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WITCHS BREW CAFE - ESTABLISHMENTSO(et� core 1 >n f� D�i6y S't«el� universal one,M www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE IN USA v Commonwealth of Massachusetts r City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: File Number: BHF -2004-000357 LOCATED AT: Witch's Brew Cafe 156 Derby Street Salem MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2011-0275 Jan 1, 2011 Dec 31, 2011 $280.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $280.00 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIINIBERLEY DRISCOLL MAYOR DAVID GREENBAUM, RS ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET. 4T" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 - DGREENBAUNlQSALHM. COM 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Cy/TCHS 92¢6v e4 F !�' TEL # ciTE -7N5"- X717 ADDRESS OF ESTABLISHMENT ISS 01 -2G -L4 SrfL£_C_`r= FAx# q?S - NO- C) I OCt MAILING ADDRESS (if different) EMAIL -Business': 501aoKtO 9) l4OiM/J-/L.CC71VI Website: OWNER'S NAME 6P1'2C) 4�oL-)ry6Pi C�1 G 1 TEL# g -Z g_,? L1 -73&-'I ADDRESS VS& Z) �( STREET Tt2ir_-_CT 6Rur__r'A rvl/�r 0) ek1 D ZIP CERTIFIED FOOD MANAGER'S NAME(S) S?t ao KC91jANSA L1 q— i CERTIFICATE#(S) to aaa3fZ. (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON—'IS 9 1 20 lticDOrvSFll_IC-tf�_ HOME TEL# yt1-736C7 4DAYSOF.'OPERATION . , >-;Monday :1;- Tuesday; I Wed'n'esdayy ,M'Ihursday # .�', , Fnday*.Sunday: HOURS OF OPERATION ((/Y✓t if Ayr+ �/t9rh 1i /�/r t1 ASI 4l 14 vv,, Please write in time of day. ! 1 1 A (For example 1lam-11 pm) l A ✓t'� I TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 .................................................... ,-......----------------------------------- --........................................................... (Outdoor Stationary Food Cart $21 BED/BREAKFAST/ less than 25 seats =$140 -- 25-99 seats =$280 more than 99 seats =$420 $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT (such as church kitchens) YES O $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to VGLJG 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 a taxes required under the law. vtia C1a 3m Signatur Date _34_ O l - 1 D Sorciall, __Security or Federal Identification Number �.j / Revised 10/7 1 FOODAP201 Ladm Check# & Date % �_ Commonwealth of Massachusetts �) e City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED:. 0.1/04/2010 ESTABLISHMENT NAME: File Number: BHF -2004-000357 LOCATED AT: Witch's Brew Cafe 156 Derby Street Salem . MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2010-0091 Jan 4, 2010 Dec 31, 2010 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES IDecember3l,2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR DAVID GREENBAum, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TM FLOOR , d TEL. (978) 741-1800 /rz ' ' FAx (978) 745-0343 'tea llGRF.ENBAUiv QSALFM. COM ®fc � o t:,, ._ ?009 bpgRotOFcM 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT (4VF�- TEL# 61-7,0 -7q5- 97(-7 ADDRESS OF ESTABLISHMENT FAX# MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'SNAME S17'1<Zo TEL# e1-71" 7r')L4-�3C'y ADDRESS 75atc f m 6nf:* CII C1 —I0 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'SNAME(S) 57VZO V�c�u^'snt�4.E( CERTIFICATE#(S) Co3a�3$Z- (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON cS`V\0— VOkDk)- :ALYr--Ei HOMETEL# /79'%+-/c%736,6i IMon"da Tuesda`' 9DAYS9FRQP,ERAAI0N yea ; �yVgd'nesaa y 7,, =ETh rsday Fnday� ',-aturday � Sunday PERATION I j)e m OF Oite to I to. -" t -o �— JV A 10 A I JO A* POURSlease in of day. Iry For example 11am-11 m 1 A ..� q Y� \- A-- / fl�Ytt.. j �/ " Y{ �'^ yq ..n. Y n N+cH% TYPE OF ESTABLISHMENT RETAIL STORE YES RESTAURANT (Outdoor Stationary Food Cart $21 FEE (check only) NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sc.ft. =$420 BED/BREAKFAST/ YES (NO/ MAKE (not just serve). ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) les 5 seats =$140 5-99 seats =$280 more than 9 seats =$420 $100 YES $25 YES $135 YES $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance Nh the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be b itted to and approved. by the Salem Board of Health. Pursuant to MgrL Ctppter 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 pajd allsliate taxes required under the law. 0(-12. 0 2 38 Signature Revised 424/07 FOODA2008.adm Check# & Date :.f..A ,._ � 4, 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 Namen t n Ff1 iS 0..4) : l .7A Date - �CYC� Type of Ooeration(s) Type of Ins action Re -inspection Previous Inspection Date: [IPre-operation ❑ Suspect Illness E]General Complaint ElHACCP ❑ Other Food ServiceRoutine ❑ Retail ❑ Residential Kitchen ❑ Mobile El Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address � p J p Risk Level Telephone 1 �/ _ (( _` \ C r OwnerI n ( S 1 �( HACCP Y/N Person in Charge (PIC)Time f L le1l. In: (� 7 Out: ; r � �1 Inspector ` )1',blo � A Each violation checked requires an explanation on the narrative page() 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 maypose an imminent health hazard and require immediate corrective 590.009( E) E�_ 590.009 (F jp' action as determined by the Board of Health. / Duties by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded 4 FOOD FROM APPROVED'SO •N, ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition Y❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans 1 PROTECTION FROM C6NTANkNATION1_ 7 G3w4, 3 GP21 K A l d ❑ 8. Separation/ Segregation/ Protection ^Q 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FO -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. 5001nspe FomSf4dm // ❑ 12. Prevention of Contamination from Hands Nr13. Handwash Facilities ;[PROTECTION FROM CHEMICALS a y� ', m El14. Approved Food or Color Additives ❑ 15. Toxic Chemicals '71ME/TEMPERATURE CUNTROLS (Potentially HaPaardou# FdOds) Wat- IsP dk�a.0 a;:i a� '�ia.n,a ". u�,c rni„ ®mAsaP&wwu:Wu.=. �..,:er.Fn�eavawv ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding [120. Time As a Public Health Control [[ kEOUIREMENTS FOR HIGHLY $URG PtIBLE PCIPULATIDFjS (HSP) �" ❑ 21. Food and Food Preparation for HSP CONSUMERADVISORy,=14r,Tj, ,..fflLm� `'fi ,Ex uL.;1ai a ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: I.Print: PIC's Signature: (/ (` Print: S l k 0 I/ n (IN`g )'A `i`r- Page 0� ages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge* 2-103.11 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of. the person in charge to Compliance with Food Law* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinkim , Water* Applicant To Report To The Person In Drinking Water from an Approved S stem* 590.006(A) Charge* 590.006(B) 590.003((7) Reporting by Person in Charge* 3 1 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Resttictions C C C C FOOD FROM APPROVED SOURCE -Denotes critical item in the federal 1999 Foal Clare or 105 CMR 590DOO. PROTECTION FROM CONTAMINATION $ Food and Water From Regulated Sources 590.004(A B) Compliance with Food Law* 3-201.1.2 Food in a Hermeticall • Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Fu as and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinkim , Water* 5401.11 Drinking Water from an Approved S stem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* WashinR 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 Reautalory Authontv 3-202.18 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Ftx)d Safe and Unadulterated TagstRecords: 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 E ui ment* Conformance with Approved Procedures /HACCP Plans 3-502.11 S ecialiwd Processing Methods* 3-502.12 Reduced oxygen packang, criteria* 8-103.12 Conformance with Approved Procedures* -Denotes critical item in the federal 1999 Foal Clare or 105 CMR 590DOO. PROTECTION FROM CONTAMINATION $ Cross-contamination� 3-302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-30211(A)(2) Raw Anunal Foods Separated from Each Other* Contamination from the Environment 3-3021t(A) Food Protection* 3-302.15 WashinR Fruits and Vegetables 3-3(4.1 1 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)CBL Returned Food and Reserviee of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501..111 Manual Warewashing - Hot Water Sanitization Tem eratures* - 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness.* 4-601. I I (A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of 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 Cleaninn Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eatin , Drinkin or Using Tobacco* 2-401.1.2 Discharges From the Eyes, Nose and Momh* 3-30'(12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees*, 13 Handwash Facilities Conveniently Located and Accessible 5-203.11. Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility. Operation andMaintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drvin *Provision 121 Al I BOARD OF HEALTH Establishment Name: `I ) i J -,I SA '_�n P A _2 _f A j Date:)— �) 0 —t Pager of A" ;Item, No.:r Code 01 a- Ref r Cz Critical Item; Item W' VIOLATION/PLAN OF CORRECTION 4, �A vo I 4, M av, -r Date Verified �-1 All Yle sA t an 4s0 bo) I �40 4&.0A.. AAA, _V�, k IA%t�.k7l wrjf;� 4-7A J '4-1+7 4 ",a' k'A k _f Q_e, -YV\A 0 '0 4 An AA 0 1A o o l') 0 4()()( A"\ �)P A 4), 1 A A,\ of -4 60 1 � 'WX1LL'-- 7K/1-�\ft 0 0A AP 19X Ia A 71111 Q V V11L (f-& r)v a 17,E-— Discussion With Person in Charge:- d' 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 CoQ I understand that noncompliance may result in daily fines of twerity-five"dollars or suspension/revocation of your food permit. 66r!ective Action Required: 'e"o/ � "W', LI 0 I , %'4� ' - �' ; z Yes I Vounary Compliance C3 Employee Restriction l t 0 Exclusion Lj Re -inspection Scheduled Ll Emergency Suspension 0 Embargo L1 Emergency Closure U Voluntary Disposal Lj Other: L>A Vituations Related to Foodborne Iftness, Interventions and Risk Factors (items, 1-22) (Cont) URWE ��r � 2 L14— Food or Color Additives. --- 3-20212 Ad(Ttiv,,* 3-30114 Protection from Unapproved l- 15 Poisonous or Toxic Substances -- Identifying Info) twiAiort - 0ii.-inal 11-101.11 Commilittled Fule Mcas k, Garviv -1,501.16fir) Conotirjefs" 10,2711 ommon I lare- - Wor n 'Ontaill It TZli I (A)(2) -E" L Restriction -- Pr(?stn(x,,wd Use* 7-202.12 Conditions of Use 7-'(13.11 Toxic (,rintausei--Prohibinom* F7 7-204.11 Saint izers, Criterie -- Chernicrls* 7-2f4.12 as Idnee, Cl itenO ChQcals ftsWM, Pr i nli F7�204.14 'titeria" 3-401.12 ContICT. I,Ubr1CaDtS* 17 200,11 riu14IJ;,,e Pesticides. Critcie)* 17-2e36.12 4_�(Ydtfo Ban Stati()M" r-1—7 7-206.13 I------ 1 f7racking Potv&rs, Fesi Control and MMMMMETITIMMENM - Den -ow, arucql gew in the (,,Icod 1909 Foal C<xfe or Itis (MIt 590 M), 1 3-501. IVO Proper Cooking Temperatures for PHFis 3-401.11A(11(2, Fgg,- I55 7F 3.7,es� 3 'rwi to J31,v�.:1 Lyu_ijcdm wSeivicc 145'Fl5re c, I GV,) Commilittled Fule Mcas k, Garviv -1,501.16fir) AninmLS 15 Sec'k -401.,11(8)( 1) (2) - — Pork and Beet Roast - 130"F 121 win* TZli I (A)(2) Ratitcs, Injeocri Nlciz - 155-'F 15 I'U'V � 3 40t.11(Ay3) Poultry, Wild (3arne, Sm!fed PITTs, Stuffiag Containing Fish tvfeai Ltrtor katiws-i651', Osec. _±oin 1-4() �lt I f C) 3 �,Whok-nriievlc Inowt Beef Sicaks; 145 1 'I 3-401.12 i iw Animal Foods Cooked in a Miciowavc 165'F -T461,1 I All Othei T11Fq -- 145'1� 15 sec iry Reheating for Hot Holding 3-403.I ITA)&(6) PIIF4,, 161 'F I � set;. I I—A 3-403.11(B) Miaowaw- t65' F 2 "viinw Standing I 3-403.11 (C) Time* Commercialby Processed RTE Fottd -403,11 (P) 140'F' Remahun2 Unsliced Portions of ficef froasl"* ig 5 Proper Cooling of PHFs-4 —4 Costing Cooked PHI -'s from 140*F to 70'F Within 2 1 lotio; and From 'IFF l0 417, '45'F W'ithm 4 Hour.,.' PHFs!1vbrdeFo)ntAmbicnt Temportrurc lo4l'B'45'F Within 4 Ilourst - Den -ow, arucql gew in the (,,Icod 1909 Foal C<xfe or Itis (MIt 590 M), 1 3-501. IVO Pfff,s Received at Temperatures Awarding to last Cwhed it) 4 1 "Fir -5'F Within" Hours, 3 'rwi to Tamp, as a Public Health Control' PHF Not and God Holding -1,501.16fir) Cold PHFs Miotipitained at rit below 590 (X)4(F,,, —1 41°t45° F- 7; 1 F" j Hot 111 -IT, _M"l—int'loledat , —sbo�:T I'U'V � 501.1 ti(.A) I kwsts Reid at or above 130°F. Time as a Public Health Control 3 'rwi to Tamp, as a Public Health Control' 3-801 3-801 I I i I Raw or Partaih Cooked Ariijrjtij Food and ole, S','d S 'rorritt Nor Set ted —=., .. ff-, r,.,.,r nr. N"',t 22 1 :3b0• , II Coniurnor Atai isol t Posted for CoTowuption of ArthoM Foodthat tire Raw, Underatoked v; Not CkJrnrwrse Poce-0ed to EJiminate I I Ph " -oo-T p!rte noUZA SPECIAL REQUIREMENTS T97o-o6iA) -(,)) -T Violation, of Secttion in cracrinq,, mobile fetid, temporary and reridea rt;td kitchen operations Qiould be dchited uirder the appropriate sec'Itrnjs n10 ve if related to fx)dborntillness inter ventions and risk faciors, CAher D0.009 violations relminc, to qixxi retail gra tices. ,hokild be debited under #29 - Spy tat Reeluirements, (lustus 23-30) Crar,al and non -ort vrokoiwre which do no relate to the, ftrodborne idtrasr iniet ventiow taid 7 W j4crorr lietedabove_ wn b,, 11ound it, !hr foileming sertsons of die Fond Code was 105 (MR 590ift), � +,V " , CITY OF SALEM J'l BOARD OF HEALTH Establishment Name: kZ0, Date: Page: of 'tom No. Code Rate ri+J C-Criticalltem, R - Red Ite, 01 U DESCRIPTION OF VIOLATION PLAN OF CORRECTION' I" ' �,e X" _05 -I -, 7k 3 Date i verfied fi aC�-064 Q '-A `/I ,^. A 4 -TA (2 —176M, 'ak\ 6A I0 4e SZ 4� 0'_ ida KAVb) J AAA 'eA ._J) Vk,'13:11) U JOX 'elf Aj)o 11.6 YA i s i n AAA 0/iAj 0f M.Y C�jAtVA_I�Q LI- A I JGA V�O 0 AY& 'Y\ 00I-IVI Q A 14A_� U\A/91�k `,;AA li7l CL OAA (a_'ej OA14111 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 R No a-, Yes o Voluntary Compliance 0 Employee Restriction Exclusion ED Re -inspection Scheduled L:j Emergency Suspension L] Embargo Lj Emergency Closure Lt Voluntary Disposal L:l Other: Violations Related to Foodborne fitness Interventions and Risk Factors (aeras 1.22) (Cont.) PROTECTION FROM CHEMICALS Lt4 w db IM TIME/TEMPERATURE CONTROLS proper Cooking Temperatures for 3-402.11 A(l)(2) I @ggs- I55 F 15 Sac. -40L11(A)(2) Cumminuted Fish, Meats & Char Ariuvals - ,j5°F" 15 3-40 L1 i (H)i i r('2) Pork and Beet Roast -19U t 121 minx .r-�301.11(Ay 2) Raihce , ii jec n kicats 155 �i I5 ct _ 3-4G1-21(A;C3j Pt7uhr r_l'�'iid (iimc Stu(fui PhP%s, Sniffing Containing Fvql, Meat Aniliec or Ranter 163°I 15 we 3-A01.iltCti3i Whale-rnuscic,6 tractB3efiiteaks l4S Imo' _ 3-401.12 Ria Annual 1 rxud5 Cookad in a Mie owave 165'Y _* _ _ -dOl 1(Zi H6_i 111 Other fall - 1451 15 sec 1 3-403.1)(A)I&A.)) Piths WIT d-3 sena I 3-dO3.11 6) !liciovave-tb5"F2MinuteStandin 3-1Q3.1 I(C} I Commercially Processed RTE: Fc"1.. 3AO3.1i(E) I Retnaiturtr :3-501 14A) � CeoliogCookedPHFs from 140'F to 70"1: Within 2 hours and From 70,F _ to 1I "1,145'P W itt in 4 Hour.. - 3-SOl.l4(8) Coofua4 PHR Made Frnt Arnbienl Temperature ingrcdienes to 41`F145"F Within 4 flotn,* ` Derr tees critical item la the ("dual 1999 Fo(xl Codeor M (Alk 59il €00 J 5O1 1 -ECC'.) PHTs Received at Teniparaturas A-aolmag, to lawCooled to _ 41 f%a_S €� Within v Hours. 3-501.,5 Cexilin,'Mod x#.sforPHFs 3-50I M(6) Cord Plll s Maintained at or beloi 590.004(F) 41 /45` t 2 -SOI, f 6(:-) [ha PH1 c 5.famtained at or above I JWP r Rtxists Held at or above 130"F. Time as a Public Health Control 'i90.004(H) I Y'areorw Requirement REOUIREMENTS FOR HIGHLY SUSCEPTIBLE _ POPULATI_O_NS (HSP 21 3-8Q' td{A)'U^zpmtcurirsdf*re-1zeu:l:agcdltiictswid� 3-801 11tD) Rau or Partiaid d f oriked Aattnal Fond and _ {(-R lu st cd tuts Nor Suited 1-801 JI(C)I t�nrrac ned Ilax{ Packaer Net Re served CONSUMER ADVISORY 22 d Consurn� r ldviscxt >'ost�d rix <'utisutnption n£ vthnid F xxit'11zat art €tiax Cndercookcd to cru OtlierKise PTtn.csted orhi inmate P ttlte�ns * �.. ria -3u2 13 i P&;te nr..d Fg#I 4uhs riot. to. Raw Shelf SPECIAL REQUIREMENTS 590.0(i4te�1 tl)) Violatf ais of Section '594.(X)9(A)-(D) in catering. mobile fixici, teropurary and. 1 remdent al kitchen opi ations shoold fie dobe ed under Pile appropriate a eioas .tx v �f rclaPed ice lixxlboritc t","o, css iulei-venbous and risk faclors.Other 54Q.J09 t iulatiuns relatitt to ixf retail prrcticcs ahould be debited under #29 - Speci'r]lduntlir:crietrts. RETAIL PRACTICES (,ttema 23-30) Cririraf and rion-cruwal vlotaliona, whack do fun retofe to tie ¢nodbarne t{I»auirwi ventinrir and rokfaetors issued above, ran be ,found in the of Fond Code atd 105 (WR Food or Color Additives ¢ 242.I2 Adluves* ._...-. __ 3 3t)Z.f4 Pr+xcct in fran'zIna) piveed Additives* Poisonous or Toxic Substances ---a 7-101.11 ldentifping information - Od-mid Containers* 7-102.12 1 CommonNam_e- WmkirrgContainers* 7-2011 f S2para on- SnJ]1t ve*_ 1,L202.11 Re.1riction - I'resenca and Use' -7-202-12 Condition~ of Usa* i '03-11 ! 2O4.Ii Toxic (ou(am Prnhdxrtioms Samiizcus C'ntt a ChennciW _ 7 2174 E2 Cticnuc a,tot 1) ichni:r larichice,.. C ihaij i 7-20-4,14 i05.I t Incidental 1 r)d Contact. Lilhncants* I° 205611 Ru oicted U!a Pe riczdes. Cotetii* 7-206.12 ..v Rodman Bait Stations`` _ 206 1? Lacking Pc»vdCts, Pest Control and TIME/TEMPERATURE CONTROLS proper Cooking Temperatures for 3-402.11 A(l)(2) I @ggs- I55 F 15 Sac. -40L11(A)(2) Cumminuted Fish, Meats & Char Ariuvals - ,j5°F" 15 3-40 L1 i (H)i i r('2) Pork and Beet Roast -19U t 121 minx .r-�301.11(Ay 2) Raihce , ii jec n kicats 155 �i I5 ct _ 3-4G1-21(A;C3j Pt7uhr r_l'�'iid (iimc Stu(fui PhP%s, Sniffing Containing Fvql, Meat Aniliec or Ranter 163°I 15 we 3-A01.iltCti3i Whale-rnuscic,6 tractB3efiiteaks l4S Imo' _ 3-401.12 Ria Annual 1 rxud5 Cookad in a Mie owave 165'Y _* _ _ -dOl 1(Zi H6_i 111 Other fall - 1451 15 sec 1 3-403.1)(A)I&A.)) Piths WIT d-3 sena I 3-dO3.11 6) !liciovave-tb5"F2MinuteStandin 3-1Q3.1 I(C} I Commercially Processed RTE: Fc"1.. 