Loading...
WHITE HEN PANTRY - ESTABLISHMENTS (2)WHITE HEN PANTRY 28 NORMAN STREET a J y E a 0 a E n r ® White Hen Pantry -..White Hen Pantry, Inc 41 Montvale Ave. Stoneham, Massachusetts 02180 (617) 438-1140 1 FAX. )617) 438-9354 Richard F. Randazzo _ Zone Manager New England Region Flo White Nen Pantry I White Hen Pantry, Inc. 41 Montvale Ave. _ Stoneham, Massachusetts 07180 + (6 17) 438 1 140 FAX (617) 438-9354 Bob Pelletier Store Counselor New England Region ® new England Pantry, Inc. 290 Vanderbilt Avenue Norwood, MA 02062 I Pam Labrie Business Development Manager Direct: 781-349-1125 Cell: 781-475-8810 - Office: 781-762-4444 Fax: 781-762-2995 Email: pam.labrie@clarkretail.com ` 1 ��Jf Commonwealth of Massachusetts City of Sal@m Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 03/29/2010 ESTABLISHMENT NAME: File Number: BHF -2004-000365 LOCATED AT: White Hen Pantry 28 Norman Street Salem MA 01970 0028 NORMAN STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2010-0203 Jan 4, 2010 Dec 31, 2010 $280.00 TOBACCO VENDOR BHP -2010-0204 Jan 4, 2010 Dec 31, 2010 $135.00 PERMIT EXPIRES Total Fees: $415.00 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR DAVID GREENBAim1, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"r FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGREENBAUMiC77SALEM. COLI 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT LU h; H! Hepr) TEL # (11�1 9 - y s _ )Q95- ADDRESS OF ESTABLISHMENT Q9 Al n rYymry,T, ,S&Jern 41A. FAX # 9:79— 74/b -51-4 MAILING ADDRESS (if different) EMAIL - Business': OWNER'S PiRa= TEL# 9-7,9- L/74- 2 1 oe-< ADDRESS r2 /?e wPs B) E-� pt�cn/-1/4 cn cir Inc) _ STREET CI— TY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) r (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOMETEL#339-q!16- 215y ' DAYS$QFQPERATION ' lvtoilday? �*Tues"'d'ar , Wedn_`estlay Thursday ,*,.f Fndal i '`:.atu(day Sunda_Y HOURS OF OPERATION Please write in time of day. ! For example Ilam-11pm ! ! ! TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO han 1000sc ft70 more than I0,000sq.ft. =$420 -----------------•--------------------------------------------------------------------------- RESTAURANT YES less than 25 seats =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 ----------------------------------------------- BED/BREAKFAST/ YES NO $100 ADDITIONAL PEKMII5 MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVES $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES UO $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 i �. / s / Social Security or Federal Identification Number. ---- -� -------------------/- I---�7 � -7------------------------------- Revised 424/07 F00DAP2008.adm Check# & Date ? / a%jD�f 8 .ilk-,Snr-.tr+;t "'�'• ;1'sn. .�.. J.. ^P. �i.. s.a:n' .R't. :Yal,.r� `-i,r{i !. . A:rir. ?.l.,F r' f ��,m.. ��`.'1/"* , Massachusetts Department of Public Health Salem Board of Health Y I 120 Washington, Street, 4i0 Floor Division of Food and Drugs 1 s; Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT,, kn' lel. (978) 741-1800 Fax (978) 745-0343 NameD e Type of Operation(s) Type of Inspection ❑Routine J Food Service Address Risk ® Retail 1�Re-inspection l� Level ❑ Residential Kitchen El Mobile Previous Inspection Date: (p/81( p Telephone _ / �� f HACCP Y/N 11 Tempo ff, E]Pre-operation Owner �1 t 4 v ! / J SP1- ElCaterer ❑ Bed & Breakfast El Suspect Illness ❑ General Complaint Person in Charge (PIC)4 Time In: io/ Out: .k y Permit No. ElHACCP ❑ Other Inspector ) Each violation checked requires an explanation on the narrative page(s) ano a citation or speciric provisionts) violatea. 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 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned / Knowledgeable / Duties ❑ 13. Handwash Facilities „� EMPLOYEE HEALTN g re -�� um' �4 L ? � „-� ,� ��3� ,ka �" PROTECTION FROM CHEMICALS F�� ''�'''"z; � ° 4 a° n7 " igr ° �'�`',g `❑ 2. Reporting of Diseases by Food Employee and PIC •.gay° M,'r1`�amr.t�a ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals g FOOD FROM APPROVED SOURCE 4. Food and Water from Approved Source DTIME/TEMPERATURE CONTROLS (Poterrtialty rd Hazaous Fowls],,Ai F ❑ pp ''. m,xa E]5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans 'PROTECTION FROM CONTAMWAT10N=Oe`"'"� `'gg,�`' ak`" 9„I ❑ 8 Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate ❑ 11. Good Hygienic P 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 immediatelyior within 90 days as determined by the Board of Health. ! j'. 23?Management and Personnel 24'iFood and Food Protection 25' Equipment and Utensils 26'Water, Plumbing and Waste 27. Physical Facility 28. Poisonous or Toxic Materials 29. Special Requirements 30. Other " S, 501nsp aFo� ,ad o Inspector's Signature: PIC's Signature: (FC -2)(590.003) (FC -3)(590.004) (FC -4)(590.005) "(FC -5)(590.006) (FC -6)(590.007) (FC -7)(590.008) (590.009) Print: ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FDR HIGHLY SUSCEPTIaL� POPULAT1l3IJS'_(PISPj" ❑ 21. Food and Food Preparation for HSP ❑ 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, yo0 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: Page". i of-UPages i• Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 T596.003(A) Assignment of Responsibility* 590.003(B) Demonstration of ledge* 2-103.11. Person in charge -- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an 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 Ce C LE FOOD FROM APPROVED SOURCE "Denotes critical item in the federal 1999 Food Cale or 105 CMR 590.100. ♦- PROTECTION FROM CONTAMINATION F8-- Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.1.2 Foci in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.1.3 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.A I 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 Ve *etables Shellfish and Fish From an Approved Source 3-20114 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590,004(C) Wild Mushrooms* 3-201.17 Game Animate 3-701.11 ReceivinglCondit[on 3-202.1.1. PRFs Received at Proper Temperatures* 3-202.15 Package Ihte it * 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.1.2 Shellstock Identification Maintained* TagslRecords: Fish Products 3-40111 Parasite Destruction* 3-402.12 Records. Creation and Retention* 5900040) Labeling of Ingredients" Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures IHACCP Pians 3-502.11 Secia'ized ProcessingMethods* 3-502.1.2 Reduced ox en packaging, criteria* 8-103.12 Conformance with Approved Procedures* "Denotes critical item in the federal 1999 Food Cale or 105 CMR 590.100. ♦- PROTECTION FROM CONTAMINATION F8-- 3-302.11 (A)(] 3 -302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 7302A 1(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection" 3-30115 Washing Fruits and Ve *etables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition ofAdulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501,111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.1[2 Mechanical Warewashing- I -Tot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601_II(A) Equipment Food Contact Surfaces and Utensils Cleats" 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* 1(1 Proper. Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms" 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 1 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2401-12 Discharges From the Eyes, Nose and Mouth* 3-30112 Preventing Contamination When Tastin " 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Convenientty Eocated 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, Availabilit g 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Date: F �„ J Page:: 2 of Item No. Ceee Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - - y PLEASE PRINT CLEARLY - Date Verifled + - � 1'l7cokUe :c t/ ^ vi (Aic-)t« ArLP Old, III QS' rb 1/ &c of li,JOVSD a li l r C 47 cK7 vonr I ( (.S W. -L.J Ojo :Q0 M C / 6C�0 C Zd _ ^ G �A- _r? r IrIe(V rh C).r� O _ 571(_ 4-� S GMS. S %1 �.t p (3P lA �IJr 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.1 Corrective Action Required: ❑ No l7 y'Xes: ❑ Voluntary Compliance ❑ Employee RestrictionG/ \ / Exclusion � Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 11 Violations Rela(ad to Foodborne Illness tnterventions and Risk Factors (IteYns 1-22) (Cont) PROTECTION FROM CHEMICALS 14 Food or Color Additives 3-202,12 Additne.a 3-302.14 _ Protection front Unapproved Additives": 15 Poisonous or Toxic Substances 7 [01.11 tdentii}mrinfounation On mal 3-501.16(B) Cold PHF. Maintained at or below 7 10111 I Common Name -- N orkm_,,> C om tin »*_ 7 201.1 l—i-Srpai tuun - Stvi tgc _--„ (`' 202.I 1 Re,tttuicm-E'r:.xncr rmd 7`202.12 Condition. of Use" _ 7 ?03. 11 Toxic C o tiainei Prohibi ioi i nJ41i samnreiv Criteria ChemicI _ I7. 2(4 12 l hutucalt tot W ivhitLl ad_i e C-iTTeria"' F7204,14 Dning Avcov. Criterialf t--IIS-li IIn<zdntilrk."d lituLobivaity QV i RN111U ll-lC Pe nlldf. 1. C ntc 1 1 7-200. 12 itixle n 13,11t S.MIOM - 1. '1 rico. g Pnu-dc !Ybl C.:antr-1 xnd taitnrin- TIMElTEMPERATURE CONTROLS IF Proper Cooking Tompetalures for PHF's lntru<dr etc Ser tat tTT 15sec' f01.11t Vr �._...� C un r [noted t rth ^" t. (I' it Amill.tis 155 °aA inl_Uet Rot�t_1)i i i_mn'_ 1 .40L1 [(A)(') K n ie;, hi eel.a M, ?.[s i i'!. 1 - i � i 3-40LII(AV 1) 1 Poulrry, 'A ild Gaimt, SWifed PliFs I S rifer i,, Cunt uni i - tis'; t<L are I P `) ivtea aidexi �' r��i.-i �i�_!1e4alC i [IGS �`-tip;+p iX;G. 19 LZ0 -5(1l.14(C) i01 i1iA it �i er i''k1i ?? — .L t 103.Uti}it,iD) Rehr. t ng for Hot Holdrtg --- , 11 [e '1 17 a .... _ J —h7tirc., 3-501.15 3 403.11(H,----- 1 tie«.tntevc�lt ti I'5i.rndin:: PHF Hot and Cold Holding 3-501.16(B) Cold PHF. Maintained at or below 590.0010F 3-d@3.E1(C) i Corwn^trialii !'ux-sCr +oki- l Ifni PH(v Maintained at or above 40'R t vltlRoIsis I _ v 'tU00liHa -1RIFI ;v4J3.i1(I7 Re near nine Un<licad Porticos ri'Bcef (g� `_ opor Gaoling of PHFs JjI °.-501,14(A) in C ia,hiw C'xik d PHl c from 140 - Flo l 01; Within 2 Ifow: sod From — h _5171, to 41 11-145"P Within -1 Hini � _— 3 i_4(f3_ Cl a li g PR Madc From Ambient T nil.'('a(nTe hWrtdient5 TO W1 Within 4 HiAnsc- `) ivtea aidexi �' r��i.-i �i�_!1e4alC i [IGS �`-tip;+p iX;G. 19 LZ0 -5(1l.14(C) PHPs Received at Temperatures Aarording to LaN Cooled to __ 41TF145"F Widtin 4 Homs. k 3-501.15 Coolime Wffiflds for PHFs PHF Hot and Cold Holding 3-501.16(B) Cold PHF. Maintained at or below 590.0010F 41%45° F _ 3-5!l I'll 6i A) Ifni PH(v Maintained at or above 40'R t vltlRoIsis I _ v 'tU00liHa Held at or above 130°[ =. +' Time as a Public Health Control Tim(as a Public Health Cunlrol* VariapaReqoiraqlellt REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 21 1 +-Tt11 11(A) I Line ivicuiizad ire i ! agCd 7victs and HevPv et/ with Wal ulfl Pa,tewizedEc„, i 3 -Beef 7 I(li) Raw ur Puti ail Gail. d 1m ma1 Fait/ unit p—, A ei ne. 1 1.'e a s'a.d Padrae_ Ivo! R. lervcd. CONSUMER ADVISORY. _ 22 34.() � l l � ('or;suinri N'!v sots Po't' f ibrt on nmption of 'vaiun:d that arc Rain. Und. nuxiked ar Ei poi Otk isc i'rtwc ti d -. l�tir;rnate FL"; tol Raw _ SPECIAL IAL r.EOU'REMENt' _ caateri k. MA'bilc t v, i ' gap ra v and � rt,:d nt d titch a tr ctaitcyn� sitrnild la' u.td:r tilo aporupriatt .�r'rons } nb' ' «1*.;'E1 u;nr'e7 i' __. Ali i � 1 _ i iLp+1{1 ! i�.lUi tali i; t 1 4k_� W ✓IOLATiONS /'?ELATED i O GOOD RE7A)! F P?4CTIC£$ {items 23-3(H CII t o .!IlOrr.. e'w'a?. r.=h.ers.n ichdo+:w elate ,iOw { �trhurnc f?Grrs "ec r7-ent� ins and n}t }z7rtor, llvied abow" call Eir cern,: err dt� J tnr ;ag Er,Code, u.10Cnse' :jf¢ 1 Wr­ Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs ' y 120 Washington Street, 4th Floor' 9 S I MA 01970 3 23 FOOD ESTABLISHMENT INSPECTION REPOF{ aem, 5 4el.^(878)741-1800 Faz(978)745-0343 Name L ) r �0 ! Date (OR I Type of Operation(s) T e of Inspection outine ElRe-inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness ❑❑ HGeneral ACCP Complaint El Other -" 78 -Food Service Retail r Residential Kitchen, ❑ Mobile s ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address tv r Risk Level Telephone,Yn�-�i �. f TSF Owner �jjd-51' JF1C.7) r 4r VJ I )ACCP YM Person in Charge (PIC) 'Time In: Out.l_0\V Inspector i7 kj/ t Each violation checked requires an explanation on the harrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590:009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. a FOOp PROTECTION MANAGEMENT,, �' l' ,,-�.I.m,� C ❑ 1. PIC Assigned/ Knowledgeable/ Duties EMPLOYEE HEALTH "`' T -r F i.1 i-11 ,.i is ' a, ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded n FOOD FROM APPROVED SOURCE,,.,„.m•' ❑ 4. Food and Water from Approved Source 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATIONerr �:y 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 Citical:(C) violations marked must be corrected Immediately or within 10 days as determined by the Board • J of:Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. ,23. Management and Personnel (FC -2)(590.003) }(' 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.006) 29. Special Requirements (590.009) 30. Other 5: 590In5pBCIFo�14.tla I?/1 n ❑ 12. Prevention of Contamination,from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS'Tel" rye',) a ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATUREOONTROLS (Poiemially Hazardous Foods) iW ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling Hot and Cold Holding ❑ 20. Time As a Public Health Control REOUIREMENTS FOR HIGHLY SUSCEPTIBLE.POPULATIONS (HS0) ❑ 21. Food and Food Preparation for HSP f", CONSUMER .ADVISORY !_ »„� �'"._„•,.,a`-.--.®.,,.o_�a"�(u.;w.�n."�'�wFr.'iS ❑ 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: fJ i(, JO) o - Ce, �1 Inspector's Signature:` _Print: . PIC'sSiguature:,rt >;. Print: 4v�5 0dA' C-0 Pap- oL�:Tages J Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT '1 590.003(A) Assia ment of Responsibility* 590.003(6) Demonstration of Knowled e* 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 E, -as* 590.003(F) Responsibility Of A Foul Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In 1 Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(0) Reporting by Person in Charge* 3 590.0030 Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C C I FOOD FROM APPROVED SOURCE 'y Denotescritical item in the federal 1999 Foal 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 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell E, -as* 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.1.1 1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Came Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at 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* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590,004(J) Labeling of Ingredients' Frequency of Sanitization of U't'ensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures 1HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxygen packaging. criteria* 8-103.12 Conformance with Approved Procedures* 'y Denotescritical item in the federal 1999 Foal 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 Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Amoral Foals Separated from Each Other* Contamination from the Environment 3-302.1 1(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3 304.11. Foal Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservier of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe F(x)d* 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 Sanitisation- temp., pH, concentration and hardness. * 4-601.A 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 U't'ensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization -Iiot Water and Chemical* 10 Proper, Adequate Handwashing 2-30111 Clean Condition - Hands and Arms* 2.301.12 Clean- Procedure* 2-301.14 When to Wash" F-11- Good Hygienic Practices 2-401..11 _,Eating. Drinking or Using Tobacco* 2401.12 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 Eurto gees* 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 y Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision I r - Y CITY OF SALEM } BOARD OF HEALTH Establishment Name: ��, Y �� ✓' . k Date: tdqll9 Page: O of Item' - Code C - Critical nem DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference 'R Red Item < I. PLEASE PRINT CLEARLY.... Verified ;j'-, al -or Wu ^dshi/ &,7 - Jell e / // 116VO, rj &/� &, d Jc a �1- 4 C hI cl/r /r, Ae nr G�I J r G . 4c o. I0q j� M L 1 a �e d ./ �7=� HF o4_ ar O �c {I ^ r t IL A n , A AGt..�zrica 4 T)t r, \ r n Discussion With Person in Charge: Corrective Action Required: ❑ No IY Yes I have read 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 Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars-or-suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. f Voluntary Disposal ❑ Other. 74, _ Violations Related to Foodborne fitness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 17 r 18 TIMEffEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives'" 3-302.14 Protection from Unapproved Additives* 19 Poisonous or Toxic Substances 7-101.. I 1 Identifying Information - Original Containers* 7-102.11 Common Narne - Working Containers* 7-201,11 1 Se.. oration - Storaeea` 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use' 7-203.11 Toxic Containers - Prohibitions" 7-204.11 Sanitizers, Criteria - Chemicals* 7.204.12 Chemicals for Washin¢ Prixlnec, Criteria* 7-204.14 Drying Agents. Criteria" 7-205.11 Incidental Food Co'ntaet. Lnhricants" 7-206.11 Resit icted Use Pesticides. Criteria" 7-206.12 Rodent Bait Stations* 7-206.13'Tricking Powders, Pest Control and Monitoring' TIMEffEMPERATURE CONTROLS " Denotes critical item in the Federal t999 Food Code or 105 CMR 590.000. Proper Cooking Temperatures for PHFs Received at'Temperamres ' According to I.aw Cooled to 41'F/45''F W'itbin 4 Hours. * PHFs 3-401. I.1 A(1)(2) Eggs- 155'F 15 Sec. 19 Ergs- hmnediate Service 145'1715sec* 3-401.11(A)(2) Comminuted Fish, Meats & Ganite 3-501.16(11) 590.004(F) Anirmds - 155'F 15 sec. * 3-40 1. H (11)(1)(2) Pork and Beef Roast - 130"F 121 min. 3-401.1 I(A)(2) Ratites, Injected Meats - 155'F 15 3-501.16(%) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed P11Ps, Time as a Public Health Control Stuffing Containing Fish, Meat, 3-501.19 Poultr • or Ratites -165`F J5 sec. 3-401.11(C)(3) Whole -muscle,' Intact Beef Steak's Variance Re uirement 1.45°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165"F * 3-401,11(A)(1)(b) All Other PHFs -- 1.45'F 15 sec. Reheating for Hot Holding 3-40111(A)&(D) PHFs 1650.F 15 sec. * 3-403.11(B) Microwave- 165" F 2 Minute Standing Time" 3-403.11(C) Commercially Processed RTE Food - 140'F* 3-403.1.1(E) Remaining Unslieed Portions of Beef Roasts" Proper Cooling of PHFs 3-501. W(A) Cooling Cooked PHFs from 140'F to 70'F Within 2 Flours and From 70'F to4FT/45"F Within 4 Hours. * 3-501-14(B) Cooling P14Fs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* " Denotes critical item in the Federal t999 Food Code or 105 CMR 590.000. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-501.14(C) PHFs Received at'Temperamres ' According to I.aw Cooled to 41'F/45''F W'itbin 4 Hours. * 3-561.15 Cooling Methods for PHFs 19 3-801.1 I (D) PHF Hot and Cold Holding Food and Food Protection - 3-501.16(11) 590.004(F) Cold PHFs Maintained at or below, 411145' F* _ 25. _ ___ 26. 27. 3-501.16(A) Hot PHFs Maintained at or above 140"F. * .005 .006 .007 3-501.16(%) Roasts Held at or above 130°F. 20 .008 Time as a Public Health Control Special Requirements 3-501.19 Time as a Public Health Control* 30. 590.004(11) Variance Re uirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801-11(A) Unpastemized Pre-packaged Juices and Beverages with Warning Imbels* 3-801.I1(B) Use of Pasteurized Ews- FC --2 3-801.1 I (D) Raw or Pmlially Cooked Animal Food and Raw Seed Sprouts Not Served. 't Food and Food Protection - 3-801.11(C) Unopened Foots Package Not Re -served. 22 3-603.1 1 Consumer Advisory Posted for Consumption of 23. Animal Foods 'I'hat are Raw. Undercooked or FC --2 _ 003 Not Otherwise Processed to Eliminate Food and Food Protection - FC --3 Pathogens." E"'' 'ods _ 25. _ ___ 26. 27. 3-302.13 Pasteurized Eggs SnbSkUlte for Raw Shell .005 .006 .007 28. E=�s* Jrc: diAL mcuunrumnacr4 i J 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections a1iove if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Speeial Requirements. (Items 23-30) Critical and non-critical violations, which do not relate to tine foodborne illness inteivention,s' and risk factors listed above, can be found in rho foliowing sections of the Food Code aid 105 CMR 590.000. Item Good Retail Practices ---AC--590.660 23. Mena ement and Personne_I_ FC --2 _ 003 24. Food and Food Protection - FC --3 .004 _ 25. _ ___ 26. 27. _ _ Equipment and Utensils Water. Plurnbinq and Waste Ph sicalFacili F_C - 4 FC 5 FC -6 .005 .006 .007 28. Poisonous or Toxic Materials FC -7 .008 29. Special Requirements .009 30. _ Other ssporon:1n.1te.z*„ g CITY OF � BOARD OF HEALTH Establishment Name: l 1 4cf1 wt/7&1 Date:/ " Page: of i Item No. Code Reference - _.. ,C -Critical Rem R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION °i*" - s% PLEASE PRINT CLEARLY Date Verified �5 rbc 17 c�na2, Grp e "e ��' i - V ` S Cck;F/t, Con A IiJ Sh e -YCec4f r 6 G4 z e �•�1 - �r 4 V v I / z� .4- ( !%u �I �_iL tZtri ct (AC, 2755 C - So G -✓ I JG Q TF 3 Gc rINI 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-suspens' rdrevocation of your food permit. /`- Corrective Action Required: ❑ No.. Yes Voluntary Compliance ❑ Employee Restriction / Exclusion Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure j o Voluntary Disposal ❑ Other: � ► 7 rY i + f Violations Related to Foodborne Illness Interventions and Risk Factors (items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 - -- 15 17 18 . TIMEITEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additkcs* 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` 7-201.11 Separation - Stora e" 7-202.11 Restriction - Presence and User 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sardtizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 jrguts, Criteria* 7-205.11 -2D Incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring" TIMEITEMPERATURE CONTROLS *Denotes critical item in Ilse federal 1999 Food Code or 105 CMR 590.000. E3-501.15 Proper Cooking Temperatures for PHFs Received at Temperatures According to Law Cooled to 41 -F/45'F Within 4 Hours. Coaling Methods for PHFs PHFs 3-401.I1A(1)(2) lggs- 155"17 15 Sec. FC - 2 B gs-Immediate Service 74_5°Fl Ssec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(A) Amorals - 155'F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 26. 27.---. sec. 3-401.11(A)(,3) Poultry, Wild Game, Stuffed PHFs, Time as a Public Health Control* Stuffing Containing Fish, Meat, 590.004(H) Poultry or Ratites -165'F 15 sec. 3401.11(C)(3) Whole -muscle Intact Beef Steaks 145"F * 3401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-40 1.11 (A)(1)(b) All Other PHFs- 1.45'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 Focal - 140"Ist 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-50114(A) Cowling Cooked PHFs from 140'F to 70'F Within 2 flours and From 70"F to 4t"F/45"F Within 4 Hours. * 3-50L14(B) Cooling PF[Fs Made Froni Ambient Temperature Ingredients to 41 °F/45`F Within 4 Hours'F *Denotes critical item in Ilse federal 1999 Food Code or 105 CMR 590.000. E3-501.15 3-501.1.4(0) PHFs Received at Temperatures According to Law Cooled to 41 -F/45'F Within 4 Hours. Coaling Methods for PHFs 19 3-80Ll1(.B) PHF Hot and Cold Holding FC - 2 3-501.16(B) 590,004(F) Cold PRFs Maintained at or below 410/45" F* Food and Food Protection 3-501.16(A) Ilia PHFs Maintained at or above 140" F. * 25, 3-501, 16(A) Roasts Held at or above 130'F. F-2ol 26. 27.---. Time as a Public Health Control FC -5 FC-6 3-501.19 Time as a Public Health Control* Poisonous or Toxic Materials 590.004(H) Variance Requirement REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3 -SOL I I(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.000 3-80Ll1(.B) IlseofPasteurized Eggs* FC - 2 3-801.'11(D) Raw or Partially CookeL.Animai Food and Raw Seed S trouts Not Served. Food and Food Protection 3-801.77(0) Uno enedI^god Packa>e Not Re -serve!. * IODXT r 22.. 3-603.1 I. Consumer Advisory Posted for Consumption of 590.000 23. Animal Foods'Lhat are Raw. Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC -- 3.004 Patho"ens.* e`"'�"''''10'� 25, 3-302.13 Pasteurized Eggs Substitute for Raw Shell OOS 26. 27.---. Water, Plumbing and Waste -Ph sical Facility, Ma'UP2rcrM 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. iPlwu17am (Item 23-30) Critical and non-critical violations, which do not relate to the foodborne- illness inter venoons and risk factarx listed above, can be found in the f:41roviug seclians of the Food Code and 10.5 CMR 590.000. its Good Retali Prac_ tices FC 590.000 23. _ Manao qement and Personnel FC - 2 .003 24. Food and Food Protection FC -- 3.004 25, Equipment and Utensils FG - 4 OOS 26. 27.---. Water, Plumbing and Waste -Ph sical Facility, FC -5 FC-6 .006 .007_-- 28. Poisonous or Toxic Materials FC - 7 .008 29- S genal Re uiremonts .009 30, _ ether ssont. �,m,�ea-zixm CITY OF SALEM (� n ( BOARD OF HEALTH Establishment Name: / 1 /G✓11�� Date: ro/ / Page: of Item No. Code References C - Critical nem R —Red Item- f DESCRIPTION OF VIO -ATION / PLAN OF CORRECTION t PL ASE PRINT CLEARLY -x T Date ( Verified QUI /J i /� �r f r, re t, r a4 /tom r lt�� ./ i , r r n l c).Y- P I-lJ5s2-110n1-' —TU) QQ-*k OM F bLwe -Ler y (fie CoaGz, r 1 how ruck _ Crites �)1-1 l I (( jJ 4:6 V% 4 r-,?i6k rf rvv/ "_ mss`" ;�57J(- L7 v�� �j'�+JJ<'azp„-Y{'"•5 �"j `C�'' ,4� �'O �, 2P x / A V� Co'JJI,ti Cell, t� I/r//L f-ry eL (,elrGyP U ^1i�n rQ'I,n IJCCr COt6 J) W91^ 1f I^C— 1-0j.4e -1/9 Discussion with Person in Charge: 1 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 ExclusioRestriction / n Re -inspection Scheduled ❑ Emergency Suspension i ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 17 18 TIMET EMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives'" -_- 3-302.14 Protection from Unapproved Additives* 19 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers` 7-102.11 Common Name - Working Containers* 7-201.11 1 Separation - Storage` 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use' 7-203.11 Toxic Containers - Prohibitions* 7-204.,11 Satitizers, Criteria - Chemicals* 7-204.1.2 Chemicals for Washing Produce, C iterial, 7-204.14 Drying encs. Criteria* 7-205.11 Incidental Food Contact. Lubricants - 7 -206.11 Restricted Use Pesticides, Criteria* 7-206.12 1 Rtxient Bait Stations* 7-206.13 Traeking Powdus, Pest Conerol and Monitoring* TIMET EMPERATURE CONTROLS Denotes critical item in tht tederd 1999 Food Code or 105 CMR 590000. Proper Cooking Temperatures for PHFs Received at'lemperatures According to taw Cooled to 41°F/45" F Within 4 Hours. PHFs 3-401-I.IA(D(2) Eggs- 155°F15Sec. 19 Eggs -Immediate Service 145°F15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(B) 59090417) Animals - 155°F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast -130°F 121 ruin* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 3-501.16(A) sec * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Time as a Public Health Control Stuffing Containing Fish, Meat, 3-501.19 Poultry or Ratites -165`F 15 sec. *' 3-40 1.11 (C)(3) Whole -muscle, Intact Beef Steaks Variance Requirement 145°F * 3101.12 Raw Animal Foods Cooked in a Microwave 165`F * 3-401.11(.A)(1)(b) All OtherPHFs- 145°F '15 see. Reheating for Hot Holding 3-403.1 I(A)&(D) PHFs 1650.F 15 sec. * 3-403.11(B) Microwave -165°F2 MinuteStandina Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* _ 3-40111(E) _ Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PRFs 3-501.14(A) Cooling Cooked PHFs from 140cF to 70°F Within 21[cars 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 tht tederd 1999 Food Code or 105 CMR 590000. 6 • ei io 21 3-501.14(0) PHFs Received at'lemperatures According to taw Cooled to 41°F/45" F Within 4 Hours. 23. Mona ement and Personnel 3-501.15 Cooling Methods for PHFs 19 3-801.11(D) PHF Hot and Cold Holding 25. Equipment and Utensils 26. Water. Plumbinq and Waste 3-501.16(B) 59090417) Cold PHFs Maintained at or below 41%45° F* 27. Phswal Facility. _-.-__ 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 28. Poisonous or Toxic Materials 3-501.16(A) Roasts Held at or above 130°F. 20 Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590004(H) Variance Requirement 6 • ei io 21 3-80 111(A) Unpostemizcd Pre-packaged Juices and Beverages with Warning Labels* 23. Mona ement and Personnel 3-801.11(13) Use of Pasteurized 'Eg .s* 24. Food and Food Protection- 3-801.11(D) Raw or Partially Cooked Anunal Food and Raw Seed S rout's Not Served. 25. Equipment and Utensils 26. Water. Plumbinq and Waste 3-801.11(C) Uno erred Food Package Not Re -served. CONSUMER ADVISORY 22-7 F Consumer Advisory Posted for Consumption of 23. Mona ement and Personnel - FC -- 2 Animal Fcads'rhat are Raw. Undercooked or 24. Food and Food Protection- FC -3 Not Otherwise Processed to Eliminate 25. Equipment and Utensils 26. Water. Plumbinq and Waste FC - 4 FC S Pathogens.* eger" """ 27. Phswal Facility. _-.-__ 3-302.13 Pasteurized Eggs Substitute for Raw Shell 28. Poisonous or Toxic Materials FC -- 7 E gs* SPECIAL REQUIREMENTS 590909(0)-(D) Violations of Section 590.009(A) -(D) in catering. mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail. practices should be debited under 7129 - Special Requirements. F141 ff#Xt9RM;74 "2 (Items 23-30) Crilical and non-critical violations, which do not relate to the foodborne illness interventions and riskfactors tisied above, can be found in the following .sections of the Food Code and 105 CMR .590.000 Item Good Retain Practices_ F 590.000 23. Mona ement and Personnel - FC -- 2 .003 24. Food and Food Protection- FC -3 .004 25. Equipment and Utensils 26. Water. Plumbinq and Waste FC - 4 FC S .005 _ 27. Phswal Facility. _-.-__ FC -6 __.006 007 28. Poisonous or Toxic Materials FC -- 7 .008 ------- 29 S ecial Re uirements 30 Other 009 CITY OF SALEM �1 BOARD OF HEALTH r Establishment Name: IM'I sc�i /�L._ bg Date: / F o Page: s of ` Item No. Code Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - < PLEASE PRINT CLEARLY bate Verified - t 1 6 A � raA4 „a, 17 fn � - E . I 7 J. e �iLt- Jr l4 a%. I�• A\f 6<a4c n3 2 nd tw- rer, ,A t o iG 2A- k'pa,-C- Q/Ic- 9 3-c,-0116 0IY H �� f_ ?4 c� 1- 3� - 7 ( / SP " . od_ 6'' VDT»I.t2 t/L ns �l v l wf,z ,t 6, f Skv I CC' e f G� ✓�E� yI Z L + ro F— L ./4-0 /3"! jlyw,de , -k-cIMnn( o /l r11�� n Cn (e [ T Cc. � 1 4 i f o2t7! 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/rev'ocation of your food permit. Corrective Action Required: ❑ No Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion e -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 17 18 TIMEffEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-501.16(B) 590.004F) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers" 7-102.11 Common Name - Working Containers* 7-201.1 1 Separation - Storage" 7-202.1.1 Restriction - Presence and Use* 7-202.12 Conditions of llse* 7-203.11 Toxic Containers - ProhibibonO* 7-204.11 Sanitizers.Criteria- Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria'` 7-204.14 Drying Agents, Criteria's 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* TIMEffEMPERATURE CONTROLS * Denotes critical item in 1110 federal 1999 Food Code or 105 CMR 590-000. 19 20 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.11A(1)(2) Eggs- '155'F 15 Sec. 3-501.16(B) 590.004F) Eggs- Innnediate Service 145'F15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.1.6(A) Animals - 155'F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast -,130'F121 min* 3-401.1'I(A)(2) Ratites, Injected Meats- 155'F 15 590.004(H) sec. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PRFs, 27. Stuffing Containing Fish, Meat, FC --6.007 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 165F * 3-401AI(A)(1)(b) All Other PHFs --145'F'15sec, Reheating for Hot Holding 3-103.11(A)8r.(D) PHFs 165°.F 15 sec. ^` 3-403.11(B) Microwave -165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Foxed - 140°F* 3-103. H (E) Remaining Unslieed Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Coaling Cooked PHFs from 1.40'F to 70'F Within 2 Hours and From 70'F to 41.'F/45'F Within 4 Hours. * 3-501.14(6) Cooling PI-IFs Made From Ambient Temperature Ingredients to 410F/450F Within 4 (lours* * Denotes critical item in 1110 federal 1999 Food Code or 105 CMR 590-000. 19 20 3-501.14(C) PHFs Received at Temperatures According to Iaw Cooled to 41�F/45`�F Within 4 Hours. 3-501.15 Coolin-, Methods for PRFs 23. PHF Hot and Cold Holding 3-501.16(B) 590.004F) Cold PFIFs Maintained at or below 4P/45'F42 3-501,16(A) Riot PHFs Maintained at or above 14WR * 3-501.1.6(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) VaIia'nee Reulrement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with We, nine hibels* FC 3-501_ 11(B) Use of PasteurizedEees* 23. 3-801. t 1(D) Raw or Pattially Cooked Animal Food and Raw Seed S routs Not Served. 'r FC - 2 3-501.11(C) Uno eared Food Package Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of FC Animal Foods That are Raw, Undercooked or 23. Not Otherwise Processed to Eliminate FC - 2 Pathogens.* ",n.7nm 3-302.13 Pasteurized Eggs Substitute for Raw Shell FC - 3 E s* 1:%4*1l1MORNIRIAtF7 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and tisk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. W.T-Tafitraxy (Items 23-30) Critical and non-critical violations, which do not relate to the ,foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR' 590.000 Item Good Retail Practices FC 5k000 23. _ Manu emenl and Personnel FC - 2 .003 24. __ Food and Food Protection_ FC - 3 .004 25. ---- -.__-- E ulpment and Utensils FC .005 26. -- Water. Piumbin and Waste --.4 ----....------ --- FC -5 ...006 -- 27. Ph sical Facilit _ FC --6.007 28. Poisonous or Toxic Materials FC -- 7 .008 29. - - S ecial R uirements .009 30. J.0ther ss�aro„m�a-z.o-,c Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4t Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Namehr U' le I �lq I ",?A , A Arv. Da % b/ Type of Ooeration(sl ❑ Food Service Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Type of Inspection ❑ Routine 5� 8e -inspection Previous Inspection Date: - G ❑ Preco erationr ❑ Suspect Illness ❑ General Complaint F-1 HACCP ElOther �l Address�n 9 Risk Level Telephone r j as ^ HACCP Y/N Person in Charge IC) / Inspector Time In: Out Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action.as determined by the Board of Health. lS� 1 PIC Assigned /Knowledgeable / Du4es �❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3.. Personnel with Infections Restricted/Excluded FOOD FROM APPROf/EDSOUFtCE '„H ,a„a" a�� El 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 12. Prevention of Contamination from Hands ❑ 13 Handwash Facilities PROTECTION FROM CFi�MICALS '�i� a - , ��"� `�" �� ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals `.TIMEREMPERATURE CONTROLS (Potendegy Haardous Foods)"'-� � ❑ 16. -Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling " PROTECTION FROM CONTAMINATION � � `, � �i , � n k° r m ❑ 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„ IP„i 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007)' 28. Poisonous or Toxic Materials (FC -7)(590.006) 29. Special Requirements (590.009) 30. Other S50na lFame 14,a I n ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control �;,REOtIIEtEMENTS FOR H16MLY SUSCEPTIBLE FOPULATIONS_{HSPj ❑ 21. Food and Food Preparation for HSP CONS, UWRADVISORY». „�u,�u�ng .rawer. �...w�:,2w,.a'.0 ❑ 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: 01111101 Inspector's Signature: Print:�7 PIC's Signature: ! ..�__-� Print: l(.Y ✓n r-1// S C PSC' ,, Paged ofy,.Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 596.003(A) I Assignmeht'ofResnonsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to Compliance with Food Law* 3-201.13 require reporting by foal employees and 3-201.13 Fluid Milk and Milk Products* applicants" Shell Eggs* 590.003(F) Responsibility Of A Foal Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Char e* 590.006(B) 590.003(03) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions Im 6 FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Pax] Cale or 105 CMR 590.000. PROTECTION FROM CONTAMINATION S Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.13 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.1.3 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0" Washing Fruits and Vegetables Sheltlrsh and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authorit 3-202.18 Shellstox k Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.1.1. PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstoek identification * 3-203.1.2 Shellstoek Identification Maintained" Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.1.2 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 tacka 'ng, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Pax] Cale or 105 CMR 590.000. PROTECTION FROM CONTAMINATION S Cross -contamination 3-302.11(A)0) _ Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.1.5 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 Warewashina - Hot Water SanidzationTerr eratures* - 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem eratures* 4-501..114 Chemical. Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Arms* 2-301-12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2-101.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tastin " 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placernent* 5-205.1.1 Accessibility. Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.1.2 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: 1()4 Page: -i. of Item No. Code I,C9 Referen4 Reference C —Critical ltemfj�, R ��'Red Item DESCRIPTION OF VIOLATION PLAN OF CORRECTION ON,, A P LEASE PRINT CLEARLY„" Verified 4� 'rified �44 4--\ r VDate [nn A.t)V—_ Ce, I It' C Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. PI [Corrective Action Required: LI: No _,Yes, cl Voluntary Compliance 0 Employee Restriction Exclusion U Re -inspection Scheduled 0 Emergency Suspension U Embargo D Emergency Closure Ll Voluntary Disposal U Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Zerns, 1-22) (Cont) PROTECTION FROM CHEMICALS braFood or Color 16 Additives -72(12,12 1 Additive," PHFS Poisonous or Toxic Substances -- 7101.11 ron iginal nlifying Infornea- Or 3-501A6,(W Containers- 7 102,11 Corwarat N'Larre - Work, In'Cotaaiaera* 7-20 (A i -SIT±1 4rieli 7-202.17 Presence and Usc* 7-502E Conditiow of Use* 7-203,11 Toxic Cxarlairre.Ts - Prohibintavg* 7-204. SanitVei7s.Tnieria - Chante ds* 7-204.E I Pr2dacc-, clitcriall (Fhu1jCak forYVas!� -- lle, 7-204,14 tiri9tl 41. colt, criwria- -717i(Ti-1 I Incidental Food Etnta(t. EiIi tcanW Sniffute Containing Fish, Meet, —ne-T,*ticides. Criteria* 7-206.12 Rodent Bait Sutwais' 7-2065.'13 Tracking Pow(Jcra, Best Control and Rh lc mtu,Fc, Intact Becf Steaks ixforriorin" 16 NiFF Reecived at Temperatures Proper cooking Temperatures for AX('Tdill.'1 to Um Cooled In PHFS 3-401A 151'F 15 Sec. PHF Hot and Gold Holding 3-501A6,(W I ri"'F15sec- �90 0IM(F) ')r H. INA) TZ07i.1T(A)(2) Comunnoted Fish, Meats & Game i "IiOast 5 licid at 01 above 130E �iTu Ani natis 155"F 3-ioi 19 IU.n04tH) 740i I F(B)( 1)(2) Poik and Feel Rimst - 1301- 121 nriW a[az WFtnSettY 3 -401 1 (A)' 2) i Rvtn", Ituc(i,,d Mcms 155'F 15 2i 8,51 11 fT) Utq,.tclari..cdl 11rc-pacraged Anocs and 3-40 1.11 (A)( '3) s' Sniffute Containing Fish, Meet, . Pc ultror kaatcs-165° 15 sec. I'- 3-40I.IltC)9) Rh lc mtu,Fc, Intact Becf Steaks t47 F. —a 3-401.12 R;m In Microwave 165'F* 3-401,11IA)(lab) All Other PHFs -- 1451i5sec. Eli: Reheating for Hot Holding (5) PfIF, 105°F 15 sec, I 3-403.11 (b) Miciomwe- l(&'F 2 Minnie Situating Time' 3-403.11(C) Coorincrcially Paxess'ed RTE F'X)d - i 40"F I Reamminui, Roast,* Proper Cooling of PRFs -50 1, 14(A) Ctx,liag Cook,,,d PHrs from 140'F to 101, Within 2 hours and From 70"F C"oahngPHlrent ITT,,, T Toripe r attire w nit in 4 1 ItA its, N I 105 ('lull{ MR 59i t 000 '4-50 1 - i 4W) NiFF Reecived at Temperatures AX('Tdill.'1 to Um Cooled In i)'F/45"F Within_4 Hows, Coofiw, Mellrods for PHIPs 19 PHF Hot and Gold Holding 3-501A6,(W Cold PHI s Moinutoted at or below �90 0IM(F) ')r H. INA) 4t 145` (' I lot PHI Madel iined at or above i "IiOast 5 licid at 01 above 130E �iTu me as a Public Health Control 3-ioi 19 IU.n04tH) Tit Me as a Nbf;c I loath (."OritroP RG a[az WFtnSettY REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HS� 2i 8,51 11 fT) Utq,.tclari..cdl 11rc-pacraged Anocs and to 5r Sjuroac, Not Served, Fkyxi Packacc No Re-sencd CONSUMER ADVISORY iTTC--Z63-1 Fj-1C'-o-UaoI(11 A -0-c k--oi Y­P­o�ted 1 - or —Consumption of Arinol That arc Raw. Urrderc )ked ol %'ot Othem rte rregscd to Flimirraic 3-3.6'.11 1 FaI2=SoWwnrle for Raw SPECIAL REQUIREMENTS r ;T -t 5Violalicln, of Section 590.0)9(A) -(D) in cawrinymobil- temcit teinpoiany and residerilat kitchen oporatimis ,mould be, dchled u,ndcr the appruprirte Sections above if related to frodhorm: illness iwcfvenflons and ri-A factors. Other 590.00c1 violations relakinlo to good retail pniefic(,c slhonldh- debited under #29 - Spe!c-W (Itents 2.1-3(f) '/ovdfiorfw illness and nAkja, tort 1ict4 d above wn be foand in Ow,joiiou vuf se(tions qlt At, Fo,id Cod, and )05 CXIR 90 -000 Massachusetts Department of P Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Sj ubllc Health Salem Board of Health 120 Washington Street, 416 Floor J Salem, MA 01970-3523 A Tel. (978) 741-1800 Fax (978) 745-0343 Name Ie Ho, D to Type of Operation(s) Type of Inspection ❑Food Service Retail Residential Kitchen ❑ Mobile i❑ Routine Re -inspection Previo s Inspection Date ;gp/v � 1 a O Address^ S32 �hyfMel isk Level Telephone ElTemporary ❑ Pre-operation OwnerHACCP I�Ortj_ JI [ YM ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑❑ General Complaint -I Person in Charge (PIC) f/ ' Time Ind, HACCP Inspector out:3:ds' Permit No. El Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated:, Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. s" FOOD PROTECTION #ANAJQ0#EJ I,®4M,VICIP11111f I ' ❑ 12. Prevention of Contamination from Hands 1 PIC Assigned/ Knowledgeable/ Duties _ ❑ 13 Handwash Facilities EMPLOYEE HEALTH,,,�,aa.s,.i�:`i "PROTECTION FROM CHEMICALS~ i,'9x-k �❑ 2. Reporting of Diseases by Food Employee and PIC +` _ „» °� -�„ ��ssflt�= =13c ❑ 14. Approved Food or Color Additives ❑ 3.. Personnel with Infections Restricted/Excluded fl 15. Toxic Chemicals FOOD FROM APPROVED SOUgCF ia 4 ' E ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements L LS TIME/TEMPERATURE CONTRO(Foterltiaily Ha ardous Foods),`= A6&.