WARD II SOCIAL CLUB (002)WARD II SOCIAL CLUB
1 & 3 E. COLLINS ST.
0
v
P
Pern
KIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM,
MASSACHUSETTS
BOARDOr HEALTH
120 WASHINGTON STRpw, 4- FLOOR
T)FL. (978) 741-1800 FAX (978) 745-0343
1t—grad nnSBICtD'.COID -
v
reb11c8[eatth
Mnanl. PmmW, ge1M.
LARRY RAMDIN, RS/RENS, CHO, CP -PS
HEALTH AGENT
Food Establishment Permit Application
(Applicationmust be submitted at least 30 days before the planned opening date)
1) Establishment Name:
No
l I s S�- S A 1-0
3) Establishment Mailing Address of different):
KIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM,
MASSACHUSETTS
BOARDOr HEALTH
120 WASHINGTON STRpw, 4- FLOOR
T)FL. (978) 741-1800 FAX (978) 745-0343
1t—grad nnSBICtD'.COID -
v
reb11c8[eatth
Mnanl. PmmW, ge1M.
LARRY RAMDIN, RS/RENS, CHO, CP -PS
HEALTH AGENT
Food Establishment Permit Application
(Applicationmust be submitted at least 30 days before the planned opening date)
1) Establishment Name:
2) Establishment Address: - 3 F A S �- c o
l I s S�- S A 1-0
3) Establishment Mailing Address of different):
4) Establishment Telephone No: 7 C,' f -
(
5) Applicant Name & Title: L I' c j i
.6) Applicant Address:
7) Applicant Telephone No: �j ' 3 �) - 24 Hour Emergency No: Email:
8) Owner Name & Tide (if different from applicant):
g) Owner Address (if different from applicant):
10) Establishment Owned by:
An association
A corporation
An individual
A partnership
Other legal entity
11) If a corporation or partnership, give name, title and home address of
officers or partner.
Name Title Home Address
12 Person Directly Res onsible For Daily Operations Owner; Person in Cha e, Supervisor, Manager, eta
Name & Tide:
Address:
,
- 3
-/A s4- c c)I -rns 5 }
Telephone No:
Email:
Emergency Telephone No:
13) District or Regional Supervisor (N applicable)
Name & Tide:
Address:
Tele hone No:
Fax: Email:
_1
Check #: Date: Amount -9
rooa r-statinsnment information
14) Water Source.,
15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable)
16) Days and Hours of Operation:
17) No. of Food Employees:
18) Name of Person In Charge Certified In Food Protection Management
Required as of 101112001 In accordance with 105 CMR 590.003(A)
19) Person Trained In Anti -Choking Procedures ( if 25 seats or more): 0 Yes
No
20) Location:
22) Establishment Type (check all that apply)
(check one)
O Retail ( Sq. Ft)
Cl Caterer
Permanent Structure
0 Food Service - ( Seats)
Cl Frozen Dessert Manufacturer
Mobile
0 Food Service -Takeout
0 Residential Kitchen for Retail Sale
0 Food Service - Institution
0 Residential Kitchen for Bed and
( Meals/Day)
Breakfast Home
0 Food Delivery
0 Residential Kitchen for Bed and
Breakfast Establishments .....................
21) Length Of Permit:
(check one)
RETAIL STORE
RESTAURANT
Annual
0 Less than 1000sq.fL $ 70
0 Less than 25 seats $140
Seasonal/Dates:
01000-10,000sq.iL $280
0 Residential Kitchens $140
0 More than 10,000sq.ft. $420
0 25.99 seats $280
0 More than 99 seats $420
Bed $ ....../.W...ur.....g..........------------------------------------------------ .........---
BreakfastlChildcare Services sinHome$100
Temporary/DatesMme:O
..........:..-.._..............-........-------------•--...............................--••------•-•---------......................----
ADDITIONAL PERMITS
0 MAKE ICE CREAM, YOGURT/SOFT SERVE
$25
0 PASTURIZATION
$25
0 ALL NON-PROFIT"
$25
*Including, church kh'chensi state funded chl/dcare 8 private club
23) Food Operations:
Derynidons: PHF- potentiallyhazardous food (dme%Nnpwaturecontrols required)
(check that
. NonnPHFs- non -potentially hazardous
food (no dinotempersture co Wols required)
all a PPIY):
RTE -rea to -eat foods Ex. sandwiches salads muffins which need no further processing
Sale of Commercially
PHF Cooked to Order
Hot PHF Cooked and Cooled or Hot Held
Pro -packaged Non-PHFs
for More Than a Single Meal Service
Said of Commercially
Preparation of PHFs For Hot And
PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs
Cold Holding for Single Meal Service
Susceptible Population Facility
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended to be
Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially
Customer Self -Service
Use of Process Requiring A Variance
Processed Foods for
and/or HACCP Plan (including bare hand
Service Within 4 hours
contact alternative, time as public health
control.
Customer Self -Service of
Ice Manufactured and Packaged for
Offers Raw or Undercooked Food of
Non-PHF and Non-
Retail Sale
Animal Origin
Perishable Foods Only
Preparation of Non-PHFs
Juice Manufactured and Packaged for
Prepares Food/Single Meals for Catered
Retail Sale
Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
Retail Said of Salvage, Out of Date
or Reconditioned Food
To be completed by the Board of Health
Total Permit Fee:
Payment is due with application
I, the undersigned, attest to the accuracy of the Information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been Instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Appllcard:
Pursuant to MGL Ch. 62C, ser. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name:
Commonwealth of Massachusetts
'
a
City of Salem
Board of Health _
Kimberley Driscoll
.
120 Washington Street, 4th Floor
Mayor
%71,
SALEM, MA 01970
o
a
As
Food/Retail Establishment Permit
Vis,
DATE PRINTED: 12/14/2012r
a
ESTABLISHMENT NAMES Ward H Social Club
_
_ a ReNumber BHF -2004-000359 f
1& 3East Collins Street
- ,� -
,
a
-
Salem.
