WAYLOS VARIETY INC - ESTABLISHMENTSW�)jO ✓A(ie�% IA
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universal oneTIA
www.myuniversalop.com
phone: 1-800-756-4676
UNV16162
MADE IN USA .
Massachusetts Department of Public
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
Health
Salem Board of Health
120 Washington Street, 4th Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name
at
of Operation(si
Tvpe of Inspection
od Seryice
tail❑
rR
PIC's Signature:
Print:
❑Routine
Re -inspection
Address a C
Risk
l
Telephone
Level
sidential Kitchen
❑ Mobile
Previous Inspection
n
E
Date:
❑ Pre-operation
Owner I /� \
HACCP YM
Caterer
❑ Bed & Breakfast
Permit No.
❑ Suspect Illness
El General Complaint
❑ HACCP
❑ Other
Person In Charge PIC _
g (PIC) �
Ti e,
,�/�
In:
Out: wA
Inspector
Each violation checked requires an expianv n 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- PROTE-CTION MANAGEMENT°
El 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH 11 1 It
•❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE - •'_
El 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
❑ 8. Separation/ Segregation/ Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
G11. 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.
t' C N .
23. Management and Personnel (FC -2)(590.003)
24. Food and Food Protections_ (FC -3)(590.004)
V 25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
GI 27. Physical Facility (FC -6)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.008)
29. Special Requirements (590.009)
30. Other
Ss901nspecfFomb-fa.Mc , /1 /�]/je ^ 1 / ��i�`
[:112. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIME/TEMPERATURE CONTROLS (Potentlally HamMou_a Fo_ods).
El 16. Cooking Temperatures y
❑ 17. Reheating
❑ 18. Cooling
19. Hot and Cold Holding
20. Time As a Public Health Control
----
REQUIREMENTS FOR HIOXLY_SUSCEPTIBLE POPULATIONS.(HSP)!
❑ 21. Food and Food Preparation for HSP
_CONSUMEFI DVISORY__-- _ - _
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions a
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: t U _ _� 6-0
Inspector's Signature:(
Print:
f
PIC's Signature:
Print:
t�
h/
Page.0r g.
Y
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assignment of Responsibility*
590.003(6) Demonstration of Knowledge"
2-103.11. 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 ! g 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
tem*
Drinking Water from an Approved System*
590.006(A)
Charge*
590.006(B)
590.03 G)
Reporting by Person in Charge*
3
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(1:)
Removal of Exclusions and Restrictions
LE
5
FOOD FROM APPROVED SOURCE
* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
in
PROTECTION FROM CONTAMINATION
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food law*
3-201.12
Foal in a Hermetically Sealed Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell ! g s*
3-202.14
F ggs and Milk Products, Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-101..11
tem*
Drinking Water from an Approved System*
590.006(A)
Bottled Drinkin • Water*
590.006(B)
Water Meets Standards in 31.0 CMR 22.0*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Shellfish and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Mollusca'
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
Proper, Adequate Handwashing
Game and Wild Mushrooms Approved by
Re Mato Authorlt
3-202.18
ShellstackIdentification Prescnt*
590.004(0)
Wild Mushrooms*
3-201.17
Game Animals*
2-301.14
Receiving/Condition
3-202.1.1
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated
TagsfRecords: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained*
12
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.1.2
Records, Creation and Retention*
590.004(7)JR-
abeling of Ingredients'
Handwash Facilities
onformance with Approved Procedures
ACCP Plans
3-502.11
edah-1 Processin Methuds*
3-502.1.2
duced ox gen acka "ng. criteria*
8-103.12
onfo mance with r1 roved Procedures*
* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
in
PROTECTION FROM CONTAMINATION
9
Cross -contamination
3-302.1.1(A)(1.)
Raw Animal Foods Separated from
Cooked and RTE Foods*
4-501.111
Contamination from Raw Ingredients
3-302.11(A)(2)
Raw Annual Fork Separated from Each
Other*
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
Contamination from the Environment
3-302.1.1(A)
I Food Protection*
3-302.15
Washing Fruits and Vegetables
3-304.11
Food Contact with Equipment and
Utensils*
4-602.1.1
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Resemice of Food*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Disposition of Adulterated or Contaminated
Food
3-701..11
Discarding or Reconditioning Unsafe
Ford"
9
Food Contact Surfaces
4-501.111
Manual Warewashing- Hot Water
Sanitization Temperatures*
4-501.11.2
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization- temp., pH;
concentration and hardness. *
4-601_ I1(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..1.2
Cleaning procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2401_11
Eating, Drinking or Using Tobacco*
2.401.12
Discharges. From the Eyes, Nose and
Mouth*
3-30(.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 Drying Provision
Establishment Name:
BOARD OF HEALTH
Date: q— I I n Page: U, of
Item
No.
Code
Reference
C — Critical Item s DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
'R — Red Item- -
PLEASE PRINT CLEARLY �
Qn
cafe
Verified
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1 14 IM 0,1
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Discussion With Person in Char
Corrective Action Required:
❑ No ,
l2fes -
Voluntary Compliance ❑ Employee Restriction /
/ Exclusion
U Re -inspect' n Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other
FORM 7348 (REV. 7/2000) HOBBS & WARREN, -BOSTON This Form Approved by the Department of Public Health
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*
7-206.11
Restricted Use Pesticides, Criteria*
7-206.12
Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Monitoring*
TIME/TEMPERATURE CONTROLS
16.
PHFs Received at Temperatures
According to Law Cooled to
41 °F/45°F Within 4 Hours.*
Proper Cooking Temperatures for
Cooling Methods for PHFs
3-801.11(B)
PHFs
3-501.16(B)
590.004(F)
3-401.i1A(l)(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*
3-401.1l(A)(1)(b)
All Other PHFs- 145°F 15 Sec.*
17
Reheating for Hot Holding
3-403.11(A)&(D)
PHFs 165°F 15 Sec.*
3-403.11(B)
Microwave - 165°F 2 Minute Standing
Time*
3-403.11(C)
Commercially Processed RTE Food -
140°F*
3-403.11(E)
Remaining Unsliced Portions of Beef
Roasts*
18
Proper Cooling of PRFs
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
DE
3-501.14(C)
PHFs Received at Temperatures
According to Law Cooled to
41 °F/45°F Within 4 Hours.*
3-501.15
Cooling Methods for PHFs
3-801.11(B)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold PHFs Maintained at or below
41°F/45°F*
3-501.16(A)
Hot PHFs Maintained at or above
140°F.*
3-501.16(A)
Roasts Held at or above 130°F*
25.
Time as a Public Health Control
3-501.19
Time as a Public Health Control*
590.004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
`21
.:--.
3-801.11(A)
Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
590.00
3-801.11(B)
Use of Pasteurized Eggs*
FC - 2
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served.*
Food and Food Protection
3-801.11(C)
Unopened Food Package Not Re -served.*
CONSUMER ADVISORY
'.. 22
3-603.11
Consumer Advisory Posted for Consumption of
590.00
23.
Animal Foods that are Raw, Undercooked or
FC - 2
.003
not Otherwise Processed to Eliminate
Food and Food Protection
FC - 3
Pathogens.* Eneetive 1/1/20"
25.
3-302.13
Pasteurized Eggs Substitute for Raw Shell Eggs*
590.009(A) -(D) Violations of Section 590.009(A) -(D) in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements.
VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
(Blue Items 23-30)
Critical and non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following sections of the Food Code and 105 CMR
590.00.
Item
Good Retail Practices
FC
590.00
23.
Management and Personnel
FC - 2
.003
24.
Food and Food Protection
FC - 3
.004
25.
Equipment and Utensils
FC - 4
.005
26.
Water, Plumbing and Waste
FC - 5
.006
27.
Physical Facility
FC -6
.007
28.
Poisonous or Toxic Materials
FC - 7
.008
29.
Special Requirements
.009
30.
Other
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT' y
A 4N 1;,4
3
Salem Board of Health
120 Washington Street, 45" Floor
"t Salem MA 01 9770.8,23
t �Tel.1(978) 741-1'800 Fax (978) 745-0343
Name
c7S C CLQ
Date
S O
Tvoe of 0 eration(s)
Tvoe of Insoection
❑ Routine
(kRe-inspection,'f
Previous Inspection
Date: ��2Co �ar1
ElPre-operationOwner
❑ Suspect Illness
❑❑ General HACCP Complaint
❑ Other
❑Food Service
'Retail
❑ Residential Kitchen
❑ Mobile
ElTemporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
Address
Risk
Level
'S
Telephone _ -
I
'26.
f CA G
HACCP YM
Person in Charge (PIC) /
Time
In: /1,11.
Out:
Inspector
Each violation checked requires aft explanation on the narrative page(s) and a citation of specific provision(s) violated. ..;
Noncompliance with:
Violations Related to Foodborne Illness Interventions and Risk F;ictors
Anti -Choking Tobacco
Violations marked may pose an imminent health hazard and'require immediate corrective 690.009( E) ❑ 590.009 (F)
action as determined by the Board of Health.'
5
'FOOD PROTECTION MANAGEMENT'„';',�,
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH Fri
�„�.„ _�,�
El 2. 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 withh,Approved Procedures/HACCP Plans
PROTECTION FROM CONTAMINATION +g, A s °°" '^
❑ 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. 1
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=�,�,Fo,.� n
0'2T. Prevention of Contamination from Hands
❑ 13 Handwash Facilities
14. Approved Food or
❑ 15. Toxic Chemicals
}.TIME/TEMPERATURE CONTROLS (Potentially Hazardous
El 16. Cooking Temperatures {
t ❑ 17 Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
'4r,'REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) „,j
El 21, Food and Food Preparation for HSP
;;CONSUMER ADVISIDAY
M1vx v. �A r.„li,
❑ 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 checkedindicate 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 w 1 vl f
i
f
Page of 7 es
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) _ Dem msteation of Knowledge*
2-103.11. Person in charge - Buttes
EMPLOYEE HEALTH
2
590.003(,C)
Responsibility of the person in charge to
Compliance with Food Law"
3-201.1,2
require reporting by food employees and
3-201.13
Fluid Milk and Milk Products*
applicants*
Shell Eggs*
590.003(F)
Responsibility Of A Food Employee Or An
3-202.16
Ice Made From Potable Drinking Water*
Applicant To Report To The Person In
Drinking Water from an Approved System*
590.006(A)
Charge*
590.006(B)
590.003(0)
Reporting by Person in Charge*
3
590.003(D)
Exclusions and Restrictions*
3-201.19
590.003(E)
Removal of Exclusions and Restrictions
C
C
C
I
FOOD FROM APPROVED SOURCE
* Denotes critical item in the Waal 1999 Ftmd Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
8
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 Water*
5401.1.1
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 220*
Washing Fruits and Vegetables
Sheitlish and Fish From an Approved Soume
3-20114
Fish and Recreadonal'ly Caught Molluscan
Shellfish*
3-201.19
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*
3-202.15
Package Inte it
3-101.11
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained"
Tags/Records: Fish Products
3-40111
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(7)
Labeling of Ingredients'
-
Conformance with Approved Procedures
MA CP Plans
4-703.11
S e valized Processing Methods*
3-502.12
Reduced oxygen paging, criteria*
8-103.12
Conformance with Approved Procedures*
* Denotes critical item in the Waal 1999 Ftmd Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
8
Cross -contamination
3-302.1.1(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3302.1.1(A)(2)
Raw Amoral 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 of Reconditioning Unsafe.
Food*
9
Food Contact Surfaces
4-501..1.11.
Manual Warewashing - Hot Water
Sanidzation'rent eratures* -
4-501.112
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-501.114
Chenncal Sanitization- temp., pH,
concentration and hardness. *
4-601..11(A)
Equipment 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
2-301.1.1.
Clean Condition - Hands and ArmO
2301.12
Cleaning Procedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2401.11
Eating, Drinking or Using Tobacco*
2401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventin Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Em to •ces*
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
Hindwashing Cleanser, Availability
6-301..1.2
Hand Drying Provision
i
ti
Establishment Name: I
,tem Co:SeT- C—Critical It
No. Re7erence R — Red Rem
CITY OF SALEM
BOARD OF HEALTH
1i Vr,� Fr l� Date:
DESCRIPTION OF VIOLATION / PI
Page: -:�L_ of �2
Verified a
3. -
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
inspection, to observe all conditions as described, and to
violations before the next ins P
Ll Re -inspection Scheduled
❑
Exclusion
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
❑
Other:
I
Violations Related to Foodborne fitness Interventions and Risk
Factors (Rents 1-22) (Cont)
PROTECTION FROM CHEMICALS
F14
qt cd 1Roan 121 min,
Food or Color Additives
3-202.12
Af"tives*
0 1
4 J77
3-302.14
Protection from Unapproved Additives"`
3-501.15
Poisonous or Toxic Substances
19
7 101.11
kknufymtiInfoimmlon - Otiggmal
Contain--ri;3,
-1 102,11
7-201.1 1
Common Nianift . WorkifijL± o)13A`f,tr.,*
Sr_paiaufm - slojap-*
-202.11
R""vicoort - po,xpfse-itud Us�-�
ReN,tfog for loot Holding
7-202-12
7-203.11
Coudlooll:. of ITSQ"
Toxic Cowajrrcr Prollibitiowsti
7-204.11
Sanil;7eL4. Ctilw - chcoficdv
'little'
tan iroLnJalli, Prcr.rs.cd R,i -, I, vd
Ff-�20�4.12
Chogicak for 'Odoce, Cjito(iil
lniid�-mall iyd Contact, Luln icalitS4
7-206A I
Resint w Petikfdey, Crirel i.1,
2-X12
Rkxhnnl 13�tlt
:-(76.'13
1 Poi,.th14,g Contro I aria
lon;1orin•-
TIM FJTEM PCRATURE CONTROLS
l�rope, s,ockirg Temperatures for
NiFs
55 SS
F1th, & G.1111f
j
qt cd 1Roan 121 min,
PIIFs Reuived at Temperatures
Acwriding to Lav, Cooled to
0 1
4 J77
------- ------
lkibrf Gaulo, Stuffed Pill
41 "F/451 Within 4 Howl.
3-501.15
Cooling Methods for PHFs
19
—4
PHF Hot and Cold Holding
3501.16(B)
Cold PHF( Maintained at or below
59Q004(F)
41°/450 F,
ReN,tfog for loot Holding
ti #,!'5.11(5}r D i
---- ----- -- ------ ----- ----- - ----- -- --
If,,; i:
14(j'F,
'little'
tan iroLnJalli, Prcr.rs.cd R,i -, I, vd
18
i iulJ4fA) C(ohtli! cty)ki'd pfflis fforn kv)Foo
70'F Within 7 1 fours: awl From -70"!
Houo,,
501,14(b) (ix law PHR k11ic f=ront Al ibient
Tcinpci dwre In redient,
I! . t (, 41 F/,r 5 i F
Willon IkRu �,
1 A!, -�a1EICA lifill, i 1i' : 11- - , �, ":,: I d, ,r i(IS is %4k .90 00o
REOUIREMENTS.FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HIS
1, IIIA) Unptcunzcd Ppiwkogcd Joices and
3 -8k) 1. 1103) Uc". of pa,wo:i7ed ELUI�,�
I RdWOr Cookcd Animal FoodmJ.
Not R,:screed. `
CONSUMER ADVISORY
2 -3-60; 11 i. on qo net Act r I -.r" Po ! i lor( on, wn,,t; i, -it
%nim,l i Axl. fl,foja !'av-
N'ot Oth s 1,
F-1
LL -------
Vida i,00, of
.
cHer ;i-. !wbilc leer , tkopotaiwd
1 kboed Mid"'I tlll
-A,
VIOLATIONS RELATED TO GOOD RE "'Ail. PRACTICE'.'.;
(Itents 23-30)
0,41"wi aIwl lion-, 1*11JI:i2i iri it irisw;:h:hAf "w ?CW(f
fwurd in of 2ani cootl Code cs ;!li ,! R
(1f). ow
i-- --- - - — - - -- -- Good Retail Prac ices FI-,- -- -- --- -- Z- - -- -- -
Item. 1 C 590-Vitio
23
and Peronne�li'
- -- - -------- - -----
•
4 Frv)d and =OW Prolection PC 3 00A
Eqt�, matLI ar!dt�ei ,rts �T5
Wat FC 5
'-Phi i Fa '1 F
1 2d. Pc,.sonous or Tow, Viatprwls 1 FC -7 000,
Said Ric irerr(�n!-.
3-501A4(C)
PIIFs Reuived at Temperatures
Acwriding to Lav, Cooled to
41 "F/451 Within 4 Howl.
3-501.15
Cooling Methods for PHFs
19
--
PHF Hot and Cold Holding
3501.16(B)
Cold PHF( Maintained at or below
59Q004(F)
41°/450 F,
3-50116(A)
I [fit Maintained it or above
14(j'F,
16(,k)
Rtgistt, field at or Arti%tt I 10"F
Time as a Public Health Control
1 -No I 17
flw,is a Public Health
REOUIREMENTS.FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HIS
1, IIIA) Unptcunzcd Ppiwkogcd Joices and
3 -8k) 1. 1103) Uc". of pa,wo:i7ed ELUI�,�
I RdWOr Cookcd Animal FoodmJ.
Not R,:screed. `
CONSUMER ADVISORY
2 -3-60; 11 i. on qo net Act r I -.r" Po ! i lor( on, wn,,t; i, -it
%nim,l i Axl. fl,foja !'av-
N'ot Oth s 1,
F-1
LL -------
Vida i,00, of
.
cHer ;i-. !wbilc leer , tkopotaiwd
1 kboed Mid"'I tlll
-A,
VIOLATIONS RELATED TO GOOD RE "'Ail. PRACTICE'.'.;
(Itents 23-30)
0,41"wi aIwl lion-, 1*11JI:i2i iri it irisw;:h:hAf "w ?CW(f
fwurd in of 2ani cootl Code cs ;!li ,! R
(1f). ow
i-- --- - - — - - -- -- Good Retail Prac ices FI-,- -- -- --- -- Z- - -- -- -
Item. 1 C 590-Vitio
23
and Peronne�li'
- -- - -------- - -----
•
4 Frv)d and =OW Prolection PC 3 00A
Eqt�, matLI ar!dt�ei ,rts �T5
Wat FC 5
'-Phi i Fa '1 F
1 2d. Pc,.sonous or Tow, Viatprwls 1 FC -7 000,
Said Ric irerr(�n!-.