3AO3.1i(E) I Retnaiturtr :3-501 14A) � CeoliogCookedPHFs from 140'F to 70"1: Within 2 hours and From 70,F _ to 1I "1,145'P W itt in 4 Hour.. - 3-SOl.l4(8) Coofua4 PHR Made Frnt Arnbienl Temperature ingrcdienes to 41`F145"F Within 4 flotn,* ` Derr tees critical item la the ("dual 1999 Fo(xl Codeor M (Alk 59il €00 J 5O1 1 -ECC'.) PHTs Received at Teniparaturas A-aolmag, to lawCooled to _ 41 f%a_S €� Within v Hours. 3-501.,5 Cexilin,'Mod x#.sforPHFs 3-50I M(6) Cord Plll s Maintained at or beloi 590.004(F) 41 /45` t 2 -SOI, f 6(:-) [ha PH1 c 5.famtained at or above I JWP r Rtxists Held at or above 130"F. Time as a Public Health Control 'i90.004(H) I Y'areorw Requirement REOUIREMENTS FOR HIGHLY SUSCEPTIBLE _ POPULATI_O_NS (HSP 21 3-8Q' td{A)'U^zpmtcurirsdf*re-1zeu:l:agcdltiictswid� 3-801 11tD) Rau or Partiaid d f oriked Aattnal Fond and _ {(-R lu st cd tuts Nor Suited 1-801 JI(C)I t�nrrac ned Ilax{ Packaer Net Re served CONSUMER ADVISORY 22 d Consurn� r ldviscxt >'ost�d rix <'utisutnption n£ vthnid F xxit'11zat art €tiax Cndercookcd to cru OtlierKise PTtn.csted orhi inmate P ttlte�ns * �.. ria -3u2 13 i P&;te nr..d Fg#I 4uhs riot. to. Raw Shelf SPECIAL REQUIREMENTS 590.0(i4te�1 tl)) Violatf ais of Section '594.(X)9(A)-(D) in catering. mobile fixici, teropurary and. 1 remdent al kitchen opi ations shoold fie dobe ed under Pile appropriate a eioas .tx v �f rclaPed ice lixxlboritc t","o, css iulei-venbous and risk faclors.Other 54Q.J09 t iulatiuns relatitt to ixf retail prrcticcs ahould be debited under #29 - Speci'r]lduntlir:crietrts. RETAIL PRACTICES (,ttema 23-30) Cririraf and rion-cruwal vlotaliona, whack do fun retofe to tie ¢nodbarne t{I»auirwi ventinrir and rokfaetors issued above, ran be ,found in the of Fond Code atd 105 (WR TOWN OF MARBLEHEAD - FOOD ESTABLISHMENT INSPECTION REPORT Establishment FOOD PROTECTION I iolations Related To Foodborne Illness Interventions And Risk Factors MANAGEMENT I IC LPIC is not qualified - PIC is not certified or certification /KI10 geable/Duties has expired. does not employ (FTE/PIC over 18 yrs. 2.Eified 11CC((JJ, certified as as an o on site manager. �CLUQ/) io 3. Certification not posted. 4. Alternate PIC is not trained in food safety. Certification � not required but they must be knowledgeable in food safety. CIO 5. Non employees in non restricted areas of the kitchen, 2rep area or ware -washing area. EMPLOYEE HEALTH 2. Reporting of diseases by Food (.Employer is not checking on the health of the employees or O. Employee and PIC The employees are not telling the PIC of their health problems. 3. Personnel with Infections 1. PIC is not excluding or restricting an employee who has Restricted/Excluded health symptoms. 2. PIC is not following procedure for exclusion and restriction of employees. 3. PIC is not following procedure for the removal of exclusions and restrictions of an employee. FOOD FROM APPROVED SOURCE 4. Food and Water from Approved 1. Food or bottled water not from an approved source. lee not Source2.Food from an approved source. not sealed properly 3. Milk and Shell Eggs not Grade A standards. 4. Fish not approved for sale or recreationally caught shellfish. Shellfish not tagged or from an approved source. 5. Game animals on the endangered species list. Wild mushrooms that are not inspected. S. eeeiving/Condition L PHF not received at 41- or below. HACCP- RECEIVE 2• Raw eggs not received in refrigerated equipment at 45o or _ ...�n less. 3. PHF cooked to a temperature not received hot or at a temperature of 135- or above. p 4. Frozen foods not received frozen. 5.Foods received that have evidence of previous to temperature abuse. 6. Foods that are not received in good condition, dented cans or torn packages. 6. Tags/Records/Accuracy of 1. Shellstock not obtained in containers with legible tags or Ingredient Statements 0 labels affixed by the harvester or dealer. 2. A tag that does not have the harvester's identification N HACCP- RECEIVE and the date of harvesting. 3. Tags that do not have dealer's information and certification number -tag stating to keep tag for 90 days. 4. Label tops from shucked shellfish missing. 5. Fish received damaged. Raw or raw -marinated ready to eat fish - fish that is not frozen at -4 - or below for a minimum of 168 hours. 6. Fish that does not have records of temperatures, sale and records kept for 90 days. 7. Any fish 0hat does not have labeling or in redients. w 7. Conformance with Approved1. Establishments that have not received a variance for Procedures/ HACCP Plans smoking food, curing food or preparing foods that require a variance. 2. Establishment that packages PHF using a reduced oxygen packaging method without an approved HACCP Plan. 3. Does not comply with the HACCP plans and procedures that have been approved. 4. Does not provide records to demonstrate procedure for Critical Control Points. P ROTI� CTION FROM CONTAMINATION 8. Separation - Segregation - 1. Not separating raw foods from each other, cooked and RTE foods during storage, preparation, holding and display. Protection 2. Not arranging each type of food in separate equipment HACCP - STORE 3. Packages are received opened or cut. HACCP-PREPARE Storing damaged, spoiled or expired foods. 4. Not washing fruits and vegs before they are cooked or (/VU served. 5. Food in contact with urs utensils or surfaces. 6. Re -serving food that has been returned or not eaten except been re e for condiments in jars or containers with lids. 7. Serving food that is not from an approved source - RTE foods that have been contaminated by an employee - foods have been contaminated by employees or consumers. . 8. ood not covered 9. ood Contact Surfaces Cleaning 1. Manual ware washing - temperature is not 171- or '26d Sanitizing :her. 2. echanical ware washing -temperatures for rinse are not n 65- for stationary rack or 180-194- for other machines. 3. A chemical sanitizer used in a solution for manual or mechanical operation does not meet the criteria determined by the test kit. 4. Food contact and utensils not clean to sight or touch. Food contact surfaces of cooking equipment not free of grease or soil accumulation. Non food contact surfaces not free of dust, dirt, food residue and debris. 5. PHF equipment and utensils not cleaned every 4 hours. 6. RTE, salads bars not cleaned every 24 hours. 7. Ice tea dispensers, ice dispensing nozzles, ice makers, and any dispensing lines not cleaned on a regular basis. 8. Utensils and food contact surfaces not sanitized before or after cleaning. 9. Cutting boards dirty, deep cuts or chipped. 10. Proper Adequate Hand- 1. Employees are not keeping their arms and hands clean. Washing 2. Employees washing their hands in sinks not designated for Hand Wash. HA CCP - PREPARE (a)Employeesffo 3. Employees not following a hand wash procedure or not using paper towels to dry their hands and arms. not washing their hands before they engage in n any type of food preparation, set up or serving, oran r 5. Employees not washing their hand after touching body �f O „1 � LWI parts, animals, soiled equipment or using the rest rooms. 6. Not washing hands when switching from raw foods to RTE Foods. 11. ood Hygienic P ctices 1. Eating, drinking or smoking in a non -designated area. CP -PREPARE 2. of drinking from a closed container. 3, Employee working with a persistent discharge from eyes, 9,� nose or mouth. 4. An employee that uses a utensil more than once when tasting food. E1 a i 12. Prevention of Contamination ].Except when washing fruits or vegetables or handling RTE - from Hands a foods an employee not using utensils such as deli tissue, patulas, tongs, single use gloves or dispensing equipment. 2. No gloves, tissues or utensils readily available. 13. Hand -Wash Facilities 1. Establishment does not have a Hand -Washing Sink O available. 2.Establishment does not have a utility sink with a Floor drain /' 3. Hand -washing sink not located in prep area and/or in or adjacent to rest rooms. V 4. A hand -washing sink being used for multiple purpose. 5. A hand -washing sink that does not have hot water, soap and a heated drying system or paper towels. 6. A Hand Wash Sink not labeled for Use. PROTECTION FROM CHEMICALS 14. Approved Food or Color 1. Foods that have added chemicals or pesticide residue. tt 1 �f Additives JV 2. Eggs, milk, cheese or ice cream that is not pasteurized. 15. Toxic Chemicals n) 1. Cleaning bottles, sanitizers or poisonous materials not IVIV H -STORE labeled. Or smaller containers from bulk products not -ACCP Cn n�C-- \ n _ properly labeled. 2. Poisonous or toxic materials are above food, equipments y V utensils or linens. 2 Poisonous or toxic materials that are not used in the ��,Q � e3.s establishment are on the premises. 4. Containers originally used for toxic materials are now used to store or transport food. 5. Facility not using a sanitizer to clean food contact surfaces. • 6. Lubricants used on equipment coining into contact with food. 7. Rodents bait is not covered or in a tamper resistant bait station or a tracking powder pesticide is being used in the food establishment. TIME/TEMPERATURE CONTIM-LS (Potentially Hazardous Foods) 16. Cooking Temperatures / 1. One or more of the following foods have not been cooked Q' lrr% HA CCP - COOK up to temperature. Eggs- 155- for 15 secs. Or 145 -for immediate use. Pork or beef roast 1300 Injected meats 155 -Poultry , wild game or stuffed meats 165-, Comminuted fish, meats & game 150- 2. Microwave food 165- 17. Reheating 1. Foods that are not reheated at 165- for 15 sec. HA CCP - REHEAT � 2. Microwave food not reheated at 165- and a 2 minute standing time. 3.Commercially RTE not reheated at 140- 18. Cooling1. Not cooling cooked PHF from 140- to 70- within 2 hours. IIA CCP -COOL- FREEZE- THAW 2. Not cooling cooked PHF from 70 -to 41 -within 4 hours. 3. Food that is thawed not using a cooling method such as, ice baths, running cold water, or cooling in the refrigerator. 19. Hot and Cold Holding \ 1. Cold PHFs not maintained at or below 41-. HA CCP - HOLD a 2. Hot PHFs not maintained at or above 140- 3. Roasts not maintained at 130-. 4. No thermometers visible or accurate readings. 5. Frozen food not kept at 0- 20. Time - Public Health Control 1. Food that has exceeded 4 hours and was not removed HA CCP - SERVE, from service or discarded. C REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS [ISP 21. Food and Food Preparation for _ 1. Unpasteurized pre-packagedjuices and beverages being HSP served to children 9 years and under. 2. Raw or partially cooked animal foods and raw seed sprouts are being serviced to HSP 3. Unopened food packages being re -served to HSP. CONSIJMFR ADVISORY 22. Posting of Consumer 1. Foods are not properly labeled to include 2 or more ._. ingredients listed by descending order by weight, quantity of Advisories contents or an artificial color, flavor or chemical preservative. 2. Foods are not honestly presented by using colored overwraps or lights that misrepresent the true appearance of the food. VIOLATIONS RELATED TO GOOD Violations Which Do Not relate To Foodborne Illness RETAIL PRACTICES (C or N) Interventions and Risk Factors 23. Management and Personnel 1. Employees hair restraint is not worn or excess jewelry . Fingernails are not short, clean or unpolished. 3. Personal items in restricted areas. 24. Food and Food Protection 1. Food prepared in private home being sold retail. 2. RTE foods being handled with bare hands. 3. Food not covered in fridge, freezer or room temp. 4. Frozen foods not kept at 0- or below. 5. Utensils are not handles up for distribution. 6. Food is not stored at least 6 inches off the floor. 7. Refrigerator or Freezer units are not clean. S. FIFO is not being conducted. 9 eusable towels used for drying hands, paris and utensils. 25. quipment and Utensils 1. efrigerators or freezers do not have visible or correct ermometers or are not working. 2. Food slicer or prep areas are not clean Cabinets, shelves, ovens, fryer or ranges are not clean. 4. xhaust hood and filters are not clean. 26. ater, Plumbing d Waste Bottled or drinking water not coming from an approved source. 2. Chlorine test kits or chemical sanitizers not being used I t, to check on cleaning and sanitizing. 27_. hysieal Facility 1.,Screens or doors not installed properly or torn screens. hrF'�ee bay sink not labeled.-- 3. Flies in any part of the establishment. 4. Garbage cans are not clean or emptied. U 5. Boxes and containers are not removed from the site. AA Et4 6. Loading docks and dumpsters are full or not cleaned. 7. Open doors or windows without screens. 8. Unfinished construction. 9. Lights that are not shatter -proof or do not have shields. 10 Floors and walls are not clean. 1. Restrooms do not have hot water, soap, toilet paper or paver towels. 28 olsonous or Toxic Materials heT ails are nj stored properly. Special requirements 1. Caterers -Not informing the BOH of events whe e they are catering. 30. Other HACCP Plans V-) Commonwealth of Massachusetts r City of Salem Board of Health IGmberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/30/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000357 LOCATED AT: Witch's Brew Cafe 156 Derby Street Salem MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2009-0316 Dec 30, 2008 Dec 31, 2009 $280.00 ESTABLISHMENT t i PERMIT EXPIRES Total Fees: $280.00 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Paye 1 0 KIMBERLEY DRISCOLL MAYOR ,JANET DIONNE, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4` FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 IDIONNL@SALEM. COM 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTI� t rCPi'S 13 2� � CFS TEL # 97q-79!5 -87/ 7 ADDRESS OF ESTABLISHMENT t S& tkt-Q-fbH 5raE-C71— FAX # MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'S NAME TEL # 9-18'74y- '73&q ADDRESS STREET ST CITY t_<1_, n -n STATE A CERTIFIED FOOD MANAGER'S NAME(S) til?\2o t GL3&3SLA Vk CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON 5-e%40 HOME TEL # ,DAYS OF OPERATION Monda ': % '. Tuesda' Wi dnesda . •'it: Thursday: :. Friday,-` Saturday . Sunda HOURS OF OPERATION t 1,4 Please write in time of day. (For example11amllpm) 1 Ar-,. TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES O less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -------------------- - RESTAURANT YES NO ..................................................... less than 25 seats (Outdoor Stationary Food Cart $ 0 25-99 seats =$280 more than 99 seats 20 - --------------------------------------- ------------------------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $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 bl�submitted to and approved by the Salem Board of Health. Pursuant toAGL 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 iaSd all state taxes required under the law. o --)2a a 3c)3 Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check# & Date 156 Derby Street Telephone: 744-7369 Owner: Spiro Kounsalieh PIC: Spiro Kounsalieh Inspector: Elizabeth Salandrea Date Inspected: Correct By: 7172008 Risk Level Permit Number: BHP -2008-0277 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) Witch's Brew Cafe City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED we"nment: 1 knife in knife rack had some food debris on it. All knives must be properly washed, rinsed and sanitized after use prior to storage. Pelutting board at soup holding table stained and scored. Resurface or replace cutting board. We scoop at the bar not being stored correctly. Store ice scoop in a clean, sanitized container or in ice with handle extending out. Handwash Facilities FAIL Critical ❑V RED teb-m-ment: Handwash sink at bar obstructed with a bowl. All handwash sinks must be accessible 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. Jul 15,2008) Page 1 oft RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and FFQod Protection FAIL Critical BLUE L�C,o/mment: Uncovered food in walk-in fridge. Cover all foods in storage to prevent cross contamination. �kleer, unit in kitchen had some uncovered food in the bottom compartments. Cover all food in storage. Karge freezer in kitchen had ripped bag in it. Cover/wrap all food in storage. Equipment and Utensils FAIL Non -Critical &15mment: Walk-in fridge needs general cleaning on the floor. BLUE 4,1114th freezers in basement missing internal thermometers; one was present but broken. Provide visible, accurate internal thermometers for both freezers. helving in very back corner of kitchen needs general cleaning. �ul system due for cleaning 5/2008. Have ansul system professionally cleaned. cont fryolator needs general cleaning, including beneath it. /oth freezers in kitchen need general cleaning. El quor cabinet in bar needs general cleaning inside. Physical Facility FAIL Non -Critical BLUE �mment: Lights in basement above dry storage area do not have covers. Provide protective covers for all lights over food storage area in basement. creen on screen door in kitchen torn. Repair screen door. ere are some stained ceiling tiles in the men's room. Investigate source of leak and replace all stained tiles. Reinspection to take place Wednesday July J6, all violations to be corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 15,2008 ) Page 2 oft �kw • 156 Derby Street City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Telephone: 744-7369 Owner: Spiro Kounsalieh PIC: Spiro Kounsalieh Inspector: Elizabeth Salandrea Date Inspected: Correct By: 7/16/2008 xRisk Level: 'Permit Number: BHP -2008-0277 Status: SIGNED OFF # of Critical Violations: €0 ,Time IN: Time OUT: Status Violation Urgency Description(s): BLUE: I All violations noted in the 7/7/08 inspection report have been corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 \ days)(Non-critical violations must be corrected immediately or within 90 days) 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 Witch's Brew Cafe Critical Urgency ( Rev. Jul 16,2008 ) Page I aft RED:-- „ - ..