fiery Buffalo sauce, Celery and house made Blue Cheese dressing $8.00 Ploughman's Lunch Crusty Bread, hardboiled Eggs, three Cheeses, pickled vegetables, sliced Tomato, Pate and Green Apple $9.00 Pan Fried Crawfish Cake House baked Molasses and rosemary Beans, Chipolte Aioli and Lemon $7.00 Grilled Sausage Du Jour Grained Mustard, English Cheddar and sweet and sour Cabbage $6.00 Salads Green Green Salad Field Greens, Green Apple, Spiced Walnuts, shaved Parmesan and Balsamic vinaigrette $7.00 Blue Cheese Wedge Iceberg wedge draped with apple wood smoked Bacon, House dressing, Tomatoes and Red Onion $7.00 Mushroom Salad Sauteed Portobellos, Crimini, and Buttons, over baby Arugula, sweet Truffle Vinaigrette & shaved Parmesan $8.00 * Consuming raw or undercooked meats & fish may result in a Food borne illness * Please let us know if you have any food allergies Entrees Slow Roasted Pork Shoulder Apples and sage, Cheddar Floddies and Onion gravy $16.00 Grilled Atlantic Salmon Truffled Mashed Potatoes & creamy sauteed Mushrooms $17.00 Hand Cut Mafalda Pasta Sausage, Black Olives, Tomatoes, Cream, Cilantro and Feta $14.00 Grilled Hanger Steak Bubble and Squeak, Wow Wow sauce $17.00 Pan -- Roasted Statler Breast Cranberry cream, English Peas and Cheddar Mashed Potatoes $16.00 Seared Jumbo Sea Scallops Wild Rice Pilaf, Apple wood smoked Bacon and aged Balsamic $17.00 Garlic Roasted Portobellos Baby Arugula, wid Rice Pilaf, Red Pepper coulis and Chevre with Balsamic drizzle and Frites $15.00 Pan Roasted Lamb Indian Curry cream, Cashews, Red Peppers, Onions and Basmati Rice $18.00 Pub Stuff Deluxe Double Cheeseburger Bacon, Lettuce, Tomato, Onion, Pickle and sauce, with Fries $8.50 Grilled Chicken Sandwich Marinated Breast, Portobellos, Cheddar and Fries $8.50 Slow Roasted Pork Sandwich Pulled and Pressed, with Pickles, Dijonnaisse and Swiss $7.50 Toad In The Hole Pork Sausage baked in Yorkshire Pudding, with Onion gravy $7.00 Beer Battered Fish - n - Chips English Ale battered fresh Haddock with Fries and Malt Vinegar wrapped in paper $12.00 Old Spot Meat Pie Ground Lamb and Beef, toasted Corn and Onion gravy baked under Mashed Potatoes $ 10.00 Grilled Sirloin Tips Fries, thick cut Onion Rings, home made sweet ketchup $13.00 Drafts Sierra Nevada Pale Ale, Fuller's E.S.B. Anchor Liberty Ale I.P.A Magic Hat #9 Paulaner Hefeweizen Boddington's Pub Ale Guinness Stout Bass Ale Newcastle Brown Ale Pabst Blue Ribbon Smithwick's La Chouffe Saison Coffee House Porter Paulaner Oktoberfest Woodchuck Hard Cider Blue Point Toasted Lager Black & Tan Shandie *Bottle Selection: Samuel Smith's Nut Brown Ale Orval Trappist Ale Samuel Smith's Old Pale Ale Corona Left Hand Brewery's JuJu Ginger Amstel Light Rogue Dead Guy Ale Miller Lite Saison Du Pont Farm Ale Mike's Hard Lemonade Red Wines Estrella Cabernet Sauvignon $5.50 Geyser Peak Cabernet Sauvignon $6.50-$25.00 Estrella Merlot $5.50 Andrew Peace Shiraz $6.50-$25.00 Oakley Five Reds $5.75-$22.00 Grao Pascal Dao, Portugal $5.00-$20.00 Blue Moon Pumpkin Ale White Wines Hacienda Chardonnay $6.25-$24.00 Geyser Peak Chardonnay $6.50-$25.00 Sterling Vineyards Sauvignon $6.00-$23.00 Cielo Pinot Grigio $5.75-$22.00 Casal Garcia Vihno Verde $5.25--$20.00 Forestville White Zinfandel $5.00 Examinee Score Analysis - Detail" ` National Restaurant Association EDUCATIONAL FOUNDATION page 1 of 1 Developing the Restaurant and Foodservice Indu Monday, September 1 Examinee Score Analysis Report - Detail This report is meant for online viewing only. Printing a hard copy of this report may not be considered appropl documentation to meet regulatory requirements. If you passed this course, you will receive a Certificate of Completion from the individual your proctor designs responsible for exam results. If, for any reason, you need to obtain a duplicate of the original certificate issued to you click here. Course Name: ServSafe Food Safety Manager Certification Exam Student Name: MILISSA B ORAIBI Class Tracki Test Class Organization g Instructor Exam Exam T Type of Hold Hours Certification 75% Number Name Name Location Date Training Code of Number Pa Training 550193 Pilgrim Hosp Richard MA 8/29/2006 Classroom 8 5017397 F Doyon Test Pass Your Form Percent Percent Personnel Score Score 4289 75% 85% Foods 82% Clean/Sanitize/Maint. 