MA 01970
-k
,
.
= LOCATED AT: 0001I EAST COLLINS STREET
E
SALEM; MA 01970.
Permit Type Permit No. Permit Issued Permit Expires, Fee Restrictions !Notes
FOODSERVICE BNP-2013-Odst-• $25.00Jr ec ,
wre
-
ESTABLISHMENT
s Total Fees: $25.00
'-
<
k
�,
PERMIT EXPIRES,
IDeceniher 31 2013
Board of Health
must "reissued of ownership or location. The permit must be posted
; z
This Permit is not transferable and be upon change
r
.in a prominent location in the Establishment.
Sanitary Code, beofre improvements, or equipment changes are made;'
;
In accordance with the State any'revonations,
all plans for such must tie submitted to and approved by the Salem Board of Health.
° `: -Page 1ji
,
°x.
t
KIMBERLEY DRISCOI.L
MAYOR
CITY OF SALEM,
MASSACHUSETTS
BOARD OF HE?AI: ]f
120 WAS] RNGTON S'IRGI:I', 4" ' FLOOR
Tr:L. (978) 741-1800 FAN"(m8) 743-0343
Iramdii a salem.com
LARRY RAMDIN, RS/RELIS, CI10, (T -1'S
HG: AL'ff I AGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name:
Add ff 6OUPC PC b-2)
Establishment Address:
3) Establishment Mailing Address (if different):
/
4) Establishment Telephone No: m '7o'-
5) Applicant Name & Title:
IYl . CYVIU -(/ .•er
6) Applicant Address:
-m
�2� A 5 -t-
7)
7) Applicant Telephone No:
9»' f ydf 1-24 Hour Emergency No: 71 211%J,fOEmail:
8) Owner Name & Title (if different from applicant):
9) Owner Address (if different from applicant):
10) Establishment Owned by:
An association
� A cor 'er?
r'� d4id aI
A partnership
Other legal entity
11) If a corporation or partnership, give name, title and home address of
officers or partner.
Name Title Home Address
/1A111eS1 a.e*1 r1V
II CI1¢Q.L SOS ItlBC/ /7
'
cK Coofdo, -1 ,0rr l S ")T sr 5&ei#
/arra 111 -. Cera '-,� tl Liv SO —4- 60
oi,iiato , lorfls (&,c `,_ rd
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc.
Name &Title:
% rr ' vtatla(;e� iutrde�n �14inaG�'
Address:
,' �0 � (l�llSEiiT -�✓eN1
Telephone No:
7P 7 S(/ - /0yyD,, Fax: Email:
Emergency Telephone No:
9 Af 7V/- /! Lr IW
13) District or Regional Supervisor (if applicable)
Name & Title:
Address:
Telephone No:
Fax: Email:
/I V —7044
, ,W
t
Check#: � t9 Date: v Amount:
Food Establishment Information
14) Water Source:
DEP Public Water Supply No: ( if applicable)
15) Sewage Disposal:
0(Jb4 I C r
16) Days and Hours of Operation:
&X0643 l Gi1S S /%
/
17) No. of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A) 1(4it''471/) e- 6�,
19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): Ves
No
20) Location:
(check one)
22) Establishment Type (check all that apply)
❑ Retail ( Sq. Ft)
R/Caterer
Permanent Structure
❑ Food Service - ( Seats)
❑ Frozen Dessert Manufacturer
Mobile
❑ Food Service - Takeout
❑ Residential Kitchen for Retail Sale
❑ Food Service- Institution
❑ Residential Kitchen for Bed and
( Meals/Day)
Breakfast Home
❑ Food Delivery
RETAIL STORE
❑ Less than 1000sq.ft. $ 70
❑ Residential Kitchen for Bed and
Breakfast- Establishments -/)_✓___
R TAURANT mofi7
Its $`f46
21) Length Of Permit:
/ (check one)
N4nnual
Seasonal/Dates:
❑ 1000-10,000sq.ft. $280
❑ More than 10,000sq.ft. $420
❑ Residential Kitchens $140
❑ 25-99 seats $280
..1711%orethan.99-seats,_-..$.420. e
b -B- --ed---8---B------------------------------------------- ------- -- - -
reakfasUChildcare Services /Nursing Home $100
Temporary/Dates/Time:
--------- -------------------------- ---------------------------------------------
ADDITIONAL PERMITS
---------------— ----------------------
❑ MAKE ICE CREAM, YOGURT/SOFT SERVE
$25
❑ PASTURIZATION
$25
❑ OBACCO VENDOR
WALL NON-PROFIT
$135
$25
(Including, church kitchens, state funded childcare 8 private clubs)
23) Food Operations:
Definitions: PHF- potentially hazardous food (timeltemperature controls required)
Non-PHFs - non -potentially hazardous
food (no time/temperature controls required)
check all that apply):
RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing
,Sale of Commercially
Pre-packaged Non-PHFs
PFS Cooked to Order
✓
H t PHF Cooked and Cooled or Hot Held
/for More Than a Single Meal Service
ale of Commercially
Pre-packaged PHFs
Preparation of PHFs For Hot And
Cold Holding for Single Meal Service
PHF and RTE Foods Prepared For Highly
Susceptible Population Facility
Delivery of Packaged PHFs
Sale of Raw Animal Foods Intended to be
Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially
Customer Self -Service
Use of Process Requiring A Variance
Processed Foods for
and/or HACCP Plan (including bare hand
Service Within 4 hours
contact alternative, time as public health
control.
