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WILLOWS VARIETY - ESTABLISHMENTSWillows Variety 153 Fort Ave (formerly Lummie Yum.) s UPC 10230 No. H163 HASTINGS. MN luny%es E CITY OF SALEM,MASSACHUSETTS ` '� BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR - ` SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR - HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: George Hoxha Name of Establishment: Willows Variety Address of Establishment: 153 Fort Avenue Type of Establishment: RETAIL FOOD Application Date: 04/23/2003 Restrictions: Permit for Food Establishment 288-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 63-03 These Permits Expire December 31, 2003 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 AGENT 4. _1. �coxor CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH U (*'--•L 3 120 WASHINGTON STREET, 4TH FLOOR �lJ e SALEM, MA 01970 - �,p� TEL. 978-741-1800 On FAX 978-745-0343 l STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ilv; LL o � s tqO- nS=(_�EL # 9O -7-( Lf /3W ADDRESS OF ESTABLISHMENT FvfL l Avg- MAILING Vg MAILING ADDRESS (if different) OWNER'S CITY CERTIFIED FOOD MANAGER'S ZIP TEL# 1 92 R -7V'--I / 3GU (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON ��`^��5 1'�t��vei HOMETEL#. HOURS OF OPERATION: Mon.—Tue. - g We.? Thu. - �- Fri =� Sat. 7- Sun? -9 TYPE OF ESTABLISH 1� g b� FEE check only RETAIL STORE YES O ✓- less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVEYES, NO $5 TOBACCO VENDOR YES ' 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. Pure C a ter 63C--89cli 9A, I certify under the pains and penalties of perjury that I, to my tl�est knowledg n have file= ta1te tax returns and paid all state taxes required under the law. ©2� lt�'Z Ln Ln `4 Signature Date Social Security or Federal Identification Number Revised 11/25/02 FOODAP2.adm Check# &Date lea A CITY OF SALEM, MASSACHUSETTS '�, - - BOARD OF HEALTH • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 . TEL. 978-741-1800 FAX 978-745-0343 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR - HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: Elizabeth Kelley Name of Establishment: Lobster Shanty Address of Establishment: 25 Front Street Type of Establishment: FOOD SERVICE Application Date: 04/23/2003 Restrictions: Permit for Food Establishment 287-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 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 •s 4 STANLEY USOVICZ. JR. 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 f� _ t� ~IN I lip APR 2 2 2003 CITY Ufi -!�,t,LrNi BOARD OF HEALTH MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT -T 1 C C- Q 51,{ R 21L v i�'*.- NAME OFESTABLISHMENTak/G Lct]5TFcZ sc ADDRESS OF ESTABLISHMENT 2S irZoro"T 57 SAL C-" 1'(9 al 418 MAILING ADDRESS (if different) OWNER'SNAME �c�� Ott µetCe �/ TEL #- erlA --145 -3864n ADDRESS fo SJ-1l� N aV CITY S%?k STATE_t(Fr Z!P ol�i !O CERTIFIED FOOD MANAGER'S NAME(S) ; (iKx;� CERTIFICATE#(s) 2-5�909 1 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Ni lL L- i."�c LL c HOME TEL # HOURS OF OPERATION: Mond%- t Tue.tt- 1 Wed. 11- I Thu. N - I Fr.1i § Sats 1 1 Sun. 1 TYPE OF ESTABLISHMENT RETAIL STORE YES NO -a3 RESTAURANT ES NO BED/BREAKFAST YES NO ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO TOBACCO VENDOR YES NO ALL NON-PROFIT (such as church kitchens) YES NO FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25-99 seats =$15 more than 99 seats =$200 $100 $5 $50 $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 o/�ledge and belie h�ve fi d all state tax returns and paid all state taxes required under the law. M �. ,,, a-�; `�9( A 12 ye --4 q -I. = D -i U '/ 2- It 0 7 / Date Social Security or Federal Identification Number Revised 11/25/02 FOODAP2.adm Check# & Date' #- /7(J• 3 d . 9 THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel: (978) 741-1800 Fax: (978) 745-0343 Name�1 . `� S-`. Date / /l/ SCJ Tvne of Operation(s) A Food Service Tyne of Inspection ❑ Routine Address q�-- f _ ( / l Risk level LlRetail ❑ Residential Kitchen ❑ Mobile ElRe-inspection Previous Inspection Date: Telephone ❑ Temporary ❑ Caterer _ [I Bed &Breakfast ❑ Pre-operation ❑ Suspect Illness El General Complaint Owner �. '' }} HACCP YIN Person in Charge (PIC) Time In: Out: Permit No. ❑ HACCP El Other Inspector�"� //}f � ^ Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation / Segregation / Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating El, 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: FA Inspector's Signature: Print: c 4_5r: PIC'sSignature: -E,int: Pag€ of Pages FORM 734A HOBBS & WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION MANAGEMENT 1.: 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in Charge - Duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the Person in Charge to Compliance with Food Law* 3-201.12 require reporting by Food Employees and 3-201.13 