��We, 'm ❑ 16. Cooking Temperatures 1 ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONT%1MINATION'I`tT �""; ''°; ❑ 19. Hot and Cold Holding 8 �/ Segregation/ g = i �/ Pr tee " li a. 20. Time As a Public Health Control ❑ P8. Separation/ Segregation/ Protection ❑ . ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices 11 Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. iC<14 0 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:5901nsp UFCm 14,tl n fin hE6U1_REMENTS FOR HIGHLY SUSCEPTIBLE.POPULATWNS (F#S0-- ❑ 21. Food and Food Preparation for HSP ❑ 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: G Inspector's Signature: Print: PIC's Signature: v g � C Print: J.,� / l it, ;�nn:r�' es Page-( of -4 -Pages g g U v Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A} Assn mentofResponsibi.lity*----=__� 590.003(B) Demonstration of ICnowled�* 2-103.11 Person in charge- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System" 590.006(A) Charge* 590.006(B) 590.003(11) Reporting by Person in Charge' 3 591).003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 FOOD FROM APPROVED SOURCE * Denotes critical item in the Peder d 1999 Food Code x 105 CMR 590A00. r 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 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..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 ShefHish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Iisted Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authori 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* 3-202.1.5 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(7) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ntent* Conformance with Approved Procedures -/HACCP Plans _ 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the Peder d 1999 Food Code x 105 CMR 590A00. r PROTECTION FROM CONTAMINATION 8 Gross -contamination 3-302.1I(A)(l) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Ford Contact with Equipment and _ Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Foot* -. 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 Warewashino Hot Water Sanitization Tem eratures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-60 Li I(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Ftotl- Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ntent* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301..11 Clean Condition - Hands and Anus* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2401.11 Eatin , Drinking or Usin Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing, Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently located and Accessible 5-203.11 Numbers and Capacities* 5-204.11. Location and Placement* 5-205.11 Accessibility, 0 reration and Maintenance Supplied with Soap and Hand Drying Devices - 6-301.11. Haridwashing Cleanser, Availability 6-301.1.2 Hand Drying Provision N Establishment Name: CITY OF SALEM (� BOARD OF HEALTH 1. Yn 111C I �rin �. 1. Date: r?/-; Ile') ry Page: ��— of 2r:: Item +Code C -Critical Item.;; DESCRIPTION OF VIOLATION / PLAN OF CORRECTION «3' ` 1- 'Date ,_g Verified t No. Reference' R - Red Item 4 1 ;, > - PLEASE PRINT CLEARLY 0 �Oltrc �Cl-Qs _fbVr •11/1 ^ ��7� CC YPCrA� brit AJszP C�U,5 G I O(7 V� l Gn/hJCCtno '4(144(4 �n r tSdO/LSP/ 61iDD i - f. t r rY.I! Ce_�n �1, u fEz�t �� S11 �eRr s✓ 7i�ne f 5 ICi mc,r r�c G A IY) <J. 1 qr 14 0,' I L( v -I f I n J,_fn Ury . 1 . �N� f7� (Z/1/ /iAi'n71 i- )\DAJ0A (<(-rr /In .f J111 AA I I A {n� 6 _xv— c« 3(j:( 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 / Exclusion violations before the next inspection, to observe all conditions as described, and to )\�Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure t your food permit. ,_.--------��� ❑ Voluntary Disposal 0 Other: Violations Relatad to Foodborne fitness interventions and Risk Factors (Items 1-22) (Cont) PROTECTION FROM CHEMICALS 114 l� a --i�—� Food or Color AdtltuvesF� 3-202.22 Additives* 3102.14 Protection from hnappaz>s°edAddttrres"__� Poisonous or Toxic Substances '-R)l I 1 � Idernifying lntormation -; Original _ Contaui w _ 7 i02_i1 C_offimonNi ame-Workia'Containers* 7-201.11 5Latton — Sun a�C' 7-202.11 Restriction — Presence and t"e* 7-202.12 Conditiole, of Usil* 7-203 11 Toxic Containers—prohibitiow* 7204. i 1 Sannirers Crit na Chunicals . - 7-204.12 Chenncak for washillg I iroduecC uteda* �7.904.1_4 DTv—i r, 4$eu ' Criteria,, _ 7-205.12 Incidental Food t untact, l.tibaictnits' 7-206.11 Rosiruledl sa Re ticides. criteliat �. 7-2UG.t2 Radon( Bait SUAIOTiS° "i 206.13 Tracking Polvdec . Pest Cunte01 and 4tou�tarings _ v T Proper Cooking Temperatures for _ PHFs 3- 401.1.1.A(l)(2) Fggs 17� F 15 &.,c. _ i -.as. lniaaediate Service (45rFi5sec 3-401.11(A)(") Comminuted fish Meats panne Annuals - i i'i l 15 sec _ i 34(31.1E(13)(1)(2) Polk, and Beef R(mm-136 f 121 minr`� 3-401.11(A)(2) �R rotes, fill ect d h4r.nts 155 F 1 _ sec _ -46t.iktAy l_ poultry, Wild Crarue. Stuffed PHFs StofiuigComantint Fish Meat I>Ouhr brRautes iG5°F 15xc. 3-401.11(C)(3) tVboh-mus to Ittictl3ecfSicaks 1 TZ I J 2��— Raw Animal Foods Conked in a i __ _ Microwave 165'F 1-4 * _ U1.11(Ai(1)(b) All Otliec PHFs 14';'F 15 kec. Reheating for Hot Holding 3 403.1 k(A)R(D) 1114F x 165°f 15 vec 3-403. 11 (B) MictolAave lbs' F2 Minute Stauding _ Tmie' 3 103. i I (C) Commerciaiy prroce'sed RTE 1.1xx1- j 140'F* 3.403.11(6) Remsuning U'nsliced Portions of Beet Roasts* Proper Cooling of PHFs 3-501.14(A) Catling Cooked PFiFs from 140`F to 70°F Within 2 Flours and From 701` _ to 4l'F745`F Within 4 Hours. * ) 1 501,146) C(mlinst PIdFs Made From Ambient Temperature Ingredients 1(,41"1/45`F ( � Willits g 11(mr, v IMIVAOs cnticsl ii¢rn ht the &'doral 1999 Food Cixfe or 105 CM 591) 000. 3 SQ1 i-ifL"} N€•s t ao rfillb to faai Cooled ratures to i t Fi45 F Within4 Hun's_ =3501,i3 a Caahnz Me€hais for 1114Fs 1 5Ui 16(H) Coat:! PHF, Maintained at or below 590 004F) 41 i45" F - 501 J fi4.A,) � lint PHFs Mainrained at or above I nr, P 3-5011 ifi(A) I Roasts field at or above 130°F. i Time as a Public Health Control Ptmc as at Public Health Control* Variance Recuirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _ POPULATIONS (HSPj 21 13-80i. 5-801ANAI IUnpvsteurize i pre-pac{.aged tutees uid i-50! I t(13t Ls o1 Past( lit ed t. Vis* �.� 3-80( 1 It1)) Raw or PalliatiC(K*k d Auimat Food and _ R n S( d patois 'Vol Screed. .-K{) !ICC) Ssn me tied Faxi Paclau,v but Reserved. " 22 3-60? 11 { Consanner 4dvisor5 Postod f;orConsumption of aihr ii f mtdc Chat are, Raw. Undercaiked or 4otOhiemiwProcessed toFiunmate t>athtenS * " "F 3-30".Ln 1',tearir d l.uz.' 4.ihsatatr for Raw Shell SPECIAL REQUIREMENTS 59U.099tA)-{C})� V iolducrn s of Se coon 590.009(A) -(D) in atcrwa. inobile iood, teniporary and reeid( ntiat kitchen operations should be debued under The aPprOpriate vectwns alone if resited To foodhorne illness interventions and risk factors Othcr 590.009 violations relating to good retail hrar tires should be debited under #29 — Spccod Regtiircnt itis. (penis 23-10) Ctficlw rand non-erilwai (i< 6atioris-, which do no retare to ifir foodborne Ulness tired above, can be found Lt nhe J )Piowng serrirnis of tie Food Code mid 105 CMR v T Proper Cooking Temperatures for _ PHFs 3- 401.1.1.A(l)(2) Fggs 17� F 15 &.,c. _ i -.as. lniaaediate Service (45rFi5sec 3-401.11(A)(") Comminuted fish Meats panne Annuals - i i'i l 15 sec _ i 34(31.1E(13)(1)(2) Polk, and Beef R(mm-136 f 121 minr`� 3-401.11(A)(2) �R rotes, fill ect d h4r.nts 155 F 1 _ sec _ -46t.iktAy l_ poultry, Wild Crarue. Stuffed PHFs StofiuigComantint Fish Meat I>Ouhr brRautes iG5°F 15xc. 3-401.11(C)(3) tVboh-mus to Ittictl3ecfSicaks 1 TZ I J 2��— Raw Animal Foods Conked in a i __ _ Microwave 165'F 1-4 * _ U1.11(Ai(1)(b) All Otliec PHFs 14';'F 15 kec. Reheating for Hot Holding 3 403.1 k(A)R(D) 1114F x 165°f 15 vec 3-403. 11 (B) MictolAave lbs' F2 Minute Stauding _ Tmie' 3 103. i I (C) Commerciaiy prroce'sed RTE 1.1xx1- j 140'F* 3.403.11(6) Remsuning U'nsliced Portions of Beet Roasts* Proper Cooling of PHFs 3-501.14(A) Catling Cooked PFiFs from 140`F to 70°F Within 2 Flours and From 701` _ to 4l'F745`F Within 4 Hours. * ) 1 501,146) C(mlinst PIdFs Made From Ambient Temperature Ingredients 1(,41"1/45`F ( � Willits g 11(mr, v IMIVAOs cnticsl ii¢rn ht the &'doral 1999 Food Cixfe or 105 CM 591) 000. 3 SQ1 i-ifL"} N€•s t ao rfillb to faai Cooled ratures to i t Fi45 F Within4 Hun's_ =3501,i3 a Caahnz Me€hais for 1114Fs 1 5Ui 16(H) Coat:! PHF, Maintained at or below 590 004F) 41 i45" F - 501 J fi4.A,) � lint PHFs Mainrained at or above I nr, P 3-5011 ifi(A) I Roasts field at or above 130°F. i Time as a Public Health Control Ptmc as at Public Health Control* Variance Recuirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _ POPULATIONS (HSPj 21 13-80i. 5-801ANAI IUnpvsteurize i pre-pac{.aged tutees uid i-50! I t(13t Ls o1 Past( lit ed t. Vis* �.� 3-80( 1 It1)) Raw or PalliatiC(K*k d Auimat Food and _ R n S( d patois 'Vol Screed. .-K{) !ICC) Ssn me tied Faxi Paclau,v but Reserved. " 22 3-60? 11 { Consanner 4dvisor5 Postod f;orConsumption of aihr ii f mtdc Chat are, Raw. Undercaiked or 4otOhiemiwProcessed toFiunmate t>athtenS * " "F 3-30".Ln 1',tearir d l.uz.' 4.ihsatatr for Raw Shell SPECIAL REQUIREMENTS 59U.099tA)-{C})� V iolducrn s of Se coon 590.009(A) -(D) in atcrwa. inobile iood, teniporary and reeid( ntiat kitchen operations should be debued under The aPprOpriate vectwns alone if resited To foodhorne illness interventions and risk factors Othcr 590.009 violations relating to good retail hrar tires should be debited under #29 — Spccod Regtiircnt itis. (penis 23-10) Ctficlw rand non-erilwai (i< 6atioris-, which do no retare to ifir foodborne Ulness tired above, can be found Lt nhe J )Piowng serrirnis of tie Food Code mid 105 CMR v IMIVAOs cnticsl ii¢rn ht the &'doral 1999 Food Cixfe or 105 CM 591) 000. 3 SQ1 i-ifL"} N€•s t ao rfillb to faai Cooled ratures to i t Fi45 F Within4 Hun's_ =3501,i3 a Caahnz Me€hais for 1114Fs 1 5Ui 16(H) Coat:! PHF, Maintained at or below 590 004F) 41 i45" F - 501 J fi4.A,) � lint PHFs Mainrained at or above I nr, P 3-5011 ifi(A) I Roasts field at or above 130°F. i Time as a Public Health Control Ptmc as at Public Health Control* Variance Recuirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _ POPULATIONS (HSPj 21 13-80i. 5-801ANAI IUnpvsteurize i pre-pac{.aged tutees uid i-50! I t(13t Ls o1 Past( lit ed t. Vis* �.� 3-80( 1 It1)) Raw or PalliatiC(K*k d Auimat Food and _ R n S( d patois 'Vol Screed. .-K{) !ICC) Ssn me tied Faxi Paclau,v but Reserved. " 22 3-60? 11 { Consanner 4dvisor5 Postod f;orConsumption of aihr ii f mtdc Chat are, Raw. Undercaiked or 4otOhiemiwProcessed toFiunmate t>athtenS * " "F 3-30".Ln 1',tearir d l.uz.' 4.ihsatatr for Raw Shell SPECIAL REQUIREMENTS 59U.099tA)-{C})� V iolducrn s of Se coon 590.009(A) -(D) in atcrwa. inobile iood, teniporary and reeid( ntiat kitchen operations should be debued under The aPprOpriate vectwns alone if resited To foodhorne illness interventions and risk factors Othcr 590.009 violations relating to good retail hrar tires should be debited under #29 — Spccod Regtiircnt itis. (penis 23-10) Ctficlw rand non-erilwai (i< 6atioris-, which do no retare to ifir foodborne Ulness tired above, can be found Lt nhe J )Piowng serrirnis of tie Food Code mid 105 CMR SPECIAL REQUIREMENTS 59U.099tA)-{C})� V iolducrn s of Se coon 590.009(A) -(D) in atcrwa. inobile iood, teniporary and reeid( ntiat kitchen operations should be debued under The aPprOpriate vectwns alone if resited To foodhorne illness interventions and risk factors Othcr 590.009 violations relating to good retail hrar tires should be debited under #29 — Spccod Regtiircnt itis. (penis 23-10) Ctficlw rand non-erilwai (i< 6atioris-, which do no retare to ifir foodborne Ulness tired above, can be found Lt nhe J )Piowng serrirnis of tie Food Code mid 105 CMR .. .11 � ... -�y! :. ` •�..a�y�...4q/, �.^ .h -r: - ty4"+�6�;,"r , „`F,.. k. � Mw S,'.1��" ''.. i^ �. Y.b Q*"I �.r,:,. yt. ,.bnY ^'a.'..- � A *_ Massaousetts Department of Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPOR Public Health T Salem Board of Health 120 Washington Street, 4'" Floor Salem, MA 01970-3523 Tel. (978) 741-1800; Fax (978) 745-0343 Name 1.t �/n /)A -"j Dto c� 3D/0 CI Type of Operation(s) ❑ Food Service $ Retail Type of Inspection Routine Re -inspection Address/ Risk' �/ JJ uSn Level ❑ Residential Kitchen Ell Mobile Previous Inspection Date: Telephone '44 0 [I Temporary ❑ Pre-operation Owner 'R HACCP Y/N El Caterer E] Suspect Illness f 3dC'n l) iS E] Bed & Breakfast [J General Complaint ❑ HACCP Person in Ch ge (PIC) Time `` Inspector p In: 3t3� Out':�}5 Permit No. El Other Each violation ecked requires an explanation on the narrative page(s) and a citation of specific provisions) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 5910.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANl1C+EWENT " � L ki .., 3 a _" ""J ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned / Knowledgeable / Duties i wa •, SRI •� .�„ �H m -n ,;y,.. ❑ 13. Handwash Facilities iEMELOYEEHEALTWF., x,�a ,'� �', '�j F itl�i=`3 ❑ 2 Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded i. FOOD FROM APPROVED SOURCE Egl T&MM" El 4. Food and Water from Approved Source 6(5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans rPROTECTION FROM CHEMICALS �ty',=�z w,ry r:a ,� m N �; 4 5 t i ei....,a.m4lrWaiad� . (..-' El 14, Approved Food or Color Additives k5. Toxic Chemicals ii TIMEITEMPERATURE CONTROLS (PotentiaHq Hazardous Foals) [116. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling PRb TECTION F OM CONI `MINA ® N ` `tl g'� `���' ` ❑ 19. Hot and Cold Holding El 8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control r_19. Food Contact Surfaces Cleaning and Sanitizing - P`:REOUIREMENTSFOfi HIONLY-$USGEo, C POPULATION$ (HSP) J ❑ 21. Food and Food Preparation for HSP ❑ 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. G ,R 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, 5901nVp Fom 14,dm CONSU, RADVISOtiY,';,„„„,.«.,,�„ .�.ry..�..,., ���, ` '� �wi. `'Rip llml ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION' N `/ a�� Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) _ FOOD PROTECTION MANAGEMENT 1 590.003(A) Assign 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 whit Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge' 3 590.003(D) Exclusions and Restrictions* 3-201,15 590.003(E) Removal of Exclusions and Restrictions C L C C FOOD FROM APPROVED SOURCE * Denotes critical item in Phe. Federal 1999 Food Code or 105 CMH 590.000. �rw PROTECTION FROM CONTAMINATION 8 Food and Water From Regulated Sources 590.004(A -B) Compliance whit Food Law* 3-201.12 Food in a Hermeticall • Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washurz Fruits and Vegetables ShelHrsh and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201,15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present" 590.004(0) Wild Mushrooms* 3-201..17 Game Animals* 3-701.11 Receiving/Condition 3-202.1.1. PHFs Received at Proper Temperatures* 3-202.15 Package integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Sheilstock 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' Frequency of Sanitization of Utensils and Food Contact Surfaces of ui mcnt* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Me0tods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in Phe. Federal 1999 Food Code or 105 CMH 590.000. �rw PROTECTION FROM CONTAMINATION 8 Cross -contamination - 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Fails* Contamination from Raw Ingredients 3-302A I(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washurz 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 F,W* 9 Food Contact Surfaces 4-501..111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.11.2 Mechanical Warewashing=Hot Water Sanitization Temperatures* 4-501.11.4 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of ui mcnt* 4-703.11 Methods of Sanitization - Flot 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* i 1 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2.401,12 Discharges From the Eyes, Nose and Mouth* 3-301. t2 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 59R004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement.* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashin Cleanser, Availabilit b-301.1.2 Hand Drying Provision I_ d,-q^v, , . I /Im_,_ _ r'\1_ I 1 1_ _ h_-[/-_1_ _ _ . /.- _! .0 I 1 Discussion With Person in Charge: t Corrective Action Required: I ❑ No I5 ❑ /Yes' x CITY OF SALEM I have read this report, have had the opportunity to ask questions and agree to correct all I 1-P VoluntaryCompliance❑ BOARD OF HEALTH /F9� �O violations before the next inspection, to observe all conditions as described, and to tt, jl`J Establishment Name: � {� t`nn 1/meq 1y1 Date: P c Page: � of nem„�,CodeL,z„ 'No. noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of C- Criticainema 'R=Red Embargo �uyuDESCRIPTION OFVIOLATION / PLAN OF,CORRECTION.x- f verifled ❑ Other: , a Reference Item' PLEASE PRINT CLEARLY _ I_ d,-q^v, , . I /Im_,_ _ r'\1_ I 1 1_ _ h_-[/-_1_ _ _ . /.- _! .0 I 1 Discussion With Person in Charge: t Corrective Action Required: I ❑ No I5 ❑ /Yes' I have read this report, have had the opportunity to ask questions and agree to correct all ❑ VoluntaryCompliance❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to `❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne fflness Interventions and Risk Factors (item 1.22) (Cont) PROTECTION FROM CHEMICALS r Fond Or EE ditives- 202,12 Adctiuv"* 3-302,14 Prrotecuon front Unapproved Addnrvesl � y4 Poisonous or Toxic Substances 1 ;-101.11 idenUtymgktfotmanon_-thi tnai !G __ Contain rs* t T02,11 CommonNaroe li or k. n,!(outain4xe” 1 21111. t } .� $ dim atxtn Slot tge' -20111 Restncuou - P, re"ance and 1 se. 7-202.12 Cor do anv of Usv* 7-243.11 ToxicContainn-Vrobibifionst` r "04.11 __._ Samuren Court+ Chuanc+is 7-204. 12 Chemicals frn W t<hi Prochlee Cnteiial 7204.14 Drying Arents_Criteria- ';l-2105,)l rauta J 2105)l Incidental Food C ontact rI_abt cants 7 ,.06. t 1 � Resini led t ae Pe trades, ('titetia* _ 7-4206A2 Rodent rt Sm Tracking Powte*, P 3z Control and l Moamt)rioaa ]G- L_ Calor Ad Proper Cooking Temperatures tar PHFS 3-101.1 t A(l)(2) 3 g.'S- 15i'F 15 S:c. }s7mm�dtue�5ecvicr t45'F15see� _ 3-40L11(A)(2) — Com ... inwed Fish, Meats & Gator Animals - 155'F 15 sec. _ 3-401.11(B)( 1)(2) Fork and )feet Roast - 1)( € 121 Film* 3-401.11(A)t2) ( llrotes, tnjtcc,,d Mcats -155"F 15 i-- 3-401,11(Ay 1) Poniny,Wild Gam Stuf('e1F'NFs, sruftnte coulatnint Fish. Meat, Poultry or Katims 1651' 15 s, -c. 3-401.1)iC,.)(3) Whcle mus lc. ImactBQcfSleaks 1451 ; 13-301.12 Raw AnimalIkxds.Cooked ura Miclowave105`P* — 3-401,111A)(1)(b) All Other PHI -%s - 145"17 15 sec._ try Reheating tar Hot Holding _ 3-193.11 (A)&(D) PHF.g 165"F 15 set;. 3-403.11(13)� Microwave- 165'F2Minute, Standing 3-403.11(C) Commercially Nix ssed RTF Faxtit- 140'14' _ -3 4J I 1(E) _ I2unaining Fnsilred Pornons af.t�eel Roasts*,_____ 18 Proper Cooling al PHFS 3-501.14(A) Cueing C(x;ksd PHFS from I40`F to _ 3-5(ll.14([3t 70`'F Within 2 Hours and From 70'`1' to 41'F145°F Within 4 Houn;. * i Coahng PHF= Made From Ambient Ta rnMatnre lily redientS to 41 "1'745'F ]G- L_ Proper Cooking Temperatures tar PHFS 3-101.1 t A(l)(2) 3 g.'S- 15i'F 15 S:c. }s7mm�dtue�5ecvicr t45'F15see� _ 3-40L11(A)(2) — Com ... inwed Fish, Meats & Gator Animals - 155'F 15 sec. _ 3-401.11(B)( 1)(2) Fork and )feet Roast - 1)( € 121 Film* 3-401.11(A)t2) ( llrotes, tnjtcc,,d Mcats -155"F 15 i-- 3-401,11(Ay 1) Poniny,Wild Gam Stuf('e1F'NFs, sruftnte coulatnint Fish. Meat, Poultry or Katims 1651' 15 s, -c. 3-401.1)iC,.)(3) Whcle mus lc. ImactBQcfSleaks 1451 ; 13-301.12 Raw AnimalIkxds.Cooked ura Miclowave105`P* — 3-401,111A)(1)(b) All Other PHI -%s - 145"17 15 sec._ try Reheating tar Hot Holding _ 3-193.11 (A)&(D) PHF.g 165"F 15 set;. 3-403.11(13)� Microwave- 165'F2Minute, Standing 3-403.11(C) Commercially Nix ssed RTF Faxtit- 140'14' _ -3 4J I 1(E) _ I2unaining Fnsilred Pornons af.t�eel Roasts*,_____ 18 Proper Cooling al PHFS 3-501.14(A) Cueing C(x;ksd PHFS from I40`F to _ 3-5(ll.14([3t 70`'F Within 2 Hours and From 70'`1' to 41'F145°F Within 4 Houn;. * i Coahng PHF= Made From Ambient Ta rnMatnre lily redientS to 41 "1'745'F Witlnn4Hour.0 ` liettoues aawal ism in the foleral 1999 Foml Clea or 165 t: MR 591) 000, 3-5,11, 0(c"1 P}1Fe Reeeived at Temperatures a a Edi t to Lav Copled to 11 1 i45 1 Within 4 Homs - r511' i 5._ _ L 1 e.,tinm Methods for PHFS 1S ! 1 PHF"and 3-50!.10(B) gold PHFi Mi nnttined at or belt), 3 501 t(i{:A) 111nt Ptll +'damtained —ator above 3-51a�1Ci{�1) y�� c,;,gts Hold at or above 13t1�,.}s_ Time as a Public Neatih Cantrot 3 SOE.I� __— rim. as a PubheNealth(,nlniP' 991).0piF13 t V'danex, Reataircmetu REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HS 21 ±-3�?t t i tA? Establishment Name: [A'� inn I/r _" ITY OF SALEM BOARD OF HEALTH Date: i'r�a/D 17 Page: of Item-, 'Code 7- C -Critical Item -t q _>` r. DESCRIPTION OF VIOLATION / PLAN OF CORRECTION 'Date,, Verified No. �. Reference ...� R - Red Item, e .-. ,tz F: " _ r PLEASE PRINT CLEARLY -`'+' -- ""� '_u 5( s, 1'.n! i S S/✓7,71�1/! /_i/r l �W nc—� 4 �Zo /fCc, n I f -1 �,+ 1�J nJf Sk/C SC00� a -bP Com' �P rvtc - eS�.?� 2 /vJ 0 clod —(-6704- _ c d41 e) e Mitt �f _ n, (, a ar- /orl- e-, /-)-,o G f! c 7 Wl ! s f-1GG r IF -5 .r r r r7 C, 1141 1 / �T"tt SLS �6 Ic0 dlAi17 `F,) A 0- n1�_f S(Nrr !n 1Mr)A .jn4:'- <,. t, Al• G( %9C 9 � 4nlcc(� , G la-, I n/ (,[c.MPcc( /-- Discussion With Person in Charge: V Corrective Action Required: 1 .1Eli' No 01.___es' I have read 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 Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five/�dol�lars orsu�p"e'n-sio—n/revocation of ❑ Embargo ❑ Emergency Closure your -food permit. ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne illness interventions and Risk Factors (items 1-P2) (Cont) :a•, c*i, i, Proper Cooking Temperatures for food or Color Additives�� PHFs 3-20212 Egg-- 1,55'F 15 S e. Addled s* r" C- omni d, FR. 5 rditc 1*5'F15sec, 3-30114 Proton T -1 -Ton, l naf.Pr<n�ed �daEtrves":-� 15 -101.1 t Poisonous or Toxic Substances Identifying infdt mation .- Oiti inal V ii'hole-mn le-L4tact Ile f Steaks !Containers* q=i(11.12 7-i02-11 ComrnonName--WorkingC'ontainom* :'-dOLFHA)(1)(b) 7-20(.11 17 Sa arution -Storage" ____ x03.11{A)K(1)) 7-24211 3-403.11(13) Restriction Presence and Use" 7-202.12 3-401 11(C) Condiiions of Use* 34013.11(F i- 7-201311 Toxic Co_utainei:,--P_robibinoc.si* [=!8f-'-- E 7-204.11 _ SanIIizer4, Criteria-Chemiciils" _ 11(B) 7-204.12 l Chenne ils ton Wash 1''']diet C moria_* .� 7''OA.14 Dr,ui4, Ateutt, Crttui t- . 7-205,11 Incidental Faxl C vntact lalhiic los' 7206.11 . Fzestricled Use Pe ttcides. Crit-nal'_ 206.12 1Rodent beat Stations' (1 7'206.13 Itackmg Powders, Pest Contrail and � _�millinain. RUMNMITITTERFEWROMETM 1.6 Proper Cooking Temperatures for L PHFs 3_^401.1.14(1)(21 Egg-- 1,55'F 15 S e. r" C- omni d, FR. 5 rditc 1*5'F15sec, i-401.11.('1)(2) _ i i 401.11(]3 i i)(2) 1-401.11(A)(2) C ommimood l iSh Mews ak Glow Animals - 15,'F 15 se': i'urk and tinct Roast - 130'1-' 121 ruin"x Hmtec,lnjcc�dWats 1a5�F15 we _ Ibui wdPwdC'aamc .SYufPu1PH'Fs, Stuf%IDk('Om-af t nc. Fish bleat, 1 onbry or Rantcli1659 15 sec. s 3-40i.11((,')(3) ii'hole-mn le-L4tact Ile f Steaks 1451 q=i(11.12 lite,' antuul Fuiulti Caked llt a� MEctowave 165^$* :'-dOLFHA)(1)(b) _ All Other PHFl -- 14'i'F 15 sec. 17 Reheating for Hot Holding x03.11{A)K(1)) PHt 165V U sec, 3-403.11(13) Mrcrowavr 145" F 2 Minnie Sumdin;, . Time 3-401 11(C) Commercially Pixxesaed HTE. Koo 34013.11(F i- 140"P Remaining Unsliced Portions of F1ix.f Roasts* [=!8f-'-- Proper Cooling of PHFs S -5t l TI(A) _ Cooling Cook d PHFs from 14t F ill _ 11(B) 10°1 Within a Hours and From 701' to 41 F/45 F W-ithin d Hmur...' Cooling PHF-, Made: FromAnibleut l Tempctarora lneredieras to 41'f145`F Within 4 Hoar< ' ' ,Urnotes critical lien in m7' 4,leral 1 F49 Food Crate oe 1b5 CMR 59U 6(H). -SCi i. ld£Cj j i'i£Fs Rec.-iwci mt `Cemp€ratures 1 Acca dole' to Lain Caned to f 41`FAS'F 1 dein d Hours. 3-501,15 1 Cxsolin,t M4rethcds for PIfFs 3 501 )6,B) ( Ci>t..l PHFs Maintained at or balaw 590A4(F) �41 045' f _ - 50 16( A) l i u PF -ti Maintained et i,, above t WVt 3,5111 16(A) Roasts Held at or above. 130'F. w I Time as a Public Health Control rime as a Public ieatch REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 2i f a_git} ll(Aj -�Unpa tem teed f'rc pac n*ed 7utcxs add t F#c.aei a es teilb Watoin labsls� 3-801 i'f$)._},. Ls ast Pa tent? ed F _ a-ftIT i i(1)) Raw or Pam tit Cooked Anneal Food and �Ri> tie d SlilqitY Not Seivvd 22 3 40 1 1 ! Conetni c r Advisor s Pont sd for Consumption of ! 'OollA l +de'rhat arc Raw, Underaxtkedcr (;thc i sc r'rexcased t.) Eliminate �Path"�'ns * #� 3(1, � .i I j Fe%leuriz,cl E-zR- S.ibstttnex Co Rdw Shell Violation. of Sc tion 5i)0,009tA)-(DI in eatetiae mobih, €chid to nlpolaoi, and rcmdeniiad kitcbetl operations 4iovId be debited under the appropriate sections alvve, if seLued to fkxAbora. Alms, inteii.entions kod risk Pac`tors. Other 590.W9 violations relating (o good retail practices Aicadd be debited under N29 - SFeetal Regtiircalettts. (Items 23-30) Critical rand non, rhicat vwlalions, lchith der uoi rebore to rhr faodharne illness bucrrrsilhnta cntd ris,fim fors 1l,ted above can be found hi Ml } tt `(n, wg l,a Fiow of she' Food Code find 105 CMR 540-0(Kt. Establishment Name: Ll L &,Y7 /44w/— L, CITY OF SALEM BOARD OF HEALTH Date: 9 6, j /6) 9 Page: 4 of f -- Item i 'Code C;7 Critical Item r DESCRIPTION OFYIOLATION /PLAN OF CORRECTION;/t/,� 1,�, % _Ar N, Da a t Verified No:� Reference Rele R - Red Item '4 PLEASE PRINT CLEARLY 10 e. 7, \D 0�,.Iti/ C�k ni? J cir'l A, � L4 cr 0,1, 07 1, J01(( Al)"All -I A 11,016��4 rjA/5� tV2A4 A -5 fn C(I C� v -e Of 1 2Y I r A ;r (4c�5 5hv I I— / D�/ 14 1 zzx- /V 2 C7' �_ 4_h%I.-) C, 0 5 c) --FD,-Ij ),9 A)J _ ow C/ �r4, '(?A/L TVG J4 I, \1 IfIr" t -D AU4- 1,/1'J0-o3A/L IAJ. C 21 'f r1 ­l7/ At:: IS 11M A_-iT' oli-L, + �OP1,4- cr 20DIs 06 LQ /'Iowu 6 1 LC r an a -?--.o Discussion With Person in Charge: Corrective No I have read this report, have had the opportunity to ask questions and agree to correct all 0 Voluntary Compliance 0 Employee Rdstriction Exclusion violations before the next inspection, to observe all conditions as described, and to e�inspection Scheduled Q 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 ci Embargo Lj Emergency Closure your food permit. L, Voluntary Disposal U Other: Violations Retated to Foodborne fitness Interventions and Risk Factors (items 1-22) (Cont) PROTECTION FROM CHEMICALS 314 _ Flood or Color Addihves -201" 12 AddoaveO3-30114 1 t,gy- 155'F 1.5 Sec. P10I.W1on,frontlJtrpprocedActdth,eti,. -j 3-401.11(A)(2) it L Poisonous or Toxic Substances —Arnmais- 1S5 F 15. 'C':. 3-401.11 i Pork end 6ec1 Roast - 1304' 121 terin" ? 401.11(A)t2) 101.11 Identifying 1nfoa matron - Oul,inal bee ' X401 111 A)a it Contain r'' _ 7 102.t I M.. Common Ntme Rorkia C an[ a tern* Indtno''Runtes 165°rI. la Sv.. * I 7-20t.1 ] Se m anon Sir iaKC 20111 . Pestricion— Prcu.nu.ewd t.4c* Raw 3inntai F .xis Caaked ur a. 7-201 12 Condiflmr o 7U i-ip3AI(A)&('D) 7203.11 Toxic Grntamex PcnbtSulonv* Murowavc 165 172Minuh Standin 1 1204.11 Sannarets Ct_?_teria Chrniir Is" _ i-403.1 1(C') 7-2( .12 Cheuicals for W ashit e 13 fxhrec C riteiia*— 7 204.14 ( 7-205 l i C)r tit A>_c.tite._Criwria. Incidental food Contact. LAIN i uan� Reins nm; Lnshc ed Portions ofBeef �J-20ti. (I Re�,rwied Vise Pc. ticide.. Criteria 7-206.12 Raicat Halt station,, Ca:dine Co r&,,d PHFs front 140-F to S 206 13 Tracking Poevdecs Prst Control and�� to 411,14Y F Witlon 4 Hams. 3 Monitoring^ Coolijig PHFc Male Front Ambient 9 18 ° Denotes critical itean in tfie k, tem! I a9l) Vorxl Cie e,r I65 (. MR 590 1100. -r-Slit t4(C} PHFs Received at `temperatures Aceordiaa to Law Cooled to F'j4,51 Widrui 4 Hours. 15 1 t'shins b4, thexrh for PHFs 3-50i 1(0) Cold PHF Maintaincel at or below 590,0040-) W/45 -F- 3 5O /45°ta-50 3 IN A) � Hot F'HF s Maintained at or above rurc � j Roasts He o tt or abo%e 1 VE Time as a Public Health Control 3-a01 .17 I Ctmn as a Public Health Control' 21 13-R11 l (At i;np tauri zd 3Rc Isackagcd Fuices wad .�.�.__ Bctietacc_teiihYiatntn�rahwts" �S-$Odllti3} i LuatPasteu:�zed_t� 3-8d1. i 1(D} � I2 rw ar Partiarl i L� eked Animal Fot�i and I Raw Sc: 'd Snroius Not Saved. Not Re -served - 22 3+s(1_ 11 j Cotmineer Auyis(,I i Ponied for Constnnption of I Animal I oods'fhai are Raw. Undercooked or 1 Not fhhem Ise Prescsved to Eliminate PlMearsn,d F gg:: subsl-tate Ra Raw Shell Viol nit}t s of Section _9UX)9W-(I1) in omerrog, mobi1c, fooil,temporaryand rased nt,al kitchen operations Should he dcboed under the appropriate, sections alluve, if rehuod totocxlborne illness Interventions and isk (actors Ot11er 591).)09 violations, relating to goal retail pi.5etcev,ihould he debited under #29 - 4pe tai Reyuireiai;nts. (Items 23-30) Critical ap;d riven -critical vuollevoni, which do not .-elate to the fora leorere a7lracSS ixmrveraiorr� and rt<jin-Dor_c lived above cera be fountl in theyi'cthminr setei ti, of Foci Code and 105 Ch9X <p'rR 13,,41 i— Proper Cooking Temperatures for_._. PRFs 3-401.1 i A(11(2) 1 t,gy- 155'F 1.5 Sec. F ass, brumaliatc. 5c.rriu 1459.15,eci -j 3-401.11(A)(2) it Comtnninn d Fish. Mea � n Gone. —Arnmais- 1S5 F 15. 'C':. 3-401.11 i Pork end 6ec1 Roast - 1304' 121 terin" ? 401.11(A)t2) (Kiures,Injcued Meats l75'F Is bee ' X401 111 A)a it Poathr). 'Wild Gaane, StuffedPEIFs, Stnlf na Contmnmk Fish Meat Indtno''Runtes 165°rI. la Sv.. * I _ 3-401.11tC)(3) Whsle muscle, 411act6cef Steaks 145'T _...._.._.. 3-401.12 Raw 3inntai F .xis Caaked ur a. 3�10111tA)(tai;) Microwave 16.5"T All CkherPlil v - 145`1 15 sec. -c i-ip3AI(A)&('D) Reheating for Hot Holding _ PHF> 16YF 1 sec. '' _ 3-403.11(6) Murowavc 165 172Minuh Standin 7rmt* _ i-403.1 1(C') Comma, h 1!v 't ex -raced RT1: F+. wI - 6401B' t(El Reins nm; Lnshc ed Portions ofBeef �1-4C);.1 Roasta* Proper Cooling of PPHFs _ ;t-501.1:d(A) Ca:dine Co r&,,d PHFs front 140-F to 70"B Within 2lkru6 and Brom T1`1' to 411,14Y F Witlon 4 Hams. 3 3-501.14(6} Coolijig PHFc Male Front Ambient Cemperetuire htvreaients to 41`F'!45`F Within 4 Hours'r ° Denotes critical itean in tfie k, tem! I a9l) Vorxl Cie e,r I65 (. MR 590 1100. -r-Slit t4(C} PHFs Received at `temperatures Aceordiaa to Law Cooled to F'j4,51 Widrui 4 Hours. 15 1 t'shins b4, thexrh for PHFs 3-50i 1(0) Cold PHF Maintaincel at or below 590,0040-) W/45 -F- 3 5O /45°ta-50 3 IN A) � Hot F'HF s Maintained at or above rurc � j Roasts He o tt or abo%e 1 VE Time as a Public Health Control 3-a01 .17 I Ctmn as a Public Health Control' 21 13-R11 l (At i;np tauri zd 3Rc Isackagcd Fuices wad .�.�.__ Bctietacc_teiihYiatntn�rahwts" �S-$Odllti3} i LuatPasteu:�zed_t� 3-8d1. i 1(D} � I2 rw ar Partiarl i L� eked Animal Fot�i and I Raw Sc: 'd Snroius Not Saved. Not Re -served - 22 3+s(1_ 11 j Cotmineer Auyis(,I i Ponied for Constnnption of I Animal I oods'fhai are Raw. Undercooked or 1 Not fhhem Ise Prescsved to Eliminate PlMearsn,d F gg:: subsl-tate Ra Raw Shell Viol nit}t s of Section _9UX)9W-(I1) in omerrog, mobi1c, fooil,temporaryand rased nt,al kitchen operations Should he dcboed under the appropriate, sections alluve, if rehuod totocxlborne illness Interventions and isk (actors Ot11er 591).)09 violations, relating to goal retail pi.5etcev,ihould he debited under #29 - 4pe tai Reyuireiai;nts. (Items 23-30) Critical ap;d riven -critical vuollevoni, which do not .-elate to the fora leorere a7lracSS ixmrveraiorr� and rt<jin-Dor_c lived above cera be fountl in theyi'cthminr setei ti, of Foci Code and 105 Ch9X <p'rR 13,,41 i— CITY OF SALEM / �7 + BOARD OF HEALTH Establishment Name: I 41 `7�/I t/f�1j Date: �11��i q Page: S of °Item � Code' ` ' C -Critical Item <, - - 11,v - s 1,%-j -' DESCRIPTION OF.VIOLATION /PLAN OF CORRECTION °,.Dates a < No. Reference, - R - Red Item 4'° e- x r PLEASE PRINT Verified ? �J� V( /CLEARLY I /. /✓�� �� i h�R'r' it ! n P C ( �ASii!_ � NI.-�/ �2�� Jt i 1� C�Tt ./ !/�k � � / /.7' f i7 S .�/� i rin<Jtl r u A14- Chen ...,g\ ,_,q^ id IL li <'r f/ tff/1/ /it tt�� SiC D'� Vh4 - _f /ave 1 1/11 �72 11t /%i.r n 1 V J - ___ /'ri ✓I TI i� :) . / l �:iILV Zk K(/_C ejno 1 0, n /- J - - Discussion With Person in Charge: Corrective Action Required: . ❑ No . ❑ya Yes r I have read 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 O Re -inspection Scheduled ❑ Emergency Suspension -Comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. YYY ❑ Voluntary Disposal ❑ -Other: �G� Violations Related to Foodborne fitness interventions and Risk Factors (ttents 1-22) (Cont) PROTECTION FROM CHEMICALS is food or Color Additives lli:,::t�f��irW:lai IIit�t3B�IlllYeJ�bi 16 3-202,12 Addmivc,* 3-30114 protection frout �Identifyinglnfonnabon Poisonous or Toxic Substances -101.11 -Original _ _ containers,* -102.11 C:otnmon Name- Working Coarainers'" 7-201.1.1 Se ar,;tiun 5turage=` 7-202.11 Restriction - Presence and Use* 7-202.12 _ Conditions of Uso* 7-203.l1 Toxic07ai ineu .-P,rohibiuon0c 7 204.11 Sanitizers, Criteria - clieinic, 7-204.12 Chemicals tell Washing Pre,dum C;irteas" 7-204,14 Dr in A¢eW Criu r i r,. r i05 11 incidental hod! ( )MUt 1_abr waned 306.11 _ i7,otrided Use PC neides. C.ravaia" � 7 20G.12 R� odea L lit St:mims 7-20613 Tricking Poazlerc, Peso Control and Mcraitorin�-* lli:,::t�f��irW:lai IIit�t3B�IlllYeJ�bi 16 Proper Cooking Temperatures for PRFs 3-401.1.1A(l)(2) F'ggs- 155'F 155cc:��� _ _ f. hnn)ediate Servicc 145'h'15see, .-401.11.(A)(2) Comulinat. d F rep Meats .4 Game A umaia 155"F 15 cec ,t01.I I(H)(1)(2) _ Pork and Beet Roast - i30"F 121 min' 3-401.11(A)(2) -_� Rath", laject i bicats 155'F 15 _ tier _ 3-401.1UA()) Poultry, Wild Game- Stuffed l'tiF s, Sluf ine Containing Fish Meal, S 11tritry or 3tautc 165°F 15 sec. Whc e -mus lc [matt Beef Steaks 1451T " 3-401.12 Raw iurtud Foods Cookcd in a ,. Microwave 165'b 401.11.(A)(I)(h) All ()ther T'IIFS _. 145`1' 15 sec. " t7 Reheating for Hot Holding 3-4031 NA}8 tl7} PHF, 165"T 15 wl;: 3-403. t I B) Microwave 165° F 2 Mintae Standing ;3-403.11(C.) Commercially Pvo'�cssed RTl' Food - 140'W_ __ 3-403.11(E) Remaininguns[icedPortions )Flicef Roasts* Proper Cooling of PRFs 1 3-501.14(%) Cotdiae Cooked PHFfrom 1400 tv 70 F Witton 2lfours aid From 70°l' _ Lo, ^ 1-F745 F Within 4 Hours. ' jjj�0114O CsxrhngPHFs`viaeieFumAmbicat Temperature fngredientg to 41'F145`F Within 4 Fhxir s Denotes crilral item ill the 4,1eml 1994 Rood Crxie or 105 ( NRR 591} COO. 3-SsF1.1d{C} P}[Fs Received nt'reniperatures According, to Lac C(x)ied to i 41°A451'' F Within 4 Hi rine 3-5{,� 16tBi I Cold PHFs Maintained at or 3601.16'A) I1 a PHF n Maintained at or above _ 40'', 3-501, 16(A) R(xsts Held at or above 13001;. _ Time as a Public Health Control ?_501 iv, Ti rue as a Public Iieaith ControlT 590.004rFf)� Vtnancc�edremcnr REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 21 3.801.11(A) Unpsteurizsci Pre packaged lu,:cs and ,..__ Eve vezazeg wiih W a o6 t„drrxls* _ 3-801.11(A) F,, of pwteu_nz�d &q ;' _ t3Z5 1t3 i I (t)) Raw or Pastinll r Cuoked Animal Fcxjd and R i v SI—X Sdrr ruts tNot Served 34 i j,C) Unopened Faxl Packa¢c Not Re -served, _CONSUMER ADVISORY 22 3_f'( l I Consumer Advisor} Potted for Consumption of Animal F,,xxi, That are Raw. Underca)ked ur Net Othel'ty ise1'roc:e5sed to Eliminate _ Perdu) ens.'r erxm....,.,,rza;` 3-1302.13 S Paste r it 'i Eq:; substoutr for Paw Shell 590A0'3(A) tF)r Vialanous of Section 790.f)09(A)-(D) in entering, raohilr Rx)ct tempor at v and t iueul al kitcher3 opcaations should be elchiud under the appropriate wovills i above if related to fcwdbornc illness intei enttons-and risk factors. Other 590.009 violations relating to good retail practices Awald lv debited under i Special Requirements, (Items 23.30) Criii:wl vnd lion-crawai vioierfwn,s, which do noz rebate to the foodborne illness ixrerveniions rout risk fociors listed above. can be found in dw fiWowing .r mons ref the Food Code and 105 CMI? l N i ".'le 2.4 HUB REFRIGERATION & HVAC CO. 244 WILLARD STREET W/O # . QUINCY, MASS. 02169 (800) 649-1911 FAX (617) 471-1920 F f DATE ORDERED ' NAM ` F,p -.., DATE SCHEDULED y STRE� WEATHER -- CITY r( _ STATE ZIP MAKE MODEL SERIAL NUMBER IIWARRANTY I I CONTRACT I ; SERVICE CONTRACT IINORMAL I I PES. I I COMM. it - �fY, -' i - JOB LOCATION - LABOR CHARGES HRS. HRS. _ ._rt } TIME " ' ARRIVED - TIME DEPARTED TRAVEL TIME so ,: ENDING - START- MILES TOTAL X % TRIP CHARGE $ . -�.""" ' .. . �` TYPE REFRIG. t RECOVERED? VES ,r.�,- -.ar - t 2 RECYCLED YES r_ 3 RECLAIMED? VES RETURNED TO ❑ THIS SYSTEM? YES MR,= a DISPOSAL IHR. = NON USEABLE ES 5 DISPOSAL - NO NO El- NO (❑ NO NO SYSTEM QTY, QTY DTV. QTY. OTY. OTY. .. .. E OUTCHAI(ORD ❑ U REPLACED)? YES NO DIS- I -J �_1 M MANTLED? YES NO REFRIGFERANT DISPOSAL N _ T © TECHNICIAN � � S y,. w�. t r-CEF.LTM.,.._ TOTAL SIGNATURE e PARTS I. „.: _. -. • • • ... x&.'.; I HAVE THE AUTHORITY TO ORDER THE ABOVE WORK AND OO TAX SO ORDERAS OUTLINED ABOVE, IT ISAGREED THATTHE SFLLER LABOR WILL RETAIN TITLE TO ANY EQUIPMENT ON MATERIAL FUR. NISHED UNTIL FINAL & COMPLETE PAYMENT IS MADE, AND IF SETTLEMENT IS NOT MADE AS AGREED, THE SELLER SHALL TRIP HAVE THE RIGHT TO REMOVE SAME AND THE SELLER WILL BE CHARGE HELD HARMLESS FOR ANY DAMAGES RESULTING FROM THE , REMOVAL THEREOF - - - `- AUTHORIZED SIGNATURE ' i PERSONNEL RECOMMEND: OWNER'S INITIALS ACCEPTED DECLINED ABOVE ORDERED WORK HAS BEEN COMPLETED AND I ACKNOWLEDGE RECEIPT OF MY COPY X DATE Commonwealth of Massachusetts r City of Salem --- Board of Health-- - ----- — -'r—`-'- ^= - 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/12/2009 ESTABLISHMENT NAME: File Number: BHF -2004-000365 White Hen Pantry 28 Norman Street Salem MA 01970 LOCATED AT: 0028 NORMAN STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2009-0365 Jan 9, 2009 Dec 31, 2009 $280.00 TOBACCO VENDOR BHP -2009-0366 Jan 9, 2009 Dec 31, 2009 $135.00 Total Fees: $415.00 1�01,7tL1Yr0/��IND1. Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR JANET MANCINI, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4.. FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 IMANCIN12SALEM. COM 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT LUii�e HLs�) ��V\i-V—cAIC rninnc TEL # q`4qS- I:)a-- ADDRESS OF ESTABLISHMENT ,:� ?5 Al c,r mct n I S aae m FAX # / MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'SNAME Rmmrn�6 an Hot -4 LAOUSS4 TEL# 9.4 e, ADDRESS CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) 6 EMERGENCY RESPONSE PERSON -Rol' UY\ �j\. C HOME TEL # q -4 E, -I-IV 6 - 21 S y DAYS OF'OPERATION,;. 