Customer Self -Service of
Ice Manufactured and Packaged for
Offers Raw or Undercooked Food of
Non-PHF and Non-
Retail Sale
Animal Origin
Perishable Foods Only
PreparatioA of Non-PHFs
✓✓
Juice Manufactured and Packaged for
Retail Sale
/ Prepares Food/Single Meals for Catered
V Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage, Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code. n -
24) Signature of Applicant:
Pursuant to MGL Ch. 62C, secy49A, I certify under the Onalties of perjury that I, to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: /j�J3I (i I
26) Signature of Individual or Corporate Name:
O
•
KIMBERLEY DRISCOLL
MAYOR
LARRY RAMDIN, RS/REHS, CHO, CP -FS
HEALTH AGENT
is
0
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4T" FLOOR
TEL. (978) 741 -1800
FAX(978)745-0343
LRAMDIN([),SALEM.COM
COMPLAINT INTAKE FORM
Date: l Time: )OZ _ _,- d p _ Received By: L
Complaint Number: 0532
Complainant
Address: Phone:
Investigated By: Date:
Property Owner/Occupant
Telephone #:
►ate ,�,w
� ���
twc�vv��� ry
�ti Jam e
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street, 0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
City/Town of
FOOD ESTABLISHMENT INSPECTION REPORT
Address:
Tel.
Name
�_
Da
T pe of Operations)
Type of Inspection
❑
- S
corrective action as determined by the Board of Health.
Food Service
❑ Retail
❑ Routine
X Re -inspection
Address
k
❑ 13. Handwash Facilities
Levi
❑ Residential Kitchen
❑ Mobile
Previous I sp ction
Date:
Telephone
P
„ 7
E - . _. _.
El 14. Approved Food or Color Additives
❑ Temporary
❑ Caterer
❑ Bed &Breakfast
❑ Pre er �io�
[ISuspect Illness
❑General Complaint
Owner
/
J1{
HACCP YIN
Person -in Charge (PIC)
Time
[117. Reheating
In:j? D
❑ 18. Cooling
❑ 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.
Print:
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items)
❑
Tobacco 590.009 IF
Violations marked may pose an imminent health hazard and require immediate Tobaeco 590.009 (F) ❑
y P❑
Allergen Awareness 590.009 (G)
corrective action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT: w_ _ - _
❑ 12. Prevention of Contamination from Hands
„.
❑ 1. PIC Assigned/Knowledgeable/Duties
.... _ -. . ,. .....
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
._ ,.,
PROTECTIOkFROdM'CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC
E - . _. _.
El 14. Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
,._ _ ,,.. _ ...
El.. 15. Toxic Chemicals
FOODFROM APPROVEDSOURCE
❑ 4. Food and Water from Approved Source
'71MEREMRERATURE:CONTROLS(PotentlallyHazaidousF.00ds) ;
.. .. _
❑ 5. Receiving/Condition
❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements
[117. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans
❑ 18. Cooling
PROTECTION FROM CONTAMINATION _ ?
[119. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection
❑ 20. Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
REQUIREMENTS FOR HIGHLYSUSCEPTI ,LE-POPULATION&IHS P)' a
El 21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
;CONSUMERADVISORY W
❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue
Items) Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Noncritical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C N
23. Management and Personnel (FC -2)[590.003)
Food and Food Protection (FC -3)(590.004)
25. Equipment and Utensils (FC -4x590.005)
6. Water, Plumbing and Waste (FC5X590.006)
27. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7x590.008)
29. Special Requirements (59o.00e)
30. Other
Number of Violated Provisions Related
To Foodborne Illnesses Interventions
and Risk Factors (Red Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of Health at the above address
within 10 days of receipt of this order.
DATE OF RE -INSPECTION:
Inspector's Signature:
Print:
PICS Signatur .
Print:
Page of
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22) ppnTFcrinfJ FRnee rnrareutuA-rinu
_ FOOD PROTECTION MANAGEMENT
1 590.003(A) Assignment of Responsibility*
590.003(B) I Demonstration of Knowledge*
2-1.03.11 1 Person in charge -duties
EMPLOYEE HEALTH
2
540.003(C)
Responsibility of the person in charge to
Compliance with Food law*
3-201.12
require reporting by foots employees and
3-201.13
Fluid Milk and Milk Products"
applicants*
Shell Eons*
590A03(F)
Responsibility Of A Food Employee Or An
3-202.16
Ice Made From Potable Drinlciu 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
III
C
C
C
FOOD FROM APPROVED SOURCE
' Denotes critical item in the federal 1999 Food Cade or 105 CMA 590.000.
8
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food law*
3-201.12
Food in a Hermetically Scaled Container*
3-201.13
Fluid Milk and Milk Products"
3-202.13
Shell Eons*
3-202.14
Eggs and Milk Products. Pasteurized*
3-202.16
Ice Made From Potable Drinlciu Water*
5-101.11
Drinking Water from an Approved System*
590,006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0*
Washing Fruits and Vegetables
Shegfish and Fish From an Approved Souire
3-201.14
Fish and Recreadonaliy Caught Molluscan
Shellfish*
3-201.15
Mollusean Shellfish from NSSP Listed
Sources*
Contamination from the Consumer
Game and Wild h1ushrooms Approved by
Autltodt
3-202.18
_EELulato,j
Sheilstock identification. Present'
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals" .
3-701.11
Receiving/Condition
3-202.1.1
PHFs Received at Proper Temperatures*
3-202.15
Package litre it *
3-1(ll . 11
rood Safe and Unadulterated
TagslRerords: Shelistock
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(.))
Labeling of Ingredients'
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*'
Conformance with Approved Procedures
IHACCP Pians
3-502.11.
Secialized Processing Methods*
3-502:1.2
Reduced ox enacka'ng, criteria*
8-103.12
Conformance with Approved Procedures*
' Denotes critical item in the federal 1999 Food Cade or 105 CMA 590.000.
8
Cross -contamination
3-302.11(A)(1)
Raw Animal Foals 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 Rescrvice of Food*
Disposition of Adufterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
9
-
Food Contact Surfaces -
4-501.. f I I.