-- t Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 16,2008 ) Page 2 oft t 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 NameDate n i PIC's Signature: Print: Tvoe of Operation(s) Type of Insoaction ®Food Service E]Retail ❑ Routine 5(] Re -inspection 1 T,) G Address S I Risk Level ❑ Residential Kitchen ❑ Mobile Previou inspeption Date: I p9 Telephone �t A I T�1 1 ^ [:1 Temporary ❑ Caterer ad ❑ Bed &Breakfast ❑ Pre-op ration El Suspect Illness El General Complaint Owner . t S !Q �� HACCP YM Person in Charge (PIC) Time _ In: !. Out: I (S -SW Permit No. ❑ HACCP ❑ Other Inspector �` P Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. r FOOD PROTECTION MANAQEMEN7.F",,,,'"„,�,�5 ❑ 1. PIC Assigned/ Knowledgeable/ Duties P EMPLOYEE HEALTH � r �.. - El 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded )i{ FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities ."PROTECTION FROM ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals (,,TIMEITEMPEFiATURECONTROLS(PotemrallyHatardousFoods) , ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 16. Cooling CPROTEC710N FROM COHTAMINA170N19. Hot and Cold Holding fdo.. .ve+.-.... .. r.. _,n".r ls�m¢++n�v Wt+Y-..v aTshl oove..mnwmn' ❑ 8. Separraa-tti' on/ Segregation/v Protection ❑ 20. Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board ` of Health. Non-critical (N) violations must be corrected .immediately or within 90 days as determined by the Board of Health. 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) t 30. Other [_REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (RSP)T] El21. Food and Food Preparation for HSP CONSUMERADVISORY..y�l,ul.,'�'�aPary„�;::,�at5,! E:]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: An AA Inspector's Signature: PIC's Signature: Print: Page lof /7 Pages 'N\ Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT �r590.003(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 Mi lk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Cr 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 Cbar e* 3 590.003(D) Exclusions and Restrictions* 3-201-15 590.003(E) Removal of Exclusions and Restrictions 4 C in C FOOD FROM APPROVED SOURCE a Denotes critical item in the federal 1999 Food Code or 105 CYIR 590.000. 10 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 Mi lk and Milk Products* 3-202.13 Shell Eggs* 3-202.1.4 F,g >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 310 CMR 22.0"' Washin Fruits and Ve etables Shelfish 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 Shelistock Identification Present* 590.004(0 Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 - PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11. Food Safe and Unadulterated Togs/Records: Shellstock 3-202.18 Shelistock Identification * 3-203.12 Shelistock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui icnt* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Promising Methods* 3-502.1.2 Reduced oxygen packa ging, criteria* 8-103.12 Conformance with Approved Procedures* a Denotes critical item in the federal 1999 Food Code or 105 CYIR 590.000. 10 PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.1.1(A)(]) - Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3502.11(A)(2) Raw Anirnal Foods Separated from Each Other" Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washin Fruits and Ve etables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice, of Food'* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Rewnditioning Unsafe Food* 9 Food Contact Surfaces 4-501..1.11 Manual Warewashing - Hot Water Sanifization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.I I(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui icnt* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2401.11 Eating, Drinkin or Using Tobacco" 2401.12 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* 5-204.1.1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11. Hindwashing Cleanser, Availability 6-301.12 Hand Drying Provision t CITY OF SALEM BOARD OF HEALTH F;QtAhIi_qhMPnt Name- UA_�k_3 IR -o'- I(: Date: ci Lq Page: 4-5) lern N de Coverified Refere� a C - Critical Item 0 2;'Re R d Item AMZ� DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION r=�4kw �, PLEASE PRINT CLE "LY Date kof^r/ Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code.." I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. /_ Z - � Corrective Action Required: 0 No es Voluntary Compliance U Employee RestrictionExclusion Lj Re -inspection Scheduled L3 Emergency Suspension L3 Embargo L3 Emergency Closure I U Voluntary Disposal Li Other: Violations Rotated to Foodborne Illness Interventions and Risk Factors (item 1.22) (Cont) j Food Eff I • a '. 0 ).� or Color Additives 3-202.12 Adedti e:* _ 3-302,14 Protection from Unapproved Additives" 1 Poisonous or Toxic Substances 7 101.11 _ �klentifying tnfonnation - Original {:olttmneW _ 7-102.11 _ Cotnlnon Name Workup C owainers" 7-201.11 Sc aiation Storage 7-20211 7,202.12 Restncuon- pr<scncemidLao" _ C_bnditions of Use* 7-203.11 ToxicOntaineta- Ptohibitionsl 7-2'A1'1 _ Sanirizeas,Cdte:ii-Chentiteds* ?-2041 12 Chende its for W ash 1'LElut.c Criteria': 7 204.14 Dr}ing Anent€. Criteria' r- 05.11 lnui&ntat Food t e mail, bibitc min' 7 20f>.21. i{enrrlc(d use Pr ncidec Cntelt_ ll 7-206.12 (1 7 206 13 Roden Beit Stt:nrnts' I'ra kris, Pgyvdar, P" m Control 1tonit nngc Food Eff I • a '. 0 ).� Proper Cooking Temperatures for PHFs 3-=1flh.11At1)(2} _ Fig . I 55 15 Sen, Itnnxthate sereicr IWT15sw 3-401ANA)(2) Cotmromned Fish, Meat, & Chane _ 3 401.1 1(B}([7(2} 3-491.11(A)[ 2)� .Animals- 1>5 F 1_ sec.__ _ Pork and Bed Roast -130`{` 121 ilii Rauw, Injected Wats 155 �F 15 � sec _ 3-4O1,11(Ali 3) Poultry,Game, _$tuttedPNF,, Stuffing Containing fish Meat, Poultry or Hautes 1654 15 yea. "` { 3-4O111tG)(3) aihole mascic b lent Beef St'eak's 145 1 * t 3-401 . k2� R�iw Anima[ F'c;rttls C:atkett in a Microwave 165'F 3-401.11(,31(13(6) At Mier PHFs -145`17 15 sec. * . 17 Reheating for Hot HoldingW 3-103,11iA)&(D) 21-Wi lbs" F 15 sec. :^ _3p -403.11(B) Microv, ave -165' F 2 Mimae Standin}, Time, _ 3403.11(C) commerciaih,PrtxesseclRTFFtit - 14W ' 3-h{13-11(17) Remajilmg Utrsheed portions of Beef Roasts" I jg 3 501_idlA) Prc psi Cooling of PHFs C7shag.Cooked PHFs from 14O`F to 7011; Within 2 Flours and From 70T 3-501-14(6) to 41'F/45'FWithin 4 Finurs. rooling PHF Made Front Ambient Temperature htgredients to 4l`Fi45`F Within 4 Hums"' *Dentes critical item hl the reBeral 1999 FoM C,xfeor 105 CMR 590 600. W. PHFs Reuived at Temperatures According to Lau- Cooled to 41 °F/45" F Within 4 Howsti 7- 19,, 19PHF Hot and Cold Holding 13 S0 7.)5(B) Cold PHFs Maintained at or t atout 3-501.16(A) 13ot' PHF , Maintained at or above 140 E ,lA01 '1FCAp 1 0 --lo Kin FA m .tee ohas s d(laG 20 1 1 Time as a • 21 1 3.801.11(A) Unp t euny.ttl Pic -packaged Arius and Bev—os es with Waraait $0l.11(ii} Clic of Pa,tetapnd F3 -$111.11(D) Raw or Parti. di Cored Animal Food and �__� P-, s, . a s— o,r... c ., ,. 1 3-R(;} 1l(C) 1 Unopened Food Package Not. Re -served. ' CONSUMER ADVISORY 22 3fi>0311 Consumer Adtls iv Posted for C"ottsitmptionof Anins rl t :til& that ire Raw, Underca>ked o: Not Othei kx Process"d to Fdtmincte Path(r1Si 330? 13 " P.stec rte d 1 ae= Substitute fir Raw Shell 590B)t9tA)-A violanonsofsection59O.009fA)-.(D)in catering. mobilt ftxxi, temporary and resideuliat kitchen operations should be debited under the appropriate sections adxwc if related to to(Aborne illness inlet venUons and tisk factors Otbtr 590.009 violations relating to good retail practices ;,should be debited under #29 — Specia7 Requirements_ (items 23-30) Criairal c rid inn -s ritual viutaiolna, elach do the rebate ro the .foodborne illness noerveno,ea• and ri, dk j rctet" lisredahove. Cern be ,found in ettc j slowing sections o/ the Good Code and 105 CUR Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT n Salem Board of Health 120 Washington Street, 0 Floor ) f a < Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name ( I / I I I % 1!O Date i! Type of Operations) Type of Inspection a -Food Service ❑ Retail El Residential Kitchen ❑ Mobile [I Temporary p �' ❑ Caterer ❑ Bed & Breakfast I Permit No. ©Routine El Re -inspection Previous Inspection Date: 6//J ❑ ❑ Suspect Illness E3 General Complaint ❑ HACCP ❑ Other Address/ O r 1 A o t�J Risk I Level Telephone _ Owner (7 °SY}� 1 C HACCP YM Person in C arge (PIC)1 �4 n IIn: Time )a. a . Out: P.4 e) Inspector �� q�n Each violation checked re uires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. )FOOD PROTECTION MANAGEMENT,,. ❑ 1. PIC Assigned / Knowledgeable / Duties " EMPLOYEE HEALTH ell ❑ 2 Reporting of Diseases by Food Employee and PIC ❑ 3.. Personnel with Infections Restricted/Excluded ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities i PROTECTION FROM q`'"` �.��.j El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals i_r = ' FOOD s�€�., iTIMEITEMPERATURECONTROLS(#�otenUeflyHazardous Foods) fw g E]4. Food and Water from Approved Source __ as�iat"„ »api( ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans ' PROTECTioN FROM CONTAMINATION7T,�r � '' �" "` &rU' mniiz� 8. Separation/ Segregation/ Protection EP9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ` Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S:5WM�crFon -ia.m / l / /1 // ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control 11E00IRE6IENTS FOR HIGHLY $650EPT19LE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP r,CONSUMEF,?ADVISORY'," El 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's SignatuI 1:� k Print: J PIC's Signature: ° Print:,,S" P btu LII Page/ of -2 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 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 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 S stem* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclumnc and Restrictions* 3-201.15 590.003(F) Removal of Exclusions and Restrictions C 6 C 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* 3-201.12 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..1.1 Drinking Water from an Approved S stem* 590.006(A) Bottled Drinking Water* 590.006(B) 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* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* _ Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Game Animals* 3-701.1.1 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package lnte it * 3-101.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-20312 Shellstock Identification Maintained* - Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(1) Labeling of Ingredients* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans 3-502.11. Specialized Processing Methods* 3-502.12 Reduced oxygen tackaging. criteria* 8-103.12 Conformance with Approved Procedures* ° Denotes critical item in the federal 1999 Fowl Code or 105 CMR 590.000. 8 Cioss-contamination 3-302.11(A}(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-30211(A)(2) Raw Animal Foals Separated from Each Other` Contamination from the Environment 3-302.11(A) Food Protection* 3-302.1.5 Washin Fruits and Ve etables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.1.1 _ Discarding or Reconditioning Unsafe Food* F9-- 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. 'k 4-60111(A) Equipment Fax! 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 -Hut Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11, Clean Condition - Hands and Ante* 2-301..1.2 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-40112 Discharges From the Eyes, Nose and Mouth* 3-301..12 preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(F) Preventing Contamination from Fm to ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.1.1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Nand Drying Devices 6-301.11 Hindwashing Cleanser, Availabilit 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH J Establishment Name: ' t�!l� r !�C'(N_ ��, Date: LJJO, Page: 7 of3_ Rem - Code Reference .,.g..„�ry'-n. C -Critical ttem,' R -Red ItemP.: z DESCRIPTION OFtlIOLATION /PLAN OF CORRECTION r t r'''`-�,�.^a' ; �r. a, afi �."''+- „,. "6zF. '.. . PLEASE PRINT CLEARLP.. ��+'8 :lr: „-..'d�, au",,F ...�a Date Verified':, eu.`.. K.U��v F41 7.I�k'�� ,. tit', n4 n. IV oo J-4 J0 h.P L06011n re a (�. Dpi- Qu C a �if Nel c5 l ql7 ni n 1 67 ./- G .� . f 12F1 i��r�U//l r( SK:(cl,v ;� U;'11SQ. � S J? C l— ? U(�1, �?- X� . cvn A r� o�Mtr .j 1 {7 r. w L - (]) 3 Oc . Pei A4.(( _1 -3-0 IMAi + +�^ ` k)Q4'r t IX(/nrn 1A LA U1 e�tor� Jeo 1 4(^ i n (no H n.�,� „ 1J� )C-r�sCcc0., � r o I/ rO r ^ / � k;-) G V( iYl .MOI / I -4c L, Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all p PP Y 4 ❑ Voluntary Compliance ❑ Employe 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 A/I understand that Emergency closure noncompliance may result in daily fines of twenty-five dolls orr sua`V n/revocation of Embargo ❑ your food permit. ❑ Voluntary Disposal Cl Other: L f. Violations Related to Foodborne, illness Interventions and Risk Factors (Ilms 1-22) (Cont.) EiTwyi3gi6Tlqpj:T#TiT,yiOF41TIIW�m 1=4 Food or Color Additives 7-2-0-21-2— --- Additive,'4 T302.14 protection 15 # Poisonous or Toxic Substances 7-101.11 we"lifying info) mailon - Original -744R. I I (B)( 1 }(2) Polk and beef Roast - 130'F 121 min" 7-102,11 Common Name- Workin� T-2TI. Ijarion - Sto2ESL_-- 7 1-2011] Restriction - Pr,,scnce and U�e* 7-202.12 Conditions of Use 7-203.1T— —TZX-ic—Coatwnci—Prohihoiopi* 7-204.11 Sanvizers, Criterie, - Chemicals* 7-204 12 Chemicals for C1 itei iat' 1 7 204 14 -v(}5.3 I criteria, Incidental V"A Cunlet Lubricants' [?7ta6A I R.,�oicted L'lw Pesticides, Crit 7•-206.12 206 13 Rodent Bali stariolls' Tracking faolvdori. Rest Control and All (kher 1"IfFs- J45'47 15 sec, lvfookorin84 - - --- RT 730311937TURTA IWO T.Ff ;row 16 Proper Cooking Temperaturesfor L— T 3101.71 A(1)(-); PRFs Fgg.,- 155'F 15 Sec. 145"k<15sec, 1-ZI R(A)(,) Comminuted fi,h, Meats &- thine Animal, 15 sec. I -744R. I I (B)( 1 }(2) Polk and beef Roast - 130'F 121 min" 3-40 1.11 (A)(z i RiniiecIlowcd Meats 1�5'F 15 scc. 3,401 I I (Ay 3)4[l Wild (name, stutred lllfFli, Swifing Containing Fish. Meal, 15 sec. -hajlo-N=rRatncs-165'f WjR1lQ StOakS —I 3-401.12 Ra% In Microwave 165'F TF6 1, 11 (A)(1)(b) All (kher 1"IfFs- J45'47 15 sec, L17 Reheating forHotHolding 3-4031 PKF, 165-F 15 sec. -1 -7;103.11 (ii) -Micvow aw- 165'F 2 Moline Standine, Time, 3T63 140 commeacia y Pio eyed R -f botd 140'F* 3-403 11 (F) Remaining Umliced Portions (if Beef Roast,* Llg Proper Coaling of P RFi ; �501 14(A�) to t. o." IP 40)"l-, to Cix,liag PH 700F Within 2 Hours, and From to 4 I'F/45'F Within 4 Hours, ' .141B) L— Cooling I'l-fFi, Made From Ambient T�,mpetzvkrre liqlredierng o,41'F/45' Within 4 Ill*irs* , Dcn,aes 'meal stem ill the l"Jeral 7949 Pood C,Ae or 105 ("NIR 590 000. 14(C) PITFe Received Accordint, to Law Cooled to -11 'F45'F Witbin 4 Hkqus- P11,1 lot,,nd Cold Holding �i PH Cold PHFs aintaicel:1 at or below 3 501,16(A) I lot PHFs Maintaincalat or above )4(,,'F, 1st01 Time as a Variance REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSPS___ 17 ?-801.11 tA) Unpli,aetn iced 1"re-packaged Juices and I i3cseca>ea with WarnitlL Labelsf "-801.1E {B) ? i2 iw or Pan all Uxrk d Animal Ford and 3,801,1 IfCi I Unopened Folili Packaac Non Re -served. � CONSUMER ADVISORY F�22 -i-Zi)37111 onsulnel A(tii� �Try iloswj lor C;�wuloption ,ianiwal PoiAs Thai arc Raw, Underwlked o; Not Odkel-� Lse Rox:�%sed to Eliminwe Patho' -'e w 102.13 F&&: Subsaituir fo Raw Shelf 1,7 540-009(A) (Ui Violations of Sutton 590.009(A) -(D) in cateriog, mobilo, lbodtemporary and residentalkitchen lipeiiaaiiirls 4wuld be debited under the appropriate sections above if rejaim to RKAborno ithloss ollervoBlionS and ris.k factori, Other 590.004 violations relating 10 food retail practices,ilicadd be debited under #29 - Special Requirernerm- (Iteras 23.30) Criii,q' r ; and non -i iocal violaiiomj, wilich do eat relate jo rare foodhorne illness wict vcniwrvand rukjactors Ii.wed above can bil finand ie the joibraint sections of the Food Code aced .105 CXIR It 1 CM�Fdichmnnf Nsfmn• /'J l t I` S (l r V A,/ fir_ _ )F SALEM OF HEALTH— 1 Date: l /nKa F� i Page: of Rem No. Code ,. Reference M .P3 -C - Critical item .r R - Red Item s c ,-' ; ,',;. -: DESCRIPTION OF VIOLATION / PLAN OF CORRECTION a - x, PLEASE PRINT CLEARLY II avv Sro.l-: , :4 Acs A, ,L ck �u�r Q V (r c Date Verified = . _ COD�'� Q P(� r Pfd CLrj 4_ . ;�24- � 3� 1 � �i..