1 .::Mond . ' l . Tuesda,- „ :'.:Wedriesda .' ' Thursda'`"-F.rida' Saturda ,.ai HOURS OF OPERATION Please write in tune of day. ev e v.. I � (For examplellam-ttpm) v i ------------------------------------------- NO TYPE OF ESTABLISHMENT RETAIL STORE YES RESTAURANT YES (Outdoor Stationary Food Cart $210) BED/BREAKFAST/ YES "NO =$ 70 =$280 =$420 =$140 =$280 =$420 $100 MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y S ND $25 TOBACCO VENDOR YE NO $135 ALL NON-PROFIT (such as church kitchens) YES _NO $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date 4 / q ) O Security or Federal Identification Revised 424/07 FOODAP2008.adm Check# & Date N4-1 11 tf /_d9 $ qt,!� Ds -qJ-9DO4 FEE (check only) NO less than 1000sq.ft. 1000-10,000sq.ft. more than 10,000sq.ft. ------------------------------------------- NO -- - - - ------------ less than 25 seats 25-99 seats more than 99 seats BED/BREAKFAST/ YES "NO =$ 70 =$280 =$420 =$140 =$280 =$420 $100 MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y S ND $25 TOBACCO VENDOR YE NO $135 ALL NON-PROFIT (such as church kitchens) YES _NO $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date 4 / q ) O Security or Federal Identification Revised 424/07 FOODAP2008.adm Check# & Date N4-1 11 tf /_d9 $ qt,!� Ds -qJ-9DO4 O FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED - PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU SIGNED FORM 4009 MARE IN U.S.A. NOTES _CtAA'✓\Cl�(i�s cowc� cry �< �V4iu,V� i a j FEBV5-2009 11:50 FROM:DPH FOOD PROTECTION 617 983 6770 10:978 745 0343 P.1'2 Sandra Cox 305 South Street Jamaica Plain, NUC 02130., Phone: 617 063.6700 FAX -647 663+8770 Y D To;, Salem BOH From:.. SandraCox._ (976)745-0343 Fax, Pages: 2.. Phorm Date: February. 25.2004 Re: Complaint #09-050 CC- D Urgent 0 For Review-- O Please -Comment O -Please Reply 0 FKt . s Comments: Good Morning I am faxing.over.a.copy of,a complaint we received_ concerning.Whits Hen Pantry on Norman St., can U send us a copy of any follow up done, this would be appreciated. Thanks and have a nice day. NOTICE The pages comprising this facsimile transmission contain confidential information from -the- Departtuent_of.P_ubliaHealtl>_-This -information is.intended only. for, the use by the recipient listed above. if you are not the intended recipient or the employee or agent of.the. intended.recipient.responsible_t'or the delivery of this -information, you_are� hereby notified that the disclosure, copying, use or distribution of this information is strictly prohibited. If you have received. this- transinission. in- error, please. notify-us, immediately by telephone to arrange for the return of the transmitted documents to us or to verify their destruction— FEB -25-2009 11:50 FROM:DPH FOOD PROTECTION 617 983 6770 TO:978 745 0343 P.212 Massachusetts Department of Pubtic-Hegllth Food Protection Program 305. South. St. Jamaica-Pla)n,.MA_ 02130___ Ph(81.7)983-67t2, Fox(617)983.6770 ........... 9-q60._._.._.._.._.._.._.._.._.._.._.._....._.._.._.._.._.._.,..._................._.._.._.._.. Complaint Number ...... ....................................... I ........................................... I.................................. Date or Complaint'. 2/232009 Foodeome Illness? n It Yep. Fill out Foodborne Illness Form Form.ot Complaint. Other(Webelts)... Source of ComplatM'-- Consume` Complainant Name Julienne MCkeman Address: 5 Summit St. JJ OK to give out Phone: (970) 3006937 Name/# to company Notes: Ju)uftoQaotcom —,,u, .. ....,w nen rumry, nann.n a,., carom, ran. I wem In there 10 buy some lunch meat because b was cheap, when I got home them was old dried most and cheese pieces on the new meat I bought: llaterfaond 0U" -someone-whoworkedthere tharthey only clean me$(leer with bleach and water and they do not break it down and Wean the parts as you are supposed 10, the atom is also dirty. I second guessed myself but wanted to save money so I figured I would try xrbut that did not work out to well as I soon found out. I em afraid that someone will got sick from this. I myself will never shop there again Since I shopped (here that Ono time I have heard a lot of horror stories about the store. I just wanted to try to get someone to look Into this and maybe help.th rm to have a better. businesa.pquilloa. Thank You Nature of Complaint. PI/UC F1 Visaed Health Care Provider- Visa Dsle: NameofProuder, Product Information ProductBrand-Name. Product Name. Product SmetWeigm:... Sell By Date' EvpiratioNaast ~Dow Date of Puroate. Category-- MeaUPoukry_ Product Code/Serial Number: Package_Type: UPC Code:\ ❑-Imported-Product IU ProductUsed Date Used: Amount Remaining. Establishment Where Purchased,. Manufactured By: DisUibuled ny ... .. ._ White -Haft Pantrr- ...__.. _.... Norman St. Salem MA Phone: Pbone: Phons. Complaint Received By: SC Referred To 80" Phone Number. (617) 993.6763 Comments 2125/04. Faaadcopy of complaint to RON and.asked for copy of.follow.up-dons, Disposition'. Page 1 of t CITY OF SALEM BOARD OF HEALTH Establishment Name: � A Date: aJag 4'1ol Page: of Item No. Code ,F Reference - C -Critical nem R - Red Item - ',wt.., DESCRIPTION OF VIOLATION / PLAN OF CORRECTION =. i < - •' _ - 'ssX s PLEASE PRINT CLEARLY ' Date Verified e« �aMY� rc�YL n!tnitt c ^)CiP� Vltn� v� + t`Mn(t� nl Pt p� i \Yl�tr ovi, OrG)C. fowl 1l�_SnPc El W� f a�cc� CCIVtc�iA� rPri C]tn�i "II//R ny) ih)(>dc. / 1�/1( i:il lc.,yl 111 (+)CA 5�n4 (1 (IV\S�!� cxirl .�(lV1i {i7Ft(X eqn.N �nr\r�r)e(' <Dk� nvog n.tn�7��fi � ra1 nII-livrta5e rn o t he CnC0Pc1_(-7d>, All Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations I.�eforethe next inspection, to observe all conditions as described, and to comply with all In of the Mass/Federal Food Code. I understand ce mathat ,,, noncompliany 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 Ll Re -inspection Scheduled Ll Emergency Suspension o Embargo L3Emergency Closure ❑ Voluntary Disposal ❑ Other: i Violations Related to Foodborne illness Interventions and Risk Factors (Reins 1.22) (Cont.) PROTECTION FROM CHEMICALS `Good or Color Additives _._. 3-20212 PHFs 3-302.14 Protection from Unapproved Additives" l Poisonous or Toxic Substances T[ OlAI identifyingfnfoiynation- Original Contuuers" 7-101 t1 7201.11 Cotnman`.+me_Workinn, Couttiners Se aia.uon-stolage _ . 7-202.13 Reotriction -Pi xrnce and t Eo* 7-202.12 Conditions of Use" 7-303,11 TOyk Ointainelti —P oinhn.A)n.01 204.11 Sanitizeis, Crteria -chemicals* 7-204.11- Chemicals for Wash in> k'r-rx3nce; Criteria* -���� Dnnrtg A=sone, Criteria" H7-2tki-34 7-205.11 Incidental Faxl Contact. I,ubiicants*-- _ 7-206.[l Re triued tis' Pesticides. Criteria' 7-206.12 Ralent Beit Stat ons* 206-'13 Tracking Po, dW r< ,Psi Control and �7 ______ � Monitoring" ���� N TIMEITEMPERATURE CONTROLS r t)elwli s.-ciuml item ill the to:kz l 191J9 Food Cade or 105 CMR 59f) 00(1. Proper Cooking Temperatures for 19 PHFs 3401. HAt1)(2) _ tIgo. 155m15Sc ISS immcditte.Sc.rvi�c 145:(15secr _ '1-401.31(.1)(2) Comminuted Fish -,Meats k. flame Animals - IS 5' F.15 secs" .� 3-401.11(11)(1)(2} j -r-R Peork and l3ecf Roast -130 F 121 film 3401AI(A)(2) tires, blje t,ai Mata 155"F IS - 0111{,)[3) S Poultry, Wild haate StutfefPl-tE"s; StuffingColeamingFisfi Meat. P oiling or Rantc.s 16.5`1 15 s, c.. 3-401.i1.tC}{3) whole-muute.Intaatt3cefSteaks -145 T 13-401.12 Raw Aniond Fr flus Cooked in a Mitnowavt 165`1=* _ I3-40Llf(A)(t)(b) All Other PHfi-1w5"F`15sec. Reheating for Hat Holding 3-40311{A)Fi(D} PHFs 165°P IS sec, * 3-403.11(6) Mlcrxrw ave- 105' F - Tvlintue Standing Time" _ 3-403.11(C) Comrnereiatly Prrxecsrd R CE Faxi - 140'F" 3 403.! I(E) Remaining Unshced Portions of Beef Roasts'* Proper Cooling of PHFs 3-501,14(A) Catling Cooked PHI i; from l dt `F Sn 70"F Within 2 Hours and From 701' to 41 'F/45 H Within 4 Hours, * 3501.14(6) Coling PHFs Made From Ambient Tempe( Ingredients to41°Fi45'F .��Within 4 IlouiO r t)elwli s.-ciuml item ill the to:kz l 191J9 Food Cade or 105 CMR 59f) 00(1. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (H. n _ 2T73 -86T I i (,A) Unpasteurized Pte-pad:aged Suices std I i 3evetaaes with Waruine Labels* 3 -?501-1 I (D) (linty or Puriall Cooked Abimal Pcxxl and 3-90I.I I (Ci I Unopened Faxi Packaer Not Re -served. " CONSUMER ADVISORY b322 ai 03-11 Contin r Aclt isorti Posted for Consumption of loon tl Food, That arc Raw. Underawked or trot 0there. iso Pnxxegsed to Elim}nate Pattfo�-c.ns ?01 13 flstaunruf Fg44 Substitute for Raw Shell SPECIAL REQUIREMENTS_ 590,009(A)-(17) Gic+iutinwn of Section 590.009(A) -(D) in catering. mobilc ftxxL temporary and re.: ids m at kitchen operations h'oald be debited trnder the appropriate sections aly e if rehoesd to ibudborne dlncs� into lreotjtiws and risk factors. Other 590-009 violations relating to good retai? prat aces sttouid be debited under H29 - Specral Requirements VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) criticai and non-cn6cal vio&'Bolls, which do not relate in the ,Inodhnrne i'lnes.s itnei ver riores and roA]tit iors listed above, can be - %t+nd fri the jotirnving se(7iorts of rhe Food Cade and 105 CMR PHFs Receivedat Temperatures According to Lztw Cooled to _ 41=F145`F Witbin 4 Houns * 5(71.15 Cooling Methods for PHR 19 PHF Hot and Wit Holding 3 501.16(B) Cold Pff1 s Maintained at or below 590.W4F) 410/45° b- ,-;-50 1 16(A) loot 11H' � Manimoted at or above _ t 401'. 3-5171 16(A) I Ruists Held at or above 1300F, 2(iI Time as a Public Heafih Control T-- -3-.5111 k9 1 T nie as a Public Health Control' oO.rtYlfli)1 Variance popli-vinerit REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (H. n _ 2T73 -86T I i (,A) Unpasteurized Pte-pad:aged Suices std I i 3evetaaes with Waruine Labels* 3 -?501-1 I (D) (linty or Puriall Cooked Abimal Pcxxl and 3-90I.I I (Ci I Unopened Faxi Packaer Not Re -served. " CONSUMER ADVISORY b322 ai 03-11 Contin r Aclt isorti Posted for Consumption of loon tl Food, That arc Raw. Underawked or trot 0there. iso Pnxxegsed to Elim}nate Pattfo�-c.ns ?01 13 flstaunruf Fg44 Substitute for Raw Shell SPECIAL REQUIREMENTS_ 590,009(A)-(17) Gic+iutinwn of Section 590.009(A) -(D) in catering. mobilc ftxxL temporary and re.: ids m at kitchen operations h'oald be debited trnder the appropriate sections aly e if rehoesd to ibudborne dlncs� into lreotjtiws and risk factors. Other 590-009 violations relating to good retai? prat aces sttouid be debited under H29 - Specral Requirements VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) criticai and non-cn6cal vio&'Bolls, which do not relate in the ,Inodhnrne i'lnes.s itnei ver riores and roA]tit iors listed above, can be - %t+nd fri the jotirnving se(7iorts of rhe Food Cade and 105 CMR CITY OF SALEM 11111 OF HEALTH Establishment Name: - Date: Q f n h'01_ Page: of Item. No. ;Code_=111 ReferenceRed C -,Critical Item R Item DESCRIPTION OF VIOLATION /PLAN OF CORRECTION N.!, X PLEASE PRINT CLEARLY Date'� Verified - I W--, h 4P �—tj 'o -f biKed on f\Q yj --Q)dnf'-A' Y) r7 r rAF 1; P-1 h4l. nxl-Pi nvi -Mg ah5610cl NZOd V) D VV_ 6Q.0 CC (roo c7l(Y-4 Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: car No ❑0 Voluntary Compliance 0 . Employee Restriction Exclusion LD Re -inspection Scheduled L:j Emergency Suspension Li Embargo L3 Emergency Closure U Voluntary Disposal U Other: Violations Related to Foodborne Illness Interventions and Risk Factors (iteMs1-22) (Cont) PROTECTION FROM CHEMICALS �a w t u' a 'a Food or Color Additives 3-202-12 Additives* 3-302.14 Protection from Unapproved Additives' Poisonous or Toxic Substances "1-101.1 i Identifying information -Original Containers* _ 7-102.11 _ ntaers* Common Name _- Workm , Coin -��� _ 7-201.11 Se ation- Storac"' Seim 7-202.11 Restriction - Presence and Use* - 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prolnhitions* 7.204.11 Samii-rxrs,Criteria- Chemicals* 7-204. 12 Chemicals for W tsl 1'tnd tce f ntetitO - 7204,14 Uritne Ave rits_(riter L.� 1 ii � 7-206.11 L 206.1 I �7-206.12 7.206.13 L�� Incidental F xxl Contact Loin scants' Rentrtrled Use Pe ticules. Criteria* Rodent But Sittuons 11 ickinb Powder,. Pest Control and Monitoring^ t u' a 'a ' Denotes critical stein in lh; krieral 19991btxl Qrde or 105 (AR 590 0)0. _ Proper Cooking Temperatures for +SOL74(C:.I) PRFs.T.v-�. _ 3 401A 1A(l)(2) 1-991- 155'F I5 &C. *smlmmcdiatcService 145"Fl5sec, 3 401.1I (A)(2] Comminuted Fish, %feats & name 41 .045'F Within 4 How s, Animals - I55"F 15 sec 3-401.11(8)(1)(2) Purl and BM Rust 130'1' 121 nwi* 3-AW.11(A0(2) FRantes, Injected Mcats -- 155'F 15 PHF Hot and Gold Holding sac. 3-40PIIIAII) Inulrry, Wild Conte, Smtted PRFs, 590.0(}4(F) Stuffing Containing Fish, Stela, 41"!45° F- Poultry nt Ratites 165`1 SS sec. 3-401, t 1 tC)(3} Whop muscle, boact. Beef Steaks _ t45°F 3-401.12 Raw Animal Foods Cooked in a 1 bLu rw<ve 165`F ?-401,1 1 (Al(i)b) all Others 111:117, -- 14517 15 sec. " _Rt 1 Time as a Public Health Control Reheating for Hot Holding 3-10T, )(A)&( )) PHF, 165°l= 15 ties. 3-403.11(B) Microwave- 765° F-1 Minute Standing y 3tnlei. 3-403.11(C) Commerciatiy Processed RTE. Form -- 3-403.11(13) Retnaining Uie4iced Portions of Beef R<>nsis* Proper Cooling of PHFs 3-501.14(A) Cooline C(x)k(,d PHI -',g front 140'F to 7WF Within 2 Hours and From 71)"F to a 1'F/4Y F Within 4 Hours. ' ���� 3 51) L 14(14) Cmling, PHFs Made From Ambient 'Pemperanere Ingredients to 41°E745"F 4 8amrs* ' Denotes critical stein in lh; krieral 19991btxl Qrde or 105 (AR 590 0)0. _ � Y +SOL74(C:.I) PHIts ReccivU�(I of "I'enoperAtures According to Law Curled to !! 41 .045'F Within 4 How s, Cochin r Methods for t'RF't PHF Hot and Gold Holding 3501.16CB) Cold PRFs Maintained at or below 590.0(}4(F) 41"!45° F- 3-501.16(A) Hot P1-IFs Maintained at or above _ 14WK 3-56t 16(A) sts Held at or above 130`F. _Rt 1 Time as a Public Health Control Variance REOUIREMENTS FOR HIGHLY SUSCEPTIBLE _ POPULATIONS (HSPS 2hF 3 - -So I.t I(A)�Unpasteurizedlie-packaged Juices and 11_I_(_A�.t_..j.,.Uec of Pa,teurixcdd 3-'S01 I1}f)} i RtworPailiatl Cuok dAnimal1oodand R o Sccd `_pnnits 'vol Sewed ' 3-R03.ti(Cc lJlts ned 14xid- Packanc Not Reserved 22 1 :3-60, 11 ( t omemnr r Adiscsv Posted 1;n' Cottsumption of ( vniwtt F,,o& That are Raw, Under ked of Not Otherwise Pox c sw d to Eliminate 3i<.6.. 4 &rcdrn iPpC= 3-302 13 1 Pasteurized Egg., Substitute for Raw SPECIAL REQUIREMENTS 590. G4(A)-t l7 }T Violation; of Section 59(3.IX)9(A)-(D) in j eateries;. mobile font, temporary and rt ide rwal kitchen operations should be debited Linder the appropriate sections above if related to fixAborric illness interventions and risk factors. Other 590.009 vsolations relating to good retail pi acttccs a'hould be debited under #29 - Special Requirements. (Item 3-30) Crairal mrd nnrr(rilh:at violations. which do not relate to lire filodhorne ilokess lino venoolty and risk factors listed above (an be found in the follna-ing .verfi,.ns of w Food Code and 105 CUR 59d. EX70. `i Commonwealth of Massachusetts City of Salem \ Board of Health 120 %shington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/17/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000365 [Qmberiey Drisooll Mayor White Hen Pantry 28 Norman Street Salem MA 01970 LOCATED AT: 0028 NORMAN STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued. Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2008-0369 Jan 16, 2008 Dec 31, 2008 $280.00 TOBACCO VENDOR BHP -2008-0370 PERMIT EXPIRES Jan 16, 2008 Dec 31, 2008 $135.00 Total Fees: $415.00 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 2 KIMBERLEY DRISOOLL MAYOR JOANNE SOOTT, HEALTH AGENT QTY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 411' FLOOR `ISL. (978) 741-1800 FAX (978) 745-0343�/ IsOOTrOSALEM.00M I �1 ED 'JAN 15 2008 CITY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Lu i I -e ken TEL # Q I R - T4J S - )Q_9- S ADDRESS OF ESTABLISHMENT ' R A/ or marl S>: FAX # MAILING ADDRESS (if different) EMAIL - Business': / Website: ' 9T8-y�G-2t5L/ OWNER'SNAME 14313y 6bW'RnMAA/j YouSSrF TEL#q�R_14 ADDRESS yh lJ0 U SS CERTIFIED FOOD MANAGER'S NAME(S)�A R y V o u SS e� CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON save HOME TEL # Please write in time of day. va- -5 (For example 1 lam -11 pm) TYPE OF ESTABLISHMENT RETAIL STOREYES NO - - ---- RESTAURANT YES NO (Outdoor Stationary Food Cart $210) BDfykiAFA§ f/ -------------------- VIES----- --------------.._---- CHILDCARE SERVICES ---------------------- ----O 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. _ > 1000-10,000sq.ft. more than 10,000sq.ft. _ less than 25 seats =$140 25-99 seats =$280 more than 99 seats =$420 >o ZIP `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid all state taxes required under the law. IS: • . Date Social Security or Federal Identification Number ----------------------------_-----------------^--- - -' -------- Revised 4/24/07 FOODAP2008.adm Checkft S Date T L 1 —' S $ 100 $ _- ...---------------- YES ----.. $23_ YES NO 135 YES /VO $25 >o ZIP `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid all state taxes required under the law. IS: • . Date Social Security or Federal Identification Number ----------------------------_-----------------^--- - -' -------- Revised 4/24/07 FOODAP2008.adm Checkft S Date T L 1 —' S $ 0028 Norman Street Telephone: (978) 745-1225 Owner: Romany & May Yousseuf PIC: Mary Yousseuf Inspector: Elizabeth Salandrea Date Inspected: Correct By: 6/2/2008 Risk Level Permit Number: BHP -2008-0369 Status: VIOLATION # of Critical Violations: 3 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: ❑ White Hen Pantry Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing FAIL Critical &g mment: Inside panel in ice machine has accumulation of grime. Thoroughly clean this panel. RED — Ice scoop being stored on top of ice machine, not in its container. St9re_ice scoop in clean, sanitized container designated for the scoop only, or in ice with handle facing out. LLgM5i05 )" 1'Nrz�4i{•L21.t Wnitizer a bit weak at 150ppm - provide sanitizer of proper concentration (200ppm) at all times. +sanitizer log not being maintained daily. Daily log of sanitizer concentration must be kept. tting board at the deli unit is stained and scored. Resurface or replace cutting board. —1 knife in rack had food debris on it. Knives must be properly washed, rinsed and sanitized prior to storage in rack. Handwash Facilities FAIL Critical ❑W RED Comment: Employee bathroom missing paper towels and soap. Provided soap and paper towels in dispensers at all times. 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. Jun 03,2008 ) Page 1 of IMA RED: _ w^._..- ._._... Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Violations Related to Good Retail Practices (Blue Items) Status Violation Critical Urgency Food and F d Protection FAIL Critical 6LUC omment: Haagen das freezer in back room had some uncovered/unwrapped food in it. Cover all food in storage to prevent cross contamination. — Some items in sandwich display case fridge and smaller desert display case fridge not properly dated. All food for sale must be labelled properly. Vlfhe following items were removed outdated: -50 24oz gatorades 21 powerades -12 cartons of eggs 15 sierra mist free 9 honey maid cereal 6 aquafina sparkling water 6 ken's salad dressing 5 dole of 5 sandwiches in the sandwich display case 3 grape nuts cereal 3 diet dr pepper 3 kraft creamy ranch dip 3 garelick farms milk 2 nestle pure life iced tea 2 diet Pepsi 2 balance bars 2 boxes cheez its 2 life cereal 2 dr pepper _ 2 garelick farms of 1 cheese danish 1 nesquik milk 1 mountain dew wner to closely monitor all expiration dates. Equipment and Utensils FAIL Non -Critical BLUE yxont�mment: Muffin freezer in back room has accumulation of crumbs/food debris on bottom. Thoroughly clean this freezer. !Fume unit missing thermometer inside. Provide visible, accurate internal thermometer for this unit YAV Ik-in cooler needs general cleaning/sweeping under all shelving. p sitting in the mop sink. Store mop hanging to air dry. 4Taagen das freezer needs de-icing and general cleaning. WI/ a unit missing thermometer. Provide visible, accurate internal thermometer for this unit. 7ven needs general cleaning. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (976) 741-1600 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 03,2008) Page 2 of Item Status Violation Critical Urgency slicer needs general cleaning, including undersides of all components. tdBeverage air deli unit needs general cleaning. Physical Facility FAIL Non -Critical BLUE .Comment: Dumpster area has cardboard all over ground and cardboard dumpster is full. Cardboard must be removed and area must be maintained in a clean, sanitary manner. Reinspection in one week, all violations to be corrected. Please have March and April extermination invoices available at reinspection. 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. Jun 03,2008 ) Page 3 of L 0028 Norman Street i Telephone: (978) 745-1225 •Owner. Romany & May Yousseuf ;PIC: Mary Yousseuf Inspector: Elizabeth Salandrea Date Inspected: Correct By: 6/9/2008 Risk Level: a Permit Number: BHP -2008-0369 I Status: I PARTIAL COMPLY I# of Critical Violations: T Ime IN: I Time OUT: I Urgency Description(s) City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ White Hen Pantry Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing FAIL Critical LJ RED W6mment: Ice scoop is now being stored hanging on front of ice machine, not in its container. Store ice scoop in its clean, jN 1 CSL J� sanitized container designated for the scoop only, or in ice with handle facing out. .s( —Sanitizer log not being maintained daily. Daily log of sanitizer concentration must be kept. knives in rack had food debris on them. Knives must be properly washed, rinsed and sanitized prior to storage in rack. Handwash Facilities FAIL Critical ❑d RED bathroom missing paoer towels and scan. Provided soap and paper towels in dispensers at all times. dations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE cw,.Aaccz.(cEs, —Comment: Some items packaged by establishment in sandwich display case fridge and smaller desert display case fridge are still not properly dated. All food for sale must be labelled properly with dates. 1 Physical F ility FAIL Non -Critical BLUE `r"oCK I ex� omment: Cardboard dumpster has been emptied, however dumpster area still has trash and debris on the ground. All trash and debris on the ground must be cleaned up, and dumpster area must be maintained in a clean, sanitary manneiv, BLUE: I Final re -inspection will take place on Friday, June 13 2008, all outstanding violations to be corrected. Violations Related to Good Retail Practices (Critical Xease ther violations noted in the 6/2/08 inspection report have been corrected. violations must be corrected immediately or within 10 have extermination invoices faxed to the Board of Health within 3 days. days)(Non-critical violations must be corrected immediately ' or within 90 days) wtedkea-• *vh s�c,�i �S Int 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. Jun 12,2008) Page I oft / q - k, fil ,RED: Violations Related to Foodborne Illness Interventions` and Risk Factors (Require I immediate corrective action). Item Status Violation Critical Urgency A-� 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. Jun 12,2008 ) Page 2 oft 0028 Norman Street Telephone: (978) 745-1225 Owner: Romany & May Yousseuf PIC: t Mary Yousseuf Inspector: Elizabeth Salandrea Date Inspected: Correct By: 6/13/2008 Risk Level Permit Number: 1 BHP -2008-0369 1 Status: PARTIAL COMPLY # of Critical Violations: 12 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: ❑ White Hen Pantry Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing FAIL Critical Comment: Sanitizer log not being maintained daily. Daily log of sanitizer concentration must be kept. Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical RED BLUE Comment: Some items packaged by establishment are still not properly dated. All food for sale must be labelled properly with dates. Owner discarded all potentially hazardous items that were not dated. All other violations noted in the 6/2/08 and 6/9/08 inspection reports have been corrected. Owner may be contacted by the Health Agent regarding failure to properly date re -packaged items that are for sale for sale and may be subject to fines for future repeat violations of this nature. 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. Jun 17,2008) Page I 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® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 17,2008) Page 2 of R HACCP Risk Assessment City/Town of: Salem • e , 1 e - Turkey Sub with lettuce, tomatoes, cheese and mayo Describe Product Flow °, { ` ' (P reparation Steps) Who, What, Where, When ,.,:.. yE',suspensions Establishment Name White Hen Pantry lin gredlents;., -` C; - ' fi Source Verified - Address 28 Norman Street, Salem, MA 01970 Perdue Turkey Breast Boston Salad C — Turkey Person -in -Charge Mary Yousseuf Land -O -Lakes White American Cheese Boston Salad (Critical Lettuce and Tomatoes Mayo Russo's Produce Boston Salad Information for the Risk Assessment was obtained by: ❑ Observation of Suspect Food/Process ❑ Observation of General Food Handling and Sanitation Practices Interview with Food Employee Responsible for Preparing Implicated Food. Interview with Person -in -Charge or Other Employee Dates of Investigation: 1/10108 Roll Perkins Control Two loaves of turkey in the walk in had for the customer to buy. S — Turkey Weight/Volume of Suspect Food Prepared or Served: 1 Sandwich PLEASE PRINT CLEARLY = " Describe Product Flow °, { ` ' (P reparation Steps) Who, What, Where, When ,.,:.. yE',suspensions Describe Environmental Data Collected to Verify Control or Lack of Control of Hazards_ „', h ;_y HAZARDS -Contamination Survival # Proliferation ` ' Describe Corrective and Preventive MeaInitiated " h ;for correcthongembarooes/daisdlosals,rfood ores, orders g p employee restrictions, food safety training, emergency -- and closures, etc.) Verified - ❑CCP Perdue turkey breast is ordered from The meat is held at the required temperatures until C — Turkey The unit for pre -made subs must be repaired to (Critical Boston Salad and delivered once a week. the pre -made subs are placed in the Hussman unit maintain a temperature of 4leF or below. Control Two loaves of turkey in the walk in had for the customer to buy. S — Turkey expiration dates of 3/17/08. The turkey is The meat slicer and all knives must be properly Point) delivered through the front door and P —Turkey cleaned and sanitized after each use and prior to placed directly in the walk in at a storage. temperature of 3TF. From the walk in it The meat slicer does not appear to be properly is taken to the front deli case where it is cleaned and sanitized after each use. Wrap or cover all deli products. rotated by FIFO. Turkey is pre -sliced approximately 10 slices at a time and cut Dirty knives found stored in the knife rack. about 3-4 times a day. Cut turkey is stored in a sandwich unit at 40°F. Subs All deli meats and cheeses are stored inn the deli are pre -made and made to order. Pre- case unwrapped. made subs are held for 24 hours and then discarded. They are held in a case that had a temperature of 53.8°F. The land -o - lakes cheese goes through the same process as the turkey breast. Page: Number)of l HACCP Risk Assessmerd Report Form (Updated 09/05) Page: Number 7=of Z HACCP Risk Assessment Report Form (Updated 09/05) The sub rolls are delivered by Temperature of freezer is 10°F, above mandated P — Rolls Repair freezer to maintain a temperature of 0°F Perkins once a week. They are 0°F. or below. ❑CCP delivered in the front door and go directly into a freezer that had a temperature of 10eF. They are thawed for 15 minutes and placed into an oven to complete thawing. Then placed into bags in a bread drawer. Lettuce and tomatoes are supplied by The meat slicer had an accumulation of food C — Lettuce and Properly clean and sanitize the meat slicer after Russo's Produce. They are delivered debris. Dirty knives were stored in the knife rack. tomatoes each use and prior to changing from one food ❑CCP through the front door and stored The dedicated produce sink had dirty coffee pots — Lettuce and product to another. directly in the walk in. The stored in it. tomatoes t t Properly clean and sanitize all knives prior to temperature of the walk in was 37°F. storage in the knife rack. The lettuce and tomatoes are washed P —Lettuce and in a dedicated produce sink prior to tomatoes Properly clean and sanitize the produce sink being used for sandwiches. The prior to washing vegetables. lettuce is cut on the meat slicer and the tomatoes are cut with a knife. Mayo is delivered from Boston No health violations or concerns noted at this Salad. It is delivered through the time. ❑CCP front door and stored directly in the walk in at 3717. it is taken from the walk in and a small amount is placed in the deli unit at 35°F for use on sandwiches. The container is place in the deli display case. Page: Number 7=of Z HACCP Risk Assessment Report Form (Updated 09/05) HACCP Risk Assessment City/Town of: Salem rkey Sub with lettuce, tomatoes, cheese and mayo Describe Product Flow (Preparation Steps) E ;,#? Who, What; Where, When - + Establishment Name !g!dients! Describe Corrective and Preventive,"r Measures Initiated ; -- +` (Include changes in food handling procedures, orders for correction, embargoes/disposals, food. employee restrictions, food safety training, emergency suspensions and closures, etc.) Date Verified �' White Hen Pantry Perdue turkey breast is ordered from Source r C — Turkey Address 7st o- Boston Salad and delivered once a week. 28 Norman Street, Salem, MA 01970 Perdu Boston Salad Person -in -Charge Mary Yousseuf Land -n Cheese Boston Salad for the customer to buy. Lettuc Russo's Produce Information for the Risk Assessment was obtained by: Mayo Boston Salad ❑ Observation of Suspect Food/Process ❑ Observation of General Food Handling and Sanitation Practices ® Interview with Food Employee Responsible for Preparing Implicated Food. ❑ Interview with Person -in -Charge or Other Employee Dates of Investigation: 1/10/08 Roll Perkins Point) delivered through the front door and P — Turkey cleaned and sanitized after each use and prior to Weight'Volume of Suspect Food Prepared or Served: 1 Sandwich PLEASE PRINT CLEARLY Page: Number I Of Z HACCP Risk Assessment Report Form (Updated 09/05) Describe Product Flow (Preparation Steps) E ;,#? Who, What; Where, When - + Describe Environmental Data Collected to',HAZARDS Verify Control or Lack of Control of Hazards " .., r ° t - �* ' _ ' -Contamination -Survival - -Proliferation "q Describe Corrective and Preventive,"r Measures Initiated ; -- +` (Include changes in food handling procedures, orders for correction, embargoes/disposals, food. employee restrictions, food safety training, emergency suspensions and closures, etc.) Date Verified �' ❑CCP Perdue turkey breast is ordered from The meat is held at the required temperatures until C — Turkey The unit for pre -made subs must be repaired to (Critical Boston Salad and delivered once a week. the pre -made subs are placed in the Hussman unit maintain a temperature of 410F or below. Control Two loaves of turkey in the walk in had for the customer to buy. S — Turkey expiration dates of 3/17/08. The turkey is The meat slicer and all knives must be properly Point) delivered through the front door and P — Turkey cleaned and sanitized after each use and prior to placed directly in the walk in at a storage. temperature of 370F. From the walk in it The meat slicer does not appear to be properly is taken to the front deli case where it is cleaned and sanitized after each use. Wrap or cover all deli products. rotated by FIFO. Turkey is pre -sliced approximately 10 slices at a time and cut Dirty knives found stored in the knife rack. about 34 times a day. Cut turkey is stored in a sandwich unit at 400F. Subs All deli meats and cheeses are stored inn the deli are pre -made and made to order. Pre- case unwrapped. made subs are held for 24 hours and then discarded. They are held in a case that had a temperature of 53.80F. The land -o - lakes cheese goes through the same process as the turkey breast. Page: Number I Of Z HACCP Risk Assessment Report Form (Updated 09/05) Page: Number I of Z HACCP Risk Assessment Report Form (Updated 09/05) The sub rolls are delivered by Temperature of freezer is 10°F, above mandated P — Rolls Repair freezer to maintain a temperature of 0°F Perkins once a week. They are 0°F. or below. ❑CCP delivered in the front door and go directly into a freezer that had a temperature of 10eF. They are thawed for 15 minutes and placed into an oven to complete thawing. Then placed into bags in a bread drawer. Lettuce and tomatoes are supplied by The meat slicer had an accumulation of food C — Lettuce and Properly clean and sanitize the meat slicer after Russo's Produce. They are delivered debris. Dirty knives were stored in the knife rack. tomatoes each use and prior to changing from one food ❑CCP through the front door and stored The dedicated produce sink had dirty coffee pots S Lettuce product to another. directly in the walk in. The stored in it. — and temperature of the walk in was 37°F tomatoes Properly clean and sanitize all knives prior to The lettuce and tomatoes are washed P —Lettuce and storage in the knife rack. in a dedicated produce sink prior to tomatoes Properly clean and sanitize the produce sink being used for sandwiches. The prior to washing vegetables. lettuce is cut on the meat slicer and the tomatoes are cut with a knife. Mayo is delivered from Boston No health violations or concerns noted at this Salad. It is delivered through the time. ❑CCP front door and stored directly in the walk in at 37°F. it is taken from the walk in and a small amount is placed in the deli unit at 35°F for use on sandwiches. The container is place in the deli display case. Page: Number I of Z HACCP Risk Assessment Report Form (Updated 09/05) 0 gv 6 +' KIMBERLEY DRISCOLL MAYOR JOANNE SCOTT HEALTH AGENT CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL, 978-741-1800 FAX 978-745-0343 To: avu 1 4rrl s Fax# 6)? - q93-6-770 RE Date : /- 9-07 JSCOTT@SALEM.COM Facsimile Transmittal Page(s): including this cover # Message: bzjv T. -a roe- is he 1154-rdl-- Board of Health News----------------------------------------------------------------For Your Information OFFICE HOURS: Monday, Tuesday, Wednesday 8:00 AM to 4:00 PM Thursday 8:00 AM to 7:00 PM Friday 8:00 AM to 12:00 NOON Kimberley Driscoll Mayor January 8, 2008 Robert Kibero CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 286 Washington Street Salem, MA 01970 Dear Mr. Kibero: Please contact Tracy Giarla, Public Health Nurse, or me, Joanne Scott, Health Agent, at the Salem Board of Health so that we may obtain information necessary to follow up with your complaint regarding illness associated with a turkey sandwich purchased at White Hen Pantry. Our hours are Monday through Wednesday, 8 AM to 4 PM; Thursday 8 AM to 7 PM; and Friday, 8 AM to Noon. Our telephone number is 978-741-1800. If you cannot call, please visit our office during business hours. We are located at 120 Washington Street, 4th Floor. Thank you. cerely, nne S� Health Agent HP Fax Series 900 Plain Paper Fax/Copier Last Fax Date Time Twe Jan 8 2:53pm Sent Result: OK - black and white fax Identification 916179836770 Fax History Report for Joanne Scott Salem BOH 978 745 0343 Jan 08 2008 2:54pm Duration Paees Result 0:37 2 OK JAN -08-.200Q 12:04 FROM:DPH FOOD PROTECTION 617 983 6770 TO:978 745 0343 L(Sq�,LL�' CommCrWealll'. OtDeportrttent of Public Health ; Food Protection Program To: Salem, Board of Health From: Tara Harris Foodborne Illness Coordinator PhoneIFAX 978 745 0343 Phone/FAX Phone: 617-9836756 To: Health Agent From: 617.983-6770 All FAX: 617.524-8062 Phony Date 118108 Re: Foodbome Illness Pages; 2 Including cover page ❑ Urgent ❑ For Review 171 Ptease Comment ❑ Please Reply ❑ FYt e Comments: This complaint was sent to you by Beth Altman as a general complaint N 08-007. Howewr, I'm sending it to you as a foodbome illness complaint because a HACCP risk assessment of the implicated food should be conducted. Please refer to the Department's 'Foodbnme 11kress Investigation and Control Reference Manual" for guidance. The manual and other investl9ation reference materials and tools are available On our web site at htol/www.massaov/dphdoodbomellingog. Please forward all documentation incGluding an Inspedion report and the risk assessment as soon as possible and nobly me as soon as possible I the product is manufactured at another location. If you have any further questions or need assistance, please call me at 617-983.8756. Thank you for your cooperation in this matter. Sincerely, Tara Harris NOTICE: The pages comprising this facsimile transmission contain confidential information from the Department of Public Health. This information is intended only for the use by the recipient listed above. If you are not the intended recipient or the employee or agent of the intended recipient responsible for the delivery of this information, you are hereby notified that the disclosure, copying, use or distribution of this information is strictly prohibited. If you have received this transmission in error, please notify us immediately by telephone to arrange for the return of the transmitted documents to us or to verify their destruction. P. 1'2 JAN -08-2008 12:04 FROM:DPH FOOD PROTECTION 617 983 6770 70:9713 745 0343 P.2,2 Massachusetts Department FOODBORNE ILLNESS COMPLAINTWORKSHEET Date: 11712008 MDPH Food Protection Program Food protection Program: (617) 983-6712 305 South Street, Jamaica Plain, MA 02130 Division or t-yidemiology; (617) 983.6600 WG 0. 2008-01-C11 Fax: 16171983-6770 Enterics Laboratory: (6171983-6609 PERSON COMPLETING INFORMATION Name Beth Altman Affiliation State DPH (DFD) Phone 4 (617) 983-6712 REPORTER ICOMPLAINANT Name Robert Kibero Affiliation Consumer Phone 0 Unknown Town; Salem Address: 286 Washington St. ILLNESS INFORMATION 0 Persons it a Symptoms: Vomiting Onset Earliest: 111 Person(s): Name Town Kibero. Robert Salem Medical attention received (by anyone)? Duration: Unknown Telephone Age (yrs) Occupation Med. Prov. U Yes n No V Unk Stool specimens submitted: (by anyone)? F I Yes ❑ No L ] Unk (toSLI) ❑ Yes ❑ No W Unk Medical diagnosis reported? FOOD HISTORY Date/ Time: a Exp: Foods consumed: Restaurant/ Store where purchased: Place Consumed: Food Avail. able? Sent to SU? Specify: Mrs to Mittel: Eanm•1 1-0875", 113/2008 Turkey Sandwich White Hen Pantry, Salem 28 Norman Su Unknown No lMk NOTES The complalantant stated that he got sick approximately 6 hours after consuming his sandwich. He stated that this was the second episode of illness after eating food from the White Hen Pantry. Printer!: 1/812008 10:50:31 AM R COMPLAINT NUMBER: Page 1 of 3 FOODBORNE ILLNESS COMPLAINT WORKSHEET COMMONWEALTH OF MASSACHUSETTS - DEPARTMENT OF PUBLIC HEALTH WORKING GROUP ON FOODBORNE ILLNESS CONTROL For Local Board of Health Use Only Division of Food and Drugs Division of Epidemiology Enterics Laboratory (617) 9836712: Fax: (617) 9836770 (617) 983-6800: Fax: (617) 9836813 (617) 983-6609, Fax: (617) 983-6618 I. REPORT INFORMATION • Received By: 2 Date • Describe Person/Agency Reporting Information: D City/Town Board of Health D Consumer D Food Establishment D Hospital D Long Term Care Facility D Media D Medical Provider/HMO D School D State Dept. Public Health D Other Agency: (specify): D Other: Reporter's Name: ,) c e nnv Srx44 Reporter's': (p-7,?) 7VI - i&a d II. ILLNESS INFORMATION • Number Reported III: 1 2 Total Number (both ill and not ill) Exposed: Who was ill? 4 Obtain complete information for at least one ill complainant (case): • Case Name (Last, First): I : i 6 e ro - RO b e,- W: ( ) - • Case City/Town: 5ra b m Case Address: 29b (� Ja Sti717y 4M Other Illness Information: 2 First (or only) Known Illness Onset: Date k, Time: / / _ _ DAM DPM 2 Last Known Illness Onset: Date & Time: / / _ DAM DPM • Reported Symptoms (mark if reported for one or more cases): D Diarrhea D Vomiting D Nausea D Abdominal Cramps D Fever D Bloody Stool D Headache D Muscle Aches D Chills D Loss of Appetite D Fatigue D Dizziness D Burning Sensation in Mouth D Other symptoms: • Duration Of Illness: D Less than 24 Hours D 24-48 Hours D More than 48 Hours D Unknown D Was Medical Attention Received By Any Cases? D Yes D No D Unknown Medical Care Provider / W: 2 List Any Reported Medical Diagnoses: 9 Data entered into the WGFIC Foodborne Illness Complaint Database OCTOBER, 1997 0 COMPLAINT NUMBER: Page 3 of 3 IV. LABORATORY INFORMATION A. Consumer Specimens: Q Will/Did SLI Receive Any Consumer Stool Specimens? ❑ Yes ❑ No ❑ Unknown Approximate Number Of Specimens Submitted: # List Cases' Names Who Submitted: Any Consumer Stool Specimens Submitted To Other Labs (Non-SLI)?o Yes ❑ No ❑ Unknown List Cases' Names/ Lab Names/ LabV: B. Food Handler (FH) Specimens: ga Will/Did SLI Receive Any FH Stool Specimens? ❑ Yes ❑ No ❑ Unknown Approximate Number of FHs Specimens Submitted: # Estimated Total # FHs At Facility: # List FHs' Names Who Submitted: Any FHs' Specimens Submitted To Other Labs (Non -SLI)? []Yes ❑ No ❑ Unknown List FHs' Names/ Lab Names/ Labg: C. FOOD/OTHER Specimens: Ka Will/Did SLI Receive Any Food Or Other Specimens? ❑ Yes ❑ No ❑ Unknown List Type(s) Of Food Specimen(s) And Date(s) Collected: Type: Date: Type: Date: Type; Date: GENERAL NOTES: 9 Data entered into the WGFIC Foodborne Illness Complaint Database OCTOBER. 