Manual Warewashing - Hot Water
Sanitization Te raiures*
4-501.112
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-50 i.l 14
Chemical. Sanitization- temp., pH,
concentration and hardness. *
4-601..11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.1.1
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*'
4-702.11.
Frequency of Sanitization of Utensils and -
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization -'Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301..12
CleaninE Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2-401..11
Eatin , Drinking or Using Tobacco*
2-401.12.
Discharges: From the Eyes, Nose and
Mouth*
3-30L12
Preventing Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(F)
Freventing Contamination. from
Employees*
13
Handwash Facilities
Conveniently tocatedand Accessible
5-203.11
Numbers and Capacities*
5-204.11
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Suppled with Soap and. Hand Drying
Devices
6-30L11
Handwashin Cleanser, Availability
6-301.12
Hand-Drying:Provision
Establishment
CITY OF SALEM
BOARD OF HEALTH
Date: C4(tti Page: _Of64^-
Item
Code
Reference
C - Crltleal Item
R - Red Item
DESCRIPTION OF VIOLATION /PLAN OF CORRECTION
' PLEASE PRINT CLEARLY
Date verified
Verified
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 Food Code. I understand that
noncompliance may result in daily fines of twe ty-five dollars or sus ension/revocation of
your food permit. —t�
Corrective Action Required:
❑ No
Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
0 Voluntary Disposal ❑ Other:
Violations Related to Foodborno Illness. Interventions and Risk
Factors (Items 1-22) (Cant.)
PROTECTION FROM CHEMICALS
14
.16
17
T1MEMEMPERATURE CONTROLS
Food or Color Additives
3-202.12
rAdditives*'
3-302.14
_
Protection from Unapproved Additives*
- FC - 2
Poisonous or Toxic Substances
7-101,)1
Identifying Information - Original
Containers*
7-102.11,
Common Name - Working Containers*
7-101.11
Separation - Storage*
7-202.11
. Restriction -Presence and Use*
7-202.12
Conditions of Use*
7-20111
Toxic Conudners - Prohibitions*
7-204.11
Sanitizers. Criteria - Chemicals*
7-204.12
Chemicals for Washing Prodms, 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
Moniturin *
T1MEMEMPERATURE CONTROLS
' Denotes edneal item in the L-&rji 1999 Foal Cate or 105 C.MR 590.000.
3-501.14(0 PHFs Received at Temperatures
According to Law Cooled to
41'F/45°F Within 4 Hours. *
Proper Cooking Temperatures for _
19
PRFs
3-40i.IIA(1)(2)
Eggs- 155,F15 Sec.
- FC - 2
Eggs- Immediate Service 145'F15sec*
3-401.11(A)(2)
Comminuted Fish. Meats & Game
3-801.11(C)
Animals -155'F 15 see. *
3-401.11(B)(1)(2)
Pork and Beef Roast -130'F 121 min*
3-401.71(A)(2)
Ratites, Injected Meats -155`F 15
I Water. Plumbing and Waste
see *
3-401.1.1(A)(3)
Poultry, Wild Game, Stuffed PHFs,
Phsical Facility
Stuffing Containing Fish, Meat,
.1107
Poultry or Ratites -1650F 15 sec
3-401..11(C)(3)
Whole -muscle, Intact Beef Steaks
.009
145'F 4'
3-401.12
Raw Animal Foo& Cooked in a
.009
Microwave 165F
31401:1 t(A)(1)(b)
All Other PHFs - 145'F 15 sec.
Reheating for Hot Holding
3-403.11(A)&(D)
PHFs 165-F 15 sec. *
3-403.11(B)
Microwave -165' F 2 Minute Standing
Time*
3-403.11(C)
Commercially Processed RTE Food -
140°F*
3403.11(E)
Remaining Unsliced Partious 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 edneal item in the L-&rji 1999 Foal Cate or 105 C.MR 590.000.
3-501.14(0 PHFs Received at Temperatures
According to Law Cooled to
41'F/45°F Within 4 Hours. *
3-50IA6(B) Cold PHFs Maintained at or below
590.004(F) 4101450 F*
3-50L16(A) Hot PRFs Maintained at or above
at
as a
REQUIREMENTS FOR HIGHLY SUSCEPT16LE
POPULATIONS (HSP)
21
3-501..15 Cuolin Methods for PHFs
19
PHF Not and Cold Hotding
3-50IA6(B) Cold PHFs Maintained at or below
590.004(F) 4101450 F*
3-50L16(A) Hot PRFs Maintained at or above
at
as a
REQUIREMENTS FOR HIGHLY SUSCEPT16LE
POPULATIONS (HSP)
21
3-801.1 ] (A)
Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
590.000 !
3-801.11(B
UseofPasteurized Eggs*
- FC - 2
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed S rts Not Served *
Food and Food Protection
3-801.11(C)
Unopened Food Package Not Re -served. K
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for Consumption of
590.000 !
23:_
Animal Foods That are Raw. Undercooked or
- FC - 2
.003
Not OtherwiseProcessedto Eliminate
Food and Food Protection
I FC -3
Path ogens.*Fr `�t
25. Equipment and Utensils
3-302.1.3.
Pasteurized Eggs Substitute for Raw Shell
! 26.
I Water. Plumbing and Waste
1 E
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements.
(Items 23-30)
Critical, mrd non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following secrions,gf the Food Code and 105 CMR
590.000.
II im
Good Retail Proctices
FC
590.000 !
23:_
I Man ameni and Personnul
- FC - 2
.003
' 24.
Food and Food Protection
I FC -3
.W4
25. Equipment and Utensils
_ 1 FC - 4
.005
! 26.
I Water. Plumbing and Waste
FC -5
006 1
27.
Phsical Facility
FC -6
.1107
26.
Poisonous or Toxic Materials
! FC - 7
.009
29.
