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THE TIN WHISTLE - ESTABLISHMENTS2t.�f J�uen �V� universal one. www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE IN USA ., �.-�- .;... �}...;�,ia�:T Fl "�.,. .. ,t, s.kv, �: }i<«;qt',:�/. iM#i y��fi.•rti.."..y¢'�_ » tfl^, r`,-' .. .. .1' Massachusetts Department of Public Health s cern Board of Health Division of Food and Drugs 120 Washington Street, 4" Floorl 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name `� I �1 I r ({t W t Date Vif v 7 e of O eration s Type of Inspection Food Service LJRetail ❑ Residential Kitchen ❑ Mobile ❑Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. ❑ Routine 5Re-inspection Previous Inispection Date:3 31 re -operation ❑ Suspect Illness ❑ General ❑ HACCP Complaint ❑ Other Addressa ( - �� Risk Level Telephone moi - r�iia Owner (� C It G , ID HACCP WN Person in Charge (PIV) !_ Time In:I ) Out: cr i Inspector �J pyo Each violation checked requires an explanation on the narrative p'age(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 haza_rd:and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. I FOOD PROTEc noN MANAGEMEN'! ' _,-„, 5 '1 ❑ 1. PIC Assigned / Knowledgeable / Duties r EMPLOYEE HEALTH + ,r Laa, i,p .< +, i arra 72 ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMicALS JA3..u,w etir ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOODFROM APPROVED SOURCE t..s,,- tTIMEtTEMFEATURECO RhITROLS(PcteHtiallyazadousFtads) `rl E] 4. Food and Water from Approved Source w0 H� , rd ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling 'PPROTECTION SROM CONTAMINATION' "�"�°F'1 ❑ 19. Hot and Cold Holding ❑ 8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices 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) 28. Poisonous or Toxic Materials (FC -7)(590.0011) 29. Special Requirements (590.009) 30. Other 5: 5901nspeclPom,614.Orc nn El REQUIREMENTS FOR HIGHLY Sl15CEpTIB;LE POPULATIONS (HSPl`4 ❑ 21. Food and Food Preparation for HSP CONSUMER ❑ 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: - i PIC's Signature: Print: S R1� V Page -L of�Pages t Violations Related to Foodborne Illness interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) I Assi nmentofResponsibihty* 590.003(B) I_Demonstration of Knowledge*____ 2-103.] 1. Person mcharge - dpties EMPLOYEE HEALTH 2 590.003(0) Responsibility of theperson 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 plicams* Shell Eggs* 590.003(F) Responsibility Of A Fund Employee Or An 3-202.16 lee Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System" 590.006(A) Charge* 590.006(B) 590.003(0) Re orcin b Person in Char e* 3 590.003fD) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions FN - 6 ro Denotas critical item in the federal 1999 Food Code or 105 COIR 590.000. 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* 3-202.1.3 Shell Eggs* 3-242.14 Eggs and Milk Ptnducts. Pasteurized* 3-202.16 lee 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* Fruits and Vegetables ShelNish and Fish From an Approved Source 3-241.14 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 3-20218 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. t5 Pucka a lute it * 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-20118 Shellstock Identification * 3-20112 Shellstock Identification Maintained* Tags/Records: Fish Products 3-40111 Parasite Destruction* 3-402.12 Records- Creation and Retention* 590.004(7) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans 3-502.11 S ecialized Processin Methods* 3-502.12 Reduced Ox en aacka 'nu; criteria* R-103.12 Conformance with A roved Proczdures" ro Denotas critical item in the federal 1999 Food Code or 105 COIR 590.000. PROTECTION FROM CONTAMINATION $ Cross -contamination 3-302.1.1(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 3-302.1l(A) Food Protection* 3-302.15 Fruits and Vegetables 3-304.11 ..Washing Fuad Contact with Equipment and Utensils* Contamination from the Consumer 3-30 .14(A)TL 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 1'em eratures* 4-501.112 Mechanical Warewashing- I -lot Water Sanitization Temperatures* 4-501.11.4 Chemical Sanitization -temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-60211. Cleaning Frequency of Equipment FOOT Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - I -lot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301_t2 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2401.11 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 6-301.12 Hand Drvim� Provision Establishment CITY OF SALEM BOARD OF HEALTH Date: Page: o� Item No. Code Reference C — Critical Item R — Red Item.. DESCRIPTION OF"VIOLATION / PLAN Ari OF CORRECTION- / PLEASE PRINT CLEARLY Date - Verified n 10— q�q1 j n — r .. z� c Discussion With Person in Charge: I have read this report, have had tIhe opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to p comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. � -Corrective Action Required: ❑ No ��Yes oluntary Compliance ❑ Employee Restriction / Exclusion � Re -inspection Scheduled ❑ Emergency Suspension O Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne fitness lntervenffons and Risk Factors (Itelits, 1.22) (Cont) PROTECTION FROM CHEMICALS Prop r Cooking TempLratwestor --TPHFS— -------- i I! Af 1 FIS,, :5i F' SEC. KILPLA�, Food or Color Additives PRFs Received at Temperatures 3-2012.12 A(Jkhtm�s,4 3-30114 proteclion front UnapproV-d Additivcs` Poisonous Or Toxic Substances 4 1 �F/45'F Within 4 Hours, 7 101.11 Identifying tnfoi inalion - 3-5(11.15 Containr,,' 19 PHF Hot and Cold Holding T ()1.16(B) Cold PHFs Maintained at or below 7—'LO)2I �2 COndmon, of Uso" 41`!45° F' ?03 11 Co is tont - 7�DTI 1 501. INA) —0, F-7 �7 1 ,,11117eks, ;i -01,.1oiCj,1v 1 7-1-04,12 E hna11, k, )Nah ,�d,tw,(nrcmal Held at, or above 130°F. To;e 7.W4 14 Di,irn, AW -ins. Criteria, 1 7 205A 1 hind."Ina) F.Xl Contact, I nbi wa])W 7 206-12, S;;won:,, rim , ds a Vubfie, lleadfh Con T oi— Prop r Cooking TempLratwestor --TPHFS— -------- i I! Af 1 FIS,, :5i F' SEC. KILPLA�, 3-4C3, 1 10-j 1 RInamilq,� Unsiwej po!uo"s of, li,A,; I Proper Cooling of PHFS 4 -- Within 2 Hour.; cnd From -/:P1 -ithin Hmt�:, I I EF/4 5'F �k r - jol, i-103) Cco!ivu PHR kfidc Hoot Ambient CMPz[,awre fa ru ienrl t( 4 krmA I -�, r i2,[ PRFs Received at Temperatures - — --- ------ - According; In Lam Cooled to 4 1 �F/45'F Within 4 Hours, 3-5(11.15 P�,�t 'S 19 PHF Hot and Cold Holding ()1.16(B) Cold PHFs Maintained at or below 590 i)04(Fl 41`!45° F' 1 501. INA) —0, Hot PFIF51kfaintained at or above 140'F. * I- 4 16rA IRkmsts Held at, or above 130°F. To;e 3-4C3, 1 10-j 1 RInamilq,� Unsiwej po!uo"s of, li,A,; I Proper Cooling of PHFS 4 -- Within 2 Hour.; cnd From -/:P1 -ithin Hmt�:, I I EF/4 5'F �k r - jol, i-103) Cco!ivu PHR kfidc Hoot Ambient CMPz[,awre fa ru ienrl t( 4 REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS 21 80' Ili 1 Epp' 1-1---- A CONSUMIER, ADVi,2011Y Sh4 ----------- CaIEN UW,r kiJ. fxcxi, u.i,ipk,rai and 01, J0 vioi-A rovs Wal rEu 55 GO-- (Iferns 23-301 ORI o0r, M!, a, hwh Elf" w)i U.c 1,• lhP Codeand JE!5 1--!/R -------- - -- -- ---- i from 1 FC 590,000 1 F C F-o,.V And Foc)d Pn:�cTt�on FC, 3 Cr,'4 FamAmAni Ann ljlp,^ilq ............... j Po:sonAu� or TIX,c t,'jtejE-,;i,;s 3,0, 011) 3-50I.W(C) PRFs Received at Temperatures According; In Lam Cooled to 4 1 �F/45'F Within 4 Hours, 3-5(11.15 Conlin.- Methods for liffFs 19 PHF Hot and Cold Holding ()1.16(B) Cold PHFs Maintained at or below 590 i)04(Fl 41`!45° F' 1 501. INA) —0, Hot PFIF51kfaintained at or above 140'F. * I- 4 16rA IRkmsts Held at, or above 130°F. To;e as a Public Health Control rim , ds a Vubfie, lleadfh Con T oi— fl) Vante Refmo.meot REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS 21 80' Ili 1 Epp' 1-1---- A CONSUMIER, ADVi,2011Y Sh4 ----------- CaIEN UW,r kiJ. fxcxi, u.i,ipk,rai and 01, J0 vioi-A rovs Wal rEu 55 GO-- (Iferns 23-301 ORI o0r, M!, a, hwh Elf" w)i U.c 1,• lhP Codeand JE!5 1--!/R -------- - -- -- ---- i from 1 FC 590,000 1 F C F-o,.V And Foc)d Pn:�cTt�on FC, 3 Cr,'4 FamAmAni Ann ljlp,^ilq ............... j Po:sonAu� or TIX,c t,'jtejE-,;i,;s 3,0, 011) ° Massachusetts Department of Division of Food and Drugs Public FOOD ESTABLISHMENT INSPECTION REPORT • r # ,. i. Health Salem Board of Health • 4 1120 Washington,Street, 0 Floor Salem„MA 01970-3523 f ;Tel.,(978) 741-1800 Fax (978) 745-0343 NameL. Dat T e of Operation(s) Tvoe.of Inspection„ / ' 5 i � V _Food Service Retail W Routine C3Re-inspection Address �Risk C Level ❑ Residential Kitchen ❑ Mobile Previous Inspection Date: Telephone / El Temporary ElPre-operation Owner HACCP Y/N ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (E C) Time In:4.aa Ou . Permit No. ❑ 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 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. k u =FOOD PROTECTION MANAGEMENT ," •., -_ - y,e „e_ ;'y ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned / Knowledgeable /Duties i � v -113. Handwash Facilities EMPLOYEE HEALTH F0R6TECTION FROM CHEMICALS"' `" ❑ 2. Reporting of Diseases by Food Employee and PIC [114. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded !�FOODFRONIAPpROVEDSOURCE„„%,,%'.`'-..`"�a,'�_'v„„®,,;e�„�,�:;31 E] 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accu `acy of Ingredient Statements ❑ .7. Conformance with Approved Procedures/HACCP Plans i PROTECTION FROM CONTAMINATION ❑ 38. 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) Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 7. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S: 5Mnep UFCr 14= 1 1 - n ❑ 15. Toxic Chemicals `# TIME/TEMPERATURE CONTROLS (Fotentiallg Hazardous Foods)•'" '""] .a u7 "w.t .. .. ,. . wL"_w,w.ds r ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling a19. Hot and Cold Holding ❑ 20. Time A§ a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ;A El 21. Food and Food Preparation for HSP `.CONSUMER ADVISORY;', ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature -.1 1 Print: n PIC's Signature: ( Print: )n d f 4 Page- ofZages J 04 1. Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 11 596.003(1) 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 Iaw* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eg a* 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)B2ttled Charge* 590.006(B) 590.003(13) Reporting by Person in Charge* 3 1 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(5) Removal of Exclusions and Restrictions 4 0 C C * Denot e� critical item in the federal 1999 Food Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION S Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Iaw* 3-201.1.2 Food in a Hennetieall y Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eg a* 3-20214 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)B2ttled 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 Regualoty Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Came Animals* 3-701.7'1 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package lnteerit y* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.1.2 Shellstock Identification Maintained* Tags/Records; Fish Products 3402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(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 ox gen packaging, criteria* 8-103.12 Conformance with Approved Procedures` * Denot e� critical item in the federal 1999 Food Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION S Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE F(xds* Contamination from Raw Ingredients 3-3021.1(A)(2) Raw Anitnal Foods Separated from Each Other* Contamination from the Environment 3-302.1.1(A) Food Protection* 3-30115 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 3-701.7'1 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111. Manual Warewashing - Hot Water Sanitization Temperatures* - 4-501.1 t2 Mechanical Warewashin„ Hot Water SamfizationTem matures* 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* to Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms" 2-301.12 Cleaning Procedare* 2-301.14 When to Wash* 11 Good Hygienic Practices 2401.11 Eating, Drink'in 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(5) Preventing Contamination from Emtln gees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.1.1 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11. Hindwashing Cleanser, Availability 6-301..1.2 Hand Drving Provision I; 4 Establishment CITY OF SALEM BOARD OF HEALTH Date: / U Page:-,? Item No. Code Reference C - Critical Rem R - Red Item DESCRIPTION OF VIOLATION / PEAN OF CORRECTjON 1 -:. PLEASE PRINT CLEARLY- Date' Verified t C n o .� I o _ C, �. 0V- sl, , I. I - 1 h I C �Or h ✓ - Al a I Y�J l Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to P comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twentyr,�ive�/��dollars or suspension/revocation of your food permit./, , p// 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 (heft 1-22) (Cont) PROTECTION FROM CHEMICALS 14 t i Food or Color Additives 3-202A Addrhves* 3-3611 Protcainn frvm Unapproved d7tiiti_ve-S __ _ i5 3-501.15 j Poisonous or Toxic Substances 19 101.11 I khnitdGmg Info n ition - Original i-1 �' t2 Sl I'rtt� Cot tarn n" ter Hot Hotmr q 7 10111 ti ame N irk i,; C nu u r ra* ,'0t.11 }"-C_oratnon i S�aacnn -5rti tom" It.. 2112.11 _ __: R,,,t ict l - Pr, n. c un1 L t L7-202-12 j Condi lie of Usc Fi'_0.3.1' ! 'LLxr f u n trnct P nbdritivr a: i0 ?04.1 I 7 -'Cut. l2 Sane vers, C"ritc i i Ut.riic Owmic it, for q shit c k =tid c. C rttet9a" 204,14 Urirn 4r c t t, C rn u r _j � . tt5.1 i htcrt. nt ti (><xi i urr ct i.ubruw r' ii l 7.206_( ke" �u a _,. Pe hcaic._G fear � r .06.1, TF'xk r 13,61 i ,fess o n1" - i6 ,to 1. i,I1V ;f.I; i: 9t :55 F 1.5 SQC. 3 r a t:ti ctc S ic- -,59 3sec•' 3-•i(it 1 St.. i :izf} N 1 ..l`J t31 12ia�5S - !^)01 t i .` SaT According to Law= Cooled to _ 41 `F(45"F Within 4 Hots. 3-501.15 Cooling Methods for PHFs 19 � r i-1 �' t2 Sl I'rtt� Cold PHF, Maintaoned at or below ter Hot Hotmr q (!)3.11 i 11 .,lc 1111 16`-i t 5 3-50 I I6iAj lint PHI-, Maintained tt or above It.. #03.iltri tJmm" et_i$itvltCn.�'.Lt�R 1•x~fi- ,403.1 i(F! Itrinrinirr, nsiict'ti pu=bong of Hcef ($ r I Proper Cooling of PHFS 901.1-I(A) .. i C t><,d"n_ Cexik: d PHPs it U [dti`'F to P Within 5 trop,c a,!;1(ro117T"F I ,..:.O1,14ilii s ofiug I1HFz '4l do From `int .,nt FC, 1TIPCI eZ t lTe to r �i.sit, i t�a5'F' .I (lt rtr r I Hour � ? REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS {HSPS_ y 17 X71 ! liA i� lhtT i. tcuriced 7'rc ucF:aged Jvices w:d 12 SP} iti)} l kat or lli,utiii {rvi^d Animal Fo(d and kir, tie:d .`,irirz No!S..r;eB. -hC! 1 .t{,; i U rl :wd t4uvl P.ickda; ir. R, .enr i. f }NSUMER ADVISORY _ 603, i E �,:or, u!r c lis -iso: v poq :l for Colt ompticn of viut: � 1 (xis "`}ia i 5 lin �i ux5ktd �a �{]t O < ISc !lit t c d . Yi:.r ttiu L3 SFECiAL REQUtitrix#i:1`9i':; I - r&1;41 r_ rlt�ir,.r ,}t,i:.tl�-'ti t:i4i(Ibe ! .iJIL tt irtCi'.'S ?11 at tR'jiir:l( �_.,Oii= YIDLADONS Rr : A rED 20 G001).t?LTAe. q Ti'cS (helps 23-30) Cir „'..r -<'-Y, a.:f ...,'411. <.. 1., m,wfmh xpapJ ,r"... tr,r o i>r- 1,- ;/1 IS'xiln ertt 13 xlnd ri A, ilwloU a ifi ,d 'colr_ e<tn iw 'tt:ht, h .W <a.t . .r rci.dCode w i?t_}CM? 24, FC a p_s. 07 '�s is "r Toz tr C , 00. )4(C) PHFs Received at Temperatures According to Law= Cooled to _ 41 `F(45"F Within 4 Hots. 3-501.15 Cooling Methods for PHFs 19 PHF Hot and Hold Holding 3-501 1'6(B) Cold PHF, Maintaoned at or below 590.004(F) 41`/451. 3-50 I I6iAj lint PHI-, Maintained tt or above 140'1-_* t-50 Irl _ Held !oratxnce 130"T *_ I time as a Public Health Control 3V 1 t _� n, 5S r Public, tie' h L'JHti..1` 9t1 -Its' ri} _-- i V r ,uce ka�ui-enteat �_� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS {HSPS_ y 17 X71 ! liA i� lhtT i. tcuriced 7'rc ucF:aged Jvices w:d 12 SP} iti)} l kat or lli,utiii {rvi^d Animal Fo(d and kir, tie:d .`,irirz No!S..r;eB. -hC! 1 .t{,; i U rl :wd t4uvl P.ickda; ir. R, .enr i. f }NSUMER ADVISORY _ 603, i E �,:or, u!r c lis -iso: v poq :l for Colt ompticn of viut: � 1 (xis "`}ia i 5 lin �i ux5ktd �a �{]t O < ISc !lit t c d . Yi:.r ttiu L3 SFECiAL REQUtitrix#i:1`9i':; I - r&1;41 r_ rlt�ir,.r ,}t,i:.tl�-'ti t:i4i(Ibe ! .iJIL tt irtCi'.'S ?11 at tR'jiir:l( �_.,Oii= YIDLADONS Rr : A rED 20 G001).t?LTAe. q Ti'cS (helps 23-30) Cir „'..r -<'-Y, a.:f ...,'411. <.. 1., m,wfmh xpapJ ,r"... tr,r o i>r- 1,- ;/1 IS'xiln ertt 13 xlnd ri A, ilwloU a ifi ,d 'colr_ e<tn iw 'tt:ht, h .W <a.t . .r rci.dCode w i?t_}CM? 24, FC a p_s. 07 '�s is "r Toz tr C , 00. Commonwealth of Massachusetts ` • City of Salem Board of Health lGmberiey Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: File Number: BHF -2004-000335 The Tin Whistle 241 Jefferson Avenue Salem MA 01970 LOCATED AT: 0241 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2010-0046 Jan 4, 2010 Dec 31, 2010 $140.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $140.00 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR DAVID GREENBAum, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4' FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGRF.ENBALIM&ALEM. COM 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTT/4 P rMq/ E TEL # ?ZF N1 4/ z ADDRESS OF ESTABLISHMENT 2V cJ0ffMd1Q A✓ir FAX# MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'S NAME ailt6 �'be 0"D TEL# 6/7 Yd'd 7993 ADDRESS STREET II CITYJ STATE ZIP (� CERTIFIED FOOD MANAGER'S NAME(S) 1�{6 J/e, 04to CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON 6 c 6 ®S ted -r 41- HOME TEL # 17h' 744 / Yfdo ©AYS+O Z11 -s y;;�T,uesday �Ned_'nescay,a _ - Thuisday g Enda 4% 6A ISunday, HOURS OF OPERATION Id( �M /f H par/ ay. % — /nJ Please write in time of day. (For example t tam -11 pm) I /PnM P Om , ./s TYPE OF ESTABLISHMENT FEE (check only) CHILDCARE SERVICESMURSING HOME ---------------------------------------------------------------------------------------------------------------------- RETAIL STORE YES NO less than 1000sq.ft. =$ 70 MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO 1000-10,000sq.ft. =$280 $135 more than 10,000sq.ft. =$420 -------------------------------------------------------- RESTAURANTE NO ---------........ less than 25 seats (Outdoor Stationary Food Cart $21 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICESMURSING 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 ag9,paid kstate taxes required under the law. , Date Revised 424/07 FOODAP2008.adm Check# & Date or .w�+.t,14A 7- f1.7 `'Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4t" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name "Ttq- Date n'( Te of Operation(s) Type of Inspection Food Service Retail ❑ Residential Kitchen ❑ Mobile El Temporary ❑ Caterer ElBed & Breakfast Permit No. F Routine 9 Re -inspection Previous Inspection Date:-��dG� 1-1Pr -operation ` ❑ Suspect Illness E] General Complaint ❑HACCP El Other Address �, /1 n n� ; k� Risk Level Telephone ! (? Owner I nI �• ' t HACCP WN Person in Charge (PIC)/ Time In: r out: : �,G�wl Inspector �o r ; ,� Each violation checked requires an planation 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) P 590.009 (F) IX action as determined by the Board of Health. T FOOD PROTECTION MANAGEMENT "",„„„ ❑ 1. PIC Assigned / Knowledgeable / Duties w.. "EMPLOYEE HEALTH ` ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE E] 4. Food and Water from Approved Sour _ urce U : nti �.r�mw=-� TwE/rEMPERATURE CONTROLS (Poteally HazaMous Fopds) • 3 � ,iss, ❑ 5. Receiving/Condition 01 6 . 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling q PROTECTION. FROM CONTAMINATION ------ ❑ 19. Hot and Cold Holding ❑ 8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control O9. 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) 28. Poisonous or Toxic Materials (FC -7)(590.0011) 29. Special Requirements (590.009) 30. Other S: 580/W6 lFom 14tl !REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) �ti# ❑ 21. Food and Food Preparation for HSP 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: �I � _ a - /(t q� l fix: U1034-/V1a� Inspector's Signature: U a Print: l PIC's Signature: n `� (� Print: �` i Page4 of-aPages V Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) AssignmenfofResp bnsibility* 590.003(B) Demonstration of Knowledge* - 2-103.11 Person in charge -duties EMPLOYEE HEALTH 2 590.On3(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3.201.13 Fluid Milk and Milk Products* applicants" Shell Eggs* _ 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water" Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge' 590.0(6(B) 590.003(G) Reporting bj Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 C 0 C FOOD FROM APPROVED SOURCE * Denotes, cridw] item in the federal 1999 Foal Cate or 105 CMR 592000. PROTECTION FROM CONTAMINATION $ Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermeticail 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* 590.0(6(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Ve. etables 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 ReceivingfCondition 3-202.11 PHFs Received at Proper Tem eratures* 3-202.15 Packa e Lite it * 3-I01.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstuck Identification * 3-203.12 Shellstock Identification Maintained* TagetRecords: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(7) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures lHACCP Pians 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes, cridw] item in the federal 1999 Foal Cate or 105 CMR 592000. PROTECTION FROM CONTAMINATION $ Cross -contamination 3-302.1](A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3302.11(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 Ve. etables 3-3(4.11 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 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 Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and - Mouth* 3-30'L 12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 59R004(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 Nand Drying Devices 6-301.11. Handwashin y Cleanser,.Availabilit b-301.12 Hand Drying Provision CITY OF SALEM ,�i BOARD OF HEALTH Establishment Name: \ f\ /Yl I) A S 1 Ii�� Date:Page: Z of Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF ORRECTION ,Or Date No. Reference R - Red Item - k _ _ ',,-T Verified, Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of {our food permit._ ❑ No I ❑ Yes ❑ Voluntary Compliance ❑ Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Voluntary Disposal ❑ Emergency Closure ❑ Other: Violations Related to Foodborne fitness Interventions and Risk Factors (Itenla 1-22) (Cont) PROTECTION FROM CHEMICALS 14 (i,mmillwen F; b, a ciII s t: (iel c Food or Color Additives _-_ I Aninri5-u7; 1_ �Aec.^` 3-202.12 .additives'" J 3-501.15 3-362.14 __ Protection from Unapproved Additives" 1S 3-501.16(B) Poisonous or Toxic Substances 540-004(F) 7-101.11 Identifying Intonnation - Original ° tI' R Containers" 3-501,76(A) �r 102,11 Common name N intoo„C owame A� P.C, xq:,rtd t�','i: CrI,i,'.,_. 2011. 11 SattWvr Sunac- 202.1. i 7 c+t tct on - Pr unu v d t_, 1 Rehm ting for (Sot 111Iding 7-202-12 Condition of usv 7- 303. 11 Toxic Coniarnex Proldbn>on ' 204.I1 x204.13 sal 1111 (Fri 1erw Owl nicl, Is _ Chimicahiforxkashuv Ltnd cW Cnte6a” AteLim Crnvtit t 7..2{)5,11 htud ntai Food Contact, Lubl anre�: -206.1 _ R mood l u Pc btidf . Crtett t L7 Ofl.t_ t Rkxf n l3tt S-anons, 13 l rnvr,t lg Pod=der Pi,s[ and I �_..�..� Morilontom__ 16 ! ' Proper Cooking Temperatures for HFs -11)1 1.1 v: l qct _ i 1'��,. 155 F 15 Sl:c. 1 3-403111(C) C.on..nea:'ialh 1Scnwc cil RIF IIi"d -._4103_i I(L) 12 I tdmaming Uwted Porttoxv"I lied si<t' (g t Proper Cooling of PHFs ?-S01_14(A) �� C Count C(K)k'ir. PHh,, h, IJO"i'to :`r'F Within 2 1fotrs and From 19 t' to 41 F/45 "F SS thin S How!,, n r; trx Itt 1'1{F %Lidc f-rcnt kin ent IN Wltbin4 Hour", 1 � F'. n1-.rreurre 3h._r,.atcncs t:• 41 E;vS`i< 19 20 r3 -501.14(C) (i,mmillwen F; b, a ciII s t: (iel c _-_ I Aninri5-u7; 1_ �Aec.^` t ;-40L I (I3)(I )f2; Po; and B of Roam - I_I 1 12 i nxn*_ 3-501.15 Cooling Methods for PHFs t 3-501.16(B) Cold PHFs Maintained at or below 540-004(F) Fish. MeIli, 3-50 L WA) ° tI' R iml lc:I�c.t J..m. 3-501,76(A) I � ._:. i.'. P.C, xq:,rtd t�','i: CrI,i,'.,_. lu i ` � r _ �v:..ouc Re' 1 Rehm ting for (Sot 111Iding -- - �}Jtcacvcgae- If IMUie SI.Mdinf, 3-403111(C) C.on..nea:'ialh 1Scnwc cil RIF IIi"d -._4103_i I(L) 12 I tdmaming Uwted Porttoxv"I lied si<t' (g t Proper Cooling of PHFs ?-S01_14(A) �� C Count C(K)k'ir. PHh,, h, IJO"i'to :`r'F Within 2 1fotrs and From 19 t' to 41 F/45 "F SS thin S How!,, n r; trx Itt 1'1{F %Lidc f-rcnt kin ent IN Wltbin4 Hour", 1 � F'. n1-.rreurre 3h._r,.atcncs t:• 41 E;vS`i< 19 20 r3 -501.14(C) PHFs Received at Temperatures According to Law Cooled to _ 91 °F/45`F Within 4 Homs. 3-501.15 Cooling Methods for PHFs PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 540-004(F) 41`/45° F' 3-50 L WA) Hot PI -112c Maintained at or above 140'F. 3-501,76(A) Beasts Heid at or above 130°F. T —Time as a Public Health Control lu i imrt as It Public Health Conn- _ �v:..ouc Re' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 2t ( bCll I't.i) I Unp tsteuri td Pr I at agcd Juices and I IL ver f es with WatnntE lab is' 5w 11(13) UK of Pa vu6zvd t �* .i b;, t I i (h 7) �h,,t or Pnlisll (t>tm::d Aaunat Rx;d and �� Ra S, d 7 dot Not iciwd tt : w lCi U, ,.,ed Pood 1 tttagv Lu R orvca'- C NCUI ;ER ADVISOn' _ 22 b(E 1 1 Coonlau ILr Aio,niotti ,'t.wd for C rnt ut:stir,•„ o 3 -n IM! FINK!' Illat Jlc fv a.v Underr .)kcd o: ._tllllnilu i 1 11;+Rau Shell s, )'3391 A)- s) i tient t,.. , Se hLt �{9.OEn}, 1 CY3j;o j alnr tk- m,l d"', lt>;r(L temp .taf deal f,:fchcn oywiitions shotio,' c n .