� S-i�r�� ,-ir�,�n� I,J 1 �-(�r � a.�r' c� ��-..✓t�� _ to nr- n fin, X77— - �I . s kmcic-A .1�, ✓> - - O " o r '7 ��,on� - l Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all p pP Y q 9 violations before the next inspection, to observe all conditions as described, and t0 comply with all mandates of the Mass/Federal Food Crde. I understand that noncompliance may result in daily fines of twenty-fivAollars or suspension/revocation of your food permit. X i / Corrective Action Required: o No O�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 (Rents 1-22) (Cont.) PRnTFhitt9111 FAnM N-IFUMALS gq Proper Cooking Temperatures for Food or Color Additives PHFs 3-202.12 �- Addrm,.' e _ _ 3-302.14 _ Protection from Unapproved Addittaes' - -P5 Poisonous of Toxic Substances 3-401:1 t(B)i11;(22i 7-161.11 Identifying Into] ntation - Original -R+fnes, lnjecteu i4ge ds 155 P 15 Set _ Containers* -102.11 Common Name - W orkin * C'oht iinerse� 22n�-165`F 1S soo. '-' 1..201:31 SoLJaraukat Storage* 7.20211 Restriction - Presence and I)se'" _ Raw +,mme1 PI> Z Evoked III 7-202.12 Conditions of t)sa* -401. I I(A)(1)(b) 1?OS_11 Toxic fontamers-Probibitions" Reheating for Hot Holding 7-204.11 Saincizecs, Criteria -- Cherniads* -4033I(B) 7.204.12 Chcnncab; for YvY , hn Produce, Cinereal Time 7-204,14 DK± A effiz. (ern r i i j, 205. i 1 Incidental t W Contact Lubr icmus* ' Remaining Uie, iced Portions of.Bcef -T-20671 R srrioed i w Pe=ncides. Cntena" 7-20(1.12 R(xiew Bat SkAiews" CaIhmg Cooked PHFs hcnn 14()`F to 7 106 13 Tracking Powders, P-si Control and , Monitorin- I� t ' 1YoWes critical item in ihr r,,Ieral 1999 Food Cafe or 105 Cb2R 590 WO, 3-501-34W) PHFS Received la Temperatures According to Lay. Cooled to -4j i °F145"F Within 4 Homs. ,3Q1 15 1 Coolim Methods for PHR, 1-501 16(B, Proper Cooking Temperatures for Cold PHl s Maintained at or below PHFs _ I I AO i(1) } 8ps15 F 15 S c _ _ 1:�s�nnrnede;ztp SerJtcc lA5"F=tSsec-. 3-401.11.(A)(2) Comminuted Fish, Meats k Game Animals- i55 -7.I> sec." , 3-401:1 t(B)i11;(22i I Pork and Beef Roast - 13o`P 121 ruin* 3-�10I I I(A)(2) -R+fnes, lnjecteu i4ge ds 155 P 15 Set .i-40Lt11A)(3) Ponhrv, R'i1d Game, Stuffed PHPs, Stu Ging Contait,ing Fish, Meat, 22n�-165`F 1S soo. '-' 3-401111O(3) Whole-ninscle,lntact Beef Steaks 14,51l * 3-401—,12 � _ Raw +,mme1 PI> Z Evoked III Miceowace ih5°F -401. I I(A)(1)(b) All Other 1111.3- 145`P 15 sec. Reheating for Hot Holding 3 403.£I(A)&(D1 PHFa 165'P IS sec. ` -4033I(B) Microwave- 165" F2 Minute, Standing Time 3-41)3.1I(C) Commerciativ Pi(K ssrdRT Frood- 140°h` 3-403.11(E:) ' Remaining Uie, iced Portions of.Bcef Roast.* Proper Cooling of PHFs zS01, i9(A) CaIhmg Cooked PHFs hcnn 14()`F to 10°F Within 2 Htwrs and From 70`1' to4I'FI45'F Within 4Hours, + j 4{B 3 -St 0i.3—) ix,o inn, PI -IFS Male From Ambient Temperature Ingredients lo411-AS .Within 4llomO ' 1YoWes critical item in ihr r,,Ieral 1999 Food Cafe or 105 Cb2R 590 WO, 3-501-34W) PHFS Received la Temperatures According to Lay. Cooled to -4j i °F145"F Within 4 Homs. ,3Q1 15 1 Coolim Methods for PHR, 1-501 16(B, Cold PHl s Maintained at or below 540.OS14(E) 1i'f45a1 -5O1,16(A) _____ 1Jot PIIFv, Mntruauued at or above M Op * 3-501.16(A) Raises Held at or above 13VF. T I Time as a Public Health Control 3-501.19 Time as a Putin, Health Control - 21 ( 3-'3(I A I (A) IUtrp istcuriud Pt S acl agnd Juices and Beveia es with Warain-, Labels* ' 3-801 I I(BI 1 U e e f Pa: teur,zsd 1 - "5-861.11(Uw or 1"�u2inElr Ceiad Anuml Pei and _ —Ltto Sced S }ront> loot Sri yed i I7 rdV—i pl,f.eo.. kllf 22 3-OWA I j t7oastnner �Sst'issots Posted faint"ostaatnption of ' -'Wmil tI I nrds drat arc Raw, k, ndercooked ar lii~ot Other,. ise Prot essed to 1"1 aminate athor(n+* 3 30? 13 1 1'asteanr d FE) -,s 5ubstimic fel Paw Shell SPECIAL REOUIREMENTS T Viokaii�mn ofSection 590JX)9(A)-(1)) in cateringnlobik7. ftxrd, ac'tnporary and resident:al kitchen operations Should be i debited tinder the appropriate s"Itons alwve if related to ftx)dborne illness interventions aird risk factors, (Aber 590.009 violations relating to good retail Mattrees touk l be debited ander #129 - j Special Requirements - (Items 23.30) Critical and non -r rnicat violafi cs, winch do not relate io rile foodborne fUcess nate venlitamsraid riskfenders 1,oied abate. atn be found no rhe fo7loc mg .eecrccz,s of.he Food Code and )(e,5 C49k 596 000, DATE PRINTED: Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit 01/08/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000357 LOCATED AT: lQmbedey Driscoll Mayor Witch's Brew Cafe 156 Derby Street Salem MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2008-0277 Jan 7, 2008 Dec 31, 2008 $280.00 ESTABLISHMENT 'TOBACCO VENDOR BHP -2008-0280 Jan 7, 2008 Dec 31, 2008 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31.2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 3 of 3 KIMBERLEY DRISOOLL MAYOR JOANNE SCOTT, HEALTH AGENT QTY OF SALEM, MASSACHUSEM BOARD OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TtL. (978) 741-1800 ;' I� FAx (978) 745-0343 "� ISCOTrOSALEM. COM �® NUV 2 ??pp7 Co''Yo w?o aF`'gtFM 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT tJU ITGN 5t2EC W (f�Yi °G- TEL # STATE ADDRESS OF ESTABLISHMENT l �� 4-21 \ S� FAX # nJ I MAILING ADDRESS (if different) EMAIL - Business': 1,1 T Website: 10 ( >9 OWNER'SNAME�\�\2d T�(7C�A9`0�4L1�� TEL# ADDRESS 1S (o l� eft cmc �2££ i SAL.E-v✓2 � A- O l 4( 7(� STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) 6i 11Lv �(ouNSR L1 �:\ ( CERTIFICATE#(S) 71/9,F4,51 (Required in an establishment where potentially hazardous food is prepared) =$280 — more than 99 seats EMERGENCY RESPONSE PERSON rj(A V-0 HOME TEL # C1 2 8' J9 dl '73 DAYS OF OPERATION i Monday i Tuesday Wednesday Thursday i Friday 1 Saturday Sunday HOURS OF.OPERATION ) 1 l ) Please write in time of day. I �� . / — f /.e,. fAm )1 �ZA n .,__ „__ /}vr rr. a+l ru tr TYPE OF ESTABLISHMENT RETAIL STORE YES NO - - ....----------- RESTAURANT QOYESNO (Outdoor Stationary Food Cati $2 ----- -- -=--- -------------------- BED/BREAKFAST/ YES NO CHILDCARE SERVICES FEE (check only) less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -------------------- --------- than 25 seats --------.less =$140 25-99 seats =$280 — more than 99 seats =$420 ----------------------------------------------- ---- $100 -- - ..... ...----------------------------- ------------- ---------- ------------ - ------------------------- ------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR <: $ NO $135— ALL 135—ALL NON-PROFIT (such as church kitchens) YES 4frO) $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 MGI`Ghapter 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 pai0tiflAtate taxes required under the law. 4909�� 11 _27-a'/ o42923 o3 Signatur Date Social Security or Federal Identification Number - ---------------- -------r----) S �--- Revised 4/24/07 FOODAP2 8.adm Checkht & Date II%R1�! T/�J 156 Derby Street City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Witch's Brew Cafe Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-7369 j Physical Facility FAIL BLUE Owner: splro Icounsauen PIC: Rodrigo Sampaio Inspector: David Greenbaum Date Inspected: Correct By: 6/12/2007 Risk Level: Permit Number: 1 BHP -2007-0212 j 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) Comment: There are water stained ceiling tiles in the kitchen. Investigate the source of the leak and repair. Replace all stained ceiling tiles. The light above the basement counter needs protective covers. GENERAL COMMENTS: All other violations cited in the 6/4/07 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. Jun 13,2007 ) 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® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 13,2007) Page 2 oft 114 41 156 Derby Street Telanhnna- 744-7369 Owner: Spiro Kounsalieh PIC: Spiro Kounsalieh Inspector: David Greenbaum Date Inspected: Correct By: 6/4/2007 Risk Level: Permit Number: BHP -2007-1 Status: VIOLATION # of Critical Violations: 4 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) Witch's Brew Cafe City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency PROTECTION Food Contact>Lrrfaces Cleaning and Sanitizing FAIL Critical RED ),Lbmment: The meat slicer has an accumulation of food debris. Thoroughly clean and sanitize the meat slicer after each use. e ice scoop found stored on top of the ice machine. Properly clean and sanitize the ice scoop and store in the ice handle side up. Good Hygienic Practi FAIL Critical ❑.� RED Com nt: Employees drinks observed in the kitchen. Employees must eat and drink in a designated employee area or in the d' ng room prevent cross contamination. Ha ash Facili s FAIL Criticald❑ RED The kitchen hand wash sink found obstructed. Keep hand wash sinks clear and accessible at all times. Violatioris Related to Good Retail Practices (Blue Items) Food and Food P ction FAIL Critical BLUE ment: The salads in the True salad unit are wrapped together with one plat directly on top of the salad. Wrap the salads individually to prevent cross contamination. Equipment and sils FAIL Non -Critical BLUE The long silver reach in not working. Repair unit to good working order and do not use until the unit is repaired. �eshelves in the basement walkin have an accumulation of grime. Thoroughly clean all shelves. 7 Cold Spot freezer in the basement has an accumulation of frost. Thoroughly defrost this freezer. Physical Facility FAIL BLUE Comment: There are water stained ceiling tiles in the kitchen. Investigate the source of the leak and repair. Replace all stained cedin es. ere is water on the basement floor. Investigate the source of the leak and repair. Remove all water e—� The light above the basement counter needs protective covers. 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. Jun 05,2007) Page 1 oft i Item Status Violation Critical Urgency RED: GENERAL COMMENTS: Violations Related to Reinspection will be on Tuesday, June 12, 2007, all violations to be corrected. Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) 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. Jun 05,2007 ) Page 2 oft CITY OF SALEM, MASSACHUSETTS e y BOARD OF HEALTH RECEIVED / 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DEC - 4 2006 TEL. 978-741-1800 FAx 978-745-0343 CITY OF SALEN1 Kimberley Driscoll www.SALEM.COM BOAR(} OF HEALTH Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT V'2 &`}`0 C\O'Fe TEL # 9-7.9 - 7{'I `4' S '17 ADDRESS OF ESTABLISHMENT 1 r5(' —X:�>'E-e4a�i�k STQ-E. i FAX # q 7 S - 7"-I 0 `.O f 6"I/ MAILING ADDRESS (if different) ------ less than 25 seats ;/25-99 seats EMAIL -- Business': Owner's: p� OWNER'S NAME cJ �' < <' 0 K0 U M SAI I r= N TEL # 91 i 71-t 1-1 7 3 6 9( ADDRESS `CJ �2(?�� STQ .�f Sf1 L 4 ^n Im 4 Ci 1 C1 -70 STREET CITY STATE ZIP 512120 VoVr-25rgL-iE 1-4 CERTIFICATE#(S) LI -S BOO CERTIFIEID FOOD MANAGER'S NAME(S) (Required in an establishment where potentially hazardous food is prepared) TOBACCO VENDOR kitchens) S KG0)14'- t �`i HOME TEL # y71F �iCJ EMERGENCY RESPONSE PERSON ip(�o ALL NON-PROFIT (such as church DAYS OFOPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION II/' Please write in time of day. 11-� i i i' A _ /pAN� I 1 7 A ,an-IaM Ilq,, .IAM l %JIA-'LrtM IForexample llam-llom) A�^ A, a ,w, TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 CES)__------ RESTAURANTNO ------ less than 25 seats ;/25-99 seats --$ <C15 more than 99 seats =$200 - - -- - ------ - ----- -- ---- --- ----- ----- ------ ----- BED/BREAKFAST YES CO ---- -- $ -- ------ ---- ----- $100 ---- ------------ ------------- - -------------------- --------- ----- --- --- --- --- ---- ....-- ----- - - ----- ADDITIONAL PERMITS SOFT SERVE -------- ------------ YNO MAKE (not just serve) ICE CREAM, YOGURT, TOBACCO VENDOR kitchens) Y S NO YES NO --$5 ALL NON-PROFIT (such as church '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. MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief. I state tax returns and paid all state taxes required under the law. a303yd0/ Social Security or Federal Identification Number -------- - --------------- Revi- sed 11113/06 FOODAP2007.adm "Check# & Date _6 )2D I "_ _o,R 5 trn,Q� f �rj �aaj�4 i; ..u., F^+P, 6081'd'Or IIe81t11 'T 4m;; 4 120 Washington Street,.4th Floor IGmbefiey Driscoll . Mayor a SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: File Number: BHF -2004-000357 LOCATED AT: Witch's Brew Cafe 156 Derby Street Salem MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2007-0212 Dec 20, 2006 Dec 31, 2007 $150.00 ESTABLISHMENT TOBACCO VENDOR BHP -2007-0216 Dec 20, 2006 Dec 31, 2007 $150.00 Total Fees: $300.00 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 11 of 11 156 Derby Street Telephone: 744-7369 Owner: City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item PROTECTION FROM CONTAMINATION Separation/ Segregation/ Protection Status Violation PASS Critical Witch's Brew Cafe Critical Urgency RED Comments: Beer bottles found stored in the ice for customer drinks. Do not store anything in ice to be consumed by customers to OPiry n.vunsauen prevent cross contamination. PIC: ! Food Contact Surfaces Cleaning and Sanitizing PASS Critical RED Spiro Kounsalieh Inspector: David Greenbaum Date Inspected: Correct By: 11128/2006 Risk Level: Permit Number: BHP -2006-0285 Status: SIGNED OFF # of Critical Violations: 0 Time IN: Time OUT: I 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) Comments: Dirty knives found stored between the wall and rack above the two bay sink. All knives to be properly cleaned and sanitized and stored in the knife rack. Dirty knives found stored in the back knife rack. All knives to be properly cleaned and sanitized prior to storage. Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS Critical Comments: The long silver reach in has some uncovered food. All food in storage must be covered. Equipment and Utensils PASS Non -Critical Comments: The White Westinghouse freezer in the basement needs a thorough cleaning. The Cold Spot freezer in the basement has an accumulation of frost. Thoroughly defrost this unit. The canopener needs a thorough cleaning and scouring. The Turbo Air freezer in the kitchen needs a general cleaning. The True salad unit needs a general cleaning. Physical Facility PASS Non -Critical Comments: The kitchen screen door is in disrepair. Repair or replace the screen door. GENERAL COMMENTS: All violations cited in the 11/20/06 inspection report have been corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 BLUE BLUE MILE= GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 28,2006 ) Page 1 oft RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 I1� GeoTMS@ 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 28,2006 ) Page 2 oft 156 Derby Street Telephone: 744-7369 Owner: Spiro Kounsalieh PIC: Spiro Kounsalieh Inspector: David Greenbaum Date Inspected: Correct By: 11120/2006 Risk Level: Permit Number: BHP -2006-0285 Status: PARTIAL COMPLY # 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 FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item PROTECTION FROM CONTAMINATION Separation/ Sft6re-gation/ Protection Status Violation FAIL cntical Witch's Brew Cafe Critical Urgency KEU it: Beer bottles found stored in the ice for customer drinks. Do not store anything in ice to be consumed by customers to cross contamination. Food Contact Surfaces Cleaning and Sanitizing FAIL Critical I] RED t: Dirty knives found stored between the wall and rack above the two bay sink. All knives to be properly cleaned and and stored in the knife rack. knives found stored in the back knife rack. All knives to be properly cleaned and sanitized prior to storage. Violations Related to Good Retail Practices (Blue Items) Food and Food P otection FAIL Critical C ment: The long silver reach in has some uncovered food. All food in storage must be covered. EquipX Utensils FAIL Non -Critical The White Westinghouse freezer in the basement needs a thorough cleaning. pot freezer in the basement has an accumulation of frost. Thoroughly defrost this unit. e opener needs a thorough cleaning and scouring. Air freezer in the kitchen needs a general cleaning. True salad unit needs a general cleaning. FAIL Non -Critical The kitchen screen door is in disrepair. Repair or replace the screen door. COMMENTS: 998:Reinspection in one week, all violations to be corrected. BLUE BLUE BLUE 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 20,2006) Page 1 oft RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 20,2006 ) Page 2 oft Item Status Violation Critical Urgency RED RL : "'' Violations Related to Good Retail Practices (Blue Items) Violations Related 4 to Food and Food Protection PASS Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comments: The basement walkin has uncovered food. All food in storage must be covered immediate corrective action) * .