Fluid Milk and Milk Products* Applicants* Shell Eggs* 590.003(F) Responsibility of a Food Employee or an 3-202.16 Ice Made from Potable Drinking Water* Applicant to Report to the Person in Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3: 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4 5` IN FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 8 9 10 13 C s PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made from Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3.201.14 Fish and Recreationally caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 8 9 10 13 C s PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM , BOARD OF HEALTH Establishment Name: )Lk: Date: O3 Page: of Rem No. Code Reference C - Critical Item R — Red Item DESCRIPTIONOF_VIOLATION/ PLAN OF CORRECTION" PLEASE PRINT CLEARLY Date Verified -A Ta S �► i/ �7c�Si✓7/z� - S�iC�� -f lr7 � r� - � - s✓� S � l 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 xyour food permit. 11 Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure 0 Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 1.5 In 17 18 * Denote, Critical itern in the federal 1999 taxi Cate or 105 CMR 590.000. 19 < ' Y 3-501.14(C) 3 -501 -IS Food or Color Additives 3-202.12 Additives* 3-302.1.4 Protection front Unapproved Additives* 3-501.16(A) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers" 7-102.tI CommonName- WorkingContainers" 7-201.1.1 Separation - Stora e=` 7-20111 Restriction - Presence and Ilse* 7-202.12 Conditions of Use' 7-203.1.1 'roxicContainers- Prohibitions* 7-204.11 Sauitizers. Criteria -Chemicals* 7-204.11 Chemicals for Washing Proctnce, Criteria* 7-204.14 Drying Agetim Criteria' 7-205.1.1 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 Monitorine* * Denote, Critical itern in the federal 1999 taxi Cate or 105 CMR 590.000. 19 < ' Y 3-501.14(C) 3 -501 -IS Proper Cooking Temperatures for Unpasteurized Pre-packaged .Juices and Beveaca,es with Warnin-I.atbels* PHFs 3-401..11A(1)(2) Eggs- 155^F 15 Sec. 3-501.16(A) Eggs -Immediate Service 145'1.15sec_, 3-401,11(A)(2) Comminuted Fish. Meats & Game 3-801.1.1(C) Animals - 155°F 15 see. * 3-401.11(13)(1)(2) Port: and Beef Roast - 130'F 121. min" 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 ..�.----------------... sec. * 3-401.11(A)(3) Poultry, Wild Game. Stuffed PHFs, Stuffing Containing Fish, Meat, Pouilry or Ratites -165'F 15 sec. 3-40L1I(C)(3) Whole -muscle, Intact Beef Steaks 145'F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'1` * 3-401.11.(A)(1)(b) All Other PHFs -- 145'F 15 we. Reheating for Hot Holding 3-403.1,1(A)&(D) PHFs 165'F 15 sec. * 3-403.11(13) Microwave- 165' F 2 Minute Standing Titre* 3-403.1.1(0) Commercially Processed R'IEFood - 140'F' 3-403.11(1`) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cowling Cooked PHFs from 140`F to 70"F Within 2H;ours and Front70'F to 41"F/45'F Within 4 Floors. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* * Denote, Critical itern in the federal 1999 taxi Cate or 105 CMR 590.000. 19 < ' Y 3-501.14(C) 3 -501 -IS PHFs Received at Temperatures According to I.aw Coolcd to 41:-1`/45°F Within 4 Hours. Conlin Methods for PHFs Unpasteurized Pre-packaged .Juices and Beveaca,es with Warnin-I.atbels* PHF Hot and Cold Holding 3-501.16(11) 590.004(1`) Cold PHFs Maintained at or below 41'/45° F" 3-501.16(A) Hot PHFs Maintained at of above 40'F.* 3-501.16(A) Roasts Held at or above 130'F. 3-801.1.1(C) Time as a Public Health Control 3-501.19 Time as a Public Health Control" 590.004(H) Variance Requirement 21 3-801.1.1(A) Unpasteurized Pre-packaged .Juices and Beveaca,es with Warnin-I.atbels* 23. I_ Management and Personnel ! 3-601.11 (B) Use of Pasteurized E' s* 24. Food and Food Protection 3-801.11(D) Raw or Partially Cooked Anumal Food and Raw Seed S mxns Not Served. * 25. Equipment and Utensils 26. Water,Plumbin and Waste 27. Physical Facility 3-801.1.1(C) Uroened food Packa w Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of .Animal Foods That are Raw. Undercooked or Not Otherwise Processed to E1lminate P�tb,�,.Pn� #: Eneer•�a +i+.2ooi 3-302.13 1 Pasteurised Eggs Substitute for Raw Shell SPECIAL REQUIREMENTS _ i%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 1129 -- Special Requirements. (Items 23-30) Critical and non-critical violations, which do not relate to the ,foodborne illness imernentions and risk factors listed above, can be found in the foilox•inb+ sections of the Food Code and 105 CMR 590,000. r Item Good Retail Practices FC 530.000 23. I_ Management and Personnel ! FC -2 003 I 24. Food and Food Protection - FC 3 .004 25. Equipment and Utensils 26. Water,Plumbin and Waste 27. Physical Facility F C 4 FC -5 4 FC -6 005 -006 .007 x_M i' Poisonous or Toxic Materials FC - 7 .008 29.-1 Special Requirements 1 30.'1 Other -----�.-. ..�.