?Y
Massachusetts Department
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION R
of Public Health
EPORT'
Salem Board of Health
120 Weshingtori'Street, 41h Floor
Salem, MA 01970-3523
Tel. (978) 7414800 Fax (978) 745-0343
Name
G Q3 G(Z '
Dat
TVDe of Operationfs)
❑Food Service
Retail
❑ Residential Kitchen
❑ Mobile
El Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
Tvoe of Inspection
❑Routine
PEI -Re -inspection
Previous Inspection
Date: 6(IY1t)�
El Pre -opera tion
❑ Suspect Illness
❑ General Complaint
El HACCP
❑ Other
Address clJ
Risk
Level !
1
Telephone c/ 6
(�
Owner r �1
e- r�to�u \
HACCP Y/N
.�
Person in Charge (PIC) r-> ti,
Time +'
Out:'
Inspector trf) �O
Each violation checked requires an explanation on the narrative page(syand 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 MANAG.EMENT;�, t, `�j; r' ""
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH '.'t
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
c 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.'Jr
❑ 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)
74 25. Equipment and Utensils (FC -4)(590.005)
26. Water, Plumbing and Waste (FC -5)(590.006)
7. Physical Facility (FC -6)(590.000'
28. Poisonous or Toxic Materials (FC -0(590.008)
29. Special Requirements (590.009)
30. Other
S'590;.IdFcm 14.d.
l l
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIMErtEMPERATURE CONTROLS (Potentieliy Hizardoua Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIoNB (HsW) 9u
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:
.�
Print:
PIC'sSignature:
Print: /A )i f M ,./rte
t-
PagerZ of- ;�]Pages
w
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assignment of Responsibility*
-90.003(B) I Demonstration of Knowledge"
2-103.11 1 Person in charge - duties
EMPLOYEE HEALTH
2
590.(H)3(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 MilkProducts*
applicants*
Shell Eg=gs*
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.(N)3(D)
Exclusions and Restrictions*
3-201.15
590.003(F.)
Removal of Exclusions and Restrictions
M
C
C
FOOD FROM APPROVED SOURCE
"Denotes critical item in the federal 1999 fwxl Cate w 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
8
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Food in a Hermetically - Scaled Container*
3-201.13
Fluid Milk and MilkProducts*
3-202.13
Shell Eg=gs*
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*
Washing Fruits and Vegetables
Shellfish and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP listed
Sources*
Contamination from the Consumer
Game and Wild Mushrooms Approved by
Re ulato Author"
3-202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
3-701.11
Receiving/Condition
3-202.11
PRFs Received at Proper Temperatures*
3-202.15
Package hue it *
3-101.11
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained*
Tags/Records: Fish Products
3-4021 I
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(1)
Labeling of ingredients*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Conformance with Approved Procedures
/HACCP Plans
3-502.11
Specialized Processing Methods*
3-502.1.2
Reduced oxygen tack° mm, criteria*
8-103.12
Conformance with App. ed Procedures*
"Denotes critical item in the federal 1999 fwxl Cate w 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
8
Cross -contamination
3-302.1.1(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from Raw Ingredients
3-302.1.1(A)(2)
Raw Amoral Foods Separated from Each
Other-,
Contamination from the Environment
3-302.1 I(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)
Retuned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food"
9
Food Contact Surfaces
4-501.11 I.
Manual Warewashing - Hot Water
Sanitization Temperatures-
en eratures-4-501.112
4-501.112
Mechanical Warewashing- I-Iot Water
Sanitization Temper mes*
4-501.114
Chemical Sanitization-temp.,PH,
concentration and hardness. *
4-001.. 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*
F-11-
Good Hygienic Practices
2401.11
Drinking or Using Tobacco*
2401.12
..Eating,
Discharges From the Eyes, Nose and
Mouth*
3-3011.12
Preventing Contamination When Tasting"
12
Prevention of Contamination from Hands
590.004(F;)
Preventing Contamination from
Employees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
.5-204.11
Ucation and Placement*
5-205.1.1
Accessibilit. 0 oration and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.71.
Handwashing Cleanser, Availability_
6-301.12
Hand Drying Provision
i
Establishment
FY OF SALEM T
BOARD OF HEALTH _ 7
Date: !'n? lacl _ Page: of T
Item
Code
C - Critical Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
'Date
No.
Reference
R - Red Item
'..
w PLEASE PRINT CLEARLY .. I
Verified
I
jp
11
t (/
ALO
fr
-7
f
jj
' (i� ii' 1 GP — • C.tJ G i eili n
o .�
i
'^
1 Y) n
'"f 1J. 9V I c rAlii
_(D
1rI,
Y —' �.� ��
.. - -
- e
If -
/I
(Jed W-. 1A7
-,
.� uJ
1,0 1 f3
.SM 41A za
Discussion With Person in Charge:
Corrective Action Required:
❑ No
-5"is
I have read this report, have had the opportunity to ask questions and agree to correct all
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
inspection, to observe all conditions as described, and to
violations before the next ins P
Re -inspection Scheduled El 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
p Embargo_ ❑ Emergency Closure
your food permit.
"
0 Voluntary Disposal 0 Other:
`: I
V --
Violations Related to Foodborne fitness and Risk
Factors (Ilefrs 1-22) (Cont.)
PROTECTION FROM CHEMICALS
--T
14 —
--
Food or Color Additives
Et2
According, to Law Coolod to
1-302.14
Prote.ction fromUnajjELwved t� �dilivL
I L-15—
Poisonous or Toxic Substances
101.11ld�,,m
i,N ing, Intot imil ion 04,nal
PHIF Hot and Gold Holding
1501 lb(B)
Cold PHN Maiml,ined at or beFIW—,
4
W )TL j Ti i, l, m) r. I ol
—IT
lcl;oo -PI Sq T,ca aild t"C'
V, dd 'wi,tc, S�wri 04;
flot 111-fFs, %ttlintamed at c at,
lexi( Conlairim Pon N*iml
2!4,11
`Bull vciti Crit"Till cllr.rift ;,I�
,.n^
('11cim"ak to W,,dhmg, i s t
14 1
Crw"ria' ---------- --- - -------
-n05 11 1
lmid��Ilkai k.Xj Cullom.1. Ib
W'i
ti
— - - --------- ----
t 40,111
rapC,c
jlj �
0 - i4 --i i-7
--
I—If W -s —Rea,ived afTevtperatures
According, to Law Coolod to
i NFs
10 1 1 Ai I
CITY1
Cooling tilt (hods for PRFs
PHIF Hot and Gold Holding
1501 lb(B)
Cold PHN Maiml,ined at or beFIW—,
ro,
590 00((F)
----------
11 rict! ,ii %t,
V, dd 'wi,tc, S�wri 04;
flot 111-fFs, %ttlintamed at c at,
1010: Good Rrtail A
,.n^
HeM a[ or 'lboce 0
�:tq Ici lto!
1
Time lisa lublic Health Control
W'i
ti
ailublicAkWt) t onuoi
t 40,111
rapC,c
jlj �
- --- - - - -- --------
I Prapo, Coolinq of PHFs
4OL 4(A)
flial" i!,I
It TOM 1%, 1
WoJ15114 How,
r------
3 �01 401i
1 Cp NIF4t Fiom Ailibi.-na
T
0 - i4 --i i-7
--
I—If W -s —Rea,ived afTevtperatures
According, to Law Coolod to
Within 4 Hours. t
CITY1
Cooling tilt (hods for PRFs
PHIF Hot and Gold Holding
1501 lb(B)
Cold PHN Maiml,ined at or beFIW—,
ro,
590 00((F)
41 /15" F*
3 )()1.16(A)
flot 111-fFs, %ttlintamed at c at,
1010: Good Rrtail A
HeM a[ or 'lboce 0
10
1
Time lisa lublic Health Control
ny-�,, �Ind looll Prolwtw,
ailublicAkWt) t onuoi
L5o()
rapC,c
REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULAMNS (HSP)
21 Tz-sol
11 (TI r 1 ol
1 iluwd F, a"d
No!
CITY1
("d !a
ro,
1010: Good Rrtail A
%fian'xi'mc, nt Z,,;d Per mi��
C
ny-�,, �Ind looll Prolwtw,
qufp,.21'�ot and ,,ii 3
- -- - -- ----
jlj �
� -4e-1
T,
epf-
r.''! 0.
rt
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
lln
Irtx
h�
Salem Board of Health
120 Washington Street, 4`" Floor 1 `"
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
NameD
5 r r,
t
JDj0c7
Type of Operation(s)
Type of Inspection
❑ Food Service
Retail
1 Residential Kitchen
El Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
'Routine
ElRe-inspection
Previous Inspection
Date: �j3/II'',,
J
❑ Pre- peration
❑ Suspect Illness
❑ General Complaint
❑ HACCP
❑ Other
AddressRik
0 C)
7// i Y
Level
TelephoneElMobile
Owner 1
(V Q0 /I�( n
HACCP Y/N
Person in Charge (PIC) 1
Time
in:T.?r
Out
Inspector
Each violation checked r6quires 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„ r "` ` m'P g`w' "` "
w nM®
❑ 1. PIC Assigned/ Knowledgeable/ Duties
n EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
L FOOD FROM APPROVED SOURCE2"Ni, ZIF7055, ,0„y0
❑ 4. Food and Water from Approved Source
5. Receivin onditiori
6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
PROTECTION FROM CONTAMINATfON'
� V1 Ha :r „.
-m. a, mob -0
z
«-w,%aM.nkS.bhs ` .w6«.rvw-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.
4 T fi'
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
ss0M,.tFo�,e.� n
,A
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
`PROTECTION FROM CHEMICALSZfi
g..d,4�uc.�i�-.GJa
El 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
'TIMErrEMPERATURE CONTROLS (Potentially Haiardous Foods] "'mak
El16. Cooking Temperatures a.:
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
[120. Time As a Public Health Control
[,REQUIREMENTS FOR HIGHLY SUSOEPTtBLE OOPULATIQNs,',(HSP);u
El 21. Food and Food Preparation for HSP
r, CONSUMER ADVISORY' t`a„ ",
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions
and Risk Factors (Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
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: '01III/A
"Print: ^
PIC's Signature:
Print:, /L�
Page,(,ofages
_
7// i Y
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*
2-10-3 11 Person in charge - duties
EMPLOYEE HEALTH
2
590.003(0)
Responsibility of the person in charge to
Compliance with Food Law*
3-201.12
require reporting by food employees and
3-201.13
Fluid Milk and Milk Products*
applicants*
Shell Eggs*
590.003(F)
Responsibility Of A Food Employee Or An
3-202.16
Ice Made From Potable Drinking Water*
Applicant To Report To The Person In
tem*
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
LN
FOOD FROM APPROVED SOURCE
* Denotes critiad item in the Weral 1999 Food Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
8
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Fond in a Hermetically Seated Container*
3-201.13
Fluid Milk and Milk Products*
3-202.1.3
Shell Eggs*
3-202. t4
Eggs and Milk Products. Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-1.01..1.1
tem*
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0"
Washing Fruits and Vegetables
Shellfish and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201-15
Molluscan Shellfish from NSSP Listed
Sources*
Contamination from the Consumer
Game and Wild Mushrooms Approved by
Re Mato Author'
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*
3-202.15
Package hue it *
3-101.11
Food Safe and Unadulterated
TagsfRecords: Shelistock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained"
Tags/Records: Fish Products
3402.11
Parasite Destruction*
3-402.12
Records, Creation and Retention*
590.004(1)
Labeling of Ingredients'
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Conformance with Approved Procedures
IHACCP Plans
-3302.11
S actializedProcessin Methods*
3-502.13
Reduced oxygen packaging, criteria*
8-103.12
Conformance with Approved Procedures*
* Denotes critiad item in the Weral 1999 Food Code or 105 CMR 590.000.
PROTECTION FROM CONTAMINATION
8
Cross -contamination
3-302.11(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Fads*
Contamination from Raw Ingredients
3-302.11(A)(2)
Raw Animal Fads Separated from Each
Other*
Contamination from the Environment
3-302.11(A)
Food Protection*
3-302.15
Washing Fruits and Vegetables
3-304.11
Food Contact with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
9
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Temperatures* -
4-501.112
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-601.11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency off 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 - FIot Water and
Chemical*
10
Proper, Adequate Handwashing
2301.11.
Clean Condition - Hands and Arms*
2-301.1.2
Cleaning Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2-001.11
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
Em to ees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-204.1.1
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11.
Handwashing Cleanser, Availability
6-301.12
Hand Drying Provision
L I
Establishment Nar
CITY OF SALEM
BOARD OF HEALTH
Date: (�; a i,�5 Pager of
Rem
No.
code
Reference
C - Critical Item:
R - Red Item f'
E
- DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
PLEASE PRINT CLEARLY
Dater .
; verified
_
od.t3
}��
rr
Yj CK5 i.7 �Jlc�,n `(J�, [ f2n - 1 A)"C!s c c
C�o,n
S�Ct.i 6aC'4, C,i� .,C.Lz 4l "U cn rQW K
C 0641 i__Mn_ !c1 (2)4A51
r1�
II
dp- rc id _ta-U--
--7-
-Erp rfr7V_11L11 / rr l , sic60
Ilo ✓i ,
I
f
( n J`
A
f
Q
vir Gtr 4 :
�)
4 .l
O ��% r n .Y� I .ro
r
�a ,
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
p
_comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twen�llars or suspension/revocation of
your food permit11 _.
11
Corrective Action Required:
❑ No
Yes
❑ Voluntary Compliance ❑ Employee Restriction
j Exclusion
Re -inspection Scheduled ❑ Emergency Suspension
J
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal 0 Other:
W
Violations Related to Foodborne Illness interventions and Risk
Factors (items 1-22) (Cont.)
PROTECTION FROM CHEMICALS
,51-4
Food or Color Additives
Flv
3-202.12 Additives'"'
3-30114 Pnx coon from l7napproved Additives,
IS
or Toxic Substances
4 1 'F/45'F Within 4 How's.
—+Poisonous
3-403.1
Identifyinginfonnation -Oij�gmal
19
C ontaillers-
PHF Hot and Cold Holding
(-)2 I I CoaunwaiName R 1 ki uutal 1 11 n'.
3-501.16(B)
7-201.1 ti�aia wn-::-S
-------
FC -7
-202-11 �Retic on - vfe�.occ mid Use' —
its
PS oats i i i w U ns I i ce d Port to -
7-202.12 1 ('011ifilion, of Usel
3-501,10(A)
, T(Alk: Cialtamelz -- llrolabitio[
7-204. Samiizevs, Coteria - Cheroiclils*
'04.1 't
Proper Cooling of PHFS
Ch.,nacaN ioi
—,-(
7204.14 Dintw, Ai,eots. Criteria,
77�o
1116ticittal I kxxj contam LoNIE
Foi,Fw, Cexlk A PHI's i i orn 1,4) F I
[-206� 11 i
2- d I!Sc liecldekCiitk:
7 206.12
Witilm 4 1-iom,
16
401 11 Al�
i Es!� iolia,�diatc SS vw,: 11,5 1
------- ----
;-7 --------------- -,-, , I
1 t. rw
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATION'S (HSP)_
1 21 r I -$0 'I 11 tjN) k."npotcurizv.d Pru -im6 aited Juices and
(13) Us t, pa: teal
7,, dL
.1 It it
CONSUMEflt ADVISOry
U 11 j Cow,uoa,� lcusi,r'Pi,zi,tJ 11)rk"o),,kmV1--;.,
0
l r
C'0 T'i 'I I tk.' lit k ) al ti�m, v 'Oral,
GP'dI 'I jl,�
WikW:; l_...
VIOLATIONS REL 4 TZ:,1 10 30'00 RE` TAi. P,IACW-L's
I Items 23-:
"'todborile Ows., imf Pine+ wal 10-finlo's liq, dwk f",
J'"and in J;, pibming f,t!um% Fwd Code w 1 „ k -4,1R
IJ (100
Item Good Rata,f Practices FC
590.V(f)
hA,n i. -f —,rt P., ...... i Gf' 11 1 b10
3-5w.j 4(c)
Flv
n,"Vkz"6nq to; Ky, Hoithng
rC - 4
4 1 'F/45'F Within 4 How's.
VVatoj
3-403.1
Cooling Methods for PHFs
19
)Phys tcal Fkl� 11V
PHF Hot and Cold Holding
3-501.16(B)
Cold PHF., Maintained at or bahnv
-------
FC -7
1 3.401 1 !(Fl
its
PS oats i i i w U ns I i ce d Port to -
i S peom JR, kq,a tFr
3-501,10(A)
Hot Plihs Maintaillet! at of above
Proper Cooling of PHFS
ELS
—,-(
Ptiasas Held at of above 13(1 F.
77�o
1 1
Foi,Fw, Cexlk A PHI's i i orn 1,4) F I
70:1: Within .7 1 four:: ,!id Front 701'
Witilm 4 1-iom,
r(111�Itov fliffit, Madc From Afohew
It 41 1-145 F 1
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATION'S (HSP)_
1 21 r I -$0 'I 11 tjN) k."npotcurizv.d Pru -im6 aited Juices and
(13) Us t, pa: teal
7,, dL
.1 It it
CONSUMEflt ADVISOry
U 11 j Cow,uoa,� lcusi,r'Pi,zi,tJ 11)rk"o),,kmV1--;.,
0
l r
C'0 T'i 'I I tk.' lit k ) al ti�m, v 'Oral,
GP'dI 'I jl,�
WikW:; l_...