1997 HP Fax Series 900 Plain Paper Fax/Copier Last Fax Fax History Report for Joanne Scott Salem BOH 978 745 0343 Jan 14 2008 3:18pm Date Time T_)= Identification Duration PAM Result Jan 14 3:17pm Sent 916179836770 1:43 7 OK Result: OK - black and white fax 0028 Norman Street Telephone: r. {978) 745-1225,-, Owner: °. Romany & May Yousseuf " ry PIC: i Inspector: - David Greenbaum By:, *. 'Date Inspected: By:, Y , , � 11/812007 � Risk Level: �M a Permit Number-,.- umber BHP2007-0416 aa', 1131-113720'07--04116 Status.. .- PARTIAL COMPLY { " # of Critical Violations 3 x' Time IN '' . :Time OUTr Urgency Description(s): ,BLUE: ;Violations Related to Good ,Retail Practices (Critical % ;violations must be corrected immediately or within 10 jdays)(Non-critical violations` must be corrected immediately or within 90 days) } City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ White Hen Pantry Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing FAIL Critical iment: The cutting board on the deli unit is stained and scored. Resurface or replace the cutting board. RED inside panel on the ice machine has an accumulation of grime. Thoroughly clean and sanitize the panel. acilitiws FAIL Critical ❑d RED The bathroom hand wash sink has a hot water temperature of 95°F. Restore hot water to a minimum temperature 110°F A plumber is scheduled to repair the hot water today. Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comment: There are price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. Equipment and Utensils FAIL Non -Critical BLUE C m ent: The door on the long white box freezer in back is in disrepair. Repair or replace the door. Hussman freezer in back has an accumulation of food debris. Thoroughly clean this freezer. GENERAL COMMENTS: All other violations cited in the 11/1/07 inspection report have been corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 08,2007) Page 1 oft iRED:. ,5 Violations Related to: Foodborne Illness Interventions 'and Risk Factors (Require 'immediate corrective' action)_ Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 08,2007) Page 2 of IA ` 0028 Norman Street Telephone: (978) 745-1225 Owner: PIC: & May Yousseuf & Mary Yousseuf Inspector: David Greenbaum Date Inspected: Correct By: 11/112007 Risk Level: Permit Number: BHP -2007-0416 Status: VIOLATION # of Critical Violations: 5 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: ❑ White Hen Pantry Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Separation/ Segre ation/ Protection FAIL Critical RED Cment: Plastic wrap storred directly on top of food products in the deli unit. Do not stroe plastic wrap on food products to reventcross contamination. /,,tact are dirty dishes in the produce sink. Clean and sanitize the produce sink and use only for produce. Foo Surfaces Cleaning and Sanitizing FAIL Critical RED Comment: The cutting board on the deli unit is stained and scored. Resurface or replace the cutting board. . The inside panel on the ice machine has an accumulation of grime. Thoroughly clean and sanitize the panel. Good Hygienic Practices FAIL Critical ❑ RED Cment: Employee drinks observed in food prep areas. Employees must eat and drink in a designated area away from food prep o prevent cross contamination. Handwash Facilities FAIL Critical 91 RED ^�Comment: The bathroom hand wash sink has a hot water temperature of 95°F. Restore hot water to a minimum temperature 110°F I immediately. 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. Nov 01,2007 ) Page I of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions t�. and Risk Factors (Require Comment: There are price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. immediate corrective action) The following items removed outdated: 2 - Kraft horse radish sauce 5 - Realemon lemon juice 4 - Heinze cocktail sauce 3 - Stove top pork stuffing. 9 - Pringles pizza chips bars y5ower lance Bars gratin potatoes mburger helper 1 - Cabot sour cream ,, 5 - Cabot salsa 2 - Cabot Veggie dip 1 - Pilsbury orange sweet rolls 1 - Pilsbury pizza crust 1 - Nestle cookies - 3 - pints Garelick heavy cream 3 - quarts Garelick 1% milk 9 - gallons Garelick milk 2 - Dannon fusion smoothie Owner must closely monitor all expiration dates to insure there is no expired product out for sale. re is food stored directly on the walk in floor. Store all food at least 6.8 inches off the Floor. e ,,Th are paper products stored directly on the back room floor. Store all paper products at least 6-6 inches off the floor. Equipment an tonsils FAIL Non-Critical BLUE mment: The deli unit has an accumulation of food debris. Thoroughly clean this unit. ,Trad drawers need a thorough cleaning. 'PeD e deli case needs a thorough cleaning of both the top and bottom. The microwave needs a general cleaning. OT Moffat oven has an accumulation of grease and food debris. Thoroughly clean this oven. i-. The door on the long white box freezer in back is in disrepair. Repair or replace the door. �- The Hussman freezer in back has an accumulation of food debris. Thoroughly clean this freezer. T e soda needs a thorough cleaning. e Hershey ice cream freezer needs a thorough cleaning and defrosting. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (976) 741-1600 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 01,2007) Page 2 of Item The same unit needs a visible, accurate thermometer. GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. 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. Nov 01,2007 ) Page 3 of IMPORTANT MESSAGE DATE PLEASE CALL M-71�L WILL CALL. AGAIN WANTS TO SEE YOU OF - RETURNEDYOUR CALL PHONE %el- T �•S �'�D,� AREA CODE NUMBER EXTENSION U FAX U MOBILE AREA CODE -NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL. AGAIN WANTS TO SEE YOU RUSH - RETURNEDYOUR CALL WILL FAX TO YOU MESSAGE SIGNED WNWFORM 4009 MADE IN U.S.A. NOTES M, -7-/6, - d 7 Kimberley Driscoll Mayor May 3, 2007 White Hen Pantry 28 Norman Street Salem, MA 01970 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT M�n Dear Romany & Mary Yousseuf: On Monday April 9, 2007 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17 -year-old Male purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. White Hen Pantry is in violation of Section III (A) of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section, the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of (One Hundred Dollar fine) for the first offense. FOLLOWING THE THIRD (3R) OFFENSE, THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore, you are ordered to pay a fine of $100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street, 4"' floor, within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 978-741-1800. Si rely yours, oanne Scott Health Agent JS/mfp CERTIFIED MAIL: 7005 3110 0000 7160 2500 cc: North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members ps . .1` ROMANY Z. YOUSSEr F - < 5-7515/110 I° MARY Z. YOUSSEF 71004952744 308 28 NORMAN STREET % SALEM, MA 01970 2 ✓ ee or ci SbI $loo. is #Sovereign Bank 1:01107S1S01: 7 10049 5 2 74411• 03 TO THE ACCUSED NAMED ABOVE You are hereby notified that an application for a criminal complaint to issue against you for the offense(s) listed above has been made in this court by the complainant named above. This notice is to inform you that a hearing will be held at this court by a Magistrate to determine whether criminal proceedings will be commenced against you in this matter. The hearing will be held at the time and date shown above. You may appear at this time to present your side of the case. You may bring witness- es with you and you may also bring a lawyer, although it is not required that you be represented by counsel. Please bring this notice and report to the Clerk -Magistrate's office upon your arrival at the court. The court house address is listed above. If you do not appear for your hearing at the time and date noted, the criminal complaint may issue against you on that date. 0 e . I of k Lei =1 INFORMATION ABOUT ACCUSED AME (FIRST MI LAST) AND ADDRESS .................................................... .................................................... White -. :............................................. 28 Norman Street Salem, MA 01970 ................................................ -------------------- .......... ..._ .:: ..._.._.......: ............ ......• �. _....................................................._ ........................................... ........... •.... ................. ................... ............................................................. .................. - CASE INFORMATIONinf—veal&'it OMPLAINANT NAME (FIRST MI LAST) COMPLAINANTTYPE El POLICE El CITIZEN El OTHER ..:......:...............a..,:..:............_.......................... PLACE ...... �. - ......................................... ,� .................... F.- CITATION NO(S) DESCRIPTION Tlpfenrinnt failed to pay a $100-00 Fine fn� the gale of :VARIABLES (e.g. victim name, controlled substance, type and value of property. other variable inforniation: see Complaint Language Manuel) ... . . e. DESCRIPTION OFFENSE DATE VARIABLES • •. •ESCRIPTION OFFENSE DATE VARIABLES UA HEARING PON • . • .•E OF HEARING TIME OF HEARING i COURT USE ONLY ILL BE • AT THE ABOVE COURTADDRESS j AT TO THE ACCUSED NAMED ABOVE You are hereby notified that an application for a criminal complaint to issue against you for the offense(s) listed above has been made in this court by the complainant named above. This notice is to inform you that a hearing will be held at this court by a Magistrate to determine whether criminal proceedings will be commenced against you in this matter. The hearing will be held at the time and date shown above. You may appear at this time to present your side of the case. You may bring witness- es with you and you may also bring a lawyer, although it is not required that you be represented by counsel. Please bring this notice and report to the Clerk -Magistrate's office upon your arrival at the court. The court house address is listed above. If you do not appear for your hearing at the time and date noted, the criminal complaint may issue against you on that date. APPLICATION FOR APPLICATION NO. (COURT USE ONLY) PAGE Trial Court of Massachusetts CRIMINAL COMPLAINT of District Court Department I, the undersigned complainant, request that a criminal complaint issue against the accused charging the Salem District Court offense(s) listed below. If the accused HAS NOT BEEN ARRESTED and the charges involve: 65 Washington Street ❑ ONLY MISDEMEANOR(S), I request a hearing ❑ WITHOUT NOTICE because of an imminent threat of Satem. MA. 01970 ❑ BODILY INJURY ❑ COMMISSION OF A CRIME ❑ FLIGHT ❑ WITH NOTICE to accused. ❑ ONE OR MORE FELONIES, I request a hearing ❑ WITHOUT NOTICE ❑ WITH NOTICE to accused. ARREST STATUS OF ACCUSED ❑ WARRANT is requested because prosecutor represents that accused may not appear unless arrested. ❑ HAS ❑ HAS NOT been arrested INFORMATION ABOUT NAME (FIRST MI LAST) AND ADDRESS BIRTH DATE SOCIAL SECURITY NUMBER Romany & Mary Yousseuf, Owners PCF NO. MARITALSTATUS White Hen Pantry 28 Norman Street DRIVERS LICENSE NO. STATE Salem, MA 01970 GENDER HEIGHT WEIGHT EYES HAIR RACE COMPLEXION SCARS/MARKS/TATTOOS BIRTH STATE OR COUNTRY DAY PHONE EMPLOYER/SCHOOL MOTHER'S MAIDEN NAME (FIRST MI LAST) • FATHER'S NAME (FIRST MI LAST) INFORMATIONCASE COMPLAINANT NAME (FIRST MI LAST) COMPLAINANT TYPE PD Salem Board of Health ❑ POLICE ❑ CITIZEN D OTHER PLACE OF OFFENSE ADDRESS 120 Washington Street, 4th Floor 28 Norman Street Salem MA Salem, MA 01970 INCIDENT REPORT NO. OBTN CITATION NO(S). OFFENSE CODE DESCRIPTION OFFENSE DATE for the sale of 14/9/07 tFine VARIABLES (e.g. victim name, controlled substance, type and value of property. other variable information; see Complaint Language Manual) tobacco to minor. OFFENSE CODE DESCRIPTION OFFENSE DATE 2 VARIABLES OFFENSE CODE DESCRIPTION OFFENSE DATE 3 VARIABLES REMARKS COMPLAI NTS IG TORE DATE FILED x COURT USE ONLY A HEARING UPON THIS COMPLAINT APPLICATION TE OF HEARING NJ TIME OF HEARING COURT USE ONLY WILL BE HELD AT THE ABOVE COURT ADDRESS ON AT 0 DCCR-2(08/06) COMPLAINANT'S COPY „+ Board of He `` IGmbef q Dnscol „ 120 Washington Street 4th FlooraMayor'` ” SALEM MA 01970 Food/Retail Establishment Permit DATE PRINTED: 03/01/2007 ESTABLISHMENT NAME: File Number: BHF -2004-000365 LOCATED AT: White Hen Pantry 28 Norman Street Salem MA 01970 0028 NORMAN STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2007-0416 Mar 1, 2007 Dec 31, 2007 $100.00 TOBACCO VENDOR BHP -2007-0417 Mar 1, 2007 Dec 31, 2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES !December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH _ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 �ernNs TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT W14;ne fler-1 AdTRTEL# 9 y9_ ZY-r /.7-�s ADDRESS OF ESTABLISHMENT d I 00201011V 5'7% FAX # MAILING ADDRESS (if different) EMAIL -- Business': Owner's: OWNER'SNAME RomnNN 'r /gnRS/ YJYJPeor TEL ADDRESS -O/V&5 I H` CITY STREETQe A q.� �/ Yo u JJt w � CERTIFIED FOOD MANAGER'S NAME(S) MAaY %urJt� r= CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL #_ Please write in time of dall. TYPE OF ESTABLIS T RETAIL STORE YES NO RESTAURANT YES NO FEE (check only) t. less than I000sci =$ 50 . 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 --- less than 25 seats - - - =$100 25-99 seats =$150 more than 99 seats =$200 ------- - ---------- ----- ----- ------ -------------- -- --------------- ----------------- $100 - BEDIBREAKFAST YES NO ------- - --- - ---- - - - -- - --- ---- Y 0 �1 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 YES NO$50 YES NO $25 TOBACCO VENDOR " ALL NON-PROFIT (such as church kitchens) `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, ail 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. Social Revised 11113 FOODA6'2007.adm Check# & Date Identification Number Massachusetts Department of Public)Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name I /�/ /y //� Ift° Yi�h'/T/Y!( - Date Type of Operation(s) LJ Food Service Tvoe of Inspection ❑Routine Address p Risk Retail ED-Re-inspection yU Level ❑ Residential Kitchen ❑ Mobile [I Temporary ❑ Caterer El Bed & Breakfast Previous Inspection Dater _&09 EDPrig-operation '❑ Suspect Illness ❑❑ General Complaint Telephone ter_ -_ f Owner �f���//, ��� ��• S HACCP YIN Person in Charge (PIC)/Jr� Time I In: Out: Permit No. HACCP ❑ Other Inspector J ✓ ��• y Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action.as determined by the Board of Health. ! t `FOOD PROTECTION MANAGEMENT= = . ❑ 1. (PIC Assigned/ Knowledgeable / Duties EMPLOYEE HEALTNt ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3.. Personnel with Infections Restricted/Excluded ❑ 12. Prevention of Contamination from Hands ❑ 13 Handwash Facilities r PROTECTION FROM CHEMICALSs- �;. ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE „'�,g'E"a ❑ 4. Food and Water from Approved Source , TIMEITEMPERATURE CONTROLS (Potentlally Hazardous Footls) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans p PROTECTION FROM CONTAMINATION,-,, ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C, ,N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) v, 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other 5: 5901nspectPormS 14 Doc n �^ ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. TimelAsta Public Health Control if REOUIREMENTS FUR HIGHLY SUSOEPTIaLE POPULATION$ (HSP) a j' ❑ 21. Food andiFood Preparation for HSP I.CONSUMER ADy1S0Ry,', ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions 1� and Risk Factors (Items 1-22): C/ 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's3rg fre'� � /.( n /� Print:r 11 � NA f l(C - PIC's Signatu - `�C Print: -�' =-` '''"� Paged`` of Pages i / 6,-- v/ Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) _ FOOD PROTECTION MANAGEMENT 590.003(A) Assignment of Responsibility* �90.003(B) Demonstration of Knowledge* 2-103.11 1 Person in chargee -- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* _ 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 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; Restrictions C C C FOOD FROM APPROVED SOURCE * Denotes critical item in the fedend 1999 Pond Code or 105 Ci41R 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 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* 5401.11 Drinking Water from an Approved System* tem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.071 Washing Fruits and Vegetables SheAfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.1.2 Shellstock Identification Maintained* - Tags/Records: Fish Products 3402.11 Parasite Destruction* 3402.12 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 packaging. criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the fedend 1999 Pond Code or 105 Ci41R 590.000. PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.1 1(A)(1) - Raw Animal Foods Separated from Cooked and RTE Fcxxls* Contamination from Raw Ingredients - 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3302.11(A) - Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.1 I. 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* UL Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Tent eratures* - 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures- em eratures*4-501.114 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. .« 4-601..1 [(A) Equipment Food Contact Surfaces and Utensils Cleats* 4-602.11. Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Bating, Drinking or Usin Tobacco* 2-401.1.2 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tastin 12 Prevention of Contamination from Hands 590.004(F.) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.1.1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6 301.11. Handwashing Cleanser, Availability (-301.12 Hand Drying Provision 1 ; CITY OF SALEM llL(� BOARD OF HEALTH ? Establishment Name: �//1� Date: �? ^� Page: 65F ofQh�v a Nem Code C —critical Item r` DESCRIPTIONOF VIOLATION / PLAN OF CORRECTION Date No. Reference R — Red Item ,,.. E Verified I . I ..:. PLEASE PRIM CLEARLY .' �/ r r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to Exclusion p i ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand t>rdt noncompliance may result in daily fines of twenty-five dollars or sus ension/revocation of ❑ 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 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 Common Name- Working Containers* 7-201.11 Se aration - Storage* 7-202.11 1 Restriction - Presence and Use* 7-202.12 Conditions of Use, 7-203-11 'toxic Containers - Prohibitions* 7-204.11 Satdtizers, Criteria -Chemicals* 7-204.12 Chemicals for Washin¢ Produce, Criteria, 7-204.14 Din . rents. Criteria - 7 -205.11 Incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stations* 7-206.13'Cracking Powders, Pest Control and Monitoring* TIMEITEMPERATURE CONTROLS * Denotes critical item in the f,, dera1 1999 Food Code or 105 CvIR 590.006. 19 3-501,14(C) Proper Cooking Temperatures for 3-501.15 'IPHFs 3-401.11A(l)(2) Eggs- 155'F'15See. 3-501.16(B) 590.004(F) E r¢s- Itmrediate Service 145°FtSsec* 3-401.11.(A)(2) Comminuted Fish, Meats &Game 3-501.16(A) Animals- 155'F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, injected Meats - 155°F 15 590.004(H) sec. * 3-40L11(A)(3) Poultry, Wild Game, Stuffed PHFs, .00a Slatting Containing Fish, Meat, Poultry or Ratites -165"F 15 sec. a` 3-401.11(C)(3) Whole muscle, Intact Beef Steaks 145'F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-40L11(A)(1)t1)) All Other PHFs- 1.45`F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°.F 15 see. I, 3-403.11(B) Microwave- 165' F2 Minute Standing Timc* 3-403.11(C) Commercially Processed RTE Food - 1409F* 3-403-1.1(7.) Remaining UnslicedPortions ofBee f Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140"F to 7097 Within 21lours and From 70'F to 41'F/45"F Within 4 Hours. 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 119F/45"F Within 4 Hours* * Denotes critical item in the f,, dera1 1999 Food Code or 105 CvIR 590.006. 19 3-501,14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Hours. 3-501.15 Conlin, Methods for PH7s 3-8o1.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 4Y1450 F" 3-501.16(A) Hot PI-IFs Maintained at or above 140'F. * 3-501.16(A) Roasts Held at or above 130°F. M. Water, Plumbin and Waste Time as a Public Health Control 3-501.19 Timc as a Public Health Control* 590.004(H) Variance Requirement 21 3-801-] (A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels* 23. nana ement and Personnel.... 3-8o1.11(B) Use of Pasteurized Fees* 24. Food and Food Protection_ 3-801.1 l(D) law or Pmtiaily Cooked Animal Food and Raw Seed S grouts Not Served. 25:_____ Equipment and Utensils 3-801.14Cj Uno cued Food Packa re Not Re -served, +` « , it . =M 22 3-603.11 Consumer Advisory Posted for Consumption of 23. nana ement and Personnel.... FC - 2 Animal Foods'Chat are Raw. Undercooked or 24. Food and Food Protection_ FC -3_ Not Otherwise Processed to Eliminate 25:_____ Equipment and Utensils FC 4 Pathogens.' M. Water, Plumbin and Waste 3-302.13 Pasteurized Eggs Substitute for Raw Shell 27. Ph sical Facility_____ FC -6 Ei r raY k711 it.'i;ad_.gk1[-7 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (items 23-30) Critical and non -4 ritical violations, which do not relate to the foodborne illness interventions and risk factors listed above„ can be found in the following sections of the Food Code and 105 CMR 590.000. Item Good Retail Practices FC 590.000 23. nana ement and Personnel.... FC - 2 .003 24. Food and Food Protection_ FC -3_ .004 25:_____ Equipment and Utensils FC 4 .005 M. Water, Plumbin and Waste _'i FC -5 .066 27. Ph sical Facility_____ FC -6 ..007 28. Poisonous or Toxic mleriais FC - 7 .00a 29. Special Requirements .009 30. Other _ .tbxrs-z u,r CITY OF SALEM ,y d� �I BOARD OF HEALTH ? Establishment Name: (L1�kl _ / 1 Date: J G Page: of / Item Code C- Critical Item DESCRIPTION OF VIOLATION! PLAN OF CORRECTION Date No. Reference R —Red item. j. '`7 Verified . ei cecc omur ri cem v .. ... _.:r M 5 F Discussion With Person in Charge: F 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. Required: ❑ Voluntary Compliance ❑ Re -inspection Scheduled ❑ Embargo 0 Voluntary Disposal No 1 ❑ Yes ❑ Employee ttestriction i Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 16 t� 18 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* Maga ement and Personnel Poisonous or Toxic Substances 7-101.I1 Identifying Information - Ori. nal Containers" 7-102.11 Common Name- Working Containers* 7-201.11 Separation - Stoiit e* 7-202.11 Restriction - Presence and Use" 7-202.12 Conditions of Use - 7 -203,11 Toxic Containers - ProhibiLions" 7-204.11 Sanitizets, Criteria - Chemicals:, 7-204J12 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 Mon'itor'ing* TIME/TEMPERATURE CONTROLS 4 Denotes critical itein in tine Federal 1999 Food Code or 105 ('M12 590.000- Proper Cooking Temperatures for Utrposteurized Pre-packaged Juices and Beverages with Waging Labels* PHFs 3-401.11A(1)(2) Eggs- 155'F 1.5 Sec. Maga ement and Personnel Eggs- Immediate Service 145'F15scc* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-801.1 ] (C) Animals - 155'F l5 sec. * 3-401.11(B)(1)(2) Pork. and Beef Roast - 130+ 121 mm* 3-401.1 I(A)(2) Ratites, Injected Meats -155°F 15 Equipment and Utensils Wates--Plumbin and Waste -- -- -- Physic al Facility--__.- see. * 3-401..1.1(A)(3) Poultry, Wild Game, Stuffed PHFs, Poisonous or Toxic Materials Stuffing Containing Fish, Meat, - 7 Poultry or Ratites -165°F 15 .sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks _ ___ 1450F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401, 1 l(A)(1)(b) _ All Mier PHFs-145'F'15see. Reheating for Hot Holding 3-40111(A)&(L)) PHFs 1650F 15 sec. 3-403.11(B) Microwave -1 tis° F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140'F* 3-403.11(E) Retraining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling C'ook'ed 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 Front Ambient Temperance Ingredients to 41 `F/45'F Within 4 Hours* 4 Denotes critical itein in tine Federal 1999 Food Code or 105 ('M12 590.000- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 2'1 3-50114(C) w PHFs Received st Temperatures According to Iaw Cooled to 41'F/45'F Within 4 Hours. Utrposteurized Pre-packaged Juices and Beverages with Waging Labels* 3-501.15 Cooling Methods for PHFs 19 PHF Hot and Cold Holding Maga ement and Personnel 3-501.16(B) Cold PHFi, Maintained at or below 590-004(F) 41`/45° F* Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 'n 3-501.I6(.A) Hot PHFs Maintained at or above 140'T', * 3-801.1 ] (C) 3-501.16(A) Roasts Held at or above 130'F. 20 Time as a Public Health Control Pasteurized Eggs Substitute for Raw Shell 3-501.19 Time as a Public Health Control* Equipment and Utensils Wates--Plumbin and Waste -- -- -- Physic al Facility--__.- 590.004(H) Variance Re ulrement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 2'1 3-80t.11(A) Utrposteurized Pre-packaged Juices and Beverages with Waging Labels* 3-801.11(N) Use of Pasteurized Fess" Maga ement and Personnel 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 'n .003 3-801.1 ] (C) Uno ened Food Pucka >e Not Re -served. " s •} 22 350111 Consumer Advisory Posted for Consumption of 590.000 Animal Foods Tfiat are Raw, Undercooked or Maga ement and Personnel FC Not Otherwise Processed to Eliminate .003 24. Pathogens.* e''v`n,F vvom FC 3-302.13 Pasteurized Eggs Substitute for Raw Shell 26. _ 26. --- 27. Equipment and Utensils Wates--Plumbin and Waste -- -- -- Physic al Facility--__.- E g* Violations of Section 590.009(A) -(D) in catering. mobile food, temporary and residential kitchen operations should he debited under the appropriate sections above if related to foodborne illness Interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements, r/Iij* ir*jA tl (Items 23-30) Critical and non-eridcal violations, which do not relate to the foodborne illness btteiventions and risk factors listed above, can be. ,found in the following sections of the Food Code and 105 CMR 590.000, Item Good Retail Practices FC 590.000 23. Maga ement and Personnel FC - 2 .003 24. Food and Food Protection FC -- 3 .004 26. _ 26. --- 27. Equipment and Utensils Wates--Plumbin and Waste -- -- -- Physic al Facility--__.- FC - 4 FC -5 FC -6 .005 1.006 - .007 28. Poisonous or Toxic Materials FC - 7 .008 29. _ 30. S ecial Re uirements _ Other _ ___ _ .009 S " ,c 2 u,, IMPORTANT MESSAGE FORsi�ilf A. M DATE C-2-3 -� 9- r7 ' TIME .1 r13v To OF PHONE UZ- a, AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL .TELEPHONED LEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU 'I RUSH RETURNED YOUR CALL WILL FAX TO YOU i SIGNED FORM 4009 qwrm. MADE IN U.S.A. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT MEMO To: File From: David Greenbaum, Sanitarian Re: Tropicana Twister — White Hen Pantry A complaint was received at the Board of Health regarding Tropicana Twister juice drinks that were purchased at the White Hen Pantry on Norman Street. The complainant stated that he bought three flavors of the drinks. He opened one and drank quickly and after noticed a sour taste and a bad smell in the bottle. An inspection was conducted at the store. A sampling of Tropicana Twister juices were opened and some smelled rancid. The manager was told to remove all Tropicana Twister from the shelf and notify the distributor of this problem. 02/27/2007 20:54 5085202760 3D LIGHTING 3-D UGH ING 235 COTTAG STREET FRANKLIN, 02638 1-508-52 757 FAX: 508-522750 EMAIL: SALES@3-D IGHTING.COM FAX TRANSMISSION�COVER SHEET ro: j(tks- -D;onkp,- FAX NUMBER: FROM; 0.. DATE: 8 _, _ ©— MESSAGE: �Q mac{ C inVoiS A f�flOtA). b,0� & i\,Urec�- -to 7)'lan6 Number of Pages: (Including cover) PAGE 01/03 �)p l.S 04- agcool •'s �aq - * a01 �3(� ck . 4-cAcky I c), a. aLgomome SYSTVAS UQKTINQ 06 00rrAQEVr- - FRAMWIA MAC2M CWHI 520-2767 3w SOLD TO: FM LD, *-. M-042605SH4PPED TO WHITE HEN WHTTE HEN PANTRY-SALEM JOHN MANN-- 1'-'£5306-5 290 VANDERBILT AVE 29 NORMAN STREET NORWOOD MA 02062 SALEM MA 01970 mt... M5WHITE V07 01 /07 ET T48TI0/Cw OOL:WlilTr:,-, ;8. 0 2.7200 101. 60712/f j6 OLWHM. e 4 5 -00 , su "'. FOR F60TI2 N it! 2.9900 13 SUB TOTAL rAX "HARD TO FIND" WE ARE EXPERTS AT PRODUCTS! TOTAL LIGHTING PLEASE ASK ABOUT OUR CURRENT SPECIALS! EL ECMOPXC SmEm UGHTM 06 COITAOt RT.. PRAMMIN, KA Oe= (506) 5262757 FM I.D. N, 043442606 SOLD TO WHITE HEN JOHN MANNT 290 VANDERBILT A* I 'E NORWOOD MA 0206, M5WHII E WE: ARE EXPERTS Af "HARD TO FIND" TAX LIGHTING PRODUCT'-' TOTAL PLEASE ASK ABOUT OUR CURRENT SPECIALS! op' T. 7U P L A / r 12 =4 billt/ 4:�k I tI SM PRED To girder` a WHITE HEN PANTRY --SALEM PLA/1I2--- 10 X 45 1/2, 28 NORMAN STREET SALEM MA 01970 s�I/0 7.. 10 order *H I PP I NG HAND L I NG C Hl 7.98 0 WE: ARE EXPERTS Af "HARD TO FIND" TAX LIGHTING PRODUCT'-' TOTAL PLEASE ASK ABOUT OUR CURRENT SPECIALS! op' T. 7U SM PRED To WHITE HEN PANTRY --SALEM 1--8306-5 28 NORMAN STREET SALEM MA 01970 s�I/0 7.. 10 I. 7.98 0 WE: ARE EXPERTS Af "HARD TO FIND" TAX LIGHTING PRODUCT'-' TOTAL PLEASE ASK ABOUT OUR CURRENT SPECIALS! op' T. 7U Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name I// �j,� ` 11�(i 4-11 n /L2 Date _Type of 0 eration(s) Tvpe of Inspection ❑ Food Service XRetail ❑ Residential Kitchen ❑ Mobile ❑ Temporary E]Caterer El Bed & Breakfast Permit No. ❑Routine E-1Re-inspection Previous Inspection Date: �P5.Pre-operation El Suspect Illness E] General Complaint El HACCP ❑ Other Addresso /� Risk Level )91L Telephone < 1 2 _ J� 7 OwnerYM A mance v Maa �D Sse HACCP Person in Charge (PIC)- t e e// ! ✓n Time : put: Inspector 1 A Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAOEMENT,. �: ..�!1 n�� ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH n laui w.mntn tLtlamdde„a.-..a+wu ivi ❑ 2. Reporting of Diseases by FoodEmployeeand PIC ❑ 3. Personnel with Infections Restricted/Excluded L.`FOOD FROM APPROVED SOURCE rl�A,,,,„'""„„'y„ ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 12. Prevention of Contamination from Hands ©3.Handwash Facilities f'PROTECTION FROM CHEMICALS ­ 1 a�j ri�,A.� �❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals 1 nmErrEMPERATURE CONTROLS (Potsmialty` Hazardous Foods) i 4 a ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling I PROTECTION FROM CONTAMINATION'" ❑ SySeparation/ Segregation/ Protection i P/9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing 0111 . 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) i25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 'P7. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S.5 InVp lFom 14.Cx l� [119. Hot and Cold Holding ❑ 20. Time As a Public Health Control L REOUIREMENTS FOR HIGHLY SUSGEPTI6LE POPULATIONS (HSP)_ ❑ 21. Food and Food Preparation for HSP "CONSUMEFi./1UVISORY„""� Mia.;' „.�;' � "h ,T, 3'�"; i l�t, ❑ 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: Inspector's Signature Print: 9 / PIC's Signature: / 1. {�1J. '(..t.4�\. n I�wt Print: / / r /F j r c.st T oleo �rU�, c Page r/ of` Pages J "0 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 596.003(A) Assign ent of Responsibility* 590.003(B) Demonstration of Knowledge* 2503.11. Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Foal Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(6) 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 In FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 fail Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION F-8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.1.2 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.1.4 FW <s and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 31.0 CMR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.1.7 Game Animals* 3-701.11 Receiving/Condition 3-202.1.1 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(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 packaging, criteria* 8-103.12 Conformance with A. roved Procedures* * Denotes critical item in the federal 1999 fail Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION F-8 Cross -contamination 3-302.1IWO) - Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-3(4,11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 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 - 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` l.1 Good Hygienic Practices 2401..11 Eating, Drinking or UsJU Tobacco* 2-401.1.2 Discharges From the Eyes, Nose and Mouth* 3-30L12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.0(4(E) Preventing Contamination from Employees 13 Handwash Facilities _ Conveniently Located and Accessible 5-203.11. Numbers and Capacities* acities* 5-204.11 Location and Placement* 5-205.11 Accembilit,Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-30L11. Handwashing Cleanser, Availability 6-301..12 Hand Drying Provision CITY OF SALEM -2n�m V46l Violations Related to Foodborne fitness Interventions and Risk Factors(items 1-22) (Cont.) PROTECTION FROM CHEMICALS 1a 15 IN 17 TIMEITEMPERATURE 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* 7-10211 Common Narne -- Working Containers - ontainers-7-201.1 7 -20 1.1ISe arauon - Stora e'` 7-202.'11 Restriction- Presence and Use* 7-202.,12 Conditions of Use* 7-201,1.1 Toxic Containers - Prohibitions* 7-204.11 Sanitizers,Criteria- Chemicals* - 7-204.12 Chemicals for Washin 1'Indoce, Criteria* 7-204.74 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 Mrndt2ri2 TIMEITEMPERATURE CONTROLS I Denotes critical item in lb,, foicral 1999 Food Code or 105 CN1R 590.000. Proper Cooking Temperatures for PHFs Received at Temperatures PHFs 4-401 1 IA(1)(2) Eggs- 155'F 15 See. FC - 2 Eggs- Immediate Service 145'F15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.15 Animals - 155^F 15 sec. * 3-401.1I(B)(1)(2) Pork and Beef Roast -130"F121nim* 3-401.11(A)(2) Ratites, Injected Meats- 155`F 1.5 3-50L16(B) sec. * 3-401.17(A)(3) Poultry, Wild Game, Stuffed PHTs, 41%45"1^* Stuffing Containing Fish, Meat, 3-501,16(A) Poultry or Ratites -165"17 15 sec. 3-401 . I I (C)(3) Whole -muscle, Intact Beef Steaks 140'F.* 145'F * 3-401.12 Raw Animal Foods Cooked in a 20 Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs -- 145'F 15 sec, 3-501.19 Reheating for Hot Holding 3-403.11(A)&(D) PHFs 1650F 15 sec. 3-403.11(B) Microwave- 165' F 2 Minute Standing Time* -7403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.1.4(A) Cooling Cooked PHFs from 140'F to 70'F Within 2 Hours and From 70'F to 41°F/45'F Within 4 Hours. * 3-501.14(B) Cooling PRFs Made From Ambient Temperature Ingredients to 41 `17/45'F Within 4 Hours* I Denotes critical item in lb,, foicral 1999 Food Code or 105 CN1R 590.000. REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-50 L 14(Ci PHFs Received at Temperatures 3-901,11(B) Use of Pasteurized Ees* 23. ,According to Law Cooled fa FC - 2 _ 41'F/45'F Within 4 Hours. " Food and Food Protection 3-501.15 Coolito, Methods for PHFs, 19 3-302.13Pasteurized PHF Hot and Cold Holding .005 3-50L16(B) Cold PHFs Maintained at or below FC -5 590-004(F) 41%45"1^* Ph sical FacHity_ ___ 3-501,16(A) Hot PHFs Maintained at or above 28, Poisonous or Toxic Materials 140'F.* .008 3-501.16(A) Roasts Held at or above 130'17. 20 ,009 Time as a Public Health Control ---------- Other 3-501.19 Time as a Public Health Control* 590.004,(H) Variance Re uiremenl REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-80'L17(A) Unpasteurized Pre -Packaged Juices mtd Bevel�ges with Warnine Labels* Consumer Advisory Posted for Consumption of 3-901,11(B) Use of Pasteurized Ees* 23. 3-801.11(D) Raw or Partially Cooked Animal Focal and Raw Seed S routs Not Served. * FC - 2 3-901.11(C) Uno ened Food Packa,w Not Re -served. " CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.1100 23. Annual Foods That are Raw. Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC -3 Pathogens." Enna +: vsani 25. _ 3-302.13Pasteurized Eggs Substitute for Raw Shell .005 26. Eggs, arc4Wt. ISCW Vil'icMl civ 1 J 590.009(A) -(D) violations of Section 590.009(A) -(D) in catering. mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to Foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail. practices should be debited under #29 -- Special Requirements. 11 M01 (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne, illness interventions and rick factors listed above-, con be found in the following ,sections of the Food Code and 105 CMR 590.000. Item Goad Retail Practical FC 590.1100 23. _ Mana ement and Personnel FC - 2 .003 _24. Food and Food Protection FC -3 .004 25. _ Egui inent and Utensils FC--- 4 .005 26. Water, Plumbing and Waste FC -5 .006___ 27. Ph sical FacHity_ ___ FC -6 .007 28, Poisonous or Toxic Materials FG -7 .008 29_ S eclat Re uirements ,009 30 ---------- Other _.____._..-.-..I__--.-._____. sam�m�„n.,do-zs�c CITY OF SALEM BOARD OF HEALTH �J Establishment Name: /A/VI/ �(�/ iK�i '/11� i Date:/X� r!� Page: of Item Code C—Criti al Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R— dltem _: -__, ,: - Verified vl� 117 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. �N Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Re -inspection Scheduled LJ Embargo 0 Voluntary Disposal ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: Violations Related to Foodborne illness Interventions and Risk Factors (items 1-22) (Cont,) PROTECTION FROM CHEMICALS 14 15 IIt 17 TIMEITEMPERATURE CONTROLS Food or Color Additives 3-202.12 AcUtives* 3-30214 _ Protection from Una i roved Additives" FC - 2 Poisonous or Toxic Substances 7-10t.1 I Identifying Information - Original Containers* 7-102.11 Compton Name - Workinn Containers* 7-201.11 Se. aratiou -Storage* 7-202.11 Restriction - Presence mid Use'' 7-202.12 Conditions of Use* 7-20111 Toxic Containers - Prohibitions* 7-204.,11. Sanitizers, Criteria - Chemicals* 7-2041.2 Chemicals for Washing Reduce, Criteria" 7-204.14 Drying Agents. Criteria' 7-205.11 Incidental Food Contact, Lubricants* 7-206.11. Restricted Use Pesticides. Criteria* Rodent Bait Stations* r!L Tracking Powders, Pest Control and Monitoring,* TIMEITEMPERATURE CONTROLS " Denotes critical item in the foderad 1999 Food Code or 105 CNIR 590.000. Proper Cooking Temperatures for 19 PHFs 3-401,11A(1)(2) Eggs- 155`F 15 Sec. FC - 2 E >gs- hnmediate Service 145"F15sec* 3-401.11(A)(2) Comminuted Fish, Meats roc Game 2g Animals - 155°F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast - 130°F 121 min* 3-401.11(A)(2) Ratites, Injected Meats- 155`F 15 26. sec. 3-40111(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 * 3-401.1.2 Raw Animal Foods Cooked in a Microwave 165°F * 3-401, 1 l(A)(1)(b) All Other PHFs; -145'F15sec. _ - Reheating for Hot Holding 3-40111(,6)&(D) PHFs 1650E 15 sec. 3-40111(B) Miaowave-165' F 2 MinuteStauding Time" 3-403.II(C) Commercially Processed RTE Ford - 140"F* 3-403.1.1(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PRFs from 140°F to 70°F Within 2 Hour and From 70"F to 41.'F/450F Within 4 Hours... 3-501.14(13) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 hours* " Denotes critical item in the foderad 1999 Food Code or 105 CNIR 590.000. 21 3-501, 14(C) �PHFs Received at Temperatures According to Liw Coaled to 41.°F/45°F Within 4 How s- 3-5ol'i5 5CoolinoMethodsforPHFs 19 PHF Hot and Cold Holding 3-501-11(B) i-50 AO(B) Ca1d PHFs Maintained at or below 590.004(F) 41°145°F - *3-501.160) FC - 2 T -501 160)Hot PHFs Maintained at or above 40T, * Raw or Partially Cooked Animal Food and Raw Seed S trouts Not Served.'' 3-50J 16(A) Roists Held at or above 130°F. 2g Time as a Public Health Control 25. 3-501.19 Time as a Public Health Control* Pasteurized Eggs Substitute for Raw Shell 590.004(H) Variance Re augment 21 3-801.11(A) Unpasfeurized Pre-packaged Juices and Beverages with Warning Labels* 590,600 3-501-11(B) UseofPasteurized� FC - 2 3-80111(D) Raw or Partially Cooked Animal Food and Raw Seed S trouts Not Served.'' _ _ _ _ Food and Food Protection 3-80L11(C) Uno sped Fond Package Not Re -served. "' AVItE. 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. f a�K+.+. fl-t7*T•Tiiir(d�C^i (Items 23-30) Critical acrd non-critical violations, which do not relate to the ,foodborne- illness interventions and risk factors listed above, can be band in the followuul sections of the Food Code and 105 CMR 590.000. Ptem Good Retail Practices Consumer Advisory Posted for Consumption of 590,600 77i" Aninufl Foods "That are Raw, Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate _ _ _ _ Food and Food Protection FC -3 Pathogens: ^ E" "I * ,. 