Special R uiremems
.009
30
1 Other
i
s �vnrnmt�us.:. m:
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street, 0 Floor
Division of Food and Drugs alem; MA 3523
Tel. (978 Fax (978) 745-0343
City/Town of
FOOD ESTABLISHMENT INSPECTION REPORT
Address:
Tel.
Name5
Priet`�
T pe of Operations)
ype of Inspection
Prin
Page10 4Pages
ood Service
tail
outine
Re -inspection
Address
R k
��
Level
❑ Residential Kitchen
❑ Mobile
Previous I pe on
Date:
Tele
Telephone
P
[I Temporary
El Pry era �CbrY
Owner
Lhrj C
HACCP YIN
❑ Caterer
❑ Bed & Breakfast
❑ Suspect Illness
❑ General Complaint
Person -in -Charge (PIC)
Time
In:
Ou Y
Permit No.
[I [3
Q 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 -(Red
Items)
Violations marked may pose an imminent health hazard and require immediate
corrective action as determined by the Board of Health.
;FOOD PROTECTION MANAGEMI
❑ 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
Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices_ (Blue
Items) Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Noncritical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C N
23. Management and Personnel (Fc -2X590.003)
24. Food and Food Protection (FC -3X590.004)
25. Equipment and Utensils (FC -4X590.005)
26. Water, Plumbing and Waste (FC5X590.006)
27. Physical Facility (FC -6X590.007)
28. Poisonous or Toxic Materials (FC-7X590.o08)
29. Special Requirements (590.009)
30. Other
1
Anti -Choking 590.009 (E) ❑
Tobacco 590.009 (F) ❑
Allergen Awareness 590.009 (G) ❑
❑ 12. Prevention of Contamination from Hands
513. Handwash Facilities
,PROTECTION FROM'CNEMICALS_ _ _
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
`TIMFITEMPERATURE:CONTROLs(PotenttaltyHaLrdousF.00ds)7 j
❑ 16. Cooking Temperatures
❑ 17. Reheating '
[118. Cooling
W19. Hot and Cold Holding
❑ 20. Time as a Public Health Control
l REQUIREMENTS FOR HIGHLYSUS..CEPTBLE_=POPULATiONS`.(HSP)'. a
❑ 21. Food and Food Preparation for HSP
CONSUIiii6DVIISORY_,
❑ 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 ins ection
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:
IL/ afl!7
Inspector's Signature:
Priet`�
PICS Signature:
Prin
Page10 4Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22)
FOOD PROTECTION MANAGEMENT_
I 590.003(A)Assio tment of Res onsibilit *
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 I aw*
3-201.12
require reporting by food employees and
3=201.13
Fluid Milk and Milk Products*
applicants*
Shell Eo -s*
590.003(F)
Responsibility Of A Food Employee Or An
3-202.16
ice Made From Potable Drinking Water*
Applicant To Report'ro The Person In
Drinking Water from an Approved System*
590.006(A)
Charge*
590,006(8)
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
I
C
C
C
FOOD FROM APPROVFD SOIIRCF
' Denotes critical item in, the federal 1999 Pant Code or 105 CMR 590.000,
C
PROTFCTION FRnfal enklTAu1MA-nnM
Food and Water From, Regulated Sources
590.004(A -B)
Compliance with Food I aw*
3-201.12
Foal in a Hermetical) • Sealed Container*
3=201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eo -s*
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(8)
_
Water Meets Standards in 310 CMR 22.0*
Shellfish and Fish From an Approved Source
3-201.14
Fish and Rea eationally Caught Molluscan
Shellfish`
3-201.15
Molluscan Shellfish from NSSF Listed
Sources*
4-703.11
Game and Wild Mushrooms Approved by
Regulatory Authority
3-202.13
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
Receiving/Condition
3-202.1.1.
PHFs Received at Proper Tem erasures$
3-202.15
Packa4ehite,rit *
3-101.1 i
foal Safe and Unadulterated
_
TagsMecords: Shellstock -
3-202.18
Shellstock Identification *
3-203.1.2
Shellstock Identification Maintained*
Tags/Records; Fish Products
3-402.11
Parasite Destruction*
-3-402'.12
Records, Creation and Retention*
590.004(1)
Labeling of Ing. edients•
Conformance with Approved Procedures
IHACCP Plans
3-502.11
S-cialized ProcessingMethods*
3-502:12
Reduced oxygen packagin& criteria*
8-'103.12
Conformance with Ap roved Procedures*
' Denotes critical item in, the federal 1999 Pant Code or 105 CMR 590.000,
C
PROTFCTION FRnfal enklTAu1MA-nnM
2-301..1.1Clean Condition - Hands and
2-301..12 Cleaning Procedure*
2-301.14 When to Wash*
z-vw., 11. I Eating, Drinking or Using Tobacco*
2401.1.2 Discharges. From the Eyes, Nose and
Mouth*
3-301.12 1 Preventing Cnntaminarirro vU1,..,, Tai
1
and
- - ----- -----
Cross -contamination
3-302.11(A)(1)
i
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-302.1.1(A)(2)
Raw Animal Foods Separated from Each
Other*
-
Contamination from the Environment
3-302.11(A) -
Food Protection* -
3-302.15
Washing Fruits and Ve eta es
3-304.11.