VIOLATIONS REL 4 TZ:,1 10 30'00 RE` TAi. P,IACW-L's
I Items 23-:
"'todborile Ows., imf Pine+ wal 10-finlo's liq, dwk f",
J'"and in J;, pibming f,t!um% Fwd Code w 1 „ k -4,1R
IJ (100
Item Good Rata,f Practices FC
590.V(f)
hA,n i. -f —,rt P., ...... i Gf' 11 1 b10
3-5w.j 4(c)
PHFs Reaived at Temperatures
According to Di" Cooled to
rC - 4
4 1 'F/45'F Within 4 How's.
VVatoj
`S-5(11.15
Cooling Methods for PHFs
19
)Phys tcal Fkl� 11V
PHF Hot and Cold Holding
3-501.16(B)
Cold PHF., Maintained at or bahnv
-------
FC -7
5900(4(F) --41
/45°F'
i S peom JR, kq,a tFr
3-501,10(A)
Hot Plihs Maintaillet! at of above
40,1
2
3-501,16(A)
Ptiasas Held at of above 13(1 F.
I imeasa Public Health Control
lroc, a, , loblw 11,altb Conool,
Vi!rialwo Req!a!—rlolcat— — -------
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATION'S (HSP)_
1 21 r I -$0 'I 11 tjN) k."npotcurizv.d Pru -im6 aited Juices and
(13) Us t, pa: teal
7,, dL
.1 It it
CONSUMEflt ADVISOry
U 11 j Cow,uoa,� lcusi,r'Pi,zi,tJ 11)rk"o),,kmV1--;.,
0
l r
C'0 T'i 'I I tk.' lit k ) al ti�m, v 'Oral,
GP'dI 'I jl,�
WikW:; l_...
VIOLATIONS REL 4 TZ:,1 10 30'00 RE` TAi. P,IACW-L's
I Items 23-:
"'todborile Ows., imf Pine+ wal 10-finlo's liq, dwk f",
J'"and in J;, pibming f,t!um% Fwd Code w 1 „ k -4,1R
IJ (100
Item Good Rata,f Practices FC
590.V(f)
hA,n i. -f —,rt P., ...... i Gf' 11 1 b10
rC - 4
2C,
VVatoj
FC- r 1
X6
)Phys tcal Fkl� 11V
2ki.
LPiasonvajs or 1ykw V,:I'wols
-------
FC -7
008'
,29
i S peom JR, kq,a tFr
Xl?
2
Establishment Name:
CITY OF SALEM
ROARn nF HFALTH
Date: ('/i2(t) L Page: d of _
Item
No.
Code
Reference
C - Critical Item
R - Red Item.
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
� PLEASE PRINT CLEARLY! i - � ' � '''
Date+
. Verified
lag��
i.� fJiX U(t a Qi C �� Q,,rA k�/
l (PAA o.A0U I'l a� <o. /
U 1 LG�
�✓ CreC, /1fj *Ad (r✓11 !
ESI
ki 0/I,' Ionil S / Gr1
rn
/n� ^
Al 12,(X_ cXNCx Q' A 1� .+Y -,')m
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 Co5p. I understand that
noncompliance may result in daily fines off twf� e-dollarsssuspension/revocation of
your food permit.
-7--
Corrective Action Required:
❑ No -Yes
❑ Voluntary Compliance ❑ Employee Restriction
Exclusion
Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
p
Violations Refaiad to Foodborne tllness Interventions and Risk
;=actors (Itehrs 1-22) (Cont)
PROTECTION FROM CHEMICALS
14
PHFs Re"ived at Temperawros
Food or Color Additives
"Imuwjk 1 1 r i51 se'
3-202,12
AdUuvcs"
3-5(11.75
3 302.14Protection
from 1hla7aPnr,ed Adddivea°_
1 S
_
Poisonous or Toxic Substances
H!it.UfA; ;)
101.11
Identifying Inform pion - Ort g l nal
�i 1(1;❑L (f n( Ilan' 1.S�i t•� .Jf.
i 1
Com ones.'
_
51'1 16(A)
Rn!,Ye Held at or above 130 "I'=. "�--
witrnn 1 Hoatr�
I i
102,111 -
}-CommonName tiVor6ln (ouninra"--
l
9U.1)0 irH)—
r ?01 II
i StPniruan-Suntgc
02.1 _
lietit iu on -Pr uncc and t c
13.2 it1)d.uJa
j1 7--202.12�(7,011diiik4l.
of Usama
� liuw!t .t�� !t f < &Corot Standing
Toxic f oniamci Prohihriona"
"-204.11
Sannvtiti Crileri chemicals':
�C
hums all, foli W niwv k oolt C medal:
r °01 11
D. its a. u
2U5.11
111 td ❑l ) FAxf cunlac { Ubl IL IId Y` _
iidts l'e atie.C!teutl
:0(1.l?
TIME(TE!IIPERATURE CONTROLS
1C � %1 (, Et L';UOIr ID � d hQP. dlt.reS ftkF
PHFS
6
i=3.11(") (5n merclall Pllt .'z�2IE b1xW
--AOFx -
1C i i(f_t i Remaining l.n. aced Portions of Beef
[S
PHFs Re"ived at Temperawros
Proper Cooling of PHFs
"Imuwjk 1 1 r i51 se'
(
C whi Ctw6 xi P}lFc from I -10'P UI
3-5(11.75
_
(count Methods for PHFll
6
i
3-501.16(B)
tr I F/15 r � d.n }�ll�nl
H!it.UfA; ;)
FouP 1t ia' S: 1 -1.
1
�i 1(1;❑L (f n( Ilan' 1.S�i t•� .Jf.
i 1
Ft TIPS raurze „I I, redlclIt� to J r N't5, P
_
51'1 16(A)
Rn!,Ye Held at or above 130 "I'=. "�--
witrnn 1 Hoatr�
I i
1
l
9U.1)0 irH)—
lin as a Public Heal h Control$ !
Y t m -•c Rtywr nicht
p �
j H hr of rr t q trot }{ t4•r1
13.2 it1)d.uJa
t({I t651 1 <
lC1'?. i `hl
� liuw!t .t�� !t f < &Corot Standing
i=3.11(") (5n merclall Pllt .'z�2IE b1xW
--AOFx -
1C i i(f_t i Remaining l.n. aced Portions of Beef
[S
PHFs Re"ived at Temperawros
Proper Cooling of PHFs
i ' i0l.l YA)
(
C whi Ctw6 xi P}lFc from I -10'P UI
3-5(11.75
_
(count Methods for PHFll
70 1� Wilhi1 a 1four uml From 70"1 '
PHF Hot and Cold Holding
3-501.16(B)
tr I F/15 r � d.n }�ll�nl
f oiiSu
_ _
C i t hn� P}{F til Ids r, ;i,t vl b r,li _.
Plot PHFq Maintained at or above
Ft TIPS raurze „I I, redlclIt� to J r N't5, P
_
51'1 16(A)
Rn!,Ye Held at or above 130 "I'=. "�--
witrnn 1 Hoatr�
19
20
P-51111 14(
PHFs Re"ived at Temperawros
According to Ldv. Cooled to)
41`F/45`PWithin 4Howti z
3-5(11.75
_
(count Methods for PHFll
PHF Hot and Cold Holding
3-501.16(B)
Cold PHF. Nlainutinecl at or below
59O W4(F)
41"/45` F
3-50 i.16i.A)
Plot PHFq Maintained at or above
1401."
_
51'1 16(A)
Rn!,Ye Held at or above 130 "I'=. "�--
Time as a Public Health Control
l
9U.1)0 irH)—
lin as a Public Heal h Control$ !
Y t m -•c Rtywr nicht
REQUIREMENTS FOR HiGHLY SUSCEPTIBLE
POPULATIONS (HSP) -
21 3-XOi IIIA) l:npasteul¢rdPrz pa�7:ugcdJuices.md
3-81)111(1)1 1<_,c" Orl"IlIM1111itctillAn nnil Ce?a3 ar:?
_ Rai d ti ut ^ S'Ia d _
III CIri 1°n tc t'<Ilsvil rs, •,i + ti;:
CONSUMER ADVISORY _
sxurl <'t
SP E C 1 A L R FQL!IR F t,+Fi': TS
i Ili: ri 1 nuhi,r lrxx t tlp r� � x td i
i rl aids nt 1 i ii n l c t- a r t r�i 'K,
1 dr'b1lrr tllid"I 112 r(,S. r'TIXV WNI! 1
i1).
...."t4`
i Items 23-30)
Colwell .old n. trrui;i,:ai<:,,f sus_ lu r,;h do, ora' < a.: ,n t1r
foo(Aonu ill 1 »'s roar-rcentiolo t+»d ri r,atr t�>cr ti.; cr' r.mrt carr br
lcarnc Irl the , t rtu rc se< on c! Ih�Kocd fu<lc �o ' 19� C'd3R
r+0 COr�
Item `Good Retail Practices FC 50.000
23 1
7f fdMn anamn,t ud Per tmrrI _ C 2
FC
;rdola Uc td`A
_ ...
ddatcl PI mbicc.rC J afe
r :n.
..CITY OF SALEM
BOARD OF HEALTH
� J !
Establishment Name: �Y Vl/c (Cs ;i£ G(lc'1 Date: g Page:_ of 411-1
Item
Code
C — Critical Item
` DESCRIPTION OF VIOLATION / PLAN OF CORRECTION '"
Date..
No.
Reference
R —Red Item..
PLEASE PRINT CLEARLY
Verified -
1 ,� ( / e_ - 1 ,f{ qtr ,�
lnG h�w 11�.-C/ I' .Sly �iN c7 I�.7.3! io.J.,- n /V o -,A (00 rN
I
V
titt si,,11 O�
_)1Dc r 3 =7—
_41
_.
. I
4`0 . -, I V[
Com/ AW
aLl
C S S
J
�' ,
�; a I J I — r o ��G �.- ,� = ,e ;. toa �� , .
._ I - - -
ass 1I�1_I ► r
I�,�rle
Uri l�P Srbf �v4� J� (il rLJ d2�r
Discussion With Person in Charge:
Corrective Action Required:
❑ No AlorYes
I haver?ad this report, have had the opportunity to ask questions and agree to correct all
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
violations before the next inspection, to observe all conditions as described, and to
P
F
C]j 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-fi Ne rs or suspension/revocation of
❑ Embargo ❑ Emergency Closure
your food permit. /
❑ Voluntary Disposal 0 Other:
I
'_I
-1
Violations Related to Foodborne illness lnferventictas and Risk
Factors (items 1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
-fi-202
15
—12
3-302,14
I
Fwd or Color Additives
Adchtive.,t`
Pioteebon front Umqtproved Addillves'---
Poisonous or Toxic Substances
Identifying tntormation - Original
ollUtillers,
7-102,11
"3,0111
Ccvernnn Name - "'orkint,
Steal titan - Sit I
1 3-403 1 !(E)
/-202.12
Re,ql-icllop - Pr gencc 'w U,e
Claldiliou:, of Use
I L
7 103 11
!
Toxic Container f1ToIiibTlou,t*
Owmicni.0
1204.11
7-204.12
nizeis. Criteri;i -
San7
f chmticak fns
Ll
7204 14
Driml, AlIcntc. Criteria
--
f --C 2
I ,
V: -xi f,'vnlam
t
-50 1. 16(A)
n1 d 'Ist:
L20
13,to S!aws,
"a
-T
50 1, WA)
403.lilh)
'i I ac.�.nQ iwr Fo st ComfI4 iaid
1 26,
1 !-96,
----------
----- --
Propel 'i,u;aI;
PHF-c
3-.:f01.1 PIfl F i5
T
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS(
SHOiII(B1 Sic (it PaIteut izi,d Lt","
7Z it)
,..St3I 11 (D) It, jtialk
CONSUP,IER ADV;SOPY
3r Ia s11 t, 31
I c r 31it o Iii" t C r It
17
rlli IM, tf—t
It 1
(Iteniq 23,W)
11?1, I*jJ14 (TJ I k Ni, it 1,;T;h dr, :I); ! e �jw .o
fioodh, m I ; lb;osa m, i i i kjwro-,l 1,1ed I,jw,
14(-(')
PRFs Received at TemPauit-ur—es
.According to tau' CwIM to
1 3-403 1 !(E)
" r
41'P/45`F Wilbin 4 How s.
-FoZn g i4e thods for PHFs
I L
I Good Recall pfacttceb
.1 JI
3-501.16(B)
Cold PHF.q Maintained at or bell1m,
Ll
590 004(F)
41145`F
--
f --C 2
-51) 17161 A;
J*a PHF, Ttiaintained at (7,1 ab,,vc
t
-50 1. 16(A)
Ktmsts Held at or above i3O,"F,
—Timeas —[IhContrW
L20
a Pub—tic Hoa
-T
50 1, WA)
403.lilh)
Nlikrm, .lvc- In V2 t"Illm" sl indin"
T
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS(
SHOiII(B1 Sic (it PaIteut izi,d Lt","
7Z it)
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CONSUP,IER ADV;SOPY
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REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
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0(tiff -- ---- --- ---
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street, 4th Floor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 03/29/2010
1*2ILI$1341,y11u1Dieu der.13Ian
File Number: BHF -2004-000333
Walyo's Variety Inc.
20 Essex Street
Salem MA 01970
LOCATED AT: 0020 ESSEX STREET
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
RETAIL FOOD BHP -2010-0200 Jan 4, 2010 Dec 31, 2010 $280.00
TOBACCO VENDOR BHP -2010-0208 Jan 4, 2010 Dec 31, 2010 $135.00
17D31110118*49111*1
Total Fees: $415.00
2010
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1
DAVID GREENBAUM,
ACTING HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4" FLOOR
2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT l
NAME OF ESTABLISHMENT WOLgDs VftPifly IMC• TEL# q��-7gq-066
ADDRESS OF ESTABLISHMENT J 0 SS PDC -s`CQi 19-�% FAX #
MAILING ADDRESS (if different)
EMAIL - Business':
OWNER'S NAME
ADDRESS C�2 0
STREET
SSEx 57291E%
Website:
TEL# `-'76^74C 6719
A 14-9 K -- 01 q76
STATE
CERTIFIED FOOD MANAGER'S NAME(S) MIA CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON HOME TEL #
ZIP
TYPE OF ESTABLISHMENTFEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. _ 280
more than I0,000sq.ft.
RESTAURANT 1
(Outdoor Stationary Food Cart $210)
BED/BREAKFAST/ YES
less than 25 seats =$140
25-99 seats =$280
more than 99 seats =$420
$100
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YEQNO $25
TOBACCO VENDOR CYEcDl O 135
ALL NON-PROFIT (such as church kitchens) S 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 t o-es-regoir d under the law.
-� --- 12•a-7-gtrDT 03U -4a- 673,�-r
Date
or
----------------- ----------------------n— — ---------------------
Revised 424/07 FOODAP2008.adm Check# & Date 7i� 12 - I S - b"1 $ -S. 66
l C�
(978);741 1800!:,
F-�x.(978),,745t0343,+r
_ ..
DGREEibAUMR
S, LJ CONI.,
2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT l
NAME OF ESTABLISHMENT WOLgDs VftPifly IMC• TEL# q��-7gq-066
ADDRESS OF ESTABLISHMENT J 0 SS PDC -s`CQi 19-�% FAX #
MAILING ADDRESS (if different)
EMAIL - Business':
OWNER'S NAME
ADDRESS C�2 0
STREET
SSEx 57291E%
Website:
TEL# `-'76^74C 6719
A 14-9 K -- 01 q76
STATE
CERTIFIED FOOD MANAGER'S NAME(S) MIA CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON HOME TEL #
ZIP
TYPE OF ESTABLISHMENTFEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. _ 280
more than I0,000sq.ft.
RESTAURANT 1
(Outdoor Stationary Food Cart $210)
BED/BREAKFAST/ YES
less than 25 seats =$140
25-99 seats =$280
more than 99 seats =$420
$100
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YEQNO $25
TOBACCO VENDOR CYEcDl O 135
ALL NON-PROFIT (such as church kitchens) S 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 t o-es-regoir d under the law.
-� --- 12•a-7-gtrDT 03U -4a- 673,�-r
Date
or
----------------- ----------------------n— — ---------------------
Revised 424/07 FOODAP2008.adm Check# & Date 7i� 12 - I S - b"1 $ -S. 66
l C�
gar VOYl
�fi b 7NK' 89.60
1o,(- iftY_
i
STATEMENTare
,, �/
E� ¢ ar
70
\r1�plh7 S Po k'
qALYoS
W
nPEES LyO i�Qo( �A{Fi11 -.
(j!Q.=n
w �CCWni whin
t- n,.�, \
r_
L4 i
o cam. Q
OCl
s.r+wsau
Commonwealth of Massachusetts
City of Salem
Board of Health
120 Washington Street, 4th Floor
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/23/2008
ESTABLISHMENT NAME:
File Number: BHF -2004-000333
LOCATED AT:
IGmberley Driscoll
Mayor
Walyo's Variety Inc.
20 Essex Street
Salem MA 01970
0020 ESSEX STREET
SALEM, MA 01970
Permit Type
Permit No.
Permit Issued
Permit Expires
Fee Restrictions / Notes
RETAIL FOOD
BHP -2009-0210
Dec 23, 2008
Dec 31, 2009
$280.00
TOBACCO VENDOR
BHP -2009-0211
Dec 23, 2008
Dec 31, 2009
$135.00
PERMIT EXPIRES
Total Fees: $415.00
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
ICIIVIBERLEY DRISCOLL
MAYOR
JANET DIONNE,
ACTING HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4"r FLOOR
TEL. (978) 741-1800
FAX (978) 745-0343
IDIONNF SALFM. COM
2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT W 4 L-1 G TEL # (Im2 � qcl-O6O
ADDRESS OF ESTABLISHMENT o20 F.SS'G-c FAX#
MAILING ADDRESS (if different)
EMAIL - Business':
OWNER'S
Website:
TEL #(ry? V 7 Ll /-- O:p 1
ADDRESS c2D FSSi)( S,gb&tq VL7i-O.
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) NAiq CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON A L k -A M 14-1)4-N HOME TEL # '1 -?4_- 7 -LI �_- 07' 1
DAYS OF OPERATION: 'a Monda-'i-'i: n^-Tstla , ' 'Wednesd Thursda :'>
' ' rFrida
Saturday, " Sunda
HOURS OF OPERATION x,30/)f-47.3DAm 7,.3oA&l'}-36AN
V.3o Ad41
i �•3oAtj';x•30s}M1
Please write in time of day. !