&, fhl ) nrunrlat , of aXilIlom' .sr f;,i: 5 fJi11FF `'i; tt� t'tt?iflGO HI`ti i's. to d .iltil f a �. ice,,;. 3 t tiICa3G5ft S. 1 4 #iL 2Ttt7 v5 R L.4T L? 7CI GC%C1 2 t?E7Adt PRA1 i)I C01 (Items 23-30) C,;ivai st3d ru 3-r ans4r :+<'._rtra+tt. nPick ,to ao; hu ;r, tur t�3ot'In�rnf ill t s: �n reroerK 3a ❑nd 1;14/,x<lrars1:;te1 aiSole. am i"i own, in?tin. n -nn =a ., trr t[:hr Food forin and 110y C11/{ ircxi Proic:,dcr 1 and Utr,sos i ft; - 726 - Pc s- l o IS f �%f N ate 3i$_ i 6 7-6 the s �r Y:-H.'''?..w.ti`k+""'rs+�.+v...� .e+a•w�M+" r._... i. r..•k .. a,-- +-.-�. Massachusetts Department of Public Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Health, Salem Board of Health 120 Washington Street, 41h Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name _ �f� Date (7> iJ 'Type of Operationfs) [Food Service ( n Retail El Residential Kitchen ❑ Mobile ; [ITemporary ❑ Caterer [I Bed & Breakfast Permit No. Type of Inspection Routine i Re -inspection Previous Inspection Date: ElPre-operation ❑ Suspect Illness [I General Complaint ❑ HACCP ❑ Other Address v %� t `) Risk 1 t Level -:' j Telephone !a /,Ci/l' Owner PA �a Q HACCP YM Person in Charge( tC) rr11 U (A t i/✓ItD_ A Inspector 9n -P1; p�u, � U, �a p Time In:' ;�� Out:;) /}1,� Each violation checked requiresaniexplanation on the narrative'page(s) and a citation of specific provision(s) violated. vt , Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health> zard and require immediate corrective 590.009( E) ❑�` 590.009 (�X action as determined by the Board of Health. �m / Duties El2. Reporting of Diseases by Food Employee and ❑ 3. Personnel with Infections Restricted/Excluded ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities `PROTECTION FROM CHEMICALS [114. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE_,„ E>TIME/rEMPERATURE CONTROLS (Potentially Haiardous Foods)' E3 4. Food and Water from Approved Source •+ a „ µ r „ r f (5. Receiving/Condition ❑ 1kA 6. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans t'PROTECTION.FROM CONTAMINATION'»� ` '•�'` e �'""`"" '� r,�/,ter 8 Separation/ Segregation/'O,rr tection ( "' LJ 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 ofl Health. /fp. CI N.- lN- 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other 5: 5901rnspec(Fom(%G�4�0o�c�'/j 1 l [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)7,g ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY„.......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:\ JA Inspectors Signature: �f� JA Print: �� t t PIc's Signature: e' Print: C RA7C7 3 Page of_� Pages Violations Related to Foodborne Illness interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment on 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* a licants* 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 Drinking Water from an Approved System 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge' 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restriefions 4 C 6 C * Denotes critical item in the federal 1999 Food Code x 105 C.i R 590,00 0, 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 Eg s* 3-202. t4 Ew and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-1.01.1.1 Drinking Water from an Approved System 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved 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 Came Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Pro er Tem eratures* 3-202.1.5 Package hate it y* 3 101.11 Food Safe and Unadulterated TagsfRecords: Shellstock 3-202.18 Shellstock Identification 3-203.12 Shellstock Identification Maintained" Tags/Records: Fish Products 3-002.11 Parasite Destruction* 3-402.1.2 Records. Creation and Retention* 590.004(.1) Labeling of ingredients' Frequency of Sanifization of Utensils and Food Contact Surfaces of E ui nti:nt* Conformance with Approved Procedures fHACCP Plans 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced ox en packaging. criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Food Code x 105 C.i R 590,00 0, PROTECTION FROM CONTAMINATION S Crass -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 Aminal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.t5 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 Resetvice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe. Food* IF 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Tem eratures* - 4-501.112 Mechanical Warewashing- I -lot 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 t Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11. Frequency of Sanifization of Utensils and Food Contact Surfaces of E ui nti:nt* 4703.11 Methods of Sanitization - HotWaterand Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms"` 2-301.12 Cleaning Procedure* 2-301.14 When to W'asb* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.1.2 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* l2 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 SugcA5d with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.1.2 Hund Dz 'ng Provision CITY OF SALEM _1V/ BOARD OF HEALTH Establishment Name_-_T�IAA Date:, -L;— I 2—� Pager of Item v,,, No. Code vy�gg Reference IC ;Critical Item ff, R Red Item '�,,DESCRIPTION OF VIOLATION [PLAN OFCORRECTION4pF%, J,u CLEARLY X �LEAS"E' PRINT C�� Y Date • Verified '1p (29A ,-A 019 P"o 'J*t DPA�7h,10, (AI14A) V I LoWel.- //A fA, AA O.P 4)yeoll 3 9 0 A(\ j(12_,e</ (4, 0 /1 �0!./iii PAipp_'A V)OOK I,) Il" L17 -ION #,PA;A,LV T-) )�g 00An1,rrj 0 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/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. X Correc(je Action Required: ❑ No lul Yes 61/ Voluntary Compliance 0 Employee Restriction Exclusion Ll Re -inspection Scheduled 0 Emergency Suspension o Embargo u Emergency Closure Voluntary Disposal U Other: -5137 34(c) r. PHFs Received at't°esnperatures Viotsornis Related to Foodborne illness tntervenifans and Risk According to 1,aw• Coined to Factors(netts 1-22) (Cont) _ I 97 4YF 14tthzn 4 Hours. � S.11.l5 f6, l}tn,= M tbrds for PI3Fs PROTECTION FROM CHEMICALS i9 PHF Hot and Fall "ding 14 Food or Color Additives 2 )2. t2 Ad huves'x 3 S i3. C6fB) Cold PHI s Maintained at or below 590,004(F) 41 45° f 3-30114 protection fromUvahpro';ec 4 dzteves'� '}-;07 1fx£t''y HotPFils Is ._j_ Poisonous or Toxic Substances -j M ztntaiued at or above 7-101.31 } Identifying, lntennration - Ori inal . 1 . II _ 3 �s trl ifi(A) Rusts }lull at or zboce 1301, _ Containers, — -102-11 Common Matte W orkif - C aufnners� S Time as a Public Health Control � 7 20111 Se auuan Stoi e - 3-501 i9 Time at a Public, Ilealth (ontrut` 7 2011: . Restrictic n - Pre< tnec and lice° ry t •`3 Variance Rz,gtitrctne.nt T_ 7-202.12 Conditions of U o' 7'rii3.l1 Tt)ztu C o�itaaner Prolnbi ions' REGUIREMENTS FOR HIGHLY SUSCEPTIBLE 204.1 t Samozety Crti ni Chi nuc h POPULATIONS {FISP t-- I ? - �--- 21 ,)i SItJn avteariudPru t sac.1cdlwcesamr 204.12 aW 111 mCi LL jj-+-20A.14Dr m 'd encs. C rncria" Rol. era es with Wari ins+.',ab 1•.4 3-80111(bi Us of Paganr d F;a� 7-265,11 Restricted Use Incidental I cxxl i one id esLCtibnteriti. cants I �' 3.g07 11(f) Raw or Prudilx Caked Aminal Food and i Pe nud.. .�. Ran Se dSprouts Not Served 7 '06.12 Rodent }3 itf Siritions Unopened Feld Package Not $e -served- * � 1.206.13 £racking Powder. Pest Control and • `"'_"'-"""- c- 17 TIMEITEMPERATURE CONTROLS Proper Cooking Temperatures for _ _ PHFs i-401.11 A(1)(2) E.gg- 155` —15 5 c _ li m o.di etc Service 1 i5 Y75: T401. 11(A)(2) Comminuted Fish, Meats & .Game Animals- t55°3'.19 sec. " -�uv.l{ e�per etln:xnu nwi e4v.gi—a 11ii:..lw 34'01.1 l(A)(2) i Ri nitasAn eoed Mews 155�F I.5 c �b 3-1.11(A)tat Ilouitry, Wild (,ane, Stuffed PITFs, Stirftaig Cont nidua Fish Meat. Ponitry or Ratite 165°1' 15 .see. 3-401.11 if ){ } 1Yholr-muscle• Intact Beef Steaks 7145"F x __ 3-401.12 Raw Aminal Hood, Cooked in a _ Mici'owavf 16_5°F * _ 3d01.11.(A)f11(bi I All Other PHF, - 1.15"F 35 sec.'s 3403A I(.d)R(D) Pl-1Fs 165°Ft 15 sec-'^ _ 3-403.11(B) Microwave -165° F 2 Minute Standing Time'` 3d03.11(C) Commercially PuxessedRTE F+xui- 3-403-11(F) I Remaining Unslited Portions of Beer IFS Proper Coaling of PHFs tit 3-501. f4(A) tooling Cook. PHFs flow 140'F to - 70"F Within 2 Hours and From 70`F j to 4l °F145' F Within 4 Hours. ° -3S01.14(B) ColdingPHFs Made Hein Ambient i Temperature Ingredients to 43"F145'F ��. Within 4 Hours' * 7)cac+tes ruical it o; in thr iidk lit F)99 Foa3 Cc>G+c or 105 OAR 591) o00. CONSUMER ADVISORY _ 2" 3-00? 11 Conwrorr 'ts.visoiv Posted brr Consumption of l rviilrcd t vxis'lhre are Raw. Undercooked or Nor Othem ice to FAmznate �Pa�tht�2t', n_ssi ra= { .-302.13 Pisremin,ctiggsSubatztuSefin Raw Shell SPECIAL REQUIREMENTS 5907()09cA}-(D) Vielations of Section 590.(X)9{A)45) in catering. mobiic fcsxi, temporary and resid utial kitchen operations should he debited udder the appropriate ,eciunis alcove ifrel,ited to flra3bvrne Illness ntcrrpntions incl risk factors. Other 590.009 v=iodations rc;lating to good retail practices Analild 1v debited under 1129 - Speczal Requirements, (Items 23.30) Gridtrai and eio!lrlwns, which do not relate to the faodbelrne dlnesr irieervsrtFians rsrtcl rfs>{ radars Uv ei! ab'we. cart be fervid in the fplf,>nang ser rions of the Foad Code and 105 C.,WR A)r L-E200 �((�� rr BOARD OF HEALTH Establishment Name ��nn A /V1 t o O Date: 3— Page: of Item Code-;` CCrmcel tteiii' �� DESCRIPTION OF VIOLATION 1 PLAN OFC RRECTION Date NO.-; ;,Refer@nC¢ R` REd ItOm - g �' n .x. '., �' e� s z' p EASVPNMT CLEARLY VONflCd ; d O 1rjo S S Discussion With Person in Charge: �Corrective„Actlon$Regaired U No y ❑Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other Fn P. i'.. /RFV 'l /'J(1(llll N()RRC R WARRFN - R(lST(lN Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000335 LOCATED AT: IGmberley Driscoll Mayor The Tin Whistle 241 Jefferson Avenue Salem MA 01970 0241 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2009-0237 Dec 29, 2008 Dec 31, 2009 $140.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $140.00 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 i` ?! e�' !lt`l i. 1Y1 is'11 i KIMBERLEY DRISCOLL MAYOR JANET DIONNE, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH [� 120 WASHINGTON STREET, 4" ' FL TEL. (978) 741-1800 FAx (978) 745-0343 IDIONNE&ALEM. COM ��® QFC 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT THE _rlN V407 -be TEL #_(998) IV/_191Z- ADDRESS V/-191ZADDRESS OF ESTABLISHMENT L4I AffW&4 4VC- FAX #('9'1F) 7g) -1 9 ( Z MAILING ADDRESS (if different) EMAIL -Business': / /� Website: OWNER'SNAME 699lls �fF (/R/0 TEL#(W) iT0-799.3 ADDRESS STREET /JI CITY 1 STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CRAlIY CERTIFICATE#(S) I I LCo,30 5`_ (Required in an establishment where potentiallyy/ hazardous food is prepared) EMERGENCY RESPONSE PERSON_ f Oft& DON 1U HOME TEL# 9%P q6? -/d9(' R.DAY.SOF..OPERATION I'. 'Monday :^ Tdesda Wednesda Thursda Fntla SatuMa .: Sunda ' HOURS OF OPERATION Please write in time of day. 11 Atft. _ I A>W{ l p"I —1 AM (For example llam-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - _----------- - --- - - - RESTAURANT YE NO less than 25 seats (Outdoor Stationary Food Cart $210 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES ------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT (such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 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 O Date r Social Security or Federal Identification Ni ------------------------ ----------------------'—l--------- Revised 424/07 FOODAP2008.adm Check# & Date��i7 __�I 6 $ Was§achusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Sit am Board of Health 120 Washington Street, 4'" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name --- Dat Type of Operations) Type of Inspection Food Service Lp Retail t Address JI R'i k ' Routine Re -inspection 041 Level ❑ Residential Kitchen ❑ Mobile ❑I Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Previous In pection Dater� ElPre-operati3n ❑ Suspect Illness ❑ General Complaint HACCP El Other Telephone _ G I Owner (L HACCP YM Person in arg IC) Time Inc❑ Out: Inspector l D , Each violation checked equires 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,: �:r F-11. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2 Reporting of Diseases by Food „Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives a ❑ 15. Toxic Chemicals E]©4. Food and Water from Approved SourceTIME/rEMPERATURE CONTROLS (Botendany Hai"ouscsd Fs) `f n,.:'d., d...,-�...- _.�. t ✓s s p;- . ai i �_so,e � .Lm ,..,...�...k tr.x,itfJ9 ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling „ PROTECTION FROM CONTAMINATION El 19. Hot and Cold Holding s;L V r ❑ 8 Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control R- s. Food Contact Surfaces Cleaning and Sanitizing ❑l 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. I' N a 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 6. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) (990.009) 29. Special Requirements 30. Other �'/i,"'+S'S9JInsPoCIFOmB40.�ec r, REdUMENIENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)" El21. Food and Food Preparation for HSP CONSUMEFj:ADVISORY;a' El22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): F11 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: Print: ` PIC's Signature: Print: G u / , U Page of q Pages .,j 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 Witter* Applicant To Report To The Person In Drinking Water from an Approved System. 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions andRestrictions 4 in 6 1 - - Denotes critical item in the federal 1999 Fax] Cade or 105 CMR 590 006. $ Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.1.2 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Witter* 5-l0,Li1 Drinking Water from an Approved System. 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruit's and Vegetables Sheltlish 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 Ra ulato Authorlt 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 Pro ex Tem refaces* 3-202.15 Package Inte it 3-101.11. Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-20312 Shellstock Identification Maintained* Tags/Records; Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(7) Labeling of Ingredients" 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 packapng, criteria* 8-103.12 Conformance with Approved Procedures* - Denotes critical item in the federal 1999 Fax] Cade or 105 CMR 590 006. $ Crass -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 Aminal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruit's and Vegetables 3-304.11. Food Contact with Equipment and Ufenslls* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reserviee of Food* Disposition of Adulterated or Contaminated Food 3-701,11 _ Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.1.1 I. Manual Warewashing - Hot Water Sanitization Tent eratures* - 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem eratures* 4-501.11.4 Chemical Sanitization- temp., pH, - concentration and hardness. * 4-601.11(A) Equipment Foci 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* 4-70311 Methods of Sanitization -I lot Water and Chemical* t0 Proper, Adequate Handwashing 2-301.11. Clean Condition - Hands and Arms* " 2-301.12 C:leanina 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 Em to •cos* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* acities* 5-204.1.1 I-oeation and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Hindwashinz Cleanser, Availability 6-301.1.2 Hand Drying, Provision J'.:1 CITY OF SALEM BOARD OF HEALTH FQtahIIQhnnPnt Name: Date: 0 0-) Page: of Item Code C - Critical Item •Verified 7- DESCRIPTION OF VIOLATION / PLAN OF�CORRECTION Date No., No:, c Reference i Refer R Red Item 4 s, A, 1, m Z", f&"� PLEASE PRINT CLEARLY JAC'�, -f-y)e, A e 4- U -4 _>-, 10 �:67 ---- pa ").Zj 00nAA Aar�el' -1)4 - go J o n&4 -4 T_PSJ-p-JNjf A) go r"I)CA—C Icc V C, An 4- JACJ)�,,,_ 0, J Discussion With Person in Charge: Corrective Action Required: u No Yes - I have read this report, have had the opportunity to ask questions and agree to correct all u Voluntary Compliance 0 Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to Re -inspection Scheduled U Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that V noncompliance may result in daily fines of twenty- ive dollars or suspension/revocation of 0 Embargo Lj Emergency Closure your food permit. o as o Voluntary Disposal Ej Other: 21M 4) Violations Related to Foodborne Illness interventions and Risk Factors (hetes 1-22) (Cont) 119 15 M IN M Poisonous or Toxic Substances -7-- lom k1kintifying, filfol inalion -- OriViial, -------4 Comainer,� -- -7 102,11 Orisma) I a iV 72011.. ,S00araulln- ISt olugt' -20117 7-203. I I I 1-204A1 Sanitizes. Criteria - Cbemic7a Fs* 7-205-11 1 livilideatal Faod Comact, lAirn icajOs' -206' 13 j Tiacking Plmdcri, Pest Control and Proper Cooking Temperatures our PHFI; 77161AIA(l)(2) F.,&, - 155'F 15 Scc, 401 11 (A)(2i Comminuted Fish, MellLS & Geflllt 41045u F- Animals 15j'F 15 see, 3401.I1(B)a5,',l:2) —IONW-111 1 Park and 13 e Roast -130'F 121 ra --- I c7 7 Raljtee' hijeo'cd %1catA - 155 F 15 461.1 ](A) 1, P utlir,,'Alld t,aine Stuffed Piff,, stliffilra comail'ing FishMeat, or Raoles-1 65`l i,5,wc. 3-401.I I (C)(3) _Paltry Whole mundc. Intact Beef Stc,l 1451, 3_41.12 Raw Animal Foxis Cwlocl ju a Micioll'tive 165'F lliAl'll(ht I Ali Chl- roqr'.- IAS -P I 3-4i)3J1(A)&(D) Pflf`s 165'T 15 sec, I ---- 3-403AI(13bluile, ) Microwave- 165' F 2 NstandinI, 403.11(C) Coannercialiv Piwessad RTE'Fuod or —Bet LB I Proper Cooling of PHFS -- - -3-ST4,14A) Coaling Cookl.,d PHFs from 1, 70"F Within 2 H(ws and Front 7V17 3-501.14(23) ("ooltag PRF N Made Front Ambient Termscraurre tnlxedietits nl4l°F/45'F Within 4 1 iours Don"ies critical aell" lit the ie'leral 194 Food Cmre or 105 CNIR 590 501 1410; ` PHFs Recmed at Tempt ratures Amoi-ding to Lw;% Could to 4f --V45 F Within 4 HoupF 5 1.) 1 Coolin'l Mmfsralti for PHFl, 15(17 Ifi(B) Cold PHFN Muintained at or below 390,004(F7 41045u F- 3-50i,16(A) [lot PRFs Maerintined at or above IMOV t I Roasts Held at or abate 130,"F. * -----T-7ime --asa Public Heatth —Control 501 19 I Time as a Public Health Control __ Secerarescuith:Aaimngl..abyls' r r3-80 1. 11 (D) Paw or PaAmoralalIv Cooked Amoral Food and kltw SL -,d svvlms Not Se;Ved. , 0 Wil I (C � l7noriened Ilolid Packao, Not Re-1,vrverl Oxisumor Advigoz v Pos'tod for Consumption of Aniaol f Nxl, That are Raw, Undercwked vi Not Oflvlrs~ ise to E.lirnmare Pinhos,ens MW! 3303.23 i Pastelmzlei Egg: Subsoaue for Paw Shall SPECIAL REQUIREMENTS 173 Vi—vlatifw)—ofSectiot catering, mobile folx:L temporal ' v and remdential kitchen opicrationsAi(add be debited ander the appropriatesel.,tions above if related to foodborric illnoss into aventionsand risk factors Offer 590.009 violations relating to good retail practice should be debited under #29-- I 29 -i special Requirensoats. (Items 23-30) crifira? alldnofl-(raliarl violalwn' which do riot relare to Me ,foodborne ilkle-st interventions rind risk jaclors lived above con ba filand to te,-Iwnv of the Food Code acd 105 CMR �90'000' S.. " ljlsv .. 1-1 r CITY OF SALEM n BOARD OF HEALTH Establishment Name: fLn -T) /l1 (� l Date: l if t Page: 3 of i;f— 'Remx. °Code, t,f. <. =C -Critical item €'^ -", 'b �`4, DESCRIPTION OF VIOLATION /PLAN OF CORRECTION ''`` �" e y°` a "' Date:,, ,No. r _ Reference Reference+,,,.�,.. R -Red hem `,�'�x: p 'Y�„ ..�%.L. ._ k � `,`.w�a PLEASE PRINT CLEARLY �^� �' `-" sv ,S verified NO is /)a ry 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 ddllars or suspension/revocation of your food permit.''lA,,, ( Corrective Action Required ❑ Voluntary Compliance 4�e-inspection Scheduled ❑ Embargo ❑ Voluntary Disposal ❑ No I`❑\ Yes ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: 3-54)1.11(1) PkIFs Received ti Tentperatuees Violations Related to Foodborne Illness Interventions and Risk According to lav Cooled to Factors (item 1-22) (Cont)m _ 41 'FI45 F W i11nn 4 }lout s. PROTECTION FROM CHEMICALS Methods for P3iFs 14 ' �� Food or Color Additives 14 E _ PNF Not and bold Holding 3 262.1Additives- s01 t6 t3t Coed PH1 s Mmntsinul at or below _ 3-30214 Protection from i. n cFfrru ed Addelues' b-50 O>'A) lint or above PHl � 4fainfained at ti: l5 PoEsanous or Toxic Substances €.1 7I)1.1F ldcnutyenglnioimation -Oi� inai , gtit_f6(Ii) RwstsFlcldatorsbove C oittnu er, _ — -- 7-107..11 Common dime Workin = C out ine r,'" 1�-2 - -- Time as a Public Heatih Corstm€_ �- 5fiT. 19 Time as a Public health Control' I 7-201-1 Se ailu6rz Shoiage -- '9U.'01(H) SariartrRt.yu3ret;tent 7-202-11. .Rett Action - Pr strice smd Use* .... _— --- - 7202.12 CbndmonsofUSQ 7-203 11 ToxicContarnex Prolub"t:ious' REQi71REMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saunirct:.Cxitort� C°ieiniu tc_ _-c6--a°� POP(�f.AT(npa jt, -- Chemicals for W +�6tn k rx ata (hl 2t i 3-501 �. I eta) inpa tcuv 9 d Prc pair ed Juices and 7 2(g. t2 -- - — _ Br.reia e. with famin t..ibetsa 1 7-204,14 hrn enc Ie. Gruel is _icmis� iRt0i1iFAof Pa"teutved Eggs' 205,I1 Incidental Food unlct1ad)1i(7) Raw orPaifitllGtk3Animal Fixrtznd ?Q6-11 Ro,tri led tse Pesticides Cteua X R n 4e'd S rr rats `1nt Sei`vc3 " 72'06.12 Roden Bao Statnms --- �--- ---- -- (ii Ll r( �C.rE x.ned fL12Ct Packaar Loi Re -,1 1 1�e 1. _f r 2176.'13 9raekutg P,"'," Psi Control and 4ioonrrrin �_� CONSUMER ADVISORY _ ` 22 3-60_ 11 Con timer Aar s-oif Ps sted for Consuruptien of T{bAEITEMPERATURE CONTROLS 26 Proper Cooking Temperatures for Aniu zi 1 x h Miriam Kau ttnderax ed u. Prop i Noi Orh z is Processed o Elinninaie a. �Ot LIAtD(E3 (by- i.55T' IS Sre.— �_ latfio�ai 7- res- �tnru d cu. 4er.dce 1+Ti iSnecw ?.3J' t i Yaste rv,d Fgga. Ssbsoune foo RAW Shell 3-40f.11tA)f2) C mminuied Fish. Meals tk Game Anunals SPECIAL. REQUIREMENTS -40311(6111}(2) Perk, and BeetRoatt-73Qt F2Fntin* ---� --r}01.i1(r1Jt�) Ratnr.e, Ir)jeel_n'bhats 3 5 F 15 590of %1kai 590.(X')9iA)-(D)in see caterine inkA)ilc t(x)d tentp(,rary and 3-40LI1(A)0) Poultry, Wild Ciame,'Stuffed P Fs� � rerio3snt tt kitchen operation. should be j Stn$nig Containing f is1t, Sieae, i :ebn C uridet the appropriate sectio)'ts i II Poultry (n Ratites 165'F 15 s<u ' above if i.laied to icx)d(xrrne iflneis 3 40111(C){3) tshole-muscle, Inti ict Buf Steaks inter entiows and risk factors Other i �� 144 1 590.")OP") violations relating to <'ood retail � i 3-401.12 R i%An:ma I t rtcis C�tkcd iiia lame rices shoold he debited under #'29 - � t9iwawave 105 F _ Specialketl€n,renie:nYs. 401.11(A)(1)(b) Ah Other PIIF. 145"1 15 Reheating for Not Holding -VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1 PHF,> 165`F 17 set '^ (!tent; 23-30) -463.11 B) Mi lou ave 16`+ C 2 Tvhnu Standing Crurra unit non, ri fi:at a knfwas, which do inu elate to the _ Time _ _ _ to l.alnr me Mines uuerventiorry and rLkiacrnrs ]ivied above. (an be 3-403.11(7) ( C.ominerctallt Pioee&sed R a. fortlf m i found or Ill, folbl .ng s.e t,nrn C iiu Faod Crede and 105 C.1fil 3-403.11(E) of 13-54LN(A) i Cixrling Cooh dPHFsfrom 140'F to 70`F Within 2 Hunts and From 71) I to 41'1-145' F Within 4 ilnur:+. ° 3-S 7t 1 d(Bj Cooling PIII s Made Froin Ainbient Temperature Ingredients to 41-F145`F to4llourO * Ueniaes ..rBicx1 keir in the (oetat 1999 Food'3xle or 10y (Nu 597 Olin. S ,.mr�:.a.. 1Y Massachusetts Department of Public jiWith Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health -. 120 Washington Street, 4th" Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name - 0 Address Da % Cl/ isk Level TVDe of Operation(s)i' Tvpe of Inspection I� Food Service ❑, Retail ❑ Residential Kitchen E] ❑Routine a--Re-inspection Previous Inspection Date: q.� TelephoneI '1 PIC's Signature:410 El El❑Temporary Caterer ❑ Bed & Breakfast Permit No. ❑❑ Pre -e ct Ill n Suspect Illness ❑ General Complaint HACCIP ❑ Other Owner IQ- HACCP Y/N Person in C ar (r) Time In: . _7 Out: 7 Inspector -� Each violation decked rb4telres 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) E]590.0091❑ action as determined by the Board of Health V (o I (A L V- 5 � -� n �"' '3 ❑ 12. Prevention of Contamination from FOOD PROTECTION MANAGEMENT;.,,,,�m,,,. ,.,;„; �.R��-�;:; ❑ 1 PIC Assigned / Knowledgeable / Duties ❑ 13 Handwash Facilities "EMPLOYEE HEALTH _ . Q' ,+„�JZL �. t Lm�, `e ," n PROTECTION FROM CHEMICALS i'"',z`r,'1 vTa �v ti """J* r' - ❑ 2. Reporting of Diseases by Food Employee and PIC ` r i'ut � 1 � c- M.� ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded [FOOD FROM APPROVED SOURCE"„ ,'��„95611 ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 15. Toxic Chemicals i•TIM&O W0ERATORECONTROLS(PotentlalIVHakanlousFoCds)-'!t M ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling (rPROTECTION FROM CONTAMINATIONn{* ❑ 19. Hot and Cold Holding "--4;4" 20. Time As a Public Health Control E]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) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S: SMnVp tFa 5-14.Ow °.REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP},` ❑ 21. Food and Food Preparation for HSP j'CONSUMER :ADVISORY ;.§'.'�„,rw°�,�.,...�ro.....ra�.. cY ❑ 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: \ I ( Print PIC's Signature:410 Print: .1 �` ; C, My /� , �� Paged of Pages V Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) _ FOOD PROTECTION MANAGEMENT 1 596.0031( Assignment on of Knowledge" 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 590.004(A -B) require reporting by foal employees and 3-201.1.2 a flicants" 3-20113 590.003(F) Responsibility Of A Food Employee Or An 3-202.13 Applicant To Report To The Person In 3-202.14 Charge* 3-202.16 590.