----------------... s.»:noz do 1THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM BOARD OF HEALTH FOOD ESTABLISHMENT INSPECTION REPORT Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date Type of Operation s) ' 1y of Inspection WL C //- &. pot F Food Service ❑ Retail ❑Routine ❑ Re -inspection Address Risk 3 6 Level ❑ Residential Kitchen ❑ Mobile ❑ Temporary Previous Inspection Date: ❑ Pre-operation Telephone Owner HACCP YIN a ❑ Caterer ElBed & Breakfast ❑ Suspect Illness ElGeneral Complaint Person In Charge (PIC)Time In: Out: Permit No. ElHACCP ❑ Other Inspectorh, 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 (Red Items) Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑2. Prevention of Contamination from Hands ❑ 1. PIC Assigned / Knowledgeable / Duties 13. Handwash Facilities EMPLOYEE HEALTH /^^ m PROTECTION FROM CHEMICALS El 2. Reporting of Diseases by Food Employee and P.IC F� 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 ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation / Segregation / Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.006) 29. Special Requirements (590.009) 30. Other TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: i Inspector's Signature: / / Print: PIC's Signat _ Print:(D f p { -� Page _Lof'Pages FORM 734A HOBBS & WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in Charge - Duties EMPLOYEE HEALTH C C C FOOD FROM APPROVED SOURCE 590.003(C) Responsibility of the Person in Charge to W* 3-201.12 require reporting by Food Employees and 3-201.13 Fluid Milk and Milk Products* Applicants* She]] 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 C C FOOD FROM APPROVED SOURCE • Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C 9 10_ 12 Ir PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 She]] Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made from Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3.201.14 Fish and Recreationally caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(7) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* • Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C 9 10_ 12 Ir PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.1 ](A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-50L114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1.22) (Cont) PROTECTION FROM CHEMICALS L14'I' Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 15.; Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIMEITEMPERATURE CONTROLS '16 PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.11(B) PHFs 3-501.16(B) 590.004(F) 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Eggs -Immediate Service 145"F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155°F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 Min.* Physical Facility 3-401.11(A)(2) Ratites, Injected Meats - 155°F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites- 165*F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs - 145°F 15 Sec.* 17,: Reheating for Hot Holding 3-403.1l(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(B) Microwave - 165°F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 18r. Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70*F Within 2 Hours and from 70°F to 41*F/45°F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41*F/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 20 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/45°F* 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Roasts Held at or above 130°E* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) _ 21: 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.00 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* Effective 1/1/2001 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other n a � STANLEY USOVICZ, JR. ' MAYOR } NY, @a 3ti��;¢_ „rte 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 P HEALTH AGENT „ iI COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT 1 71 In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: George Hoxha Name of Establishment: Willows Variety Address of Establishment: 153 Fort Avenue Type of Establishment: RETAIL FOOD Application Date: 02/07/2002 Restrictions: Permit for Food Establishment 1 270-02 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 66-02 These Permits Expire December 31, 2002 This permif:i-s 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 J 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 (=WFC !Aki 2 J `?'00? CITY OF SALEM HEALTH DEPT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT j t9`i� �ow`� V A2iET�j TEL # Q-A - -IL14 - 1 3U0 ADDRESS OF ESTABLISHMENT JRT AVG' sp'�Qr-1 r('(1A, UiQi70 MAILING ADDRESS (if different) OWNER'S CITY CERTIFIED FOOD (required in an establishment where potentially hazardous food is prepared.) TEL# -9'1k --)qt -0293 ZIP -01`11 111J _ FICATE#(s) A o7 3co 3p +{� EMERGENCY RESPONSE PERSON aQL(,Q C16XV ' HOME TEL # DAYS / HOURS OF OPERATION: Mon. Tue.j�Wed.j$ Thu. Sr Fri.jf!