100% Facilities 85% Personnel 90% Temp. Measuring Devices 100% Allergens 100% High -Risk Populations 100% Legal/Regulatory Issues 33% Facility Layout/Design 100% Training Employees 100% I• © 2001-2006 National Restaurant Association Educational Foundation rl 175 West Jackson Boulevard, Suite 1500, Chicago, IL 60604-2814 www.restaurant.org �•• 1-800-765-2122, or in Chicagoland 312-715-1010 Legal Notices and Priv, http://www.nraef.org/IRC/classesIStudentDetail.asp?CurriculwnlD=85&StudentID=36535... 9/18/2006 Examinee Score Analysis - Detail National Restaurant Association EDUCATIONAL FOUNDATION Page 1 of 1 Developing the Restaurant and Foodservice Indu Monday, September 1 Student Curriculum Report Student: MILISSA ORAIBI Class Course Sponsor Instructor Exam Overall Overall% Course Point Student Detai Number Name Name Name Date Score Score Result ServSafe Pilgrim 550193 Food Safety Manager Hosp Doyon, 8/29/2006 85 68. Passed Student Details Certification Beverly/ Richard Exam MA Legal Notices and Priv, http://www.nraef org/IRC/classes/StudentClassDetail.asp?CurriculumlD=85&StudentID=... 9/18/2006 © 2001-2006 National Restaurant Association Educational Foundation 175 West Jackson Boulevard, Suite 1500, Chicago, IL 60604-2814 www.restaurant.org 1-800-765-2122, or in Chicagoland 312-715-1010 Legal Notices and Priv, http://www.nraef org/IRC/classes/StudentClassDetail.asp?CurriculumlD=85&StudentID=... 9/18/2006 CITY OF SALEM BOARD OF HEALTH Name of Establishment: The Old Spot Address: 121 Essex Street Owner(s): Milissa Oraibi & Brendan Crocker Phone: 978-927-4497 Date: June 14, 2006 The proposed owners of this establishment presented a Floor Plan and Menu for review in accordance with the State Food Code. FLOOR PLAN A hand sink must be located in each food prep area. A hand sink is located in the front area of the prep section. A hand sink must also be located in the rear area of the prep section. It is not clear from the establishment diagram if there is a hand sink in this location. A hand sink must be located in the bar area. Hand sinks are for handwashing only. There must be wall hung soap and paper towel dispensers at each hand sink. A food prep sink is available for washing vegetables, etc. A dishwasher is available. It must sanitize in the final rinse with a temperature of 180°F in the final rinse; or with a chemically fed sanitizer automatically fed into the final rinse. If the second option is used, there must be an alarm indicating when the sanitizer is running low. A three bay sink is also available for washing, rinsing and sanitizing pots, pans utensils, etc. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. This includes any areas used for storage in the basement. MENU/FOOD PREP All food must be purchased from a wholesaler licensed by the State. All food must be held at 41'F or lower, or 140°F or higher, at all times. Therefore, items to be held hot must be placed in the hot holding area at a temperature above 140°F. Cold items, such as vegetables, must be cold prior to being held cold in the salad unit. Food may not be added to containers in salad unit. Instead, a sanitized container with new product may replace the existing container and the old product may be placed on top of the new product. There may be no bare hand contact of ready -to -eat foods. Gloves, tongs, or tissues must be used when handling such food. CERTIFICATION There must be a Certified Food Manager working at this establishment full HMO When a CFM is not onsite there must be a Person -in -Charge (PIC) who is fully trained in sanitation techniques and has a thorough understanding of the operation. There must be a person on site at all times trained in choke saving. UNDERCOOKEDFOODS There must be an asterisk and advisory on the menu regarding undercooked foods EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' tables. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be tested daily and the results recorded on a log sheet for examination by Board of Health inspectors. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. Spray bottles and wiping pails must be clearly marked "sanitizer". Outside area of premises, including the trash area, must be kept clean and sanitary. An application was submitted. No check was received. An inspection concentrating on the physical aspects of the establishment will be conducted. Please call one week prior to opening to schedule an opening inspection. Joanne Scott Health Agent Milissa Oraibi Owner Date L -Al �Ld 6(X. THE OLD SPOT MENU APPETIZERS ONION SOUP WITH PUMPERNICKLE CROUTON AND MELTING GRUYERE CHILI-- LOADED WITH SOUR, RED ONION, SCALLION, JACK CHEESE BLACK BEANS IN ANY COMBINATION NAHCOS- TOASTED CORN CHIPS, JACK CHEESE, SOUR CREAM, BLACK BEANS, JALAPENOS, HOUSE MADE SALSA & GUACAMOLE GREEN GREENS- MESCLUN,SHAVED PARMESAN, GREEN APPLE AND WALNUTS WITH BALSAMIC VINAIGRETTE BLUE SALAD- WEDGE OF ROMAINE WITH BACON, TOMATO, RED ONION AND BLUE CHEESE CRAYFISH CAKE- WITH BAKED BEANS AND CHIPOLTE TARTAR" GRILLED SAUSAGE- SAUSAGE OF THE DAY WITH RED SLAW AND GRAIN MUSTARD MUSHROOM SALAD- PORTOBELLO, CRIMINI & OYSTER MUSHROOMS OVER SPINACH AND ARUGULA, DRIZZLED WITH TRUFFLE OIL END OF SUMMER TOMATOES- LAYERS WITH FRESH MOZZARELLA, MY GARDEN BASIL & EVOO ENTREES STEAK TIPS - WITH FRENCH FRIES AND THICK CUT ONION RINGS** LAMB TIPS- WITH FRENCH FRIES AND THICK CUT ONION RINGS** GUINESS PIE- LAMB & BEEF, GUINESS GRAVY, CARMELIZED ONIONS AND MASHED POTATOES** FISH AND CHIPS- SERVED IN PAPER WITH MALT VINEGAR BLACKBERRY GLAZED SCALLOPS WITH ROASTED SWEET POTATOES** PLANK ROASTED SALMON WITH TRUFFLED MASHED POTATO** ROSTED CHICKEN STUFFED WITH WILD RICE PUDDING** HAND CUT MALFADA PASTA TOSSED WITH SAUSAGE, OLIVES, TOMAOTES AND FETA DOUBLE CHEESEBURGER- LOADED, LETTUCE, TOMATO, ONION, SAUCE WITH FRENCH FRIES** GRILLED CHICKEN SANDWICH- MELTED CHEESE AND FRENCH FRIES** PAGE OF PORK PORK RIBS IN SOY AND VINEGAR- FALL OFF THE BONE** PULLED PORK SANDWICH WITH BBQ AND PICKLES, FRENCH FRIES** PORK CHOPS WITH BAKED APPLES, CINNAMON AND CHEDDAR MASHED** PORK TENDERLOIN STUDDED WITH FIG AND STILTON WITH AGED BALSAMIC, SHALLOT RISOTTO** OPEN FACE PORK QUESADILLA- SALSA, JACK CHEESE, SOUR, CILANTRO AND BLACK BEANS** PORK TIPS AND BAKED BEANS** ** INSERT STANDARDIZED FOOD WARNING HERE Page 1 of 1 Card 1 of 1 Current ProDerty Mailing Address Owner NOT AVAILABLE City State Address Zip Zoning B5 Al Current Property Sales Information Sale Date 4/28/2005 Legal Reference 24228-181 Sale Price 685,000 Grantor Seller VAN DELL EUGENIA M ET ALI Current Prooertv Assessment Year 2006 Building Value 396,300 Xtra Features Value 0 Land Area 0.072 acres Land Value 125,900 Total Value 522,200 property contains 0.072 acres of land mainly classified as Res. / Comm. with a(n) Mixed Use style ing, built about 1920 , having Clapboard exterior and Tar+Gravel roof cover, with 8 unit(s),12 total Legal Description Click Property Images to Enlarge http://salem.patriotproperties.com/smmnary-bottom.asp 3/29/2006 r+ pJ V rt "L L FiL � N _ F mil �. E 'j 4 - � 5fL .�__... �..w. ' FFL 9MT n� ,o http://salem.patriotproperties.com/smmnary-bottom.asp 3/29/2006