(Hi3(G) Reporting by Person in Cha �e* 3 1 590.003(13) Exclusions and Restrictions* 590.006(A) 990.003(E) Removal of Exclusions and Restrictions El in in FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 food Code or 105 CNIR 590.000. PROTECTION FROM CONTAMINATION $ Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law" 3-201.1.2 _Law Food in a Hermetical) 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 Approved System` 590.006(A) Battled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washin Fruits and Ve. etab'les 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 3-20218 She llshxk Identification Present* 590.004(0) Wild Mushrooms* 3-201,17 Game Animals* 3-701.1't Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Sheiistock 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(7) I Labeling of Ingredients" Frequency of Sanitization of Utensils and Foal Contact Surfaces of Equipment* Conformance with Approved Procedures fHACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced ax en acka hg. criteria* 8-103.12 Conformance with Approve Procedures* * Denotes critical item in the federal 1999 food Code or 105 CNIR 590.000. PROTECTION FROM CONTAMINATION $ 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 Antral Faxls Separated from Each Other- therContamination Contaminationfrom the Environment 3-302.11(A) Food Protection* 3-302.15 Washin Fruits and Ve. etab'les 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A) Returned Food and Resetvice of Food* Disposition of Adulterated or Contaminated Food 3-701.1't Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501..111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Her 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 Foal 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* 71 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 I-ocation and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11. Hindwashing Cleanser, Availability 6-301.12 Hand Drying Provision Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name ( �_ Dae / C � / O T e of 0 eration s Type of Inspection ood Service Retail ❑ Residential Kitchen El Mobile El Temporary ❑ Caterer ElBed & Breakfast Permit No. ElRoutine [YRe-inspection Rrevious Inspection Date:/ ��J" ElPre-o er�fon " ❑ Suspect Illness ElGeneral Complaint [IHACCP E) Other Address �, i_ Level Telephone(J Owner HACCP YM Person in ChargeIC) -- _ _ inspector Time In: iB �_ Out:Out: y1 Each violation check`ed1equ(re`s 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,,;.;.,„��,,��,.,d;G :-„ ❑ 1. PIC Assigned / Knowledgeable / Duties C � EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded g" FOOD FROM APPROVED SOURCE_„�:7.!�,.,,,�,,.....,,„„�;,,,,,_.,, ❑ 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 7 T'17'7%" ,' a �i,C A \ ❑ 8. Separation/ Segregation/ Protection y�l 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. �Ce' AT 11 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 ,b S5tFo�,a� ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities rPROTECTION FROM CHEMICALS ,` ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals f` TIME/TEMPERATl1RE CONTROLS (Potemtally Hazardous Foods)3v'�"" - 1:116. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control (REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP);;; El 21. Food and Food Preparation for HSP FCONSUMER ADVISORY_= 3 .��»....,,..-�.,L, El 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions I 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: llb) PIC's Signature:VW L- Print: P ' AU 1 Page of Pages 0 Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1I 590.003(A) AssDemonstration of KnowResponsibility* e* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(,0) Responsibility of the person in charge to CompliancewithFood .Law" 3-201.1.2 require reporting by food employees and 3-201.13 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 Drinking Water from an Approved System* 590.006(A) Charge,* 590,006(B) 590.003(0) Reporting by Person in Charge* 3 1 590.003(D) Exclusions and Restrictions* 7201.15 590.003(E) Removal of Exclusions and Restrictions C C C 1 FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. .• el i♦Y ik f l diM1771=4 S Food and Water From Regulated Sources 590.004(A -B) CompliancewithFood .Law" 3-201.1.2 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eg s* 3-202.1.4 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" Washinz Fruits and Vegetables SheRiish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 7201.15 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 Came Animals* 3-701.1.1 Receiving/Condition 3-202.11. PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Togs/Records: Shellstock 3-202.18 Shellstock Identification * 3-20312 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(1) ILabeling of ingredients* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures 1HACCP Pians 3-502.11 S ec alized Processin Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. .• el i♦Y ik f l diM1771=4 S Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-3021I(A)(2) Raw Anirrul Foods Separated from Each Other* Contamination from the Environment 3-302.1.1(A) Food Protection* 3-302.1.5 Washinz Fruits and Vegetables 3-304.1 t Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.1.1 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Tetu eratures* 4-501.112 Mechanical Warewashina Hot Water Sanitization Temperatures* 4-501.11.4 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 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's 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* 3-301.12 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 6-301.12 Hand Drving Provision CITY OF SALEM tt // BOARD OF HEALTH // // Establishment Name: AP nJ �L(� Date:_�il�O/iiy Page: C9 of Item „;; Code v> C — Critical Item _> r ' x '�°"' Date ,," .gaff DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION p 3 o � M i' Verified ',. No „ Reference R =Red Item _ ...m < sr .�a s < *I-,. _ _ s, � � .� .:� '� € _ _ _ _PLEASE PRINT CLEARLY J Discussion With Person in Charge: have read this report, have had the opportunity to ask questions and agree to correct all Corrective Action Required: TT No Yes ❑ Voluntary Compliance ❑ Employee Re triction / Exclusion violations before the next inspection, to observe all conditions as described, and to Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of tvinty-f ve dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. L �� VV Mme/ ❑ Voluntary Disposal ❑ Other: Violations Robited to Foodborno Illness interventions and Risk Factors (Itervis, 1-22) (Cond.) L4_ Food or Cc 10-282.]2 L5 Poisonous or Toxic SubstAnces 4— – -7-101.11-- -- Idersifying, irthonnation - Onginal is cooling, lvlethod4 for 111fFs Containem' PHF HCA and Gold Holding 7-102,11Coraction Nartio - Workir�(, La�,Lme�rs old PHFs Maintained at or below T—kpaiZOR – S10' -2011 Re,7ric;ion — 'd L;e*' PHFs 7-202.12 Conditions of Uso* Cook -cd PRI -'s from 14,0`1' to501 CcN:,Iutg I/ 203' I I Toxic Container, – prolato6ouK'� 70'F Within 2 Hours and From 'MF 1 '-204. 7-7 —Sanili/ecs" crio -- Chek—nicals� io4I'F145'FWithin4Hours.' rT (4. �12 �Chenhcak(Fir Washint Produce. Criteria"- Ic 7-205 11 incidental Food Cotitact, IAN ican" 7-206:T—i —TTI -7117d Use Re -1111-011 3-40L 1, 1 A(l)(2) Eggs I55 F 15 S�C 145'Fl 5secll &' Annnals 1�5'1: i.', sec. 130'1`121nen' 1-4f) 1. 11 (Ali,! 1 Ratites, Li)iectod Muat,, - 155"F 15 3-46T I I(A)r3) Pouftr). V, its Gaine$tuffed KfFs. Stuffing Containing Fish, MeaK, llotdlLtry or Ratites 76551 i5sec. T-461 -FVh,Ie'na1Sdc' Intact haeof Sic�aks 7-441.12 Miciowtve 10s 'F 340JAUZQ)�In) I Ah Othei Nik -- 145'T 15 xec. 3-1,03.1 )(A)&, ID) 1651T ]5 sco ,1-403. D (b) Nficrowave- 165, F2 Minule Standing, Time" ccul oitelciaik No, 140'F� 7401 11 (E i Reniainim) UngliceRJ Porciona of Beef oasts* Pro -or Coolins at 1 According to Lim Cooled to 4 I'F/45'17 Within 4 Hours, is cooling, lvlethod4 for 111fFs 19 PHF HCA and Gold Holding 6fB) old PHFs Maintained at or below 5 90 O(WF) 41'745° F, PHFs %failitained at or above PHFs 146A) Cook -cd PRI -'s from 14,0`1' to501 CcN:,Iutg 1 Time as a Public Health Control 70'F Within 2 Hours and From 'MF io4I'F145'FWithin4Hours.' �TO 1. 14(B I Cooling PHFs Made Front Ambient 111 Temperature logredients to 410F145'F ... .... "Witinn 4 Hours* Dinhjel lrftvfllwnl" Vll 1he F,4aal 1999 F(hx'K'We"r M (MR 591) 000, 1 According to Lim Cooled to 4 I'F/45'17 Within 4 Hours, is cooling, lvlethod4 for 111fFs 19 PHF HCA and Gold Holding 6fB) old PHFs Maintained at or below 5 90 O(WF) 41'745° F, PHFs %failitained at or above Rfaisis Hold at or above 130'E 20 i 1 Time as a Public Health Control variance REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HS 217-i —S01 TI 0.4iTcap'--tcunfcd Pie-pacl:agcd Juices and haWSL yan Not served. s-2;031.11(0) I Uyionene.dFood Packatc Not Re -served. CONSUMER ADVISORY 22 3 Cortainibc- AO\isory Posted fi)r Cowumption of art,. Raw. UndercAx)ked o; Not Oflwrvvise if) 1-16ninate t'3o2.3 9 I F", .�teunzzd E.gg.,- Subrtiiulr ton Paw Sli,11 SPECIAL REQUIREMENTS a9-'j7)—n9F7)T j—)) TVitiations of Sectic an 5')01i)9(A)-(D) in eatering. mobilc h(iod, temporal v and rcsidtmCal kitchen operations should he debits wider the tippropriate sections ,fly inierventions and ill: factors Other 590.009 violations relating to'wd retai! twactrees ;(could be debited under #29 - Spcent Requircinem. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Cri;irolanj non-(rowal violaoona iihich do noi route w the foodborne dIness filael venlionsand risk joK lars Vvtcd cabovc. (an be found in thcpiloo-mg sections of Mc, Fazed Codc erred )(6 041? -7_ ODnv:S 1 The HALLMAR 468 p'p.Bol( 01971. sm,gm' 744-0880 SERVICE: (978) FAx: (97 81 745-3808 Gl G tECE D BY DATE 7hank'J°S�L uorpjtral! for �1LK A® A-1 Exterminators PLEASE REMIT PAYMENT TO: 183 SHEPARD STREET, LYNN, MA 019024597 INVOICE P.O. BOX 310, Lynn, MA 01903-0310 781592-2731 1-8003254025 FAX 781-592-7641 413 .r 49E CURRENT 30 DAYS60 DAYS 90 DAYS Pest and Termite Control Professionals 48.00 I 0.0711 0.00 005"0828 ThLt 101 08/28/08 v TIN WHISTLE CONTROLFOR REGULAR. FEST CONTROL SERVICE CHARGE 4B. Lk 241 .JEFFERSON AVE -- NUMBER UNIT PRICE AMOUNT SALEM MA 01970 MOUSE GL BD 978-741'-1912 06/30/.08 11:00-11.30AM MULTI -CT TRAP DATE �' �� PROTECTA PROTECTALP CHECK NO. RTU BAIT STA COMMENTS ❑ MC ❑ VISA ❑ DISCOVER RAT GLUE BD KITCHEN/BAR/DINING RM/RR J�v1 aC�CX Ca� �,� T„•d.�o t Floors- Clean................................................................ ❑ ❑ CounterSurfaces- Clean ............................................ ❑ ❑ DraiK Areas - Clean ....................................................... ❑ ❑ Rest Rooms - Clean ..................................................... ❑ ❑ Dining Areas - Clean ..................................................... ❑ ❑ Employee Areas - Clean .............................................. ❑ ❑' . Locker Areas - Clean - ................................................. ❑ ❑ Storage Area; - Organized .......................................... ❑ `. El aamments BUREAUNSUMER SHEETS, DAYSPRIO ,TOAPPDCATION ACCT # EXP DATESALES TAX C.O.D. ElCHGb N/C ❑ TOTAL DUE TOTALAMOUNTPD DWELLING TYPE 1 Family ❑ 3 Family ❑ 2 Family ❑ 6 Family ❑ REASON FOR NO WARRANTY IANTY•INFORMATION WARRANTY YES ❑ NO ❑ 30 Days ❑ 60 Days ❑ 90 Days ❑ 6 Mos. ❑ • Partial service requested.............................................................fie,.................. ❑ • Poor sanitation.....................................................................................--.......... ❑� • Kitchen/bathroom cabinets not prepared...................................................... ❑ • Closets/fumiture not prepared ..........................................................................❑ • Rodent proofing needed.................................c............................ ................... ❑ • Other EIVED ALL MASSACHUSETTSOEPARTMENT OF FOOD 8 AGRICULTURE'S PESTICIDE TEN STATEMENTS, POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2-7 THE ABOVE SERVICE HAS BEEN SATISFACTORILY COMPLETED. m s -i TIME IN Massachusetts Department of Public Health Divisio!a 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 (978) 745-0343 Name- II II Date Tvoe of Operation(s) Type of Inspection ® Routine [I Re -inspection AJ S 1 ! 3t .Food Service LJRetail Address • ) �r �v Ris / a 17 Level ❑ Residential Kitchen ElMobile Previous I action Date: 101 ....�� Telephone -74-1_ ' Id El Temporary ❑ Caterer El Pre -operation ❑ Suspect Illness Owner ( HACCP YM i oz 4',t [IBed & Breakfast El General Complaint Person in C argevlC) fi Time F� In:,3 -(J El HACCP Inspector ® Out:a Permit No. El Other Each violation checked re2(uires 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 a EMPLOYEE HEALTH vi.jo-».m,; w.. E,e,3 ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded ��«r,.�. �sr M FOOD FROM APPROVEb SOURCE ,,,�„�„,,,,,,�, „„;,w�aa ❑ 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 CONTdM1wnoN: w ❑ 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) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other s501nsp�Fo.�14da (-� „ nn ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities r PROTECTION FRAM ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentla0y Hazardous Focds) . L..v.e 1� tu. [116. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HiGHLYSUSCEPTIBLP POPULATIONS ❑ 21. Food and Food Preparation for HSP j CONSUMER ADVISORY.=^..., aye,.wi..0 C:�. .- .. ❑ 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: \ 1 f Print: J n PIC's Signature:�UI Print: 1� f w Page ofages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 590.003(A) Assignment of Responsibility* 590.003(B) of Knowledge" 2-103.11. _Demonstration Person in charge - duties EMPLOYEE HEALTH 2 590kW(,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 E, -as* 590,003(F) _ Responsibility Of A Faxi Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Char c* 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 S C C * Denotes critical item in the federal 1999 Foal Cate or 105 CNIR 590.000. PROTECTION FROM CONTAMINATION S Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetical) Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell E, -as* 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 Drink n 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 3-202.11 PHFs Received at Proper Temperatures* 3-202.1.5 Package Inte it * 3-101.11. Food Safe and Unadulterated Togs/Records: Shellstock - 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-40112 Records- Creation and Retention* 590.004(7) Labeling of Ingredients' Frequency of Sanitization of Utensils and .Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans 3-502.11 S ecialized Processing Methods* 3-502.1.2 Reduced oxygen tacka 'nom. criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Foal Cate or 105 CNIR 590.000. PROTECTION FROM CONTAMINATION S rose s -contamination - 3-302.11(A)(I) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1.1(.0)(2) Raw Animal Foals Separated from Other* Contamination from the Environment 3-302.1](A) - Food Protection* _ 3-30115 Washing Fruits and Vegetables 3-304.21 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 i 1 Manual Warewashing - Hot Water Sanitization Tent eratnres* - 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 For d - C ontact Surfaces and Utensils* 4-70111 Frequency of Sanitization of Utensils and .Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization -Hot Water and Chemical* 16 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Arms" 2-301.12 -Cleaning Procedure* 2-301.14 When to Wash* 1t Good Hygienic Practices 2401.11 Eating, Drinking or UsinE Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 730112 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 Nand Drying Devices 6-301.11 Handwashin Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM _BOARD OF HEALTH Establishment Nam Date: 3 t__) Page: of Item No. Code Reference C -Critical Item R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY *` Date+ Verified IJonj IJQtf.trn l,a. Vem-, r,4- b - 4L' Po Dt_.t IJA 1i J , I �nlC. �� CV1G�M��1�l1�1/� (�r G.6�h,n� YU/C�P_{'Gi J , I 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 P comply with all mandates of the Mass/Federal Fo6d/Code. I understand that noncompliance may result in daily fines of twenty„five dollar"s/or suspension/revocation of your food permit. ��el Z'� � Corrective Action Required: ❑ No Yes ® Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: ry p r Violations Related to Foodborne, fitness Interventions and Risk Factors (items 1-22) {Cont.} 3-501.14(C) l"IfFs Reeerveda!'Fcorperiaures According to LawCot)IW in 1 419-=/45`F Within 4 Holds, * LL9 PHF Hot and Gold Holahan Food or Color Additives 3-501 16(B) C0141 PI-IFsMainulined at or below 3-202.22 Adduiv,'* F- 3-302 14 Protection from_lLia raved Additives" ___j pZr ]lot 1`111'stfaintainedat or above Is Poisonous or Toxic Substances 140'1-- [()[.If Identifying Intonnation -- far) gnum coluelaerw" -501,1 '0(A) R(Q�,tsfitidator:ibovei3O,','F,* Time as a Public Health Control 1-102,11 ConinAm Name Wo.rking Container.,` ---Tth 11-401 19 Time as a Public Hen 7-20L 11 Sea abon - Slot <90J) mianee Rcaurcaici 7-2'11T Rcaric6orr - Presti,ce mid 11'te* 7-202.lf�(®r sell �r,<:m, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 203.21 I loxic Conlavicir", PrOlebVi011ir POPULATIONS HSS_ 7-204. cho-1101-1—s-— r 7-204.12 chenecals for washally, I'Visdam" cliterit" 21 €jl11(A)TGnT ivtenri u~d Pre-packaged Ances and verates �araial-,abols* 7204-14 — 3-80 1, 11 (B) U'� of Pa tenor 7-205,11 Incidental —11bocar1N1--'-- — 7-206.IT-- —Resllicid —U4e pe—sticitles, Criset3-SOL I i Evi or flmiallv Crroked.Acivial 14'(xyJ and Raw Sted SETL-h� 7-406.12 R(xiew 13cat St;aiows 1- — D E-1 I =1C �P'16'a 1� 7-1-06,11 Trackln��pm�der' P�st Control and CONSUMER ADVISORY 3")03,1 1 1 Postol to I olmnittlition of TIMErrEMPERATURE CONTROLS imunwl F':Kxle'Illat I jrc Raw, undercooked cc 16Rroper Cooking Temperatures for tiot Otherwise processed to Millumae, HFS I" ��W" llalfiti"en' Sema 3-302.13 Pzvteurrycd Fitltk. Stibuitalr for Raw Shell Coqiinnua�d Fi�h, '�Icats &- Gaine Epgs' Anitnais 155'T 15 sec. " SPECIAL REQUIREMENTS 3-401.1 UH)(I)(2) (k and Nef Roast -1 61 121 rillin, Violoti(ins of Sutton 5()0.00')iA)-(D) in calering. mobile ".)(1, temporiotr and fcsickarflal kitchen operations 3-441.21(A)(3) Poultry, Wild home, $tufled 111-117s" ; iould be Sniffing Containing Fish, Meat, defiled under tire whoft-muslc Imact Beof mcdks inten ventions and risk factors, %or 590.009 violations Telalin�o to rood retail 3-401.12 12 mIrra �um Foi U, C,,,k,d ma ptaci tc es, should be debi led under #29 - ' ' Mict owave I 0.5'F Special Requirements, 311111 3-.401,11fAall)(b) All Othei NiFs -- 14 "F 15 sec, � I 1� Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403,110, 7&F)) Ff-IRc IfiTF 15 (Items 23-30) 4 0 3 _J1 (B) "punas- ye 16�' r 2'Minnae Standing cfirie"Jf rand min -crifical violatwim, il-hif'It do no relate to lite lnnc- foodlan-ne itiness inter venfions ond rikjartorr Pool above can be 3-TO� �H(C� clanwelcim)v pnm.esccd RTE Fecid - found in the -ftilkni-ingveils Ins o,i the Food Code evid 10-5 ()A/,R 3-403.1l(8) I Reirranila", I"wheed 1 proper cooling Of P"FS 3-501. 14(A) cooling Cooketipfil"sfrom 1401 -to 70"F Within 2 Hours and From 7(ff to 41 °T!45� F Within 4 Hours. I �3 501 14(13) CrOinif PHFs Made Front Ambient Temperature Ingreditarts to 41l'i45cF Aithia4hour* � Denotes crqical Aerii in the lo,ittial t 499 Foml C(xk or 105 (MR 594? 000. I S I 'U, "wv ZA, Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Foo&Retail Establishment Permit DATE PRINTED: 01/07/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000335 LOCATED AT: fGmberley Driscoll Mayor The Tin Whistle 241 Jefferson Avenue Salem MA 01970 0241 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2008-0260 Jan 4, 2008 Dec 31, 2008 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 10 of 10 QTY OF SALEM, MASSACHUSEM tt(rc' BOARD OF HEALTH t 120 WASHINGTON STREET, 4'm FLOOR 'ISL. (978) 741-1800 KIMBERLEYDRISCOLL FAx (978) 745-0343 RECEIVED MAYOR )scOTr(a)sALeM. COM JoANNE socm, NOV 3 0 2001 HEALTH AGENT CITY OF SAL. A BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 7JR9� _TPI WM15TL-E TEL # 919' I`7 I H Q - ADDRESS OF ESTABLISHMENT 2-41 1 0:7f�aJ AVE FAX # MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'SNAME C1.F/& �QE70XN TEL# 91!? V -149Y ADDRESS ? YONICM CITY STATE CERTIFIED FOOD MANAGER'SNAME(S) Clem& 1 LrOR/iJ CERTIFICATE#(S) )j7-(.305 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON `-'Am& 2>tD,<� I V HOME TEL # DAYS OF OPERATION Monday 1 Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION Please write in time of day. ►IR»7-IAM;IIAnd-IAnI;/IAM-I a^4',llfhrol Irf+N IIArN-/Anq IIi1N-1An1 !I2PM-llhtl Wor exarlde l l am -11 Dmf TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - --------- - --- - - ---------- RESTAURANT YES NO (Outdoor Stationary Food Cart $210) BED/BREAKFAST/ YES NO CHILDCARE SEPERMITS RVICES ADDITIONAL_..._. ------------------------------------ ---------------- MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) ........................ .. ........ less than 25 seats 25-99 seats =$280 more than 99 seats =$420 $100 YES $25 YES $135 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. , Date 6005 - Social Security or Federal Identification Number / J Revised 4/24/07 FOODAP2008.adm Chcckq & Date 'y h /�✓f /� $ It f 0241 JEFFERSON AVENUE Telephone: 741-1912 nwnar, William & Craig DeOrio PIC: Craig DeOrio Inspector: John Gehan Date Inspected: Correct By: 7/2/2007 Risk Level: Permit Number: BHP -2007-0211 Status: SIGNED OFF # of Critical Violations: 1 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) HACCP: City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection 0 The Tin Whistle Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comment: Meat thawing at room temperature. All potentially hazardous foods to be thawed beneath running water, in a unit with temperature of 41°F or below or in a microwave. Equipment and Utensils FAIL BLUE Comment: White Haler unit requires general cleaning. Physical Facility FAIL BLUE Comment: Door open at time of inspection. Door to remain closed to prevent entrance of rodents and or insects. 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. Jul 02,2007) Page / of RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 02,2007) Page 2 oft ` 0241 JEFFERSON AVENUE Telephone: 741-1912 Owner: William & Craig DeOrio PIC: Craig DeOrio Inspector: John Gehan Date Inspected: Correct By: 1/24/2007 Risk Level: City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing PASS Critical Comments: Cutting board stained and scored. Resurface or replace board. Sanitizer eeading to high. Sanitizer to be reading at 50ppm when using bleach. i Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS Critical The Tin Whistle Critical Urgency VO BLUE Comments: Knife found in knife rack with accumulation of food debris. Thoroughly clean and sanitize utensils after each use. Equipment and Utensils PASS Comments: Freezer in kitchen requires general cleaning. Permit Number: Microwave requires general cleaning. BHP -2007-0211 Garland oven requires general cleaning. Status: SIGNED OFF Ice machine inside panel has accumulation of grime. Thoroughly clean and sanitize panel. # of Critical Violations: Physical Facility PASS 0 Time IN: Time OUT: Comments: Door to back of establishment has visible air gaps. Seal gaps to prevent entrance of rodents. Urgency Description(s): GENERAL COMMENTS: BLUE: All violations from 1/07 have been corrected. 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) BLUE BLUE 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. Jan 24,2007) Page 7 oft RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 24,2007) Page 2 oft '0241 JEFFERSON AVENUE Telephone: 741-1912 Owner: William & Craig DeOrio PIC: Craig DeOrio _ Inspector: John Gehan Date Inspected: Correct By: 1/17/2007 Risk Level: Permit Number: BHP -2007-02.11 Status: 7 Open # of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item The Tin Whistle Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing FAIL Critical P/ t: Cutting board stained and scored. Resurface or replace board. anitizer eeading to high. Sanitizer to be reading at 50ppm when using bleach. Violations Related to Good Retail Practices (Blue Items) Food and Food FAIL Critical INAR" BLUE Knife found in knife rack with accumulation of food debris. Thoroughly clean and sanitize utensils after each use. Equipment and Utens' - - FAIL BLUE ment: Freezer in kitchen requires general cleaning. icr ave requires general cleaning. Garland oven requires general cleaning. Ice�achine inside panel has accumulation of grime. Thoroughly clean and sanitize panel. L Physical Facility FAIL BLUE /Comment: Door to back of establishment has visible air gaps. Seal gaps to prevent entrance of rodents. 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. Jan 17,2007 ) Page 1 oft Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 17,2007 ) Page 2 oft 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 e of O eration s Tvoe of Inspection Eood Service Retail ❑ Residential Kitchen El Mobile E] Temporary El El Bed &Breakfast Permit No. f P I f/ PIC's Signature: ✓/�/ ,..d9� ❑t. Routine ❑ Re -inspection Previous Inspection Date: � A ) El Pre-operation [I Suspect Illness [I General Complaint ElHACCP ❑ Other Address J 1 T Ris Level Telephone v (_ Owner ' , v rrv� HA YM Person in Charge (PIC Inspector �` x Time In:I puf 0 Each violation cfiecked feg5ires an &planation 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) ❑ 599.