� Satj - Sun: S' TYPE OF ESTABLISHMENT FEE check only RETAIL STORE NO �-0 $40 RESTAURANT N or -$40 BED & BREAKFAST YES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $10 NO CHARGE FOR NON -PROF (such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPTFORM Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief have filed all state tax returns and paid all state taxes required under the law. Date Social Security or Federal Identification number ----- -- --- -- — — — Z— ----------_------------------------ Revised 11/1/01 foodapladm Check# & Date_ �� -Z' -v a -- Establishment Name: Discussion With Person in Charge: CITY OF SALEM BOARD OF HEALTH Date: 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. FORM 734B HOBBS & WARREN - BOSTON Page: of ❑ Voluntary Compliance ❑ Re -inspection Scheduled ❑ Embargo ❑ Voluntary Disposal ❑ No ❑.Yes ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1.22) (Cont) PROTECTION FROM CHEMICALS L!14L Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* I5 •i+ Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS 16, PHFs Received at Temperatures According to Law Cooled to 41'F/45*F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 23. PHFs 3-501.16(B) 590.004(F) 3-401.11A(1)(2) Eggs - 155'F 15 Sec. Hot PHFs Maintained at or above 140°F* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155'F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 Min.* Physical Facility 3-401.1l(A)(2) Ratites, Injected Meats- 155°F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165*F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs - 145*F 15 Sec.* 17 Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(B) Microwave- 165'F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 18): Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70'F Within 2 Hours and from 70°F to 41°F/450F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. `;20 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45*F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 23. PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41'F/45°F* 3-501.16(A) Hot PHFs Maintained at or above 140°F* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) CONSUMER ADVISORY 22 3-801.11(A) Unpasteurized Pre-packaged Juices and 590.00 23. Beverages with blaming Labels* FC - 2 3-801.11(B) Use of Pasteurized Eggs* Food and Food Protection 3-801.1 I(D) Raw or Partially Cooked Animal Food and 25. 3-302.13 Raw Seed Sprouts Not Served.* .005 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* EBecuve vv210t 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* MJ 4M L'1• 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other Establishment Name: CITY OF SALEM BOARD OF HEALTH Date: Page: of Item No. Codi, Referenc6 C4Crificalltem R"-Redltem DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION 1 ,PLEASE PRINT CLEARLY Date, Verified Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: LI No 71Yes D Voluntary Compliance U Employee Restriction Exclusion D Re -inspection Scheduled U Emergency Suspension U Embargo U Emergency Closure ❑ Voluntary Disposal U Other FORM 734B HOBeS&WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name -Working Containers* 7-201.11 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS 16' PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 23. PHFs 3-501.16(B) 590.004(F) 3-401.11A(1)(2) Eggs - 155°F 15 Sec. Hot PHFs Maintained at or above 140°F* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.1l(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155°F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast -130°F121Mm.* Physical Facility 3-401.11(A)(2) Ratites, Injected Meats - 155°F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165*F 15 Sec.* Other 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs - 145°F 15 Sec.* 17`e Reheating for Hot Holding 3-403.1l(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(B) Microwave - 165°F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 18 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70*F Within 2 Hours and from 70°F to 41°F/45°F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45*F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 19 3-50I.14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 23. PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/45°F* 3-501.16(A) Hot PHFs Maintained at or above 140°F* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21- 3-801.11(A) Unpasteurized Pre-packaged Juices and ELBeverages 23. with Warning Labels* FC - 2 3-801.11(B) Use of Pasteurized Eggs* Food and Food Protection 3-801.11(D) Raw or Partially Cooked Animal Food and 25. 3-302.13 Raw Seed Sprouts Not Served.* .005 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* Enectwe 11112001 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodbome illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC -6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other ,.,.va�sra�'.. '-u '.