01'1 25. 3-30213 Pasteurized Eggs Substitute for Raw Shell .005 26. E es` AVItE. 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. f a�K+.+. fl-t7*T•Tiiir(d�C^i (Items 23-30) Critical acrd non-critical violations, which do not relate to the ,foodborne- illness interventions and risk factors listed above, can be band in the followuul sections of the Food Code and 105 CMR 590.000. Ptem Good Retail Practices FC 590,600 23. _ Mang eq mane and Personnel FC - 2 .003 24, _ _ _ _ Food and Food Protection FC -3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbi9and WasteFC-5 .006 27. _ Physical FacilityMaterials FC - 6 .007 26. Poisonous or Toxic Materials FC - 7 .008 29. 5 eciai Re uiremsots .009 30. _ Other _ - �s,mrommea:e.z:n� CITY OF SALEM BOARD OF HEALTH Name of Establishment: White Hen Pantry Address: 28 Norman Street Owher/President: Romany & Mary Youseff Phone: 978-745-1225 5-� Date: February 15, 2007 55e The proposed new owners of this establishment discussed plans for this establishment. The plans were reviewed in accordance with the State Food Code. The change in ownership will occur on March 1, 2007. CERTIFICATION Both owners will be Certified Food Managers who will work full time at this location. A "Person in Charge" or "PIC" must be available at this location when the CFM is not present. The PIC must have knowledge of sanitation techniques, holding temperatures, operations, etc. FLOOR PLAN A Hand Sink is located in the front service area. The hand sink must have a wall hung soap and paper towel dispenser. These must be stocked at all times. The hand sink must be used for hand washing only. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. This includes any storage of these items in the basement. A three bay sink for washing, rinsing and sanitizing all utensils equipment, dishes will be used. MENU/FOOD PREP Reviewed preparation of soup items, salads, and deli items. All food must be held at 41'F or lower, or 140°F or higher, at all times. Therefore, soup and other hot items should be brought to boiling before being held hot. Food may not be added to containers in holding unit. Instead, a sanitized container with new product may replace the existing container and the old product may be placed on top of the new product. There may be no bare hand contact of ready -to -eat foods. Gloves, tongs, or tissues must be used when handling such food. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the 3`d bay of the 3 -bay sink and spray bottles may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. Outside area of premises, including the dumpster area, must be kept clean and sanitary. )•Ppb 164 t" /Uo cQ-pE � ��� a2 -/L 07 Joanne S ott Date Health Agent N'I/Ma Lk Z 15 -o I Romany Youso# Date <sc� i5 -C + Mary Youseff Date CITY OF SALEM, MASSACHUSETTS o BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM Kimberley Driscoll ,JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT QUESTIONAIRE — GREASE TRAPS 2007 (please complete and return to the Salem Board of Health) NAME OF ESTABLISHMENT: 2. ADDRESS OF ESTABLISHMENT: 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLO 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN- HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? (if not available, request that a copy be sen to the department within 7 days) WHITE (AsN -?& NOR✓IAfa h 0 o - d a to s r FI 1 2 3 4 5 6 7 B ® SCHEME A 9 10n x 5GHEME B ® 12 li = 17 x Is WHITE (AsN -?& NOR✓IAfa 0028 Norman Street Telephone: 745-1225 Owner. Ali S. HamzaAbderrahim Be PIC: abderrahim benlantmania Inspector: John Gehan Date Inspected: Correct By: 1 0/2 412 0 0 6 Risk Level: City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Violations Related to Good Retail Practices (Blue Items) Equipment and Utensils Comment: door gasket in disrepair. Gasket on order. Status Violation FAIL Walk in unit requires general cleaning of walls and ceiling. Spills and splatter observed. Sanitizing log not on hand at time of inspection. Log to be on hand and kept daily. P�cal Facility FAIL White Hen Pantry Critical Urgency BLUE 1.11119 Comment: Dry storage area has accumulation of spills and splatter. Walls by newspaper has accumulation of mold. Thoroughly clean and sanitize wall. t fetling tile above walk in door has visible water damage. Repair leak. Replace tile. I Permit Number: BHP -2006-0283 GENERAL COMMENTS: Status: 'New owner to fax over copy of extermination report to BOH PARTIAL COMPLY # 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) Same pest control company staying with White Hen. 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. Nov 06,2006) Page l 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® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 06,2006) Page 2 oft 0028 Norman Street Telephone: 745-1225 Owner: Ali S. HamzaAbderrahim Be PIC: abderrahim benlantmania Inspector: Sanitizing log not on hand at time of inspection. Log to be on hand and kept daily. John Gehan GENERAL COMMENTS: Date Inspected: Correct By: All violations have been corrected. 10/2412006 Risk Level: City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation White Hen Pantry Critical Urgency Violations Related to Good Retail Practices (Blue Items) Equipment and Utensils FAIL BLUE Comment: door gasket in disrepair. Gasket on order. Owner to call once repaired. Walk in unit requires general cleaning of walls and ceiling. Spills and splatter observed. Monitor for possible mold growth. Permit Number: BHP -2006-0283 Status: SIGNED OFF # of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 06,2006 ) Page ! of 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® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 06,2006) Page 2 oft �'� �� �, i j -a-:� =, �.a �k .. _ I � �;.. � y { CITY OF SALEM BOARD OF HEALTH Name of Establishment: White Hen Pantry Address: 28 Norman Street Owner/President: Abderrahim Benlaatmania Phone: 978-745-1225 Date: October 19, 2006 The proposed new owner of this establishment discussed plans for this establishment. The change in ownership will occur on October 23, 2006. A permit will be issued, however, a full inspection in accordance with the State Food Code will be conducted on the same day and all violations must be corrected immediately. CERTIFICATION Fatima Benlaatmania will be the Certified Food Manager who will work full time at this location. A "Person in Charge" or "Piff must be available at this location when the CFM is not present. The PIC must have knowledge of sanitation techniques, holding temperatures, operations, etc. FLOOR PLAN A Hand Sink is located in the front service area. The hand sink must have a wall hung soap and paper towel dispenser. These must be stocked at all times. The hand sink must be used for hand washing only. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. This includes any storag t - A three bay sink for washing, rinsing and sanitizing all utensils equipment, dishes will be used. MENU/FOOD PREP Reviewed preparation of soup items, salads, and deli sandwiches. All food must be held at 41°F or lower, or 140°F or higher, at all times. Therefore, soup and other hot items should be brought to boiling before being held hot. Food may not be added to containers in holding unit. Instead, a sanitized container with new product may replace the existing container and the old product may be placed on top of the new product. There may be no bare hand contact of ready -to -eat foods. Gloves, tongs, or tissues must be used when handling such food. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the 3rd bay of the 3 -bay sink and spray bottles may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. Outside area of premises, including the dumpster area, must be kept clean and sanitary. Anne Scott ealth Agent Ab&rrahim Benlaatmania /0 .-/ y_. Date /,9- /Y- 0r uate }...^ • M1 ;: v5 "' .« t:. .� Ott u:• Z r'x = . 3. (�yv :T k Board of Health $ x IQmbelley Dnscoll 120 Washington Street, 4th Floor MByOf'z v ,1 SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2007 ESTABLISHMENT NAME: File Number: BHF -2004-000365 White Hen Pantry 28 Norman Street Salem MA 01970 LOCATED AT: 0028 NORMAN STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2007-0242 Jan 2, 2007 Dec 31, 2007 $100.00 TOBACCO VENDOR 13HP-2007-0243 Jan 2, 2007 Dec 31, 2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 7 of 7 CITY OF SALEM, MASSACHUSETTS o a BOARD OF HEALTH RECEIVED a 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 - DEC 2 8 2006 TEL. 978-741-1800 FAx 978-745-0343 _ CITY 0'= SALEM WWW.SALEM.COM _ BOARD OF HEALTH Mayor Kimberley,Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Aif�/SHL /w/ TEL # q2f ADDRESS OF ESTABLISHMENT Z O /J��M}'✓ FAX # MAILING ADDRESS (if different) DMIAIL - Business OWNER'S NAME 4 tDn�r;ll � ADDRESS 13 v CITY TEL STA N ZIP CERTIFIED FOOD MANAGER'S NAME(S)�g ///tfe- [ & CERTIFICATE#(S)fc�" (Required in an establishment where EMERGENCY RESPONSE PER TEL #_a / Lg6 (o�_D HOURS OF OPERATION Please write in time of day. /f r' e !P r[nr ov�mnlw llnmAlnml "' TYPE OF ESTABLIS AE -.NT RETAIL STORE YES)NO FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ----- \./ --- ---- ---- ---- ---- ----- ------ ------- ------------ - ------------- ----------- - --- --- YES -- - fS0 less than 25 seats =$100 RESTAURANT 25-99 seats =$150" more than 99 seats =$200 - - ---------- - O - - -- - -- - -- - - - - - $100 - - -- BED/BREAKFAST YES' N; - - - -- - - ---- - --- -- -- -- - -- -- - ----------- ----- ---- - --- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE�S NO $5 TOBACCO VENDOR ( ESQ O $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. Pursua o MG ,hapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fit ,' all st e tax returns and paid all state taxes required under the law. Sig ure ate Social Security or Federal Identification Number ----------------------------- ------------------- ------ -- /p� ---------�-'--x --------------------------- --- --------------- Revised 11/13/06 FOODAP2007.adm Check# & Date S a - ° gmexe f�°° City of Salem - Board of Health Tobacco Control Regulation - Violation Notice OCT 2 52006 CITY OF SALEM BOARD OF HEALTH This notice is to inform you that your establishment violated the Salem Board of Health Youth Access (YA) Regulation and/or Environmental Tobacco Smoke (ETS) Regulation. J/J �N,►�0_.Q�K 1n�.fird Name of establishment u)-0�-( Date of violation Inspefct�or 1 (Ordinance, Section, R (Act Constituting Viok Time of violation Minor's age/gender Minor' �)OCk(ol, cel j 'F 4 r ly V Gk IC Narrative information: vb I affirm, under the:pains and penalties of perjury, that the above report is true to the best of my knowledge VEND9R STATEMENT: I acknowledge I received this Violation Notice on �i 1 20 C') p at `1 % �� ` AM/PM and I am being given a carbon copy of this notice. I also acknowledge that I T have been informed lltat [he Salem Board of Health will provide additional, follow-up information to this violation notice. (Print name) If vendor refuses this Notice or if the inspector feels unsafe in delivering it, an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information, contact the North Shore Tobacco Control Program at 781-477-0432 n b X/ Establishment -white NSTCP-yellow Board of Health -pink I affirm, under the:pains and penalties of perjury, that the above report is true to the best of my knowledge VEND9R STATEMENT: I acknowledge I received this Violation Notice on �i 1 20 C') p at `1 % �� ` AM/PM and I am being given a carbon copy of this notice. I also acknowledge that I T have been informed lltat [he Salem Board of Health will provide additional, follow-up information to this violation notice. (Print name) If vendor refuses this Notice or if the inspector feels unsafe in delivering it, an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information, contact the North Shore Tobacco Control Program at 781-477-0432 n b X/ Establishment -white NSTCP-yellow Board of Health -pink A o -em-) owrl�l- o b ArJ p,, '/ o,r o w cloys hod %ow e PX41M'/� 0-�,4- y l y�✓ ass s i BOSTONIA. p a.pm�'muvaaen �°bmen� City of Boston Inspectional Services Department and Food Service Manager's Certification Program Acknowledges That ABDERRAHIM BEMLAATMONIA Has successfully met the criteria necessary to qualify as a Certified Food Manager in Boston. This manager has completed a Food Sanitation Course and passed a qualifying examination. FEBRUARY, 1, 2000 Date Issued ASST. Commissioner ISD 3154 Certificate Number PLEASE POST CONSPICUOUSLY FEBRUARY 1, 2004 Date Expired Program Director FM TP Certificate valid for four years, and renewable before expiration date. Certificate is non -transferable, and may be suspended or revoked for violations of State Sanitary Code. X6452 Rev. W98 �, m Page 1 of 1 Joanne Scott From: Lamont, George [George. Lamont@whitehen.com] Sent: Tuesday, October 17, 2006 2:10 PM To: Joanne Scott Subject: White Hen Pantry New Franchisee Meeting Joanne, If it's possible a 1:00 pm meeting in Thursday October 19th for the new White Hen Pantry franchisee's Abderrahim & Fatima Benlaatmania would be appreciated. I tried earlier to contact you your phone was busy. I'll try again today to confirm a meeting time. George Lamont Manager of Franchising & Training New England Pantry, Inc. 2006 New England Retailer of the Year 290 Vanderbilt Ave. Norwood, MA 02062 George.Lamont@whitehen.com 781-349-1132 10/19/2006 Caesar Salad Piled high with romaine lettuce, gourmet croutons, creamy Caesar dressing, and Parmesan cheese ................................ Small $3.99 Large $4.99 Add our marinated chicken breast .............. Small $4.99 Large $5.99 Chefs Salad Combines tender chunks of turkey, imported ham, and cheddar cheese with the goodness of fresh salad greens topped with your favorite dressing and gourmet croutons ................................. Small $3.99 Large $4.99 Tossed Salad Full of crunchy iceberg lettuce with freshly cut peppers, onions, cucumbers, red ripe tomatoes, and tasty gourmet croutons served with your choice of dressing .................................................. Small $3.49 Large $4.99 Featuring Kettle Cuisine soups, made with all natural ingredients`: Our daily soup selections are chosen from the following: Wild Rice with Chicken, Italian Wedding, Hearty Beef Barley, Stock Pot Vegetable, Minestrone, Chicken Noodle, Chicken Tortellini, Clam Chowder, Seafood Chowder, Corn Chowder Medium 12 oz....... $2.99 Large 16 oz ...... $3.99 Hearty 32 oz .... ..$6.59 Medium 12 oz....... $3.49 Large 16 oz ...... $4.49 Hearty 32 oz ...... $7.89 $1.50 More Choose either a... Salad with a 12 oz. Soup OR Single -serve Wise Chips and 12 oz. Can of Soda J Fresh All items and prices subject to change without notice. Breakfast & Lunch (D TH23 Eah any ra v pr parfially cooked food from animal@ increases your risk of fog borge i eessrs. Pllyassesnofify us 079 ft any iaod allergigs you may have. Consumers who are espeaally wlnerab�e to taod should order and eat tool from animals thoroughly cooked or pasteurized. mffiCite14 Menu Salem, MA 01970 Tel: 978-745-1225 AMena�k4nuFba Franchisees �fmcr✓.r26 5 Ank f� re astx wferFr es Lunc .. . Our delicious Egg & Cheese & Meat Sandwich - served on a Bagel, Buttermilk Biscuit or English Muffin..... $1.59 with Bacon, Ham or Sausage ............................................. $2.29 • :• Egg & Cheese Sandwich with 16 oz. Coffee .........................$2.29 Egg, Cheese & Meat Sandwich with 16 oz. Coffee .............. $2.49 fiorFresh. _ ' n? .mow- .;,s,uw-„�,+x�..._r_, br . .................................... $4.99 The White Hen Chicken Breast, Muenster Cheese, Lettuce, Tomato & Honey Mustard. Chicken Cordon Bleu Rotissierie Chicken, Black Forest Smoked Ham Swiss Cheese, Mustard & Mayo. The Smokey Joe Smoked Ham, Smoked Turkey, Cheddar Cheese, Hot Honey Mustard. Ragin' Cajun Wrap Hamcola, Santa Fe Turkey, Hot Pepper Cheese, Hot Honey Mustard. The Texas Twister Wrap Honey Barbecue Chicken, Cheddar Cheese, Lettuce, Tomato & Honey Mustard in a Wrap. The Norman Street Special Oven -Roasted Turkey, Bacon, Lettuce, Tomato, Horseradish Sauce & Mayo. The Chicken Caesar Wrap Marinated Chicken Breast, Romaine Lettuce, Gourmet Croutons, Creamy Caesar Dressing and Parmesan Cheese. The Buffalo Chicken Wrap Buffalo Chicken, Lettuce & Tomato with Blue Cheese Dressing. Have your favorite sandwich made to order on your choice ofbulkie roll, sub, white, wheat, or light & dark rye breads. Roasted TurkeyQ4e Hone Corned Beef Honey Glazed Ham Ham & Cheese American Cold Cuts Tuna Salad Seafood Salad Meat Chicken Salad Veggie (Meatless) Italian Cold Cuts Bulkie/ Small Large Whole Bread Sub Sub Wrap $3.79 $4.49 $5.29 $5.29 Bacon or Fresh Mozzarella... add 50¢ Cheese ... add 30¢ Double Stuff any Sandwich..... add $1.00 Meatball Chicken Parmesan Chicken & Peppers Steak & Cheese BBQ Steak & Cheese Small Sub Large Sub $4.49 $5.29 JI Inn nIu I nnl I I IN I u I Jill a Nil I I I I nus I III rn nn III n n I III I I I Jnnr Ill Ill Ill $1.50 More Choose either a 12 oz. Bistro Soup OR Single -serve Wise Chips (1.5 - 3 oz.) and 12 oz. Can of Soda �rnnnnnnunun�nuu�nu�uuu�nunnuu�nnun�nnn���uunnn� Chicken / Beef Medium Large $5.99 $6.99 Condiments available at Mayo — Mustard — Honey Mustard — Hoagie Dressi Tomatoes — Onions — Green Pepper - Massachhhhhhhtisetts 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 I Print: Dae Tvoe of Ooerattonts) Tvoe of Inspection ❑ Food Service Retail Residential Kitchen ❑ Mobile El Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. ❑ Routine :7 Re -inspection Previous Inspection Date:/e /� ❑ Pre- peva ion ❑ Suspect Illness ❑ General Complaint ❑ HACCP El Other Address Q Q1Level Rik Telephone _ Owner HACCP Y/N Person in Charge (PIC) Time In: J• pu{. Inspector Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANACEMEN7 : `' _- ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned / Knowledgeable / Duties � z ❑ 13. Handwash Facilities -'EMPLOYEE HEALTH{PROTECTIbN FROM CHEMICALS"' _..' ❑ 2. Reporting of Diseases by Food Employee and PIC El 14. Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded �� 1X15. Toxic Chemicals g. FOOD FROM APPROVED SOURCE ®„m�,„�-a .�r-.,.7( :;h,.w,:,��-� ,�:a. ❑ 4. Food and Water from A IMENEMPERATURE CONTROLS (Pgtentlaliy Hazardous Foods) r' Approved Source R, `Tm , a w ,A i.,�a i� �� k,- uw , a w;a. El 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling 'PROTECTION FROM CONTAMINATION El19. Hot and Cold Holding El8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ,,iREOUIREMENTSPOR HIGHLY SUSCEPTIBLE POPULAtiONS (HSP),,; ❑ 21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices r CONSUMER AOvISORY;" re .r, ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions ' immediately or within 10 days as determined by the Board �_ and Risk Factors (Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C' N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC -2)) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC -3)(5590.90.00044) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC -4)(590.005) the food establishment permit and cessation of food 6. Water, Plumbing and Waste (FC -5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC -6)(590.007) F have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC -7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE -INSPECTION: S: 50lns FFOm IdWc Inspector's Signature: I Print: PIC's Signature: Print: l l Page1of_2Pages 2 1. Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) PROTECTION FROM CONTAMINATION' FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* x2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food law* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Fool 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 - stem"590.006(A) 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 im FU FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 fowl Code or 105 CMR 590.000. 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 Eos and Milk Products. Pasteurized* \ 3-202.16 Ice Made From Potable Drinking Water* 5401.1.1 Drinking Water from an Approved System - stem"590.006(A) 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables ShelHish and Fish From an Approved Source 3-241.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulaboty Authority 3-202.18 Shellstmic Identification Present* -590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.1.1 PHFs Received at Proper Temperatures* 3-202.15 Packa e Into it * 3-101.11 Food Safe and Unadulterated Togs/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.1.2 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 4(1)Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans 1S N ecialized Processin Methods* 2 Reduced ox en tacka ho; criteria* 2 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 fowl Code or 105 CMR 590.000. 8 Cross -contamination 3-302.1.1(A)0) Raw Animal Foods Separated from Cooked and RTE Foals* Contamination from Raw Ingredients 3-30111(A)(2) Raw Animal Fouls Separated from Each Other* Contamination from the Environment 3-302.1l(A) I Food Protection - 3 -30115 Washing Fruits and Vegetables 3-304.11 Foal 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 Fold* g Food Contact Surfaces 4-501.tII Manual Warewashing- HotWater Sanitization'rent eratures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem eratures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean - 4 -602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arse, 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* I.1 Good Hygienic Practices 2-401.11 -T-401, Eating, Drinking or Using Tobacco* 12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* _ 5-204.11 Location and Placement* - 5-205.11 - Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying . Devices 6-301.11 Handwashin Cleanser, Availabilit g 6-301..1.2 Hand Drying Provision 4 �Y CITY OF BOARD OF HEALTH Establishment Name: Page: a of Item Code No. Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION f PLAN16F. CORRECTION PLEASE PRINT CLEARLY Date Verified i' 1 Y 4on 114,6 7 T G Pl M(c-6)-,e c 'Y I �f�41 c> 9. . 1 , t C'c� fi r FDssion With Person in Charge: read thisreport, have had the opportunity to ask questions and agree to correct all before the next ins ection, to observe all conditions as described, and to P comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: ❑ No /Yes rrK Voluntary Compliance ❑ Employee Restrictionons Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 CE 17 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives' 3-302.14; Protection from Unapproved Additives* _24. Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Stora e" 7-202.11 Restriction - Presence and Use" 7-202.12 Conditions of Use, - 7-203.1.1 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-20-1.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, LubricanW 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 1 Rotten' Bait Stations* 7-206.13"Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS * Dcnotes Critical item in the federal 1999 food Code or 105 CMR 590.000. Proper Cooking Temperatures for Unpasteurized Pre-packaged Juices and Bevernees with Warning Labels" PHFs 3-401.1IA(1)(2) Eggs- 155'F 15 Sec. _24. Bees -Immediate Service 145g1715sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-90t. I1(C) Animals - 155'F 15 sec. * 3-401.11(6)(1)(2) Pork and Beef Roast - 130°F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155°F '15 S ectal Re uirements sec. * 3-401.i1(rt)(3) Poultry, WildGame, Stuffed PHFs, Stuffing Containing Fish, Meat, Poultry or Ratites -165'F 15 sea. " 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.I I(A)(1)(b) All Other PHFs -145°F 15 sec. " Reheating for Hot Holding 3-103.11(A)&(f)) PHFs 1650F 15 sea. * 3-403.11(B) Microwave- 165' F 2 Minute Standing Timc* 3-403.11(0) Commercially Processed RTE Food - 140'F* 3-403-II(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 and From 70'F to 4I'F145'F Within 4 Hours. * 3-501.14(13) Cooling PIIFs Made From Ambient Temperature Ingredients to 41°F/45`17 Within 4 Hours* * Dcnotes Critical item in the federal 1999 food Code or 105 CMR 590.000. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-501.14(0) - PHFs Received at Temperatures According to Iaw Cooled to 4FF/45°F Girithin 4 Homs. Unpasteurized Pre-packaged Juices and Bevernees with Warning Labels" 3-501.15 Cooling Methods for PHFs, 19 PHF Hat and Cold Holding _24. 3-501.16(13) Colli PHFs Maintained at or below 590.004(F) 41'!45° F* Raw or Partially Cot>ked Animal Food and Raw Seed Sprouts Not Served. * 3-501.16(A) Hot PHFs Maintained at or above 14WF. * 3-90t. I1(C) 3-501.16(A) Roasts Held at or above 130'F. 2I Time as a Public Health Control Pasteurized Eggs Substitute for Raw Shell 3-501.19 Time as a Public Health Control* S ectal Re uirements 590.004(H) Variance Re turement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.1) (A) Unpasteurized Pre-packaged Juices and Bevernees with Warning Labels" 23. 3-801.11(B) Use of Pasteurized Eggs* _24. 3-801.11(D) Raw or Partially Cot>ked Animal Food and Raw Seed Sprouts Not Served. * 25. 26. 27. 3-90t. I1(C) Uno ened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 23. Manatp_ement 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. 27. E9uipment and U(ensils (FC -4 Water,Piumbingand Waste FC -5 Physical Facility FC -6 Pnthrwons.* 28. 3-302.13 Pasteurized Eggs Substitute for Raw Shell 29. S ectal Re uirements 009 ov=t Li 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 1129 - Special Requirements. FW4W, iW (Items 23-30) Critical and non -Critical violations. which do not relate to the foodborne illness inteiventions and risk factors listed above, can be fowtd in the following sections of the Food Code and 105 CMR 590.000. item Gcod Retail Practices FC 590.000 23. Manatp_ement and Personnel _ FC -2 - -----.... _ .003 _24. - Food and Food Protection � FC -3 .004 25. 26. 27. E9uipment and U(ensils (FC -4 Water,Piumbingand Waste FC -5 Physical Facility FC -6 005 .006 .007 28. Poisonous or Toxic Materials FC - 7 ''i.008 29. S ectal Re uirements 009 30. _..Other smx.n! e146a2 a 11 w Massachusetts Department of Public=Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT )Salem Board of Health ♦120 Washington Street, 41" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name � Date Tvoe of Ooeration(s) Type of Inspection ❑ Food Service ❑ Retail ❑ Routine ❑ Re -inspection L N p ]Print: `� Addressr Fr Level ❑ Residential Kitchen ❑ Mobile Previous Inspection Date: Telephone t^ ❑ Temporary E]Pre-operation Owner HACCP YM ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness E] General Complaint Person in Charge ( IC) I Time 0 Z7 Permit No. ACCP ❑ El HOther j Inspector �` Each violation checkid-rekIlilred ane planation on the narrative page(s) and a citation of specific provision(s) violated. oil 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. I I'FOODPROTECTIONMANAGEMEN`r„,g i,�1E',� "` 4 -Cat'! ❑ 1. PIC Assigned/ Knowledgeable/ Duties r EMPLOYEE HEALTH c 7'M ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3.. Personnel with Infections Restricted/Excluded C FOOD FROM APPROVED SOURCE;,,,,a ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FRoM CONTAMINATION ❑ 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. Ci[ S'f 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 &501nepecrFom 14. x 1 I �/ I ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities 'PROTECTION FROM CH EMICALS�,�� x-0- i1 L'- edvWwem.e. +w..wn.. ....2 _..0A [114. Approved Food or Color Additives X15. Toxic Chemicals j TIMEREMFERATURE CONTROLS (PoteMlally Hazardous Foods) 'i ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling Je19. Hot and Cold Holding ❑ 20. Time As a Public Health Control T -REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP [CONSUMERADVISORY; ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: /�CLJ Inspector's Signature: / Print: --- J gol w PIC's Signature: ]Print: `� Page ofd Pages / ,� , 4 ''- '-' Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 591).003(A)AssiytmentofResponsibility* 590.003(B) Demonstration of'Knowledge"` 2-103.11 Person in charLe - 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 Fad Employee Or An 3-202.16 Ice Made From Potable Drinking Witter* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions Im 6 FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. w PROTECTION FROM CONTAMINATION S Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.1.4 EMs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Witter* 5-1.01.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 31.0 CMR 22.0* Washing Fruits and Vegetables Shelffish 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* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11. PHFs Received at Proper Temperatures* 3-202.15 Package rote 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 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(1) Labeling of ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures IHACCP Plans 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. w PROTECTION FROM CONTAMINATION S Cross -contamination 3-302.1 l(A)(H Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients -Ta;, 3-302.1.1(A)(2) Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11.(A) Food Protection* _ 3-302.15 Washing Fruits and Vegetables 3-304.11 Foal Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Resctsice 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 Tem eratures* - 4-501.1 t2 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical. Sanitization- temp., pH, - concentration and hardness. * 4-60 Ll I (A) Equipment Food Contact Surtaxes and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils'P 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 Cleanino Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.71 Eating, Drinking or Using Tobacco* 2401.1.2 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 Em to ces* 13 Handwash Facilities Conveniently located and Accessible 5-203.11 Numbers and Capacifies* 5-204.1.1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision /� C1 I t I A n t Establishment Name: BOARD OF HEALTH c) r, Page:_ hof } Item No. Code Reference C - critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION �' �'' T PLEASE PRINT CLE RLV' Date Verified n u 149 lu of /LASfA4n ��44 412 c,Ce� (� 1 C aLer l 1, / cz. -Iop C&4pco,!r,r o L ✓' t+1 J I e. I01 a ` T cps -- + t 6 ap 3r Vt �i o r // t CL r Q r C12 ue I 1 O Co c J—� 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 conditionsas 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' a dollars or suspension/revocation of your food permit. `fVi =JET Corrective Action Required: ❑: No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure r ❑ Voluntary Disposal ❑ Other: .eir C2 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS la 15 16 17 TIMEITEMPERATURE 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 - Orignat Containers* 7 102.11 Common Name - Working Containers* 7 20L 11 Se aration - Storaee* 7-202.11 Restriction - Presence and Use" 7-202.12 I Conditions of Use" 7.203.11 Toxic Container s-Prohibitiors,* 7-204.11 Sanitizets. Criteria - Chemicals" 7-204.12 Chemicals for Washing Produce, Giteria" 7-204.14 Drying Agents. Criteria" 7-205.11 Incidental Food Contact. Lubricants - ubricants*7-206.11 7 -206.1 -1 Restricted Use Pesticides, Criteria" ___. _ Rodent Bait Stations* M7-206.12 7-206.13Tracking Powders, Pest Control and Monitoring* TIMEITEMPERATURE CONTROLS " Denote critical item in tha Neral 1999 Food Code or 105 CMR 590.000. Proper Cooking Temperatures for 19 PHFs 3-401.11A(U(2) , Eggs- 1.55°F 15 Sec. FC -2 Ergs- Ltnnediate Service 145'Fl5secl 3-401.11(A)(2) Comminuted Fish, Meats & Game 20 Animals - 155'F 15 sec. * 3-401.11(5)(1)(2) Pork and Beef Roast- 130°F 121 min* 3-401.11(A)(2) Ratites, Injected Meats- 155'F 1.5 27. sec. * 3-401.11(A)(3) Poultry, W ild 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 * 3-401.11(A)(1)(b) All Other PHFs -- 145'F 15 sec. Reheating for Hof Holding 3-40111(A)&(D) PHFs 165'F 15 sec.'s' 3-403.11(B) Microwave- 165° F 2 Minute Snrndinc Tune" '3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unshced Portions of Beef Roasts'; Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140"F to 70°1' Within 2 Hours and From 70'T to 41''F/45'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Matte Front Ambient Temperature Ltgredients to 41'F/45'F Within 4 Hours" " Denote critical item in tha Neral 1999 Food Code or 105 CMR 590.000. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-501.1<1(C) PHFs Received at Temperatures According to Law Cooled to 4I" F/45`'F Within 4 Hours. 3-501.15 Coolim, Methods for PHFs 19 PHF Hot and Cold Holding 3-861..11(B) 3-501.16(5) Cold PHFs Maintained at or below 590.004(F) 41'/45° F" FC -2 3-501.16(A) Hot PHFs Maintained at or above 140'F. Raw or Pattially Cooked Animal Food. and Raw Seed S trams Not Served.'" 3-501.1.6(A) Roasts Held at or above 130°F. 20 Time as a Public Health Control - ontrolTit)1.19 25 26. - Tit) 1. 19Time as a Public Health Control* Pasteurized Gggs Si&dtute'for Raw Shell 590.004(H) Variance Re nirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beven ges veldt Waiving Labels* 76�� 3-861..11(B) Use of Pasteurized Eggs* FC -2 3-801.1. t(D) Raw or Pattially Cooked Animal Food. and Raw Seed S trams Not Served.'" Food and Food Protection 3-901.11(C) Una. erred Food Package Not Re -served. s' CONSUMER ADVISORY JYCiriHL r5C4t UIrIC1U1 CIV 1 b 590.009(A) -(D) Violations of Section 590.009(A){ll) 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. r1xv- (Items 23-30) Critical and nun -critical viok+tions, which do nor relate to the ,foodborne illness interveruions and risk factors listed above, can he found in the following sections of the Food Code and 105 CMR 590.000. Item Goad Recall Practicesices ------ Consumer Advisory Posted for Consumption of 76�� 23. Annual Foods That are Raw. Undercooked or FC -2 .003 Not Otherwise Processed to'Eliminate Food and Food Protection FC --3 Pathogens.* E'rew,e ,nrzuni 25 26. - 3-302.13 Pasteurized Gggs Si&dtute'for Raw Shell .005 .006 27. Eggs* JYCiriHL r5C4t UIrIC1U1 CIV 1 b 590.009(A) -(D) Violations of Section 590.009(A){ll) 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. r1xv- (Items 23-30) Critical and nun -critical viok+tions, which do nor relate to the ,foodborne illness interveruions and risk factors listed above, can he found in the following sections of the Food Code and 105 CMR 590.000. Item Goad Recall Practicesices ------ FC 590.000 ` 23. Management and Personnel FC -2 .003 24. -- Food and Food Protection FC --3 .004 25 26. - -- ---- equipment and Utensils Water, Plumbing and Waste --- FC - 4 FC -5 .005 .006 27. Physical Facility _ _ __ FC - 6 007 28. Poisonous or Toxic Materials -FC-7 _ .008 29. _ Special Requirements 009 30. _ Other ___. _ ssvom„m:nw.2 i, I Establishment Name: I BOARD OF HEALTH _ . Date: 2; &- c6 Page: of Item No. Code Reference C -Critical Item R — Red Item - DESCRIPTION OF VIOLATION / PLAN OF CORRECTION. - PLEASE PRINT CLEARLY. F Date Verified DI- f T17t. 6 !l>Ib u 4nr I nct3 _ - O h ,tG L / a II _ J ' ,44 o I HC' q' r o�x f- L � rQ v . v 1 0) -f i i It Ij S Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all 4iolations 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 doll rs or suspension/revocation of your food permit. Corrective Action Required: ❑ No es ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion e -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 Food or Color Additives 3-20112 Additives:" 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 7-101..11 Identifying Information-gl:iginal 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* 7-203.1.1 Toxic Containers - Prohibitions* 7-2(A.I i Sattitizers. Criteria - Chemicals°` 7-204.12 Chemicals for Washing Produce, Clit'eria* 7-204.74 DryingAgerim Criteria* 7-205.11 Incidental Food Contact. Lubricants' 7-206.11 Restricted lise Pesticides. Criteria` 6.12 Rodent Bait Stations" !2U06.13 Tracking Powders, Pest Control and Monrtorma* 16 18 TIMFR'FMPFRATIIRF CONTRI111 R "Denotva critical item in 1110IMoral 1999 food Code or 105 CMR 590.600. Proper Cooking Temperatures for F3-501-15'- PHFs 3-401.1IA(1)(2) Eggs- 155'F 15 Seo. FC -2 Eggs- Inuntediato Service 145"F15sec* 3-401.11.(A)(2) Comminuted Fish, Meats & Game 3-901.11(C) Animals - 155"F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast -130"F 121 min* 3-401.11(A)(2) Ratites, Injected.Meat's- 155'F 1.5 26. sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27 Stuffing Containing Fish, Meat, FG 6 Poultry or Ratites -165"17 15 sec. 3-401.1 t(C)(3) Whole -muscle, Intact Beef Steaks FG - 7 145`17 * 3-401.12 Raw Animal Foods Cooked in a Microwave 165"F * 3401_il(A)(1)(b) All Other PHFs 145"F'15sec. * ____ Reheating for Hot Holding 3-403.11(A)&Ci» PHFs 165'F 15 sec. * 3-403.11(B) Microwave- 165" F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Foul - 140"F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PRFs 3-50114(A) Cooling Conked PHFs from 140'F to 70'F Within 2 Hours and From 70'F - to 4t"F145"17 Within 4 Hours. 3 -50'i -'14(B) Conlin, PRFs Made From Ambient Temperature Ingredients to 41'F/45"F Wolin 4 Hours' "Denotva critical item in 1110IMoral 1999 food Code or 105 CMR 590.600. 2'I 3-501.14(C) PHFs, Received at Temperatures According to Law Cooled to 41 F/45`F T4 htht(i 4 Hours. F3-501-15'- Cooling Methods for PHFs 19 PHF Hot and Cold Holding FC -2 3-501.168) Cold PHPs Maintained at or below 590.004(F) 41V45` F* Raw or Pam a] I v Cooked Animal Food and Raw Seed Sprouts Not Served. 3-501.100) Hot i Maintained at or above 14WR 3-901.11(C) 3-501 16(A) Roasts Held at or above 130'F- 20 Time as a Public Health Control Pasteurized Eggs Substitute for Raw Shell 3501.79 Time as a Public Health Control* 26. 590.004(H) VarianceRe ulrement 2'I 3-801.11(A) Unpasteurized Pro -packaged Juices and Beveraees with Warning Utbels* 590.000 3-801.11(B) Use of Pastenri7ed Eggs* FC -2 3-801.1 I(D) Raw or Pam a] I v Cooked Animal Food and Raw Seed Sprouts Not Served. Food and Food Protection 3-901.11(C) Uno. goad Food Pucka �e Not Ro-served. 16141 TrTdii. a . 22 3-60311 Consumer Advisory Posted for Consumption of 590.000 23. Annual Foods That are Raw. Undercooked or FC -2 7603 Not Otherwise Processed to Eliminate Food and Food Protection FC -3 Pathogens.'* t"eLdV' "="'0" 25.-_ -E 3-302.13 Pasteurized Eggs Substitute for Raw Shell 005 _ 26. Eggs* JC'eLIHt_ rfc4t4lIF1CrvI C1Y l b 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering. mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and tisk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements, fiZ�� [I'���fllcTiZl37 (items 23-30) Critical and non-crideal violations, which do not relate to the foodborne illness interventions and risk factors listed above, can he found in the following sections of the Food Code and 165 CMR 59001Y) tram Good Retail Practices_ FC 590.000 23. Manaaement and Personnel FC -2 7603 24. Food and Food Protection FC -3 .004 25.-_ -E _- - ui arent and Utensils __FC -4 005 _ 26. _Water, Plumbing and Waste FC S .006 27 Ph slcai Facility___ FG 6 .007 28. Poisonous or Toxic Materials FG - 7 .008 29_ S ectal Re uiremenis .o09 30. _ _ Other ____ ;S Ift,rs*k6.2d,, Kimberley Driscoll Mayor April 24, 2006 White Hen Pantry 28 Norman Street Salem. MA 01970 Dear Owner: CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT On Wednesday April 12, 2006 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17 -year-old Female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. White Hen Pantry is in violation of Section III(A) of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section, the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of (Three Hundred Dollar fine) for the Third offense. FOLLOWING THE THIRD (3RD) OFFENSE, THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore, you are ordered to pay a fine of $300.