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT, ❑ 1. PIC Assigned / Knowledgeable / Duties r EMPLOYEE HEALTH-- 4m,- El EALTH ` "'� ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3.. Personnel with Infections Restricted/Excluded eP 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 ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities i°'PROTECTION FROM ❑ 14. Approved Food or Color Additives 1 ❑ 15. Toxic Chemicals InME/TEMPERATURE CONTROLS (PStemially Hazardous Foods) ` ❑ 16. Cooking Temperaturese ❑ 17. Reheating ❑ 18. Cooling r PROTECTION FROM N_ CONTAMINATIO"' * _' k 1�" IY"T El 19. Hot and Cold Holding .w.� t«m.mo&xn Aa osauk,obl 8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing L REGUMEMENTS FOR HIGHLY StISOEPTIISLE POPULATIONS (HSP) f/ PIC's Signature: ✓/�/ ,..d9� ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing Print: �� IAfeO �'; P ao, El;; 11. Good Hygienic Practices ' ® CONSUnAEH AOVI50Rv, ❑ 22. Posting Consumer Advisories }o /Practices of �- Violations Related to Good Retail Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C X 23. Management and Personnel (FC -2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC -3)(590.004) order of the Board of Health. Failure to correct violations 1. 25. Equipment and Utensils (FC -4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC -5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC -6)(590.067) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC -7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE -INSPECTION: S: 5900speOFom 14.Ca' Inspector's Signature: J t/ j Print: D f/ PIC's Signature: ✓/�/ ,..d9� /�� Print: �� IAfeO �'; P ao, Page. ! of�Pages ,/V a Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1I 590.003(A) Assia ment of Responsibility* 590.003(B) Demonstration of Knowledge* F-2103,11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* _ 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) .590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 C_ I '' Denotes critical item in the federal 1999 Food Code or 105 CMR 590,000. Voisill;("Ke ,e 111111 et _t, �e •. F 8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 rood 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-t01.'t I Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" W'ashin Fruits and Ve*etables 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 Regulatoty Authoritl 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.1.7 Game Animals* - 3-701.11 Receiving/Condition 3-202.1.1. - PHFs Received at Proper Temperatures* 3-202. t5 Package Integrity* 3-101.11. Food We 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(7) 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 Methis* 3-502.1.2 Reduced oxygen packagin& criteria* 8-103.12 Conformance with Approved Procedures* '' Denotes critical item in the federal 1999 Food Code or 105 CMR 590,000. Voisill;("Ke ,e 111111 et _t, �e •. F 8 Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other' Contamination from the Environment 3-302.11(,0) Food Protection* 3-302.15 W'ashin Fruits and Ve*etables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Resetwice 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 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* 4-602.11 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 Anus* _ 2,301..12 Cleaning Procedure* 2-301.14 When to Wash* 11 ' Good Hygienic Practices w. 2401.11 , Eating, Drinking or Using Tobacco* 2401.1.2 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting' 72 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 73 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacifies* 5-204.1.t Location and Placement* - 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 - Handwashin Cleanser, Availability 6-30112 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: (ham 15)e Date: Qb(.T X Page: of -i� Item Code c -Critical nem DESCRIPTIONOF VIOLATION / PLAN OF CORRECTION Date No. Reference R — Red Item Verified - ..._ .. .... PLEASE PRINT CLEARLY.. - -- Y' z Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all Corrective Action Required: ❑ No s ❑ Voluntary Compliance Cl Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to p e -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twentyfivveldgllars or uspension/revocation of your fc)od p`e`rmit. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne fitness Interventions and Risk Factors (items 1-22) (Cont) PROTECTION FROM CHEMICALS 19 15 16 17 TIME/TEMPERATURE CONTROLS Food or Color Addifives 3202.12 Addrnves, 3-302.14 Protection front Una i roved Additives* 3-801.1 ] (C) Poisonous or Toxic Substances 7-101.11 Identifying Information - )-tiginal Containers" 7-102-I1 CommonName-Workino- Containers* 7-201.11 Separation - Storage" 7-202.11 Restriction -Presence and Ilse'" 7-202.12 Conditions of Use* 7.203.1.1 Toxic Containers -Prohibitions* 7-204.11 _ Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria"` 7-204.14 Dain Aents.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 Motaimrinn* TIME/TEMPERATURE CONTROLS * Denotes critical item in rhe federal 1999 Food Cade or 105 C SIR 590000. Proper Cooking Temperatures for PliFs Rece9ved at Temperatures PHFs 3-401.11 A(] )(2) Eggs- 155`F 15 Sec. 3-801.1 ] (C) E ,its- immediate Sery ice 145°Fl5sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game Equipment and Utensils Annuals - 155'F 15 sec, + 3-401.11(B)(1)(2) Pork: and Beef Roast - 13WF 121 min* 3-401.11(A)(2) Ratites, Injected Meats- 155'T 15 _ sec. 3-401.1DA)(3) Poultry, Wild Game„ Stuffed PHFs, 41°145° F' Stuffing Containing Fish, Meat, 3-501,160) Poult - or Ratites -165`P IS sea * 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 140°F * 145°F * 3-401.12 _ Raw Animal Foods Cooked in a 20 165°F * 3-401-I l(A)(1)(b) _Microwave All Other PHFs - 145°F 15 sec. 3-501.19 Reheating for Hot Holding 3-403.1I(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 - 4WF 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501, J 4(A) Cooling Cooked PHFs from 1407 to 70`F Within 2 Hours and Frons 70°F to 41 °Fi45°F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature hagredients to 410F/45°F Within 4 Hours'x * Denotes critical item in rhe federal 1999 Food Cade or 105 C SIR 590000. IMM0119 • s 3-801. I I (A) 3-501.14(17) PliFs Rece9ved at Temperatures Use of Pasteurized Eggs* 3-80,1 A 1(D) According to Law Cooled to 3-801.1 ] (C) Uno ened Food Packs re Not Re -served 41'F/45` F Within 4 Hours. E3-501,15 Equipment and Utensils Cooling Methods for PHFs 19 -302.13 PHF Hat and Cold Holding 27. 3-501.16(B) Cold PHFs Maintained at or below 28. 590.004(F) 41°145° F' 29. 3-501,160) t-Iot PHFs Maintained at or above 30. -----Other_ _---�--- 140°F * 3-501.1.6(A) Roasts Held at or above 13WR 20 Time as a Public Health Control 3-501.19 Time as a Public Health Control` 590.004(H) Variance Requirement IMM0119 • s 3-801. I I (A) Unpasteurized Pre-packaged Roces and Bevel aees with W arninit Labels* 3-80111(B) Use of Pasteurized Eggs* 3-80,1 A 1(D) Raw or Partially Cooked Animal Faxf and Raw Seed Sprouts Not Served. * 3-801.1 ] (C) Uno ened Food Packs re Not Re -served CONSUMER ADVISORY Ht:WUnitMtN l ti 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 7129 - Special Requircraeits. W;Wf T (Items 23-30) Critical mid 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. item 17Consumer Advisory Posted for Consumption of 23. Marraciernent and Personnel Animal Foods That are Raw. Undercooked or :T-60' --rote-------- Food and Food Protection_ Not Otherwise Processed to Eliminate 25. Equipment and Utensils Path 26. _ -302.13 Pasteurized Eggs Substitute for Raw Shell 27. Ph sisal Facility._ Egos* Ht:WUnitMtN l ti 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 7129 - Special Requircraeits. W;Wf T (Items 23-30) Critical mid 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. item Good Retail Practices ) FC 590.000 23. Marraciernent and Personnel FC -2 .003 24. --rote-------- Food and Food Protection_ F_C -- 3 .004 25. Equipment and Utensils -4 005 26. _ ____Eq Water, Plumbing and Waste _ FC 5 27. Ph sisal Facility._ _)-.006__ FC -6 .007 28. _ Poisonous or Toxic Materials FC - 7 .008 29. S ectal Re uirements .000 30. -----Other_ _---�--- s.vnm,�, 1'0 d,< IA Establishment ITY OF. SALEM BOARD OF HEALTH Date: �a Page: of Item No. Code Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - PLEASE PRINT CLEARLY x Date Verified e r (c,. CiAd o ?T nP Ir / aJ 'l n O s t C ,J 12 C'D.3 Ice c, r c yr r lU �2r �2 S� 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 coniply 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 .es ❑ Voluntary Compliance ❑ Employee F(estriction / Exclusion Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: ��J Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 1S IN TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives" - 3 -302.14 Protection from Unapproved Additives* 3 -501.15 Poisonous or Toxic Substances 7-101.11 Identifying Information - Or Containers` 7-102.11 C,ommonNarne- WorkinnContaincrs* 7-201.11 Se aradon-St'orapc* 7-202.11 Restriction - Presence and I1see 7-202.12 Conditions of Use" 7.20:3,11 Toxic Containers - Prohibitions'` 7-204.11 Sanitizet's, Criteria -Chemicals* 7.204-12 Chemicals for Washita, Produce, Criteria* 7-204.14 Dr 'in ents. Criteria` 7-205.11 Incidental Food Contact. Lubricants* .7-206.1 I. Restricted Use Pesticides. Criteria* 7-206-12 Rodent Bait Stations* 7.206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS * Denotas critical item 'rn the federal 1999 Food Code or 105 CMR 590.000. 14 21 3-50114(C) ° Proper Cooking Temperatures for 3-801,11(B) PHFs 3-401.11A(l)(2) _ Eggs ---155'F 15 Sec. - 3 -501.15 E as-'tnmtediate Service 145�F15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(11) Animals - 155'F 15 sec. * 3-401.11(11)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats- 155'F 1.5 27. see. 3-401-1.,1(A)(3) Poultry, Wild Game, Smff ld''PHFs, 28. Stuffing Cont'aining',F7sh, Meat, 3-501.19 Poultry�or Ratites -165°P 15 sec. . ' 3-401A 1(C)(3) Whole -muscle, Intact Beef Steaki 145°F': 3=401.12 Raw Animal Foods Cooked in a Microwave 165"14 * 3-401..1 I (A)(1)(b) _ All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-40111(A)&(D) MIPs 165'P 15 sec. * 3-403.11(B) Microwave- 165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Foot - 1.4WF 3-403.11(E) Remaining Unsliced Portions of Beef Roasts's Proper Cooling of PRFs 3-501..14(A) Cooling Cooked PHFs from 140'F to 70'F Within 2 Hours and From 70"F to 41'F145'F Within 4 Hours. * 3-501.14(B) Cooling PI11's Made From Ambient Temperature Ingredients to 41 `F145F Within 4 Hours'" * Denotas critical item 'rn the federal 1999 Food Code or 105 CMR 590.000. 14 21 3-50114(C) PHFs Received at Temperatures 3-801,11(B) According to I.aw Cooled to 3-801.11(D) 41'F(45 -F Within 4 Hours - 3 -501.15 Coolie,, Methods for PHFs Not Otherwise Processed to Eliminate F and Cold Holding 3-501.16(11) 'Id PIFs Maintained at or below �41`14H50!'F* 590.004(F) 3-501.16(A) Hot PHFs Maintained at or above 27. 140'F, * 3-501.1.6(A) Roasts Held at or above 130°F - 28. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Re uirement 3-801.11(A) Unpasteurized Pre-packaged Juices and Bevera*es with R: arnine l (bels^ 3-801,11(B) Use of Pasteurized Eegsi._i,a 3-801.11(D) Raw or Partially Cooked Aminal_.tool and Raw Sud Sprouts NotServed, 3-801.1](C) Uno 3ened Fcwd Paekae Nor', Re -served. CONSUMER ADVISORY 22 3-603-1 1 Consumer Advisory Posted for Consumption of 590.000 _ 23. Animal Foods That are Raw, Undercooked or _17-0 _-2 .003 Not Otherwise Processed to Eliminate _ Food and Food Protection FC - 3 Pathogens." E""'^°�'�,rool 25. 26. 3-302.13 Pasteurized Eggs Substitute for Raw Shell L.005 .006 27. Fad it_ SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above it related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail ' practices should be debited under /`129 - Speciai Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Critical and non-crilicat violations, which do not relate to the foodborne illness interventions and n`sk factars listed above, can be foundot the following sections of the Food Code and 105 CMR 590.000. Item Good Retail Practices FC 590.000 _ 23. Manu ement and Personn_e_I _17-0 _-2 .003 24. _ Food and Food Protection FC - 3 .004 25. 26. Equipment and Utensils Water,Plumbing and Waste -Physical FC -4 FC -5 L.005 .006 27. Fad it_ FC -6 I .007 28. Poisonous or Toxic Materials FC - 7 .008 29. S carol Re uirements----------__-- i .009 30, Other sswnm„�m.woc CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH RECEIVED s 120 WASHINGTON STREET, 4TH FLOOR �/ SALEM, MA 01970 DEC 13 2006 nxx TEL. 978-741-1800 FAx 978-745-0343 CITY OF SALEM WWW'SALEM.COM BOARD OF HEALTH Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TETE► WFFISTLI_ TEL R�$ 7yI'i`iIZ ADDRESS OF ESTABLISHMENT,241 IEFf SCJ i,V� FAX # MAILING ADDRESS (if different) EMAIL -- Business': OWNER'S ADDRESS Owner's: CITY TEL # j79 9 10°1-1 $9$ STATE CERTIFIED FOOD MANAGER'S NAME(S) CIL416 'l 1; olt.t0 CERTIFICATE#(S) I Izb3a� (Required in an establishment where potentially hazardous food is prepared) q7? IoC1 — 1 `4CQ EMERGENCY RESPONSE PERSON C P.n Ira T)'li-Olzru HOME TEL # 978 I J -fit 7_(VJ DAYS OF OPERATION Monday Tuesday Wednesday Thursday friday Saturday Sunday rF10easewr'i,t'e SOPERATION intimTidaY. ,Iltrn- IaM Ilawr-1^" Ilawr-(4rv.examle llam 11am1 TYPE OF ESTABLISHMENT RETAIL STORE YES NO ---------- RESTAURANT YES NO BED/BREAKFAST YES NO FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ---------------- - - - -- - - less than 25 seats = 25-99 seats =$150 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$5 YES $50 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 aqgLpaid all state taxes required under the law. owl Signature to •• Social Security or Federal Identification Number ------------------------------------------------------- Revised 11/13/06 FOODAP2007.adm v Check# & Date 4y*4o /;/"6/-/p_ sJ5-O,.QO SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: �aira.ilmraaa:rtaza�zffn�nz>isi LOCATED AT: The Tin Whistle 241 Jefferson Avenue Salem MA 01970 0241 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2007-0211 Dec 20, 2006 Dec 31, 2007 $150.00 ESTABLISHMENT Total Fees: $150.00 PERMIT EXPIRES ,December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 10 of 11 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 NameJ ' Date Tvoe of Operation(s) Tyne of Inspection Food Service Retail ❑ Routine [P Re -inspection A1 T q Addresst -- Risk/ 'f `I Level / ❑ Residential Kitchen EI Mobile Frrevious Inspection Date: 6 A G /J Telephone4 El Temporary ElPre-operati n Owner C((� 4 HACCP YM ❑ Caterer ❑ Suspect Illness ❑ Bed &'Breakfast ❑ General Complaint Person in Charge (PIC) Time In:/' Out. , Permit No. [IHACCP El 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 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. A FOOD PROTECTION M/tNAGEMENTr",; , _� ,. m E31. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2 Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans j PROTECTION FROM CONTAMINATION, 7I� rias w ❑ 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)(59o.o07) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S:SWInsPoUFo1 -14,dx [ " ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals WTIME7TEMPERA7URE CONTROLS (Potentlalty Haz"ardou"s Foods)""a... [-116. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control xREOUIREMENTs FOR HIGHLY SUSCEPTtBIE POPULATIONS (HSP)'.. L1 21. Food and Food Preparation for HSP 1CONSUMEk ADVISORY,;,"''Mrw',s ;;... ❑ 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: I Inspector's Signature: Print: 2S 152 PIC's Signature:_ Print: 'Lek) Page ofd Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 596.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge" 2-1.03.I1 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food law* 3-20112 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants*, Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Re orcin b Perstln in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 C a C 'Denotes elided item in the federal 1999 Foad Code or 105 CMR 590.000. i PROTECTION FROM CONTAMINATION $ Food and Water From Regulated Sources 590.004(A -B) Compliance with Food law* 3-20112 Food in a Hermeticall • Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eg " 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* 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 Lasted Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Ppaufatory Authorit 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.1.1 ReceivinglCondition 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(J) 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 Specialized Processing Mefhods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* 'Denotes elided item in the federal 1999 Foad Code or 105 CMR 590.000. i PROTECTION FROM CONTAMINATION $ Cross -contamination 3-302.1.1(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3302.11(A)(2) Raw Animal Foods Separated from Each Other - Contamination from the Environment 3-302.1.1(A) Food Protection* 3-30115 Fruits and Vegetables 3-304.11 -Washing Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition ofAdufterated or Contaminated Food 3-701.1.1 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization 2ieratures"`� 4-501.112 Mechanical Warewashing- Mot 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 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 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* 5-20511 Accessibility, Operation and Maintenance Supplied.with Soap and Hand Drying Devices 6-301.11. Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision Establishment CITY OF SALEM 1 BOARD OF HEALTH Date: !i&/Or, Page: a of 2 Rem No. code Reference c - critical Rem R - Red Item DESCRIPTION OF VIOLATION / PLAN F CORRECTION j_... PLEAS PRINT CLEAR Y. Date Verified 4 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 tw y -five dollars or suspension/revocation of your food permit. Corrective Action Required: ❑ No Yes Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne fitness Interventions and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS F-14 TIMEITEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-902.14 Protection from Una o roved Additives* 3-801.11(C) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name -Working Con[uiners* 1-201.11 Separation - Slot atse^ 7-202.11 Restriction -Presence and Uw' 7-202.12 Conditions of tfse* 7-203.1.1 Toxic Containers - Prohibitions` 7-204.11 Sanitizers, Criteria - Chemicals" 7-204.12 Chemicals for Washing Produce. Criteria* 7-204.14 Drvin A ents. Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides, Cnteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIMEITEMPERATURE CONTROLS '^ Denotes critical item in the Federal 1999 Food Code or 105 CMR 590.600. ,\ Proper Cooking Temperatures for P3-501.15 PHFs 3-401,11 A(1)(2) Eggs- 155'F 15 Sec. 3-801.11(C) Eggs- Immediate Service 145'F15sec* 3-401.11(.A)(2) Comaunuted Fish, Meats & Game FC -- 3 Animals - 155'F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats - 155'F 15 26 sec. * 3-401-11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containim3 Fish, Meat, FC -6 Poultry or Ratites -165'F I5 see. _ f 3-401.11(C)(3) Whole -muscle, Iutael Beef Steaks FC - 7 1450F " 3401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs -145'F15see. * -------1-------- Reheating for Hot Holding 3-4031 H( A)&(D) PRFs 165'F 15 .sec. * 3-403.11(B) Microwave- 165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140'F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Coked PHFs from 140'F to 70'F Within 2 Fours and From 70'F to 41'F/45°F Within 4 Hours. 3-501.14(6) Cooling PI-IFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* '^ Denotes critical item in the Federal 1999 Food Code or 105 CMR 590.600. ,\ 21 3-801.1](A) 3-SOLL4(C--,�PHFs Received at'Cemperatutes According to Law Cooled to 4I'F/45'F Within 4 Hours. P3-501.15 Coolins Methods for FHFs 19 PHF Hot and Cold Holding 3-801.11(C) 3-501.16(B) Cold PHI's Maintained at or below, 590.004(F) .11`145' F* Not Otherwise Processed to Eliminate 3-501. b6(A) Hot PHFs Maintained at or above t40`R * FC -- 3 3-501-1.6(A) I Roasts Held at or above 1300F. 20 Time as a Public Health Control Pasteurized Eggs Substitute for Raw Shell 3-501.19 Time as a Public Health Control* 26 590.004(H) Variance Requirement 21 3-801.1](A) Unpnstem ized Pre-packaged Juices and Beverages with Warning Labels* 3-801.,11(B) Use of Pasteurized Ewes* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 3-801.11(C) Umr ened Food Package Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of 599.000 �I 23. Annul Foods That are Raw. Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC -- 3 PathoLn6.* F_Hecyva Yf112001 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell ..005 26 Estes* SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under 7129 - I Special Requirements. flimfi#Yli�S9 (Iterns 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000. Item Good Retai! Practices _ FC 599.000 �I 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC -- 3 .004 25. Equi ment and Utensils FC - 4 ..005 26 Water, W FC- 5__ _ _006 27. Phsicai Facility _- FC -6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. S ectal Re uiremsnts .009 30. Other -------1-------- 9:5�OfcmiAB&68'c Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4t" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name Dat 374 / Tvpe of Operation(s) Type of Inspection ❑ Routine ❑-Re-inspection Previous I spe tion Date: /�j/z ❑ Pre-ooperatib v' ❑ Suspect Illness ❑ General Complaint ElOther '[h]�rood Service ❑ Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address Risrk Level Telephone y 66 1 a Owner I J /I j , , j HACCP Y/N Person in Charge (PIC) Time In, 0U Ou }, --� Ins ector P Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE" ` ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. CN 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) oe 6. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S. 501n=ceC,Fo�-14,dac ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/FEMPERATURE CONTROLS (Potentially Hazardous Foods)" ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE. POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP t 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:. -fes / �9��_ Print: �G I �, v 5.� Paged of Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assi. litnent of Rus lonsibility* 590,003(B) Detnonsuation of Knowledge" _ 2-103.1.1 Person in charge -- duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to Com liancewith1-oodLaw* 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 ReportTo The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Char e* 3 590.003(0) Exclusions and Restrictions* 3-201.15 590.003(F, RemovaloTExclnsionsaitdRe<Strictiona Fe C C C "Denote; critical item it) the federal 1999 Food Code or 105 CMR 590,600. g Food and Water From Regulated Sources 590.004(A -B) Com liancewith1-oodLaw* 3-201.12 Food in a flermeticall Sealul Container" 3-201,13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 E gs 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*= Washitre Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfiskk 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authouty 3-202-15 Shellstock Identification Present" 590.004(C) Wild Mushrooms" 3-201.17 Garne Animals" 3701.17. Receiving/Condition 3-202.11 PIiF's Received at Proper Temperatures* 3-202.15 P ickage br eufity' 3-101.1.1 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.13 Shellstock Identification 3-203.12 Shellstock Identification Maintained'* Tags/Records: Fish Products 3-402.71 Parasite Destruction* 3-402.12 Recor(s. Creation and Retention* 590,00-1(7) Labeling of Ingredients" -Contact Frequency of Sanitization of Utensils and Food Contact Surfaczs of E ui ment* Conformance with Approved Procedures /HACCP Plans 3-502.11S ecialized Processin> Methods" 3-502.12 Redu ed oxy �cn ackagin , criteria* 8-103.12 Conformance with A iroved Pro edges" "Denote; critical item it) the federal 1999 Food Code or 105 CMR 590,600. g Cross -contamination 3-302.11 (A)(1) Raw Animal Foods Separated from Cooked and. RTE Foodsi° Contaminaltion from Raw Ingredients 3-302-11(A)(2) Raw Aminal Foods Separated from Each Other* Contamination from the Environment 3-302.1 t(A) Food Protection* 3-302.75 Washitre 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 or Food* Disposition of Adulterated or Contarninated Food 3701.17. Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 4anual Warewashing- [lot Water Sanitization "rem reratures* 4-501.112 Mechanical Warewashing-Hot Water Sanitization Tem eramres" 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-001_I7(A) Fquipment Food Contact Surfaces and Utensils CleanT -"'211Cleaning Frequency of Equipment Food- Surfaces and Utensils' 4-702.'1 I -Contact Frequency of Sanitization of Utensils and Food Contact Surfaczs of E ui ment* 4-703.11 Methods of Sanitization -- Hot Water and Chemical'- to Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms" 3301.12 Cleaning Procedure* 2-301.14 iMien to Wash*' LLL Good Hygienic Practices 2-401-71 Eatin , Drinkin or LJsine Tobacco^' 2-401.12 Discharges From the Eyes. Nose and Month's 3-301.12 Prevertbma Contamination When Tustin =* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination' from Enr rlovees* t3 Handwash Facilities Conveniently Located and Accessible 5-203-1.1 Numbers and Ca acities' 5-204.11. Lavation and Placement* 5-205A 1 Accessibility, O enation and Maintenance Supplied with Soap and Rand Drying Devices 6-301_11 HandwzshinpCleanser.Availabilit° 6-301-12 Hurtd Drvin> Provision Oil Establishment Name: Item Code C—Critical Item No. Reference R — Red Item -)/1 7 -'tAa. 1, ITY OF SALEM BOARD OF HEALTH Dater :RIPTION OF VIOLATION / PI I __. PI. FASF PRINT CLEA'. 