�,..yyr �..:;y,.ypJa•.....�r m+M.c .:ia. ..-..-,re.»".aiy xR4w^bl+.g:ssi.i'�W!N'+m? ::s.n,..�.'y. A �4 THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Board of Health FOOD ESTABLISHMENT INSPECTION REPORT Address: 9 North Street Salem, MA 01970-3928 Tel: (978) 741-1800 Fax: (978) 740-9705 Name Print: Date T e of 0 eration s Typeof Inspection PIC's Signatu Prin .c \ -0?0- 0'2- Routine �KRe-inspection Rr Food ServiceQ ❑ Retail Address Risk a ase de Level ❑ ❑ Residential Kitchen Mobile Previous Inspection Dater 3'13-va Telephone / ❑ Temporary ❑ Pre-operation Owner HACCP Y/N ❑ Caterer ❑ Suspect Illness Ll Bed & Breakfast El General Complaint Person in Charge (PIC) Time Q In: 1-1HACCP ElOther Inspector � V /'�1l�C4� lei S Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) Violated. Non-compliance with: RED Violations (1-22) Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law Cl FOOD PROTECTION MANAGEMENT ❑ 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 ❑ 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 1110. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices BLUE Violations (23-30) Related to Good Retail Practices Critical (C) violations marked must be corrected Immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N ,.... 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (Fc-7)(59o.om) 29. Special Requirements (590.009) 30. Other 5: 5901nspeclFwm6-140oa ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) [121. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number Violated Provisions Related To Foodborne Illnesses Interventions F71 and Risk Factors (RED Items 1-22): Official Order of Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: T e Print: PIC's Signatu Prin .c \ page of oZ Pages x Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION AND MANAGEMENT 1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH F4- F5 - LL 7 ! t FOOD FROM APPROVED SOURCE 590.003(C) Responsibility of the person in charge to L2 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) Char e* 590.006(B) I 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003E Removal of Exclusions and Restrictions F4- F5 - LL 7 ! t FOOD FROM APPROVED SOURCE *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C � 9- 12 X� PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) I Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish From NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records; Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records Creation and Retention* 590.004(7) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C � 9- 12 X� PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, concentration and hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges from the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: 3--2,0 - OA Page: c2 of Item Code k C -_Critical Item, t DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date:, Red Item Verified No, Reference R PLEASE PRINT CLEARLY A0 LL //tIza aecZ /,3 �eqoe— Aee Aj e -we 5941c�2 111/1 Discussion With Person in Charge: Corrective Action Required,' ❑ No ❑Ye'a I have read this report, have had the opportunity to ask questions and agree to correct all Q Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to comply Exclusion with all mandates of the Mass/Federal Food Code. I understand tbat,n.Dncompliance may J Re -inspection Scheduled U Emergency Suspension result in daily fines of twenty-five dollars or_suspenstp/r649��cation of your ibed permit. Q Embargo U Emergency Closure Voluntary Disposal J Other FORM 7348 HOBBS &WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) (Cont.) PROTECTION FROM CHEMICALS I4 15 TIME/TEMPERATURE CONTROLS 16":` Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS 16":` PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.11(B) PHFs 3-501.16(B) 590.004(F) 3-401.1IA(1)(2) Eggs - 155°F 15 Sec. Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Eggs - Immediate Service 1457 15 Sec.* 25. 3-401.1l(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155°F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* Physical Facility 3-401.11(A)(2) Ratites, Injected Meats- 155*F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165°F 15 Sec.* Other 3-401.1l(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°F15Sec.* 17+.'r Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(B) Microwave- 165°F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Within 2 Hours and from 70°F to 41°F/45°F Within 4 Hours.* 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41 *F/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 19' ,;20 ,- . a 3-501.14(C) - PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/45°F* 3-501.16(A) Hot PHFs Maintained at or above 140°F.* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ',.. 