For
For example Ilam -11 pm) 101 00 effi; (c --3O F" 10PM10 •ts-c ISM
10-16019"
Id, on GM °I.3D ft-
OF ESTABLISHMENT
RETAIL STORE YES
(Outdoor Stationary Food Cart $210)
FEE (check only)
NO less than 1000sq.ft. =$ 70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
less than 25 seats =$140
25-99 seats =$280
more than 99 seats =$420
BED/BREAKFAST/ YES v $100
CHILDCARE SERVICES
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y No $25
TOBACCO VENDOR ES NO $135
ALL NON-PROFIT (such as church kitchens) O $25
'Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns and paid all state taxes required under the law.
�90 ,, of- Social Security,or Federal Identification Number
Revised 424/07 FOODAP2008.adm Check#&Date -)ryAO. U Lf I C 6p $
COURT DOCKET NO CITATION NO.
CITY SALEM P®6 4 3-
VIOLATION NOTICE
NgME,(LA,S�T,,,F%PST, IN L)
IYl ail / v�R,v � vue
�EETA ESS CIT //T�O�WN (� SyTAAT,,E ^� [Z�IPP
70
LICENSE NO. D i DATE
DATE OF BIRTH
O R'S NAME (LAST, FI
ct► 42e+
STREETgD09ES5 —CITS�I 3 QYWm STATE
7YIv fi V f l �o
REGISTRATION NO.
STATE
EXP. DATE
MAKERYPE
YEAR
COLOR
DSA%TEJ((,0FF+VI/QL�ATION
,J -!o,
TIME_ETA
❑ PM
q,A7T/FjCRATI NWRaITTEN nER goenL
/ 7 ��p YES
NO
LOCATION F VIOLATION ENFORCING
W s}• Sa(.2m
DEPT.
OFF SE yCHAP.
A Q�} door-
SECT.
FINES
a
oat
a
c
OF/F1I"Rc I.D. NO.
c- Sa1a1? ctYla;L
TOTAL
FINE.
DUE'
$ aG
v
vrri ,mm �Lm I bits ULWY GIVEN TO VIOLATOR
f/11�75/J ❑ IN HAND
0 BY MAIL
DO NOT MAIL CASH - PAY ONLY BY POSTAL NOTE, MONEY
ORDER OR BY CHECK MADE PAYABLE TO:
CITY CLERK
CITY HALL
93 WASHINGTON STREET
SALEM, MA 01970
TEL. (508) 765.9595 X 251
1 HEREBY ELECT TO -EXERCISE THE FIRST OPTION AS STATED ON
REVERSE, CONFESS TO THE OFFENSE CHARGED, AND ENCLOSE .
PAYMENT IN THE AMOUNT OF
$ CASE #
SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL
•—COURT DOCKET NO. CITATION NO.
SCITY SALEM PD6438
VIOLATION NOTICE
NAME (LAST, FIRST,
fWINIITrT��L���)� �
avos
Tn
fq\Od ee
BaIDDRESS CITYrTOWN STATE ZIP
coA .x at, SD(kvn mh of r7
LICENSE NO.
LIC. EXP. DATE
DATE OF BIRTH
OWNERNAME (LAST. FIRS INITIAL)
FIRS
p YY//
STREET ADD$ t SCcl L.e m STATE
REGISTRATION NN•OO..'Il
STATE
EXP. DATE
MAKE/TYPE
YEAR
COLOR
DATE F VIOLATION
? ,5106
TIME
�+
DATE CITATION WRITTEN
? a3 ��
/
PERSONAL
IwuRONO
❑PM
LOCATION OF VIOLATION ENFORCING
9.0 Csx •, Sa Ce m
DEPT.
OFFENSE ,,,
A "fC)Y)+ C100r-lb I' �r.tul (ShIna,
CHAP.
l
SECT.
FINES
'rl 41
PDS' al
c
OFFICZRCC,�..,,,, / A� I.D. NO.
�.✓✓+fCtn L1l FINE
TOTAL
@ i
p LR�
OFFICER CERTIFIES COPY GIVEN TO VIOLATOR
❑ IN HAND
X ❑ BY MAIL
DO -NOT MAIL CASH - PAY ONLY BY POSTAL NOTE, MONEY
ORDER OR BY CHECK MADE PAYABLE TO:
CITY CLERK
CITY HALL
93 WASHINGTON STREET
SALEM, MA 01970
TEL. (508) 745-9595 X 251
1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON
REVERSE, CONFESS TO THE OFFENSE CHARGED, AND ENCLOSE
PAYMENT IN THE AMOUNT OF
$ CASE #
SEE OTHER SIDE FOR FURTHER INFORMATION
ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL
0020 Essex Street
Telephone:
744-8960
Owner:
Pradeep Madan
PIC:
Pradeep Madan
Inspector:
Elizabeth Salandrea
Date Inspected: Correct By:
7/23/2008
Risk Level:
Permit Number:
BHP -2008-0068
Status:
SIGNED OFF
# of Critical Violations:
0
Time IN:
Time OUT:
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Walyo's Variety Inc.
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Physical Facility FAIL Non -Critical BLUE
Comment: Floor of the walk-in fridge in disrepair. Floor must be repaired. This to be completed by next routine inspection.
All other violations noted in the 7/15/08 inspection report have been corrected.
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts
( Rev. Jul 24,2008 ) Page 1 oft
M
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® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 24,2008 ) Page 2 oft
f`
0020 Essex Street
Telephone:
744-8960
Owner:
Pradeep Madan
PIC:
Pradeep Madan
Inspector:
Elizabeth Salandrea
Date Inspected: Correct By:
7/15/2008
Risk Level:
Permit Number:
BHP -2008-0068
Status:
Open
# 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)
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Walyo's Variety Inc.
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection FAIL Critical BLUE
�mment: The following were removed from the shelves, outdated;
21 sierra mist
7 sobe adrenaline rush
6 propel water
6 miracle whip
1 hawaiian punch
1 mountain dew
1 diet Pepsi
1 schweppes ginger ale
1 aunt jemima syrup
Ow er to closely monitor all expiration dates.
Ow
price labels obscuring expiration dates. Do not cover expiration dates with price labels.
Equipment and Utensils FAIL Non -Critical BLUE
t�omment: Mop stored in the bucket. Store mop hanging to air dry.
ack coke fridge needs general cleaning along bottom and in door tracks.
ZIP110"or of the wine fridge is in disrepair. Repair or replace the floor of this fridge.
X._-edoor Pepsi fridge needs thorough cleaning along bottom and in door tracks.
psi gatorade fridge needs general cleaning including door tracks.
c�e cream freezer needs general cleaning and de-icing.
[�Smmall coke fridge needs general cleaning.
Ktig t -hand side of frozen foods freezer needs de-icing, and whole unit needs general cleaning.
Some items on bottom shelves have a considerable accumulation of dust. Dust bottom shelves and items.
Physical Facility FAIL Non -Critical BLUE
Comment: Floor of the walk-in fridge in disreoair. Floor must be reoaired. r-,L.t�" K.0 -
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800
GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts
( Rev. Jul 15,2008 ) Page I,of2
RED: - - -'^- -- - -
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
Item
Status Violation Critical Urgency
Povide new doorsweep for front door; gaps were observed. at bottom of door.
sorront door was propped open at inspector's arrival. $25 fiine will be issued; future repeat violations of this nature will be subject to
fines. Door must remain closed at all times.
Reinspection in one week, all violations to be corrected.
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMSO 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts
( Rev. Jul 15,2008 ) Page 2 oft
'w° �aa.'.;.,....ex
Commonwealth of Missachusetts T
.� f 4 » 'ys
- .�ti City of Salem c
Board of Health lGmbetley Driscoll
120 Washington street, 4th Floor_ Mayor
SALEM, MA 01970 -
Food/Retail Establishment Permit
DATE PRINTED: 01/03/2008 -
ESTABLISHMENT NAME: _
File Number: BHF -2004-000333
Walyo's Variety Inc.
20 Essex Street
Salem MA. 01970 .
LOCATED AT: 0020 ESSEX STREET'
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes
RETAIL FOOD BHP -2008-0068 Jau 3; 2008 - Dec 31, 2008 $280.00
TOBACCO VENDOR BHP -2008-0106 Jan 3, 2008 Dec 31, 2008 $135.00
Total Fees: $415.00
I
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 41 of 46
0
QTY OF SALEM, MASSAQHUSEM
aS, . Ira BOARD OF HEALTH
9epy 120 WASHINGTON STREET, 4" FLOOR
TSL. (978) 741-1800
KIMBERLE,�,Y DRISCOLL FAX (978) 745-0343
MNYOR \ ISOOTraSALEM. COM
NOV 2 710p
SCOTT, CI Vy O_
HES AG NT 130gRo OF N1LE1W
2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT WL
%S VI`-POxl I IVC • TEL # q�6 ' 7 t �(— 9-W6
ADDRESS OF ESTABLISHMENT o�2b FAX # Ct&_& 6-7-19
MAILING ADDRESS (if different)
EMAIL - Business':
OWNER'S
ADDRESS
Website:
TEL# 7C)�-- SUS --o3/%
b Esser .S4tp_$4— WItlSS— b 19 0 .
SIAIL
LIF
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON l� L K, I IM ACD --N HOME TEL # 1q� 9— _74C—PIC/
HOURS OF OPERATION �$o• levo:
Please in time day. 3p. JD. LO 30. jo,ce
-+3b to�b 3D • 16 do
x,36 to t3D $.3b. q•3o
write of
(For example 11 am -11 pm) AW Pm �U PP( 1}IM Pitt
Ahn PIM kV(U — P�
9a- lM P� '. ` WW1
TYPE OF ESTABLISHMENT
FEE (check only)
RETAIL STORE YE NO
less than 1 000s.ff.
OO
=$ 70
_$280
- --
more than 10,Uuusq.ft.
420
-4
- .........----.....-------------------------------le
---25- ---se..------------
- - - ---------------------------
RESTAURANT NO
a...ts
s--s---th- an
=- $1----0-....
!Outdoor Stationary Food Cart $210)
25-99 seats
=$280
more than 99 seats
=$420
- - ...----------------------------------------------
---------------- -
BED/BREAKFAST/ YES NO
$100
CHILDCARE SERVICES,_.,
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE
TOBACCO VENDOR
YE4 NO
YES O
$25
b
ALL NON-PROFIT (such as church kitchens)
YES NO
$25
`Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax
returns and paid all state taxes required under the law.
Dq3- S7_03cpb
Date n- c) S , 02 bi�-_l . Social Security or Federal Identification Number
Revised 4/24/07 FOODAP2008.adm Check# & Date
f
0020 Essex Street
Telenhone:
744-8960
Owner:
Pradeep Madan
PIC:
Pradeep Madan
Inspector:
David Greenbaum
Date Inspected: Correct By:
5122/2007
Risk Level:
Permit Number:
BHP -2007-0019
Status:
SIGNED OFF
# of Critical Violations:
0
Time IN:
Time OUT:
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Walyo's Variety Inc.
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Physical Facility
FAIL
Comment: The flooring in the walk in is in disrepair. Repair flooring and replace all damaged floor tiles.
This violation to be corrected by the next routine inspection.
GENERAL COMMENTS:
All other violations cited in the 5/14/07 inspection report have been corrected.
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. May 29,2007) Page I of
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
Item
Status Violation Critical Urgency
Y1 'j",
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 29,2007 ) Page 2 oft
0020 Essex Street
Telephone:
744-8960
Owner:
•I J
=r
PIC:
Pradeep Madan
Inspector:
David Greenbaum
Date Inspected: Correct By:
5/14/2007
Risk Level:
Permit Number:
BHP -2007-0019
Status:
PARTIAL COMPLY
# 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)
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item Status Violation
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection FAIL Critical
Walyo's Variety Inc.
Critical Urgency
:AvJq
Comment: There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price
labels.
The following items found outdated:
25 - Sunflower seeds
10 - Pop tarts
8 - Stove top stuffing
Owner must closely monitor all expiration dates.
Equipment and Utensils FAIL Non -Critical BLUE
Comment: The mop found stored in the bucket. Clean mop and store upside down not touching any surface to air dry.
The True Pepsi reachin needs a thorough cleaning.
The Beverage air Pepsi reach in needs a thorough cleaning.
The True Coke reach in in back needs a thorough cleaning.
The wall freezer needs a thorough cleaning.
The Coldin reach in has an accumulation of food spills. Thoroughly clean this unit including all racks and fan covers.
All shelves have an accumulation of dust. Thoroughly clean and dust all shelves.
Physical Facility FAIL BLUE
Comment: The front door found open. All openings to the exterior must be sealed.
Future violations of this nature will be subject to a monetary fine of $25.00.
The flooring in the wall in is in disrepair. Repair flooring and replace all damaged floor tiles.
GENERAL COMMENTS:
Reinspection in one week, all violations to be corrected.
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 14,2007 ) Page 1 oft
Item
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
Status Violation Critical Urgency
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 14,2007) Page 2 oft
CITY OF SALEM, MASSACHUSETTS
o : BOARD OF HEALTH RECEIVE®
= 120 WASHINGTON STREET, 4TH FLOOR 1d"
SALEM, MA 01970 DEC - 4 2006
TEL. 978-741-1800
FAx 978-745-0343 CITY OF SALEM
WWW.SALEM.COM BOARD OF HEALTH
Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO
Mayor HEALTH AGENT
2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT W 614YOS ll)�RibT 7 1 R16. TEL # qjt _7wr- g- 6a
ADDRESS OF ESTABLISHMENTS_C' �' �GTo FAX #
MAILING ADDRESS (if different)
EMAIL -- Business':
OWNER'S
ADDRESS
Owner's:
TEL# R7E70tP X60 ,
- VAA-SS-
CERTIFIED FOOD MANAGER'S NAME(S) Nkz� CERTIFICATE#(S)
LIP
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON A LK ill M A9_79) ArK HOME TEL # —SUS -O �q
TYPE OF ESTABLIS T
RETAIL STORE YES NO
RESTAURANT
BED/BREAKFAST
--------- -------------
YES NO
YES NO
--...---- --------------- ----------- ---- --- - - .......
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE
TOBACCO VENDOR
ALL NON-PROFIT (such as church kitchens)
FEE (check only)
less than 1000sq.ft.
=$ 50
1000-10,000sq.ft.
- 100
more than I0,000sq-ft.
=$250
less than 25 seats
=$100
25-99 seats
=$150
more than 99 seats
=$200
$100
0Y NO $5
ES NO $50
Y S 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 retu snq paid all state taxes required under the law.
Signature Date Social Security or Federal Identification Number
---------------------------------------------
Revised 11/13/06 FOO DAP 2007.adm "Check# 8 Date1I.
r s - 4 �„-a.uwwuuncunu va i�aaaauwuacau r,s r „ r ,ay- '•y
� k i iy� �� � T dl
'+� w
Ci of Salem
.+'♦ s*t4 +a *3-L 3^ �tyjY k 6 ri `a. 'i>�, v <. '�'i�,i �r 'I 113ry t't°7 4\,.a
Board of Health .f S�t.:.�mbetiey Dnsooll "
4 a w120 Washington StreetAth Floor.a ° *MeyOr+
SALEM, MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 12/19/2006
ESTABLISHMENT NAME:
File Number: BHF -2004-000333
LOCATED AT:
Walyo's Variety Inc.
20 Essex Street
Salem MA 01970
0020 ESSEX STREET
SALEM, MA 01970
Permit Type
Permit No.
Permit Issued
Permit Expires
Fee Restrictions / Notes
RETAIL FOOD
BHP -2007-0019
Dec 19, 2006
Dec 31, 2007
$100.00
TOBACCO VENDOR
6HP-2007-0040
Dec 19, 2006
Dec 31, 2007
$50.00
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 25 of 29
0020 Essex Street
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Item Status Violation
Walyo's Variety Inc.
Critical Urgency
Telephone: PROTECTION FROM CONTAMINATION
744-8960 Handwash Facilities FAIL Critical RED
Owner: Comment: The handwash sink found obstructed. Keep handwash sinks clear and accessible at all times.
Pradeep Madan Violations Related to Good Retail Practices (Blue Items)
PIC: Food and Food Protection FAIL Critical BLUE
Inspector:
David Greenbaum
Date Inspected: Correct By:
6/26/2006
Risk Level:
Permit Number:
BHP -2006-0278
Status:
PARTIAL COMPLY_
# 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)
Comment: There are price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels.
The following items found outdated:
16 - Rice-a-roni
7 - Jelly
2 - Tartar sauce
2 - Miracle whip
8 - Jiffy pop
10 - Oscar Meyer ham
8 - Hot dogs.
Closely monitor all expiration dates to insure no expired product is out for sale.
Equipment and Utensils FAIL Non -Critical BLUE
Comment: The Pepsi cooling unit in front needs a visible, accurate thermometer.
The mop stored in mop bucket. Rinse mop and store upside down not touching any surface to air dry,
Physical Facility FAIL Non -Critical BLUE
Comment: There are many broken/damaged floor tiles throughout the establishment. Replace all broken/damaged floor tiles.
GENERAL COMMENTS:
675:Owner to notify the Board of Health within one week that all violations have been corrected.
City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800
GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2006 ) Page 1 oft
,,0'
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® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2006 ) Page 2 oft
0
ok
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 -2004-0333
Walyo's Variety Inc.
20 Essex Street
Salem MA 01970
LOCATED AT: 0020 ESSEX STREET
SALEM, MA 01970
Permit Type
Permit No.