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street, 4th floor, within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. It you have any questions regarding this notification please call me at 741-1800. Sigcerely yours, tf '-'Joanne Scott Health Agent JS/mop CERTIFIED MAIL. 7003 3110 0005 1992 2285 cc North Shure I uhnccu Cunlrul Pruyram Christina 1-l;iri in'llon, Rnord ,J I lu.tllh chnirmaii an(l f,4unihcr5 MANAL KURBAJ ALI S. HAMZA 53'139113 460 z212692112ll 20 STATION ROAD SALEM, MA 01970 DATE 5///a16 THE ORDER OF cls � Q� 1Ci� J $ _.11 GPAY TOU 1I L Century Bank 612 mEmo Salem, Alassa U 01 70 1:0113013901: 11' 2 1 269 2 1 ill° 0460 Mas.chusetts Department of Public Health Divfsf Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name ) Date Type of Operationts) Type of Inspection / al 7 ❑Food Service R) Retail ❑ Routine A Re -inspection Address n Rik Telephone �-1 ace Level ❑ Residential Kitchen Previous ns action ❑ Mobile ❑Temporary ❑ Caterer ❑ Bed & Breakfast Date: /�P G ❑Pre( partition ❑ Suspect Illness ❑ General Complaint Owner �ZQ HACCP Y/N Person in Charge (PI) Time /D" OuT/ iJ. S� Permit No. ❑ HACCP ❑ Other InspectorIn 1 ���•• - lw4uuoa au aewyraraauvra titin me narrative page(s) ano a citation or 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 7- - ❑ 2. Reporting -of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance. with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 6. Separation/ Segregation/ Protection r ❑ 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 r of Health. C N; 23. Management and Personnel (FC -2)(590.003) s 24. Food and Food Protection (FC -3)(590.004) - 25. Equipment and Utensils (FC -4j(590.605) 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. 5Mn5 cfFol -ia doc Inspector's Signature: Print: PIC's Signature: A Print: ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals ;' TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods)- " ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control d 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 1.590.000/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 mayxesult inssuspension or revocation of the food establishmenf'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: Page orPages 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) Demoash anon of Knowled e* 2-103..11. Person in charge --du es EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to Ccempliance with Food [aw'* 3-201.12 require repotting by food employees and 3-201,13 Fluid Milk and Milk Products* applicants* - Shell Eons* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Repott'ro The Person In Drinking Water from an Approved System* 590.006(A) Chane* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3 -201.15 590.003(13) Removal of Exclusions and Restrictions x C C I benotes critical nem in the federal 1999 Fred Code er 105 Cb9 R 590.000. j�IN F8-1 Food and Water From Regulated Sources 590.004(A -B) Ccempliance with Food [aw'* 3-201.12 Food in a Hermetically Seated Container" 3-201,13 Fluid Milk and Milk Products* 3-202.13 Shell Eons* 3-202.14 Eggs and Milk Products, Pasteurized" 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinkin Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Ve=etables Shellfish and Fish From an Approved Source 3-201.14 (Fish and Recreationally Caught Molluscan Shellfish - 3 -201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Came and Wild Mushrooms Approved by Re ulato Authorit 3-202.78 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Game Animals* Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package tette i� 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(.1) Labeling of Ingredients' Proper, Adequate Handwashing Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxyen packaging, criteria* 8-103.12 Confannance with roved Procedures'" benotes critical nem in the federal 1999 Fred Code er 105 Cb9 R 590.000. j�IN F8-1 I Gross -contamination 3-302.11(A)(I) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw ingredients 3-302A I(A)(2) Raw Anirned Foods Separated front Each Other' Contamination from the Environment 3-302.1 I(A) Food Protection'" 3-302.15 Washing Fruits and Ve=etables 3-304,11 poor] Contact with Equipment and utensils* Contamination from the Consumer 3-306.14(A)(B) Returned rood and Reservice, of Food* 3-701..11 .� Disposition of Adulterated or Contaminated Food Discarding or Reconditioning Unsafe Food,: 9 Food Contact Surfaces 4-501.1.71 4-501.112 - Manual Warewashing - Hot Water Sanitization' rem eratare's"` Mechanical Warewashing- Hot Water Sanitization Tem eratures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Sut1aces 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 Eqti ment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean. Condition - Hands and Arms"` 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco" 2-401.12 Discharges From the Eyes. Nose and Mouth* 3-301.12 Preventing Contamination When 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 5-205.11 Location and Placement* Accessibility. Operation and felaintenance 6301.11 Supplied with Soap and Hand Drying Devices HandwashinE Cleanser, Availability 6-301.1.2 Hand Drying Provision CITY OF SALE BOARD OF HEALTH Establishment Name: l Item CodeC — Critical It No. Reference R — Red Item I C a � Page:__L�-? _ of ION IDate Verified Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all oluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twe ty-five ollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i Violations Related to Foodborne Illness Interventions and Risk Factors (items 1.22) (Cont) PROTECTION FROM CHEMICALS 14 16 17 18 TIME)TEMPERATURE 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* 7-201.1 1 Separation - Slot age' 7-202.11 Restriction - Presence mud Use* 7-202.12 Conditions oflJse* 7-203.1.1 Toxic Containers -Prohibitions* 7-204.11. Sanitizers, Criteria - Chemicals* 7-204.1.2 Chemicals for Washine Produce, Criteria* 7-204.14 Drying ents. Criteriat 7-205.tI Incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring" TIME)TEMPERATURE CONTROLS Denotes ci tucal item in dw federal 1999 Nod Code or 105 CMR 590 000. of, f 19 20 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.I JA(i)(2) Eggs- 155°F 15 Sec. 3-501.16(B) 590.004(F) Ergs- Iain ediate Service 145°Fl5sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-507. tb(A) Animals - 155°F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef toast-13WF121nue 3-401.1't(A)(2) Ratites, Injected Meats -155'F 1.5 590.004(H) see. * 3-401..1.,1(A)(3) Poultry, Wild Game, Stuffed PHFs, .009 Stuffing Containing Fish, Meat, ___ _ __ Poultry or Ratites -165°.F 15 sec. 3-401A 1(C)(3) Whole -muscle, Intact Beef Steaks 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165"F * 3-401_11(A)(1)(b) All Other PHFs -145°F15see. * Reheating for Hot Holding 3-403.1 I (A)&(D) PHFs 165-F 15 sec. 3-403.11(B) Microwave- 165° F 2 Minute Standin, Timc* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.1.1(E) Remaining Unsticed 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 ci tucal item in dw federal 1999 Nod Code or 105 CMR 590 000. of, f 19 20 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41°;145°F Within 4 Hours. 3-501.15 Cooling Methods for PHFs, 3-801.II(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41145' F's 3-501.16(A) Hot PHFs Maintained at or above 140°F. * 3-507. tb(A) Roasts Held at or above I30'P. Ph sal 27 ---si Time as a Public Health Control 3-501.19 Time as tt Public Health Contra)* 590.004(H) Variance Re nirement 21 3-801.11(A) UnpastemizedPre-packagedluicesancl Beverages with Warning labels* 23. Mona ement and Personnel 3-801.II(B) Use of Pasteurized Ecus* 24. Food and Food Protection 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 'r 25. E�u�ment and Utensils 26. Water�Plumbinc and Waste 3-801.11(C) Unopened Pond Package Not Re -served. " CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 23. Mona ement and Personnel FC - 2 Animal Foods ,chat are Raw. Undercooked or 24. Food and Food Protection FC -- 3 Not Otherwise Processed to Eliminate 25. E�u�ment and Utensils 26. Water�Plumbinc and Waste FC -4 FC -5 Pathogens.* snd�ovd rnrmaa Ph sal 27 ---si 3-302.13 Pasteurized Eggs Substitute for Raw Shell 28. Poisonous or Toxic Materials FO -7 E es* 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering. mobile food, temporary and residential kitchen operations should be debited ander the appropriate sections above if related to foodborne illness Interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under 7129 - Special Requirements. YYtIs7i7�7+7 (Items 23-30) Critical and non-critical violations, which do not relate to the ,foodborne illness interventions and rc (facrors fisted above, can be found in the following sections -of the Food Code and 105 CMR 590.000, Item Good Retail Practices FC 590.006--- 23. Mona ement and Personnel FC - 2 .003 24. Food and Food Protection FC -- 3 1 .004 25. E�u�ment and Utensils 26. Water�Plumbinc and Waste FC -4 FC -5 .005 006 Ph sal 27 ---si _ FC -6 7 -- .007 28. Poisonous or Toxic Materials FO -7 .008 29. S eciai Re uiremenis .009 _ 30. Other ___ _ __ Snbua;-a 1rµ v v f>.y/. in • r� M � � _ .n. ...rrn Y.r ..r e..: ✓ .va...Y�.. .o ..,_ _ Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Net) G/) r Dat 6 T Me of Operation(s) Tvpe of Inpection ❑ Food Service Retail Residential Kitchen ❑ Mobile ❑Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. ®Routines ElRe-inspection Previous In pection Date: (g. 1dai- ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint El CP ❑ Other AddressRisk lJ3 M 0 Level Telephone Owner I G�1 HACCP YIN Person in Charge (PIC) Inspector Time o O Out: i3� 64411 V1Vlaiwu auccnea requires an explanation on me 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 .5-5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans „PROTECTION FROM CONTAMINATION: ❑ 8. Separation/ Segregation/Protection A 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 (rC-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 S5900Vp Fc m -1440 PIC's ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS - ❑ 14. Approved Food or Color Additiva,' ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: J4��� a °�''� Page of-' Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 .590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in chamc - 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 Eons* .590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G)- Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(F.) Removal of Exclusions and Restrictions M FON In is FOOD FROM APPROVED SOURCE *Denotes critical item in the federal 1999 Fond Code or 105 CD112590.000. $ 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* 3-202.1.3 Shell Eons* 3-202.14 F� 8s and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-1.01.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0,, Disposition of Adulterated or Contaminated Food Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed. Sources* Food Contact Surfaces Game and Wild Mushrooms Approved by Regulatory Authorit 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-501.114 Receiving/Condition 3-202.11. PHFs Received at Proper Temperatures* 3-202.15 Package integrity* 3-101.11 Food Safe and Unadulterated TagslRecords: Shellstock 3-202.18 Shellstock Identification 3-203.12 Shellsmck identification Maintained* - 10 Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(1) Labeling of Ingredients' Cleauinn Procedure* Conformance with Approved Procedures /HACCP Pians 3.502.11 Specialized Processing Methals* 3-502.12 Reduced oxvaen acka 'oma, criteria* 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Fond Code or 105 CD112590.000. $ Cross-contamination-� 3-302.1.1(A)(]) Raw Anima( Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) 3-302.11(A) 3-302.15 Raw Animal Foods Separated from Each Other* Contamination from the Environment Food Protection* 4Vashin 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' L9- Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Tem eratures* 4-501.112 Mechanical Warewashing- Hot Water Sanitizabon Temperatures* 4-501.114 Chemical Sauitization- temp., pH, concenhation and hardness. 'k 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" 2-301.12 Cleauinn Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eatin , Drinking or Usin Tobacco*` 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventin p 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 Ca acities^' 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Dr ing Provision CITY OF SALEM t 'n BOARD OF HEALTH H'j� - � �o �... lh.,,� Date: //-��Page: of _y - r�DW4�LlO Item Code C -Critical Item - DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date Verified No. Reference R — Red Item PLEASE PRINT CLEARLY-- C.(SI�.J� lr- Cc• - /1'� S -r_ �, oc- a, c>11 �� d . Ism Cx, a� �� ✓ Itztr 5- n S o ni Q 14f �� 7✓� Gel I ✓ / e-( r" ISA U r btc�} % C U/�2 J I vtJ _-V'NC oQ 4rL z � , G 'Discussion With Person in Charge: Corrective Action Required: ❑ No Yes F I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion r: i r violations before the next inspection, to observe all conditions as described, and to �qe-inspection Scheduled ❑ Emergency Suspension Code: and that \ t comply with all mandates of the Mass/Federal Food Jl unders noncompliance may result in daily fine of tw my -five Ilar ar suension/.revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: k i �y Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont) PROTECTION FROM CHEMICALS 14 15 9 18 TIMEITEMPERATURE CONTRnt S Food or Color Additives ' 7202.12 Additives'' '-- 3-302.14 Protection from Unapprrned Additives* [3-51f)1Jt(A) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Container* 7-102.11 Common Name - Working Containers - 1201 -11 Separation - Storage" 7-202.11 Restriction - Presence and use 7-202.12 Conditions of Use, 7-303.11 Toxic Containers - Prohibi.tionss` 7-204.11 Sanitizers,Criterin- Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria'lc 7-204.14 DryinA rents. Criteriii" 7-205.11 Incidental Food Contact, Lubricants - 7 -206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations' 7-206.13 Tracking Powder, Pest Control and Monitoring* TIMEITEMPERATURE CONTRnt S "Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 3-502-14(C} PRFs Receivedst Temprratures Acvordinb to Law Cooled to =tl F145 F Within 4 Homs. 3-541.15 ; Cooline Methods for PHFs 3-501.16 i) Proper Cooking Temperatures for 540.004 (F) PHFs 7401. t IA(1)(2) Eggs- 155'F 15 Sec. [3-51f)1Jt(A) E Igs- Tuunediate Service lA5°P15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game ------ FC -5 Animals - 155'F 15 sec. * 3-40 1.1 l(B)(1)(2) Pork and Beef Roast - 130`F 121 min* 3-401.)1(A)(2) Ratites, Injected Meats- 155°F '1.5 FC - 7 sec. * 3-401.11(A)(3) Poultry, Wild Game, Smffcd PHFs, .009 Stuffing Containing Fish, Meat, Poultr or Ratites -165°F I5 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(.k)(1)(b) All Other PHFs -145T15sec.* Reheating for Hot Holding 3-403.11(3)&(D) PHFs 165'F 15 sec, a' 3.403.11(9) Microwave- 1W, F 2 Minute Standing Time* 3-403.1 1(C) Commercially Processed RTE Food - 140°F* 4)3.1.1(E) Remaining Unsiiced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.1.4(A) Cooling Cooked PHFs from 140°F to 70'F Within 2 Hours and From 70'F to 41.'F/45'F Within 4 Homs. 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41 °F/45°17 Within 4ldours "Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 3-502-14(C} PRFs Receivedst Temprratures Acvordinb to Law Cooled to =tl F145 F Within 4 Homs. 3-541.15 ; Cooline Methods for PHFs 3-501.16 i) Cold PHFs-,7sunLtincd at or below 540.004 (F) 41'145° FK FC -3 Itot PANS Maitainedat or above [3-51f)1Jt(A) 140'F. -1.Il 1, A) Roasts Held at or above 130°F. ------ FC -5 Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Renuireru,u 21 1 3-801,11(A) I Unpasteurized Pre-packaged hues and Bevema" with Wartting fab ls* I1(B) 1 Use of Pasteurized Eats* I t(D) Raw o, Partially Looked Animal Food Raw Seed Snrouts Not. Se.rvr.d * 3.801.11(C) I Unopened Fund Package Not Re -served- * I s 1_ 22 T60'% t I Consumer Advisory Posted for Consumption of 24. Food and Food Protootlon FC -3 Anhml Foods 9'hat are Raw, Undercooked or _ 25 Equipment and Utensils ._-._ FC - 4 Not Otherwise Processed to Eliminate 26 Water Plumbing and Waste ------ FC -5 Patho-nS.* Errcnvc v;;anar 27. Ph +}sisal Facillty__ 3-302.13 Pasteurized Eggs Substitute for Raw Shell 28. Poisonous or Toxic Materials FC - 7 E s" ItlIL1Y 1 y7 .590,009(A) (D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations sheald 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) RETAPR PRACTICES (Reins 23-30) Cripral and non-critical violations, which do not relate to the foodborne illness interveivions and risk factors listed above, can be- found'tie the foilowixg SC(. lions of the Food Code and 105 CMR 590.000. Item Good Retail Practices 23. Marapement and Personnel FC FC -- 2 5- - 90.000 .003 24. Food and Food Protootlon FC -3 ,004 _ 25 Equipment and Utensils ._-._ FC - 4 I .005 26 Water Plumbing and Waste ------ FC -5 .006 27. Ph +}sisal Facillty__ FC -6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. S ecidl Requirements .009 30 Other }"'W . ba4b2apc a Establishment CITY OF SALE ROARn nF HFALTH Date: Page: of - Hem No. Code Reference .,. C — Critical Item R—Red Item DESCRIPTIONOF VIOLATION / PLAN OF CORRECTION Date Verified -PLEAS PRINT CLEARLY ----- /�—= �o � � t m » Lem, use - o 52 S- ar �5 C nA(2 4-- r 071-ilL 0 A42" _ Set ( h; D X-C) ') O lop Q tcP/I� G✓ l,1 Q 3e -v— i 1 a�� S )1 41. c /O (7 IU ! c iii J �1 c +U✓1 I"Maek(314IONI Pr f)Wn 2 cop6 / / I V >3 J f J� _ l G rb % .:; c i _Pin Discussion With Person in Charge: o correct all I have read this report, have had the opportunity to ask questions and agre;xc violations before the next inspection, to observe all conditions as described, a'nd to comply with all mandates of the Mass/Federal Food Code. I derstarad"t i�at" noncompliance may result in daily fines of twent/y five doll rs or suspension%revooation of your food permit. ( / Corrective Action Required: b No Yes J Voluntary Compliance ❑ Employe ee Restriction / il Re-i� tion Scheduled ❑ Emergency Suspension p Embargo o Emergency Closure ❑ Voluntary` Disposal ❑ Other. Violations Related to Foodborne illness Interventions and Risk Factors (items 1.22) (Cont) , PROTECTION FROM CHEMICALS 14 16 17 18 TIMEIfEMPERATURE 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 Nam - Workinl- Containers* 7-201.11 Separation - Stora e* 7-202.1.1 Restriction - Presence turd Use's 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* TIMEIfEMPERATURE CONTROLS * t)eni lvs crincai item in the f,dend 1999 Food Code or 105 CMR 590.900. N 20 -3-5J,1.14.tC) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.11A(1)(2) _ Eggs- 155°F 1.5 Sec. 3-501.16(B) 590.004(F) Ees-LnmedtateService145°F15sec* 3-401A 1.(A)(2) Comminuted Fish, Meats & Came ' Aninuds - 155°F 15.sec. s 3-401.11(13)(1)(2) Pork and Beef Roast -.130" F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 990.004(1-1) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHPs, 28. Stuffing Containing Fish, Meat, - Poultr y of Ratites -165"'F 15 sec. d' 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F * 3401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3401A l (A)(1)(b) All Other PHFs - 145°F 15 see. Reheating for Hot Holding 3-40111(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 - 1.40°F* 3-403.11(Fs) Remaining Unsliced Portions of Beef Roasts" Proper Cooling of PHFs 3-501.1.4(A) Cooling Cooked PHFs from '140°F to 70°F Within 2 Hours and From 70°F to 41.°F/45°F Within Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41`F/45°F Within 4lloursss * t)eni lvs crincai item in the f,dend 1999 Food Code or 105 CMR 590.900. N 20 -3-5J,1.14.tC) PHFs Received at Temperatures According to Law Cooled to 41017,145T Within 4 Hours. 3-501.15 Coolin" Methods for PHFs .3-801.1 t(D) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41'145° Fs 3-501.16(A) Hot PH'Fs Maintained at or above 14WR a 3-501,16(A) Roasts Held at or above 130°F. 25. 26. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 990.004(1-1) Variance Ra uirenrent 3-801 1 VA) Unpasteurized Pre-packaged Juices and _ Beverages with Warning I. bels* 3-801,11(B) Use of Pasteurized'Eegs* .3-801.1 t(D) Raw or Pmtialt} Cooked Animal Food and Raw Seed Sprouts Not Served. 3-8(l,l ,hl (C') Una cued Pcxxi Package Not Re -served. ` I 22 3603.11 Consumer Advisory Posted for Consumptiod'of 590.000 23. Annual Foods ,chat are Raw, Undercooked or FC -2 - Not Otherwise Processed to Eliminate Food and Food Protection__ FC -- 3 Pathogens.* E6e "' "n901 - 25. 26. 3-302.13 Pasteurized Eggs SnbSti[nte '£or Raw Shell . .006 27. Eggs* 5 ..... XMA) -(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 Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Retrial 23-30) Critical and non-critical viokttions, which do not relate to the foodborne illness bacrventionv and riskfirrtors livied above, can be ,found in the followbrg sections of the Food Code and 105 CMR 590.010. Item Good Retail Practices Inc 590.000 23. Mona ement and Personnel FC -2 .003 24. Food and Food Protection__ FC -- 3 .004 25. 26. _ Equipment and Utensils Water, Plumbing and Waste -----.-----. FC -4___1_.005 FC -S .006 27. Ph sical Facii_ity. _- FC -6 _- .007 28. Poisonous or Toxic Materials FC -7 .008 29: 90 S eciai R uiremenis Other 1 .009 $:5Ooo,p.bµ 02.d�,, { CITY OF/SALEM 11 BOARD OF HEALTH Establishment Name: n i Date: / 6 Pager_ of 6 Item Code No. - Reference C - Critical Item R — Red Item �. DESCRIPTION OF.�VIOLATION / PLAN OF CORRECTION f.. �" PLEASE PRINT CLEARLY VDate erified \Ce > Ci cD J�i/ P 'All—F n >o _I nl Jr— Al QQr f 1 rl t Ici �(Y% JJ .S rbin/ T N� 4 O / ,�� n r I CDa - i e� e �t 1 God z •` u I � I P4 -,6ja 1/45 4yy -; .� A i1 u.fP Q -f 1 4t, f (1�4,(c ()Ad, 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 Foodod . I underst[ t a noncompliance may result in daily fin twen,y-f' Iars�Nenslon/revocation of your food permit. Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo i ❑ Emergency Closure ❑ Voluntary Disposal } ❑ Other: P �. I Violations Related to Foodborne Illness Interventions and Risk Factors (items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 16 17 I8 TIMEJTEMPERATURE CONTROLS Food or Color Atlditives 3-202.12 A'lditkcs' 3-302.14 Protection from Una roved Additives* 3-501.16(B) .590004(F) Poisonous or Toxic Substances 7-101..11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Stora e* 7-202,11 Restriction - Presence and Ilse* 7-202.12 Conditions of Ilse* 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 Ilse Pesticides. Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring,,* TIMEJTEMPERATURE CONTROLS 4 Denotes critical item in the federal 1999 Food Code or 105 CMR 590,000. • ,i 19 20 3-501.14(Ci) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.11A(1)(2) Eggs- 1.55`F 1.5 Sec. 3-501.16(B) .590004(F) Eyes -Immediate Service 145'F15sec* 3-401.1l(A)(2) Comminuted Fish, Meats & Game 3-50116(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 5)0.004(H)VaritmceRe see. 3-401,11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Scoffing Containing Fish, Meat, FC -6 Poultry or Ratites -165°17 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 * 3401,11(A)(1)(b) All Other PHFs - 1.45'F'15 sec. Reheating for Hot Holding 3-40111(A)&(D) PHFs 165°F 15 scc. 4' 3-403.11(B) Micaowave- 165' F 2 Minute Standing Time* 3-403.11(C) Commercially PiccessedRTE Food - 140'F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.1.4(A) Cooling Cooked PHFs from 140'F to 70'F Within 2 Hours and From 70'F to 4FF/45'F Within 4 Hours. 3-50L 14(B) Cooling PHFs Made Front Ambient Temperature fitgredients to 41c'F/45"F Within 4 hours ` 4 Denotes critical item in the federal 1999 Food Code or 105 CMR 590,000. • ,i 19 20 3-501.14(Ci) 'PHFs Received at'leriperatures According to Law Cooled to 4I'F/45-,F Within 4 Hours. 3-501.15 Coobn, Methods for PHFs 3-801.11(13) PHF Hot and Cold Holding 3-501.16(B) .590004(F) Cold PHFs Maintained at or below 41°14VF* 3-501.16(A) Hot PHFs Maintained at or above 140'F. *. 3-50116(A) Roasts Held at or above 130°F. 25,_Equipment Time as a Public Health Control )-101,19 Tirne as a Public Hea([h Control* 5)0.004(H)VaritmceRe nirentent REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11 fA) Unpasteurized Pre-packaged Juices and Beverages with Wam n I abets* 590.000 3-801.11(13) Use of Pasteurized E,,gs* - FC - 2 3-8011 I(D) Raw or Partially Cookcd Animal Food and Raw Seed Sprouts Not Served. * Food and Food Protection 3-80'1.1 l (C) lino ened Food Package Not Re -served CONSUMER ADVISORY 22 3-603.'1 t Consumer Advisory Posted for Consumption of 590.000 23. Animal Foods'I4tat are Raw, Undercooked or - FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* E""'"1e unzoo� 25,_Equipment 3-302.13 Pasteurized Eggs Subwtute for Raw Shell 005 26. E s`" blatz'LAAL Kt:Q!. 1HEMENI S 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering: mobile food, temporary land residential kitchen operations should be debited wider 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. trr1=lSYi9wol (Items 23-30) Critical and non-cnitical violations, which do not relate io the foodborne illness interventions and risk factors listed o&ore, can be found in the follon=ing sections of the Food Code and 105 CMR 590.000. - - I Item Goad Retail Practices FC 590.000 23. --------- Management and Personnel -------------------- - FC - 2 .003 24. Food and Food Protection FC - 3 .004 25,_Equipment and Utensils FC -4 005 26. Plumbin and Waste _ FC -5 __ .006 27. --Water, Ph sical Facility FC -6 _ .007 28. Poisonous or Toxic Materials FC - 7 .008 29. S ectal Re uiremants � .009 30 4 Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2006 WHO'S PLACE OF BUSINESS IS: File Number: BHF -2004-0365 LOCATED AT White Hen Pantry 28 Norman Street Salem MA 01970 0028 NORMAN STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2006-0283 Jan 4, 2006 Dec 31, 2006 $100.00 TOBACCO VENDOR 13HP-2006-0282 Jan 4, 2006 Dec 31, 2006 $50.00 Total Fees: $150.00 PERMIT EXPIRES LDecember 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 13 of 20 n STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT `)J ec, Ay- 1 TEL # q 7 P��LIS- 2Z S ADDRESS OF ESTABLISHMENT 2,9 t�i_. - Cdr - o� �„�" lot 0 MAILING ADDRESS (if different) OWNER'S TEL# a :7 -Sao-C4-C o-7 CITY c o \Q STATE ZIP r5tcL'-7 d CERTIFIED FOOD MANAGER'S NAME(S)t CERTIFICATE#(s) AN-, F4a,,,- M -2,t 6 V S (required in an establishment where potentially hazar ous food prepared.) EMERGENCY RESPONSE PERSON N ,� HOME TEL # LIO 01 HOURS OF OPERATION: Mon. �Tue.Wed.ZTh �Gi-IFri. �j�l,Sat. un.��� TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE Y S NO less than 1000sq.ft. 1�2 OL 1000-10,000sq.1t. $-1 more than 10,000sq.ft. = 250 RESTAURANTO YES O 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, S,Q T S VE YES 62 $5 CTOBACCO VENDOR) O8P YES 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 knowleoe and belief, have filed all state tax returns and paid all state taxes required under the law. aS Signature Date' Social Security or Federal Identification Number --------------------------------------------------------------------- �t 'L V 14 i--'--`------1-�t------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check# & Date — p -r STANLEY J. USOVICZ, JR. MAYOR November 9, 2005 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT White Hen Stofe #1-8306-5 c/o Ali & Manal Hamza 28 Norman Street Salem, MA 01970 Dear Ali & Manal Hamza: The Salem Board of Health requests your presence at the next Board of Health meeting to discuss the fine for selling Cigarettes to a minor. The meeting will be held Tuesday, November 15. 2005 at City Hall Annex, 120 Washington Street 3rd floor conference room at 8:30 p.m. If you have any questions, contact me at 978-741-1800. Sincerely, For the Board of Health Joanne Scott, Health Agent JS/mp cc: Christina Harrington, Chairperson of the Board of Health and Members North Shore Tobacco Control Program, 85 Exchange St., Suite 307, Lynn, MA 01901 c/o Joyce Redford mar -oa�e : -' h;s s 0 r µcs t f-0 a- rn Y�t4V"n� l ��re H- �SOGrG1 0' T1frtIik 0 oCJ() 6f 3,coos , aPerurrmtI -1-om t'hc-Tolccev LOntro) rfoc�fam Yi,,J conc/(V C.le(I q C 0 W f UfklC-e 01efk Ih my �S�GbI S�weMt,io�incaou� �� wewoulclse �i r�(Ore lis i'a g vrl� nor, / j �2 r smm� l C (Q i �n s �k4 f of 1 % - /err - 016 �Y mG Ie h,. C �uIC6sfed wart -T from mn Ci,tk, Tki l5 a) rtm,' �Y op rofed sfOr,,w, P^+tiIG10-01��/L.. yf (oto e-sic,6)(SIli?IJ a II�9roKnoj !4412 (.5 6ynd rlCjW C(M ay, 6,flze knoviU�e o cis o�S�a�e th< )zest me�h.�c�S tQ en sur e,cpLc/41�Y L!/nGRFtW th COns'4ua+c�J anG1 (?vnu��y o Sell �g tobacco pra4uct f laM'nar , Cyn S wrl) 0rti, ons rnO�her )AC jdj5 0 afro N', -C Siam (IS a CclSii'ero), bid shcrf 4(3o wFll YrlstrucQ Ylol +-c, Sell -�o bucc0 is a»1inrr,am-d She glways ask's dr 0r,!Cl • t4 ySryn mn Yhonc(ay-CV'MI'n5 or(oYG'inr�. %-6 mYp malher, y7•eS pure wus �43Y he �ak9ht<r was M a s aPdwttll, Y-0 a CC,(fttAR'vv • w'h; It M y w C)"7er tv4f 'r\(;nq t0.sP-tdVP h� pry c�jS a4 "d) YJ CUIt1,4rner 5 -W, 0 O i-oyjo� k .I p she, 1n i mo l- e haj aSG(eG e 5 r I i She 5 YES, 1 unGIer NLAt mymobeShok(d ham qS�l � r Skca (j, u/&v "fr"'( motor w41 �'n A�Nn i'e Si �'ua�ion ae OJ �'� I' ru111 t6 cyc7 U"" -/- gc,'n9I buv7 itcomer -)o mY under lanolinuj �f 1 I's w<I ) ami ,,nilru!hd �o �, I 1 t-�, �e i 7rtil�l 'She_ l i tj 9, }�(r el�i �' n)Y Mli j r fkgl Shei) lk, A S um' I i' t" " o of o Odn U / r 6,f -1-o r uC 411, "J S IAM -A f u ase yieyo�cr r��fharr�, ndf rz/�� fuba��a f o �f{uIQ u�Cc�f my Si'nCcrC c�6oloyK�crn(/ �/L' plcm'!c �i,�.e--eXf✓Pi�n�Y CareTti� until CouSiaNri+'ITT �lti�luye., C) LVV�z/ G 612Q�u�dY 0 c �� MlrygTfT' p STANLEY J. USOVICZ, JR. MAYOR June 22, 2005 White Hen Pantry 28 Norman Street Salem, MA 01970 Dear Owner: CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT On Wednesday June 15, 2005 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17 -year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. White Hen Pantry is in violation of Section III(A) of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section, the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of (ONE Hundred Dollar fine) for the FIRST offense. FOLLOWING THE THIRD (3RD) OFFENSE, THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore, you are ordered to pay a fine of $100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street, 4th floor, within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, ,' �anne Scott Health Agent JS/mfp CERTIFIED MAIL: 7003 3110 0005 1992.4.& 9- cc: North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members 0028 Norman Street HACCP: ❑ Telephone: - 9AC 4"C _ Owner: 11 Ali S. Hamza PIC: Carol McIntyre David Greenbaum ' Date Inspected: Correct By: 7/25/2005 Risk Level: Permit Number 1. BHP -2005-0268' Status:` a= vioLATION # of Critical Violations: 5- - Time IN Time OUT - _ Notes: 233. Urgency Description(s): BLUE: Violations Related to Good. Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations White Hen Pantry 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 ❑d RED EMPLOYEE HEALTH Not Done Reporting of Diseases by Food Employee and PIC PASS RED Personnel with Infections Restricted/Excluded PASS ❑J RED FOOD FROM APPROVED SOURCE Not Done Food and Water from Approved Source PASS ❑d RED Receiving/Condition PASS RED Tags/Records/Accuracy of Ingredient Statements PASS RED Conformance with Approved Procedures/HACCP PASS ❑d RED Plans GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc ( Rev. Jul 25,2005 ) Page 1 of 0028 Norman Street must be corrected immediately, or within 90 days) RED. Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) White Hen Pantry PROTECTION FROM CONTAMINATION Not Done ❑d f Separation/ Segregation/ Protection FAIL Critical RED sley freezer in back has potentially Prevention of Contamination from Hands hazardous food stored with ready to eat ❑d RED E oyee making sandwiches not wearing food. All RTF and PHF must be stored sepe_>plyto prevent cross contamination. Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED utting boards are badly stained and foods must wear disposable gl ves-... Handwash Facilities FAIL Criticald❑ ' scored. esurface or replace all cutting RED The bathroom handwash sink h hot or board cold water. Repair the hot water and I coop needs to be thoroughly cleaned d sanitized. Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS ❑d RED Prevention of Contamination from Hands FAIL Critical ❑d RED E oyee making sandwiches not wearing oyes. Employees handling ready to eat foods must wear disposable gl ves-... Handwash Facilities FAIL Criticald❑ RED The bathroom handwash sink h hot or cold water. Repair the hot water and restore the cold water immediately. PROTECTION FROM CHEMICALS Not Done Approved Food or Color Additives PASS ❑d RED Toxic Chemicals PASS ❑d RED TIME/TEMPERATURE CONTROLS (Potentially Haz Not Done Cooking Temperatures PASSd❑ RED Reheating PASS RED Cooling PASS ❑d RED Hot and Cold Holding FAIL Critical RED Produce oling unit had a temperature of . 60°F. epair unit to maintain a to erature of 41 °F or below. Time As a Public Health Control PASS ❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS 0 RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A 0 RED GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jul 25,2005 ) PaQe 2 of 0028 Norman Street White Hen Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE Ma products found outdated. Closely nitor all expiration/sell by dates. Many p ducts have price labels obscuring the iration/sell by dates. Do not - any expiration/sellby dates with Pcure rice labels. Continued violations of this nature will result i r onetary fines being issued. ' Equipment and Utensils FAIL Critical ❑ BLUE,H man ezer in back needs a thorough eam inside and out. eed a visible accurate ves in the front knife rack. gstoFra asleaned and sanitized prior The at sl r has an accumulation of fo de s. Thoroughly clean and sanitize is e deli case needs a thorough cleaning. gSam s a visible accurate I rmo r. The ed pastry case has an a mulation of food debris. Thoroughly clean case. Walki or needs to be thoroughly cl ed. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non -Critical ❑ BLUE Ope reqs in ceiling in back room and by t athroom. Seal all open areas in the ceiling. p. Many wa stained ceiling tiles in back. Repl all damaged ceiling tiles. Li ptin the backroom need otective covers. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other- See Notes PASS ❑ BLUE GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jul 25,2005 ) Pake 3 oro 0028 Norman Street White Hen Pantry GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jul 25,2005 ) PaQe 4 oto 0028 Norman Street HACCP: ❑ Telephone: 745-1225 Owner: Alt S: Hama PIC: Inspector:., David Greenbaum Date Inspected: Correct By: 8/1/2005 ` ,m Risk Level: Permit Number: BHP -2005-0268 Status: P � F PARTIAL COMPLY # of Critical Violations: Time IN: � Time OUT. Votes: 237: Description(s): -A White Hen Pantry City of Salem RETAIL FOOD - Food Establishment Inspection Item Status Violation Critical Urgency Nature of problem or correction Non-compliance with: Not Done PASS Anti -Choking PASS ❑ RED' Tobacco PASS ❑ PASS FOOD PROTECTION MANAGEMENT Not Done FAIL CriticalJ❑ PIC Assigned / Knowledgeable / Duties PASS RED EMPLOYEE HEALTH Not Done Reporting of Diseases by Food Employee and PIC PASS./❑ RED Personnel with Infections Restricted/Excluded PASS RED FOOD FROM APPROVED SOURCE Not Done Food and Water from Approved Source PASS ❑d RED Receiving/Condition PASS ❑d RED Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED Conformance with Approved Procedures/HACCP PASS ❑d RED Plans PROTECTION FROM CONTAMINATION Separation/ Segregation/ Protection Food Contact Surfaces Cleaning and Sanitizing Proper Adequate Handwashing Good Hygienic Practices Prevention of Contamination from Hands Violations Related to Good. Retail Practices (Critical Handwash Facilities violations must be corrected immediately or within 10 days)(Non-critical violations GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc. Not Done PASSd❑ RED PASS RED PASS ❑d RED' PASS ❑D RED PASS RED FAIL CriticalJ❑ RED There is no hot hot water in the restroom. Restore hot water immediately. Owner will notify the Board of Health when hot water ( Rev. Aug 01,2005 ) Page 1 of r 0028 Norman Street Not Done White Hen Pantry must be Corrected Immediately PROTECTION FROM CHEMICALS Not Done RED or with in'90 days) .,.. Approved Food or Color Additives PASS RED RED: Violations Related t0 `� Toxic Chemicals PASS RED RED Foodborne Illness InterVentlonS Not Done Management and Personnel TIMEITEMPERATURE CONTROLS (Potentially Haz Not Done BLUE and Risk Factors (Require Cooking Temperatures PASS ❑d RED immediate corrective action) expiration/sell by dates. Price labels must Reheating PASS ❑d RED Cooling PASSd❑ RED Equipment and Utensils Hot and Cold Holding PASS ❑Q RED Water, Plumbing and Waste Time As a Public Health Control PASS Q RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS 0 RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS ❑d RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE There are price labels obscuring expiration/sell by dates. Price labels must be affixed so as not to cover any expiration/sell by dates. Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non -Critical ❑ BLUE There are some watewr stained ceiling tile in back. Replace all stained tiles. Provide protective covers on all light fixtures. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other- See Notes PASS ❑ BLUE GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 01,2005) Page 2 of 0028 Norman Street White Hen Pantry GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 01,2005) Page 3 of IMPORTANT MESSAGE FOR .J6\/1 d PLEASE CALL DATE TIMET L�M. WILL CALL AGAIN n PA( /1 Vl I WANTS TO SEE YOU RUSH OF o C RETURNED YOUR CALL (y I O fN Cj- PHONE O(� W AREA COOE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CA TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU -IF rlo_ Nq, WX 'V110 ORM SIGNED FORM 4009 FORMADE IN U.S.A. STANLEY J. USOVICZ, JR. MAYOR CITY OF 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 TTS 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: White Hen Pantry Address of Establishment: 28 Norman Street Owner's Name: Ali S. Hamza Restrictions: Application Date: 12/6/2004 Permit for Food Establishment 179-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 43-05 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 . a. i ,. -CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH _ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 .lye, TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT (�/h �e I �Pir� p(ni' TEL # less than 1000sq.ft. 0 1000-10,000sq.ft. ADDRESS OF ESTABLISHMENT �' A/dr man Lt sy // tarnIM GQ 9 2G 1 RESTAURANT YES (:�:O:) MAILING ADDRESS (if different) OWNER'S NAM TEL YSYJ -7 ADDRESS 0-0' �'on CITY jo,,t ST TE ZIP C/ . G CERTIFIED FOO ANAGER'S NAME(S) CERTIFICATE#(s) I_y-2,SS (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON - R m:ja6,f ku r (erl HOME TEL #� HOURS OF OPERATION: Mon. V9 Tue._7,Wed.J�Y_Thu._?,4 Fri. 24 Z O Sun aY TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. 0 1000-10,000sq.ft. =$100 n/ more than 10,000sq.ft. =$250 1 RESTAURANT YES (:�:O:) 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 TOBACCO VENDOR L�2-ajr YE NO Coalem ALL NON-PROR, (such as church kitchens) lI✓✓ YES rIUO�14 If�1Pi�3' se pay total�Ceck V'payv payable -th --64City This Permitis not transferable and must be reissued upon changeoof ownership. The Permit must be posted in a prominent location in the Establishment. CITY OF SALEM 0OF HEALTH In accordance with the State Sanitary Code, before any ren s, 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 "mg ledggiand belief, have filed all state tax returns and paid all state taxes required.under the law. Social Security or Federal Identification Number Revised 11/03/03 FOODAP2.adm Check# & Date eC.57 /z,/.21Qy -6. < a �o STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741.1800 FAX 978-745.0343 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: White Hen Pantry Address of Establishment: 28 Norman Street Owner's Name: Ali S. Hamza Restrictions: Application Date: 1/13/2004 Permit for Food Establishment 255-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 60-04 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. U HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH s s 120 WASHINGTON STREET, 4TH FLOOR 3 SALEM, MA 01970 .pBR TEL. 978-741-1800 FAX 978-745-0343 STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �'T� 1' O-JfY TEL #T7 b'- 145 Q.15 ADDRESS OF ESTABLISHMENT_ S A 01^ mIlr1 t Sa"" M am O MAILING ADDRESS (if different) 99 OWNER'S NAME , Ali" _ S. 461m g G ADDRESS ;2 0 CITY��p STATE M. fi ZIP CERTIFIED FOOD MANAGER'S NAME(S) A I. Na shy (required in an establishment where potentially hazardous food is prepared.) TEL# 3t—S9Y-51% EMERGENCY RESPONSE PERSON J{)pY (J k[oY IJA.S HOME TEL /��-S `/') —S P77 HOURS OF OPERATION: Mon.Z�Tue. Z LWed. Lhu. 2K -Fri. LV. Sat.