3-801.1 I(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.00 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801.1 I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or FC - 2 .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* Effective 1/1/2001 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* ArrWAL HCUU1htMrN 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 above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other ...-.....r.�.r••..:.......ens+q...nH^r....+.�i.�....�Ow+1'++.+Y'^^."A!'"'y..... rr'�-�.:.-.va>ar:'sr.:y"^+.'..JIMS'1•�:'.:y.,r*\.rv'++-Yte�+.w.+ww^++!-r.\ix%N+.r'rA''AP.s.::a..-......::,:w �.. THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Board of Health FOOD ESTABLISHMENT INSPECTION REPORT Address: 9 North Street Salem, MA 01970-3928 Tel: (978) 741-1800 Fax: (978) 740-9705 Name GIcECGS Date T of 0 enation s Type of Inspection I/� f / T c 3 -/,3-d1 IVFood Service CP/Retail ❑ Routine ❑ Re -inspection Address 7 Risk S Aox', P. Level ❑ Residential Kitchen ❑ Mobile Previous Inspection Date:// -13-0/ Telephone 7,lq-OO ❑ Temporary ❑ Pre-operation Owner HACCP Y/N ❑ Caterer ❑ Suspect Illness ❑ Bed & Breakfast ❑ General Complaint Person in Charge (PI ) _ Time tOR E In: Out: Permit No. ❑ HACCP ❑ Other Inspector Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) Violated. 11 Non-compliance with: RED Violations (1-22) Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation / Segregation / Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 1:110. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices BLUE Violations (23-30) Related to Good Retail Practices Critical (C) violations. marked must be corrected Immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590:006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (5so.009) 30. Other S. MntFa,,:sia.d� ❑ 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) s ❑ 16. Cooking Temperatures V. Reheating . 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 Illnesses Provisions Related To Foodborne Illnesses Interventions f and Risk Factors(RED Items 1-22): Official Ordel"of Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: .� Print: PIC's Signature: _r' n'nt: r i x Page / of 9Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION AND MANAGEMENT 81 1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 require reporting by 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* IF '3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003E Removal of Exclusions and Restrictions T4_ C C 7 FOOD FROM APPROVED SOURCE *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 9 10 ll ,12 113 It PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish From NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Ta s/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records Creation and Retention* 590.004(J) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 9 10 ll ,12 113 It PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, concentration and hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges from the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 1 Hand Drying Provision rJ CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: 3-/3-Gb2 Page: ,? of .2-- Item No. Code Reference C.2'Criticat Item = DESCRIPTION OF VIOLATION`! PLAN OF CORRECTION . R= Red Item _ puEAse rRirrr CLEARLY, u .. Date - Verified iPDu..... !v C- .P rG,dD /NS OCr'i<7 /y"S n S / 74aleL/ rle,1W, .s- ('irr/ o. Don �-- Pv e_ 7,4e / /�� "4d'- a- .syn e, J �A`/�diJIP 'Pi@ /N Qi1 y O PIPs Q'. e ' f 67"44 v/,5/ Gv a reiva ', c 7/!> -ld /)L/ 41 l Xd e d S rJIYJ¢ F -ems cc VSs t�is ,rR CAL /C , y- A606 /Ri/K" 12L P.r 01 S o ze_ GY r / Ife"C;'/G le ✓ GPt d d�7 fD As. AOL5 /7lt //1-P.il_tc - f�✓.�J/�Xs ✓ B P i.1��/O/tcI 9aa°rlf %liF7.G _. S'f /n O P.P BY/ t/ i/n ,' Y�r7 .0 40rr . SAt7Ta./HrC i -Pnrfi_71/9'_C - Fa' �/ Awx°Cof?,f ae d/soeUr Discussion With Person in Charge Peen sloEz fic n d�z� bVee/t 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 —sus-pension/revocation of your food permit. ` — - Corrective Action Required:' O No ` OYes ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 73413 HOBBS & WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 Food or Color Additives 3-202.12 Additives* 3-202.14 Protection from Unapproved Additives* 115§ Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Se aration - Stora e* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents, Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS 16 PHFs Received at Temperatures According to Law Cooled to 41*F/45°F Within 4 Hours.* Proper Cooking Temperatures for Cooling Methods for PHFs 3-801.1 I(B) PHFs 3-501.16(B) 590.004(F) 3-401.11A(I)(2) Eggs - 1557 15 Sec. Hot PHFs Maintained at or above 140°F* 3-501.16(A) Eggs - Immediate Service 145°F 15 Sec.* 25. 3-401.11(A)(2) Comminuted Fish, Meats & Game Time as a Public Health Control* 590.004(H) Animals - 155°F Sec.* FC - 5 3-401.11(B)(1)(2) Pork and Beef Roast - 130°F 121 Min.