Permit Issued
Permit Expires
Fee Restrictions / Notes
RETAIL FOOD
BHP -2006-0278
Jan 3, 2006
Dec 31, 2006
$100.00
TOBACCO VENDOR
BHP -2006-0279
Jan 3, 2006
Dec 31, 2006
$50.00
PERMIT EXPIRES
Total Fees: $150.00
31,2006
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all
plans for such must be submitted to and approved by the Salem Board of Health. Page 5 o111
CITY OF SALEM, MASSACHUSETTS o
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOORi
SALEM MA 01970
a
TEL 978-741-1800 �sw ,
JLE4Y,J.-,Usovlczi JR T s� r `'trJ{'�'�+�t(ptjt'FAXr97$,y,74�,0343rya 4ks.tu us ,� L� C./ry � a��;. Oj�+i�a
.JOANNE SCOTT, MPH, RS, CHO 9�OFy/ �C�FA'1
HEALTH AGENT viI Ti .
2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT W prL qo S V WP 1PY IN(iEL # -t 4-p —3"uli —"Y o
ADDRESS OF ESTABLISHMENT 20 `t✓oC S't ►2� � �4 54 L I
MAILING ADDRESS (if different)
OWNER'S NAME - RkQ 9:-f P M fi::: 4-N TEL#
ADDRESS 2 D E Sstx
CITY Wl STATE MM7 � S ZIP VIE
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICA
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON
A L K 'f}
1'gADO-N HOME TEL #
HOU RS0FOPERATION:Mona%36Tue.a3(,Wed.A3t-
Thu. 3o Fri. ?-3cSat.-43v Sun. --3 ANI
q30
�
ct.3b
C1 '960 t°M
TYPE OF ESTABLISHM FEE (check only)
LRETAIL_STORE less than 1000
ES NO J / mac/ 1000 10 000sgsftt.ft =$100
more than 10,000sq.ft.
------------------------------------------------ —---------------------------------------------------------------------------------------------------------
RESTAURANT YES
BED/BREAKFAST YES
less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGU SOFT SERVE NO $5
[TOBACCO VENDORS �jD� O YE NO $50
ALL NON-PROFIT (such as church kitchens) YES NO $25
*Please pay total with one check payable to the City of Salem .
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted
in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes
are made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best
knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
.2q.28o!�-
Signature Date Social Security or Federal Identification Number
--------------------------------------------------------------------------------y---------------------------------- --
Revised 11/03/05 FOODAP2.adm Check#&Date Rn 0
5
-A J60
0020 Essex Street
HACCP: ❑
Telephone:
744-8960
Owner:
Pradeep Madan
PIC:
Pradeep Madan
Inspector.
David Greenbaum
Date Inspected: Correct By:
9/1/2005
Risk Level:
Permit Number:
BHP72005-0246
Status:
SIGNED OFF
# of Critical Violations:
Time IN Time OUT.
a
Wa/yo's Variety Inc.
City of Salem
RETAIL FOOD - Food Establishment Inspection
Item Status Violation Critical Urgency Nature of problem or correction
Non-compliance with: Not Done
Anti -Choking PASS ❑
Tobacco PASS ❑
FOOD PROTECTION MANAGEMENT Not Done
PIC Assigned / Knowledgeable / Duties PASS - 0 RED
EMPLOYEE HEALTH Not Done
Reporting of Diseases by Food Employee and PIC PASS V RED
Personnel with Infections Restricted/Excluded PASS ❑d RED
FOOD FROM APPROVED SOURCE
Not Done
Food and Water from Approved Source
PASS
Receiving/Condition
PASS
Tags/Records/Accuracy of Ingredient Statements
PASS
Conformance with Approved Procedures/HACCP
PASS
Plans
PROTECTION FROM CONTAMINATION
Not Done
Separation/ Segregation/ Protection
PASS
Food Contact Surfaces Cleanin and Sanitizin
PASS
Notes. 9 9
264: s Proper Adequate Handwashing PASS
Urgency Description(s): Good Hygienic Practices PASS
BLUE:' v- Prevention of Contamination from Hands PASS
Violations Related to Good "
Retail Practices (Critical= _. Handwash Facilities PASS
violations must be corrected
immediately or within 10,
days)(Non-critical violations
GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc.
0
0
0
RED
RED
RED
RED
RED
RED
RED
RED
RED
RED
( Rev. Sep 01,2005 )
Page 1 of
0020 Essex Street
Not Done
❑
BLUE
Walyo's Variety Inc.
must be corrected immediately
PROTECTION FROM CHEMICALS
Not Done
RED
There are many missing/broken Floor tiles.
or within 90 days)
Approved Food or Color Additives
PASSd❑
RED
RED:
Violations Related to
Toxic chemicals
PASS
d❑
RED
Foodborne Illness Interventions
TIME/TEMPERATURE CONTROLS (Potentially Haz
Not Done
completed by the nexyt routine inspection.
and Risk Factors (Require
Cooking Temperatures
PASS
❑Q
RED
immediate corrective action)
PASS
❑
BLUE
wall. Owner has hired a contractor to
Equipment and Utensils
Reheating
PASS
❑d
RED
Cooling
PASS
RED
Poisonous or Toxic Materials
Hot and Cold Holding
PASS
[]
RED
Special Requirements
Time As a Public Health Control
PASS
BLUE
RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO
Not Done
❑
BLUE
Food and Food Preparation for HSP
PASS
❑
RED
There are many missing/broken Floor tiles.
CONSUMER ADVISORY
Not Done
Owner has a hired a contractor to replace
Posting of Consumer Advisories
PASS
RED
missing/broken floor tiles. This must be
Violations Related to Good Retail Practices (Blue
Not Done
completed by the nexyt routine inspection.
Management and Personnel
PASS
❑
BLUE
There is a large open space in the back
Food and Food Protection
PASS
❑
BLUE
wall. Owner has hired a contractor to
Equipment and Utensils
FAIL Non -Critical
❑
BLUE
The reach in freezer has an accumulation
food debris and grime. Thoroughly clean
Poisonous or Toxic Materials
PASS
❑
BLUE
unit.
Water, Plumbing and Waste
PASS
❑
BLUE
Physical Facility
FAIL
❑
BLUE
There are many missing/broken Floor tiles.
Owner has a hired a contractor to replace
missing/broken floor tiles. This must be
completed by the nexyt routine inspection.
There is a large open space in the back
wall. Owner has hired a contractor to
actress this violation. This must be
corrected by the next routine inspection.
Poisonous or Toxic Materials
PASS
❑
BLUE
Special Requirements
PASS
❑
BLUE
Other- See Notes
PASS
❑
BLUE
All other violations cited in 8/24/05
inspection report have been corrected.
GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc.
( Rev. Sep 01,2005) Page 2 of
0020 Essex Street
Walyo's Variety Inc.
GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 01,2005) Page 3 of
0020 ,8ssex Street
City of Salem
RETAIL FOOD - Food Establishment Inspection
HACCP: ❑
Walyo's Variety Inc.
Telephone:
Item
Status Violation
Critical
Urgency Nature of problem or correction
Non-compliance with:
Not Done
744-6960
Owner:
Anti -Choking
N/A
❑
Pradeep Madan
Tobacco
PASS
❑
PIC:
FOOD PROTECTION MANAGEMENT
Not Done
Abhl Madan
PIC Assigned / Knowledgeable / Duties
PASS
Q
RED
Inspector.
EMPLOYEE HEALTH
Not Done
David Greenbaum"
Date Inspected:
Correct By:
Reporting of Diseases by Food Employee and PIC
PASS
❑d
RED
6/24/2005
`
Personnel with Infections Restricted/Excluded
PASS
❑d
RED
Risk Level:
FOOD FROM APPROVED SOURCE
Not Done
Food and Water from Approved Source
PASS
❑d
RED
Permit Number: ;.
BHP -2005-0246
Receiving/Condition
Tags/Records/Accuracy of Ingredient Statements
PASSd❑
PASSd❑
RED
RED
Status: ` -
VIOLATION -
Conformance with Approved Procedures/HACCP
Plans
PASS
RED
# of Critical Violations:
't
PROTECTION FROM CONTAMINATION
Not Done
Time IN:..
Time OUT.
Separation/ Segregation/ Protection
Food Contact Surfaces Cleaning and Sanitizing
PASS
N/A
❑
RED
RED
Notes:,
252.Relnspectlon lnTWeek.
Proper Adequate Handwashing
PASS
RED
Urgency Description(s):
BLUE: .. _ - I -
Violations Related t0 Good
Good Hygienic Practices
Prevention of Contamination from Hands
PASS
PASS
❑Q
❑d
RED
RED
Retail Practices (Critical:=$,t
Handwash Facilities
FAIL Critical
❑d
RED T e handwash sink outside the bathroom
violations must be corrected
ound obstructed. Handwas sinks must be
immediately or within ,10> -,
kept clear and accessible at all times.
days)(Non-critical violations
GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc.
( Rev. Aug 24,2005) Paee I of
0020 Essex Street
must be corrected immedia
or within 90 days) y
RED:
Walyo's Variety Inc.
PROTECTION FROM CHEMICALS Not Done
_ Approved Food or Color Additives PASS ❑J RED
✓solations Related to
=oodborne Illness Interventions
and Risk Factors (Require
mmediate corrective action)
Toxic Chemicals
PASS
0 RED
TIMEITEMPERATURE CONTROLS (Potentially Haz Not Done
Cooking Temperatures NIA 0 RED
Reheating
N/A
0
RED
Cooling
N/A
Posting of Consumer Advisories
RED
Hot and Cold Holding
PASS
RED
Time As a Public Health Control
PASS
RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO
Not Done
Food and Food Preparation for HSP
N/A SO] RED
CONSUMER ADVISORY
Not Done
Posting of Consumer Advisories
N/A 0 RED
GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 24,2005) Poke 2 of
0020 Essex Street
Walyp's Variety Inc.
Violations Related to Good Retail Practices (Blue
Not Done
Management and Personnel
PASS
❑
BLUE
Food and Food Protection
FAIL Critical
❑
BLUE
Ther are many items that have price
,,/many
over the expiration/sell by dates. Do
of obscure any expiration/sell by dates
with price labels.
_
20 itergs found outdated. Owner must
cl y m or all expiration dates to
sure epired product is sold.
Equipment and Utensils
FAIL Non -Critical
❑
BLUE
The ns in the milk cooler have an
umulation of dust and grime.
horoughly clean fans.
The reach in freezer has an accumulation
of dirt and grime on the bottom shelf.
Thoroughly clean unit.
The s and ceiling in the walkin have an
ccumulation of dust. Thoroughly clean
the waj and ceiling.
The Iving throughout the establishment
s an accumulation of dust. Thoroughly
clean all shelving and product.
Water, Plumbing and Waste
PASS
❑
BLUE
Physical Facility
FAIL Non -Critical
❑
BLUE
—There is an open space in the back wall
that is unfinished. Opening must be
finished to make all floors, walls and
ceilings impervious.
There are many broken/missing floor tiles
throughout the establishment. Repair or
replace all missing/broken floor tiles.
Poisonous or Toxic Materials
PASS
❑
BLUE
Special Requirements
PASS
❑
BLUE
Other- See Notes
PASS -
❑
BLUE
GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 24,2005 ) Page 3 of
STANLEY J. USOVICZ, JR.
MAYOR
ti ry
CITY OF SALEM9 MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR ..
SALEM, MA 01970
TEL. 978-741.1800
FAX 978-745.0343
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment:. RETAIL FOOD
Name of Establishment: Walyo's Variety Inc.
Address of Establishment: 20 Essex Street
Owner's Name: Pradeep Madan
Restrictions:
Application Date: 12/3/2004
Permit for Food Establishment 152-05
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products 37-05
These Permits Expire December 31, 2005
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
CITY OF SALEM, MASSACHUS ll 1!O
�n BOARD OF HEALTH ��ll
$
120 WASHINGTON STREET, 4TH FLOOR NOV 3 0 2004
a SALEM, MA 01970
°guy TEL. 978-741-1800 CITY OF SALEM
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH
MAYOR HEALTH AGENT
2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
r . r /� ( -7 ��y
NAME OF ESTABLISHMENT (J &1OS /\11W 16TY INC. TEL # � g -2.70q- zs`160 .
ADDRESS OF ESTABLISHMENT (�-b ESS'20c -57Q�7_-g r
MAILING ADDRESS (if different) <, ALF_ W- VY11iS$ D 1EN ,
OWNER'S NAME IqA--PA-N s —TEL #- ���r���{f LI'� q66
CITY
STA
ZIP
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON e7a I ' CBd,G t, HOME TEL #
'7 30-10 ' 30,10 30-10 - 30.10-7-36,10 '-345 To9.�°
HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun.
TYPE OF ESTABLISHM FEE check only
RETAIL STORE E r NO^ 4
less than `5 • , ���� a
w i ?4i5A&'
>k�<y ,'i:s�d��T'J.:�t yf >t �' t5 ,s• ,taW �• ��'%In°�' *`s � rWI �,� '!1 �t�" w 4 "� I�.���M1G bsY1T,000-'0:000s0morea q ft at,=� 100 r r„ x • )�..�' .� ,,,
OOOsq.ft. -$250
1`
RESTAURANT YES NO
BED/BREAKFAST YES NO
less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
$100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR 3 ,,n5 NO 50
ALL NON-PROFIT (such as church kitchens) YE3 NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Signature ,Date foSfor Federal Idrem f�ica�tioSn
Number�-ff2�
-Z_ �
Revised 11/03/03 FOODAP2.adm Check# & Date f, 1�Y tl� Z�2.
0% -
T
STANLEY J. USOVICZ, JR.
MAYOR
CITY OF SALEM9 MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: RETAIL FOOD
Name of Establishment: Walyo's Variety Inc.
Address of Establishment: 20 Essex Street
Owner's Name: Pradeep Madan
Restrictions:
Application Date: 12/2/2003
Permit for Food Establishment 75-04
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products 17-04
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 AGEN" T
r
CITY OF SALEM, MASSACHUSETT�III,,,,�����1,jjjyyy
BOARD OF HEALTH
i 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 NOV 19 2003
TEL. 978-741-1800 rdi 1 Y OF SALEM
FAx 978-745-0343
STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH
MAYOR HEALTH AGENT
2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
r
NAME OF ESTABLISHMENT W OLY OS VAR IPTY I NC TEL#
ADDRESS OF ESTABLISHMENT S ptr 41 ^ I q7
MAILING ADDRESS (if M different)
OWNER'S NAME ,-akpge>' I ,+,,Dh--N TEL
ADDRESS 2 D
CITY <,
CERTIFIED FOOD MANAGER'S
<-rQ�Ei r,
ZIP DI Cl -/�D
CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.) p
EMERGENCY RESPONSE PERSON HOME TEL # 9 7l'I J —0;19
`330.430 �3o-1?30 a3536 i?0R3-o
HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun.
tri}` Y, RETAILOSTO.F2EBLISHR., r �r-�,'les's hanE,000sq ft,IYSf
s ! :YES NO $ 50
-
/ D 1000-10,000sq.ft. 10
Jt ' more than 10,000sq.ft. =$250
RESTAURANT YES NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR t',.- pES NO $50
ALL NON-PROFIT (such as church kitchen: S NO 5
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belie—t filed all�e tax returns and paid all state taxes required under the law.
Social Security or Federal Identification Number
-------------------------------------------------------------------------------------------------------------------------------------
Revised11/03/03 FOODAP2.adm Check#&Date 5617-11-17-0-3
0 /—Qp`_
G �
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
! -kw
Date /
Type of Operation(s)
Tyore of Inspection
rood Service
Retail
n Routine
dRe-inspection
Address-
Risk
�G
Level
❑ Residential Kitchen
Previous Inspection
Telephone
❑Mobile
Date: 9-0
I
❑ Temporary
❑ Pre-operation
Owner /
HACCP Y/N
,p,s pY F
❑ Caterer
ElBed & Breakfast
❑ Suspect Illness
ElGeneral Complaint
Person i 'Charge (P C) _ l
Time
Q OI
In:
Out:
Permit No.
[I HACCP
ElOther
Inspector !
k�
Each vioiation cneCltea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors 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 j
❑ 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 (560.009)
30. Other
S:501n5 IFa1m 44.E
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
PROTECTION FROM CHEMICALS
_I,a,, _1
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIMET 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 ti F
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 �ctor.'s ig re:�� A > .
Print:
�J
PIC's Signature: -
Print:
Page 1 of=Pages
Violations Related to Foodborne fitness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(0) Asst a-t'iofResponsibility"---=__�
590.003(B) _Demonxtxation of Knowledge"
[2-103.1 1 Person in charge - duties
EMPLOYEE HEALTH
2
590.003(C)
Responsibility of the person in charge to
Compliance with Food law*
3-201.12.
require reporting by food employees and
3-201.13
Fluid Milk and Milk Products*
applicants*
Shell Eggs*
590.003(F)
Responsibility Of A Fowl Employee Or An
3-20216
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
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
Removal of Exclusions and Restrictions
4
5
FOOD FROM APPROVED SOURCE
* Denotes critical item in the redeial 1999 Foml Code of 105 CMR 590.000.
r
8
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food law*
3-201.12.
Food in a Hermetically Scaled Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202. t4
Eggs and Milk Products. Pasteurized*
3-20216
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
Re uta tory Authority
3-202.18
Shetlstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
3-701.11
ReceivingfCondition
3-202.11
PHFs Received at Proper Temperatures*
3-202. t5
Package Lite it *
3-101.11
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shelistok Identification *
3-203.12
Shellstock Identification Maintained*
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records, Creation and Retention*
90.0(k4(J)
Labeling of Ingredients'
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Conformance with Approved Procedures
/HACCP Plans
-502.11
[3-502.12
Specialized Processing Methods*
10
Reduced ox en acka ring. criteria*
-103.12
Conformance with Ai roved Procedures*
* Denotes critical item in the redeial 1999 Foml Code of 105 CMR 590.000.
r
8
Cross -contamination
3-3011.1(A)(1)
Raw Animal foods Separated from
Conked and RTE Foods*
Contamination from Raw Ingredients
3-302.1 -(A) (2)
Raw Animal Foods Separated from Each
Otber'
Contamination from the Environment
3-302.11(.)
Food Protection -
3 -302.15
Washing Fruits and Vegetables
3-304.11
Food Contact with Equipment acid
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Rescrvice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
E9
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing-Hot Water
Sanitization Temperatures*
4501.114
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 - HerWaterand
Chemical:'
10
Proper, Adequate Handwashing
2-301.11.