• "'I There is food stored directly on the floor of the basement walkin. All food to be stored at least 6-8 inches off the floor The long silver cooling unit has uncovered food. All food in storage must be covered. The True freezer has uncovered food. All food in storage must be covered. The outside walkin freezer has food stored directly on the floor. Store all food at least 6-8 inches off the floor. Equipment and Utensils PASS BLUE Comments: The Cold frost freezer in the basement has an accumulation of frost. Thoroughly defrost and clean this unit. The canopener has an accumulation of grime. Thoroughly clean the canopener. The White Westinghouse freezer in the basement needs to be thoroughly defrosted and cleaned. The same freezer needs a visible, accurate thermometer. The GE freezer in the basement needs to be thoroughly cleaned and defrosted. The basement stairs have an accumulation of grime. Thoroughly clean the basement stairs. The True freezer in the kitchen needs a thorough cleaning. The Montague grill/oven has an accumulation of grease and food debris. Thoroughly clean the entire grill/oven. The True salad reach has an accumulation of food debris and spills. Thoroughly clean this unit. The basement is in need of a thorough cleaning and reorganizing. GENERAL COMMENTS: 713:All violations cited in the 7/17/06 inspection report have been corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 31,2006) Page 2 oft 156 Derby Street Telephoner 744-7369 . Owner: _�4 . Spiro Kounsalieh PIC: Spiro Kounsalieh Inspector: David Greenbaum'1 ` Date Inspected: Correct ey: 7/31/2006 Risk Level: Permit Number: BHP -2006-0286 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) Witch's Brew Cafe City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing PASS Critical RED Comments: The ice scoop in the basement stored on top of ice machine. Ice scoop to be cleaned and sanitized and placed in the ice handle sidd up or in a sanitized container labeled "Ice Scoop Only" The cutting board at the steam table is stained and scored. Resurface or replace the cutting board. The meat slicer has an accumulation of food debris. Thoroughly clean and sanitize the meat slicer after each use. Handwash Facilities PASS Critical E/1 RED Comments: The men's room had no soap. Provide soap in the men's room at all times. The hot water in the men's room and the the handicapped bathroom had temperatures of 102° and 104" respectively. Restore hot water to a minimum temperature of 110°F. The bar hand wash sink found obstructed. Keep hand wash sink clear and accessible at all times. 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. Jul 31,2006) Page 1 oft 156 Derby Street Telephone: 744-7369 Owner: Spiro Kounsalieh PIC: Spiro Kounsalieh Inspector: David Greenbaum Date Correct By: I x016 Risk Level: Permit Number: BHP -2006-0285 Status: VIOLATION # of Critical Violations: 3 Time IN: Time OUT: I I Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Witch's Brew Cafe Status Violation Critical Urgency PROTECTION FROM CONTAMINATION Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑0 RED Comment: The ice scoop in the basement stored on top of ice machine. Ice scoop to be cleaned and sanitized and placed in the ice handle sidd up or in a sanitized container labeled "Ice Scoop Only" The cutting board at the steam table is stained and scored. Resurface or replace the cutting board. The meat slicer has an accumulation of food debris. Thoroughly clean and sanitize the meat slicer after each use. Handwash Facilities FAIL Critical S�j RED Comment: The men's room had no soap. Provide soap in the men's room at all times. The hot water in the men's room and the the handicapped bathroom had temperatures of 102° and 104° respectively. Restore hot water to a minimum temperature of 110"F. The bar hand wash sink found obstructed. Keep hand wash sink clear and accessible at all times. 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. Jul 18,2006 ) Page 1 oft 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. Jul 18,2006) Page 2 oft 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 and Risk Factors Comment: The basement walkin has uncovered food. All food in storage must be covered. (Require immediate corrective There is food stored directly on the floor of the basement walkin. All food to be stored at least 6-8 inches off the floor. action) _ The long silver cooling unit has uncovered food. All food in storage must be covered. The True freezer has uncovered food. All food in storage must be covered. The outside walkin freezer has food stored directly on the floor. Store all food at least 6-8 inches off the floor. Equipment and Utensils FAIL BLUE Comment: The Cold frost freezer in the basement has an accumulation of frost. Thoroughly defrost and clean this unit. The canopener has an accumulation of grime. Thoroughly clean the canopener. The White Westinghouse freezer in the basement needs to be thoroughly defrosted and cleaned. The same freezer needs a visible, accurate thermometer. The GE freezer in the basement needs to be thoroughly cleaned and defrosted. The basement stairs have an accumulation of grime. Thoroughly clean the basement stairs. The True freezer in the kitchen needs a thorough cleaning. The Montague grill/oven has an accumulation of grease and food debris. Thoroughly clean the entire grill/oven. The True salad reach has an accumulation of food debris and spills. Thoroughly clean this unit. The basement is in need of a thorough cleaning and reorganizing. GENERAL COMMENTS: 696:Reinspection in one week, all violations to be corrected. 4EL 4 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. Jul 18,2006) Page 2 oft i m 'W 06 U Z m Er o- O rm O NAME (LAST, FIRST, INITIAL) 77 STREETADDRESS CITY/TOWN STATE ZIP 5 LICENSE NO. LIC. EXP. DATE DATE OF BIRTH i m 'W 06 U Z m Er o- O rm O NAME (LAST, FIRST, INITIAL) STREETADDRESS CITY/TOWN STATE ZIP 5 LICENSE NO. LIC. EXP. DATE DATE OF BIRTH OWNER'S NAME (LAST, FIRST, INITIAL) '"-'o Ne. �' —'3"-J (o STREET ADDRESS CI V 75o/-x� REGISTRATIONNO. STATE EXPDATE MAKETPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN RERsoNu -" _. ..'fl AM.._.._____.___ ,' MY ❑VES ❑ PM ❑ NO LOCATION OF VIOLATION ENFORCING DEPT � J OFFENSE CHAP. SECT. FINES C J' Unrrll%( _e/role'l'rf/ OFFICER I.D. NO. TOTAL $ ,. c) FINE ,f!) OFFICER CERTIFIES COPY GIVEN TO VIOLATOR �/-�� ❑ IN HAND !�-.}-8--:(.t�� Q-8 MAIL ,D,O'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 I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED, AND ENCLOSE PAYMENT IN THE AMOUNT OF CASE N SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL City O f cSa[zn4 4:A-a11a4c4u;lEttl F 9i¢e Sbz#aafmant oe G/ayr<rt< �n«r �ar[m,af<Aehuf<!t� 01970-3695 cJ�osi�f'yY �wui :W 596.744-1999 ��iL[ 'l1LV[nrWn `3rr 306.947-4946 liu=<au _ RECORD OF COMPLAINT 'DATE: eFtOL RECEIVED BY: -SUBJECT: t--YkI{ QIA -i—-oh, Lu s e e COMPLAINT BY: ADDRESS: SITE INSPECTED BY: DATE: COMMENTS_: 'atm k/ n J REFERRED TO: ' ' SIGNED: }�t1 Fd m R98 (Levised 3/97) 70 3`JVd FYSIVdSIQ 38IA W3-TVS Z066GtiL&S LG:Li 9002/£i/Z0 CITY OF SALEM BOARD OF HEALTH Name of Establishment: Witch's Brew Cafe Address: 156 Derby Street Owner(s): Spiro Kounsalieh Phone: 978-744-7369 Date: February 1, 2006 During an inspection, Sanitarian David Greenbaum observed a walk-in cooler for this establishment located in an outside side alley. The Board of Health had not approved this location. During the same inspection, Mr. Greenbaum observed a basement storage area where canned food and beverages were stored. This area has a chronic water problem where approximately an inch of standing water is on an section of the floor. The Food Code requires all areas where food is stored to be clean dry with impervious floors, walls and ceilings. The owner agrees to: • Place an automatic self-locking device on the outside walk-in so that unit is locked at all times except at the immediate time when an employee is adding or removing items. The automatic lock will be installed within one week. • No additional food, supplies, beverages, beer or wine will be stored in the wet basement. All food and food service items currently stored in this location will be removed by May 1, 2006 or the chronic dampness/wet floor problem will be remedied by that date. Joanne Scott Spiro KounsaTm,14, Owner 3-1-0b Date is I Zoc76 Date W AL ion 0 6 E ' s All 6 1 1. I. -_.__ _.__-_____ ..J hO BAR 0 COURT DOCKET NO. CITATION NO. CITY OF SALEM (�fj VIOLATION NOTICE A1892 NAME (LAST, FIRST, INITIAL) Ko L; Ai,cAI/ h ,� STREETADDRESS CFF TOWN STATE ZIP LICENSE NO. I LIC. EXP. DATE DATE OF BIRTH OWNER'S NAME (LAST, INITIAL) FIRST, STREETADDRESS CITY/TOWN STATE ZIP REGISTRATION NO. STATE EXP. DATE MAKE/TVPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL INIMW -'-❑AM ❑YES ❑ PM ❑ NO LOCATION OF VIOLATION ENFORCING Jam DEPT. 1 JSb lip�(a �{ �Jo OFFENSE I CHAP. SECT. FINES A jCRrrS!;1ae -1,1 B fkjt C muln101 >f i OFFICER I.D. NO. TOTAL FINE 1�oOL' '„( co ei4e DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ' 1 �;1}f�/I ,.� ❑ IN HAND X 1 YN _�! lI X/ '.-."�'/l ©-9Y 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 N SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL 156 Derby Street City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Witch's Brew Cafe Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) Physical Facility FAIL Non -Critical BLUE Comment: There is an accumulation of water on the basement floor. Owner must determine the appropriate way to seal the 744-7369 Owner: Spiro Kounsalieh basement so as not to allow water to accumulate in the basement. Board of Health will determine if alcohol only can be stored in this area. PIC: Spiro Kounsalieh F GENERAL COMMENTS: Inspector. David Greenbaum 444:Owner will provide an appropriate locking mechanism on outdoor walkin to keep the walkin locked at all times. Date Inspected: Correct By: 112312006 All other violations cited in 1/17/06 inspection report have been corrected. Risk Level: Permit Number: BHP -2006-0285 Status: SIGNED OFF # of Critical Violations: = 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. Jan 23,2006) 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® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 23,2006) Page 2 of 156 Derby Street Telephone: 744-7369 Owner: Spiro Kounsalieh PIC:. :. Spiro Kounsalieh'" Inspector: David Greenbaum Date Inspected Correct By 1/17/2006 Risk Level rT Permit Number: BHP -2006-0285 Status: VIOLATION # of Critical Violations. ;1 'Time IN: TimeUT Urgency Description(s). Y 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) Witch's Brew Cafe City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Food Bread crumbs found stored on the floor near the dishwasher. Store all food at least 6-8 inches off the floor and not under or near the dishwasher. Salad plates wrapped with plates directly touching salad. Wrap salad plates individually to prevent cross contamination. Equipment and Utensils FAIL Non -Critical BLUE �omment: The long silver reachin has an accumulation of food debris. Thoroughly clean the reachin. fhe microwaves have an accumulation of food spills and splatter. Thoroughly clean and sanitize both microwaves. jThe Turboair freezer has an accumulation of food debris. Thoroughly clean entire unit. �The White Westinghouse freezer in the basement needs a visible, accurate thermometer. The GE freezer in the basement needs a visible, accurate thermometer. The basement walkin Flooring needs a thorough cleaning. The counter where the canopener is has an accumulation of food spills and splatter. Thoroughly clean this area. \ jThe outside walkin refrigerator/freezer has an accumulation of food debris. Thoroughly clean both floors. The ladies restroom needs a covered trash receptacle. ysical Facility FAIL BLUE Comment: There are water stained ceiling tiles in the kitchen. Investigate the source of the leak and repair. Replace all water stained ceiling tiles. There are broken tiles on the post in the kitchen. Replace all broken tiles on the post. � There is an accumulation of water on the basement floor. Investigate the source of the leak and repair. 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. Jan 19,2006) Page I oj2 �F RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item GENERAL COMMENTS: Status Violation Critical Urgency 435:There is an outdoor walkin in the back of this establishment. Board of Health will confirm the need for a self locking mechanism on this unit and notify the owner at the reinspection. Reinspection will be in one weeek, all violations to be corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 19,2006 ) Page 2 oft 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 -2004-0357 LOCATED AT: Witch's Brew Cafe 156 Derby Street Salem MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2006-0285 Jan 4, 2006 Dec 31, 2006 $150.00 ESTABLISHMENT TOBACCO VENDOR BHP -2006-0284 Jan 4, 2006 Dec 31, 2006 $50.00 Total Fees: $200.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 15 of 20 STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741 -1800 Fax 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT P) -)t TC�1'S �3�L4117 6W. bu'C- TEL # g7? -7`/S -Z'7/ 7 ADDRESS OF ESTABLISHMENT 1 S MAILING ADDRESS (if different) OWNER'SNAME _5'P x'20 `Kpt7NSA Ll t=N TEL# X178-7yy-73&q ADDRESS f ry C> ptir�x�y '6T /�.vC> <- CITY STATE w1 4 ZIP O t c CERTIFIED FOOD MANAGER'S NAME(S)nintrzc V446005A r -c £ N CERTIFICATE (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 5e, 2.0 V, 0 u xD6�4 L 1 E 0 HOME TEL #q78 'XILI,73613 HOURS OF OPERATION: Mon./#vl Tue./P-1 Wed.14/ Thu./Q -r Fri./o-1 Sat. /0- Sun.70_-12 TYPE OF ESTABLISHMENT FEE (check only) CRETAIL STOREN YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than I0,000sq.ft. =$250 RESTAURANTYES NO / less than seats =$100 /T16 !/p_ 25-99 seatsis (� more than 99 seats =$200 ----------------------------------------------------------------------------------$-1-00 ..... BED/BREAKFAST YES NO $1 ------------ ------ - -'Iy..------------............-..-------------......---------------------------. ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT SOFT SERVE YES CED $5 '',TOBACCO VENDOR o —� <20> NO x$50 ALL NO'N-PROFIT (such as church kitc�ens) YES lb $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. 0 y9TQ3b3 Date Social Security or Federal Identification Number Revised 11 IdsfBT 'FOODAP2.adm Check# & Date W (07 �j A, oe,�� fill 4, I INITIAL 8ERVICE,,', 14 'r, �� e- an �r REGULAR SERVICE, REGUL yw4 EXTRA'SERVICE j4 jiS. FEMME-, ef try ev. COMMERCIAL to, SERVICE IEUEPHOqll AND INSPECTION REPORT '-,�GRI DID I I;,. iFRODUCTIONI JP�-� ! TME IW7G1TPr�TIMEJQQT, 3 !Zcdi J ^ `'SERVICEPROPERTY AT! WF"i BRANCHP`q'-1-471XV BnTrpj 7397 130 eUiev"IFrii r:) CA V OPERATOR NAME & CERTIFICATION NUMBER 0�as SUPERVISOR NAME & CERTIFICATION NUMBER � A2:1- f I S w I S98 Target U Rate 0 Indiana. Pests 0 Admandard Coci,doulde, 0 ArrenterseAnts -4micsi CI stated Product Peace 0 OmentalCockroachesU H.Adsa a silvdr(ddd 0 onver 0 U Off-da"Ants Q Flee 0 Order— Materials lurand # used 450 Insiders 620 WIND-UPTRAPS 400 Insect Writers 610 TIN CATS AM 410 Pheromone 645 Rat Bait Stations Pest Control Materials Used EPA Reg. # TIC PC Amount 600 Glue Traps 640 Mouse Bait Stations 630 Snap T Al I line fri Bait qtntione, 293 Advance GmularAnt BaR(AbatneclinBl)0.011% 499-370 Areas Inspected and/or Treated Pest Cod" requadandessi spam list at did. 295 Advance Dual Choice Ant Bell (Abardnectin 81)0.011% 499-496 315 Ascend Fire Ant Bait (Abannectin 31) 0.011 % 499-370 ClEards, Areas, , I Nines, ft. ir_�' J Deices100 slyublin Areas L dactri-acker Forms ODispl"Anvas 0 naiddry/Boter Room &tcruji"Undly, Ll Werchused Area 0 Prosecuted areas P Patient Rosen D Coast Rourn. hent J First J Extinct Parameter 0 landscaped Areas 0 Lierder, DocWDerniester 0 Other — 309 Avon Roach Bad Stations (Abandactin) 0.05% 499-467 365 Advance 38813 Ant Gel Bait (Borax) 5.4% 499492 Bond Dust (OpInDbi acid) 99% 9444-129 15 DernarniCS(Lambda-cythalothrin) JO.015% UO.03% 00.06% 100-1066 210 Deftal G (Deftamethrid) 0.05% 432-836 158 Trnie Bulk Dust(Silica Gel) 40%(Pyrethrins) 1.0% 499-429 41 Gentrol EC (hydrometry) 0.06% 1`, 2724-351 W Generation Mint Bloods Bait (Difethialone) 0.0025% 7173-218 39 Infice Granular Bait (0dhoborc Mid) 5.0% 73079-2 —Z Kicker EC(Pyr Ans) 00.05% ODA% CM2% 432-1145 550 Uqupox 11 Bait (Discal Salt of Diphacinone) 0.106% 12455-61 352 valiance PC Roach Bait Stations (FiPpanill 0.05% 432-1257 351 Maixforce FC Ant Bait Stations (Fipromr) 0.01 % 432-1256 357 Maforce PC Ant Gel Bait (Furonil) 0.001 A 432-1264 354 Mallorca PC S.1i Roach Bait Gel (Ppronit) 0.01 % 432-1259 355 Masilome FG lial Bait (Hydrannothyll 1.0% 432-1262 300 N[ban Bart/Niban PC Bait (Orthoboric acid) 5% 69405-2 45 NylarEC(Pyriproxylen) -JO.015% 130.02% 11715-307-57079 49 Opinions Turf, Tree, & Shrob WP (Acephate) 75% 59639-26-ZA 380 Pre-Empt Roach Gel Ban (Imidaclopral 2,15% 432-1365 151 PT Cy -Kick Aerosol (Cyflethrin) 0.1% 499-470 70 PT Cy Kick CS (Cyfluthrin) 0 0.011`5% 3 0.025% 3 0,05% U 0A X 499-3134 Precautions Keep cat of duch of children add pets. May cause area, note, threat, or skin inflation. Avoid ideal causes mists or dusts. Handful if swallowed Dampen commas to activate. Do not flow with rodenticide placements. Do not return to room until alter ventilation. Do . 