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Resercice of Foal*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Ford*
2-301..1.1Clean Condition - Hands and
2-301..12 Cleaning Procedure*
2-301.14 When to Wash*
z-vw., 11. I Eating, Drinking or Using Tobacco*
2401.1.2 Discharges. From the Eyes, Nose and
Mouth*
3-301.12 1 Preventing Cnntaminarirro vU1,..,, Tai
1
and
Food Contact Surfaces
4-501.1.11
Manual Warewasbing - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing- Hot Water
-
Sanitization Temperatures* -
4-501.1 l4 -
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-60 L 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
Chemiral*
2-301..1.1Clean Condition - Hands and
2-301..12 Cleaning Procedure*
2-301.14 When to Wash*
z-vw., 11. I Eating, Drinking or Using Tobacco*
2401.1.2 Discharges. From the Eyes, Nose and
Mouth*
3-301.12 1 Preventing Cnntaminarirro vU1,..,, Tai
1
and
� ✓i
Establishment
CITY OF SALEM
BOARD OF HEALTH f n
Page: 3 of
Item Code I C—Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION ware -
No. I Reference I R — Red Item I A 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 tw�araty-five dollar o suspengioi:(revocation of
our food permit. � ,� 1
Corrective
❑ Voluntary Compliance
Re -inspection Scheduled
❑ Embargo
0 Voluntary Disposal
❑ Employee Restriction /
Exclusion
❑ Emergency Suspension
❑ Emergency Closure
0 Other:
Violations Related to Foodborne Illness interventions and Risk
Factors Mums 1-22) (Cant.)
PROTECTION FROM CHEMICALS
14
Im
16
Im
18
Food w ColorAdditives
3-202.12
Additives*'
3-302.14
Protection from Unapproved
Additives*
E Immediate. Servico 145°Fl5sec*
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-.02.12
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 Powtiets, Pest Control and
Memittxin
Im
18
Denotes critical ism in the federal 1999 Ford Cade or 10 CMI R 90.000.
Mm
3.501.14(C)
Proper Cooking Temperatums for
3-501.55
PHFa
3-401.I1A(l)(2)
Eggs- 155°F 15 Sec.
3-50L16(B)
590.004(F)
E Immediate. Servico 145°Fl5sec*
3401.11(A)(2)
Comminuted Fish. Meats & Game
3.501.16(A)
Animals - 155'F 15 sec. *
3401.11(B)(1)(2)
Pork and Beef Roast -130°F 121 min*
,3-401.11(A)(2)
Ratites, Injected Meats -155°F 15
590.004H)
sec.
3-401.11(A)(3)
Poultry, Wild Game, Stuffed PHFs,
27.
Stuffing Containing Fish, Meat,
i FC -6-
Poultry or Ratites -165°17 15 sec.
3-401.11(C)(3)
Whole -muscle, Intact Beef Steaks
! FC --7.008
145°F *
3-401.12
Raw Animal Foods Cooked in a
-
Microwave 165°F *
3401.11(A)(1)(b)
All Other PHFs -145°F 15 sec.
Reheating for Hot Holding
3-403A I(A)&(D)
PHFs 165"F 15 sec. *
3-403.11(B)
Microwave -165° F 2 Minute Standing
Titre*
3-403.11(C)
Commercially Processed RTE Food -
140*F*
3403.11(E)
Remaining Unsliced Portions of Beef
Roasts*
Proper Cooling of PRFs
3-501.14(A)
Cooling Cooked PHFs from W'F to
70`F Within 2 Hours and From 70°F
to 41`F/450F Within 4 Hours. *
3-501.14(!3)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41017/450F
Within 4 Hours*
Denotes critical ism in the federal 1999 Ford Cade or 10 CMI R 90.000.
Mm
3.501.14(C)
PHFs Received at Temperatures
According to Law Cooled to
41'F145°F Within 4 Hours.
3-501.55
Cooling Methods for PHFs
3-801AI(B)
PHF Not and Cold Holding
3-50L16(B)
590.004(F)
Cold PHFs Maintained at or below
410145' F*
3-50L 16(A)
Hot PRFs Maintained at or above
140°F. *
3.501.16(A)
Roasts Held at or above 130017.
11 2S.
Time as a Public Health Control
3-501,19
Tim as a Public Health Control*
590.004H)
Variance airemant
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONs(HSP)
21
3-801.11(A)
Unpasteurized Pre-packaged Juices and
_Beverages with V4'art»nz labels*
590.000
3-801AI(B)
Use ofPasteurized Eggs*
FC -2
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sinums Not Served *
Food and Food Protection
3-801.11(C)
Unopened Food Package Not Re -served. "
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Pasted for Consumption of
590.000
Animal Foods That are Raw. Undercooked or
FC -2
.003--1
Not Otherwise Processed to Eliminate
Food and Food Protection
I FC -3
Pathogens.* F1e`a «vrzw,t
11 2S.
3-302.13
Pasteurized Eggs Substitute for Raw Shell
.005
26.
1 Eggs*
W-1=1,1AL MCUUMIMMC1715 _
590.009(A) -(D) Violations of Section 590.009(A) -(I)) 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 soul retail
practices should be debited under #29 -
Special Requirements.
(Items 23-30)
Critical,mtd non-critical violations, which do not relate to the
foodborne illness interventions and risk {actors listed above, carr be
found in the following sections of the Food Code and 105 CMR
590.000.
� Item
I Good Retail Practices
.FC
590.000
i Maf�ement and Personnel
FC -2
.003--1
2223,_
4.
Food and Food Protection
I FC -3
.004
11 2S.
Equipment and Utensils
I FC -4
.005
26.
and Waste
Water. Plumbing00
�FC-5
.6 ;
27.
Physical Facili
i FC -6-
.007
28.
Poisonous br Toxic Materials
! FC --7.008
2g.
;facial R uirements
-
.009
L 30.
Other _�
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: �. ���., n.( CL Date: Page: of
Item Code C—Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Late
No. Reference R - Red Item 1 I VerlBed
Discussion With Person in
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 I ty five dollar or suspe ion/revocation of
our food permit. � (J
Corrective Action
❑' Voluntary Compliance
111
-1 -inspection Scheduled
"`❑ Embargo
❑ Voluntary Disposal
■o= - ILE�
❑ Employee Restriction /
Exclusion
❑ Emergency Suspension
❑ Emergency Closure
13 Other:
Violations Related to Foodborne Illness Intervent/ons and Risk
Factors(ftems 1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
15
.16
17
18
TIME/TEMPERATURE CONTROLS
.