Clean Condition - Hands and Arens*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2-401.11.
Eating, Drinking or Using Tobacco*
2-401.12
Discharges From the Eyes, Nose and
Mouth*
3-301..12
Preventing Contamination When Tastin „
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
Employees"
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
5-2041 t
Location and Placement*
5-205.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11,
Handwashine Cleanser, Availabilit -
6-301.1.2
Hand Drvin , Provision
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: OVdL_,&v ,%Lrdhr� Date: Page: oZ of
Item
No.
Code
Reference
C -Critical Item
R - Red Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
PLEASE PRINT CLEARLY
Date
Verified.
A > weL e /G
A ✓iota n ,Lv r 4/ -C'171 /tis-c?`i,, v 4,51,eT 11A p e,
d �
P p _ i 'v4(
//'x
GZu,f' DU /
// --//
Q Se &Z4 rV✓ e '74/i0 )4- S>° G l.3 P �-X „b �' G�q V
A74u
e AC/re Za is dO X,0 7P SCLL 7 s�
PAZhe /It ,2/, i /E/q/PS !i
tlk 7r7
Discussion With Person in Charge:
I have read this report, have had the opportunity to ask questions and agree to correct all
inspection, to observe all conditions as described, and to
violations before the next ins P
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of
your food permit.
�y ( -1---
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
a4
❑ Other:
❑ Voluntary Disposal
Violations Related to Foodborne Illness Interventions and Risk
Factors (items 1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
15
16
17
18
TIMEITEMPERATURE CONTROLS
Food or Color Additives
3-202.12
Additives*
3-302.14
Protection front Unapproved Additives*
3-501.16(B)
590.004(F)
Poisonous or Toxic Substances
7-101.11
Identifying Information -Original
Containers*
7-102.11
Common Name - Working Containers*
7-201.11
Se aradon - Slot a O'
7-202.1.1
Restriction - Presence and Use*
7-202.12
Conditions of Use*
7-203.1.1
Toxic Containers - Prohibitions*
7-204.11
San tizers, Criteria -Chemicals*
7-204.12
Chemicals for Washine Prodnce, Criteria*
7-204.14
Drving Agents, Criteria*
7-205.11
Incidental Food Contact. Lubricants*
7-206.11
Restricted Use Pesticides- Criteria*
7-206.12
Rodent Bait Stations*
7-206.13'Track'ing
Powders, Pest Control and
Monitoring**
TIMEITEMPERATURE CONTROLS
* Denotee critical item in (he federal 1999 Food Code or 105 CMR 590000.
1247
'X y
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(B)
590.004(F)
Eggs- Immediate Service 145°Fl5sec*
3-401..11(A)(2)
Comminuted Fish, Meats & Game
3-501.t6(A)
Animals - 155°F 15 sec. *
3-401.1l(B)(1)(2)
Pork and Beef Roast -130°F 121 min*
3-401.11(A)(2)
Ratites, Injected Meats - 155°F 1.5
590004(H)
see. *
3-401.1.1(A)(3)
Poultry, Wild Game, Stuffed PHFs,
27.
Stuffing Containing Fish, Meat,
Poultry or Ratites -165°F 15 sec. s'
3401.11(C)(3)
Whole -muscle, Intact Beef Steaks
Poisonous or Toxic Materials
145"F *
3-401.12
Raw Animal Foods Cooked in a
29.
Microwave 165°F *
3-401AI(A)(1)(b)
All Other PHFs -145°F'15sec.
.009
Reheating for Hot Holding
3-403.11(A)&(D)
PHFs 165°F 15 sec. *
3-403A 1(B)
Microwave- 165° F 2 Minute Standing
Time*
3-403.11(C)
Commercially Processed RTE Food -
140"F*
3-4011.1(E)
Remaining Unslieed Portions of Beef
Roasts*
Proper Cooling of PHFs
3-501.14(A)
Cooling Cooked PHFs from 140'F to
70`F Within 2 Hours mid From 70°F
to 41.":F/45°F Within 4 Hours. *
3-501.14(B)
Ca)ling Pl IFs Made From Ambient
Temperature Ingredients to 41°F/45'F
Within 4 Hours*
* Denotee critical item in (he federal 1999 Food Code or 105 CMR 590000.
1247
'X y
3-501.14(C)
PHFs Received at Temperatures
According to Iaw Cooled to
41"F/451F Within 4 Hums.
3-501.15
Cooling Methods for PHFs
3-50LI1(B)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold Pill's Maintained at or below.
41°/45°F*
3-501.16(A)
Not PlfFs Maintained at or above
14WR *
3-501.t6(A)
Roasts Held at or above 130°F.
Time as a Public Health Control
9-501.19
Time as a Public Health Control*
590004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801,11(A)
Unpasteurized Pre-packaged Juices and
Beveraseswith WmvineLabcls*
FC
3-50LI1(B)
Use ofPastemized'Eggs*
Management and Personnel
Food and Fond Protection
3-801.11(D)
Raw or Partially Cooked Animal Faxl and
Raw Seed Sprouts Not Served. .c
.003
.004
3-801.11(C)
Uno erred Fcrod Pucka >e Not Re -served. "
CONSUMER ADVISORY
22
V 3-603,11
Consumer Advisory Posted for Consumption of
FC
500.066
Animal Foals "ifiat are Raw. Undercooked or
Management and Personnel
Food and Fond Protection
Not Otherwise Processed to Eliminate
.003
.004
25.
Pathogens.*
3-302.13
Pasteurimcl Eggs Substitute for Raw Shell
26.
Water. Plumbin and Waste
E gO
59 ...... )-(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 -trod retail
practices should be debited under 7#29 -
Special Requirements.
I9.1 iiWlKiFiI L73lITI/Jr7Ti4AtriT39
(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 /05 CMR
590.000.
Item
Good Retail Practices_
FC
500.066
23.
24.
Management and Personnel
Food and Fond Protection
FC -2
FC -3
.003
.004
25.
Equipment and Utensils
FG_ -4
.005
26.
Water. Plumbin and Waste
FC -5
.006
27.
Physical Facility _
FC - 6
__
.007
28.
Poisonous or Toxic Materials
FC -- 7
.008
29.
Special Requirements
.009
3(t
Other
_
_
s:wnra�»�eueaa.ao:
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
Salem Board of Health
120 Washington Street, 4th Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
NameDate
Q L /
4 4 f
t./
-
T e of O eration s
of Ins ection
FFood Service
LW Retail
El Residential Kitchen
ElMobile
❑ Temporary
❑ Caterer
❑ Bed & Breakfast
Permit No.
Woof
Routine
El Re -inspection
Previous Inspection
Date: 5--/s - O3
❑ Pre-operation
❑ Suspect Illness
❑ General Complaint
ElHACCP
Other
Address; 2 x �� . /
Risk
Level
Telephone
I %Lid- ��
Owner
p OQ %Ld may,-)
HACCP YM
Person in Charge (PIC)
Time
In.
Out:
Inspector/�/
Co r ! of /i7 All -I RY1/ S
Each vloiaaon 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
❑ 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
S: 5901n5 IFOm -10.tl
❑ 12. Prevention of Contamination from Hands
13. Handwash Facilities
PROTECTION FROM CHEMICALS"
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIMErrEMPERATURE CONTROLS (Potentially Hazardous Foods) ;
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time As a Public Health Control
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 3�
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" ign e: `%! / Tri
/ /�.P
Print:Cl) czew /�
PIC's Signature:
Print: .�.-,���"I
Pagel ofEPages
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assi- mentofResponsibility,
�
590.003(13) Demonslrat'ion of Knowledge*
2-103.11 1 Person in charge -- dirties
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(£)
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 Ap2roved System*
590.006(A)
Charge*
590.006(£3)
590.003(G)
ire*.
Re ortina by Person in Cb
Shel(lish and Fish From an Approved Source
590.003(D)
Exclusions and Restrictions*
3-201.15
590.003(E)
I Removal of Exclusions and Restrictions
C
C
C
FOOD FROM APPROVED SOURCE
`Denoles critical item in the fedentl 1999 Faxl Code or 105 CMR 590.000.
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food law*
3-201.12
Food in a Hermetically Sealed Container*
3-201.13
Fluid Milk and Milk. Products*
3-202.13
Shell Eggs*
3-202.14
Eggs and Milk Products. Pasteurized*
3-202.16
Ice Made From Potable Drinking Water*
5-1.01.11
Drinking Water from an Ap2roved System*
590.006(A)
Bottled Drinking Water*
590.006(£3)
Water Meets Standards in 310 CMR 22.014
Food Contac' with Equipment and
Utensils*
Shel(lish and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
Returned Food and Reservice of Food*
Game and Wild Mushrooms Approved by
Regulatory Authority
3-202.18
Shellstock Identification Present'*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
Receiving/Condition
3-202.11
PHFs Received at Proper Temperatures*
3-202. t5
Package Integrity*
3-101.11.
Food Safe and Unadulterated
Tags/Records: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained*
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records. Creation and Retention*
590.004(7)
Labeling of Ingredients'
Methods of Sanitization - Hot Water and
Chemical"
Conformance with Approved Procedures
/HACCP Plans
3-502.11
Specialized Processing Methods*
3-502.12
Reduced oxygen packang, criteria*
8-103.12
Conformance widt A. roved Procedures*
`Denoles critical item in the fedentl 1999 Faxl Code or 105 CMR 590.000.
Crass -contamination
3-302.1.1(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Foods*
Contamination from flaw Ingredients
3-302A I(.A)(2)
Raw Animal Foods Separated from Each
Other*
Contamination from the Environment
3-302.11(A)
3-302.15
FaxtProtection,
Washing Fruits and Vegetables
3-304.11,
Food Contac' with Equipment and
Utensils*
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Food*
<)
Food Contact Surfaces
4-501.1.11
Manual Warewashine - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashin„ Hot Water
Sanitization Temperatures*
4-501.11.4
Chemical Sanitisation- 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 Anns*
2-301.12
Cleaning Procedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2-401.11
Eatin , Drinking or Usin Tobacco"'
2401.12
Discharges Front 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 ( a racifies*
5-2041 t
I.Actartion and Placement*
5-205.11
Accessibility, Operation and :Maintenance
Supplied with Soap and Hand Drying
Devices
6-301.11.
Handivashing Cleanser, Availability
6-301.12
Hand Drying Provision
1 t
I
i
CITY OF SALEM
BOARD OF HEALTH /�
Establishment Name: i�.�c 1 1r� s 1lq'e/6 �/ Date: �- %- D I-/ Page: of 7
Item
No.
Code
Reference
C - Critical Item
R — Red Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
PLEASE PRINT CLEARLY --
Date
Verified
'
Z
v�
�l ear'/9/n/
////
7/
tt
i3G 1�
Gr
s'o LL »7, f Zi77 bvale /.c/ rze
_
ZXC10,Or &1aSX1A1ds
z
/
-- //e u� �G 6'ea( r-1 "d1- 7`�7Uci/
S:aC-
9 Ew-Y'7/ee 76WI f
Z 7
-,5 Q @ eS ` %A c , A1
Ale ePP v f P //✓5� _7> /S @/2 Y Pd. cc S e LUPJ
/
Z
— ICe 2,1)__S 1wrlae 0 We//v
LG d LS L G OD / S / Yui (l�d�S dx? 'J1/v5
�Jdeo' eGa a�cil
Discussion With Person in Charge:
have read this report, have had the opportunity to ask questions and agree to correct all
violations before the next inspection, to observe all conditions as described, and to
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of
your food permit. -
�-- *,�.�•--___a„�
Corrective Action Required:
❑ No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
LI Re -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
TIMEITEMPERATURE CONTROLS
Food or Color Additives
3-202.12
Additives*
3-302.14
Protection from Unapproved Additives*
3-501,16(B)
590.004(F)
Poisonous or Toxic Substances
7-101.11
Identifying Information - Original
Containers"
7-102.11
Cornmon 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
Sanitizem Criteria - Chemicals*
7-204,12
Chemicals for Washing Produce, Catena*
7-204.14
Drying Agents, Criteria*
7-2(15.1.1
htcidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria*
7-206.12
Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Monitoring*
TIMEITEMPERATURE CONTROLS
* Nnotes diticat item in (lie federal 1999 Food Code or Illi CMR 590,000.
19
20
3-501-'l4(C)
Proper Cooking Temperatures for
3-501.15
PHFs
3-401.11A(1)(2)
Eggs- 155"F15See.
3-501,16(B)
590.004(F)
E ggs- Immediate Service 1450FI.5sec*
3-401.11(A)(2)
Comminuted Fish, Meat's & Game
3-501.16(A)
Animals - 155"F 15 sec. *
3-401.11(13)(1)(2)
Polk and Beef Roast - 130'F 1.21 tnin*
3-401.11(A)(2)
Ratites, Injected Meats - 1.55'F 15
590.004(H)
sec. *
3-401.11(A)(3)
Poultry, Wild Game. Stuffed PHFs,
28.
Stuffing Containing Fish, Meat,
FC - 7
Poultry or Ratites -165'F 15 sec.
3-401.11(C)(3)
Whole -muscle, Intact Beef Steaks
145''F "
3-401.12
Raw Animal Foods Cooked in a
Microwave 165`F *
3-40 1.11 (A)(1)(b)
All Other PHFs -- 145'F 15 sec.
Reheating for Hot Holding
3-403.1.1(A)&(D)
PHFs 165'F 15 sec. *
3403.1 1(B)
Microwave- 165' F 2 Minute Standing
Time*
3-403.11(0)
Commercially Processed RTE Food -
140'F*
3-403.'t1(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 Front 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*
* Nnotes diticat item in (lie federal 1999 Food Code or Illi CMR 590,000.
19
20
3-501-'l4(C)
PRFs Received. at Temperatures
According it) Law Coaled to
41'F145'F Within 4 Hours.
3-501.15
Coolin * 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.°;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.
26.
Time as a Public Health Control
3-501.1.9
Time Its a Public Health Control'"
590.004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS(HSPI
21.
3-801.11(A)
UnpasteurizPd Pre-packaged Juices and
Beverages With Warning Labels*
590.000
3-801.11(B)
Use of Pasteurized Fggs*
FC - 2
3-801.1.1(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. *
Food and Food Protection
3-80'1. t 1(C)
Unopened Food Package Not Re -served.
CONSUMER ADVISORY
22
3-603.11.
Consumer Advisory Posted for Consumption (it'
590.000
23. _
Animal Foods That are Raw, Unciermoked or
FC - 2
.003
Not Otherwise Processed to Eliminate
Food and Food Protection
FC -3
Pathogens." cro " ""Of
25.
26.
3-302.13
1 Pasteurized Eggs Substitute for Raw Shell
.005
.006
27.
Eggg*
590.009(A) -(I)) 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 good retail
practices should be debited under 1129 -
Special Requirements.
1.1-:11JI121 "M
(Items 23-30)
Critical and non-critical violations, which do not relote to the
foodborne illness interventions and risk. facta.s' listed above, can be
found in the foltowing sections of the Food Code and 105 0IR
.590.0(10.
Item
Good Retail Practices
FC
590.000
23. _
More emeni and Personnel
FC - 2
.003
24.
Food and Food Protection
FC -3
.004
25.
26.
E jugment and Utensils
Water, Plumbina and Waste
FC -4
FC -5
.005
.006
27.
Ph sical Facility
FC - 6
.007
28.
Poisonous or Toxic Materials
FC - 7
.008
_._-
29. _f-
_
Special Requirements ___.. -,
.0_09
30.
1 Other
sa,om1, 111t"- d,,:.
CITYOF SALEM
BOARD OF HEALTH
Establishment Name: W, dyns (1a,9/e-fc;/ Date: 7- 041 Page: 3 of
Item
Code
C -Critical nem
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
Date
No.
Reference
R — Red Item
Verified
PLEASE PRINT CLEARLY ---
z
G
e u/ 444 c 1w- /v G _z4 eGvec A r
_'.v
c ,vim ;
Violations Related to Foodborne Illness Interventions and Risk
Factors (items 1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
1.5
17
18
TIMEITEMPERATURE CONTROLS
Food or Color Additives
3-202.12
Additives*
3-302.14
Protection from Unappi oved Additives*
3-501.16(B)
590.004(F)
Poisonous or Toxic Substances
7-101.11
Identifying Information - Original
Containers^`
7-102.11
Common Name - Working Containers*
7.201.11
Separation - Stoiae*
7-20111
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*
7-205.1.1
Incidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Crited a"
7-206.1.2
Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Monitoring*
TIMEITEMPERATURE CONTROLS
* Denotes critical item in the federal 1999 Food Code of 105 CMR 590.000.
20
.1
3-501.14(0)
Proper Cooking Temperatures for
3-501.15
PHFs
3-401.I1A(1)(2)
Eggs- 155°F 15 Sec.
3-501.16(B)
590.004(F)
E,e-s- Immediate Service 14517ISsec*
3--401.1 l(A)(2)
Comminuted Fish. ,Meat's & Caine
3-501.16(A)
Animals - 155"F 15 sec. *
3-401.11(B)(1)(2)
Pork and Beef Roast - 130°F 121 min*
3-401.11(A)(2)
Ratites, Injected Meats - 155°F 15
590.004(,H)
sec. *
3-401.11(A)(3)
Poultry, Wild Came. Stuffed PHFs.
.009
Stuffing Containing Fish, Meat,
Other
Poultry or Ratites -1650F 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`F *
3-401.11(A)(I)(b)
All Other PHFs -- '145'F 15 sec.
Reheating for Hot Holding
3-403.1.1(A)&(D)
PHFs 165"F 15 sec. "
3-403.1.1(13)
Microwave- 165° F 2 Minute Standing
Time*
3-403.1.1(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 of 105 CMR 590.000.
20
.1
3-501.14(0)
PHFs Received at Temperatures
Acaxding to Law Cooled to
41 °F/45°F Within 4 Hours.
3-501.15
Cooling Methods fol
3-801.11(B)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold PRFs Maintained at or below
41`/45 F*
3-50L16(A)
Hot PRFs Maintained at or above
140°F. *
3-501.16(A)
Roasts Held at a' above 1.30°F.