'such posted areas mal J, For Are reactions, remain on fueled area for a minimum of four homes se until cry, 312 FT Avert Gel Bait (Atandechn 81) 0.05% 499-410 69 PT 565 Plus XLO Acersol ( Pdrethrins) 0.5% 499-290 159 PT TriDie Aerosol (Silica Ausecigelt 4.8% (Pyerthrins) 0.6% 499-385 81 Tempo UI"WP (Cyfluthrin) 00.025% 00.05% 00,196 432-1357 83 Tempo SC Urda (Cylluthrin) U 0B25% 00.05% U0.1% 432-1363 91 UUDBP1O0ULV(Py.thnnE)1.0% 499-452/11540-9 Treatment Cade C=Cdack&Crevide V=Vdid G = General S - Spot W - Bait De= Directed Confect B 3- Bend SP - Space IN = Inspected 92 ULD BP 300 ULV (PyrohniG) 3.0% 499-450/11540-1 591 liketathert XT Bait (Bendifacound) 0.005% 100-1055 Equipment Good (EAC) CS= Good. Air Sprayer 7 - Tree as - Bait Spend HD = Hand Duster A = Accusal Do = Bar Gain PF - Poven Treatment F - JPV 7� (5) Or 6t 1!'" -71,� 0,11I --0-PrVe-&-eC9 t5 -r -'s "Ydnot- Posting Banned Sticker? 0 Va. ONO Ori peComments: UNRESOLVED PROBLEMS? CALL 1-800-TERMINIX (1-800-837-6464) SPECIAL SERVICE INSTRUCTIONS CUSTOMER'S SIGNATURE AMOUNT PAID CASH H SE C AN'S rVA ORE I TEC TU DATE r CHECK '78)'945,0',£3717 I SoLE_I 111M l "nih- fjr{Yry' L S s�p�(i '7 x h a a.10 OJ �r r1._ FnT`-ar a a,Pram t"dir dFt (1f1?1(11"doh A0 45 r 001.-- 10/17./0 p +i WITCHES' 131/1 W 156 D T{MY ST SI-'ll._L.M ,14A 01970 Y'L:RMINIX IN'TERNAT'1'ONAL. 130 RUME'£:3R0°ROAD; SUITE :11.3; NEWTON i 02466 ,17)°i69i 00:3£3 (Borax) 5.4% 499492 OPERATOR NAME& CERTIFICATION NUMBER JfIHN 1 SEE HAN 1.7 52x; SUPERVISOR NAME & CERTIFICATION NUMBER r'Isit.E_:R, r,RTE;uR 1 159E.5 - .. . -.. - - - - Target ❑ Getman cpdopaphea 0 Pavement Ana ❑ Said ❑ Occasional Infledos Pests ❑ Arnedcan Cockreecfres - ❑ Au surds ants �iae ❑ Stored Pladuct Pests U orieldaiCociwaches ❑ Flre Ams -❑ Silvmish ❑ other ❑ char cocxmadms ❑ other Ants .❑ .Flies ❑ curer Materials .used 450 Insiders 620 WIND-UPTI 400 Insect•Monitors 610 TIN CATS hemmone Traps 645 Rat Bait Sta Pest Control Materials Used EPA Reg. # T/C Etc Amount Goodue Traps 640 Mouse Bait 630 SnapTraps 655 U uitl Bait: 293 Advance Gmnular Ant BaA(Abamectin Bi)0.011% 499-370 Areas Inspected and/or Treated Pe CmfmtmatenatsasedmdicatWGycp Fpm(letleft. 295 Advance Dual Choice Ant Bait lAbamectin W)0.011% - 499-496 )rthoboric acid( 5% 64405-2 315 Ascend FireAnt Bait (Abamectin 8110.011 % 499-370 1 1 rtr........... U r46 70 PT Cv-Kick CS s used 4bamectin)0.05% 499467 ❑Qining Areas �r S U onices U public meas - CyResuLttxer Ropms ti ❑Display meas A. ❑Laundry/Bpileraoom U6loregar lily '• a� U Warehouse Area ❑ Prcces'iirg Areas'• 0 Patient Booms ❑Guest Booms emend 0Rmf 0 Exterior Perimeter 0 Landscaped Areas ❑ Loading Dock/Dumpster ❑ other (Borax) 5.4% 499492 )99% - 9444-129 lothdn) ❑ 0.015% 00.03% 00.06% 1110.1065 0.05% 432-636 40%(Pyrethrins) 1.0% I 499-429 36% - 2724-351 I (Difernial all 00025% 7173-218 otic itl�5.0 ..,,. ,:. .,_,_73079;2- .. �. ... . -: 105% U 0.1% ❑ 0.2% -432-1145 aft of Diphacinpne) 0.106% 12455-61 i ions(Fiarmi90.05% - 432-1257 firs (Flpronil)0.01% 432-12565 °ipronil) 0.001 % 432-1264 Bait Get (Fiproti9001% 432-1259 ydramethylnon) 1.0% 432-1262 )rthoboric acid( 5% 64405-2 0.015% 00.02% 11715-307-57079 WE (Acephate) 75% - 59639-26-ZA midacldprd) 2.15% vin) 0.1 % 432-1365 499-470 madd Precautions 1damt, , nose,h of throren and skin is. Imtalion. May causeeye, nose,Nmol, or Avoitl brealM1ing vapxs mists, or tluats. Harmful if swallow N. Dampen granules to activate. Do lid: with mdenticide placements. W mol ummam to room a ul after ventilation. Do nal touch heated areas until dry. F« flea treatments, mrmin on reales area for a minimum of lour hours or until dry UUWE%00.025%00.05%00.1% 499-304 In Elf 0.05% 499-410 'yrethrins) 0.5% 499-290- mgel)4.8%(Pyrethrins) 0.6% 499-385 ) 00.025% ❑ 0.05% 00.1% -432-1357 00.025% 00.05% 00.1% 432-1363 5)1.0% 5)3.0% 499-452/11540-9 499-450/11540-1 Treatment Code R/CI'. C=CrackBCrevice V=vq'vf a=General s=Spot BT=Bail DC=IArectad Contact B=3'Band SP=Space w=Nspedion ed.um)0.005% - 100-1055 Equipment Code(E/C): CS= Comp Air Sprayer T=Trap INS =Bait station HD=Hand Duster A=Aerosol BG=Bait Gun PT=Power Treatment F=DLV / Posting Service SDCkenO 0 Yes ONO Supervisor's Comments: 1'' T" J. 0 TI:3 .'d .'..:`i Tl C: E- 4 I'1iil Iiar1) A': rl l., . . . SPECIAI SFAhi March fil AMOUNT PAID y DATE CASH UNRESOLVED PROBLEMS? /l?S CHECK CALL 1-800-TERMINIX(1-800-837-6464) x 156 DERBY 5774, 2tN a iy . Gn i tx41 'A¢ 1,-'E M;M 0� 970 t = = r Service Areas ActiJ'i -and Coriditions Observed _ =„ This IPM report details where pests were found in.and around the facility. The report also lists those steps you can take to help limit or minimize pest invasions. For each of the areas listed below, numbers represent the type of pests found in the area, and letters represent any conditions present that may be contributing to a current, or possibly a future, pest infestation. Interior Areas ❑ Offices ❑ Lobby/Public Areas ❑ Entryways O'Fiest/Locker Rooms ❑ Janitor Closets ❑ Laundry & Boiler/Furnace Room ❑ Storage Utility ❑ Warehouse CY-,6asement ❑ Patient Rooms ❑ ICU ❑ Linen Storage Rooms ❑ Kitchenettes ❑ Nurses Stations ❑ Guest Rooms ❑ Banquet/Meeting Rooms ❑-bisplay Alsles #` ❑ Other ❑ Other 1. German Cockroaches 2. American Cockroaches 3. Oriental Cockroaches 4. Outdoor Cockroaches 5. Silverfish A. Drain Clogged/Dirty B. Food Debris Under Table C. Food Debris On Shelf D. Food Debris Under Appliance E. Wet Organic Matter in Cracks F. Grease Deposits on Floor G. Grease Deposits on Equipment H. Soiled Dishes Left Over Night Comments Pests Conditions 6. Pharaoh Ants 7. Pavement Ants 8. Fire Ants 9. Argentine Ants 0. Ants. I. Paper/Litter J. Water leak K. Mops Improperly Stored L. Trash Containers Need Cleaning M. Heavy Dust/Dirt Deposits N. Numerous Cobwebs Present O. Repair Floor/riles/WalVCeiling P. Seal Holes/Cracks in Walls Food Areas Pests Conditio s —"® Dining Area Stove/Oven Line Food Storeroom \'9 L7 Dishwashing Area ❑ Deli/Bakery ❑ Processing Area ❑ Packaging Area ❑ Produce Area ❑ Meat/Seafood Shop Exterior Areas ❑ Exterior Walls -North ❑ Exterior Walls -South ❑ Exterior Walls -East ❑ Exterior Walls -West ❑ Loading Dock ❑ Dumpster _ _;. ❑ Exterior StoragetRoomp ❑ Roof ❑ Other ❑ Other 11. Occasional invaders 16. Rats 12. Hunting Spiders 17. Mice 13. Web -Building Spiders 18. Stored Product Pests 14. Brown Recluse Spiders 19. Other 15. Black Widow Spiders 20. Other O. Poor Storage Practices Y. Move Dumpster Away From Bldg. R. Repair Water Damaged Wood Z. Dumpster Area Needs Cleaned S. Seal Exterior Cracks/Holes AA. Mercury Vapor Lights Outside T. Trim Back Tree/Shrub Branches BE. Keep Doors Closed U. Remove Piles of Debris CC. Repair Door/Screen V. Cut Tall Grass/Weeds DD. Replace DoorWeatherstripping W. Improve Outside Drainage EE. Poor Outdoor Storage Practices X. Install Gravel Foundation Barrier FF. Other Service Professional's Signature x, J/ Date J __ 'IkilA3 "� -.,: 1 'I, I I-_" � — , COMMERCIAL SERVICE ::ARL! !r ,TELEPHONE,';r`+-, pRANcHiix' U , I AND r�GRID r�Gi S. DAY INSPECTION REPORT I 1,l %T,1 ffPRODUCTIONNnI-aK5`7flTIW TIMEOUITi 23971-' 662OEr3 07 978) 745=E3717 170 SALE 12T 1.3 11 t'x 45.01 9/18/05 1 foaW L 7APBili SERVICE BRANCH WITCHES BRf..7.W 156 DERBY ST: SALEM ,i 0:1.970 TERMINIX INTERNATIONAL. 130 RUMFORD ROAD; S1.11111 1113; NFIJTON ,MA 02466 (6:1.7)969 -00'38 OPERATOR NAME & CERTIFICATION NUMBER JOI-114 F (41EEHAN :1. 7 ft'2 5 SUPERVISOR NAME & CERTIFICATION NUMBER FIC0_1 _-�I AR'THUR 11, 1.51 Target `t`D Ganded Ir Pa.. Ai Occasional Into" Pests 0 Anned. coclooechea 3 fteratudeArds mine ZI Stl Frail Posts C3 aiemal Cockroaches ZI R.Anda U slitairfron U Other w 13 Cheri 0 Fillus a other Materials Fusee #U. 450 Insiders 620 WIND-UP TRAPS 400 Insectifforwhous 610 TIN CATS 410 Pheromone Traps i Pat Bad Stations Pest Control Matifials Used EPA Reg. # Tic EJC Amount 600 Glue Tinaids W Mouse Bait Stations 630 Snap Traps 655 Undid Bait Stations 293 Advance GmnularMtBa4(Ab=WinBl)0,011% 499-370 Areas Inspected and/or Treated Fee ComramateriLs modidificatioddy occal ford, list al 295 Advance Dual Choice Aint Bak (Atiantectin B1) 0.111 1% 499-496 315 Ascend Fire And Bait (Ab in B1) 0.011 % 499-370 '14Food A'and, 1^Ing Asx U offids 0 Nor. Ardi 1EI Rect/Ladn"corro ❑ I-autert/i R. 'Ifistionagardich, 6"') 0 wand000d area if 0 Prod,don, Areas' Q Parent Pocono ❑ R 1 aided. 3 easement 0 Roof U Exterior Perimeter ddionecl Aaore; 0 trading Dddl4f)umpsnnr D Chair — 309 Point Roach Bad Stations (Abliftipchn) 0.05% 499467 Bail IlomL' 499-092 Ptivandt111B �4% OOBond Dust(0,=99% 9444-129 15 Demand CS(I-anabda-dynallobvin) U0.015% U0.03% 00.06% 100-1066 210 DeftaGand G (Dedowneffirin) 0.05% 432-836 158 TtDle Bulk Dust (Silica GeQ 40%(Pyrethrins) 1.0% 499-429 41 Gentrol EC (Hydroplane) 0.06% 2724-351 540 Generation Mini Blacks Bait (Difechalone) 0M25% 7173218 39 Intim GrmuimBaIHOrft"i�Mid)5.0%,�, 73079-2 43 Nicker EC(Pyreffians) Q0.05% 110.1%,'E0.2% 432-11451 550 UquiTox 11 Bait (Dificadiurn Salt of Diphacinone) 0.106% 12455-61 352 Maudome FC Roach Bait Sol (Ppronfl) 0.1 432-1257 351 Maixforce FC Ant Bell Stations (Epronild 0.01% 432-1256 357 sibuclonae FG Ant Gel Bait (Rpronil) 0,001% 432-1264 354 Mai FG Select Roach Bad Gel (Pproall) 0.01 % 432-1259 355 lituarforce i Insect Bait (Hydramethynor) 1.0% 432-1262 360 Man Bait/Niban FG Bait (Orldotionic acid) 5% 64405-2 46 NylarEC(Pyripdoxyfed) 00.015% 00,02% 11715-307-57079 49 Orthene Turf, Tons, & Shrub WP (Acephate) 75% 59639 26 ZA 380 Prei Roach Gel Bait (Imidaclopi 2.15% 151 PT Cy -Kick Aerosol Clyflutntind 0.1 % 70 F7 Cy -Kick CS (Cyfluthnn) 0 0.0075% D 0.025% 0 0.05% 0 01 A 432-1365 499470 499-304 Precautions Keep out of reach of childri and pato May cause eye. di nnort, or i whatird. Avoid local Vapors inaid, ordnod. Bari if maidavea, Condon granules to acii Po not tard,dr win rocenticide placements. cd not acturn to road until after ventilation, bt� not tri located loans until dr, For fil trantionats, remain on around area for a minimum of For thoiwa or until dl 312 PT Avert Gel Bait (Abarnectin Ell 0,06% 499410 0 PT 565 Plus XL0 Aerosol (Pyrethrins) 0.5% 499-290 159 PT TriDid Aeroflot (Silica Aercgej 4.8% (Pyreffinns) 0.6% 499-385 81 Tempo UftraWP(Cylluthnn) 00.025% 00.05% DO.1% 432-1357 83 Tempo SC Ultra (Clifluthrin) 3 0.025% 00.05% U 01 % 432-1363 91 UUDBPI000LV(PydAhnrs1.0% 499-452/11540-9 Treatodendcati cmCniallcravice V = Vaid G - Gadaral 5 -Spot BT = Bait DC - Dindcod Contact B - 3 Band SP = Strace IN - do,oVion 92 UM BP 300 ULV Pyrathi 3.0% 499-450/11540-1 591 Weatherflok XT Bait (Brudifacoun) 0.005% I00-1055 — ----------- _A_ En-land"a .-a (PC) CS= Cold, Air Spoiler T - Train as - Bait undid, No - Hand Custer A - Moil GG -Rail God PT= Power Tridarri F = JLV 2SPECIAL Posting Service Sticker? 0 rate UN. Supervisor's Comments: f) i, !'1 .1 .1. T) C fE J (/'..: F UNRESOLVED PROBLEMS? CALL 1-800-TERMINIX (1-800-837-6464) SERVICE INSTRUCTIONS STOMEFS:!!I� If AMOUNT PAID L7N CASH SEr TECHNICIAN'S SIGIN �TURE, Z" L_ �� I AT — � '_'� � I �.� C j CHECK 0WLC1'1 rl'IH V1Y/V, 1G.-a-�. "t , n , t,+»x... z ".c..."�7=ml! c = Service Areas -Ad*. wind 0onditions Observed `" °,,:'�'y,° '?;- P.4 'a!This IPM report details where ,. po pests were found in and around the facility. The report also lists those steps you can take to help limit or minimize pest invasions. For each of the areas listed below, numbers represent the type of pests found in the area, and letters represent any conditions present that may be contributing to a current, or possibly a future, pest infestation. Interior Areas Pests ❑ Offices ❑ Lobby/PublicAreas ❑ Entryways ❑ Rest/Locker Rooms — ❑ Janitor Closets ❑ laundry ❑ Boiler/Furnace Room Storage Utility TIT. b. Basement ❑ Patient Rooms ❑ ICU ❑ Linen Storage Rooms ❑ Kitchenettes: — ❑ Nurses Stations ❑ Guest Rooms ❑ Banquet/Meeting Rooms;. ❑ Display Aisles $' - ❑ Other ❑ Other 1. German Cockroaches 2. American Cockroaches 3. Oriental Cockroaches 4. Outdoor Cockroaches 5. Silverfish A. Drain Clogged/Dirty B. Food Debris Under Table C. Food Debris On Shelf D. Food Debris Under Appliance E. Wet Organic Matter in Cracks F Grease Deposits on Floor G. Grease Deposits on Equipment H. Soiled Dishes Lett Over Night Comments a Signature Conditions Food Areas Pests Condition Dining Area -iA Stove/Oven Line W1TCHEEr[3REWr�=r�- -Q Food Storeroom _-1ER Dishwashing Area -$ ❑ Deli/Bakery 1'56' DERBY ;S.T,c4 ❑ Processing Area �7"JZA 0WLC1'1 rl'IH V1Y/V, 1G.-a-�. "t , n , t,+»x... z ".c..."�7=ml! c = Service Areas -Ad*. wind 0onditions Observed `" °,,:'�'y,° '?;- P.4 'a!This IPM report details where ,. po pests were found in and around the facility. The report also lists those steps you can take to help limit or minimize pest invasions. For each of the areas listed below, numbers represent the type of pests found in the area, and letters represent any conditions present that may be contributing to a current, or possibly a future, pest infestation. Interior Areas Pests ❑ Offices ❑ Lobby/PublicAreas ❑ Entryways ❑ Rest/Locker Rooms — ❑ Janitor Closets ❑ laundry ❑ Boiler/Furnace Room Storage Utility TIT. b. Basement ❑ Patient Rooms ❑ ICU ❑ Linen Storage Rooms ❑ Kitchenettes: — ❑ Nurses Stations ❑ Guest Rooms ❑ Banquet/Meeting Rooms;. ❑ Display Aisles $' - ❑ Other ❑ Other 1. German Cockroaches 2. American Cockroaches 3. Oriental Cockroaches 4. Outdoor Cockroaches 5. Silverfish A. Drain Clogged/Dirty B. Food Debris Under Table C. Food Debris On Shelf D. Food Debris Under Appliance E. Wet Organic Matter in Cracks F Grease Deposits on Floor G. Grease Deposits on Equipment H. Soiled Dishes Lett Over Night Comments a Signature Conditions Food Areas Pests Condition Dining Area -iA Stove/Oven Line 3 -Q Food Storeroom _-1ER Dishwashing Area -$ ❑ Deli/Bakery ❑ Processing Area ❑ Packaging Area ❑ Produce Area — �� ❑ Meat/Seafood Shop J ° . Exterior Areas O Exterior Walls -North ❑ Exterior Walls- -South _ ❑ Exterior Walls -East ❑ Exterior Walls -West ❑ Loading Dock ❑ Dumpster. _ ❑, Exterior Storage Lioonfs 11� ..... .. Ll Roof ❑ Other ❑ Other 6. Pharaoh Ants 7. Pavement Ants 8. Fire Ants 9. Argentine Ants 10. Ants. 1. Paper/Litter J. Water leak K. Mops Improperly Stored L. Trash Containers Need Cleaning M. Heavy Dust/Dirt Deposits N. Numerous Cobwebs Present O. Repair Floor/riles/Wall/Ceiling P. Seal Holes/Cracks in Walls 11. Occasional Invaders 12. Hunting Spiders 13. Web -Building Spiders 14. Brown Recluse Spiders 15. Black Widow Spiders Q. Poor Storage Practices R. Repair Water Damaged Wood S. Seal Exterior Cracks/Holes T. Trim Back Tree/Shrub Branches U. Remove Piles of Debris V Cut Tall Grass/Weeds W. Improve Outside Drainage X. Install Gravel Foundation Barrier Service Professional's 16. Rats (ii, Mice 18. Stored Product Pests 19. Other 20. Other Y. Move Dumpster Away From Bldg Z. Dumpster Area Needs Cleaned AA. Mercury Vapor Lights Outside BE. Keep Doors Closed CC. Repair Door/Screen DD. Replace DoorWeatherstripping EE. Poor Outdoor Storage Practices FF. Other ii �� Daty I I 1 I t� °BRANCH. s„a`ACCOUNi, ,$Y.'rll@aD.' S. DAYj-'.IT�,$,P.F30011 ON�4' ME" .. �?IME qU,f 2397 662063 0% 978) 74�--F3717 t1Al._E 12 N 435.001 7/12 /05 70 Yru r.c ,r`SERVICE PROPERTY ATA m,7-rst'"` 2'` • ' .; _ '.'.;' `A'e. w-6RANCH �^w WITC111"S- BREW 156 DERBY ST :>AL-E:M , MA 01.970 TERMINI:X INT11RNATI0NAL- 130 Rl1MF'ORD AVE SIE 1.1.3 NI:iaTU,I , MA 02466 OPERATOR NAME & CERTIFICATION NUMBER ,JOHN F SHEE I-1AN 1762`:; SUPERVISOR NAME & CERTIFICATION NUMBER F':T.S1... E. -R, ARTHURf I r :I.59£3 �-y Target camtan cpperpache,Z' Paremmt Afip-IVS Rata ❑ ornasirolimaders Pests ❑ Amenran Cockroaches O ' A+9e^5ne Ams Mica 0 Storms Frptlrrcl Pests ❑ orental Cocbpechea ❑ Rre Ams U shrermh 0 othr ❑ ower cpckmaprl� - ❑ othorAms ❑ Nies 0 other Materials .used 4uxa q5o Insitlers 620 WIND-UP TRAPS 4001nsect Monitors 610 111416 .. heromone Tra 64.5 Rat Bak Stations Pest Control Materials USCG EPA Reg. R Tic E/C Amount iiasou,tilue Traps 640 Mouse Bait Stations 630 SnapTra 655 Li uH Bait Stations 293 Advance Gr anular Ant Bail (AbamecSn B1)0.011% 499-370 Areas Inspected and/or Treated Fast Gamma materieh used Mdi[a2dbycpCea hom lisle(lek. 295 Advance Dual Choice Ant Bait(Sullurarl 0.5% 499459 315 AsrerW Fire Ant Bait(Abamact10:81) 0.011% 499-370 �Fooa,tices O"ZL nine ❑�/O�c UYublic �/ ICBest6ackar Rooms ❑Display Areas ❑ laundry/Boiler Horn Atorage utili y 0Wamprse A,es 0P,ou's, Areas ❑ PatienrRooms 0 Guen Rooms q Basement 6 Uy 0 Root ❑ Enelor Pemneter 0 Landaraped Areas O Loading DockrDempster 0 other 309 Avert Roach Bak Stations (Abamer in) 0.05% ---74-9-9-467 365 Advance 3888 Ant Gel Bait (Borsx) 5.4% .:8" 499492 Bond Dust (Ortho Boric Al 99% : 9444-129 1s Demand CS(Lambdacyhalothrin) ❑0.015%.;,.06% 100-t0E6 00.03% ❑0 210 DeltaGard G(Deltamethrin) 0.05% 432.836 158 TriDie Bulk Dust (Silica Gel) 40%(Pyrethrins) 1.0% 499-429 41 Gentrol EC (Hydroprene) 0.06% 2724-351 540 Generation Mini Blocks Bait (Difethi bone) 0.0025% 7173-218 Irkice Gmnular Bat(Orthoboiic Acld)60% _ j,. 73079.2 _ -. 