* Physical Facility 3-401.11(A)(2) Ratites, Injected Meats - 155°F 15 Sec.* 28. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, .008 29. Stuffing Containing Fish, Meat, .009 Poultry or Ratites - 165°F 15 Sec.* Other 3-401.1 l(C)(3) Whole -muscle, Intact Beef Steaks 145°F* 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* 3-401.11(A)(1)(b) All OtherPHFs- 145°F 15 Sec.* 17 Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 Sec.* 3-403.11(B) Microwave - 165°F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140`F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* 18 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Within 2 Hours and from 70*F to 41°F/45*F Within 4 Hours.* 3-501.14(8) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45*F Within 4 Hours* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 19 J 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41*F/45°F Within 4 Hours.* 3-501.15 Cooling Methods for PHFs 3-801.1 I(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 41°F/450F* 3-501.16(A) Hot PHFs Maintained at or above 140°F* 3-501.16(A) Roasts Held at or above 130°F.* 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21. 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.00 3-801.1 I(B) Use of Pasteurized Eggs* - 3-801.1 I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served.* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.00 23. Animal Foods that are Raw, Undercooked or - .003 not Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* ERe°nue 11112001 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 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 #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Blue Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.00. Item Good Retail Practices FC 590.00 23. Management and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25. Equipment and Utensils FC - 4 .005 26. Water, Plumbing and Waste FC - 5 .006 27. Physical Facility FC - 6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009 30. Other S JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 120 Washington Street 4" Floor Tel: (978) 741-1800 Fax: 978-745-0343 COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner's Name: George & Christine Hoxha Name of Establishment: Willows Variety Address of Establishment: 153 Fort Avenue Type of Establishment: RETAIL FOOD Application Date: 06/21/2001 Restrictions: Permit for Food Establishment 291-01 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 69-01 These Permits Expire December 31, 2001 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS, CHO NINE NORTH STREET HEALTH AGENT Tel: (978) 741-1800 Fax: (978) 740-9705 2001 APPLICATION FOR PERMIT TO OPERATE A FOODESTABLISHMENT 1 NAME OF ESTABLISHMENT W i �� iC �/�(��,c�TEL 4 C/r%� ADDRESS OF ESTABLISHMENT I S TC')Q—T MAILING ADDRESS (if different) OWNER'S TEL # M CITY SpAci vh STATE ry IA • ZIP o\Q- u CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL # `11' \ O ,'Z-rI3 TYPE OF ESTABLISHMENT �2 q) -6' FEErheck only RETAIL STORE Q0 NO �40 RESTAURANT YES NO #seats_ onsm ing� $40 BED & BREAKFAST YES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT -0J SOFT SERVE YES NO (0 TOBACCO VENDOR KEES) NO $10 EXEMPTFORM 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@nd-belief,, have filed all state tax returns and paid all state taxes required under the law. Date Social Security or Federal Identification Number ---------- —------------------------------------ —---------- --------1-/-- ---- ------------------- ----------------------------------- Revised11121100 foodapZadm Check#&Date iQaT "02/—(9/ r�•.`^"awd.v'�t�s.�•-iv*�•.*�+q+rxw�nra�PNmr••-+-rtxwrr-v..r•-�-e,.+"pip^'yiq"TM'°...an.rdw.,yiar�.,..-,r...'n.w+.wr-w�++�.,.,...�. . THE COMMONWEALTH OF MASSACHUSETTS CITY 'OF SALEM Board of Health FOOD ESTABLISHMENT INSPECTION REPORT Address: 9 North Street Salem, MA 01970-3928 Tel: (978) 741-1800 Fax: (978) 740-9705 Name j Date T e of Operation(s) Type of Inspection ❑ Routine i�_`Fle-inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness El General Complaint ❑ HACCP ❑ Other Food Service ❑ Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address Risk Level Telephone -It/ Owner 4!/IeeeeC �hrif Irl e /�U�•��G HACCP Y/N Person in Charg (PIC)/ t� C!/r e 141-04-1w Time In: Out: Inspector / e Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) Violated. Non-compliance with: RED Violations (1-22) Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ eso.00s (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation / Segregation / Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing Ell 1. Good Hygienic Practices BLUE Violations (23-30) Related to Good Retail Practices Critical (C) violations marked must be corrected Immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C .N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (Fc -7)(590.008) 29. Special Requirements (590.009) 30. Other S 6W mpwtFw 14,dm ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of rotated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (RED Items 1-22): Official Order of Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/Federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes' an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: Print: _ PIC's Signature: Print:�'? 