27.
Time as a Public Health Control
3-501.19
Time as a Public Health Control*
590.004(,H)
varianceRecuirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21.
3-801,11(A)
Unpasteurized Pre-packaged Juices and
Beveraees with WarningL..abels*
23. _
3-801.11(B)
Use of Pasteurized E=*gs*
24. -Food
3-801.'11(D)
Raw or Partially Cooked Animal Food and
Raw Send Sprouts Not Served. "
25.
26.
3-801.11(C)
Unopened Food Package Not Re -served. r'
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for Consumption of
23. _
Management and Personnel FC - 2
Animal Foods That are Raw, Undercooked or
24. -Food
and Food Protection FC -3
Not Otherwise Processed to Eliminate
25.
26.
_
Equipment and Utensils FC - 4
-
Water. Plurri and Waste FC 5
Pafktogens.a; cas�rt�evvzooi
27.
3-302.13
Pasteurized Eggs Substitute for Raw Shell
28.
Poisonous or Toxic Materials FC - 7
E.>s*
aret.,IAL KrUIn LIV tivIb
590009(A) -(D) Violations of Section 590.009(A) -(p) 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. Ocher
590.009 violations relating to good retail
practices should be debited under ))29 --
Special Requirements.
tV:11rf-Th
(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 saction,s of the Wood Code and 10.5 CMR
590.0(')0.
Item
Good Retail Practices FC
590.000
23. _
Management and Personnel FC - 2
.003
24. -Food
and Food Protection FC -3
.004
25.
26.
_
Equipment and Utensils FC - 4
-
Water. Plurri and Waste FC 5
,005
-- ---
.006
27.
Physical Facilit FC -6
.007
28.
Poisonous or Toxic Materials FC - 7
.008
-29__
-Special Requirements
.009
30.
Other
S i.fW r'�k"rt' 22 dnc
V
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: /eia 4Vo ala el e -V Date: Z/ q_0 � Page: Z/ of
Item
No.
Code
Reference
C - Critical Item
R — Red Item
- DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
PLEASE PRINT CLEARLY
Date
Verified
/S Aa C 021, -ns e i2U k N A,'
e -Ae e P )4 / L 4,1 el'_ ki,v o, sl k
Lof� i 17 s a'71it N? L io-c
_740,�r f
Fe�zayz F'.4v ml�_ 7'a ,Se_ ,das 4�/ �ti �� h .
//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:
Violations Related to Foodborne Illness Interventions and Risk
Factors (Items 1-22) (Cont)
PROTECTION FROM CHEMICALS
14
15
1.6
17
18
TIME(rEMPERATURE CONTROLS
Food or Color Additives
3-202.12
Additives`"
3-302.1.4
Protection from Una roved A(lditives"
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
1 Se aradon - Star age*
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
Drvinn Agents. Criteria*
7-205.1.1
Incidental Food Contact, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria*
7 ?06.1.2
Rodent Bait Stations*
7-20(1.13
Tracking Powders, Pest Control and
Monitoring*
TIME(rEMPERATURE CONTROLS
* Denotes eriticel item in the tederal 1999 Food Cate or 105 CMR 194000.
19
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(B)
590.004(F)
Eggs- Immediate Service 145'FLSsec*
3-401.1 I (A)(2)
Comminuted Fish. Meats & Game
3-50L16(A)
Animals - 155"F 15 sec. *
3-401.11(B)(1)(2)
Pork and Beef Roast - 130'F 121 ndo*
3-401.11(A)(2)
Ratites, Injected Meats - 1.55'F 15
590.004(H)
sec. *
3-401.11(A)(3)
Poultry, Wild Game. Stuffed PHFs,
29_
30.
Stuffing Containing Fish, Meat,
Poultry or Ratites -165'F 15 sec.
3401.11(C)(3)
Whole -muscle. Intact Beef Steaks
145"F *
3-401.12
Raw Animal Foods C(x)ked 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)
PIIFs 165'F 15 sec. "
3-403.1I(B)
Microwave- 165' F 2 Minute Standing
Time"
3-403.tl(C)
Commercial lyProcessed RTE Food -
140°F*
3-403.1 I(E)
Remaining Unsliced Portions of Beef
Roasts*
Proper Cooling of PHFs
3-501,14(A)
Cooling Cooked PHFs Prom 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 410F1450F
Within 4 Hours*
* Denotes eriticel item in the tederal 1999 Food Cate or 105 CMR 194000.
19
20
3-501.14(C)
PHFs Received at Temperatures
According to Law Cooled to
4'1'F/45'17 Within 4 Hours.
3-501.15
Cooling Methods lot PHFs
3-801.11.(8)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold PliFs Maintained at or below
41°/45' Fri:
3-501.16(A)
Hot PHFs Maintained at or above
140`F *
3-50L16(A)
Roasts Held at or above 130'F.
27.
Time as a Public Health Control
3-501.19
Time as a Public Health Control*
590.004(H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801,11(A)
Unpasteurized Pre-packaged .Juices and
Beverae,es with Warnin"Labels*
590.000
3-801.11.(8)
Use of Pasteurized Eggs*
FC -2
3-801.11(D)
Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. °'
T Food and Food Protection
-Equipment and Utensils
` Water, Plumbing and Waste
3-801.11(C)
Unopened Food Package Not Re -served.
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for Consumption of -11'
590.000
23.
Animal Foods That are Raw. Undercooked at-
rNot
FC -2
.003
NotOtherwise Processed to Eliminate
T Food and Food Protection
-Equipment and Utensils
` Water, Plumbing and Waste
FC - 3
FC -4
FC -5
Pathogens.* e(1111e1o+11111110
27.
3-302.13
Pasteurized Eggs Substitute for Raw Shell g
.007
28.
Eggs* r
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
interventtans and risk factors, Other
590.009 violations relating to Imod retail
practices should be debited corder Jt29 -
Special Requirements.
(Items 23-30)
Critical and non-critical violations, which do not relate to the
/oodborne illness interventions and ria'k factors listed above, can be
found in the following ,rectiontrf' the Food Code and 10.5 CMR
590.000.
Item
I Good Retail Practices
FC
590.000
23.
Management and Personnel
FC -2
.003
24.
25
26.
T Food and Food Protection
-Equipment and Utensils
` Water, Plumbing and Waste
FC - 3
FC -4
FC -5
.004
.005
.006
27.
Physical Facility
FC -6
.007
28.
Poisonous or Toxic Materials
FC - 7
.008
29_
30.
Special Requirements.__.____
I Other
Si9114�lrnwrA-2.,L c
Massachusetts Department of 'Publ cMealth
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
1,
Salem Board of Health
120 Washington Street, 0 Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
Name 1
J
Dat
or - a
TVDe of Operation(s)
❑ Food Service
1-z' Retail
LJ Residential Kitchen
El Mobile
E3 Temporary
❑ Caterer
❑ Bed 8 Breakfast
Permit No.
Tvce of Inspection
❑Routine
Re -inspection
revious Inspection
bbbate: /
ElPro-per It 49L
❑ Suspect Illness
❑ General Complaint
El HACCP
❑ Other
Address
Rik
Level
Telephone _
%0
Owner
LIACDPG
HACCP Y/N
Person in Charge (PI)
Time
Out 3 �
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) ❑ s90.009 (F) ❑
action as determined by the Board of Health.
_n
FOOD _PROTE� CTION-
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: _
El 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 E"4" ' ' '" e_
❑ 8. Separation/ Segregation/ Protection
❑. Food Contact Surfaces Cleaning and Sanitizing
x;10. Proper Adequate Handwashing
;+' ❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices I
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)
5. 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: 501.Pecffomb-14. o
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities
[PROTECTION FROM CHEMICALS ,
❑ 14. Approved Food or Color Additives
[115. Toxic Chemicals
TIMErrEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
[119. 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: I
L
Inspector's Signature:
Print
PIC's Signature: tr.1l-N
Print:
Page of2P ges
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 Knowled e*
2-103.11 1 Person in charge - duties
EMPLOYEE HEALTH
2
590.003(0)
Responsibility of the person in charge to
Compliance with Food Law*
3-201.12
require reporting by food employees and
3-201.13
Fluid Milk and Milk Products*
applicants*
Shell Eggs*
590k03(F)
Responsibility Of A Food Employee Or An
3-202.16
Ise Made From Potable Drinking Water*
Applicant To Report To The Person In
Drinking Water from an Approved System*
tem*
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
in
0
FOOD FROM APPROVED SOURCE
* Denotes critical item in the federal 1999 Fail Cade or t(15 CMR 590.000.
C
PROTECTION FROM CONTAMINATION
Food and Water From Regulated Sources
590.004(A -B)
Compliance with Food Law*
3-201.12
Food in a Hermeticall • Sealed Container*
3-201.13
Fluid Milk and Milk Products*
3-202.13
Shell Eggs*
3-202.14
Eas and Milk Products. Pasteurized*
3-202.16
Ise Made From Potable Drinking Water*
5-101..11
Drinking Water from an Approved System*
tem*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.0*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of E ui ment"
Shetllish and Fish From an Approved Source
3-201.14
Fish and Recreationally Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
Proper, Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Autho*
3-202.18
_
ShellstockIdentification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
2-301.14
Receiving/Condition
3-202.11
PHFs Received at Proper Temperatures*
3-202.15
Package Integrity*
3-101.11
Food Safe and Unadulterated
Tags/Records: Shellstock
3 '202.18
Shellstock Identification
3-203.1.2
Shellstock Identification Maintained*
12
Tags/Records: Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records. Creation and Retention* -
590.004(J)
Labeling of Ingredients*
Handwash Facilities
Conformance with Approved Procedures
/HACCP Pians
3-502.11.
S ecialimd Processing Methotls*
3-502.12
Reduced oxygen packaging, criteria*
8-103.12 -
Conformance with Approved Procedures*
* Denotes critical item in the federal 1999 Fail Cade or t(15 CMR 590.000.
C
PROTECTION FROM CONTAMINATION
9
Cross -contamination
3-302.11(A)(])
Raw Animal Foods Separated from
Cooked and RTE Foods*
4-501.111
Contamination from Raw Ingredients
3-302.1.1(A)(2)
Raw Animal Foods Separated from Each
Other*
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
Contamination from the Environment
3-302.11(A)
Food Protection*
3-30115
Washing Fruits and Vegetables
3-304.1.1
Food Contact with Equipment and
Utensils*
4-602.1.1
Contamination from the Consumer
3-306.14(A)(.B)
Returned Food and Reservi,ce of Food*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of E ui ment"
Disposition of Adulterated or Contaminated
Food
3-7(11.11
Discarding or Reconditioning Unsafe
Food*
9
Food Contact Surfaces
4-501.111
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing- Hot Water
Sanitization Temperatures*
4-501.114
Chemical Sanitization- temp.,pH,
concentration and hardness. *
4-601.11(A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.1.1
Cleaning Frequency of Equipment Food=
Contact Surfaces and Utensils*
4-702.11.
Frequency of Sanitization of Utensils and
Food Contact Surfaces of E ui ment"
4-703.11
Methods of Sanitization - Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition - Hands and Arms*
2-301. t2
Cleamng Procedure*
2-301.14
When to Wash*
11
Good Hygienic Practices
2-401.11
Eatin , Driitlmg or Using Tobacco*
2-401.1.2
Discharges From the Eyes, Nose and
Mouth*
3-301. l2
Preventing Contamination When Tasting*
12
Prevention of Contamination from Hands
590.004(F)
Preventing Contamination from
Employees*
13
Handwash Facilities
Conveniently Located and Accessible
5-203.11
Numbers and Capacities*
acities*
5-204.11
Location and Placement*
5-2(15.11
Accessibility, Operation and Maintenance
Supplied with Soap and Hand Drying
Devices
6-30Lll
Handwashing Cleanser, Availability
6-301.1.2
Hand Drying Provision
Establishment
Mil
BOARD OF HEALTH
Date: S0 3_ ,
Pager Of 2
Rem
140.
Code
Reference
C - Critical Item
R - Red Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
PRINT CLEARLY
Date -
VerifiedPLEASE
4.; i ;AaM#-
�+
+
ter.
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 toExclusion
comply with all mandates of the Kv ass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars ors pens) )/revocation of
your food permit. A
_ ��—��'� �---��
Corrective Action Required:
❑ No PU Yes
voluntary Compliance ❑ Employee Restriction /
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors(Bems 1.22) (Cont.)
PROTECTION FROM CHEMICALS
14
15
17
18
TIMElTEMPERATURE CONTROLS
Food or Color Additives -
3-202.12
Additives*'
3-302.14
Protection from Unapproved Additives*
3-501.16(B)
590.004(F)
Poisonous or Toxic Substances
7-101.11
Identifying Information - Original
Containers*
7-102.11.
Common Name - Working Containers*
7-201.11
Separation - Storage*
7-202.11
1. Restriction - Presence and Use*
7-202.12
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Sanidzers. Criteria - Chemicals*
7-204.12
Chemicals for Washing 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
1 Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Monitoring*
TIMElTEMPERATURE CONTROLS
* Lk -nous critical hem in the federal 1999 Food Code or 105 CMR 590.000.
19
C
3-501, t4(C)
Proper Cooking Temperatures for
3-501.15
PRFs
3-401.11A(i)(2)
Eggs- 155°F 15 Sec.
3-501.16(B)
590.004(F)
Eggs- Immediate Service 145°F15sec*
3-401.11(A)(2)
Comminuted Fish. Meats & Game
3 501.16(3)
Animals - 155°F 15 sec. *
3401.11(B)(1)(2)
Pork and Beef Roast -130°F 121 mitt*
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.
Stuffing Containing Fish, Meat,
Poultry or Ratites -165°F 15 sec.
3-401.11(C)(3)
Whole -muscle, Intact Beef Steaks
i FC --7
145°F "
3-401.12
Raw Anima) Foods Cooked in a
Microwave 165°F *
3.40131(A)(1)(b)
Ail Other PHFs -145°F 15 sec.
Reheating for Hot Holding
3-403,11(3)&(1))
PHFs 165-F 15 sec. *
3-403.11(B)
Microwave- 165° F 2 Minute Standing
Time*
3403.110
Commercially Processed RTE Food -
140°F*
3-403.11(E)
Remaining Untied Portions of Beef
Roasts*
Proper Cooling of PHFs
3-501.14(A)
Cooling Cooked PRFs front 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*
* Lk -nous critical hem in the federal 1999 Food Code or 105 CMR 590.000.
19
C
3-501, t4(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
43°/45°F*
3-501.16(A)
Hot PRFs Maintained at or above
140°F. *
3 501.16(3)
Roasts Held at or above 130°F.
25.
Time as a Public Health Control
3-5D1.19
Time as a Public Health Control"
590.004{H)
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801AI(A)
Unpasteurized Pre-packaged Juices and
.Beverages with Wattling Labels*
590.000
3-801.11(B)
Use of Pasteurized E s*
i 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
3.60.3.11
Consumer Advisory Posted for Consumption of
590.000
23.
Animal Foods That are Raw. Undercooked or
1
i FC -2
303
Not Otherwise Processed to Eliminate
Food and Food Protection
FC -3
Pathogens.* >"rirnnnr
25.
3-302.13
1 Pasteurized Eggs Substitute for Raw Shell
.005
26.
E
Violations of Section .590.009(A) -(D) in
catering,'mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements.
(Items 23-30)
Critical and non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following sections of the Food Code and 105 CMR
590.000.
ttem
Good Retail Practices
.FC
590.000
23.
_
1 Management and Personnel
i FC -2
303
24.
Food and Food Protection
FC -3
.004
25.
Equipment and Utensils
i.FC-4
.005
26.
Water. Plumbing and Waste
FC -5
.006
27.
Physical FacilityFC-6
.007
26.
Poisonous orToxic Materiais
i FC --7
.008
29.
Special Requirements
.009
30. -
Other
s:yver�2 a x.
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
TVDe of Ooeration(s)
Type of Insoection
S
S 1�
❑ Food Service
kj Routine
❑ Re -inspection
Address _
Risk[Retail
Level
Residential Kitchen
❑ Mobile
Previous Inspection
Telephone q
G
ElTemporary
Date:
❑ Pre-operation
Owner '
HACCP YIN
r 2G ✓-1G
❑ Caterer
❑ Bed & Breakfast
❑ Suspect Illness
❑ General Complaint
Person in Charge (PIC)
Time
1
ln.
0 1..
Permit No.
❑ HACCP
❑ Other
Inspector
Each violation cnecxea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
VT
Non-compliance with: 3
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 f
❑ 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)
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. 5WMSWUFOm i<.d
,, n
❑ 12. Prevention of Contamination from Hands
andwash Facilities
PR TECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
[118. Cooling
19. Hot aAsublic
Holding
El 20, Time Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY - w
[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 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:Prin
PIC's Signature:
Print: G
Page of ages
Violations Related to Foodborne Illness
Interventions and Risk Factors (items 1-22)
FOOD PROTECTION MANAGEMENT
1
590.003( stsponsibility*
AmtioRoKnowled e"590.003(B)
2-103 11. Person in charge - duties
EMPLOYEE HEALTH
2
590.003(C)
Responsibility of the person in charge to
Compliance with Food law"
3-201.12
require reporting by food employees and
3-201.13
Fluid Milk and Milk Products*
applicants*
Shell Eggs*
590.003(F)
_
Responsibility Of A Food Employee Or An
3-202.16
lee Made From Potable Drinking Water*
Applicant To Report To The Person In
tem*
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
C
C
in
C
FOOD FROM APPROVED SOURCE
* Denotes critied itcni in the federal 1999 FoM Cale or 105 CMR 590.000.