-zy- Sun.2-y TYPE OF ESTABLISHM �S'� / FEE check only RETAIL STORE ES NO RESTAURANT YES NO BED/BREAKFAST YES NO less t_ 0sq.ft. =$ 50 tODO-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, S9F.T SERV S NO $5 TOBACCO VENDOR 91 - �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. to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my 4edgdpnd.,belief4ave filed all state tax returns and paid all state tales required under the law. Signature Date --------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check# & Date 2,t) or Federal Identification Number 4 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 Name0/1019 Wr/❑❑� (FC -2)(590.003) Dstetl�o Type of Operation(s) Type of Inspection Fy9od Service LJ Routine (FC -4)(590.005) 226Water, Plumbing and Waste Address Z8 27. Physical Facility Risk L��Retail 9 -F% -inspection (FC -7)(590.008) 9 Special Requirements Level El Residential Kitchen Previous Inspection Telephoner 22y ❑ Mobile ❑ Temporary Date: ❑ Pre-operation Owner HACCP YIN L / S ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) Time stows- In: El HACCP Inspector &Ownt£ Out: Permit No. ElOther Each vioiadon checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT -" El1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH El 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 ° ' " 1 -` - - ­__ -'1 ❑ 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 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) 226Water, 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. 500M,a fFmm 14.do ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS , ❑ 14. ApprovedFoodor Color Additives ❑ 15. Toxic Chemicals 1 TIME/rEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures i [117. 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. [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: Print: PI 's Signature: Print: /J / Q,L Page I of Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 I 590.003(A) AssianmentofRes>onsibrlity�_ 590.003(B) Demons ration of ledge* 2-] 03.11 Person incharge -duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201,13 Fluid Milk and Milk Products" applicants* Shell Egs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water - Applicant To Report 'fo The Person In Drinking Water from an Apiproved System-_ 590.006(A) Charge* 590.006(B) 590.003(G) Ke orting b 'Person in Charge* 3 590.(N)3(D) Exclusions and Restrictions* 3-201.'15 590.003(F-) Removul of Exclusions and Restrictions FOOD FROM APPROVED SOURCE ' Denotes critical item in the tedera11999 food Code -or 105 CMR 594000. S Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Foal in a Hermetmilly Scaled Container*�� 3-201,13 Fluid Milk and Milk Products" 3-202.13 Shell Egs* 3-202.14 rggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water - 5 -101.11 Drinking Water from an Apiproved System-_ 590.006(A) Bottled Drinkin Water" 590.006(B) Water Meets Standards in 310 CMR 22.0* Food Contact with Equipment and Utensils* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.'15 b4011usran Shellfish from NSSP Listed Sources" Returned Food and Refer%ice of Food* Game and Wild Mushrooms Approved by Regulate Authorit 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* Receiving/Condition 3-20111. 'H's Received at Pro er Temperatures" nt 3-202.15 PackageIrate it �" 3-101.11 Taal Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Rt cords, Creation and Retention* 590,0040) Labeling of Ingredients' Methods of Sanitization - Hot Water and Chemical' Conformance with Approved Procedures /HACCP Plans 3-50111 S ecialized Processing Methods* 3-502.12 Reduced ox ,gen acka ring. criteria* 8-103.12 Catfarmance witlt A troved Procedures" ' Denotes critical item in the tedera11999 food Code -or 105 CMR 594000. S 3-302.11(A)(t) Cross -contamination Raw Anbnal Foods Separated from Conked and RTE Foods* Contamination from Raw ingredients 3-302.11(A)(2) Raw Annual Foods Separated from Each Other" Contamination from the Environment 3-302.11(A) Food Protection* 3-302.1.5 Washune Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Refer%ice of Food* - Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Fa dq° 9 Food Contact Surfaces 4-501111 Manual Warewashing - Hot Water Sanitisation Tentperatnres* 4-501.112 Mechanical Warewashina Ilot Water Sanitization Temperatures* 4-501..114 Chemical Sanitization -temp., pH, concentration and hardness, 4-601,11(A) Equipment Food Contact. Surfaces and Utensils Clean - 4 -602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils" 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui stent* 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* It Good Hygienic Practices 2-401.11 Eating, Drinkin or Ushr 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 Empkwees* 13 _ Handwash Facilities Conveniently Located and Accessible 5-203.11 Nnittbers and Ca acilies* 5-204.11 Location and Placctnent* 5-205.11 Accessibiln . Operation and Maintenance Supplicd with Soap and Hand Drying Devices 5-301.11. Haudwashin Cleanser, Arailabi]iC 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH / Establishment Name: l✓mrd-- /fd-d Pia Date: di—T y Page: �'� of N Item No. Code Reference C - Critical item -R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - -- PLEASE PRINT CLEARLY Date Verified 2% ✓#4 UL 7 if' Z � ttA.tc- .;; Scs,w- %._f !`r fenvrt.d sr �cc fSr4 2� c�f.Mf /��- DalifFe �/ Mwr tts r_ J/0^1 /N PJOArenCMl /to r Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or susp nsion/revocation of ,your food permit. aN-�')t� � i Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension Li Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne fitness Interventions and Risk Factors (items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 15 18 TIME(TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Adrhtives* 3-302.14 Protection from Tina roved Additives* 19 Poisonous or Toxic Substances 7-101.11 Identifying information - Original Containers' 7-1.02.11 Common Name - Working Containers* 7-201.11 1 Separation - Storae* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.1.1 Toxic Containers -Prohibitions* 7-204.11 Sanitizers,Criteria- Chemicals* 7-204.1.2 Chemicals for Washing Produce, Critc6a* 7-204.14 Dr yin A ents. Criterin* 7-205.11 incidental Food Contact, Lubricants- ubricants*7-206.1I 7-206.11 1 Restricted Use Pesticides. Criteria` 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME(TEMPERATURE CONTROLS `I)enote.s critical item in the (edend 1999 Food Code or 105 CNIR 590 O00. Proper Cooking Temperatures for PHFs Received at Temperatures According to Iaw CWIed to 41"F/45"F Within 4 Homs. PHFs 3-401.1.IA(1)(2) _ Eggs- 155'F 15 Sec. 19 Ergs- hnmrediate Service 145'Fl5sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(B) 590.004(F) Animals - 155'F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast -130°F121min* 3-401.11(A)(2) Ratites, Injected Meats- 155'F 15 3-50L I O(A) sec. * 3-401.11(,,)(3) Poultry, Wild Game, Stuffed PHFs, Time as a Public Health Control Stuffing Containing Fish, Meat, 3-501.19 Poultry or Ratites -165`17 15 sec. 4: 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks Variance Re uirement 145°F 3401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3401.11(A)(1)(b) All Other PHFs - 145'F '15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165'F 15 sec. * 3-403.11(B) Microwave- 165° F 2 Minute Standing Timet_ 3-403.11(C) Commercially processed RTE Food - 14WF* 3-403.1.1(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PRFs 3-501.14(,,) Cooling Cooked PHFs from 140'F to 7097 Wither 2 Flours and From 70"F to 41'F/45'F Within 4 Hours. * 3-501.14(13) Cooling PHFs Made From Ambient Temperature Ingredients to 41°7/45cF Within 4 Hours* `I)enote.s critical item in the (edend 1999 Food Code or 105 CNIR 590 O00. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-501.14(C) PHFs Received at Temperatures According to Iaw CWIed to 41"F/45"F Within 4 Homs. 23. Mona ement and Personnel 3-501.15 Cooling Methods for PHFs 19 3-80 Ll I (D) PHF Hot and Cold Holding 25. E uipment and Utensils 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41;'/45°F* 26. Water, Plumbin and Waste 3-501.16(A) ]-lot PHFs Maintained at or above 140°F.* 27. Physical Facility 3-50L I O(A) I Roasts Held at or above 130°F. 20I FC -7 Time as a Public Health Control 29. _ Special Requirements 3-501.19 Time as a Public Health Control* _ 30, Other 590.004(H) Variance Re uirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3 -SOLI I(A) Unpasteurized Pre-packaged Juices and Beverages with Warning i.,abels* 23. Mona ement and Personnel 3-80LII(B) Use of Pasteurized Bees* 24. Food and Food Protection 3-80 Ll I (D) Raw or-Pattially Cooked Animal Faxl and Raw Secd S routs Not Served. " 25. E uipment and Utensils 3-801.11(C) Unopened Food Pucka =e Not Re -served- CONSUMER ADVISORY 22 3-603-1 I Consumer Advisory Posted for Consumption of 23. Mona ement and Personnel FC -2 Animal Foods'Phat are Raw. Undercooked of 24. Food and Food Protection FC - 3 Not Otherwise Processed to Eliminate 25. E uipment and Utensils FC -4 Pathogens.* 26. Water, Plumbin and Waste 3-302.13 Pasteurized Eggs Substitute for Raw Shell 27. Physical Facility FC-6 Ee s* arct,uar. nc�t�rncrvrcry r a 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under die 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 N29 -- Special.R quiiements. W141FI al (items 23-30) Critical and non-critical violations, which do not relate to the foodborne iltness interventions and risk factors listen shove, can be ,found inthe following sections of the Food Code and JOS CMR 590.000. Item Good Retail Practices FC 590.000 23. Mona ement and Personnel FC -2 .003 24. Food and Food Protection FC - 3 .004 25. E uipment and Utensils FC -4 ! .005 26. Water, Plumbin and Waste FC -5 .006 27. Physical Facility FC-6 .007 28. Poisonous or Taxic Ma_t_e_rials___________ FC -7 .008 29. _ Special Requirements .009 _ 30, Other --- S 5010k -A;;6-2 M. ti Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4t" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name I& �� DateTvae / 2'r of ODeration(s) T f Inspection Ueod Service K Hetail Routine ElRe-inspection Address d Ris (FC -4)(590.005) Level El Residential Kitchen Previous Inspection ( Telephone �vf r�/lY (FC -6)(590.007) ❑ Mobile Date: (FC -7)(590.008) 29. [-ITemporary ElPre-operation Owner7 HACCP YIN AV S % ❑ Caterer ElBed & Breakfast ❑ Suspect Illness ElGeneral Complaint Person in Charge (PIC)Time In: Out: Permit No. ElHACCP ❑ Other Inspector t racn violation cnecKea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection U,# -**Food Contact Surfaces Cleaning and SanitizingC2' [:110. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) P2 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: 50/ns fFom 14.O ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) j ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑18. ooling Z9. Hot and Cold HoldingC4,, ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) [121. 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: /fTZp/0, Inspector's Signature• Print: I/ PIC's Signature: Print: �qomZqPage _/_ of Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* �590.003(B) Demonstration ol-Knowled e* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 540.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* a tlicants* Shell Eg s* - 590.003(1`) 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) Char *e* 590.006(B) 590.003(G) Re or in by Person in Charee* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) RelnOval of EXelnFlOns and Restrictions C C C C FOOD FROM APPROVED SOURCE *Denotes critical Item in the federal 1999 Faxl Code or IW CMR 590.000_ g Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Foci in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eg s* - 3-202.4 }1`g cs 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 Drinkine Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washin Fruits xnd Vegztables Shel ish and Fish From an Approved Source 3-201.4 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 Repulatory Authority 3-202.18 Shellstock Identification Prescnt* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proter Tem eratures* 3-202.1.5 Package Into grit * 3-101.11. Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shelfstock Identification Mhintained* Tags/Records: Fish Products 3-402.11. Parasite Destruction, 3-403.12 Records, Creation and Retention* 590,004(.1) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Methods of Sanitization - Hot Water and Chemical* Conformance with Approved Procedures /HACCP Pians 3-502.11 S eeodried Proeesmn r Methods* 3-502.12 Reduced oxygen packaging. criteria* 8-103.12 Conformance with Approved Procedures* *Denotes critical Item in the federal 1999 Faxl Code or IW CMR 590.000_ g Cross -contamination 3-302.11(A)(1) Raw Animal 17oods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.1.5 Washin Fruits xnd Vegztables 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 Warewashine. - Hot Water Sanirization Tem eratores* 4-501.112 Mechanical Warewashinti-Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils'' 4-702.11 _ 4-703.'11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11. Clean Condition -Hands and Arno" 2-301.12 Cleaning Procedure- rocedure* 2-3 2-301.14 When to Wash* 1I Good Hygienic Practices 2-401.11 Eatin!?, Drinking or Usin Tobacco"` 2-401.12 Discharges From the Eyes, Nose and Mouth* I2 3-301.12 ( Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination front Ent to ,ees* 13 Handwash Facilities 5-203.11 Conveniently Located and Accessible Numbers and Capacities* 5-204. 1 Location and Placement* 5205.11 Accessibility. Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashin Cleanser, Avarlabilit, 6-301.1.2 1 Hand Ding Provision CITY OF SALEM BOARD OF HEALTH / `! Establishment Name: Date: / / 1 Z�/�y Page: of item Code C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R - Red Item Verified y . PLEASE PRINT CLEARLY L7 C 67 AOI._Lr-5tai#W 1r74 w►5 (. r/i &e0 Lei ft^r/J it J_A -,O I I a -2 1 wi/A w .L " L j. I I Discussion With Person inCharge- v I have read this report, have had the opportunity to ask questions and agree to correct all Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of tw my -five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure yOUr•fOOd permit. 7 7 c�� ��/ \\l YYY �_ ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 10 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302,14 Protection from tinat roved Additives* 3-801.11(C) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11 Common Name- Working Containers* 7-201.11 Separation - Stoj ae" 7-202.11 Restriction - Presence and Ilse'" 7-1-0112 Conditions of Ilse* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers.Criteria- Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Diving Agents. Criteria* 7-205,11 Incidental Foal Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7 ?06.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitorin * TIME/TEMPERATURE CONTROLS * Denote, critical item in the federal 1999 Food Cate or l05 CMR 590.000. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/49°F Within 1 Home Proper Cooking Temperatures for 19 PRFs 3-401.11A(1)(2) Eggs- 155gF 15 Sec. 3-801.11(C) Eegs-Immediate Service 145°F15sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game E uipment and Utensils FC 4 Water Plumbinq and Waste FC 5 .Animals - 155`F 15 sec. "` 3-401.11(H)(1)(2) Pork and Beef Roast -130'F121 min* 3-401.11(A)(2) Ratites, Injected Meats - 155'F 15 Poisonous or Toxic Materials FC - 7 sec. * 3-<401.11(A)(3) Poultry, Wild Game. Stuffed PHFs, .009 Stuffing Containing Fish, Meat, Other Poultry or Ratites -165'F 15 sec. 3-401A t(C)(3) Whole -muscle, intact Beef Steaks 145'F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs--'145'F '15 sec. Reheating for Hot Holding 3-403.1.1(A)&(D) PHFs, 165'F 15 sec. s` 3-403.11(B) Microwave- 165° F 2 Minute Standing Tile* 3-403.11(C) Commercially Processed RTE Food - 140'F 3-4011.1(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 70OF to 41'F/45'F Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41 °F/45'F Within 4 Hours* * Denote, critical item in the federal 1999 Food Cate or l05 CMR 590.000. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/49°F Within 1 Home 21 3-501.16(B) 590.004{F) 3-_501.15 Cooling Methods for PHFs 19 PHF Hot and Cold Holding 21 3-501.16(B) 590.004{F) Coad PHFs Maintained at or below 4 F145' F* 3-501.16(A) Hot PHFs Maintained at or above 140`'F 3-501.I6(.A) Roasts Held at or above 130°F, 3-801.11(C) Time as a Public Health Control 3-501.1.9 Tine as a Public Health Control* 3-801.11(A) Unpasteurized Pre-packaged Juices and Beserazes with Warning labels* 3-801.11(B) Use of Pasteurized Eggs* 3-801..11(D) Raw ar Partially Cooked Ain mal Food and Raw Sced Sprouts Not Served. * 3-801.11(C) I)noencdFoodPacka=eNot Re -served, r4roUTRIUNWINEW19F ": 22 3-603.11 Consumer Advisory Posted for Consumption of 23. _ _ Mam9ement 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. E uipment and Utensils FC 4 Water Plumbinq and Waste FC 5 Pathogens.* Erre„ere vnort 27 3-302.13 Pasteurized Eggs Substitute fru- Raw Shell 28. Poisonous or Toxic Materials FC - 7 Eg rs* 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 ilhtess interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne dhiess interventions and risk factors listed above, can be found in the following secdons r f the Food Code and 705 CMR 590.000. _Item I Good Retail Practices FC 590.000 23. _ _ Mam9ement and Personnel FC - 2 .003 �- 24. Food and Food Protection FC - 3 .004 25. 26. E uipment and Utensils FC 4 Water Plumbinq and Waste FC 5 005 .006 27 Physical Facility FC -6 .007 28. Poisonous or Toxic Materials FC - 7 .006 i 29 -- Special Requirements .009 30 Other ac..re- CITY OF SALEM BOARD OF HEALTH / Establishment Name: "41W t&t4A A Nf1�-'f Date: r11i-4>%q Page: Of Item No. Code Reference C - Critical Item R — Red Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION PLEASE PRINT CLEARLY _ Date Verified s.•� ��sx- � D M.4)00/- W2�' r4r e.� yr tr W* tiff v/A 644 att- trLo ..r. K4 A14, PU9 PC t- /1 ­/ Off VA61 r rau*Sf L N t . tAfhe- 6 C, Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-fiv dollars or suspension/revocation of your food permit. r 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 16 17 riflIT, Aid ltra;c 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 Natne- Working Containers* 7-201.11 1 Separation - Stonutc* 7-20111 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-20311 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* riflIT, Aid ltra;c * Denotes ct iocai item in tha federal 1999 Foal Code or 105 CMR 590 t)0. 19 20 3-501.14(C) Proper Cooking Temperatures for 3-501,15 PRFs 3401.1IA(1)(2) Eggs- 155'F 1.5 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(A) Animals- 155'F 15 sec.'s 3 401.11(13)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Raines, Injected Meats -155'F15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .009 Stuffing Containing Fish, Meat, ------' Poultry or Ratites -165017 15 sec, 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145'F "` 3401.12 Raw Animal Foals 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 see. * 3-403.11(B) Microwave- 165' F 2 Minute Standing - Time* 3-403.11(C) Commercially Processed RTF Food - 140°F' 3-103.11(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/450F Within 4 Hours. 3-507.14(B) Goofing PHFs Made From Ambient Temperature ingredients to 41 °F/45'F Within 4 Hours'" * Denotes ct iocai item in tha federal 1999 Foal Code or 105 CMR 590 t)0. 19 20 3-501.14(C) PRFs Received at Temperatures According to I.aw Cooled to 4FF1451T Within 4 Hours. 3-501,15 _ Coolimr Methods for PHFs FC - 2 PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PFIFs Maintained at or below 4F145° F* 3-501.16(A) Hot PHFs .Maintained at or above 14W * 3-501,16(A) Roasts Held at or above 130'F. 27. Physical Facility __ -_ Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Re uircment P* • 21 3-$01.11(.4) Unpasteurized Pre-packaged Juices and _ 23. Mona ement and Personnel FC - 2 Beverages with Warning Labels* 24. Food and Food Protection 3-801.11lB) Use of Pasteurized Begs* _. _. 25. E ui rnent and Utensils ---------- - 26. Water Plumbing and Waste `-- -- 3-801.11(D) Raw or Partialiy Cooked Animal Food and 27. Physical Facility __ -_ 3-302.13 Raw Seed S rronts Not Served. '" 28. Poisonous or Toxic Materials 3-801i1(C) UnoenedFoalPacka=eNotRe-servecL* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of _ 23. Mona ement and Personnel FC - 2 Aminal Foods: 'that. are Raw, Undercooked or 24. Food and Food Protection FC -3 Not Otherwise Processed to Eliminate _. _. 25. E ui rnent and Utensils ---------- - 26. Water Plumbing and Waste `-- -- FC - 4 _4_,005 FC --5 Pathogens.* `mxe,-o vr.-zooi 27. Physical Facility __ -_ 3-302.13 1Pasteurized Eggs Substitute for Raw Shell 28. Poisonous or Toxic Materials FC -7 F; s* 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. t.Te7•T0liY(Axti (Items 23-30) Critical and non-critical violations, which do not relate io the foodborne illness interventions and risk factors li.wd above, can be ,found in the, follortdng sections of the Food Code and 105 CMR 590.060. its Good Retail Practices C 590.000 _ 23. Mona ement and Personnel FC - 2 .003 24. Food and Food Protection FC -3 l .004 _. _. 25. E ui rnent and Utensils ---------- - 26. Water Plumbing and Waste `-- -- FC - 4 _4_,005 FC --5 1 .006 27. Physical Facility __ -_ - FC _-6 ------ .007 28. Poisonous or Toxic Materials FC -7 .008 29. __ S eclat Re uiremenis .009 30. Other -� ------' sawrm�nar#n-zao< Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4t" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name au Date SOV �LJ n(s) Tve of Operation(s) n oe ection Food Retail o.HIT-a uf ElRe-inspection Address Z Z3 Risk o rr Telephone Level El Residential Kitchen Previous Inspection T7 7/$ /zz'f-- ❑ Mobile ElTemporary Date: ❑ Pre-operation Owner HACCP Y/N LI r. /./,4,4 ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) Time e In: out: Permit No. ❑ HACCP El Other - Inspector m�S 7�nr 4/ �. I T"Lf S %i /S Each violation checked requires+an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT- " ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE _ ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION. ❑ 88. Separation/ Segregation/ Protection 2/ 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. G N` / 23. Management and Personnel (FC -2)(590.003) L/ 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: sW,ns�tFor�-,a.�c ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling V9. 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 C 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: !�`/9/� AS e r' Sign re: 17JIf -�. Print: PIC's Signature - / Print: V Page / of z'Pages w Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) AssigiunentotResponsibility" 590.003(B)�_ Demonstration of Knowledge* 2-1.03.11 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 fool employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shot[ Eggs* 590.003(F) Responsibility Of A Foal Employee Or An 3 202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved Svstern* 590.006(A) Chm ge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 1 590.001(D) Exclusions and Restrictions* 3-201.15 590.003(F) Removal. of Exclusions and Restrictions LM 5 6 7 FOOD FROM APPROVED SOURCE " Denotes critical item in the federal 1999 Food (lode 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 Shot[ Eggs* 3-202.14 Es and MilkProducts. Pasteurized - 3 202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved Svstern* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 220* Washing Fruits and Ve ,e ibles Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.1$ Shellstock Identification Present" 590.004(C) Wild Mushrooms - 3 -201.17 Game Animals- 3-701..11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and U'nadultetated Tags/Records: Sheilstock 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" 590.00-10) Labeling of Ingredients* Frequency of Sanitization of Utensils and Fad ContactSarfacesofEqui meat* Conformance with Approved Procedures /HACCP Plans 3-502.11. Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures" " Denotes critical item in the federal 1999 Food (lode or 105 CMR 590.000. $ Cross -contamination 3-302.11(A)(1) Raw Animal Fonts Separ led from Cooked and I2TE Foods* Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foals Separated from Each Other* Contamination from the Environment 3-302A 1(A) Food Protection* 3-302.15 Washing Fruits and Ve ,e ibles 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- HotWitter Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Tem )eratures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Ford Contact Surfaces and Utensils Clean* 4-60111. Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Fad ContactSarfacesofEqui meat* 4-703.11 Methods of Sanitization -- Hot Water and Chemical* if Proper, Adequate Handwashing 2-301.11. Clean Condition -- Hands and At 2-30112 Clcaning Procedure* 2-301.14 When to Wash" 11 Good Hygienic Practices 2-401.11 Patin , Drinking of Using Tobacco* 7401.12 Discharges From the Eyes. Nose and MouthO' 3-301.12 Preventing Contamination When Tast� I2 Prevention of Contamination from Hands ti90.004(E) Preventing Contamination from Fm kwees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.].1 Numbers and Ca acities'" 5-204.11. Location and Placement* 5-205-11 Accessibility, Operation and Maintenance. Supplied with Soap and Hand Drying Devices 6-301,11 liandwashing Cleanser. Availability 6-301.12 Hand Dryina, Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: NNf Ti /Y9 /J 10,4n/P%1 Date: a- �76—O 1/ Page: J. of ;7_1 Item Code C - Critical item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R - Red Item _ PLEASE PRINT CLEARLY Verified iin/P P rG �, /L;c / P I L AUJ/n/tA 001�,/ 111 S A: /dl!S'y/ a Alc r f/ s,,,, _ ' U e-' p / it t A'S e _ Ai P.0 / r19 C/e krlr" PC was P/r✓9 ' P �L//a/r> z, laow b ma 77k- ' C c nim a LIQ KeS' A f 6 '? J47 /L 0 4ZC Po% D Zi -A) 1214 2Z22 D Z k-/ ,Fr f Alelyds 19,e P11 C - !' v4 .r Pl C /l P PwR ,r FdrP /lR JSP C 2 P rf dsIr /F slog i,va IC IV &dl' rIern/�cfL /on ez r v Ari ✓ 7w1,112/Ni Discussion With Person in 16CAIti7 Corrective Action Required: ❑ No ❑ Yes _Pt✓ICG dam/-AC/A?/1S J�'e ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion 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 ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that ►noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit#&1/6 /7zMs aZe /I y,I°'d �i°71s QeS Y�777S/Uilpfxfrlsq�P f�%ia Nps /tis ❑ Voluntary Disposal ❑ Other: v/dM'1`1071. 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* 3302.14 Protection front Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying informal'ion - Original Containers - 7 -10111 Common Name - Working' Containers* 7-201.11 Se. aration - 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* TIMEITEMPERATURE CONTROLS * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 20 _73,50i -14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.11A(1)(2) Eggs- 155.F 15 See. 3-501.16(B) 590.004(F) Eggs- Immediate Service 445'F15sec* 3-401.11.(A)(2) Comminuted Fish, Meats & Game 3--501,16(A)Roasts Animals - 155'F 15 sec. * 3-401.11(6)(1)(2) Pork and Beef Roast -130°F 121 rain* 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, FC -.7 .008 Stuffing Containing Fish, Meat, Special Requirements Poultry or Ratites -165"F 15 sec. 3-401.11(_C)(3) Whole -muscle, Intact BeetSteaks 145°F * 3-401.1.2 Raw Animal Foods Cooked in a Microwave 165"F * 3401-1'1(A)(1)(b) All Other PHFs -- 145'F 15 see. Reheating for Hot Holding 3-403,11(A)&(D) PHFs 165'F 15 sec. * 3-403.11(13) Microwave- 165' F 2 Minute Standing Time"_ 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.1.1(E) Remaining Unslieed Portions of Beef Roasts" Proper Cooling of PHFs 3-501..1.4(A) Cowling Cooked PHFs from 140`F to 70'1- Within 2 Hours and From 70"F to 41'Fi45°F Within 4 Hours. 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41`F145°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 20 _73,50i -14(C) PHFs Received A Temperatures According to Iaw Cowled to 41`F145°FWithin 4 Hos. 3-501.15 Cowtim , 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 41145° F- 3 -501.16(A) Hot PHFs Maintained at or above 140'F. 3--501,16(A)Roasts Held atorabove130°F. 26. Time as a Public Health Control 3-501-19 Titne as a Public Health Control* 590.004(H) Variance Re� uircment �• z a 2'1 3-801.11(A) ! Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 23. 3-801.11(B) Use of Pasteurized Eggs* 24. 3-801.1 I (D) Raw or Partially Cooked Animal Food and Raw Seed 5' )routs Not Served. 25. 3-801 11(C) Uno oened Food Packa >e Not Re -served. "' 22 3-603.11 Consumer Advisory Posted for Consumption of 23. Management and Personnel Animal Foods `That are Raw. Undercooked or 24. _ Food and Food Protection Not Otherwise Processed to El minate 25. Equipment and Utensils Pathgvans.* En.m e, ,zoai 26. 3-302.13 Pasteurized Eggs Substitute for Raw Shell 27. Physical Facilit E s` SPECIAL REQUIREMENTS 590 -009(A) -(D) I Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness Interventions and risk factors. Other 590.009 violations relating to good retail practices should be, debited under 7129 -- Special Requirements. rTzzt>gn (.Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can he f maid in doe following sections of the Food Code and 105 CMR 590.000. ItemGood Retail Practices FC 59oA00 23. Management and Personnel FG -2 .003 24. _ Food and Food Protection FC -3 .004 25. Equipment and Utensils _ FC - 4 .005 26. _ Water, Plumbin and Waste FC -5 .006 27. Physical Facilit FC - 6 .007 28. _ Poisonous or "Toxic Materials FC -.7 .008 29. Special Requirements .009 30. _ Other Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 41" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name Date I T of Operations) Tvoe of Inspection El Food Service etail El Residential Kitchen ElMobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. ❑Routine p 6 -inspection Previous I spection Date:.,/1/0'/ ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint E] HACCP ElO herr Address Risk Level Telephone _ Owner fi HACCP YIN Person in Charge (PIC) Time O Out: Inspector F �r•GH iYn � i ..rfri � Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT,. ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities .- PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE - ❑ 4. Food and Water from Approved Source TIMErrEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 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 [110. 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 5: 590/n5pec(Fo,mS-10.�oC ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control I 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 lector' Sig ure: " Print: C's Si na ure: Print: J U.O CLC h Page I of r Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT I I 590.003( A) Assi mtnent of Res ronsibility" 590.003(8) Demonstration of Knowledge" 2-103.11 Person in charge -- duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Commence 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 OfAFood Employee Or:Ali 3-202.16 Ice. Made From Potable Drinkine Water* Applicant To Report To The Person ]it Drinking Water from an Approved System* 590.006(A) Charge* 590.006(6) 590.003(0) Re ortin -b Pearson in Charge" 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions im C C C ••• :•u - C• • • "Denotes critical item it) the federal 1999 Rood Code or 105 Ch1R.590,000. 8 Food and Water From Regulated Sources 590.004(A -B) Commence with Food law* 3-201,12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs" 3-202.1.4 Flags and Milk Products. Pasteurize& 3-202.16 Ice. Made From Potable Drinkine Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water` 590.006(6) Water Meets Standards in 310 CMR 220* Washing Fmits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources" Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authori 3-202.18 Shellstock Identification Present* 590.004(0) Wild Mushrooms' 3-201.17 Garne Animals* 3-701.11 Receiving/Condition 3-202.11 PfIFs Received at Proper Temperatures* 3-202-15 Package Inteerit °' 3-101.11 Food Safe and Unadulterated'" Tags/Records: Shellstock 3-202.18 Shellstock Identification 3-203.12 Shellstock Identification Maintained* TagslRecords: Fish Products 3-402.11 Parasite Destruction* 3-102.12 Records. Creation and Retention* 590.004(.1) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of I ui trnent* Conformance with Approved Procedures IHACCP Pians 3-502.11 Specialized Processing Methods* 3-502.12 Rcducecl oxygen acka�ine, criteria* 3-103.12 Conformance with Approved Procedures" "Denotes critical item it) the federal 1999 Rood Code or 105 Ch1R.590,000. 8 Gross -contamination 3-302.11(A)(1) Raw Animal Foals Separated fiom Cooked and RTE. Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Anitual Foods Separated from Each Other* Contamination from the Environment 3-302-11(A) Food Protection* 3-302.15 Washing Fmits and Vegetables 3-3(}9.1.1 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* q Food Contact Surfaces 4-501.111. Manual Warcwashing - Hot Water Sanitization Tem. eramres•* 4-501.1.12 Mechanical Warewashiro-[for Water Sanitization Tem eratures* 4-501.114 Chemical Sanitization- temp., pit, concentration and hardness. " 4-601.'11(A) Equipment Foul 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 I ui trnent* 4-703.11 Methods of Sanifization - Hot Water and Chemical" 10 Proper, Adequate Handwashing 2301.11 Clean Condition -- Hands and Arms* 2-301.12 Cleanim* Procedure* 2-301.14 When to Wash" 21 Good Hygienic Practices 2-401.11 Eating, Drinkin or Using Tobacco* 2-401.1.2 Discharges From the Eyes. Nose and Mouth* 3-301.12 Preventive Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Ent php �ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities " 5-204.11 Location mid Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied vvlth Soap and Nand Drying Devices 6-301.11 Handwashin Cleanser. Availabitit 6-301.12 hard Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: k #IM A14P P4ng-" Date: Page: of Item No. Code Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION _ .PLEASE PRINT CLEARLY Date Verified tl 4 LlC // e -y _fJ //sz- C �S L/ fJ I/�/NG ss-./ u � U�" i-P�0i LirII Z ° (L-BPL%Rc Vtd TtDAr % rrA� �o/i.wa a 1s sr r,.a- C17Ver 1 /L .tie G�GfTH. Nva" .o Q..c i ice. - 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 understan _that noncompliance may result in daily fines of twent five dollars or susp nsion revo ation of your food permit. Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne Illness interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 l6 17 TIMEl7EMPERATURE 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" 7-1.02.11 Common Name- Working Containers* 7-201.11 1 Separation - Stin ae* 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* 7-204.1.2 Chemicals for Washing Produce, Criteria" 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-206.1 I Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stations" 7-206.13 'Irackln, Powders, Pest Control and Monitorinm* TIMEl7EMPERATURE CONTROLS =Denotes critical item in rho federal 1999 Food Code or 105 CMR 590900. 19 20 3-5o1.I4(C) Proper Cooking Temperatures for 3-501.15 PHFs 3401.1JA(I)(2) Eggs -155'F15 Sec. 3-501.16(B) 590.004(F) E rgs-Immediate Service 145'Fl5sec* 3-401.11.(A)(2) Comminuted Fish, Meats & Game 3-501.16(A) Animals- 155'F 15 sec.'" 3-401.11.(13)(1)(2) Pork'. and Beef Roast - 130°F 121 min" 3-401.11(A)(2) Ratites, Injected Meats -155'F1.5 5,)o O( (H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, FC - 7 .008 Stuffing Containing Fish, Meat, S ectal R uirements Poultry or Ratites -165'F 15 sec. 3-401.11(,C)(3) Whole -muscle, Intact Beef Steaks 145-F * 3401.12 Raw Animal Foods Cooked in a Microwave 165'F 3401.11(A)(1)(b) All Other PHFs -145'F'15see. Reheating for Hot Holding 3-403.11(A)&N) PHFs 165'F 15 see. * 3-403.11(B) Microwave- 165' F2 Minute Standin, Time* 3-403.11(C) Commercialiv Processed RTE Food - 140°F* 3-103.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 7(YF Within 2 Flours and From 70'F to 41'F/45'F Within 4 Hours. * ' 3-501.14(13) Cooling PHFs Made From Ambient Temperature Ingredients to 41'17145°F Within 4 Hours* =Denotes critical item in rho federal 1999 Food Code or 105 CMR 590900. 19 20 3-5o1.I4(C) PHFs Received at 'temperatures According to law Cooled to 4I'F/45'F Within 4 Hours. 3-501.15 Cooliae 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 4F'/45° F* 3-501.16(A) Hot PHFs Maintained at or above 140"p * 3-501.16(A) Roasts Held at or above 130°F. 2fi Time as a Public Health Control I 3-501-19 Time as a Public Health Control" 5,)o O( (H) Variance Re ulrennent REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.1 I(A) Unpasleurized Pre-packaged Juices and Bevenc!es with Warnme I,.abels* 23. 3-801..11(,B) Use of PasteurizedEegs* 24. -- 3-801,111 (D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. - 3-801.11(C) 'Ono. cued Food Paeka >e Not Re -served. "` CONSUMER ADVISORY 22 " 3-603.1 t Consumer Advisory Posted for Consumption of 23. _ Mona ement and Pe_rsonn_e_l Animal Foods That are Raw, Undoreooked or 24. -- Food and Food Protection Not Otherwise Processed to Eliminate ------ Equipment and Utensils 11 thonens.* Fo,,",.1'"sum 2fi 3-302.13 Pasteurized Eggs Subsutute for Raw Shell 27. Physical Facility,__ E s" Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations .should be debited under the appropriate sections above if related to foodborne illness interventions and tisk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. Uterus 23-30) Critical and non-critical violations, which do not relate to the ,foodborne illness interventions and risk. factors listed above. can be ,found in the following sections of the Food Code and 105 CMR 590.000. Item Good Retail Practices FC 590.000 23. _ Mona ement and Pe_rsonn_e_l FC - 2 .003 24. -- Food and Food Protection FC -3 .004 ------ Equipment and Utensils -- FC - 4 �_ .005 2fi _ Water, Plumbin and Waste _ FC -5 .1 .006_ 27. Physical Facility,__ FC -6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29_ S ectal R uirements .009 30. Other ssmra�ko-rz.ua� T DOCKET NO.CITATION NO. CITY OF SALEMeD �f A ^� 10 VIOLATION NOTICE r NIME (LAST, FIRST, INITIAL) STREETADDRESS CITY/TOWN STATE ZIP LICENSE NO. LIC. EXP. DATE DATE OF BIRTH OWNER'S NAME (LAST, FIRST, INITIAL) ir! Glu Z' STREETADDRESS CITY/TOWN STATE ZIP '� 9 /(/h'of..j4hm gwo o/g9'd REGISTRATION NO. STATE EXP. DATE I MAKETPE YEAR COLOR DATE OF VIOLATION TIME ❑ AM DATE CITATION WRITTEN I RER�NAL INJURY `, opm - / OYES EINO LOCATION OF VIOLATION 4&A1)&13" /J_ � ENFOR�NO DEPT. .� l/�1 G1 (P a ode OFFENSE CHAP. SECT. FINES A i ,Alr 7a o,_m5M1Al B Y Wire. 7- C %%) / OFFICER OFFICER I.D. NO. TOTALFINE �l�V�•-- DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ,/]/ �}�/J -�^� ❑ IN HAND X �%,%J /f'�zk';�j!zty ❑ 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 0 rI 1 O ED O ti Er Ell m -COURT DOCKETNO. CITATION N CITY OF SALEM _ VIOLATION NOTICE PD 10 ' NAME (LAS//T, FIRST, INITIAL) - G�4/Y� 1 ' STREETADDRESS CITY/TOWN STATE ZIP 4& 4 - LICENSE . EXP. DATE DATE OF BIRTH OWNER'S E NI 11111) QLi S STREETADDRESS CITV/IOWN STATE ZIP g .�o,e min f 1a�rn D d REGISTRATION NO. -VIOLATION STATE EXP. DATE MAKEITYPE YEAR COLOF DATE OF TIME DATE CITATION WRITTEN PERS ❑ O41 ❑ YES -LOCATION -OFVIOLATION NO [///)/ E OR;P ��PI� OFFENSE CHAP. SECT. FINES A j'a 08 Al B o?Oof� A C m 7- V)WOFFICER LD. NO. TOTAL' _ ��� du ��i(S DUE i UrrlctH CtH I IFILS COPY GIVEN TO VIOLATOR X �i A''L r' /� I ❑ IN HANC ❑ 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 'AYMENT IN THE AMOUNT OF $- CASE # SEE OTHER SIDE FOR FURTHER INFORMATION LOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL 0028 Norman Street Telephone: 745-1225 Owner: Ali S. HamzaAbderrahim Be j PIC: abderrahim benlantmania Inspector: John Gehan Date Inspected: Correct By: 10/24/2006 Risk Level: Permit Number: BHP -2006-0283 Status: Open # of Critical Violations: 2 Time IN: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation PROTECTION FROM CONTAMINATION Handwash Facilities FAIL Comment: Employee restroom requires paper towel dispenser. Provide wall hung dispenser. --Ereployee restroom missing "employee's must wash hands'sign. Provide sign. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 White Hen Pantry Critical Urgency RED GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 23,2006 ) Page I of µ7o hv w(l 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 (Ftev. vcc za,zuuo ) rage z ui i Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions omment: White hussman freezer holding at 7°F. Freezer to be holding at 0°F or below as mandated. and Risk Factors (Require immediate corrective action) ror t deli case reading at 52°F at time of inspection. Three different salads were checked and read between 48°-49°F. Salads were discarded at time of inspection. Unopened products moved to refrigeration unit holding at 41°F. Maintenance person on location working on unit. r� ontinental Unit being repair on at time of inspection to maintain temperature of 41°F or below. eatballs temperatire holding at 131°F. Meatball discarded at time of inspection. Hot foods to be holding above 140°F. ,,Akeaft slicer has accumulation of food debris or splatter. Thoroughly clean and sanitize meat slicer. sonal jacket stored on top of produce refrigeration unit. All personal items to be stored in designated employee areas. Equipment and Utensils .. FAIL BLUE V omme t: Produce sink requires "Produce only" sign. Provide sign. ' fte osley freezer requires general cleaning. -*1lhh to Hussman freezer missing thermometer. Provide visible and accurate thermometer. ,.!same unit requires general cleaning. — Same unit door gasket in disrepair. Gasket on order. .Walk in unit requires general cleaning of walls and ceiling. Spills and splatter observed. ,tdfrbo fan oven requires thorough cleaning. ` LGi1ffmg board in front stained and scored. Resurface or replace cutting board. --- Sanitizing log not on hand at time of inspection. Log to be on hand and kept daily. Physical Facility FAIL BLUE Comment: Dry storage area has accumulation of spills and splatter. Walls and floor require thorough cleaning. GENERAL COMMENTS: New owner to fax over copy of extermination report to BOH. Same pest control company staying with White Hen. µ7o hv w(l 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 (Ftev. vcc za,zuuo ) rage z ui i 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. Oct 23,2006 ) Page 3 of i"A"" irComuiouwealthofMassachusetts a' City of Salem { s r Board of Health 120 Washington Street IQmberiey Driscoll 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 10/23/2006 ESTABLISHMENT NAME: File Number: BHF -2064-000365 White Hen Pantry 28 Norman Street Salem MA 01970. LOCATED AT: 0028 NORMAN STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2006-0655 Oct 23, 2006 Dec, 31, 2006 $100.00 TOBACCO VENDOR BHP -2006-0656 . Oct 23, 2006 Dec 31, 2006 $50.00 Total Fees: $150.00 PERMIT EXPIRES Decernber 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1 � s ��➢rlB Kimberley Driscoll Mayor CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT ,9�jni�d y/t5/Q C'c,zj'oe�Tirr� i-d'3d6-7 NAME OF ESTABLISHMENT .�ie7� v/i✓ rc rE v T�� �j�y TEL # ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different)i�z E or OWNER'S NAME 269 /7 TEL# 9V-636 --Iles-6 r -- CITY CERTIFIED F STATE A�119 ZIP (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOURS OF OPERATION: Mon.C7y/z TYPE OF ESTABLISHME RETAIL STORE ES NO RESTAURANT YES NO --------VIES ------ -------------- BED/BREAKFAST YES NO FICATE#(s) 3�ava'A TEL# 4715-S36-Vd.56 P-Sat.ay ,e_ Sun.a� A2A2 FEE (check only) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. more than 10,000sq.ft. _ 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 ( 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 a pter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge a gbl i ave filed all -state tax returns and paid all state taxes required under the law. X o i o - 5107 Signatur ate Social Security o Federal Identification Nu b ------------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check# & Date /0-/1-06 �tIII �//V0. A&e,8456 Ff)r t�lo�ccd �vG + w, f Massachusettsb6partment of Public Health Division of Food and Drugs. i FOOD ESTABLISHMENT INSPECTION REPORT,Ij a Salem Board of Health 126 Washingtofi'Street O Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name ' { t � I /( n ��1 t�►t i l _` I Y D t 4 Type of Operation(s) Type of Inspection Food Service Retail ❑ Routine R_Re-inspection Address Ris J (a/) Level Residential Kitchen ❑ Mobile > Previous Inspection Date: Telephone �r �,�( ❑ Temporary ❑ Pre-operation Owner � Y J U HACCP YM ❑ Caterer ❑ Suspect Illness ❑ Bed & Breakfast ❑ General Complaint t Time Person in Charg (PIC) In ). (J Out: \ Permit No. El HACCP ❑Other Inspector Each violation checked requires an explanation on the narranve page(s) ana a cnanon of specinc provrsrontsl vwra}a i r I 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. ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans i 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. C11 N1 23. Management and Personnel'' (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.067) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other 5: S901nspecfFomi614Oac ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control t -REQUIREMENTS FOR kIGHLY SUSCEPTIBLE POPULATIONS'(HSP)`:j ❑ 21. Food and Food Preparation for HSP CONSUMERADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection', today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. ' DATE OF RE -INSPECTION: k A- n _ J 4,,-/ Inspector's Signature: l /L,//f runt:. / p PIC's Signature: `- Prmt. / / a h cn ,4 1 S S Page of-]�ages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT _ 1 590.003(A) Assig mment of Responsibility* 590.003(8) D_emanstration of Knowled e" 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590,N)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 Milk Products* applicants* Shell Eggs* _ 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge" 3 590.003(D) Exclusions and Restrictions* 3-201.15 590,003(E) Removal of Exclusions and Restr coons 4 1® in C FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 FaoA 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 Food in a Hermetically Scaled Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.1.4 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-1.01..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 Shefltish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* - Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 - PHFs Received at Pro er Temperatures* 3-202.1.5 Package Integrity" 3-101.11 Foal 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(J) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of ui ment* Conformance with Approved Procedures /HACCP Plans - 3-502.11. Specialized Processing Methods* 3-502.1.2 Reduced oxygen packagung, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 FaoA Code or 105 CMR 590.000, PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.1 I (A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foals Separated from Each Other* Contamination from the Fnvironment 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)(9) 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 Teti eratrues* 4-501.112 Mechanical Warewashing- I -lot Water Sanitization Temperatures* 4-50 t.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601..11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of ui ment* 4-703.11 Methods of Sanitization- IiotWaterand 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* Ii Good Hygienic Practices 2-401.11 Eating, Drinldn or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-30112 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently located and Accessible 5-20 Al 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 Handwashi ng Cleanser, Availability 6-301.12 Hand Drying Provision 0 CITY OF SALEM BOARD OF HEALTH % / Ll., . Date: �%i f f Lf i (I % Page: 7 of Item TCcde No. Reference C-Cdticai nem R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION ' i PLEASE PRINT CLEARLY Dere i , Verlfled , I')c dVDI t.1 na A l-., 1 o 1 `I rI ✓ n- L, / t I ,T i y f 1 on With Person in Charge: ad this report, have had the o ortunit to ask uestions and a ree to correct all Fhavey q 9 s before the next inspection, to observe all conditions as described, and to 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 Restrictionpp Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Itents 1-22) (Cont) PROTECTION FROM CHEMICALS F-14 G(tronmiklit:t1l Vi�hI Meu:s GIMIC Food or Color Additives 23-- - 3-202,12 Addvrvcs`* s a711 i1 a) 3-302.14 Protection front Unapproved Additives* Is .3, 40IAI(AlCt) Poisonous or Toxic Substances 19 MI'll Itlentifyinglilfonnation -0riginal Poultr1kat ,� x102,11 Corr"1011 N;tenC -- WOrko)" ('001Mn-Irl- klowle swndill� 7 1 ir ---- --- - ---------- ---- 3-501 16(A) 3 -501,16(A) ]-lot PHFq -Maintained at or above ----- -- [C) 7.202.12 Condoiow, of Use* 7203 =5 , N4.11 Prolu-N!,ouslf Saniti7ers, Criterio - ChemiciiNt 40 T' 7- 2041 12 Cheillicals for odltcc(litelia 1--, 7104 Criteria' I '1505 f-ontacl. lAlblicallis, I 7-2)6.Ll soid Ltsv Peficitie,-- Cntemi` . �7-206.12 -306.1 Rodclil l3 Station", '1 tackmg PoetllvrConnol and INIoniiotim, 16 F,%:, - 151* i 5 S,;.. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS I(HSP) 2t Si)1 1121) imp iqteurriycd Pre-packaged Juices and Rev, fattes with Waring lah,.isz (13) Us„, 0 Pasteur rd Eg� t -mo III I ao it: i,z,)r Paiiiaij,, C-,okd Ani nal Food and kIrl"pCiled FXld packacc Not W,-scrvcd, 21' 3-60-', 11 Ad*itoit ilociclj JolI Colliquiption of \c.t kill rt is PrUcessd to Eliminate. I” qtezll)/cd4 F,gg; silaortic for Raw Shell 59,) Of 19f A -(D) Vita jjof 3i(D)in inobilo toodwriptrait 'aiid rc!,lklontl kitchen opctditaos <b(tol(j he dchdtd undei the approptiatie(uolls to iot)(Plorn'. i!!ncS--. OtNr ix� (Ich;le,4 �,,wr �icl ViOLATIONS PCLA TEL) 0 GOOD RETA)l (ltenis 23-30) ai ai;I'leon, rifizai i 1, M ; which donw !m1n, i`P1( loutfln rfl, illih,st 1;1;,,i I (Wt W WlIf liA Jot tors li+wd rwr, om lw p,and iul tit, uW,)Ijw, G(tronmiklit:t1l Vi�hI Meu:s GIMIC PfIFl, Received at Temperatures 23-- - ;-401.1103)( 1)(12 1 'rib and HI-ef kwq I I mil) s a711 i1 a) R. -i 1-11 C T,- -1-1 1 -i -le (-4 M, el I, I,oi T 1 - --------- 11`t I 4 - .3, 40IAI(AlCt) Polito-, Wild an Sm'itdPHfs, 19 1 'Nafer, in.5,F 15 swc, Poultr1kat ,� 1-501.16(B) Cold PHN Maintained at or below e low590,004F) klowle swndill� rl ir ---- --- - ---------- ---- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS I(HSP) 2t Si)1 1121) imp iqteurriycd Pre-packaged Juices and Rev, fattes with Waring lah,.isz (13) Us„, 0 Pasteur rd Eg� t -mo III I ao it: i,z,)r Paiiiaij,, C-,okd Ani nal Food and kIrl"pCiled FXld packacc Not W,-scrvcd, 21' 3-60-', 11 Ad*itoit ilociclj JolI Colliquiption of \c.t kill rt is PrUcessd to Eliminate. I” qtezll)/cd4 F,gg; silaortic for Raw Shell 59,) Of 19f A -(D) Vita jjof 3i(D)in inobilo toodwriptrait 'aiid rc!,lklontl kitchen opctditaos <b(tol(j he dchdtd undei the approptiatie(uolls to iot)(Plorn'. i!!ncS--. OtNr ix� (Ich;le,4 �,,wr �icl ViOLATIONS PCLA TEL) 0 GOOD RETA)l (ltenis 23-30) ai ai;I'leon, rifizai i 1, M ; which donw !m1n, i`P1( loutfln rfl, illih,st 1;1;,,i I (Wt W WlIf liA Jot tors li+wd rwr, om lw p,and iul tit, uW,)Ijw, 1501.14(C) PfIFl, Received at Temperatures 23-- - ------------ 1 klan Indpqcont-el . agl�i According According to Law Cooled 10 24. - Fov and F-oiill Prorttion - --------- 11`t I 4 - — - - - -- --------- I Reheating for Hot Holding Conlin.• Mcthods For -H-F-- 19 1 'Nafer, in.5,F 15 swc, o 1-501.16(B) Cold PHN Maintained at or below e low590,004F) klowle swndill� 590,004F) ir 3-501 16(A) 3 -501,16(A) ]-lot PHFq -Maintained at or above ----- -- [C) Otlitr -------- ---- ('0111loel t, I a IN, Pi 0, !111 F hieXi I RTE— Bd " p� fieldc�, at or above 130,"F. J 40 T' 3-403. IF) Replawilk,", UnFlit-ed PortivttI; ol- H(Ici frimi, as a Public, Health ControV 90`)W(H) - - ------------- - Proper Cooling of PHFs 3 501 ilA) -Fool i it f--, C<xktld PH F5 Gum 11W I o 7(1` Wit It i n 2 kiwis toi d From *r!) 1 w 4 11-14 5 F Wi till it 11 11; at i CoAlito, PI-IFt: M:ldv Flom Ambient Ternporaoire In credicni, t(I 41"I 1,15,F Within -4 tlot[10 — I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS I(HSP) 2t Si)1 1121) imp iqteurriycd Pre-packaged Juices and Rev, fattes with Waring lah,.isz (13) Us„, 0 Pasteur rd Eg� t -mo III I ao it: i,z,)r Paiiiaij,, C-,okd Ani nal Food and kIrl"pCiled FXld packacc Not W,-scrvcd, 21' 3-60-', 11 Ad*itoit ilociclj JolI Colliquiption of \c.t kill rt is PrUcessd to Eliminate. I” qtezll)/cd4 F,gg; silaortic for Raw Shell 59,) Of 19f A -(D) Vita jjof 3i(D)in inobilo toodwriptrait 'aiid rc!,lklontl kitchen opctditaos <b(tol(j he dchdtd undei the approptiatie(uolls to iot)(Plorn'. i!!ncS--. OtNr ix� (Ich;le,4 �,,wr �icl ViOLATIONS PCLA TEL) 0 GOOD RETA)l (ltenis 23-30) ai ai;I'leon, rifizai i 1, M ; which donw !m1n, i`P1( loutfln rfl, illih,st 1;1;,,i I (Wt W WlIf liA Jot tors li+wd rwr, om lw p,and iul tit, uW,)Ijw, 1501.14(C) PfIFl, Received at Temperatures 23-- - ------------ 1 klan Indpqcont-el . agl�i According According to Law Cooled 10 24. - Fov and F-oiill Prorttion 41"F/45"F Within 4 Hoinpt, 1-50L15 Conlin.• Mcthods For -H-F-- 19 1 'Nafer, PHF Hot and Cold Holding o 1-501.16(B) Cold PHN Maintained at or below e low590,004F) 28 590,004F) 41V,15° F- 3-501 16(A) 3 -501,16(A) ]-lot PHFq -Maintained at or above 30 Otlitr -------- ---- 140'F I RTE— Bd " p� fieldc�, at or above 130,"F. J 211 I Time as a Public Health Control 3-50i I'll frimi, as a Public, Health ControV 90`)W(H) - - ------------- - V�1rianceReaturclocoll ___j REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS I(HSP) 2t Si)1 1121) imp iqteurriycd Pre-packaged Juices and Rev, fattes with Waring lah,.isz (13) Us„, 0 Pasteur rd Eg� t -mo III I ao it: i,z,)r Paiiiaij,, C-,okd Ani nal Food and kIrl"pCiled FXld packacc Not W,-scrvcd, 21' 3-60-', 11 Ad*itoit ilociclj JolI Colliquiption of \c.t kill rt is PrUcessd to Eliminate. I” qtezll)/cd4 F,gg; silaortic for Raw Shell 59,) Of 19f A -(D) Vita jjof 3i(D)in inobilo toodwriptrait 'aiid rc!,lklontl kitchen opctditaos <b(tol(j he dchdtd undei the approptiatie(uolls to iot)(Plorn'. i!!ncS--. OtNr ix� (Ich;le,4 �,,wr �icl ViOLATIONS PCLA TEL) 0 GOOD RETA)l (ltenis 23-30) ai ai;I'leon, rifizai i 1, M ; which donw !m1n, i`P1( loutfln rfl, illih,st 1;1;,,i I (Wt W WlIf liA Jot tors li+wd rwr, om lw p,and iul tit, uW,)Ijw, ME 23-- - ------------ 1 klan Indpqcont-el . agl�i f�U 24. - Fov and F-oiill Prorttion --. I -- FC, 26, 1 'Nafer, —; fW- o N ... F., 11t, 28 0o, T,xv Ntt)reas 1 FC, 30 Otlitr -------- ---- ME Massachusetts Department of Public Health ; Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT4 Salem Board of Health 120 Washington'Sfreet, 4'" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 NameD� Print: Q �A / j Lrl Type of Operations) Type of Inspection ❑ Food Service X Retail ❑ Residential Kitchen EI Mobile F-1TemporaryElPre-operation ❑ Caterer ❑ Bed & Breakfast Permit No. ❑ Routine J�kRe-inspection Previous Inspection Date: C? 41U ' ❑ Suspect Illness ❑ General Complaint [I HACCP ❑ Other Address ^ I G d Risk Level Telephone ,. '_ Owner f _ fU / J >J� HACCP YIN Person in Charge PIC) Time In:�� 1 Orffi' (� Inspector Each violation checked requires an explanation on the narrative p'age(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION ❑ 1. PIC Assigned / Knowledgeable / Duties 'EMPLOYEE HEALTH__"`_' ❑ 2» Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FROM APPROVED SO4RCE"Y­ :-FOOD . 3... ❑ 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�a --4 ❑ 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. Y 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) 7. Physical Facility (FC -6)(590.007)' 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S. 5001ns &For 14. da ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities "PROTECTION FROM ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals "TIMErTEMPERATURE CONTROLS (Potentially Ha ardous Foods)'�'�.`; T❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control t„REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP);w ❑ 21. Food and Food Preparation for HSP 9CONSUMER 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: NJ5 s�- '"1 Inspector's Signature: r Print: PIC's Signature: - Print: > Kt r U (-1 0 1 C Page_iof-iPages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility' 590.003(8) Demonstration of Knowledge* 2-103.11. Person in charge - duties EMPLOYEE HEALTH 2 590.003(0) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs" 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In I Drinking Water from an A roved System's 590.006(A) Charge* 590.006(]3) 590.003(13) Reporting by Person in Charge` 3 1 590.0030 Exclusions and Restrictions* 3-201.19 590.003(F) Removal of Exclusions and Restrictions 4 C is FOOD FROM APPROVED SOURCE * Denotes coined item in the rederal 1999 rood Code or 105 CMR 590.0(1(1. PROTECTION FROM CONTAMINATION S Food and Water From Regulated Sources 590.004(A-8) Compliance with Food Law* 3-201.12 Food in a Hermetically Scaled Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs" 3-202.14 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-1.01.1.1 I Drinking Water from an A roved System's 590.006(A) Bottled Drinking Water* 590.006(]3) Water Meets Standards in 310 CMR 22.0* Washin Fruits and Ve.etables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.19 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regula toAuthorit 3-202.18 Shellstock IdentificationPresem* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.1.1. PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(7) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with App, .... Procedures* * Denotes coined item in the rederal 1999 rood Code or 105 CMR 590.0(1(1. PROTECTION FROM CONTAMINATION S Cross -contamination 3-30111(A)(1,) Raw Animal Foods Separated from Cooked and RTE Folds* Contamination from Raw ingredients 3-302.11(A)(2) Raw Amaral Foods Separated from Each Other, Contamination from the Environment 3-302.1 1(A) Foal Protection - rotection*3-302.15 3 -302. 15 Washin Fruits and Ve.etables 3 -304 -TT 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 4.5o1. i 11 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-70211, Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sauitization- HotWaterand Chemical* 10 Proper, Adequate Handwashing 2-301.11. Clean Condition - Hands and Anes* 2-301_1.2 Cleaning Procedure* 2-301.14 When to Wash" 1.1 Good Hygienic Practices 2-401..11 Eating, Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventm 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* 5-204.11 location and Placement* 5-205.t1 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.1.2 Hand Drvin Provision Establishment Name: CITY OF SALEM BOARD OF HEALTH 1/l/I /?4Date: G/� Page: of Rem No. coa Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION/ P AN`OF ICORRECTION - / PLEA—SE—PRINT CLEARLY Date Verified ^� j 1 /• I C (e&%I .S rtl2 ')� %`41%i (\ ( r / 9 G l /C P� �. /� , c . T iJ e n lq7 h r. 'f -j rn dv'�P s sI- 1 - -1, 542r¢ 2f, 5 C� n I fJ A/ ct�•n r sF L P 'rte , n f r cQ n AcH 4 5,D), (I r cr/acic2 r,J 5Oc+2 �- a Sal. 0 r us -e , i. Le 19::)A)�-41 ro r U l - 5 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 R014W to Foodborne Illness Interventions and Risk Factors (Items 1-22) (Cont.) I PROTECTION FROM CHEMICALS 14 -- Food or Color Additives Cotlaimmied Fil%h, til-ats a (IJ1114: �202 12 -T, Otvc, —* —15Poisonous 3-302,1.4 Protection from Unappi-wed Addili,,,* F, -q I-! I or Toxic Substances 101.11 IdentifyingInfu-imaiion -Original 3501.16(B) Contaiiiers, 7 110211 'latimouNanic 1-501, 16i A) . '202.1.1 1)2 1 1 Pct n Cum) - Pl."Sence and (;,c* 2 of L10 ^03.1I Toxic Cont awes -- Prollibi!w1l"I Relleatinq for Hot I icloing saniziltets, Crileri;l - chelnic�dti 2C 7 �1- �e4 2( -,fitelial -Ll------.--- s[.1ndill" 704.14 1 P- Di CrIkeria � 1 56-5-11 T_ o, lnci&ntal FiN)d C.ntllct. lab icarll Conlfncjcwlk RIF hi,�d Ii 3-401. 11(L) 7- 2'.06.12 scltilal�- r."061.1 'hickim, Pn%dcrz, Ctlwio! and I6 I Proper Cooking Temperatures PHFs 155'1 15 Scl�. I Proper Cooling of PHFs 3 501 14(A) Imm I401711t 7(j'I (1) 4 i 7/45 F Within 4 Howl,- 501.14(11) Cl ofing PHRI Madc From Ambient Temperature ltiercdicwto 41�H45tl' Vb ithin 4 `P::n cl it F 4•; i l Fw;l "r iris [ml`i )I l l It tf) F() I J 4(c) 1 ;61.11.( {) Cotlaimmied Fil%h, til-ats a (IJ1114: According to Lau Cooled to -401.1 ! Fs)f 1 2) : R,i Y f I VI ' I atm 7 i I Poi and oiz - -(�A—) —27 F, -q I-! I inieiwliA Mklits 151i F 1� Hot and Cold Holding 3501.16(B) floulti'l,, 1N ild 14111le, $,Ufrc( sli:f1mg Oei(AillinFiiht Meat, 41"A5o F' 1-501, 16i A) hlLKT 149'1 * 3-S0 I I 61,A) Roasts Bold at or above 130°F, L10 PH, ic — Time as a Public Health Control Relleatinq for Hot I icloing 165'F s[.1ndill" It 403.1 J(C) Conlfncjcwlk RIF hi,�d Ii 3-401. 11(L) l2r ma ring Unshtle(l Pitrul,, oI7 j,,7 I Proper Cooling of PHFs 3 501 14(A) Imm I401711t 7(j'I (1) 4 i 7/45 F Within 4 Howl,- 501.14(11) Cl ofing PHRI Madc From Ambient Temperature ltiercdicwto 41�H45tl' Vb ithin 4 `P::n cl it F 4•; i l Fw;l "r iris [ml`i )I l l It tf) REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSPi F() I J 4(c) PHFs Received at"Femperauns Rcvera ltet,with \k arning Iallcli;" 801,11(Bl According to Lau Cooled to P,lik or Pattillil,, Ook�,d Animal F(xKJ and 4 1 ° F/45'F Within 4 How's. F, -q CM,Methods for PHFs iwPHIF Hot and Cold Holding 3501.16(B) Cold PHFs Maintained at or bel -11w - %590V (XP(F) 41"A5o F' 1-501, 16i A) lint PHF:Mantilined at or above 149'1 * 3-S0 I I 61,A) Roasts Bold at or above 130°F, L10 — Time as a Public Health Control atm_ al; a Public Health Controv REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSPi CONSUMER ADVISORY 22 1 3 -00-'l k i 'ot»uoj(,f v Posed 1;)r Consumption Chat arc Raw. underclx)keklo! Othell%ixltiP.1iminace or Raw Shell SPEML REQUIREMENTS tcttriia 11101141; ktxl� leutporat v and &m:aI !Jtchen opciaticris should be il,!hlled undei the approln laic leoiom rckl K N, joitcd i-tldcr i;', VIOLA TiONS RFLATEr,� 70 GOOD RETAIL PRA C-,fCE--S----i 23-30) Cnit, a; ilm, lion-, nill til J.", lwl relate !" ift" 146,l,s, , q ji "0101il i" caul b,! 11 ill, fill z)%":T Ierlwl,Ll i., Ill C olle. al:d 105 CIM PrepackagedAmcs and Rcvera ltet,with \k arning Iallcli;" 801,11(Bl Utee of Paltem ied F P,lik or Pattillil,, Ook�,d Animal F(xKJ and Raw St kld ',,,I S,",d. I ljr!,lilelled rl-Ki Packaec Not Rr,-scrved, CONSUMER ADVISORY 22 1 3 -00-'l k i 'ot»uoj(,f v Posed 1;)r Consumption Chat arc Raw. underclx)keklo! Othell%ixltiP.1iminace or Raw Shell SPEML REQUIREMENTS tcttriia 11101141; ktxl� leutporat v and &m:aI !Jtchen opciaticris should be il,!hlled undei the approln laic leoiom rckl K N, joitcd i-tldcr i;', VIOLA TiONS RFLATEr,� 70 GOOD RETAIL PRA C-,fCE--S----i 23-30) Cnit, a; ilm, lion-, nill til J.", lwl relate !" ift" 146,l,s, , q ji "0101il i" caul b,! 11 ill, fill z)%":T Ierlwl,Ll i., Ill C olle. al:d 105 CIM . •.'yy;.y+: r* w?'M;niY N'W4 «r. ���.,. ;.jA. Hj.9`u'..rirr+q; i "TMtiTM9y,;. rx Y Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs `, 120 Washington Street, 4t" Floor 9 Salem,)MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT r, . _P Tel. (978)741-1801) Fax (978) 745-0343 Name I I / i J'I P \ Da J' �i Tvoe of Ooeration(s) Type of Inspection - Routine ❑ Re -inspection Previous Inspection Date: E]Pre-operationOwner ❑ Suspect Illness ❑ HGeneral ACCP Complaint ❑ Other ❑Food Service P -Retail [__1 Residential Kitchen ❑ Mobile El Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address Risk Level Telephone � _ ( a - / t� (J r r U r HACCP Y/N Person in Charge (1310. Time O'3 �� Inspector I Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. .. �. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors 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 �`� � ,!,f �_ � 'a � -,, ❑ 12. Prevention of Contamination from Hands ❑ 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, �„�„�. „„� ,,;.;'" aia"_„>. ❑ 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 CONTAMINATKIN'' R"" -"° ' w ❑"„8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing [110. 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. C4 Ni 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: seo�nspecrFam,s-�e.ex 3. Handwash Facilities '' PROTECTION FROM CHEMICALS__1R „» "" Bmf Mv ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMElrEMPERATURE CONTROLS (Potentially Ha ardpus Poods)';;y AF ,,.. ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding [120. Time As a Public Health Control j„REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSPj e ❑ 21. Food and Food Preparation for HSP 9„ CONSUMER, ADVISORY u...... .� , µ .,._. ,;'"S"1#,Z Z ,A [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: fT (r,L� Inspector's Signature: \ Print: JAf a PIC's Signature: / Print: A/O ^ 1� C /f 4_ 44Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of 1{nowledge* 2-1.03.11 1 Person in charge - duties EMPLOYEE HEALTH 2 590.003(,C) Responsibility of the person in charge to Compliance with Food Law* 3-201.1.2 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 - stem*590.006(A) 590.006(A) Charge* 590.006(B) 590.003(01) Reporting by Person in Charge* 3 590.003(D)Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C 6 FOOD FROM APPROVED SOURCE " Denotes critical item in the federal t999 Fond 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 Scaled Container" 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-1.01.1.1 Drinking Water from an Approved System - stem*590.006(A) 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 Roaul3tow Authorit 3-202.18 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Came Animals* 3-701.11 Receiving/Condition 3-202.1.1 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated TagstRecords: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* TagstRecords: Fish Products 3-40111 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(J) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ment* Conformance with Approved Procedures IHACCP Pians 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved proceduresiP " Denotes critical item in the federal t999 Fond Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION 8 Cross -contamination - 3-30111(A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredient 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-30211(A) Food Protection' 3-302.15 Washing Fruits and Vegetables 3-3(4.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) ,Returned Food and Reservice of Food* Disposkion 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 MechanicalWarewashing- HotWater Sanitization Temperatures* 4-501.114 Chenucal Sanitization- temp., pH, - concentration and hardness. * 4-601.1 I (A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment F(aA- Contaet Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ment* 4-70111 Methods of Sanitization -Hot Water and Chemical* 16 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2-401..11 Eating, Drinking or Usin2 Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-30112 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) - Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying. Devices 6-301.11 Handwashin Cleanser, Availabilit 6-301.1.2 Hand Drying Provision I L '+' C1 FY OF SALEM BOARDOF HEALTH *"V �' nate: Paqe--_ar_ of item Code F ­,,V C -.Critical R Item DESCRIPTION OF VIOLATION /PLAN 0 F CORRECTION U -'�4 Date Verified No. Reference -Red ve PLEASE PRINT CLEARLY U�)P-A�h rin&4m r),- CK �v,_, -n,o J c4 I Ir �J te- !. Icu L JI 3060 i3 I dk� , ir P r2 AL C �er, A M /�r,& r, /)6 h—A C' 0 C.�'G:5nc' Cj'e__b )r_Mj F/?—& a 0-1 -Al G r �ti C "'0' T7 SDZ-\ Lnc lcq( Corrective ActionRequired: 0 No Yes Discussion With Person in o Voluntary Compliance U Employee Restriction I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to 4� <e -inspection Scheduled U 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 C3 Embargo .,Lj Emergency Closure Y*o Voluntary Disposal U Other: aFf6od permit. I Vlobtionst Related to Foodborne Will Interventions and Risk Factors (items 1-22) (Cont) 1=4 —Food or Color —Ad d 1 t —iv a —s 3-2(2.12 Adclqivcs* 3-302.14 Protection fiont!tJndditivcs" 7 101.11 PWf-Sonoosor Toxic Substances Identifying, Infolinalion - Otl�,Jnal contaillem, -- 7102.11�Relatict.c.n--Pr_u.nccaudIlse* 7-20111 11P,�Cauon 7-20111 C21111112h"N'arne Storale, 7-202.12 Conditions, of Us'o* 7-203,11 Toxic Containtat, - Prohibitions* 7-204. 1f— -9,7nhims, G7neria - Chemict,is* 1 7-204.12 7 -?r04.14 Chemicals for lVaNhulin, flioshIce, Cnce-rT,—,� Critrria" 7-205, 11IncidentalI'llod Contact. lrdmicants'' 7 'F-'- -206A -- Restriefed [ice Pencide&. Criteria* 7,206.12 Rodent Can sta(IOTIS` ?,206,5 'frtali7in svdsrs Jpela COntrol and Mon i I or i ri�,, FuTrum f 51Trffff:7,V1Fr.TxW#1,TFf79u I Delwtesniueal Item in the r4"ileral V)99 Toad ClAle": 105 C4ti2 59()Gflr 1 , I 4(C) PHFs Received at Temperatures According to Iain Cooled to .11 ^P/s�P Wift,;n A W,-.. * 3-501,15Cu5ha, Methods for PHFs 55' Hot and Cold "ding 3-50I AUB) Cold PHFs Maintained at or below 540-(x)4(F) I i`145` F- 3 1. l6,,.-vF ;It or above Roasts Held at or above 130'F. Time as a Public Health Control Tialo as a Public fhadda Control, Variance Reonirenrent REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATION 2j-7 3-801.1 I (A) I Untia,acurixcd Pre-packaged Juices and Rass Seed SEotas N,;, Sej vcd, 3-801A](Ci 1 Unorfined KilldPackaec Not Re -served. _CONSUMER ADVISORY 2" 3-60:-7-1-1 Foasunaer Aids ilsoi y Posted fir Comae nation of Animal Fixids That an. Paw, UndeTccoked (a Not Other wole Pr(Antiled o Eliminate 4-302.13 1 Paste iwized Egg, Substitute firit Raw SPECIAL REQUIREMENTS 9400 9t A) -(D) Viofeti aos of Sc ctc)n 590.009(A) -(D) in utteriog. mobile-folid, temporary and residential kitchen operations should he dclatco under the appropriate sections tons alIcive if 1.011)(cd to ftXxIbortic Illness Intel Veolixl. and risk Factors, 00)ff 590.009 victiation,; relating to gored retail prac.fice.s iihould he debited under #29 - (Iters 23-30) Ciinoal and rion, i*tral wifith do not relate m the fitoditurne Miles? iniel Vertilm and m(jm iiars Ioled above, tan br finind ir, nto"I fi)lhatiagcet,;;ms 0 the Food Cade wid 105 (,.,VR Proper Cooking Temperatures for PHFs 3 -401 AL 1 A(l)(2) _lagt!T!��diate Fggs - 155'F Is Sic. Sctvnc,: 145�T]5sec- Comminuted Fish, Meat & Game I I (R)(I)(2) Animals - j _j' .1"F I5 s Pork and RVCf Roast L 131f J-' 121 rain' 1-401.11(A)Q) Raines, loicced MIvan, - 155 F-15 3' ti I 11, Aj7�,, Poultry, Wild Game, Staffed ill iFs, Striffintr0oat anari1-10, Mut, Pu65 15 sec, 3-401,11IC)(3) , NVIeje_njrh "de, Intact beef 'StCaks, 145,11; 3:ZE-12 Raw Ajiirn]tal 1:",vIsls C olkcd III a %4 1 ct owa" 16,5 'T * T46-1-1 I (A?( I l(b) All Other P11B -- 14T F 15 sec 153.1 Reheating for Hot Holding 165'F 15 WG. 3-403,11(1 %4jcro,7 'Sta ndin av, on, 7,r lcnut, i; Tave, 103.1 l(c) Guraiterr, ial ly Processed R'T'E J'eWld 14()L'F T�(—)3.1I w) Remain on,"Unsliced Portions of ficef R klas t olling of PHFs 3-501,14(A) 0Klli(IgCooked PHFs fame 1d(J`P to 70°F Within 2 Hours and From '10vi' -5 0.14(B) to 41`T/45°F Within 4 Houns, s Carling PHFs Made From Ambient Tempmrarre lngredienr5 n,4l"F'/45'F Within 4 tloor� I Delwtesniueal Item in the r4"ileral V)99 Toad ClAle": 105 C4ti2 59()Gflr 1 , I 4(C) PHFs Received at Temperatures According to Iain Cooled to .11 ^P/s�P Wift,;n A W,-.. * 3-501,15Cu5ha, Methods for PHFs 55' Hot and Cold "ding 3-50I AUB) Cold PHFs Maintained at or below 540-(x)4(F) I i`145` F- 3 1. l6,,.-vF ;It or above Roasts Held at or above 130'F. Time as a Public Health Control Tialo as a Public fhadda Control, Variance Reonirenrent REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATION 2j-7 3-801.1 I (A) I Untia,acurixcd Pre-packaged Juices and Rass Seed SEotas N,;, Sej vcd, 3-801A](Ci 1 Unorfined KilldPackaec Not Re -served. _CONSUMER ADVISORY 2" 3-60:-7-1-1 Foasunaer Aids ilsoi y Posted fir Comae nation of Animal Fixids That an. Paw, UndeTccoked (a Not Other wole Pr(Antiled o Eliminate 4-302.13 1 Paste iwized Egg, Substitute firit Raw SPECIAL REQUIREMENTS 9400 9t A) -(D) Viofeti aos of Sc ctc)n 590.009(A) -(D) in utteriog. mobile-folid, temporary and residential kitchen operations should he dclatco under the appropriate sections tons alIcive if 1.011)(cd to ftXxIbortic Illness Intel Veolixl. and risk Factors, 00)ff 590.009 victiation,; relating to gored retail prac.fice.s iihould he debited under #29 - (Iters 23-30) Ciinoal and rion, i*tral wifith do not relate m the fitoditurne Miles? iniel Vertilm and m(jm iiars Ioled above, tan br finind ir, nto"I fi)lhatiagcet,;;ms 0 the Food Cade wid 105 (,.,VR s CITY OF SALEM BOARD OF HEALTH Establishment Name: Prn i�� Date: .d�n` Page: 3 of nem Code C — Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - - .Date..... No. Reference R — Red Item ! ^ -� PLEASE PRI/NT CLEARLY ' Verified T �l �yy (' YILtG _r r` �- W � t•^Xn �P�.w r+l \ - jjLN o V 1 . - -- - - I A ff n A n -r r n I, ; r / - J rl .I li v + 4 S I v-�' , AV j 'L, -Al r . il��d111 )i I 1, cn. L /Az r a7 I� ..n,� trt �11 af.i �s }trti n^it ,,j 1 t i 1 i 1 it UQ _ 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 / Exclusion violations before the next inspection, to observe all conditions as described, and to e -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: I Violations Related to Foodborne Illness Interventions and Risk Factors (Itehts 1.22) (Cont) PROTECTION FROM CHEMICALS 14 _ Food or Color Additives t ,.4,r'•Lllr : ?j .1202.12 _'("uvCa* _ — i T302.14 Protection from linapp'ro• ed Addttwes* 15 1(11.11kI Poisonous or Toxic Substances ��JJ lentiyinglnto:mannn On mal 590.004(F) 41`/45°F' - lint PHF � tfai coned it or above 7 _ Contamen _ ? 5: 1 1A(1) 102.11Common 2(T[ IT Naw K Orkin- ti ,nr tin r, S jt r: mt n 5112 c �)'JO?.11�tsi 7-202,11 Rs'tncl lon - Pr a Me ud i_ e �_ 9U nr}3n-il I 7-202.12 C`smdnu?n�ofttsa' , 9'.:)_i. [ 1 _ T7,xtc f fsn doer P 0h76ii irk I 7-^204.11 �—{-Saran eu Crneu Circnic s r -04.12 f lhinu dtitxthr�hu, C:rL.ra '1'04 14 17 ems, Aia[M, ( rn ri n ,5.11 n to ill sl I rx.l t onl 1, t l t awl . 06�i i 1ae Pr hr,..e . C:ufe i Y j ; -06.12 Rw 1 l B'I't Prnrde ' :.un, -, and j ;ii' i i Proper Ceaiaag Tempr.aftaes #�;01..ltA,Ch 1 E r_;iun,tf`c'r t Slee: 4Ciaatt: 9niuiaks - I i5 1' i(1)?) 3 ',t r. I),�t-1. J _ _ _.- ...__j t ,.4,r'•Lllr : ?j ? Wild (us.Stu.f f)�(s. } Jn F i 3403, 11(F) I Rc nt.tunrr Ltsl rcd P;.mon rlirc'F PHF Hot and bold Holding }}1 Cold PHF s Maintained at or below 590.004(F) 41`/45°F' Proper Cooling of PHFs lint PHF � tfai coned it or above , �Ca.Bog C<wl•d PFiI'� jinn) l,ul'`Fto ? 5: 1 1A(1) I Roasts Held a[ or above 130'F. 711 F Within 7 I lour. nein From 79Fi° �)'JO?.11�tsi �SQnamcaic-It7I_�S�L:n,aStfadinr) `U n 19 Lea 3-501.14((!) 3-403 11 C m ro reialh 2T3 ! .wi According to Law Cooled to ` _ Jn F 3-501.15 3403, 11(F) I Rc nt.tunrr Ltsl rcd P;.mon rlirc'F PHF Hot and bold Holding }}1 Cold PHF s Maintained at or below 590.004(F) 41`/45°F' Proper Cooling of PHFs lint PHF � tfai coned it or above .501HfAl �Ca.Bog C<wl•d PFiI'� jinn) l,ul'`Fto ? 5: 1 1A(1) I Roasts Held a[ or above 130'F. 711 F Within 7 I lour. nein From 79Fi° I Time as a Public Heafth Control I' iUi t tinfn Fin) ' 9U nr}3n-il I -5171.iT(13) rf r liuPt1F 11 do F n)1 tmhient ( Tcm1 rawrchl r,1tt•t�lc J1 1745'F I W inun 4 Hearn `U n 19 Lea 3-501.14((!) PHFs Received at Temperatures According to Law Cooled to ` _ 41'F/45`1= Within 4 Haws. * 3-501.15 _ Cooling Methods for PHFs PHF Hot and bold Holding 3-501.16(B) Cold PHF s Maintained at or below 590.004(F) 41`/45°F' 3-501,16(A) lint PHF � tfai coned it or above 4OWT ? 5: 1 1A(1) I Roasts Held a[ or above 130'F. - I Time as a Public Heafth Control I' iUi t Pr m+ as t Pubht lie; Control, 9U nr}3n-il I S-riasce Re ui ut.ew REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP} 2t 3 -Silt I -h A)- linp..cteuri zed Pre- n'c a ed Joice%wid -861 11 (B Ust, t,' Pa�tiuwcd t�,� 110)) R.:, orratmai, AmmrdFaxl<ad .rrr rat Nol 3etvca _._ T;: J� .cd E o.'d Ptr.agc No r. SCrvc:i..` CONSLIMER ArIVISOP.Y i -:mal , Ad-isc,rt f.sr,i;ox(trenorp6onOf.� ' { r nm :xic'! is err Rs;v. t.h cer,' caked rn i 1 1 Y.te: , , i I:[Se-Sub n:r i?r Raw Shell 1 ' ik'aw? i ! .:Dotal., h , ,. teniporaj i and D,Ja (d he !choed v id:r th r)nn p ;at bogs (Items 23 ?0} ..u, r, ..:f'r .r , ro,n a.. x ..tr:,,,S: ;rlJrch do "wreFata t) i,:r rax d$rrnc it s r, e, ; 2rf i ,- a'd r) k jw pirc 'wed -horn call he 1a:'ak.' qtr t7m J 'K sir . a +-/h: and Mode and P6 C AIR l,0 -item Good Rer3f� Pr, fffces .,r 1.__. 1 FC - , 0.000 MJy 74 Ft,)o na axl Prot rt,Pm FC i 004 I t,_u n f t � no Cfet � s f(;-4 5C,5 ' [6' PtLbmvq y.v .Ja.,'e IFG ., � 0ft3 or 'pp M !e a!s; -_- - I -.. CITY OF SALEM �j " BOARD OF HEALTH Establishment Name: aV_C 1 iOn 1�0y irof '4' _44 Date: bI"N 09 Page: Item No. code Relerence o=Critical nem R - Red item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION :`.. PLEASE PRIN T CLEARLY Date' . . Verifled Vr, t W-qn J c 4T- & CIZ OT'," j R' Mit J ved r'V CQ 01 • �' �l ��`('fl2, n�.Prn. cic7c� O � '�e M 'lV 2 C� C�',(1 :- /1% •D� c7 _ �T Sc� L (�<Glt% iL, �l a feyJ�ce� LSD 1��CCa -�C P✓L QST r (' ' /1/\C� • i.-. i � c� TL �l �o TJ , � 3�s Q L CA J 119-7 cY't, %o H'he_-el' / t_� ,4 �/� a -J S 10 Ya t o d LR;A-A z(cd < .Joh a Ve,: f 2c L 133 t w�u 1> Discussion With Person in Charge: LFhaveead this report, have had the opportunity to ask questions and agree to correct all before the next ins ection, to observe all conditions as described, and to p with all mandates of the Mass/Federal Food Code. I understand that�pliance may result in daily fines of twenty-five dollars or suspension/revocation of d permit. I Corrective Action Required: ❑ No , .Yes ❑ Voluntary Compliance ❑ EmployeeRestrictions Exclusion O Re -inspection Scheduled ❑ Emergency Suspension LoEmbargo ❑ Emergency Closure luntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (lietrits 1-22) (Cont.) PROTECTION FROM CHEMICALS F—W Food or Color Additives Cold 3-202,12 A("tives* 1-501.16t,A) 3-30214 Pimccimn frot -d Additives, 15 Poisonous or Toxic Substances 101 IdentifyingInfitinnatifin -0m,inal FC ri ii,,ifh coooil 1. 1 it A r- 11)2 It "Commoll Nam, -- livorhfl'� 'm"n- 4 0 l< "i 0 !r"1 A TE Z) TO COD OD F r dA ii. PAA C rIelcs-- iTC-17- sepai'woa Son agc I, on Pft'Sk ncc lrkld-Us'.4 7- -102-12 WAII Of Ui TotAl nif fo r' F:if 1 al in bo 7 ?03 11 Toxic Coolaincl" -- Pmllibew[W e': ; hl' i ")wl !'(IdP wfl,_ sallili7cls. Cril-ral i DrIinit Amniv. Crlwrin�� Iieatiriq for Hol I iu;:'.ilnq Ro'ig( T.d U&C N.Ilicides 4-- �� — - ------ ---- - -- IOT ...... - ----- ------- Lj'-A& E."- T ontr;'l 'Wo Monilolill", --, - --- _.__...c_..._.-.. - -- - - -- ---------- 16 to, ;_.7")3,1 11 C.) !% Wii, BhQi jn Proper fooling of PHFs W. T-71 5 ,1 14(A} I 4iF!v I )();Ii Within 2 hour and From Hol -f!" atiffe Ili rodimit, lo IIi 45'F -i lbn III n .1 111 All !)I;I-i.''s "nzi� "i7 4'1. ill ll'�- i. ,it'! i'wW ". ! ,, (_"I'k Vi')' , , If,, Pilits Received at Temperatures According lo Lam Cooled to -WF/AG-F Within 1 14--, * 5--EfP"c"o'�orpHFl Cold C�'flllflijilllod HA ill" t 1-501.16t,A) F Hot and Holding ll �'!: ;'iland 1ire.i Roi+.! J O I Time as a Public Health Control FC ri ii,,ifh coooil 1. 1 it A Piv!lrl"' lilide" (;;n;-" sli'�)ti 4 0 l< "i 0 !r"1 A TE Z) TO COD OD F r dA ii. PAA C rIelcs-- f. I'10l, Me"[ C' ill, nif fo r' F:if 1 al in bo e': ; hl' i ")wl !'(IdP wfl,_ Iieatiriq for Hol I iu;:'.ilnq IOT ...... - ----- ------- Mi'llm"IVc- le�iF2 MlnulSo�lndmp' I'mic, ;_.7")3,1 11 C.) !% Wii, BhQi jn Proper fooling of PHFs W. T-71 5 ,1 14(A} I 4iF!v I )();Ii Within 2 hour and From Hol -f!" atiffe Ili rodimit, lo IIi 45'F -i lbn III n .1 111 All !)I;I-i.''s "nzi� "i7 4'1. ill ll'�- i. ,it'! i'wW ". ! ,, (_"I'k Vi')' , , If,, Pilits Received at Temperatures According lo Lam Cooled to -WF/AG-F Within 1 14--, * REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1i(A) Ujipicut izvd Junes Will Hewraliocs lkith Wariong- Lal)aJi;4 �-@,eif I HIM F�iw,,r Pattiall', Animal Rilid and Ric,, 1t,cd '�pnlos N.,�! UliopcnL 5--EfP"c"o'�orpHFl Cold 41`!45" F' 1-501.16t,A) F Hot and Holding REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1i(A) Ujipicut izvd Junes Will Hewraliocs lkith Wariong- Lal)aJi;4 �-@,eif I HIM F�iw,,r Pattiall', Animal Rilid and Ric,, 1t,cd '�pnlos N.,�! UliopcnL UoIll vflv� Mallitilm"I at or below 590 00-10-�, 41`!45" F' 1-501.16t,A) I lot IIHFs Matti at or above 140'F. z-.501, 161A) 1 Rsal% Held a, or above 130"F, I Time as a Public Health Control FC ri ii,,ifh coooil REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1i(A) Ujipicut izvd Junes Will Hewraliocs lkith Wariong- Lal)aJi;4 �-@,eif I HIM F�iw,,r Pattiall', Animal Rilid and Ric,, 1t,cd '�pnlos N.,�! UliopcnL adPt uon�,,.ni 4nd ytensiilt l I ikx,oici ipwjand 2 6. FG - 5 cy'W Pa".6, FC ri vol 2e F'01son 16 ot -',')Xlr klntefo" 4 0 l< "i 0 !r"1 A TE Z) TO COD OD F r dA ii. PAA C rIelcs-- I I tew23-3�➢ t C' ill, nif fo r' F:if 1 al in bo e': ; hl' i ")wl !'(IdP wfl,_ adPt ---- ---------- -- uon�,,.ni 4nd ytensiilt l I oot 2 6. FG - 5 cy'W Pa".6, FC ri vol 2e F'01son 16 ot -',')Xlr klntefo" 7 002 ---- ---------- --