43 Kicker EC iscadi ❑OD5% .1% 00.2% 432-1145 7 550 x 11 Bat( Saltof 0.10.05%D6% 12455-61 Roach Bum Maxx C ti s (i immioral 352 Maxforoe FC Roach Bail Stations (Fipronip 0.05% ___Z321257 351 Maerforce FC Ant Batt Stations (FiWanill 0.01 % 432-1256 357 Maedo¢e FC Ant Gel Bail (Fipronil) 0.001 % 432-1264 354 Madome FC Roach Bad Gel (FiproniQ 0.01 % 432-1259 355 Maxlorce FG Insect Bait (Hydmmethylnon)1.0% 432-1262 360 Niban BaiVNiban FG Bait (Orthobone add) 5%4 64405-2 46 NNar EC(Pynproxyfen) 00.015% 00.02% 11715-307-57079 49 Orthene Tod, Tree, & Shrub WP (Acephate) 75% 59639-26-ZA 380 Pre-Empt Roach Gel Bait (Imidacloinal 2.15% 432-1365 151 PT Cy -Kick Aerosol(Cyfluthrin) 0.1% 499,70 Precautions ns Keep oututioutio orchndren arm pets. May cause e, nose. throat, r skin irritation. Avoid breathing vapors mins, or dusts. Harmful it swallowed. Dampen granules to activate. m not tamper win mdenooide placements. Do net return to room until inner ventilation. Do not touch treated areas until all For nes boomers, remain on treated area for a minimum poor hours or until dry. 70 PTCy-KIck CS(CYButhrin) 0.025% 0.0590.1% 499-304 312 PT Avert Gel Bait (Aleamectin 31)'0.0% 499-410 69 F1565 Plus XLO Aer l(Pyrethrins) 05% 499-290 159 PT TriDie Aerosol(Silica Asmi 4.8%(Pyrethnns) 0.6% 499-385 121 Suspend SC (Deltamethrin) 00.01% 00, % ❑ 0.0 432-763 81 Tempo U Ultra WP(Cyfluthrin) 00.025% 00.05%Q0,1% 432-1357 83 Tempo SCUltm(Cyfluthnn)]0.025% ❑0.05% 00.1% 432-1363 Treatment Coal (TIC). c=Crack &Crevice v=void G=General S=Spot BT=Bait ne= Directed Contact B=3 Bond SP=Space IN = la5pectim 91 UUD BP 100 ULV(Pyrethrins) 1.0% 499-452111540-9 92 ULD BP 300 ULV (Pyrethrins) 3,0% 499-050/11540-1 591 Weatheri XT Bait(Brodifacouml 0.005% 100-1055 Equipment Cotle lHCt. GS=Comp. Air Bprayer T=Trap BS =Bait Station HD=Hard Duster A=Aerosol BG=Bail Gun PT=Power Treatment F=ULV Posting Service Sticker? ❑ Yes ❑ No Supervisor's Comments: ^7 x1.., 11 ad l y;l fcs . I T (i i'.'di .I. ;j t'_ t:::. :1. 3 F; 0'.., UNRESOLVED PROBLEMS? CALL 1-800-TERMINIX (1-800-837-6464) SPECIAL SERVICE INSTRUCTIONS 1G OMER'S SIGNATURE L AMOUNT PAID CASH SERl TEOHNICI 5 IG ATUHI, -' %-'--- ''-'"—'�a '�-`] 1t �,'% 0 ' CHECK CUSTOMER9�IFORMAMO15 .+ac «b a ,vim Y. y V k 4V f Y M ..?�^ i wlR�c. W;ITGHES .F3REWjR Fv i fF a Z iu4,4r , 1156 DERBY ST t' °�'x m $ w Y �.rt M�,NbTE/�M/N/X. FILL=MA ,M01970: Service Areas=Activity and Conditions Observed„ This IPM report details where pests were found �in and around the facility tThe report also lists those steps you can take to help limit or minimize pest invasions. For each of the areas listed below, numbers represent the type of *ts found in the area, and letters represent any conditions present that may be contributing to a current, or possibly a future, pest infestation. ii Interior Areas Pests Conditions .t Food Areas Pests Conditions I ❑ Offices �. Dining Area LlLobby/Public Areas ' �Stove/Oven Line n ❑ Entryways! - Food Storeroom wyr d Rest/Locker Rooms o �,. Dishwashing Area e ❑ Janitor Closets ; ❑ Deli/Bakery ❑ Laundry ❑ Processing Area ❑ Boiler/Furnace Room ❑ Packaging Area ,XStorage Utility ❑produce Area - ❑ Warehouse ❑ Meat/Seafood Shop Basement 99-S Exterior Areas ❑ Patient Rooms LI ICU L3 Exterior Walls -North 'i+r ❑ Exterior Wall"outh ❑ Linen Storage Rooms a ❑ Exterior Walls -East 4 Kitchenettes - .. ❑ Exterior Walls -West _ ❑ Nurses Stations ❑Loading Dock ❑ Guest Rooms Ll Dumpster _ ❑ Banquet/Meeting Roo ms —x _. ❑ Exteriqr StoraggRooms ❑ Display AislesIf x, e_ , . _..-. ❑ Roof _ 3..Other LI Other ❑ Other ❑ Other - 1. German Cockroaches 6 Pharaoh Ants 11. Occasional Invaders 16. Rats 2. American Cockroaches 4 Pavement Ants 12. Hunting Spiders 17. Mice 3. Oriental Cockroaches -✓& Fire Ants 13. Web -Building Spiders 18. Stored Product Pests 4. Outdoor Cockroaches 9. Argentine Ants 14. Brown Recluse Spiders 19. Other 5. Silverfish 10. Ants. 15. Black Widow Spiders 20. Other A. Drain Clogged/Dirty _., I. Paper/Litter O. Poor Storage Practices Y. Move Dumpster Away From Bldg. - B. Food Debris Under Table J. Water leak R. Repair Water Damaged Wood Z. Dumpster Area Needs Cleaned C. Food Debris On Shelf K. Mops Improperly Stored eal Exterior Cracks/Holes AA. Mercury Vapor Lights Outside AFood Debris Under Appliance L. Trash Containers Need Cleaning T Trim Back Tree/Shrub Branches BB. Keep Doors Closed E. et Organic Matter in Cracks M. Heavy Dust/Dirt Deposits U. Remove Piles of Debris CC. Repair Door/Screen F. Grease Deposits on Floor -N. Numerous Cobwebs Present V. Cut Tall Grass/Weeds DD. Replace Door Weatherstripping G. Grease Deposits on Equipment O. Repair Floor/FilesMall/Ceiling W. Improve Outside Drainage EE. Poor Outdoor Storage Practices - H. Soiled Dishes Left Over Night P. Seal Holes/Cracks in Walls X. Install Gravel Foundation Barrier FF. Other Comments IBI Signature Service Professional's Signature Date IMPORTANT MESSAGE PHONE AREA COOE NUMBER EXTENSION O FAX ❑ MOBILE AREA COOE N�M BER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU L AGAIN WANTS TO SEE YOU LRUSH RETURNED YOUR CALL TO YOU MESSAGE SIGNED . NOTES CITY OF SALEM BOARD OF HEALTH Page: of k Establishment Name: R i2 -c- W Date: 1 0 - 2\a •OJ Item No. Code Reference C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION R — Red Item ' PLEASE PRINT CLEARLY Date Verified YA Mo Z"'A FQ-\L- c/ l ZZ 1\ IT, Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to P comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revo ion of your food permit. �(/� Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion Ll 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 16 17 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-30114 Protection from Unapproved Additives* I 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 Searation - Storage" 7-202.11 Restriction -Presence and Ilse* 7-202.12 Conditions of Use - 7 -203.11 Toxic Containers - Prohibitions* 7-204.11 Sar» dzers, Criteria -Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Dr 'ing 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 * Denotes critical item in the. federal 1999 Food Code or 105 CMR 590.000. 19 20 3-501.14(0) Proper Cooking Temperatures for ' 3-501-15 PHFs 3-401.11A(L)(2) Eggs- 1.55°F 15 Sec. 3-501.16(B) 590.004(F) Eggs- Ininiediate Service 145'FI5seo* 3=01.11(A)(2) Comminuted Fish, Meats & Came 3-501.16(A) Animals - 155°F 15 sec. * 3-401.11(11)(1)(2) Park and Beef Roast - 130"F 121 min* 3-401.11(A)(2) Ratites, Injected Meats - 155°F 1.5 590.004(H) sec. * 3-401_11(A)(3) Poultry, Wild Game, StuffedPHFs, .008 Stuffing Containing Fish, Meat, 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 * 340LII(A)(1)(b) All Other PHFs -145"F15see. * Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 sec. 5= 3-403.11(B) Microwave- 165" F 2 Minute Standing Time* 3-403.11(C) Commercial lyProcesse l RTE Food - 140'F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PRFs 3-501.14(A) Cooling Cooked PHFs from 140`F to 70°F Within 2 Hours and From 70°.F to 41°F/45°F Within 4 flours. * 3-501,14(B) Cooling PHFsMade From Ambient Temperature Ingredients to 41 °F/45°F Within 4 Hours'x * Denotes critical item in the. federal 1999 Food Code or 105 CMR 590.000. 19 20 3-501.14(0) PlIFs Received at Temperatures According to Lltw Cooled to 41"F/45"F Within 4 Hours. 3-501-15 Cooilm, Methods for PHFs 3-801.L1(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold Pl-IFs Maintained at or below 41V45,1 F* 3501.16(A) Hot PHFs Maintained at or above 14W * 3-501.16(A) Roasts Held at or above 130"F. 26. Water, Plumbin and Waste Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) Variance Re uirement a• � 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning L ddb ds* 23f Management and Personnel 3-801.L1(B) I Use of Pasteurized F,>>s* _ 24. Food and Food Protection 3-801.1.1(1)) _ Raw or Partially Cooked Animal Food and Raw Sced S proms Not Served. * ;13 3-801.11(C) I Unopened Food Package Not Re -served. " CONSUMER ADVISORY 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 relatini to good retail practices should be debited under #29 - Special Requirements, r�a�rtirra�, (items 23-30) Critical and non-critical violations, which do nor relate to the ,foodborne illness interventions and risk firctors listed above, ran be found in the following sections of the Food Cade and 105 CMH 590.000. Item Good Retail Practices, ilConsumer Advisory Posted for Consumption of 23f Management and Personnel FC - 2 Animal Fo ds'rhat are Raw. Undercooked or _ 24. Food and Food Protection K:-_31114 Not Otherwise Processed to Eliminate ;13 -4 FC_4 Patho<•att.-302.73 26. Water, Plumbin and Waste FC -5 Pasteurized Eggs Substitute for Raw Shell 27. Physical Facility-_-____ -t- FC - 6 Eggs* Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relatini to good retail practices should be debited under #29 - Special Requirements, r�a�rtirra�, (items 23-30) Critical and non-critical violations, which do nor relate to the ,foodborne illness interventions and risk firctors listed above, ran be found in the following sections of the Food Cade and 105 CMH 590.000. Item Good Retail Practices, FG 590.000 23f Management and Personnel FC - 2 .003 _ 24. Food and Food Protection K:-_31114 . 25 Equipment and Utensils -4 FC_4 .005 26. Water, Plumbin and Waste FC -5 .006 27. Physical Facility-_-____ -t- FC - 6 - --- 007 28. Poisonous or Toxic Materials FC - 7 .008 _29. S ecial Requirements 30. Other sswu�m,wa-zaw 305 South Street, Jamaica Plain, MA 0213o Pnone.(617)983-6773 Fax: (617)983-6770 Priscillaneves@state,ma.us To. Joanne Scott r MA Department of Public: Health Canter for Envire11111ental Health Food Protection Program irem. PPJSCU ANEVES,-MEd; RS, CFSP Assistant Director. Food Safety and Security Fain 978-741-1800 Pages:(Inaluding Co rK 9heeg 'l Me Ow-ew 49 3 V 04 Phone: Data: /D ' �� O "r- ue. Gti rlrL, 04't" / ) . cc:.. ... ❑ Urgent O For Review 13 Please Comment Cl Please Reply ❑ Per Request Ib has received the attached complaint wnien falls within your jurisdiction. We are to you for follow -up - Please forward to the Food Protection Program, copies of reports of any follow-up actions that you may have taken. The complainant would also like to 06 informed of your findings. If you have any further questions or need assistance, please call me at (617)983-6773. Thank you for your cooperation in this matter. Massachusetts Department of Public Health Food Protection Program 305 South St Jamaica Plain, MA 02130 Ph (617) 983-6712 Fox (617) 983-6770 _.. _.. _.. _.. _.. _................. _...I............................................................. _ ....................... Complaint Number. 05-158 ... _ .. _.. ... _.. _.. _.. Dare of COmpta-M 10/14/2005 F000bome Illness* ❑lt res Fill dot Foaarvme agnea. From Form of Complamr Telephone Source of Complaint Consumer Complainant Name Anonymous Address' ❑ OK to give Out Phone: Namara to company Notes. Description of Complaint. Component reported mat me W itche's Brow Cafe located at 150 Derby St.. in Salem Oontinves to nava mice and cockroaches. The food astabkshment is Ydlny'. Two nights ago, he observed two food employees dumping buckets of grease and waste matter down the city sewer outside of the establishment. He nae already Bled a complaint with the South Essex Sinvaga Commission. ne stated trial me Salem BOn rias peen mitilmd.on numerous.occaswons but. has Mailed to enforce me regulations. He was aware met a similar complaint (004.082) was filed wlm the FPP in 20?4 N I.ry at ComcoWn, 000aNtafy, Practleea ❑ v,>,ted Mann Care Provioer visit Date. Product Brand Name Product Name. Product SaelWeignt. Sen By Date: EApirotioruBest used Date: Date of Purchase: Name of Prowler Product Information Category Product CodWSenal Number: Package Type: UPC Code: ❑ imported Product ❑ Product used Date Lair Amount Remaining. Establishment Where Purchased: : Manufactured By. Dismbute0 By WdM¢'s BRw Cafe 166 Darby ST- cSalem SalemMA Phone- Phone: Phone: Complaint Received By PN PnoMNumber (6/7)983775 Referred To: BOH Comments: BOn did cite this eatabkshmam for rodent contamination in 2004 complaint dna ordered the estatNtshment to be cleaned Complaint huea to Salem BOH. Disposition, Page 1 of 1 CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item No. Code Reference C -Critical item R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION _ 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 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 ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 18 TIMEITEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-50 L 16(B) .590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers" 7-10211 Common Name - Working Containers* 7-201.11 1 Separation - Stora e"` 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use - 7 -203,11 Toxic Containers - Prohibitions* 7-204.11. Sat» rizers, Criteria - Chemicals* 7-204.12 Chemicals for Washine Produce, CiteriO 7-204.14 Drying ents, Criteria* 7-205.11 incidental Food Contact. Lubricants* 7-206.11 1 Restricted Use Pesticides, Criteria* 7-2061 12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIMEITEMPERATURE CONTROLS Denotes critical item in the foderil 1999 Food Code or 105 C NIR 590.000. 19 24 .-•'fir •i• _.,4....-,.. :R ,.�,y{ p..` r. _ 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.11A(1)(2) Eggs- 155'F 15 Sec. 3-50 L 16(B) .590.004(F) Eggs- Immediate Service 145'Fl5sec* 3-401.11.(A)(2) Comminuted Fish, Meats & Game 3-801.11(0) Animals - 155'F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 3-401.11(A)(2) Ratites, Injected Meats- 155'F 1.5 26. ---Physical sec. 3-401_H(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC-6� Poultry or Ratites -165'F 15 set. 3-401.11(C)(3) Whole -muscle, intact Beef Steaks FC - 7 145°F 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 7401.11(A)(1)(b) All Other PHFs - 145'F 15 sec ------�-� Reheating for Hot Holding 3-403.1 I (A)&(D) PHFs 165'P 15 sec. a= 3-403.11(8) Microwave- 165'F2Minute Standing Ti mc* 3-4011.1(C) Commercially Processed RTE Food - t40"F* 3-403_I.I(E) Remaining Umliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140cF 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 .4mbiem Temperature Ingredients to 41T/45'F Within 4 Hours* Denotes critical item in the foderil 1999 Food Code or 105 C NIR 590.000. 19 24 .-•'fir •i• _.,4....-,.. :R ,.�,y{ p..` r. _ 3-501.14(C) PICFs Received at'1'emperatures According to Iaw Cooled to 4 F`F/45" F Within 4 Homs. 3-501.15 Coofnl� Methods for PHFs 3 -801,11(B) PHF Hot and Cold Holding 3-50 L 16(B) .590.004(F) Cold PHFs Maintained at or below 41'/45° F* 3-501-16(A) Her PHFs Maintained at or above 3-801.11(0) Held at or above 130'F'. L3_i140°F.01.ARoasts Time as a Public Health Control o119Time as a Public Health Control*.0046 26. ---Physical - Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS iHSPI 21 3-801AI(A) Unpasteurized Pre-packaged Juices and _ Beverages with Wm nine Labels - - -- -- _.... 590.00-0 3 -801,11(B) Use of Pasteudzsd Ecus* FC - 2 3-801-1.1(D) Raw or Partially Cooked Animal Fend and Raw Seed Sprouts Not Served. Food and Food Protection 3-801.11(0) LJno>ened Blvd Pucka �e Not Re -served. �' CONSUMER ADVISORY 22 3-603.1 I Consumer Advisory Posted for Consumption of - -- -- _.... 590.00-0 23. Animal Foods that are Raw. Undercooked or FC - 2 .003 Net Otherwise Processed to Eliminate Food and Food Protection Path * PAe'6- 1, ""'V , 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. ---Physical E es* 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 (Items 23-30) Critical and non-critical violations, which do not relate to the ,foodborne- illness interventions and risk jaetors luted above, can be ,found in the following sections of the Food Code and 105 CMR 590.000. Item -------------- Good Retail Practices FC - -- -- _.... 590.00-0 23. Management and Personnel FC - 2 .003 24. Food and Food Protection 25. Equiprnant and Utensils .. _ FC -__4 .005 26. ---Physical Water, PlumbingWaste FC_ -5 .006 27. _and Facili - FC-6� .007----- 28. Poisonous or Toxic Materials FC - 7 ! .008 29. S genal Re uirements009 30. Other ---- ------�-� zs:1s"' I„nt-zm>< CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item No. Code Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION 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: ❑ 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 '16 17 18 TIMEITEMPERATURE CONTROLS Food or Color Additives 3-202.12 A("tives* 3-302.14 Protection frorn 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 - Stoi agc" 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of (Jse* 7-203.11 'toxic Containers - Prohibitions" 7-204.11 Sanitizers, Criteria -Chemicals* 7-204.1.2 Chemicals for Washing Produce, Criteria 7-204.14 DryingAgents. Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stations - 7206,13 Trackiug Powders, Pest Control and Monitorin.* TIMEITEMPERATURE CONTROLS ° Denotes critical item in the federal 1999 Food Code or 105 Cy1R 590 000. F3-501.15 Proper Cooking Temperatures for PHFs Received at Temperatures According to taw Cooled to 41'F145F Within 4 Hours. Cooling Methods for PHF's PHFs _s -401.1.1A(1)(2) _ Eggs- 155'F '15 See. 24. -Immediate Service 145-F15sec* 3-401.11(A)(2) _Las Comminuted Fish, Meats & Game 3-501.36(A) Animals - 155'17 15 sec. * 3-401.1 l(B)(1)(2) Pork and Beef Roast -130`F 121 rate 3-401.11(A)(2) Ratites, Injected Meats - 155'F '15 sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Time as a Public Health Control* Stuffing Containing Fish, Meat, 590.004(H) Poulfr or Ratites -165'17 15 sec. " 3-401.1I(C)('3) Whole-muscle,bttact Beef Steaks 29. 