Food or Color Additives
3-202.12
Additives*
3-302.14
Protection from Una roved Additives*
3-501.16(13)
590.004(1`)
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 kir Washing Produce, Criteria*
7-204.14
Drying Agms. Criteria*
.11
Incidental Food Contact, Lubricants*
.11
Restricted Use Pesticides; Criteria*
.12
N
- Rodent Bair Stations*.13
340LII(A)(1)(b)
Tracking Powders, Pest Control and
Monitoring*
TIME/TEMPERATURE CONTROLS
.
Proper Cooking Temperatures for
3-501..15
PHFs
3-401.IIA(1)(2)
Eggs- 155°F 15 Sec.
3-501.16(13)
590.004(1`)
E -.Immediate Service 145°F15sec*
3-401.11(A)(2)
Comminuted Fish. Meats & Game
3-501.16(A)
Animals - 155°F 15 sec. *
3401.11(B)(1)(2)
Port: and Beef Roast -130°F 121 min*
3-401.11(A)(2)
Ratites, Injected Meats - 155°F 15
594.004 H}
sec. *
3-401.11(A)(3)
Poultry, Wild Game, Stuffed PHFs,
27.
Stuffing Containing Fish, AYeat,
Poultry or Ratites -165°F 15 sec,
3-401.11(0)(3)
Whole -muscle, Intact Beef Steaks
FCC 7
145°F r.
3401.12
Raw Animal Foods Cooked in a
.
Microwave 165°F *
340LII(A)(1)(b)
All Other PHFs - 145°F 15 sec.
L
Reheating for Hot Holding
3-403AI(A)&(D)
PHFs 165 F 15 sec. *
3-403.11(B)
Microwave- 165` P 2 Minute Standing
Time*
3-403.11(C)
Commercially Processed RTE Foal -
140°F*
3403.11(E)
Remaining Unsliced Portions of Beef
Roasts*
Proper Cooling of PHFs
3-501.14(A)
Cooling Cooked PHFs from 140°F to
70°F Within 2 Hours and From 70'F
to 41°F/45'F Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41017/45°17
Within 4 Hours*
" Dimxes critical ivm in the federal 1999 Foal Code ur 105 CMR 590.000.
ON
m
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
3-801AI(B)
PHF Hot and Cold Holding
3-501.16(13)
590.004(1`)
Cold PHFs Maintained at or below
410/45' F*
3-501.16(A) -
Hot PHFs Maintained at or above
3-501.16(A)
Roasts Held at or above 130°F.
25.
Time as a Public Health Control
3-541:14
Time as a Public Health Control*
594.004 H}
Variance Requirement
REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
2I
3-801.1 ] (A)
Unpasteurized Pre-packaged Juices and
.Beverages with Warning Labels*
590.000
3-801AI(B)
Use of Pasteurized Eggs*
i FC - 2
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
I Food and Food Protection
3-801AI(C)
Unopened Food Package Not Re -served.
CONSUMER ADVISORY
22
3-603.11
Consumer Adiisory Posted for Consumption of
590.000
23.
Animal Foods That are Raw. Undercooked or
i FC - 2
.003
Not Otherwise Processed to Elimmer
I Food and Food Protection
FC -- 3
Patbo * `"""'61^, (
25.
3-302.13
Pasteurized Eggs Substitute for Raw Shell
_005_ i
26.
E
F%Z1�111:7♦ ♦Ef►77
catering, mobile forid, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements.
(Items 23-30)
Critical, mrd non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following sectionsof the Food Code and 105 CMR
590.000.
i Hem
I Good Retail Practices
.FC
590.000
23.
1 Management and Personnel
i FC - 2
.003
24..
I Food and Food Protection
FC -- 3
.004
25.
E ui mem and Utensils
1 FG -4
_005_ i
26.
Water. Plumbing and Waste
1 FC - 5
om -1
27.
PhVsical FacilityFC-5
.007
�28.
Poisonous or Toric Materials
FCC 7
.008
29.
Special Requirements
.
.009
30
1 Other
L
CITY OF SALEM
p B ARD OF HEALTH /,
Establishment Name: tr�,l _�� C�6I - Date: 4 1- Page: _ of `�
Item
No.
Code
Reference
C - Critical nem
R - Red Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
.PLEASE PRINT CLEARLY
Date
- Verified
?/70 f V rCi
d
21523
/
15 v
%tS v c 1�4
D J
cti� c�✓ , J A7 Oa c
1
I I C C
C f
If
Discussion With Person in Charge:
d this report, have had the opportunity to ask questions and agree to correct all
before the next inspection, to observe all conditions as described, and to
P
th all mandates of the Mass/Federal Food Code. I understand that
Lnoncompliance may result in daily fines of twe five dollars or suspension/revocation of
permit.
Corrective Action Required:
❑ No
Yes
❑ Voluntary Compliance ❑ Employe R striction
Exclusion
e -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors (Items 1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
15
.16
17
18
TIMErrEMPERATURE CONTROLS
Food or Color Additives
3-202.12
Additives*'
3-302.14
Protection from Un roved Additives*
3-501.16(6)
590.004(F)
Poisonous or Toxic Substances
7-101,11
Identifying Information - Original
Containers*
7-102.11,
Common Name - Working Containers*
7-201.11
Separation - Stom 4'
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
Munitorin *'
TIMErrEMPERATURE CONTROLS
* Denotes critical mm in the federal 1999 Ford Cale or 105 Cii1R 590.000.
20
3-501.14(C)
Proper Cooking Temperatures for
3-501.15
PHFs
3-401.11A(1)(2)
Eggs- 155'F 15 Sec.