1.v
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
lee Made From Potable Drinking Water*
5-1.01.1.1
tem*
Drinking Water from an Approved System*
590.006(A)
Bottled Drinking Water*
590.006(B)
Water Meets Standards in 310 CMR 22.041
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Shellfish and Fish From an Approved Source
3-201.1.4
Fish and Recreationally Caught Molluscan
Shellfish*
3-201.15
Molluscan Shellfish from NSSP Listed
Sources*
Proper, Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority
3-202.18
Shellstock Identification Present*
590.004(C)
Wild Mushrooms*
3-201.17
Game Animals*
2-301.14
Receiving/Condition
3-202.11
PHFs Received at Proper Temperatures*
3-202.1.5
Package Inte it *
3.101.11
Food Safe and Unadulterated
TagsfRecords: Shellstock
3-202.18
Shellstock Identification *
3-203.12
Shellstock Identification Maintained*
12
Tags/Records:Fish Products
3-402.11
Parasite Destruction*
3-402.12
Records. Creation and Retention*
590.004(!)
Labeling of Ingredients'
Handwash Facilities
Conformance with Approved Procedures
IHACCP Plans
3-502.11.
S eeialized Processing Methods*
3-502.12
Reduced oxygen packaging, criteria*
8-103.12
Conformance with Approved Procedures*
* Denotes critied itcni in the federal 1999 FoM Cale or 105 CMR 590.000.
1.v
PROTECTION FROM CONTAMINATION
9
Cross -contamination
3-302.11(A)(1)
Raw Animal Foods Separated from
Cooked and RTE Foods*
4-501..111
Contamination from Raw Ingredients
3-302.11(A)(2)
Raw Animal Foods Separated from Each
Other"
Mechanical Warewashing- Hot Water
Sanitization Tem eratures*
Contamination from the Environment
3-302.11(A)
I Food Protection*
3-302.15
Washing Fruits and Vegetables
3-304.11
Food Contact with Equipment and
Utensils*
4-602.11
Contamination from the Consumer
3-306.14(A)(B)
Returned Food and Reservice of Food*
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
Disposition of Adulterated or Contaminated
Food
3-701.11
Discarding or Reconditioning Unsafe
Fad*
9
Food Contact Surfaces
4-501..111
Manual Warewashing - Hot Water
Sanitization Temperatures*
4-501.112
Mechanical Warewashing- Hot Water
Sanitization Tem eratures*
4-501.114
Chemical Sanitization- temp., pH,
concentration and hardness. *
4-60Ll I (A)
Equipment Food Contact Surfaces and
Utensils Clean*
4-602.11
Cleaning Frequency of Equipment Food -
Contact Surfaces and Utensils*
4-702.11
Frequency of Sanitization of Utensils and
Food Contact Surfaces of Equipment*
4-703.11
Methods of Sanitization - Hot Water and
Chemical*
10
Proper, Adequate Handwashing
2-301.11
Clean Condition -Hands and Alms*
2-301..1.2
Cleaning Procedure*
2-301.14
When to Wash*
1.1
Good Hygienic Practices
2401.11.
Eating, Drinking or Using Tobacco*
1-401.12
Discharges From the Eyes, Nose and
Mouth*
3-301.12
Preventin> Contamination When Tasting"
12
Prevention of Contamination from Hands
590.004(E)
Preventing Contamination from
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, lability
6-301.12
Hand Dr n *Provision
CITY OF SALEM
BOARD OF:HEALTH /.
Establishment Name: tI. 1oS �aLt� / Date: Page: 2 of
Item
No.
Code
Reference
o - Critical Item
R -Red Item
DESCRIPTION OF VIOLATION / PL NOF CORRECTION
�, PLEASE PRINT CLEARLY
Date-
verified(�
`
L/-4Jr).l
�e. n-� as c�nu i
� r
p
s,�lt L tr. l� J T eZp crcu„ iOV s iL r
f
`DI
0- Ws i
n- n Cc C
(
-
�G C
4, o jeS A 0'
Le�
N r to t
%2-
z0
eC
-_K0 A,[. A P'A. t
a
Sly(, f
CIO
J
LAO a
lel Grp
V1Ura - J, 3C,� kAn an / Sc ..
U
rCrr^ _fAR
Discussion With Person in Charge:
1 have read this report, have had the-op'port ity 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 -f ive-dollars or suspension/revocation of
your food permit.
Corrective Action Required:
❑ No Yes
❑ Voluntary Compliance ❑ Employee astriction
Exclusion
Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
13 Voluntary Disposal ❑ Other:
4�1
Violations Related to Foodborne Illness Interventions and Risk
Factors (items I,*) (Cont.)
PROTECTION FROM CHEMICALS
14
15
16
17
t IT.TIf �l�J�f7X 7_V�1:7��Ta7� tI Z�ls•9
Food or Color Additives
37202.12
Additives*
3-302.14
Protection from Una roved Additives*
3-50L16(B)
590.004(F)
Poisonous or Toxic Substances
7-101.11
Identifying Information - Original
Containers*
7-102.11,
Common Name - Working Containers*
7-201.1.1
Separation - Storage*
7-202.11
. Restriction - Presence and Use*
7-202.12
Conditions of Use*
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Sanitizers. Criteria - Chemicals*
7-204.12
Chemicals for Washing Produce, Criteria*
7-204.14
Drying,Agents. Criteria*
7-205.11
Incidental Food Contatx, Lubricants*
7-206.11
Restricted Use Pesticides, Criteria*
7-206.12
- Rodent Bait Stations*
7-206.13
Tracking Powders, Pest Control and
Monitoring*
t IT.TIf �l�J�f7X 7_V�1:7��Ta7� tI Z�ls•9
* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
7m
C
3-501.14(C)
Proper Cooking Temperatures tar
7501.15
PRFs
3.401.11A(1)(2)
Eggs- 155°F 15 Sec.
3-50L16(B)
590.004(F)
E Immediate Service 145'Fi5sec*
3-401.11(A)(2)
Comminuted Fish. Meats & Game
3-501.16(A)
Animals - 155'F 15 sec. *
3401.11(3)(1)(2)
Pork and Beef Roast - 130'F 121 min*
3-401.11(A)(2)
Ratites, Injected Meats -155°F 15
590.004{Hy
sec. *
3-401.11(A)(3)
Poultry, Wild Game, Stuffed PHFs,
27.
Stuffing Containing Fish, Meat,
FC -6
Poultry or Ratites -165°F 15 sec.
3-401.11(C)(3)
Whole -muscle, Intact Beef Steaks
FC -7
145°F 4'
3-401.12
Raw Animal Foods Cooked in a
Microwave 165°F *
3-401.11(A)(1)(b)
All Other PHFs -145'F 15 sec.
Reheating for Hot Holding
3-403.11(A)&(D)
PHFs 165T 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'P Within 2 Hours and From 70°F
to 41°F145'F Within 4 Hours. *
3-501.14(3)
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.
7m
C
3-501.14(C)
PHFs Received at Temperatures
According to law Cooled to
4I'F/45°F Within 4 Hours.
7501.15
Cooling Methods for PHFs
23,
PHF Hot and Cold Holding
3-50L16(B)
590.004(F)
Cold PHFs Maintained at or below
41°145°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{Hy
Variance Requirement
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS HSP
21 3-801.11(.4) Unpasteurized Pre-packaged Iuices and
3-801.11(D)I Raw or Partially Cooked Animal Food and
tz°.., c....A G,..,,,r. nu.« e--1
1 3-801,11(C) I Unonened Food Packaee Not Re -served. * 1
CONSUMER ADVISORY
22
3-603.11
Consumer Advisory Posted for Consumption of
23,
Animal Foods That are Raw. Undercooked or
-FC-2
_590.OD0
.003
Not Otherwise Processed to Eliminate
Food and Food Protection
FC -3
Pathogens* en
25.
3-302.13
Pasteurized Eggs Substitute for Raw Shell
.005
1
26.
Eggs*
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 cord non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can
found in the following sections of the Food Code and 105 CMR
59(1000.
- Rem
Good Retail Practices
FC
23,
i Manatioment and Personnel
-FC-2
_590.OD0
.003
24
Food and Food Protection
FC -3
.004
25.
Equipment and Utensils
FC -4
.005
1
26.
Water. Plumbing and Waste
FC -5
.006
27.
-Physical Facility
FC -6
.007
28.
Poisonous or Toxic Materials
FC -7
.008
29..
Special Requirements
.009
30.
Other
se*)1�2 m
F SALEM
/ BOARD OFHEALTH
Establishment Name: �Ai �{s VL ¢.� L� Date: J i Page:of
Item .
No.
Code
Reference
C -Critical Item
R - Red Item
DESCRIPTION OF V10LATION PLAN 6F CORRECTION
LEASE PRINT CLEARLY
Date
Verified
n/IQ
/QG, -. ogzx- 1v(+ a6 t- oil
�
tf2 f/4t r % uo C'9�+1ro
lS9_ ,4 Ick(�
P /i 4 I
. r r,
i t I 1p �4 c
PGG,
DI �/
LCl 1glS J (Q4 SOn AJ& C it,.,
-51,5kvuoo
ne ate z
S. (A U c
1I0,0, 1_
Q 91; 0
J J D
J e olr 1 /h
Discussion With Person in Charge:
I have_ read this report, have had the opportunity to ask questions and agree to correct all
violation befo a the ne`zt 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 Requi ed: ❑ 'No
❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ 'Voluntary Disposal 0 Other:
p
h
Violations Related to Foodborne Mines& Interventions and Risk:
Factors (Mems 1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
15
16
M
18
71MEITEMPERATURE CONTROLS
Foots or Color AddiOves
3-202.12
Additives*'
3-302.14
Protection from Unapproved Additives*
3-501.16(B)
590.004(F)
Poisonous or Toxic Substances
7-101.11
Identifying Information - Original
Containers*
7-102.11,
Common Name - Working Containers*
7-201.11
Separation - Stora
7-202.11
,Restriction - Presenceand Use*
7-202.12
Conditions of Use
7-203.11
Toxic Containers - Prohibitions*
7-204.11
Sanitizers. Criteria - Chemicals*
7-204.12
Chemicals for Washing Produce, 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*
71MEITEMPERATURE CONTROLS
* Wnotes critical item in the federal 1999 Fwd Code a' 105 CMR 590.000.
3-501-.14(C)
Proper Cooking Temperatures for
_
3-SOL15
PHFs
3401.11A(1)(2)
Eggs- 155°F 15 Sec.
3-501.16(B)
590.004(F)
Eggs- immediate Servitre 145°F15sec*
34UL11(A)(2)
Comminuted Fish, Meats & Game
3-50L16(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
590.004(H)
sec. *
3-40LI I(A)(3)
Poultry, Wild Game, Stuffed PHFs,
27.
Stuffing Containing Fish, Meat,
FC - 6
Poultry or Ratites -165°F 15 sec,
3-401.11('C)(3)
Whole -muscle, Intact Beef Steaks
'• FC-- 7
145°F *
3401.12
Raw Animal Foods Cooked in a
;
Microwave 165°F *
3-401:11(A)(1)(b)
All Other PHFs -145°F 15 sec.
Reheating for Hot Holding
3403AI(A)&(D)
PHFs 165-F 15 sec. *
3403.11(B)
Microwave- 165° F 2 Minute Standing
Time*
3-403.11(C)
Commercially Processed RTE Food -
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 410F/45017 Within 4 Hours. *
3-501.14(B)
Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/4.5°F
Within 4 Hours*
* Wnotes critical item in the federal 1999 Fwd Code a' 105 CMR 590.000.
3-501-.14(C)
PHFs Received at Temperatures
According to Law Cooled to
41°F/45"F Within Hours.
_
3-SOL15
Cooling Methods forPHFs
3-801.11(B)
PHF Hot and Cold Holding
3-501.16(B)
590.004(F)
Cold PHFs Maintained at or below
41°/45°F*
3-501.16(A)
Hot PHFs Maintained at or above
140°F.
3-50L16(A)
Roasts Heid at or above 130°F.
25.
Time as a Public Health Control
3-501, t9
Time as a Public Health Control*
590.004(H)
Variance Requirement -
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801.11(A)
Unpasteurized Pre-packaged Juices and
Bees with Waning Labels*
590.000
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)
I Unopened Food Package Not Re -served.
CONSUMER ADVISORY
22
3-6(t1l t
Consumer Advisory Posted for Consumption of
590.000
23.
Animal Foods That are Raw, Undercooked or
FC - 2
.003 .I
Not Otherwise Processed to Eliminate
Food and Food Protection
FC -3
Pathogens.* Erh `"rw'
25.
3-302.13
1 Pasteurized Eggs Substitute for Raw Shell
.005
26.
E s.,
Violations of Section 590.009(A) -(D) its
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements.
(Items 23-30)
Critical, and non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following sections of the Food Code and 105 CMR
590.000.
Mem
Good Retail Practices
.FC
590.000
23.
Management and Personnel
FC - 2
.003 .I
' 24.
Food and Food Protection
FC -3
.004_
25.
Equipment and Utensils
I FC -4
.005
26.
Water. Plumbing and WasteFC-5
.006 I
27.
Physical Facilityi
FC - 6
.007
28.
Poisonous or Toxic Materials
'• FC-- 7
.008
29,
S eeW Requirements
;
,009
30.
Other
SSYM'anYv 2d
6s,
CITY OF SALEM .
jj BOARD OF HEALTH ? C
Establishment Name: �n �A.I� ] � �� Q21 �.11i1 " ` " ` Date: J �iF z Panp. W nf I J
Item Code
No. Reference
C - Critical Rem 1
R -Red Item,
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION -
Date -
t a PLEASE PRINT CLEARLY
verified
I-,.., I
4) EA Q fill, r= r
N
- .
-
t \Jy L J K \lb
ri - V'
64.. i P 1/co fi c
,.,1E _ "A"",
J, 4/b
/
x
I/ P/v
n.c .. /ham -5 PN.r-a d —
Al f
Discussion With Person i Charge:
Corrective Action Required:
❑ No ❑; s
I haverl� e d thisr`epo'rtftrv-e'hadathe•opportunity ?b ask questions and agree to correct all
❑ Voluntary Compliance ❑ Employee Res riction /
violations before the next inspection, to observe all conditions as described, and to
Exclusion
comply with all mandates of the Mass/Federal Food Code. I understand that t
Re -inspection Scheduled ❑ Emergency Suspension
noncompliance may result in daily fines of twentyfive-dollar :or suspension/revocation of
`'
(3 Embargo ❑ Emergency Closure
your food permit. �� ..
❑ Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness, Interventions and Risk
Factors (items 1-22) (Cont.)
PROTECTION FROM CHEMICALS
14
15
16
17
18
TIMEMEMPERATURE CONTROLS
Food or Color Additives
3-202.12
Additives*
3-302.14
_
Protection from Unapproved Additives*
FC - 2
Poisonous or Toxic Substances
7-101.11
Identifying Information - Original
Containers*
7-102.11.
Common Name - Working Containers*
7-201.1.1
Separation - St
7-202.11
,Restriction -Presence and Use*
7-202.12
1 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*
TIMEMEMPERATURE CONTROLS
* ]hnotrs critical item in the federal 1999 Food Code or 105 CMR 590.000.
3-501.14(C) PHFs Received at Temperatures
According to law Cooled to
41°F/45°F Within 4 Hours.
Proper Cooking Temperatures for
I9
PHFs
3-401.11A(1)(2)
Eggs- 155`F 15 Sec.
FC - 2
Eggs- httmediate Service 145'F15sec*
3-401.11(A)(2)
Comminuted Fish. Meats & Game
3w801.11(C)
Animals - 155°F 15 see. *
3401.11(B)(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 Containing Fish, Meat,
FC -6
Poultry or Ratites -165°F 15 sec.
3401.11(C)(3)
Whole -muscle, Intact Beef Steaks
FC- 7
145°F *
3-401.12
Raw Animal Foods Cooked in a
Microwave 165°F *
3.401.11(A)(1)(b)
All Other PHFs -145°F 15 sec.
Reheating for Hot Holding
3.403,11(A)&(D)
PHFs 165°F 15 sec. *
3-403.11(B)
Microwave- 165° F 2 Minute Standing
Time*
3-403.11(C)
Commercially Processed RTE Food -
140°F*
3403.11(E)
Remaining Unsliced Portians 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 0171450F
Within 4 Hours*
* ]hnotrs critical item in the federal 1999 Food Code or 105 CMR 590.000.
3-501.14(C) PHFs Received at Temperatures
According to law Cooled to
41°F/45°F Within 4 Hours.
3-50IA6(B) I Cold PHFs Maintained at or below
3-501.16(A) Hot PHFs Maintained at or above
_ 140°F. *
3-501.16(A.) Roasts Held at or above 1300F.
Time as a Public Health Control
3-501.19 Time as a Public Health Control*
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-501.15 Conlin Methods for PHFs
I9
PHF Not and Cold Holding
3-50IA6(B) I Cold PHFs Maintained at or below
3-501.16(A) Hot PHFs Maintained at or above
_ 140°F. *
3-501.16(A.) Roasts Held at or above 1300F.
Time as a Public Health Control
3-501.19 Time as a Public Health Control*
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS (HSP)
21
3-801,11(A)
Unpasteurized Pre-packaged Iuices and
fievera es with Warning labels*
590.000
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
3w801.11(C)
Unopened Food Package Not Re -served. "
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 Otherwise Processed to Eliminate
Food and Food Protection
FC -3
Pathogens.* '" "
25.
3-302.13
Pasteurized Eggs Substitute for Raw Shell
.005
26.
Eggs*
Violations of Section 590.009(A) -(D) in
catering, mobile food, temporary and
residential kitchen operations should be
debited under the appropriate sections
above if related to foodborne illness
interventions and risk factors. Other
590.009 violations relating to good retail
practices should be debited under #29 -
Special Requirements.
(Items 23-30)
Critical, and non-critical violations, which do not relate to the
foodborne illness interventions and risk factors listed above, can be
found in the following sections of the Food Cade and 105 CMR
590.000.
Item
Good Retail Practices_
IFC
590.000
23.
Management and Personnel
FC - 2
.003
24.
Food and Food Protection
FC -3
.004
25.
Equipment and Utensils
I FC -4
.005
26.
Water. Plumbing and Waste
I FC -5
27.
P y sieal Facility
FC -6
.007
26.
Poisonous or Toxic Materials
FC- 7
.008
29.
Special Requirements
30.
1 Other
SSMM'mmheK. 26