0 Discussion With Person in Charge: Corrective Action of z Date Verified I Nave read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Hestrlctlon i violations before the next inspection, to observe all conditions as described, and to Exclusion P Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/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. ❑ �� n� / r l�M rn Voluntary Disposal ❑ Other: wR 4 Violations Related to Foodborne illness Interventions and Risk Factors (items 1-22) (Cont) PROTECTION FROM CHEMICALS 14 15 16 17 18 • Food or Color Additives 3-202.12 Additiws't 3-302.14 Protection firo'm Una roved Additives* _ Management and Personnel Poisonous or Toxic Substances 7-101.11 Identit'ving Information - Original Containers" 7-102.11 Common Name - Working Containers* 7-201.11 Separation - St'ocaee" 7-202.11 Restriction - Prescnce and Use'% 7-202.12 Conditions of Use, 7-20311 Toxic Containers - Prohibitions' 7-204.11 Saxut zers, Criteria - Chemicals* 7-2(11.12 Chemicals for Washin t Produce, C iterie 7-204.14 Dc yin t ems. Criteria" 7-205.11 Incidental Foal Contact, Lubricants - T -206. 1 11 Restricted Use Pesticides, Criteria* 7-206.12 1 Rodent B.nt Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* • "Denote, critical item in IN Weral 1999 Foal Code or 105 CMR 590,000_ 3-50T] 4((-) PHFs Received at Tereperature8 According to Iaw Cooled to AI°FtAs'F Within aNl.urc * Proper Cooking Temperatures for t4 PHFs. 3-401.11A(1)(2) Eggs- 155'F15Sec. _ Management and Personnel E Yqs- hnmediate Service l45`F15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Came 24. 25, 26. 27. 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 1.5 FC sec. 3-401.L1(A)(3) Poultry,Wild Game, Stuffed PHFs, Time as a Public Health Control* Stuffing Containing Fish, Meat, 590.004(H) Poultr or Ratites -165°F 15 sec. 3- 1.11CC)(53 Whole musele, Intact Beef Stenk.,s 145'F * 3-401.12 Raw Animal Foods Crooked 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) PHFs 1650E I) sec. " 3-403.11(B) Microwave- 165' F 2 Minute Standing Times' 3-403.11(C) Commercially Processed I2TE Food - 140'F* 3-403.1.1(F.,) Remaining UnsHced 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 411F/457 Within 4 Hours. * 3-501.14(13) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45`17 Widtin 4 Hours* "Denote, critical item in IN Weral 1999 Foal Code or 105 CMR 590,000_ 3-50T] 4((-) PHFs Received at Tereperature8 According to Iaw Cooled to AI°FtAs'F Within aNl.urc * REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 1 3-801.11(A) I Linpasteurized Pre-packaged Juices and Beverages with WamineLabels* 3-801.11 B) I Use of Pasteurized E „s* 3-80111(D) k iw or Partialh Cooked Animas Faad and Raw Seed Soronts Not Served. * 1 3-801.11(0) 1 Unooened pond Packaee Not Re -nerved. a I L* 1W1 22 3-501.15 Cooling Methods for PHIss ., t4 PHF Hot and Coid ing Hold REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 1 3-801.11(A) I Linpasteurized Pre-packaged Juices and Beverages with WamineLabels* 3-801.11 B) I Use of Pasteurized E „s* 3-80111(D) k iw or Partialh Cooked Animas Faad and Raw Seed Soronts Not Served. * 1 3-801.11(0) 1 Unooened pond Packaee Not Re -nerved. a I L* 1W1 22 3-50tA6(B) Cold PIiFs Maintained at or below 590.004(F) 41`'145'F* _ Management and Personnel 3-501.16(.4) Hot PHFs Maintained at or above .003 24. 25, 26. 27. 1401-. * FC --3 FC - 4 FC -3 FC -6 3-501.1.6(A) Roasts Held at or above 130`F. 20 FC Time as a Public Health Control '', 3-501.19 Time as a Public Health Control* 590.004(H) Variance Reoulrement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 1 3-801.11(A) I Linpasteurized Pre-packaged Juices and Beverages with WamineLabels* 3-801.11 B) I Use of Pasteurized E „s* 3-80111(D) k iw or Partialh Cooked Animas Faad and Raw Seed Soronts Not Served. * 1 3-801.11(0) 1 Unooened pond Packaee Not Re -nerved. a I L* 1W1 22 SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under )29 - Special Requirements. ([terns 23-30) Critical and rum -critical violations, which do not relate to the foodborne illness inrervenlions and risk factors listed above, can be _found in. the Jolloming sections of the Food Code and 105 CMR 590.000 - item 3-60311 Consumer Advisory Posted for Consumption of 590.000 Animal Foots That .are Raw. Undercooked or _ Management and Personnel F_C Not Otherwise Processed to Eliminate .003 24. 25, 26. 27. Pathos*ens., E`" 101/: -MI FC --3 FC - 4 FC -3 FC -6 3-302.13 Pasteurized Eggs Substitute for Raw Shell Poisonous or Toxic Materials FC E >es* SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under )29 - Special Requirements. ([terns 23-30) Critical and rum -critical violations, which do not relate to the foodborne illness inrervenlions and risk factors listed above, can be _found in. the Jolloming sections of the Food Code and 105 CMR 590.000 - item Good Retail Practices FC 590.000 23. _ Management and Personnel F_C - 2 .003 24. 25, 26. 27. __ Food and Food Protection E ui merit and Utensils water,PlLartle and tNaste Ph sical_Facili�_-_... FC --3 FC - 4 FC -3 FC -6 .004 .005 .006 ! .007 28. Poisonous or Toxic Materials FC - 7.008 '', 29. S ec.... _--............._- iai R uirements .009 30. Other 11"ON1.1"U6 2a" i;4} Massachusetts DepaHment of Public Health Salem Board of Health 120 Washington Street, 4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name - Date a 6TO Tvpe of 0 eration(s) Type of Inspection Food Service ❑ Retail ❑ Residential Kitchen ❑Mobile ❑ ❑ Caterer ❑ Bed & Breakfast Permit No. 19 Routine ❑ Re -inspection Previous Inspection �,-- Date: i0 J F E]Temporary Pre- � titin ❑ Suspect Illness ❑ General Complaint ❑ Other Address - RI k Level Telephone Owner)I kca4 Go i ?":2 HACCP Y/N Person in Charge (PIC) ( Time In:ElHACCP Ou4l� �� Inspector Each vloiaclon cnecKea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT --- -- ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC 0 ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE _ - ❑ 4. Food and Water from Approved Source \❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ; ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing' - ❑ 11. Good Hygienic Practices p 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. Manag6ffi-enttiand Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 6. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 1 30. Other S5901nsp LFO m 1C. CW g ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling i ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP), ❑ 21. Food and Food Preparation for HSP -- CONSUMER ADVISORY " 4 [122. 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 requestpust be in writing and submitted to the Board of Health at`he above address within 10 days of receipt of this order.n DATE OF RE -INSPECTION: A � 1 4 a ')D'j Inspector's Signature: ` \ Print- PIC's Signature: _,L,Print: R, vv- l4 L.e L; ciS'5W Pagel of24 ag s l., Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590003(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 Com tip ance with Food Law" 3-201.12 require reporting by food emplovees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell E,,*,*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 Drinkim� Witter from an Approved Svstem* 590.006(x'1) Chane* 590.006(B) 590.003(6) Re nrtin� b Person in Char e°c 3 590.003(11)) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions mid Res lotions 4 in C C ', Denotes Critical item ill 111c federal 1999 FObd Cs>de or 165 (`MR 590.))0. 8 Food and Water From Regulated Sources 590,004(A B) Com tip ance with Food Law" 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell E,,*,*s^ 3-202.14 E gs and Milk Products. Pasteurized" 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinkim� Witter from an Approved Svstem* 590.006(x'1) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Ve,etables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish I 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Reaulatort, Authorit 3-202-i g Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 ReceivingiCondition 3-202.11 PHFs Received at Pro ter Tem oeratures* 3-202.15 Packa7e tine itv* 3-101.11 Fawd Safe and Unadulterated Tags/Records: Sheilstock 3-202.13 Sheilstock Identification 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.0040) Labeling of Ingredients" Frequency of Sanitization of Utensils and Food ContactSurfacesofF-ui ment* Conformance with Approved Procedures IHACCP Plans 3-502.71 1 Specialized Processing Methods'* 3-502.12 Reduced oxygen packaging,criteria- A-103.12 Conformance with Approved Procedures* ', Denotes Critical item ill 111c federal 1999 FObd Cs>de or 165 (`MR 590.))0. 8 Cross -contamination 7302.11(A)d) Raw Animal Foods Separated from Conked and RTL Foods* Contamination trom 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 Ve,etables 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'rem eratures* 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 Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food ContactSurfacesofF-ui ment* 4-703.11. 6lethods of Sanitization -- Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Glean Condition - Hands and Arms` 2-301.12 Ciemtin, Procedme* 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* 3-301.12 Preventing Contamination'1Viten Tasting' 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Ent to -ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities'' 5-204.11 Location and Placement* 5-205.11 Accessibilit 5 O enation mxl Maintenmta; Supplied with Soap and Nand Drying Devices 6-301.11 b-301.12 HandwashiiigCleanser,Availabilit LE2ErlDrvin« Provision 1. e Establishment ITY OF SALEM BOARD OF HEALTH Date: Page: of Item No. Code Reference C - Critical Item _ R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Verified /� I jln to yj U - �. a. SP 6 o f t Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all,° violations before the next inspection, to observe all conditions as described, and to P comply with all mandates of the Mass/Federal Food Code. I understand that oncompliance may result in daily fines oft e Pitnty-five dollars or suspension/revocation of Il your food perm. (// Corrective Action Required: ❑ No b, -Yes Voluntary Compliance ❑ Employee Restriction / _ Exclusion Ll Re -inspection Scheduled ❑ Emergency Suspension LIEmbargo ❑ Emergency closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 16 17 k_fhTJkfid;a413;C s c r. t • Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from ling t roved Additives* 3-501.16(B) 590A04(F) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11 Common Name- kx in-, Containers* 7-201.11 1 Se anion - Stora e"` 7-202.11 Restriction -Presence and Ilse* 7-202.12 Conditions of Use" 7-203.11 Toxic Containers - Prohibitions` 7-204.11 Sanidzers,Criteria -Chemicals* 7-20412 Chemicals for Washing Produce, Criteria' 7-204.14 Dr °inlg 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* k_fhTJkfid;a413;C s c r. t • * Denotes critical iteral in Tho federal 1999 Food Code or 105 CMR 590.000. 19 3-501.74(() Proper Cooking Temperatures for 3-501.15 PHFs 3-40'1-I1A(l)(2) Eggs- 155°F15Sec. 3-501.16(B) 590A04(F) E,�s-htinic ate Service 145'Fl5sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(A) Animals - 155°F 15 sec, s 3-401.1 l(B)(1)(2) Park and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats - 155'F 15 590.004(H) sec. * 3-401. I I(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 Stuffing Containing Fish, Meat, Poultry or Ratites -165°F 15 sec. 3.401.1.1(C)(3) Whole -muscle, Intact Beef Steaks 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165"F " 3-401.11(A)(1)(b) All Other PHFs -- 145'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(I)) PHFs 165°F 15 sec. 3-403.11(B) Microwave- 165° F 2 .Minute Standing Time" 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Rernainim, Unshoed Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PRFs from 140117 to 70'F Within 2 FIours and From 70'1 - to 41."F/45°F Within 4 Hours. * 3-501.14(13) Cooling PRFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours, * Denotes critical iteral in Tho federal 1999 Food Code or 105 CMR 590.000. 19 3-501.74(() PHFs Received at'T'emperatures According to Law Cooled to 41"F/45'F Within 4 Hours. 3-501.15 Cooling Methods for PHF.s 3-801.11(D) PHF Hot and Cold Holding 3-501.16(B) 590A04(F) Cold PIIF's Maintained at or below, 41"145° F* 3-501.16(A) Ilot PHFs Maintained at or above 14W .x 3-501.16(A) Roasts Heid at or above 130'F. 26. Water, Plumbin and Waste Time as a Public Health Control 3-501.19 Time as a Public Health Crawl * 590.004(H) Variance Requirement I YOU 121i WO-11hil r 4-801..17(A) UnpastoorizedPre-packagedJuicesand Hever tees with Warning Iabels* 3-801.11(B) Use of Pasteurized Eels* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed S trouts Not Served. 3-801.11(0 Uno. erred Fcwc( Pucka<,e Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer ,Advisory Posted for Consumption of _ 23. Mana ement and Personnel FC - 2 Animal Foods That are Raw. Undercooked or 24- Fooii and Food Protection _ FC -3 Not Otherwise Processed to Eliminate 25. Equipment and Utensils FC -4 Pathos*ens.'" `r 111 ucrooi 26. Water, Plumbin and Waste 3-302.13 Pasteurized Fg&s Substitute for Raw Shell 27, Physical Faciliy____ FC-6-- E ns* ar=LIAL. r5CUUMCiVIC1V I.`f. 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 Disk factors. Other 590.009 violations relating to good retail practices should be debited under 1129 - Special Requirements. (Items 23-30) Critical and rum -critical violations, which do not relate to the foodborne illness interventions and i i.sk factors listed above, can be found in the following sections of the Foots Code and 105 CMR 590 000. Item Good Retail Practices FC 590.000 _ 23. Mana ement and Personnel FC - 2 .003 24- Fooii and Food Protection _ FC -3 .004 25. Equipment and Utensils FC -4 .005 26. Water, Plumbin and Waste FC -o .006 27, Physical Faciliy____ FC-6-- _ .007 28. Poisonous or Toxic Materials FC - 7 .008 29. S ecial Re uiremonts .009 30.� O(her __ __ svoro,»,mmn-zm� Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: File Number: BHF -2004-0335 The Tin Whistle 241 Jefferson Avenue Salem MA 01970 LOCATED AT: 0241 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2006-0256 ESTABLISHMENT Jan 3, 2006 Dec 31, 2006 $150.00 Total Fees: $150.00 PERMIT EXPIRES D cember 31, 2006 Board of Health 4�]�A 'e . This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. in accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 10 of 10 ala STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT DEC 12 2005 CITY OF SALEM BOARD OF HEALTH 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT m*ows 11tc- d%k TET/n Af!0 6 TEL # 978' N111IL ADDRESS OF ESTABLISHMENT 2¢l ,lE-PYt- ,16A1 A✓B MAILING ADDRESS (if different) OWNER'S NAME C941y'DEC)910 WIUI* n UFQtjo TEL# WTf 469-10T CITY CERTIFIED F ST (required in an establishment where potentially hazardous food is prepared.) ZIP EMERGENCY RESPONSE PERSON CAA /6 fbE 0 X J o HOME TEL # `IYY 942 -I fl4Y HOURS OF OPERATION: Mon.//-/ Tue./!_/ Wed -11-1 Thu. 11-i Fri. (I-1 Sat. //-/ Sun. /Z-/ TYPE OF ESTABLISHMENT RETAIL STORE YES NO FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO� � less than seats =$100 25-99 seatsis 150 more than 99 seats =$200 BED/BREAKFAST ........YES' N� -------------------------------------- ........................................ $100... ----------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAivi, YOGURT, SOFT SERVE YES (9D $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT (such as church kitchens) YES N $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. PA_ C11s-CJ Signature Date Revised 11/03/05 FOODAP2.adm Check#&Date ';7(4 or 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 NameI 1. l Dat Tvpe of 0 eration(s) Type of Inspection X Food Service El Residential Kitchen ElMobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit Permit No. ® Routine [] Re -inspection Previous InspectiSv Date: t;� r, - 1 05 ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint El HACCP ElO herr Address --� J f RiskRetail Level Telephone _ Owner 4 C,5ICA) i. HACCP Y/N Person in C arge (PIC) Time In: Out: Inspector ( =aW„ vwinuvn cnecneu requires an expianation on the narrative page(s) ano a citation of specific provision(s) violated. Non-compliance. with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT- ❑ 1. PIC Assigned/ Knowledgeable/ Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE - - ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS r. ❑ 14. Approved Food or Color Additives [:115. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION" - ❑ 19. Hot and Cold Holding ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwasjhing' ❑ 11. Good Hygienic Practices I 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. Ci' N' 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (Fc -7)(590.008) 29.FSpecial Requirements (590.009) 30. Other S sso1 sp dFom 141 ^ I�^ ❑ 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 105CMR 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: �r / 6 Page or�Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 9-22) FOOD PROTECTION MANAGEMENT 1 590-003(A) Assignment of Rea otQ sibility* _ 590.003(B) Demonstration of Knowledge* 2-(03.11 Ferson mcharge- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Ford Law* 3-201,12 require repotting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Ee�s* 590-003(F) Responsibility Of A Food Employee Or An 3.202.16 Ice Made From PotableDrinkine Water" Applicant To Repon To The Person In Drinkin- Water from an A moved Svstem'r 590.006(A) Chai,e* . 590.006(B) 5 90.003(G) Rctiorting by Person in Charge" 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions fi "Denote, critical item in the ru]eral 1999 Paid Code or 105 CMR 596,000. g Food and Water From Regulated Sources 590.004(A -B) Compliance with Ford Law* 3-201,12 Food in a Hennetically, ealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Ee�s* 3-202.14 IS=gs and Miik Products, Pasteurized" 3.202.16 Ice Made From PotableDrinkine Water" 5-101.11 Drinkin- Water from an A moved Svstem'r 590.006(A) BotttedDdnkin Water* 590.006(B) Water Meetc Standards in 310 CMR 22.0* \i'aslun F3,UItE mtd Ve*etables 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 ulatorr, Authority 3-202.15 Shelistock Identification Present* 590.004(0) Wild Mushrootns' 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PRFs Received at Pro Set Tem reracures" 3-202-15 Package Integrity" 3-101.1.1 Food Safe and unadulterated - Tags/Records: Sheiistock 3-202.18 Shellsnxk Identification 3-203.12 Shellsiock 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 E ui ment* Conformance with Approved Procedures /HACCP Plans 3502.11 Specialized Processing Methods* 3502.12 Reduced oxygen packaging, criteria" 8-103.12 Conformance with Approved Piocedures* "Denote, critical item in the ru]eral 1999 Paid Code or 105 CMR 596,000. g Cross-contam;nation 3-302.11(.A)(1) Raw Animal Foals Separated from Cooked and RTL; Foods* Contamination from Raw Ingredients 3-302,11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-30211(A) Food Protection* 3-302.1$ \i'aslun F3,UItE mtd Ve*etables 3-3(4.11 Food Contact with Equipment and utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reserviee of Fcarl* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioningtinsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashina - Hot Water Sanitizafion Temperatures"` - 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem ieratm'es' 4-501.114 Chemical Sanitization- temp., pH, concentration and hsuduess. " 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11. Cleaning FrequencyofEquipment Food - Contact Surfaces mud 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 ConditionHandsand Arms* 2-301.12 Ceanim, Procedure's 2-301.14 When to Wash" 11 Good Hygienic Practices 2-401.11 Farin,Drinkin>orUsincTobacco* 2-401.12 Discharges From the Eyes. Nose and Month* 3-301.12 Preventuie Contamination When Testing* j2 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em lovees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Ct acities* 5-204.11 Location and Placement* 5-205.11 Accessibilit ", O ration and Maintenance Supplied With Soap and Hand Drying Devices 6-301.11 Handwashine Cleanser. Availability 6-301.12 Eland Diving Provision CITY OF SALEM 3 BOARD OF HEALTH Establishment Name: )/ '77;_/ 11,6 Date: Page:_ of Item Code C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R— Red Item Verified PLEASE PRINT CLEARLY a10i a (45:, J0 EZ -1 IfflIV4,11 Alk 0 0161-010 do CL) fypc, 1 i r s A''✓ r SGA. J Discussion With Person in Charge: } Correc 've Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to Exclusion 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-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �. ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 17 18 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unatirnovcd Additives* 3-801.1](C) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11 CormxtonName- Working,Containers* 7-20LII Separation-Stoliwed` 7-202-11 Restriction - Presence and I)se* 7-202.12 Conditions of Use* 7-20311 Toxic Containers - Prohibitions* 7-204.11. Sanitizers. Criteria - Chemicals* 7-204112 Chemicals for Washine Produce, Criteria* 7-204.14 Dr •in ants. Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-206.11. Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stations - 7 -206.13 Tracking Powders, Pest Control and Monitoring,* TIME/TEMPERATURE CONTROLS 'c Denotes critical item in the fodera1 1999 Potcl Code or 105 CMR 590,000. r Proper Cooking Temperatures for PHFs Received it Temperatures According to I-aw Cooled to 41°F/45'F Within 4 Homs. Cool,im, Methods for PHFs PRFs 340L I1A(1)(2) Eggs- 155'F 15 Sec. 3-801.1](C) E >es- humediatc. Service 145°P15see* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(A) Animals- 155'T 15 see. * 3-4 11.11(B)(1)(2) Pork and Beef Roast 75)F F 121 nam* 3-401.11(A)(2) Ratites, Injected Meat's -155'F 15 26. 27. sec. 3-401.1I(A)(3) Poultry, Wild Came, Stuffed PHF9, Time as a Public Health Control* Stuffing Containing Fish, Meat, 590.004(H) Poultry or Ratites -165'F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145'F * 3401.12 Raw Animal Foods Cooked in it Microwave 165`F'* _ 3-401.11(A)(1)(b) All Other PHFs-1.45'F 15 we, Reheatingfor Hot Holding 3-703.11(A)&(D) PHFs 165'F 15 sec. * 3-403.11(B) _ Microwave- 165' F 2 Minute Standing, Time* 3-403.11(C) Commercially Processed RTE Food - 140'F 3.403.11(E) Renniming Unslieed Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70'F Within 2 flours and From 70'F to 41°F/4511F Within 4 Hours. * 3-501.14(13) Cooling PHFs Made Froin Ambient Temperature Ingredients to 41'F/45'F Within 4llours* 'c Denotes critical item in the fodera1 1999 Potcl Code or 105 CMR 590,000. r 21 3-801.11(A) 3-501.14(0) 3-501.15 PHFs Received it Temperatures According to I-aw Cooled to 41°F/45'F Within 4 Homs. Cool,im, Methods for PHFs 19 3-80'1 A I(D) PHF Hot and Cold Holding 3-801.1](C) 3-501,16(13) 590-004(F) Cold P1,-I1's Maintained at or below 41'145' FA Food and Food Protection 3-501.16(A) Hot PHFs Maintained at or above 140`F.* _ 25. 3-501.16(A) Roasts Held at or above 11WE 20 26. 27. Time as a Public Health Control FC -5 FC -6 3-501.-19 Time as a Public Health Control* Poisonous or Ibxic Materials Requirements Other 590.004(H) Variance Re uirement 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warninel,abels* 3-801..11(B) i)se of Pasteurized Eg,11s* 3-80'1 A I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 's 3-801.1](C) Unitiniened Food Package Not Re -served. t Violations of Section 590.009(A) -(D) in catering, mobile food, temporary mid residential kitchen operations should be debited under the appropriate sections >bove 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. P (MIJUITOWM (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and tisk factors listed above, can be foand in the following sections of the Food Code and 105 CMR 590.000 Good Retail Practices Consumer Advisory Posted for Consumption of 580.000 23. Foods That are Raw, Undercooked or FC -- 2 V Not Otherwise Processed to Euninate Food and Food Protection _ FC - 3 Pathogens."" Ems +roam _ 25. Eslui mint and Utensils Pasteurized Eggs Substitute for Raw Shell 26. 27. E¢¢s* Violations of Section 590.009(A) -(D) in catering, mobile food, temporary mid residential kitchen operations should be debited under the appropriate sections >bove 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. P (MIJUITOWM (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and tisk factors listed above, can be foand in the following sections of the Food Code and 105 CMR 590.000 asvo[yrn 02d" Good Retail Practices FC 580.000 23. Mang, omens and Personne_l FC -- 2 .003 24. Food and Food Protection _ FC - 3 .004 _ 25. Eslui mint and Utensils FC -4 26. 27. Water, Plumbing and Waste Ph sicai Facili V_ _ FC -5 FC -6 _.006_ .007 28. 