3-501.16(6)
590.004(F)
Eggs- Immediate Service 145'F15sec*
3-401.11(A)(2)
Comminuted Fish. Meats & Game
3-SO1.16(A)
Animals - 155'F 15 sec. *
3401.11(6)(1)(2)
Port: and Beef Roast - 130'F 121 min*
3-401.11(A)(2)
Ratites, Injected Meats -155'F 15
590.004(H)
see. *
3-401.1 t(A)(3)
Poultry, Wild Game, Stuffed PHFs,
27.
Stuffing Containing Fish, Meat,
i FC -6 -
Poultry or Ratites -165'F 15 sec.
3-401.1100)
Whole -muscle, Intact Beef Steaks
FC- 7
145OF w-
3-401.12
Raw Animal Fowls Cooked in a
Microwave 165F *
3401:11(A)(1)(b)
All Other PHFs -145'F 15 sec. °
i
Reheating for Hot Holding
3-403.11(A)&(D)
PHFs 165-F 15 sec. *
3-403.11(B)
Microwave- 165' F 2 Minute Standing
Time*
3703.11(C)
Commercially Processed RTE Food -
140'F*
3403.11(E)
Remaining Unsliced Portions of Beef
R ORM41
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 Ambieat
Temperature ingredients to 410F/450F
Within 4 Hours*
* Denotes critical mm in the federal 1999 Ford Cale or 105 Cii1R 590.000.
20
3-501.14(C)
PRFs Received at Temperatures
According to Law Cooled to
41'F/45'F Within 4 Hours,
3-501.15
Cooling Methods for PHFs
3 -SOI A I(B)
PHF Hot and Cold Holding
3-501.16(6)
590.004(F)
Cold PHFs Maintained at or below
410145' F*
3-50 L I6(A)
Hot PHFs Maintained at or above
140'F.
3-SO1.16(A)
Roasts Held at of above 130'F.
25.
Time as a Public Health Control
3-501.19 -
Time as a Public Health Contrcd*
590.004(H)
Variance I uiremetu
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (MSP)
21
3-801.11(,A)
Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
690.000
3 -SOI A I(B)
Use of Pasteurized Ems_
{ FC -2
3-801-II(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
i Food and Food Protection
3401.11 C
Unopened Food Parka Not Re -served.
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for Consumption of
690.000
23.
Animal Foods That are Raw; Undercooked or
1
{ FC -2
.003
Not Otherwise Processed to Eliminate
i Food and Food Protection
FC -3
Patbo ens.*tYtxeve"'
25.
3-302.13
1 Pasteurized Eggs Substitute for Raw Shell
.005
26.
E
SPECIAL
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering, mobile foal, temporary and
residentialkitchen 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..
VIOLA770AIS RELATED TO GOOD RETAIL PRACTICES
(Items 23-30)
Critical, and non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following sections of the Food Code and 105 CMR
590.000.
` Item
Goad Retail Practices
.FC
690.000
23.
1 Management and Personnel
{ FC -2
.003
' 24.
i Food and Food Protection
FC -3
.004 i
25.
E ui meld and Utensils
FC -4
.005
26.
Water. Plumbing and Waste-
! FC -5
.005
27.
Physical Facility
i FC -6 -
.007
28.
' Poisonous or Toxic Materials
FC- 7
.048
29.
Special Requirements
.009
30
1 other
i
sSveron,doc�5.x c r .
Commonwealth of Massachusetts
` e City of Salem
Board of Health Kimberley Driscoll
120 Washington Street, 4th Floor Mayor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/20/2011
ESTABLISHMENT NAME: Ward II Social Club
File Number: BHF -2004-000359 _ 1& 3East Collins Street
Salem MA 01970
LOCATED AT: 0001 EAST COLLINS STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
FOOD SERVICE BHP -2012-0102 Jan 1, 2012 Dec 31, 2012 $25.00
ESTABLISHMENT
Total Fees: $25.00
PERMIT EXPIRES ecember.31; 2012
Board of Health n
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted
in a prominent location in the Establishment:
In accordance with the State Sanitary Code, beofre any revonatlons, improvements, or equipment changes are made,
all plans for:such must be submitted to and approved by the Salem Board of Health.
Page 1 -
KINIBERLEY DRISCOLL
MAYOR
LARRY RAMDIN, RS/Rlil IS, (;110, CP -FS
1-h;Ari'll Ao;N'I'
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4'JI FI-OOR
TEL. (978) 741-1800
F_ x (978) 745-0343
Lamdic@salem com
201_ APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT/� YDi� LZ SY3 /l �.C�cxc� TEL # .9�T %/5"
ADDRESS OF ESTABLISHMENT /-, -3 -" Le1G,JS VT FAX#
MAILING ADDRESS (if different)
EMAIL - Business':
Website:
OWNER'S NAME&WX&✓I" lzrrr lne 6414 TEL# Y/
ADDRESS d &,,e,4n19,sj 1�_O/ Ile
STREET//� CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S)hDY✓&U CERTIFICATE#(S) 8,A f(e'aolo
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON_ /t//C%U1,,ZC CrX,I Qf0n HOME TEL
-DAY,S:OFOPERATION Mond ,1 Tuesday
Wednes
,.-Thursday Fdd _` Salurda i - Sunda
HOURS OF OPERATION
Please wrHeinl'aneofday.
llam-11pm)
!
%G71.6�7pD%^'�',y
f/"
(Forexam0e
/�••�
RETAIL STORE YES
RESTAURANT
(Outdoor Stationary Food Cart
less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
less than 25 seats =$140
25-99 seats =$2
more than 99 seats =$420
--- --- - ---------------------------------------------- ------
BED/BREAKFAST/-11111111-----------YES1111- --- $100
CHILDCARE SERVICES/NURSING HOME ----------------------------------1111-_
ADDITIONAL PERMITS - -- -- --1111- ----- ----
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $2.5
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
retume and paid all sta%taxes required under the law. -
Date I Social Security or Federal Identification Number
Updated 523/11 FOODAP201 Ladm Check# & Date