4 ` ' (� Page / of �' Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION AND MANAGEMENT F-8 [1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to 3-201.12 Food in a Hermetically Sealed Container* require reporting by food employees and Fluid Milk and Milk Products* 3-202.13 applicants* 3-202.14 590.003(F) Responsibility Of A Food Employee Or An Ice Made From Potable Drinking Water* 5-101.11 Applicant To Report To The Person In 590.006(A) Bottled Drinking Water* Chare* Water Meets Standards in 310 CMR 22.0* 590.003 G Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* Molluscan Shellfish From NSSP Listed Sources* 590.003E Removal of Exclusions and Restrictions ,5_ im FOOD FROM APPROVED SOURCE *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 9 10 1f; 13 PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Returned Food and Reservice of Food* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish From NSSP Listed Sources* Food Contact Surfaces Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* Equipment Food Contact Surfaces and Utensils Clean* Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* Proper, Adequate Handwashing Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* When to Wash* Ta s/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12. Records Creation and Retention* 590.004(7) Labeling of Ingredients* Preventing Contamination When Tasting* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 9 10 1f; 13 PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, concentration and hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges from the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision THE COMMONWEALTH OF MASSACHUSETTS Establishment Name n, )��l�y J J,,�Avj(f71' Date Address �5 3 ,Le/irT i�l!/�. Page-,,—�of Item No. In the space below describe all violations checked on front page. ,. /j/,/e 5 4w /JyiP�. Discussion with Management THE COMMONWEALTH OF MASSACHUSETTS r( i Establishment Name Date f /_ S_O f WI11oleiS 1/ /t, Address— nn Page % of L CR 153 /-T Aur -x. uc7 Item No. In the space below describe all violations checked on front page. A t'du or .) n4 pl, r5 P�/t� i4t'4t, 44P pec Sfd- l�hana-P5 m 15 r'_Si9k+// fa/4" LJPiP ✓'e ,J�n.��l l� c*stn,-da-,�reP. rv/�-G, f% Sial -e_ J,4vv.:, '7A/V-6P" b -el. l /C.nn�1 SLA Il 7 �rezu_5 zz-eA S/.� K nttu� Azo,--- /.r ,s V /,ni Fn -tri 1_11 iC� s'/�l-Pr4 i /6�,i� / .4 P1"7 s'✓ CiA /-f 5 / S-� NI LCI. /0[!'.� �!A // / `a / � /P. ��/!�✓/!it*-xrc(y -Pr S y�r � cua 5/>/tea P'/hal-xr S v1 (1Yr tea/ p lfJ fF%i rJn /� 1 tP/u 12e"'o /5 04 hQ.H.i ,`5n,9 / a -o ,r du he ate( U/°F / J Discussion with Management THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name �/��r� d Date 6/ /I Address�3 3 �ar WIDe % Page of Item No. In the space below describe all violations checked on front page. A(n) o0C; f 11 C At - inspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments, Chapter X, 105 CMR 590.000. The following violations were observed: P Ile C / � rs - ` Q P✓ /✓ / i Discussion with Manageme 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 Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. i_ f- � I i I I I � Imo_ -a- .+ f 1 I _i' I J__i i �� f i i -- I = F777- � -,I , --L zz 44L j f L-YI T I I It, !till LI 1-1 .,".. a. rr.-:" -' a:.. -ft...... ..'.r*, y5.•..r..r .. ._ I ,._ .Y-, AM1'S,, .vi .. THE COMMONWEALTH OF MASSACHUSETTS City of Salem Establishment Name " ff Date 7��?7_0/ o qs Address X53 r /i U2MfJ� Page / of Item No. In the space below describe all violations checked on front page. Ain) Y71)1 fD-C PSA, S inspection of -this establishment was conducted in accordance with the State Sanita Code for Food Establishments, Chapter X, 105 CMR 590.000. The followin ialationwe-were observed: ha /D/JD int✓/P k!y ,,/ . aZ/,J-ovS o S Lv ( /P Q rP O f /'too./ ✓P r! d 4x 9�8 - 7�0 - 9 �o s ,v -all ?4P V,44 IHd in a/4frtce r n U n/ M,0 hie Ud / ALA,70 Soa 42 a-.tcL tx�x• �/2lr n/�� ..r l'.+•'dv�e r�lre�,F fH G� / .sPCL b 1.o&-,-,4 �. a.rJGt r 1d lc, a •'/d P Psi dPSU o-.-. A2 0 O /Yr r co -e. a aPtP�s ✓r-l�c�>ri �� 6 D. Luf ( .o. S�r7✓ !h `CletrevP // !� n ns Discussion with Management Y/" Pw /Lltd I`/ Jv>� r iea `x, C*,et O-xei CtP-e K I have read this report, have had the opportunity to ask questions and agree .te•correctali-vielations,beforedhe.nexWr4spectiori, to observe all conditions as described, and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollar . /o `S��•r)/ (�{,JCu Y%eiU p�LL) 4y hew -e /-r )(