29.SVt�ial 30. Poisonous or Ibxic Materials Requirements Other FC -- 7 _ .008 .009 asvo[yrn 02d" I Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4`" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name Date/ / Type of 0 eration(s) Type of Inspection ©Food Service ❑ Retail VIe! Fr / f S V I 'r(o r ©'Routine ❑ Re -inspection Address? q J £ hvrC Risk I "L& 6 Leve�l4,� El Residential Kitchen Previous Inspection Telephone 17 " 1 ❑ Mobile ❑ Temporary Date: ❑ Pre-operation Owner HACCP YM ❑ Caterer & Breakfast ❑ Suspect Illness ElGeneral Complaint Person in Charge (PIC)TimeElBed In: Out: Permit No. [I HACCP ElOther InspectoW,., f Cr" r=acn violation cnecxea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties .EMPLOYEE HEALTH " ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION. - ❑ 8 ,Separation/ Segregation/ Protection P 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) 2< 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 55001 Vs lFom -14.Coc n ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION. FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)„ ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY' _ ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions , and Risk Factors (Items 1-22): 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 Signatur� r Print: PIC's Signature: __ ^ Print: / ( / c� Pagel of2Pages Violations Related to Foodborne illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT Y 790.003(A) Assignment of Responsibdttya - 590.003(B) Demonstration of Knowledge* 2- 103.11 Person m ch trgv - duttcs � 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* a r tlicunts^ Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 320216 lee Made From Potable Drinking Water" Applicant To Report To The Person In Drinking Water from an Approved Svstem* 590.006(A) Chat "e* 590.006(B) 590.003(6) Re ortinab PersonrnChar*e* 3 590.003(D) I Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Ttestrietions U0 a C I 'x Denote; critical item in the federal 1999 Food (:ode or 105 CMR 590-000. PROTECTION FROM CONTAMINATION F-8 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 Egs and MilkPraluets. Pasteurized' 320216 lee Made From Potable Drinking Water" 5-1.01.11 Drinking Water from an Approved Svstem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Wachine 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 3-202.1£ Shellstock Identification Present* 590.004(C) Wild Mushrixxns* 3-201.17 Game Animals* 3-70L1i Receiving/Condition 3-202.11 PIIFs Received at Proper Tem lei atures° 3-202.15 Package lincauit " 3-101.11 Food Safe and'tlnadultin ated Tags/Records: Shellstock 3-202.18 Shellstock [dentiftcation * 3-203.12 ShellstockIdentitication 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 Foci Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Pians 4-703.11 S ecfrhzed 7hrKessmg Methods EJ3502.11 3 502.12 Reduced oxygen patkta ng, criteux 8-.t 03.12 Conformance wnh A roved Pro*edures 'x Denote; critical item in the federal 1999 Food (:ode or 105 CMR 590-000. PROTECTION FROM CONTAMINATION F-8 Cross -contamination 3-302.11(.4)(1) Raw Animal Foods Separated Froin Cooked and R 1 H f -oats" Cot tamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other;. Contamination from the Environment 3-302.1 ] (A) Food Protection* 3-302.15 Wachine Fruits and Vegetables 3-304.1.1 Food Contact with Lquipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reserviee of Foal'^ Disposition of Adulterated or Contaminated Food 3-70L1i Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temxratures* 4-561.-112 Mechanical Ware.washing- Hot Water Sanitization Tem eramres* 4-501-114 C.henucal Sanitization- temp., pH, concentration and hardness. * 4-601A UA) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensil " 4-702.11 Frequency of Sanitization of Utensils and Foci Contact Surfaces of Equipment* 4-703.11 Methods of Sanidration -Hot Water and Chemical" 10 Proper, Adequate Handwashing 2-301.11 Clean Condition -- Hands and At 2-301-12 Cleatum-Procedure� 2-301.14 When to Wash'` 11 Good Hygienic Practices 2-401-11 Fining, Drinkin or Using Tobacco* 2-401.12 Discharges Front the Eyes. Nose and Month* 3-301.12 Preventing Contamination When Tas in ,a 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em lovees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.1.1 Numbers and Ca acides* 5-204.11 Location and Placement' 5-205.11 Accessibility, O eration and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 IlandWashing Cleanser. Availability 6-301-121Iand Lnya Provision ITY OF SALEM BOARD OF HEALTH Establishment Name: VM& V -W 44#1 "/tm Date: Page: 2 of Item Code C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date " No. Reference R — Red Item PLEASE PRINT CLEARLY Verified / f 4 Q 2 i e\ a G _rFA f ,4% cre &W .rJ uerUrdL rte.. I r,vG S'oeaa4V - r �c1 1r4 ! WWS' Au /tcctri�tJ v CIA iisC.rA4,oCdrt�dr S� h-t'r tA r - . 1 d t �60 Awls L ��L Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that snoncompliance may result in daily fines of twenty-five dollars or suspension/revocation of LIEmbargo ❑ Emergency Closure /1i ,, your food permit. �_�`---� l.. 0 Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 t.5 16 Food or Color A dditives 3-202.12 Additives* 3-302.14 Protection frontUn ipruved Additives" 3-801.11(C) Poisonous or Toxic Substances'. 7-101.12 Identifying Information -Original Containers* 7-102.11 Common Name - Working- Containers* 7-201.11 Se aradon - Storage'" 7-20-2.11 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 Dr in A grits. Criteria* 7-205.11 .Incidental Fend Contact. Lubricants, 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 1 Rodent Bait Stations" 7-206 13 Tracking Powders, Pest Control and Monitorml-* 1t1iti A1114AW 1r�1�F} aL�i.3ii€ia ;7 Deatao critical item in the. federal 1999 Food Code or 105 CMR 590.600. I3-501.15 Proper Cooking Temperatures for 19 PHFs 3-401.11A(1)(2) Eggs- 155°F 1.5 Sec. 3-801.11(C) Eggs- Immediate Service 145'Fl5sec> 3-401.11(A)(2) Comminuted Fish, kfcats & Game 0 Animals - 155°F 15 sec. " 3-401.11(B)(1)(2) Pork and Reef Roast - 130°F 121 min* 3-401.11(A)(2) Ratites, Injected Meats - 155°F 15 Poisonous or Toxic Materials sec. 3-401.11(A)(3) Paltry, Wild Game, Stuffed PHF,, x. me Stuffing Containing Fish, Meat, Other Poultry or Ratites-165aF 15 sec. 3401.1 l(C)(3) Whole -muscle, Intact Beef Steaks 145`F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165"F * 3.401.1l(A)(1)(b) All OtherPHFs- 145°F 15 sec Reheating for Hot Holding 3-403.1l(A)&(D) PHFs 1650F X15 sec. * 3-403.11(B) Microwave -165" F2 Minute Standing Time* 3-403.1 1(C) Conuuercially Processed RTE Food - 140"F* 3-403-I I(E) Remaining Unsliced Portions of Beef Riaists" Proper Cooling of PHFs 3-.501.14(A) Cording Cooked PHFs from Uh,rF to 70"F Within 2 Hours and From 70°F to 41°F/45°F Within 4 Homs. 3-501.14(8) Cooling PHFs Made From Ambient Temperattve Ingredients to 41°F/45`F Within 4 flours't Deatao critical item in the. federal 1999 Food Code or 105 CMR 590.600. I3-501.15 3-501.14(0) PHFs Received at Temperatures According to Um Cooled to 41 °F/45°F Within 4 Hours. Cooling- Methods for PHFs 19 PHF Hot and Cold Holding 3-50,1, t 1(D) 3-501.16('B) Cold PHFs Maintained at or below 590.0040 41 °145° F" 3-801.11(C) 3-501.16(A) Hot PHFs Maintained at or above 140"-. * FC -- 3 ' .004 3-501.16(A) Roasts Held at or above 130°.F. 0 _ Time as a Public Health Control 27. 3-501-'19 Time as a Public Health Control* _ FC -6 ��007-- 590,004(H) Variance Re airement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-SO'I I I(A) Unpastcuiized Pre-packaged Juices and Bevei ages with Warning Labels* 3-801_11(B) Use of Pasteurized Eggs* 3-50,1, t 1(D) Raw or Partially Cooked Animal Food and Raw Seed S xrouts Not Served. 3-801.11(C) Unopened Fend Package Not Re -served. MWKba.H1 1411 22 3-60311 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked or Not Otherwise Processed to Eliminate pfahnaenc * F't"C'" Vtzooi 3-302.13 1 Pasteurized Fu¢s Substitute for Raw Shell arcv,trarr nc�,rrnncrvrcty t 5 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering. mobile food, temporary and residential kitchen operations should he 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 thefollowing sections of the Food Code and 105 CTfR 590.000 Item Good Retail Practices FC r 580.000 23. Mana anent and Personnel FG - 2 .003 24. Food and Food Protection FC -- 3 ' .004 25. 26. -Ph E ui ment and Utensils Water, Plumbinit and Waste FC - 4 .005 FC -5 006 27. sical Facili _ FC -6 ��007-- 28. Poisonous or Toxic Materials FC -7 .008 _ 29. Special Requirements x. me 30. Other S:SYOf iniWrkG2:kx t + s e STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEMv MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: The Tin Whistle Address of Establishment: 241 Jefferson Avenue Owner's Name: William & Craig DeOrio Restrictions: Application Date: 12/3/2004 Permit for Food Establishment 153-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. CITY OF SALEM, MASSACHUSETj�llP��IIjj11��11'd,,��J jars o BOARD OF HEALTH lv� Lqv� 9i 120 WASHINGTON STREET, 4TH FLOOR 9 a SALEM, MA 01970 NOVN J 01004 TEL. 978-741-1800 �4^ FAX 978-745-0343 BOA D OF CITY OF ALCM STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO HEALTH MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TF4E _71114 Wt tSTLE TEL #(178) 1L41-191 Z ADDRESS OF ESTABLISHMENT 2-41 Jft:RSIJ&l AVENd : MAILING ADDRESS (if different) OWNER'SNAME UJILLIArvV 2XtQt10 CRAIG je-0"o TEL#(ql&) J7q—a0M CITY CERTIFIED F ST IC zip (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON CRAiE7 �£(�2Iy HOME TEL #(q-7$)'ib%-ILIgF HOURS OF OPERATION: Mon)f ✓Tue. v-Wed.�Thu. ✓ Fri. v Sat. ✓ Sun. , , A af, TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTAURANT YES NO BED/BREAKFAST YES NO FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than I0,000sq.ft. =$250 �3�a5 less than 25 seats =$100 5-99 seats =$150 more than 99 seats =$200 $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT (such as church kitchens) YES N $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 be knowledge an �•�'�eli��f-{�ave� filed all state tax returns and paid all state taxes required under the law. Date Social Security or Federal Identification Number Revised 11/03/03 FOODAP2.adm Check# & 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 / % / D Tvoe of Operation(s) T e of Inspection []'Food Service ❑ Retail El Residential Kitchen ❑ Mobile Routine ❑ Re -inspection Previous Inspection Date: Addre ` On Risk Level Telephone q� / �/� `f FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands El El Caterer ❑ Bed & Breakfast Permit No. ElPre-operation ❑ Suspect Illness ❑ General Complaint ❑HACCP ❑ Other OwnerHACCP UJ I It►Q +❑ Y/N Person in Charge (PIC) Inspect Time In: Out: �acn vrvrauvn cnecKea requires an explananon on me narrative page(s) and a citation of specific provision(s) violated. Print: 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. Page of CQPages FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned / Knowledgeable / Duties ❑ 13. Handwash Facilities v EMPLOYEE HEALTH '' .. ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS - ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ) TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) - ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION - ❑ 19. Hot and Cold Holding Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing -'REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ' El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices ,.,CONSUMER ADVISORY...- ❑ 22. Posting Consumer of Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions FT immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non -'critical (N) violations must be corrected immediately or within 90 days as determined by the Board Official Order for Correction: Based on an inspection of Health. today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC -2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC -3)(590.004) order of the Board of Health. Failure to correct violations 5. Equipment and Utensils (FC -4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste(FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC -6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic -Materials (FC -7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements . (590.009) within 10 days of receipt of this order. 30. Other 5:511 pe'Fomre-ia.coo DATE OF RE -INSPECTION: /1 )ins ct re: / Print: ZS,f s Signature• Print: Page of CQPages ( N D Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 �r)0.003tA) Assignment of 590.003(6) Demonsit ation of Knowledge" 2-103.11 Person in charge --duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporl'ing by food employees and 3-201.13 Fluid Milk and Milk Products* a tlicauts"` Shell Eggs* _5()_(),0()3(F) Responsibility OFA Food Employee Or An 3-202.16 5-1.0111 __ELLS lie Made From Potable Drinking Water* Drinkin = Water from an A roved System" Applicant To Re -port 1'o The Person In Bottled Drinking Water* 590.006(B) Charge' 3-304.11 590.003(29) Re totting b Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B) 590.003(E) Reltwaai of Exclusions and Restrictions C I -, Demttes ernical item in the iederal 1999 Foal Code or 105 C IR 590.060. PROTECTION FROM CONTAMINATION g Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 and Nlilk Products. Pasteurized* 3-202.16 5-1.0111 __ELLS lie Made From Potable Drinking Water* Drinkin = Water from an A roved System" 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 910 CMR 22.0* 3-304.11 Shellfish and Fish From an Approved Source 3-2{)1.14 Fish and Recreationally Caught Molluscan Shellfish" 3-201.15 Molluscan Shellfish from NSSP Listed Sources* 3-306.14(A)(B) Game and Wild Mushrooms Approved by Pp.nu,inciry Authorit 3-202.18 590.004(C) Shellstock Identification Present* Wild Mushraxms* 3-201.1? Game. Animals" 3-701,11 Receiving/Condition , 3-202.11. PHhs Received at Ern er Tem erahires'A 3-2011.5 3-101.11 Packa e lute it Food Safe and Unadulterated 4-501.111 Tags/Records: Shellstock 3-202..18 Shellstock Identification 3-203.12 Shellstock Identification Maintained" Tags/Records: Fish Products 3-402.11 Parasite Destrncuon* 3-402.12 Records. Creation and Retention" 590.0040) Labeling of ingredients' 3-502.11 Conformance with Approved Procedures /HACCP Plans S.ecializedProcessinaMethods* tl-502.12 Reduced osv en lecke ring. criteria* 8-103.12 Conformance with A. roved Procedures" -, Demttes ernical item in the iederal 1999 Foal Code or 105 C IR 590.060. PROTECTION FROM CONTAMINATION g Grass-contamdnathan 3-3(Y2.I I(A)(1) Raw Animsil Fools Separated from Cooked and RTE Foods*' Contamination from flaw Ingredients 3-302A I(A)(2) Raw Animal Fools Separated from Erich Other* Contamination from the Environment 3-302.1](A) Fund Protection* 3-302.15 Washine Fruits and Veeetables 3-304.11 Food Contact with Equipment and / liumsils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Rescrvice of Fund'" Disposition of Adulterated or Contaminated Food 3-701,11 Discarding or Rearndifloning Unsafe Food" 9 Food Contact Surfaces 4-501.111 Manual Warewashina - Hot Water Samfization 1'em eratures* 4-501.112 Mechanical W'arewashiag-Hot Water Sanitization Tem eratures* 4-501.114 Chemical Sannimlimr- temp., pH, concentration and hardness. * 4-601.1 I(A) EquipmentPood Contact Surfaces and Utensils Clean"` 4-602.11 Cleaning Frequency ofEquipmentFood- Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of sit anent* 4-703.11 Methods of Sanitization - Hot Water and Chemicall' to Proper, Adequate Handwashing -TIT) I.I1 Clean Condition -Hands and Arms" 2-301.12 Cleating Procedure* 2-301.14 When to Wash* I Good Hygienic Practices 2-401.17 Eating. Drinkin , 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 ccs" 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Ca ac ties 5-204.11 Location and Placement* 5-205.11 Accessibilit , Oteradon andlvlaintenance Supplied with Soap and Nand Drying Devices 6-301.11 Handwashin Cleanser, Availabilit 6-30112 Hand Drying Provision I. CITY OF SALEM / / BOARD OF HEALTH Establishment Name: 7772 71-n�h! S)/er Date: Page: a' of Item No. Code Reference C -Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION R — Red. Item - - - „ PLEASE PRINT CLEARLY Date Verified sik s ra ror empy MaTf- (Itc maii 114ulc p r�n.w rd,4 2.eIL/iv W ACUC C4V2,e 9O -n atJ• 7 .► r rJ&tvirtz.a a c�.C_ rr,f5a- rt.f .tars, arc- w-cn 614,L N. C_ Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next 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. J ❑ EmDlovee Restriction/ ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Voluntary Disposal ❑ Emergency Closure ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 1.6 17 IS * Dennie, critical item in the federal 1999 Fgxrd Code or 105 CMR 590.000. 19 20 3-501.14(C) Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Una) noved 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 5e aianon- Stora=e* 7-202.11 7-202.12 7-203-11 Restriction - Presence acid Use's Conditions of Use* Toxic Containers - Prohibitions* 7-204.11 Samitizers. Criteri r -Chemicals* 7-204.12 Chemicals for Washin > Produce. Criteria* 7-204.14 Diving Agents. Criteria* 7-205.11 Incidental Food Contact, Lubricants" 7-206.11 Restricted Use Pesticides, Criteria* 7-206.1.2 Rodent Bail Stations' 7-206.13 Tracking Powders, Pest Control and Monitoring' * Dennie, critical item in the federal 1999 Fgxrd Code or 105 CMR 590.000. 19 20 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.11A(1)(2) Eggs- 155'F 15 See. 3-501-16(B) 590.004(F) Lein- Immediate Service 145'Fl.5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Annuals - 155'1` 15 sec. d` 3-401.11(B)(1)(2) Pork and Beef Roast -130'F121.rnin* 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, 3tutnng containing Fish, Meat, FC -6 Poultry or Ratites -165'F 15 sec. 3401Al(C)(3) Whole -muscle, Intact Beef Steaks FC -7 145"F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F* 3-401.11(A)(1)(b) All Other PHI'S - 145'F'15 sea Reheating for Hot Holding 3-403,11(A)&(D) PHFs 165'F 15 sec. " 3-403.1.l(B) Microwave- 165' F 2 Minute Standing Tile.* 3-403.11(C) Commercially Processed RTE Food - 140'F* 3-403A 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 2Hours and Front70'F to 41'F1450F Within 4 Hours. * 3-501.148) Cool'urg PHFs Made From Ambient Temperature ingredients to 41'F145'F Within 4 Hours* * Dennie, critical item in the federal 1999 Fgxrd Code or 105 CMR 590.000. 19 20 3-501.14(C) PHFs Received at Temperatures According to I aw Cooled to 41.'Fl45'F Within 4 Hours. 3-501.15 Cooling Methods'for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501-16(B) 590.004(F) Cold P1iFs Maintained at or below 41°145' 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 3-501.1.9 Time as a Public Health ControPs 590.004(H) Variance Requirement 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Wanting Labels* 590.000 3-801.11(B) Use of Pasteurized Errs* Qe i FG -2 3-801.1. I (D) Raw or partially Cooked Animal Food and Raw Seed Sprouts Not Served. * Food and Food Protection _ 3-801.1.1(C) Ilno.erredFoodFacka>eNot Rc-served. CONSUMER ADVISORY 22 3-G03.11 Consumer Advisory Posted for Consumption of 590.000 I_23 Animal Foods That are Raw. Undercooked or i FG -2 .00.9 Not Otherwise Processed to El nuriate Food and Food Protection _ FC -3 Pathogens.* E'recnve vnawi 25- 3-302.13 Pasteurizes( Eggs Substitute for Raw Shell -) 26 _ Water, Plumbinct and Waste Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be adei the, - rsi-i, rr above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under fi29 - Special Requirements. (Items 23-30) Critical and non-critical violations, which do not retate 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. Item Good Retail Practices '.. FC 590.000 I_23 Maniattement end_ Personnel i FG -2 .00.9 j 24 Food and Food Protection _ FC -3 .004 25- Equipment and Utensils FG 4 -) 26 _ Water, Plumbinct and Waste FG 5 ,006 27, Ph sisal Facilit FC -6 .007 7 28._ _Poisonous or Toxic Materials' FC -7 .008 29. _l_ Speciai Requirements - �30. ; Other s_ U'ro 'Al...Idos STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEMv MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: The Tin Whistle Address of Establishment: 241 Jefferson Avenue Owner's Name: William & Craig DeOrio Restrictions: Application Date: 12/18/2003 Permit for Food Establishment 228-04 Frozen Desserts/Ice Cream 13-04 Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-74 1 -1800 FAX 978-745-0343 STANLEY USOVICZ JR NOV 18 2003 CITY OF SALEM BOARD OF HEALTH ' JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT THg�Tin1 WAiSTLr TEL#�I-C�7k/-/9/L ADDRESS OF ESTABLISHMENT 241 )arcz-stoi Ave. MAILING ADDRESS (if different) OWNER'S NAME WILWAM I,EQ210 ,C¢_A-i(. L-)CCV210 TEL# SAME ADDRESS C(T r CERTIFIED FOOD STA ZIP (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME ��I1a HOME TEL rib -1 qqV HOURS OF OPERATION: MonJl- I Tue. I It -1 Wed.l I- I Thu. It- I Fri. It - 1 Sat. I I-1 Sun. 12- 1 AM A,M `uw. A:y. TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTAURANT YES NO BED/BREAKFAST YES NO ADDITIONAL PERMITS 1(-.2— MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO 50 ALL NON-PROFIT (such as church kitchens) YES NO $25 FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$1Q0 25-99 seats 15 more than 99 seats =$200 $100 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 Jtnowledge an eli , have filed all�tate Sax� returns and paid all state taxes required under the law. Z� M /U // +3/0oy 3 y2b o�S Signatures Date Social.Security or Federal Identification Number Revised 11/03/03 FOODAP2.adm Check# & Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4'h Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax,(978) 745-0343 Name Date Type of Operation(s) T e of Inspection F 77/u i,/ iSr 211/ 41 21 Food Service LJ Retail ❑ Residential Kitchen Routine ElRe-inspectionode Previous Inspection Address rRisk Level Telephone[:1�,�1 �y/_ �9 Mobile Date:" r73 f -a ElPre-operation Owner � -ElTemporary HACCP Y/N /1/,// q,» 4 '- /� clip �c�p ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) ele�/O Time In. Out: Permit No. ❑ HACCP ❑ Other Inspector L). r_- U Each violation cnecKea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑- 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded "FOOD FROM APPROVED SOURCE' ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection © 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C -', N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (Fc -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) PE130. Other s svoinspecrFomw-ia.00c ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS - ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods) ` ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE. POPULATIONS (HSP) ,,, ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions /G 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: s ector' Si 2f(ure• ' Print: PIC's Signatures ) „ /Q"� _ Print: /1 14 `:. is F'.. /1 `� Pagel of 2'Pages U11 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) In C 6 •ai • 5,90.003(A) Assignment ol'Re onsibility' 590.003($) 2-103.1 t Demonstration of Knowled _c. ` Person in charge -- duties EMPLOYEE HEALTH 590.003(C) Responsibility of the person in charge to 590.004(A -B) 3-201.12 3-201.13 require reporting by food employees and 3-202.13 a tticants*- 590.003(F) Responsibility Of A Food Employee Or An 3 -202.16 Applicant To Report'Fo The Person In 5-101.1.1 Charge* 590.003((3) Re ortin b , Person in Charge* 590.003(D) Exclusions and Restrictions* 590.003(3) Removal of Exclusions and Restrictions Denotes critival item in the federal 1999 Food Code oi-105 CMR 590.000- - i. 8 Food and Water From Regulated Sources 590.004(A -B) 3-201.12 3-201.13 Compliance with Food Law Food in a Hermetically Scaled Container" Fluid Milk and Milk Products* 3-202.13 Shell L"'gg5* 3-202.14 EZgs and Milk Products. Pasteurized - 3 -202.16 Ice Made From Potable Drinking Water* 5-101.1.1 Di nikin r Water from an A gavel S •stem" 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" 3 -302.j.5 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* 3-202.18 590.004(0) 3-201.17 Game and Wild Mushrooms Approved by Re uiato Authorit Shcllstockidentification Present* Wild Mushrooms* Game Animals* 3-306.14(A)(B) Receiving/Condition 3-202.11 PHFs Received at Faille] Tem teratures* 3-202-15 Package Inte rit* 3-101.11 }202.18 Food Safe and Unadulterated Tags/Records: Sheilatock 5he11stouk Identitiratian 3-203.12 Shellstock identification Maintained* TagslRecords: Fish Products 3 402.11 Parasite Destruction* 3-402.12 Records. Creation and Retentions' '. 590.0040) 3-502.11 Labeling of Ingredients' Conformance with Approved Procedures /HACCP Plans S ecialized Proeessin� Methods* 3-502.12 Reduced oxygen tacky 'ng. criteria* 8-103.12 Conformance with Approved Procedures* Denotes critival item in the federal 1999 Food Code oi-105 CMR 590.000- - i. 8 Gross-contaminatxm a 302.11(A)(1) Raw Anunal Foods Separated from Cooked and RTE Foods* k3' Contamination from Raw Ingredients -302.1.1(A)(2) Raw Animal Foods Separated f'rorn Each Other" Contamination from the Environment 3 302.11(A) Food Protection - 3 -302.j.5 Washing Fruits and Virgetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer - 3-306.14(A)(B) Returned Food and Resemce of Food" Disposition of Adulterated or Contaminated Food 370 Discardinb* or Reconditioning Unsafe Food* <) Food Contact Surfaces 4-501.111 Manual Warewashing- Hot Water Sanitization Tetn2eratures* 4-501.112 Mechanical Warewashin„ Ilot Water Sanitization Tem erstures* 4-501.,114 Chemical Sterilization- temp., pH, concentration and hardness. 4-601.11(A) Equipment Food Contact Sutiaces and Utensils Clean* Cleaning Frequency of Equipment Food - Contact Sufaces and Utensils'" 4-70Frequency El of Sanidzation of Utensils and Food Contact Surfaces of E ui menta 4-703.1.1 Methods of Satnfization -Hat Water and Chemical* 10 Proper, Adequate Handwashing 2-3_01.11 Clean Condition -Hands and Arms* 2-30L12 Cleasung 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' -LF3-301.12 Pmventin, Contamination When fasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Ent tlo gees* 13 Handwash Facilities Conveniently Located and Accessible 5-203,11 Numbers and. Ca aeifies* 5-204.11 Location and Placement* 5-'_05.11 Accessibility, Operation and Maintenance Supplied with Soap and Nand Drying Devices 6-301.11 Handwaslvn Cleanser, Availabiht y 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH i Establishment Name: �—I/f 7-iry Date: Z - A, Page: c2 of Item No. Code Reference c - Critical Item R — Red Item `DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Verified J - - �L /ppm wt es u disi/�/� �Y 1 e 1 die eFaC o,, �� -IfZI —2/ �vO T e �?7it�MJ` 4 a - �,� s �� ztz,e .SfiiL/�l Z/� - L4 797QST" �I�1 %Z�l iv P c�' e�u/,1 /7 ,4 4-2/sr Z�es—PLi fives G,JOr�is apo/%�g21,tsils -00-7I �l d L)eles&v / ( 16Y K C- y �G; e.e Ile rri 6(_1 A o Pe"L/ ovOQgA Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next ins inspection, to observe all conditions as described, and to p comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. "- ��--�7 Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion El Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Intemenflons and Risk Factors (items 1-22) (Cont) PROTECTION FROM CHEMICALS 14T 17 18 TIMEITEMPERATURE CONTROLS Food or Color Additives 3-20112 Additives'k 3-302.14 _ Protection from Unai coved Additives* 3-801.1.1(C) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers" 7-10111 CommonName- Working Containers; 7-201.11 Separation - Stora e" 7-202,11 Restriction - Presence and Use" 7-202.12 7-20', It Conditions of Use" Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria" 7-204.14 Di vin* A -enol Criteria" 7-205.11 Incidental Food Contact, Lubricants* 7-20&11 Restricted Use Pesticides. Crttet5a* 7-100 12 Rodent Bait Stations'` 7-2(Ifi.I3 r!!� Tracking Powders, Pest Control and Monitoring" TIMEITEMPERATURE CONTROLS * Denotes critical item in the tedeC31 1999 Food Code or 105 CMR 590.00(1. Proper Cooking Temperatures for 3-801.11(6) PHFs 3-401.11A(1)(2) Eggs- 155'F15See, 3-801.1.1(C) Ea,,,s- Immediate Service 145'F15sec* 3-401.11kA)(2) Comminuted Fish. Meats &Game FC- 3 Animals - 155`''F 15 sec. * 3-401.1l(B)(1)(2) Pei kand Beef RoasL-130'Ft2lmm'� 3-401.11(A)(2) Ratites, Injected Meats - 155'P 15 26. sec. * 3-401.11(A)(3) Poultry, Wild Game. Stuffed PHFs, 20 Stuffing Containing Fish, Meat, �I.F_C IFC 6 Poultry or Ratites -165'F 15 sec 3-401-1 t(C)(3) Whole -muscle, Intact Beef Steaks 1 FC -7 145'F 1` 3-401.12 Raw Animal Foods Cooked in a Microwave 365'F 3-401.11(A)(I)(b) All Other PHFs -- 145'F 15 sea L__ -- Reheating for Hot Holding 3-403.11 (A)&(D) PHFs 165'F 15 sec. 3-403.11(,6) Microwave- 165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140-17 3-403.11(E) Remaining tnrsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cowling Cooked PIIFs Iron 140'F to 7WF Within 2 Hours and From 70'F to 41'F145'I' Within 4 Hours.* 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F145'F Within 4 Hours* * Denotes critical item in the tedeC31 1999 Food Code or 105 CMR 590.00(1. NO e 11 21 3-801 1. ] (A) 3-501.14(0) PHFs Received at Temperatures 3-801.11(6) According to Law C oolcd to 3-801 i l (D) 41'F145°F Within 4 Hours, 3-801.1.1(C) 3-501.15 Cooling Methods for PHFs 9 PHF Hot and Cold Holding FC- 3 3-501.16(13) Cold PHFs MZaimained at or below �r 25 590.004(F) 41'%45' F* I FC -4 3-501.16(Ai 116t PHFs Maintained at ar above 26. 140`F-* 5 3-501.I6(A) Roasts Held al or above. 130''F. 20 Time as a Public Health Control �I.F_C IFC 6 3-501.19 Time as a Public Health Control 28. 590.004(1-1) Variance Recuh'ement NO e 11 21 3-801 1. ] (A) Unpastenrized Prc packaged Juices and Beverarzes with Warning Labels* 3-801.11(6) Use of Pasteurized I.00s'f 3-801 i l (D) Raw or Partially Cooked Animal Fcxx1 and Raw Seed Sprouts Not Served. '^ 3-801.1.1(C) Unopened Fond Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of FC Annul Foods, That are Raw. UndBrcooked or 23. Not Otherwise Processed to Eliminate FC - 2 Pathogens.* 24. 3-302.13 Pasteurized Eggs Subsuane for Raw Shell FC- 3 En ,s* 590 -009(A) -(D) Violations of Section 590.009(A) -(I)) in catering, mobile food, temporary and residential kitchen operations should be debited trader the appropriate sections above if related to foodborne illness Interventions and risk factors. Wier 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 f nidhorne illness interventions and risk farta-s listed above, can be found he the following sections of the Food Code and 10.5 CMR 590.000. 'F Item Good Retail Practices FC 590.000 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC- 3 .004 �r 25 E uiment and Utensils I FC -4 .005 -1 26. Mater. Plumbinq and Waste 5 -006 27. Physical Facilli �I.F_C IFC 6 .007 28. I Poisonous or Toxic Materials 1 FC -7 .008 �_29 T Special Requirements ,009 � r 3o. 1 _ Other ---- L__ -- s' AA..onyx;..a,,,. co CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3 ,b 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ. JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: William DeOrio Name of Establishment: The Tin Whistle Address of Establishment: 241 Jefferson Type of Establishment: FOOD SERVICE Application Date: 12/20/2002 Restrictions: Permit for Food Establishment Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 Avenue 126-03 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. v HEALTH AGENT �n CITY OF SALEM, MASSACHUSETTS �• Il�� C0 �ivg � BOARD OF HEALTH �a 120 WASHINGTON STREET, 4TH FLOOR DEC 1 9.2002 SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 BOARLr 1, STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 7i h41STU^ AVE:_TEL # 9`7g -741-1 g IZ ADDRESS OF ESTABLISHMENT Z`II JE lua1) A MAILING ADDRESS (if (different) OWNER'S NAME__W luuIkVv,�e i/121 -o TEL # cOf 77c/ -WL (7ITY_ pgA-8S STATE M.ft__ _ ZIP_U �`t CERTIFIED FOOD MANAGER'S NAME(S)Carhlf _Bcr02to CERTIFICATE#(s) II'),L*30 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON V V 1Lu lftVA jf�DILIQ HOME TEL # fb%2 HOURS OF OPERATION: Mon. Imo^ (_Tue. 11 I Wed. 11'" Thu. I I I Fri.I� 1 Sat. I f -( Sun.FZ- TYPE OF ESTABLISHMENT RETAIL STORE YES NO RESTAURANT(NO /a6p 63 YES BED/BREAKFAST YES NO ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO TOBACCO VENDOR YES NO ALL NON-PROFIT (such as church kitchens) YES NO FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats = 10 25-99 seats 150 more than 99 seats =$200 $100 $5 $50 $25 Please pay total with one cheek 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 nest knowledge and belief. have filed all state tax returns and paid all state taxes required under the law. Signature Revised 11/25/02 FOODAP2.adm Check# & Date— �d �0 J or Federal Identification Number ----�-v�ti.-....r<r-:i...�r�...�^�wr'..A.Y�r..c-s+r----••r' � �K*y4ia"cwA�."""�°i,w,+Lr�"T"",e+�'wi!'wrA('+�r'+„#'�-^-""'e,-ewv.w...�+�.-. I ---THE COMMONWEALTH OF MASSACHUSETTS `- CITY OF SALEM BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT, Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel: (978) 741-1800 Fax: (978) 745-0343 Name , Date .Z pJ 46 of r i n Food Service ❑ Retail Kitchen El El ElMobile ❑ Temporary - ❑ Caterer ❑ Bed & Breakfast Permit No. Type of Inspection Routine ❑ Re -inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint ❑ HACCP ❑ Other Address Rik Level(�// / r ` Telephone Csn _ _ 1 7'd Owner HACCP YIN Person in Charge (PIC) Time In: 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 (Red Items) Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation / Segregation / Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board ,of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28.. Poisonous or Toxic Materials (FC -7)(590.008) 29.Special Requirements (590.009) 30. Other ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Calor Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number ofViolated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: r- . Inspector's Signature: Print: yi / i/� `.S-.�'I� PIC's Signature: Print: Page -/of Pages FORM 734A HOBBS & WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red 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 . 590.003(C) Responsibility of the Person in Charge to r 3-201.12 require reporting by Food Employees and 3-201.13 Fluid Milk and Milk Products* Applicants* Shell Eggs* 590.003(F) Responsibility of a Food Employee or an 3-202.16 Ice Made from Potable Drinking Water* Applicant to Report to the Person in Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* I` 3'` 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) I Removal of Exclusions and Restrictions C 5 6 FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 8 C 12 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made from Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3.201.14 Fish and Recreationally caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(7) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 8 C 12 PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) 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 Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.1 l(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating. Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision [e OF SALEM BOARD OF HEALTH Establishment Name: �� Date: Z v3 Page: Z of ItemI Code ( C—Critical Item DESCRIPTION OF VIOLATION /PLAN OF CORRECTION I Date No. Reference R —Red Item Verified I I I I w —I -a / cr-2� .5- Fl;_. CK i',�__X C // I I 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: ❑ Voluntary Compliance ❑ Re -inspection Scheduled ❑ Embargo ❑ Voluntary' Disposal 7 � G'rt• ['�-ti ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure 0 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 17 lam * Denotes crttiail item in the federal 1999 Food Code or 105 06312 s90.000. 19 26 3-501,14(0) _ Food or Color Additives 3-202.12 Additives" 3-302,14 Protection from Una .roved Additives' 3-501,16(B) 590.004414? Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Workinl- Containers'% 7201,11 Separation - Stora e* 7-202.11 _ Restriction - Presence and 11se'" 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 Dr iE Agents. C'sireria* 7-205.'11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria" 7-20612 Rodent Bait Stations" 7-206.13 Tracking Powders, Pest Control and Monitoring* * Denotes crttiail item in the federal 1999 Food Code or 105 06312 s90.000. 19 26 3-501,14(0) _ Proper Cooking Temperatures for 3-501,15 PHFs 3-401.1'1A(1)(2) Eggs- 155F 15 Sec. 3-501,16(B) 590.004414? Eggs- Immediate Service 145'F1.5sec 3-401,11(A)(2) Comminuted Fish. Meats &Game 3-5, 01.16(.4) Animals - 155'.F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast - 130F t21 mint 3-401.11(A)(2) Ratios, Injected Meats - 155°F 15 590.004(14) see, * 3401.1 (A)(3) Poultry, Wild Game. Stuffed PFfFs, a'tutnng Containing Fish, Meat, 112Lt or Ratitea-165F 15 sec. 3-401.11(C)(3) Whole muscle, Intact Beef Steaks 145"F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165`14* 3401.11.(.A)(1)(b) All Other PHFs -145+15sec. Reheating for Hot Holding 3-403,11(A)&(D) P1IFs 165`F 15 sec. ^' 3-403.11(B) Microwave- 165°F 2 Minute Standing Time* 3-403.'11('C) Commercially Processed RTE Food - 140F* 3-403.'tl(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 Harris and Front 70'F to 41'F/45'F Within 4 Hours * 3-501.14(B) CoolingPHFs Made From Ambient Temperature Togredients to 4147,15`1 Within 4 Hours` * Denotes crttiail item in the federal 1999 Food Code or 105 06312 s90.000. 19 26 3-501,14(0) _ PI-7FsReceived atTemperatures According to Law Cowled to Within 4 Hours, 3-501,15 _4PF145'F Cooling Methods for PHFs 3-801.11 (b) PHF Hot and Cold Holding 3-501,16(B) 590.004414? Cold PEfFs Maintained at or below 41'/45° F* 3-50L16(A) Her PRFs Maintained at or above 14014. 3-5, 01.16(.4) Roasts Held at or above 130°F. L 28._ Time as a Public Health Control 3-501.19 Time as a Public .Health Control" 590.004(14) Variance Recuirement a 21 3-801.1.1(A) Unpasieuri7.gd Pre-packaged Juices and Beverages with Wacnin3 Labels* 3, 23. 3-801.11 (b) Use of Pashaul7ed ERRS* 24. ___ 25. 26. 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Snout's Not Served. * ;tl-'3 3-801.11(C) Unopened Food Package Not Re -served. SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catenng, mobile food, temporary and residential kitchen operations should be andelthe i_il awuv,t., 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. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the follinving sections t f the Food Cade and .105 04R 590.000. Item Good Retail Practices I FC Consumer Advisory Posted for Consumption ofAnimal 3, 23. Management and Personnel ',,, FC - 2 Foods;`Tht are Raw, Undercooked or 24. ___ 25. 26. Foo_d_and Food Protection FC _3 _ Equipment and Utensils FC -4,005 Water. Plumbing and Waste FC n Not Otherwise Processed to Eliminate ;tl-'3 Physical Facility '.. FC -6 Pathogens.*evom:a;n" L 28._ 02.13 Pasteurized Eggs Substitute for Raw Shell 29. S ectal Requirements Eggs' SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catenng, mobile food, temporary and residential kitchen operations should be andelthe i_il awuv,t., 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. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the follinving sections t f the Food Cade and .105 04R 590.000. Item Good Retail Practices I FC 590.000 3, 23. Management and Personnel ',,, FC - 2 .003 24. ___ 25. 26. Foo_d_and Food Protection FC _3 _ Equipment and Utensils FC -4,005 Water. Plumbing and Waste FC n .004 _ ------- - --. 27. Physical Facility '.. FC -6 _,006 ,007 L 28._ Poisonous or Toxic Materials FC 7 .008 29. S ectal Requirements 30. Other sasr;o,m.�,,aa rtY THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel: (978) 741-1800 Fax: (978) 745-0343 Name Pr t L Date 7-Ala Type of Ooeration(s) Service Type of Ins epection [Q Routine Address t S��^ Risk q i ❑Retail ❑ Re -inspection Level [�%// El Residential Kitchen ❑ Mobile Previous Inspection Date: Telephone - _ `�� El Temporary ❑ Caterer ❑ Bed 8 Breakfast 1-1Pre-operation/'' ❑ Suspect Illness ❑ General complaint Owner/ C- - �� HACCP Y/N Person in Charge (PIC) Time In: ❑ 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) Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/ Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation / Segregation / Protection lUL 9. Food Contact Surfaces Cleaning and Sanitizing l� ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order 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: � / l A Inspector's Signature: - Pr t / / r- PIC's Signature: Print: C Page/ ofPages FORM 734A HOBBS& WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION MANAGEMENT nr1'- 590.003(A) Assi nment 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 Food in a Hermetically Sealed Container* 3-201.13 require reporting by Food Employees and 3-202.13 Shell Eggs* Applicants* Eggs and Milk Products, Pasteurized* 590.003(F) Responsibility of a Food Employee or an 5-101.11 Drinking Water from an Approved System* Applicant to Report to the Person in Bottled Drinking Water* 590.006(B) Charge* 3-306.14(A)(B) 590.003(G) Reporting by Person in Charge* tt:3 590.003(D)Exclusions and Restrictions* 590.003(E) Removal of Exclusions and Restrictions 4 5 C r FOOD FROM APPROVED SOURCE 590.004(A -B) Food and Water From Regulated Sources 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* 3-306.14(A)(B) 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* Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-601.11(A) 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* 2-301.14 Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients* 3-301.12 Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* • Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C 9 10 12 13 PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM v�BOARD OF HEALTH Establishment Name: \� _ Q— 1 C-)6Z:J� Date: Page: of Item No. Code Reference C-'CNtical Item,, R—Red Item : DESCRIPTION OF VIOLATION /,PLAN OF CORRECTION k - -- - u� k �z- .�;. �• F � PLEASE PRiNT.CLEARLV x• :% a� , � Date - Verified 3. f �-- f 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 noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: ' ❑ No ❑Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 734B HOBBS & WARREN — BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 614 . Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 - Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 DrvinR A 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 Monitoring* TIME/TEMPERATURE CONTROLS 16e PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.11(B) PHFs 3-501.16(B) 590.004(F) 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155*F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast -130°F 121 Min.* Physical Facility 3-401.11(A)(2) Ratites, Injected Meats - 155°F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, o09 Poultry or Ratites - 165°F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* - 17 : Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(B) Microwave - 165°F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70*F Within 2 Hours and from 70°F to 41°F/45°F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45*F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 19 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/45°F* 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) I'"r2r` 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.00 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801.1 I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22. 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* Enecfi a v112001 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under fl29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be farad in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements o09 30. Other FORM 4009 S MASE IN U.S.A. 7VTOPc IMPORTANT MESSAGE FOR DATE 7/ Z 2- 0-3 TIME � P. M. OF PHONE AREA CODE NUMBER EXTENSION O FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR MESSAGE i r r J 73 c SIED FORM 4009 S MASE IN U.S.A. 7VTOPc CALL WILL FAX TO YGU NOTES FOR IMPORTANT MESSAGE DATE MA PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA COOS NUMBER TIME TO CALL TELEPHONED LEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU SIGNED FORM 4009 Vim MADE IN U.S.A. r 0 f Er Postage $ r I M-3 Certified Fee C S Postmark Return Receipt Fee Here E (Endorsement Required) C3 Restricted Delivery Fee O (Endorsement Required) O Total Postage & Fees IC3 M l Name (Pleas dnt CI e (tp be complete by mail e-`= .......... Ir Street, Apt. No.; on PO Box Na. ------------------------------------------------ Ciry, §tete, ZIPa4 'r F5 1orni MU, Jury 16UU See Rev.,. for lnsVuclionsi Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A signature upon delivery ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First -Class Mail or Priority Mail. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables, please consider Insured or Registered Mail. ■ For an additional fee, a Return Receipt may be requested to rovide proof of delivery. To obtain Return Receipt service, please complete and attach a Return Receipt (PS Form 3811 to the article and add applicable postage to cover the fee. Endorse mailpiece 'Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPS postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent. Advise the clerk or mark the mailpiece with the endorsement "Restricted Delivery'. ■ If apostmark on theCertifiedMail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mall receipt is not needed, detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. PS Form 3800, July 1999 (Reverse) 102595-99-M-2087 .o 4aq� STANLEY USOVICZ, JR. MAYOR August 28, 2003 William DeOrio, Owner The Tin Whistle 241 Jefferson Avenue Salem, MA 01970 Dear Mr. DeOrio: On August 8, 2003 at approximately 10:20 PM, in response to complaints about smoking allowed in your establishment, personnel from the Tobacco Control Program conducted a compliance check to determine if your establishment was in compliance with Salem Board of Health Regulation #24 Concerning Prohibiting of Smoking in Restaurants and Bars. At that time, upon entering the establishment, the inspectors noted an odor of cigarette smoke. A patron was observed to be smoking in the dart board area and there was a full ashtray in this same area. Documentation is on file at the Board of Health regarding this violation. The Compliance Inspectors presented a copy of the inspection report to the owner at the time of inspection. You are in violation of Section VIII of Salem Board of Health Regulation #24. According to this section, it is unlawful for any person who owns, manages, operates, or otherwise controls the use of any premises subject to regulation under Sections IV, V, VI, to fail to comply with any provisions, or to allow smoking where it is prohibited. Section VII C of this regulation states, "Any owner, manager, operator, or employee of any establishment regulated by this regulation must ensure that the establishment is in compliance and any such person who violates any provision of this article shall be guilty of an infraction punishable by a fine of $50 for a first violation, $100 for a second violation, and $250 for each additional fine within one year. Therefore, you are ordered to pay a fine of $50 for the violation stated above since this is your first violation within one year. A check or money ,CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT William DeOrio, Owner The Tin Whistle 241 Jefferson Avenue Salem, MA 01970 Dear Mr. DeOrio: On August 8, 2003 at approximately 10:20 PM, in response to complaints about smoking allowed in your establishment, personnel from the Tobacco Control Program conducted a compliance check to determine if your establishment was in compliance with Salem Board of Health Regulation #24 Concerning Prohibiting of Smoking in Restaurants and Bars. At that time, upon entering the establishment, the inspectors noted an odor of cigarette smoke. A patron was observed to be smoking in the dart board area and there was a full ashtray in this same area. Documentation is on file at the Board of Health regarding this violation. The Compliance Inspectors presented a copy of the inspection report to the owner at the time of inspection. You are in violation of Section VIII of Salem Board of Health Regulation #24. According to this section, it is unlawful for any person who owns, manages, operates, or otherwise controls the use of any premises subject to regulation under Sections IV, V, VI, to fail to comply with any provisions, or to allow smoking where it is prohibited. Section VII C of this regulation states, "Any owner, manager, operator, or employee of any establishment regulated by this regulation must ensure that the establishment is in compliance and any such person who violates any provision of this article shall be guilty of an infraction punishable by a fine of $50 for a first violation, $100 for a second violation, and $250 for each additional fine within one year. Therefore, you are ordered to pay a fine of $50 for the violation stated above since this is your first violation within one year. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. An attorney may represent you. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 978-741- 1800. Sincerely yours, loanne Scott Health Agent Cc: Christina Harrington, Board of Health Chair John Keenan, City Solicitor Joyce Redford, Director, North Shore Tobacco Control Program Memo Date: 8/8/03 To: Joanne Scott, Health Agent From Patrick Mulligan, Compliance Inspector Joyce Redford, Program Director RE Salem Tobacco Inspections H On Wednesday, August 8, 2003 Joyce Redford and I conduct two Environmental Tobacco Smoke (ETS) inspections. These inspections were the result of violation complaints received by the Salem Board of Health. Both establishments were inspected and both were found to be in violation of the regulation. Non -Compliant Tin Whistle Inspected 8/8/03 At approximately 10:20 pm Friday evening we inspected the Tin Whistle as a follow-up to several complaints received by the Salem Board of Health. Upon entering the establishment there was an odor of cigarette smoke. We witnessed one patron smoking in the rear area of the establishment who was playing darts; we also observed a full ashtray on the chair rail in this area. When I spoke to the female bartender she went and got the establishment owner. We informed him of the violations and that we were there to follow-up on a complaint. The owner stated he was unaware that a patron had entered the establishment with a lit cigarette. The owner was advised of the terms of the regulation and given a copy of the inspection report. Given that the Board of Health has received several complaints and that this establishment is so small I question their inability to monitor their patrons. Roosevelt's Inspected 8/8/03 At approximately 10:45 pin Friday evening we inspected Roosevelts as a follow-up to a complaint received by the Salem Board of Health about smoking on the patio area. Upon entering the establishment the first thing we observed was that the door leading to the patio area was wedged open and therefore smoke was entering the indoor bar area. We also witnessed staff carrying trays and serving drinks to patrons in this area. We then witnessed a patron carry a lit cigarette inside the establishment walking right past staff at the door between the inside and outside areas. I (Joyce) followed this patron to watch and if and where he was going to extinguish it. What I witnessed next alarmed me the patron tossed the lit cigarette onto the wooden floor, I quickly extinguished it and brought it to the owner's attention. The owner was i =ed_oLtheviolation-Wt iessed-and_was given a. -Copy of the iaspection . It is noteworthy to mention that at the time of the inspection there were approximately 100 —150 patrons in the establishment. Upon witnessing the lit cigarette being tossed on the wooden floor I became concerned about capacity of the establishment as well as the ratio of staff to patrons and their ability to observe such behavior. Which also raised concern about a person's ability to escape the patio area (which appears to be completely enclosed) in the case of a fire. Lastly, it was difficult to determine who were employees and who were patrons; it was only after observing that the arson carrying drinks onto the patio was wearing a small black apron that we realized she was staff. �I 2 e /" .,( Eu Elv T/Oh) /2a HOit Tobacco Control Program r l .zf r 85 Exchange Street, Suite 307 x (781) 47T°4'32 Phone Lynn,MA 0190' INSPECTION REPO R T Auc 7 e z� nstcp o g Fax Based on an inspection today, the items above indicate the status of compliance with the City of Salem's Board of Health Regulation # 24 Information will be forwarded over to the Salem Board of Health and fin ther action may follow. Board of Health -white / NSTCP Electronic / Establishment- Pink 4 CITY OF SALEM, MASSACHUSETTS .� v9' '� BOARD OF HEALTH • i - 120 WASHINGTON STREET, 4TH FLOOR a - SALEM, MA 01970 ,y TEL. 978-741-1800 'T41yp� FAX 978-745-0343 STANLEY LISOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO,OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, _Section 305A and Chapter III, Section -5 of the General,Laws, to operate a Food Establishment in the City of Salem is hereby granted to:. Owner's Name: William DeOrio & Craig DeOrio Name of Establishment: The Tin Whistle . Address of. Establishment: 241 Jefferson Avenue Type of EStablishment:,FOOD SERVICE Application,. Date: 11/28/2001 Restrictions: 'Permit for Food Establishment 51-02 =rs4c Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These -Permits Expire December..31,:2002 This permit is not transferable and must.be reissued upon change of, ownership or location. The permit must be posted in a prominent location in the Establishment. ,. In accordance with the State Sanitary Code, before any renovations,, improvements, or equipment changes are made, all,plans for such must be submitted to and approved by the Salem Board of Health. V HEALTH AGENT IMPORTANT MESSAGE FOR / DATE ! y I -�q• 6 TIME M l� OF PHONE AREA CODE NUMBER EXTENSION U FAX U MOBILE AREA CODE ) NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE zego e?� �*�-9� ��+- �%✓ I i(ea_fi Clltrl[ gra=-r .vT SIGNED 7 VQrS MOADERRMN4009 0 STANLEOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT nlnV 2a 7.001 ItU U HEALTH DESALPT• 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TN E 1 I N WH IS t Lt TEL #/9,7,? 4/ 1 it A ADDRESS OF ESTABLISHMENT jE /%"E-T-S0n) AV MAILING ADDRESS (if different) OWNER'S MR TELA 97? 11t2— CITY T)YYN VE72S STATE YVI ZIPS CERTIFIED FOOD MANAGER'S NAME(S) "IG �Je Qio CERTIFICATE# (required in an establishment where potentially hazardous food iis, prepared.) EMERGENCY RESPONSE PERSON W I Lt I ilm Lein/0 HOME TEL It. DAYS / HOURS OF OPERATION: Mon., /11 Tue.11=1 Wed.Jl_(_Thuj- ( Fri. //=l Sat. TYPE OF ESTABLISHMENT 1 FEE check only RETAIL STORE Y�F, NO -��/ $4. RESTAURANT E NO SO BED & BREAKFAST YES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO $10 TOBACCO VENDOR YES NO NO CHARGE FOR NON-PROFIT (such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. //1QL3 /o/ 0f341-6 o Signature Date Social Security or Federal Identification number Revised 11/1/01 foodapZadm Check#& J'a IMPORTANT MESSAGE FOR A.M. P#lv OF PHONE AREA CODE NUMBER EXTENSION O FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED LEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU SIGNED i z Q m CO 1- r+..wd�a:.../.:.sl+.......L.s�.:.�+�R,..:..� r:..hnu+��..1+*.�it�'4.il.sz•tivr�•!�.rvFL*a.'+�3a..'•l::.i:eA':�}'"i�f.�.N. v=a.,:.�...+.�..ir.:..:....dw.:.9sa-^ik,.,--...•�.,w.r.,,-kwr.s..... A TM, THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM BOARD OF HEALTH OOD ESTABLISHMENT INSPECTION REPORT Name Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel: (978) 741-1800 Fax: (978) 745-0343 Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ED 590.009 (F) ❑ action as determined by the Board of Health. Local Law E] FOOD PROTECTION MANAGEMENT El 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH El 2. Reporting of Diseases by Food Employee and PIC El 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source El 5. Receiving / Condition El 6. Tags / Records / Accuracy of Ingredient Statements El 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION [18. Separation / Segregation / Protection El 9. Food Contact Surfaces Cleaning and Sanitizing El 10. Proper Adequate Handwashing El 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.006) 29. Special Requirements (590.009) L -H30. Other El 12. Prevention of Contamination from Hands [113. Handwash Facilities PROTECTION FROM CHEMICALS El 14. Approved Food or Color Additives El 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods) El 16. Cooking Temperatures F El 17. Reheating ❑ 18. Cooling El 19. Hot and Cold Holding i El 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) El 21. Food and Food Preparation for HSP CONSUMER ADVISORY El 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: 1 19 Inspector's Signature: Ppint:� PIC's Signature: A 0� Print: Pa/ -of ages I f.l v v' FORM 734A HOBBS & WARREN -BOSTON _ Date q(Z Tvoact O eration(sl Food Service Retail f In i Routine Re -inspection Address Risk Level /An ElResidential Kitchen El Mobile Previous Inspection Date: Telephone `7 _ 2W l�'{�7 / _ ❑ Temporary ❑ Pre-operation Owner - HACCP Y/N c❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PI Time In: Permit No. ❑ HACCP El Other InspectorOut: i Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ED 590.009 (F) ❑ action as determined by the Board of Health. Local Law E] FOOD PROTECTION MANAGEMENT El 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH El 2. Reporting of Diseases by Food Employee and PIC El 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source El 5. Receiving / Condition El 6. Tags / Records / Accuracy of Ingredient Statements El 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION [18. Separation / Segregation / Protection El 9. Food Contact Surfaces Cleaning and Sanitizing El 10. Proper Adequate Handwashing El 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.006) 29. Special Requirements (590.009) L -H30. Other El 12. Prevention of Contamination from Hands [113. Handwash Facilities PROTECTION FROM CHEMICALS El 14. Approved Food or Color Additives El 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods) El 16. Cooking Temperatures F El 17. Reheating ❑ 18. Cooling El 19. Hot and Cold Holding i El 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) El 21. Food and Food Preparation for HSP CONSUMER ADVISORY El 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: 1 19 Inspector's Signature: Ppint:� PIC's Signature: A 0� Print: Pa/ -of ages I f.l v v' FORM 734A HOBBS & WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) 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 I' 590.003(C) Responsibility of the Person in Charge to Compliance with Food Law* 3-201.12 require reporting by Food Employees and 3-201.13 Fluid Milk and Milk Products* Applicants* Shell Eggs* 590.003(F) Responsibility of a Food Employee or an 3-202.16 Ice Made from Potable Drinking Water* Applicant to Report to the Person in Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions Li: C 6 I® FOOD FROM APPROVED SOURCE • Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C `10 12 J3 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made from Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3.201.14 Fish and Recreationally caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* • Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C `10 12 J3 PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing -Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: n Date: % Uz Page: Z of Item Code ' Reference C -Critical Item R = Red Item a = % - DESCRIPTION OF VIOLATION / PLAN OF CORRECTION ,,,° ? A ,. _ PLEASE PRINT CLEARLY r r Date Verified' L n , c7 fnn` Vv c �S Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. • Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 734B• HOBBS & WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1.22) (Cont.) PROTECTION FROM CHEMICALS K°•14: Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 15:M Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name- Working Containers* 7-201.11 Separation - Stora e* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers,Criteria- Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS 16 PHFs Received at Temperatures According to Law Cooled to 41°F/45*F Within 4 Hours.* Proper Cooking Temperatures for ;�,... .: 3-801.11(B) PHFs 3-501.16(B) 590.004(F) 3-401.11A(1)(2) Eggs - 155°F 15 Sec. Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals- 155°F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast - 130*F 121 Min.* Physical Facility 3-401.11(A)(2) Ratites, Injected Meats - 155°F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165*F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs - 145°F 15 Sec.* 17 Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(B) Microwave - 165°F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.1 l(E) Remaining Unsliced Portions of Beef Roasts* 18 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Within 2 Hours and from 70°F to 41°F/45°F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 19 _20- 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45*F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/45°F* 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) CONSUMER ADVISORY 22 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.00 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* Food and Food Protection 3-801.1 I(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* EHectwe 11112001 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* rtevuinemety t a 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Sp ecial Requirements .009 30. Other THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel: (978) 741-1800 Fax: (978) 745-0343 Name/ Print: - ,/ ) `� L/f-/ti PIC's Signatu a Date/ Type of Ooeration(s) ❑ Food Service ❑ Retail ❑ Residential Kitchen El Mobile ElTemporary ❑ Caterer El Bed & Breakfast Permit No. Type of Inspection ❑ Routine ❑ Re -inspection Previous Inspection Date: ElPre-operation ❑ Suspect Illness El General Complaint ElHACCP El Other Address / f Risk Leve /r f 1 Telephone 7 /_ _11Z)_ / )_HACCP Owner \ , i..^ 6 Y/N Person in Charge (PIC) --pr � - Time Out: O Inspector / Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION ❑❑l! Separation / Segregation / Protection 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) s 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) '7/ 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) EH29. Special Requirements (590.009) 30. Other ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number ofViolated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: r Inspector's Signature: Print: - % PIC's Signatu a Print'�'�"'� !� -' fy --p� Page / of -Pages_ i FORM 734A HOBBS 3 WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION MANAGEMENT F. 590.003(A)Assi nment of Responsibility* P590.003(6) Demonstration of Knowledge* 2-103.111 Person in Charge - Duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the Person in Charge to Compliance with Food Law* 3-201.12 require reporting by Food Employees and 3-201.13 Fluid Milk and Milk Products* Applicants* Shell Eggs* 590.003(F) Responsibility of a Food Employee or an 3-202.16 Ice Made from Potable Drinking Water* Applicant to Report to the Person in Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3§ 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 5 C r FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 8 C i'...:10 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made from Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3.201.14 Fish and Recreationally caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 8 C i'...:10 PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: VI �i �� %� ASS '. Date: Page: of 2 item No. Code Reference C Cdticat Item R R Item= w' DESCRIPTION OF VIOLATION / PLAN OF CORRECTION .- ` - _ _ PLEASE PRIW CLEARLY 5 .. S �:. s s.;, .� - :.... Date Verified'.. rte: , ar 6 fav c�"_X� rt -p � u ct .� ST ✓1 rS O iq l� -IJ 'Zll t tI 1,n Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 734B HOBBS & WARREN - BOSTON :e Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 206.11 Restricted Use Pesticides, Criteria* 206.12 Rodent Bait Stations* r7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS 16 . PHFs Received at Temperatures According to Law Cooled to 41°F/45'F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.11(B) PHFs 3-501.16(B) 590.004(F) 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155*F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast- 1307121 Min.* Physical Facilit 3-401.11(A)(2) Ratites, Injected Meats - 155*F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165°F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All OtherPHFs- 145°F 15 Sec.* 17 Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(B) Microwave - 165°F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Within 2 Hours and from 70°F to 41*F/45°F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41 °F/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 19 I' 00. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45'F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/45°F* 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) CONSUMER ADVISORY 22 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.00 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* Eikctive 11112001 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Orr UAL ntvutrstmtN t s 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facilit FC-6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other `•THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Board of Health FOOD ESTABLISHMENT INSPECTION REPORT Address: 9 North Street Salem, MA 01970-3928 Tel: (978) 741-1800 Fax: (978) 740-9705 Name Date Type of Operation(s) Type of inspection 2' Food Service ❑ Retail �' �? Pr Routine ❑ Re -inspection Address Risk ' u Level Hyl ❑ Residential Kitchen ❑ Mobile Previous Inspection Date: Telephone / ❑ Temporary ❑ Caterer ❑ Pre-operation ❑ Suspect Illness Owner HACCP Y/N C ( `� ` ❑ Bed & Breakfast El General Complaint Person in Charge (PIC) Time In: ❑ HACCP ❑ Other Inspector SES Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: RED Violations (1-22) Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of 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 Ell 1. Good Hygienic Practices BLUE Violations (23-30) Related to Good Retail Practices Critical (C) violations marked must be corrected Immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C, N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other 5: 59JIf p wFw 6-I4,do ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of rotated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (RED Items 1-22): Official Order of Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: Print: PIC's Signature: Print: Page / of ,) Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION AND MANAGEMENT 1 590.003(A) I Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to 3-201.12 Food in a Hermetically Sealed Container* require reporting by food employees and _... 3-202.13 applicants* 3-202.14 590.003(F) Responsibility Of A Food Employee Or An Ice Made From Potable Drinking Water* 5-101.11 Applicant To Report To The Person In 590.006(A) Bottled Drinking Water* Char e* Water Meets Standards in 310 CMR 22.0* 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* Molluscan Shellfish From NSSP Listed Sources* 590.003E Removal of Exclusions and Restrictions C C r6- 7 I FOOD FROM APPROVED SOURCE *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 0, 12 13 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Returned Food and Reservice of Food* 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* Food Contact Surfaces Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* Equipment Food Contact Surfaces and Utensils Clean* Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* Proper, Adequate Handwashing Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* When to Wash* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records Creation and Retention* 590.004(f) Labeling of Ingredients* Preventing Contamination When Tasting* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 0, 12 13 PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, concentration and hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges from the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision THE COMMONWEALTH OF MASSACHUSETTS -5 —' , Establishment Name Date Address Page of_' Item No. Inthe space below describe all violations on/front page. /checked nJ /F 4YY�, /i. -.q }I saG e. �/J.•_:�!'TY/ -.Y I�'/rIl//ia✓A. �;/ > /VRTI!�/i tid //, o in ✓ / t//iJ rr ♦./i Ov7` /• <cA it 7. Discussion with Management C41Y OF SALEM A a n: BOARD OF HEALTH ~ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978.741.1800 FAX 978.745-0343 WWW.SALEM.COM �rrrt JOANNE SCOT', MPH, RS, CHO HEALTH AGENT «,• � T---2��111'1 1C�n \l U DEC 12 2005 CITY OF SALEM BOARD OF HEALTH 2W$0'!I5ii;aT1ON FOR PERMIT TO OPERATE ' /A FOOD ESTABLISHMENT NAW---yiK_ lu/NJrzE TEL# 978 T// -19/L ADfy s - , / on) MAUrIs sf1y fd different) o I EL # yT8 46R'1 y9X owro�.��efae+t:. Cw41G�_ON� 7 ,EXU ..a ziP STATE i1r0S--� 6l 4 fS / ti u CERTIFICATE#(s) IfZI.y CERTP = ; mac' 1w16 y�— ' �l,u4NAGE 3NAME(S)-5-- (requi� e y '�'�'�rnent wherrt 1'njnldlelly hazardous food Is prepared.) %1c Drzev HOMI=TEL# 97Y9-0 /Y4i OUk-- Hy'y /;II�NSE PERSt'tN._ W- Thu -11-1 _Fri._U o Sat. // / Sun. /Z-/ OU±!; •,e ,A „ �-- ,ATION: M011 -11' FEEcHeck only) TYPE - _S t/' i :"HfdEN7/� less than 100(lrq ft =$ 50 RETA,i ;riYES L'(P 1000-10,000s�Ift. =$100 more than 10.t100sq.ft. =$250 .................-- ----------------- ------------------- _....------------ less than 25 s sats = 100 REST!•111 /..111 ..'Y� .....N(t W/_ 25-99 Seats 150 (� more than 99 .eats =$200 ------------------------------------- SED/BI<I AKI At; I ------YES -..�Nt�' $100 _.... _. .---- --. ------ ... ADDITI014AL I'LlWIT S........... SOFT SERVE YES r" P'5 (v1AKE (11111 pial egtvu) ICE CREAA'1. YOGURT, YES $50 TOBAC(;() VI -111 1013 YES $25 ALL NOIVgq?OFI'h (such ns churr.11 kitchens) Please p4y 1°141 with one chock Payable to the City of Salem on than a of ov,. This PnI'u111 le Illlt transfornble pnd must be reissued up 9 lership. The Permit must be posted in a pronllnenl 14icntion In tho Establishment. renovations, imµ ..ovements, or equipment changes In accurrl4nr.e with the State S4nllary Code, before any roved b the S. are maria, 411 IH4ncr for such must be submitted to and app Y klem Board of Health. Pursuant I„ kit tl Iia for G2C, ` {jp149A, I certify under the alpstate taxes re, ,rtes of perjury that I, to my best nowda,{ 11t { Iain P �.uired under the law. i1t' ` t 11t>f, have 1110, <d1'1c11e tax returns and p. L - - -Social or Fu,^eral Identification NWmber Date ------------------------------------------------------------ t Salem Board of Health of Public Health Yw• • _ �' 120 Washington Street 4'" Floor' ` ';.,.Salem; MA.01970-3523. rs"',. is aI:: ' REPORT Tel. (978) 741-1800 Fax (978) 745-034: n rr. y. ,Datp I Ilype of Operation(s) I Me of Inspection ` ,;planation on the narrative page(s) and a citation of specific provision(s) violat( Non-compliance with: �,� � Interventions and Risk Factors Anti-ChokingTobacco e t health hazard and require Immediate corrective 590.009( E) ❑ 590.009 (F) E ❑ 12. Prevention of Contamination from Hands i �_ ❑ 13. Handwash Facilities I'PROTECTIONFROMCHEMICALS �r ee and PIC t_ � y _ _ El 14. Approved Food or Color Additives A ❑ _ Rls Retail Ej Re -inspection immeord r Level ❑ Residential Kitchen E] Mobile Previous Inschop Date: :/nr,Js Ire z'y the Board El Temporary Pre-operation ❑ _ HACCP YM El ❑Suspect Illness _r I � � FC -2)(590.003) ❑ Bed &Breakfast E]General Complaint Time -C-5)(590.006) Imp 0 4� -� r0-6)(590.007) E] HACCP - FC -7)(590.008) ;_ , l Permit No.. ❑ Other ` ,;planation on the narrative page(s) and a citation of specific provision(s) violat( Non-compliance with: �,� � Interventions and Risk Factors Anti-ChokingTobacco e t health hazard and require Immediate corrective 590.009( E) ❑ 590.009 (F) E ❑ 12. Prevention of Contamination from Hands i �_ ❑ 13. Handwash Facilities I'PROTECTIONFROMCHEMICALS �r ee and PIC t_ � y _ _ El 14. Approved Food or Color Additives A ❑ _ i:fltlCa; "- d immeord r - -� cy the Board ❑ �_,'—ACCP Plans z'y the Board ❑ _ 4 v razing C A FC -2)(590.003) -3)(590.004) FC -4)(590.005) -C-5)(590.006) r0-6)(590.007) Violattm. i:fltlCa; "- d immeord r - -� cy the Board , _. of Heah orrected z'y the Board of Hear `— C A FC -2)(590.003) -3)(590.004) FC -4)(590.005) -C-5)(590.006) r0-6)(590.007) l- - FC -7)(590.008) - (sso.00s) Inspector; �� PIC,s tii4tut,,, C — _ ❑ 15. Toxic Chemicals e TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (items 1-22): 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 be 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 revocatior 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 writinc and submitted to the Board of Health at the above addre within 10 days of receipt of this,order. j DATE OF RE -INSPECTION: , I I fi- J_� ii rte' I` Person violation checked requires an :• -TA � +0w4r'.4:-. Print: If Public Health Salem Board of Health Page4of,�4P: 120 Washington'Street 4' Floor 4i,Salem MA' --01970-3523 x PORT Tel. (978) 741-1800 Fax (978) 745-03 Dat T e of Operation T e of Ins action E 10 Food Service Retail Routine Re -inspection Risk Level ❑ Residential Kitchen ❑ Mobile Previous Ins ctiop Date: a / JS ❑ Temporary El Pre-operation I 0Z HACCP Y/N ❑ Caterer ❑ Suspect Illness ❑ Bed & Breakfast [I General Compla'. Time In:l g T �_4-- Permit No. ❑HACCP ❑ Other on the narrative page(s) and a Violations Related to Foodborne Illness Interventions and Risk Factors Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. [FOOD PROTECTION MANAGEMENT.. -gym... ❑ 1. PIC Assigned/ Knowledgeable/ Duties EMPLOYEE HEALTH �' = � � � $ ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded E F60D FROM APPROVED SOURCE, _ __Ll [14. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements 1 ❑ 7. Conformance with ApprovedProcedures/HACCP Plans p PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other of specific provision(s) viol Non-compliance with: Anti -Choking' Tobacco 590.009( E) ❑ 590.009 (F) ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities r PPROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/IEMPERATURE CONTROLS (Potentially Hazardous Foods) El16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (H' ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY [122. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspectior today, the items checked indicate violations of 105 CM. 590.000/federal Food Code. This report, when signed I by a Board of Health member or its agent constitutes a order of the Board of Health. Failure to correct violatio, cited in this report may result in suspension or revocati the food establishment permit and cessation of food establishment operations. If aggrieved by this order, yc have a right to a hearing. Your request must be in writii and submitted to the Board of Health at the above adds within 10 days of receipt of this,order. j DATE OF RE -INSPECTION: i /u Inspector's Signature: \ Print: PIC'sSignature: i7 � yam-] Print: ,)C (:)K ! Page4of,�4P: _ _ t VI 1 1 VI �Jr\L_"IVI L ' n BOARD OF HEALTH I I . Ti I �n/ 1 J!/� Date: Pager_ of ».htstaDushment Name: 1 Coda-;�$t e -critical Item;;, - DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Vete Verified �ttem� i No.` Reference" R,-Reditem' a . PLEASE PRINT (EARL- _ r✓ _ i•!y .' 'YS — p_ S �4 1 L 14 (SSi��✓ #=>�.@ tai 2=� .' T Correc We Action Required: ❑ No Yes slo" IWPerson in Charge x r' . Voluntary Compliance ❑ Employee Restriction / s report, have,had the opportunity to ask questions and agree to correct all Exclusion s the next inspection, to observe all conditions as described, and to ❑ Re -inspection Scheduled ❑ Emergency Suspension "andates of the Mass/Federal Food Code. I understand that may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure w ❑ Voluntary Disposal ❑ Other: .� �- --�� I I►v � ��'af.,