145°F * 3401.12 Raw Animal Foods Cooked in a 30. Microwave 165°F * 3-401 _ I I (A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PFiFs 165".17 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 1,40'F to 701- Within 2 Hours and From 70'F to 41.'F145'F Within 4 Hours. 3-50114(13) Cooling PHFs Made From Ambient Temperature Ingredients to 41"17f45'F Within 4 Hours`k ° Denotes critical item in the federal 1999 Food Code or 105 Cy1R 590 000. F3-501.15 3-501.14(C) _ PHFs Received at Temperatures According to taw Cooled to 41'F145F Within 4 Hours. Cooling Methods for PHF's I4 3-801.11(B) PHF Hot and Cold Holding 24. 3-501,16(B) 590.004(F) Cold PRFs Maintained ai or below 41"145,"F" .004 3-501.36(A) Ilot PHFs Maintained at or above 140'17.* FC - 4 3-501A6(A) Roasts Held at or above 130'14. 2(} Time as a Public Health Control 2T. 3-501.19 Time as a Public Health Control* 0.007 590.004(H) uirement Variance Requirement 21 3-801..11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* ------------- Maria ement and Personnel 3-801.11(B) Use of PasteurizedEgss* 24. 3-801.11(D) Raw or Parnalty Cooked Animal Food and Raw Seed Sprouts Not Served. 'a .004 3-801.11(C) Uno>ened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of ------------- Maria ement and Personnel FC -2 Animal Foods That are Raw. Undercooked or 24. Food and Food Protection Not Otherwise Prmessed to Eliminate .004 25 Pathogens.". E'^�`a„6 "Poo, j FC - 4 3-302.13 Pasteurized Eggs Substitute for Raw Shell W ater, Plumbing and Waste Eggs!' Violations of Section 590.009(A) -(D) in catering, mobile food, temporal, mud 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 f(29 - Special Requirements. IIfW lftk'I'l:%fRW ng (Items 23-36) Critical and non-critical viololions, which do not relate to the foodborne iliners interventions and risk factors fisted above, can be found in the lelloo are sections of the Food Code and 105 CMR 590.000. i Item Good Retai! Practices FC 530.000 23. ------------- Maria ement and Personnel FC -2 .003 24. Food and Food Protection FC - 3 .004 25 Equ4ment and Utensils FC - 4 .005 26. W ater, Plumbing and Waste 2T. Ph sical Facility-_ FC -6 0.007 28. Poisonous or Toric Mater_ia_I_s FC - 7 .008 29. S ectal Re uiremonts .009 30. Other -'. WW I,r.A.v_kbgds Davuf1V Cody Chef 978- 744-699( City of Salem, Massachusetts Fire Department 48 Lafayette Street Salem, Massachusetts 01970-3695 Tel 978-744-1235 FaX 978-745-4646 {I�t dcody@salem cam Mr. Spiro Kounsalieh� J} Witches Brew Cafe{ C[ 156 Derby St ,— Salem, MA 01976 fire Preven tion V1r �� f'�!� Bureau 978-745-7777 SEP 2 7 2005 .Jll✓JJ�11 BOARD OF HEACITY OF LTH MAINTENANCE, CLEANING, AND TESTING OF FIXED FIRE EXTINGUISHING SYSTEMS. MAINTENANCE, CLEANING OF HOOD AND DUCT SYSTEMS WHERE COOKING GREASE IS GENERATED ................. The Salem Fire Prevention Bureau requires that all hood and dud systems are to be cleaned from the cooking area (hood) in the kitchen, all the way to the extreme end of the duct. THIS CLEANING WILL OCCUR ON A QUARTERLY BASIS. A certificate showing the name of the company, the person, and the date of the cleaning shall be posted near the hood area. The certificate will indicate what work was performed, and will also indicate areas not cleaned. ALL FIXED FIRE EXTINGUISHING SYSTEMS ARE TO BE TESTED AND CHECKED SEMI- ANNUALLY. THIS TEST WILL ALSO INCLUDE A TEST OF THE INTERIOR FIRE ALARM SYSTEM. The cleaning company and the fixed extinguishing service company shall file within (5) five days after the work is performed; a report with the Salem Fire Prevention Bureau of all their activities relative to the above listed systems. The report shall also list any and all deficiences of the systems and the remedial action to be taken. Failure to adhere to this public safety requirement will result in the shut down of the systems. Prior to resuming operations an inspection will be conducted by this office. Per Order, Lt. Erin Griffin Date of Conveyance Fire Marshal Cc: file Health Licensing Building FORM 81R (4/05) ''I dcarlrAx(mccom September 15, 2005 Mr. Spiros Kounsalieh c/o Witches Brew Cafe 156 Derby Street Salem, MA 01970 Fire Prevention Burea c 978-745-7777 Dear Sir: You are herby ORDERED by the Salem Fire Department, Fire Prevention Office, not to use the new portion of the business located at 156 DERBY STREET until the following conditions have been met: • You have the Sprinkler System tested and accepted by the Salem Fire Department • You have the Fire Alarm System tested and accepted by the Salem Fire Department • You have the Kitchen Fire Suppression System tested and accepted by the Salem Fire Department • You receive a Certificate of Occupancy from the Salem Building Inspector The following condition of exception shall be provided for September 18, 2005 ONLY: You may occupy the new room on the condition there is a Salem Fire Department Fire Watch present during the time the room is occupied by the public. Failure to meet this condition of exception will result in EVINIEDIATE evacuation of the facility and any further enforcement as the law provides. Res ectfully, Charles R. Holloran, Jr. Fire Inspector City of Salem., Massachusetts " Fire Department 48 Lafayette Street David W Cody Salem, Massachusetts 01970-J695 C&.f 'Zef 978-744-1235 .978-i444990 Fax 978-745-4646 dcarlrAx(mccom September 15, 2005 Mr. Spiros Kounsalieh c/o Witches Brew Cafe 156 Derby Street Salem, MA 01970 Fire Prevention Burea c 978-745-7777 Dear Sir: You are herby ORDERED by the Salem Fire Department, Fire Prevention Office, not to use the new portion of the business located at 156 DERBY STREET until the following conditions have been met: • You have the Sprinkler System tested and accepted by the Salem Fire Department • You have the Fire Alarm System tested and accepted by the Salem Fire Department • You have the Kitchen Fire Suppression System tested and accepted by the Salem Fire Department • You receive a Certificate of Occupancy from the Salem Building Inspector The following condition of exception shall be provided for September 18, 2005 ONLY: You may occupy the new room on the condition there is a Salem Fire Department Fire Watch present during the time the room is occupied by the public. Failure to meet this condition of exception will result in EVINIEDIATE evacuation of the facility and any further enforcement as the law provides. Res ectfully, Charles R. Holloran, Jr. Fire Inspector :1. DavufW Cody Chief 978-744-6990 dcody@sate m. c am 2005. City of Salem, Massachusetts Fire Department 48 Lafayette Street Salem, Massachusetts o1970-3695 `lel 978-744-1235 fax 978-745-4646 have received a copy of this letter on September 15, Encl: Hood & Duct Cleaning Requirements CC: File Chief of Department Deputy Fire Chief on Duty Building Department Salem Board of Health Licensing Board fire Prevention Bureau 978-745-7777 David IV Cody chief 976-744-6990 doodyC'sale m com City of Salem, Massachusetts Fire Department 48 Lafayette Street Salem, Massachusetts 01970-3695 'lel 978-744-1235 faX 978-745-4646 Fire Prevenhbn Bureau 978-745-7777 MAINTENANCE, CLEANING, AND TESTING OF FIXED FIRE EXTINGUISHING SYSTEMS. MAINTENANCE, CLEANING OF HOOD AND DUCT SYSTEMS WHERE COOKING GREASE IS GENERATED ............:.... The Salem Fire Prevention Bureau requires that all hood and duct systems are to be cleaned from the cooking area (hood) in the kitchen, all the way to the extreme end of the duct. THIS CLEANING WILL OCCUR ON A QUARTERLY BASIS. A certificate showing the name of the company, the person, and the date of the cleaning shall be posted near the hood area. The certificate will indicate what work was performed, and will also indicate areas not cleaned. ALL FIXED FIRE EXTINGUISHING SYSTEMS ARE TO BE TESTED AND CHECKED SEMI- ANNUALLY. THIS TEST WILL ALSO INCLUDE A TEST OF THE INTERIOR FIRE ALARM SYSTEM. The cleaning company and the fixed extinguishing service company shall file within (5) five days after the work is performed, a report with the Salem Fire Prevention Bureau of all their activities relative to the above listed systems. The report shall also list any and all deficiences of the systems and the remedial action to be taken. Failure to adhere to this public safety requirement will result in the shut down of the systems. Prior to resuming operations an inspection will be conducted by this office. Per Order, U. Erin Griffin Fire Marshal FORM 81R (4/05) 9 /4 -�s� Date of Conveyance t 156 Derby Street Witch's Brew Cafe City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE REINSPECTION Inspection HACCP: ❑ Item Status Violation Critical Urgency Nature of problem or correction Telephone: '- T - Non-compliance with: Done 744-7369 owner:: Anti -Choking PASS ❑ Spiro Kounsalieh Tobacco PASS ❑ _ PIC. FOOD PROTECTION MANAGEMENT Done SSpiro KOUDS8- — Ko PIC Assigned / Knowledgeable / Duties PASS RED piro InspeDavid EMPLOYEE HEALTH Done Greenbaum =F Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED 4122/2005 Personnel with Infections Restricted/Excluded PASS ❑J RED Risk Level: FOOD FROM APPROVED SOURCE Done Food and Water from Approved Source PASS ❑Q RED Permit Number: BHP -M05-0233 .,. ?:: „ Receiving/Condition Receiving/Condition Tags/Records/Accuracy of Ingredient Statements PASS PASS ❑Q ❑Q RED RED Status: `*' SIGNED OFF Conformance with Approved Procedures/HACCP PASS ❑d RED # of Critical Violations _ Plans PROTECTION FROM CONTAMINATION Done Time IN: =. g Time OUT. d. Separation/ Segregation/ Protection PASS RED Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED Notes: 314:El ' Proper Adequate Handwashing PASS Q RED E Urgency Description(s): Good Hygienic Practices PASS/❑ RED BLUE: S Violations Related to Good Prevention of Contamination from Hands PASS RED Retail Practices (Critical - Handwash Facilities PASS RED , violations must be corrected' immediately or within 10 days)(Non-critical violations GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 22,2005) Page 1 o/2 � - F 156 Derby Street Witch's Brew Cafe must be corrected Immediately PROTECTION FROM CHEMICALS Done or within 90 days) ` Fes" Approved Food or Color Additives PASS ❑J RED RED: Violations Related to Toxic Chemicals PASS ❑d RED Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS (Potentially Haz Done and Risk Factors (Require " Cooking Temperatures PASS ❑d RED immediate corrective action) Reheating - PASS ❑d RED Cooling PASS ❑J RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Done Posting of Consumer Advisories PASSd❑ RED Violations Related to Good Retail Practices (Blue Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other- See Notes PASS ❑ BLUE - All violations cited in the 9/15/05 inspection report have been corrected. GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 22,2005) Pa¢e 2 oil 156 Derby Street Witch's Brew Cafe City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: , - ".I Item Status Violation Critical Urgency Nature of problem or correction 744-7369 Non-compliance with: Not Done Owner ,Spiro Kounsalieh 4 Anti -Choking Tobacco PASS PASS ❑ ❑ PIC: „ _ Jane Cote _ FOOD PROTECTION MANAGEMENT Not Done Food and Water from Approved Source Receiving/Condition Tags/Records/Accuracy of Ingredient Statements Conformance with Approved Procedures/HACCP Plans PIC Assigned / Knowledgeable / Duties FAIL RED Inspector David Greenbaum `°- ` EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS a W A 9/15/2005 - Risk Level: Permit Number: BHP -2005-0233 Status: VIOLATION # of Critical Violations: 4 Time IN[ -Time OU Personnel with Infections Restricted/Excluded PASS L RED ❑D RED Notes. 300: Urgency Description(s): BLUE. ' - Violations Related to Good Retail Practices (Critical, violations must be correctedt immediately or within 10 days)(Non-critical violations GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005) Pave I o(5 FOOD FROM APPROVED SOURCE Not Done - Food and Water from Approved Source Receiving/Condition Tags/Records/Accuracy of Ingredient Statements Conformance with Approved Procedures/HACCP Plans PASSd❑ PASSd❑ PASS PASS ❑./ ❑Q RED RED RED RED Notes. 300: Urgency Description(s): BLUE. ' - Violations Related to Good Retail Practices (Critical, violations must be correctedt immediately or within 10 days)(Non-critical violations GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005) Pave I o(5 156 Derby Street Not Done Cooking Temperatures Witch's Brew Cafe must be corrected immediately PROTECTION FROM CONTAMINATION Not Done PASS RED or within 90 days) Separation/ Segregation/ Protection PASS ❑d RED PASS RED:, - Violations Related to Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑� RED e dirty knives stored in the rack. /AllOesmust be cleaned and sanitized Foodborne Illness Interventions torege. and Risk Factors (Require There is no zing solution available. ___ __ immediate corrective action) Sanitizi olution of proper concentration mu a readily avail ble at all work ations at all tim . Provide sanitizer immediately. The ice sc p is stored on top of the ice machi A sanitized ice scoop must be pla d in the ice machine handle side up in a sanitized container labeled ice scoop Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS ❑d RED Prevention of Contamination from Hands PASS ❑Q RED Handwash Facilities FAIL Criticald❑ RED The en handwash sink is being used f ood prep. Handwash sinks must be sed for handwashing only, NOT for food prep. The bar dwash sink found obstructed. Ke andwas sinks clear and accessible all times. PROTECTION FROM CHEMICALS Not Done Approved Food or Color Additives PASS ❑d RED Toxic Chemicals PASS ❑d RED TIMEITEMPERATURE CONTROLS (Potentially Haz Not Done Cooking Temperatures PASS RED - Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS RED GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005 ) Page 2 of 156 Derby Street CONSUMER ADVISORY Not Done Posting of Consumer Advisories FAIL RED Witch's Brew Cafe GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005 ) PaQe 3 of 156 Derby Street Witch's Brew Cah Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE foo al Th is d stored directly on the kin 46 or. All food must be stoored at least 6-8 inches the floor. Thmall white freezers must be moved m u rhe waste line. Th owac ice machine has an _ c ulation of rust and grime. In oroughl clean the ice machine. Equipment and Utensils FAIL Non -Critical ❑ BLUE The to silver cooling unit has an ac ulation of food debris and grime. oroughly clean this cooling unit inside and out. The me cooling unit needs a visible, curate th ometer. The floo g throughout the kitchen needs a th ugh cleaning including under and and all equipment. The A icrowave needs a thorough i Vcl ment a floor. store all food quip on tables up off the floor. Th urbo Air freezer needs a thorough eamng The in floor and racks need a th ughly cleaning. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non -Critical ❑ BLUE There is accumulation of trash and rubb! in alley. Keep all trash and is an appropriate trash receptacle. Th a are openings in the kitchen ceiling. gs. e ack Th ack screen door has tears in it. cre epair he screen door. T e are leaks and puddles in the asement. Investigate the source of the leaks d repair. . T asement stairs need a thoroughl eamng. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other- See Notes PASS ❑ BLUE a kitchen is need of a thorough cleaning and organizing. - Reinspection in one week, all items to be GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005) Page 4 of 5 156 Derby Street Witch's Brew Cafe corrected. GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005 ) PaQe 5 of IMPORTANT MESSAGE r FOR�I�r loll A DAT M U A.M. TIME 1 ��P.M. OF PHONE R A COO O FAX O MOBILE NUMBER E NBIRN AREA CODTWILL UMBER TIME TO EASE CALL CA TELEPHONED CAME TO SEE YOULL CALL AGAIN FAX TO YOU WANTS TO SEE YOUSH. RETURNED YOUR CALL MESSAGE SIGNED FORM 4009 MARE IN U.S.A. z 0 1 m co a -'t'iv.-wM96 }Y4.. x•+'.+�crry :.u:...�N.+aS - .- Sy .. ...i'-.♦ x .... ...- -. -.,,� ' v. _. • A 11.E +p CITY OF SALEM9 MASSACHUS_ ETTS' BOARD OF HEALTH q� 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. 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: Type of Establishment: FOOD SERVICE Name of Establishment: Witch's Brew Cafe Address of Establishment: 156 Derby Street Owner's Name: Spiro Kounsalieh Restrictions: Application Date: 12/2/2004 Permit for Food Establishment Frozen Desserts/Ice Cream 112-05 Permit for the Sale of Tobacco Products 28-05 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. Lac l , 1491E600 (/ HEALTH AGENT -.CITY OF SALEM, MASSACHUSE 5 ; BOARD OF HEALTH • ` - $ 120 WASHINGTON STREET, 4TH FLOOR NOV 3 0 2684 o' SALEM, MA 01970 q' �s TEL. 978-741-1800 SALEM ORB CITY OF FAX 978-745-0343 BOARD F HEALTH STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS,, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERI'. IT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT W lTGfNy 132£-cJ C4, fe— TEL # rt -7-9- 7L4S- 971 % ADDRESS OF ESTABLISHMENT 15 L¢ (� MAILING ADDRESS (if different) cs Q.�:_ OWNER'S NAME �J�� C� �io C9� 7q Li �! TEL # 170-2 Ll q -73C q ADDRESS V-3to 5r ;; ^ FL_zn) 2 CITY �SW- L..r--v✓\ STATE--rVL 4- ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)'i (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON6x:>,-,Lo HOME TEL #97F—?g4-136`i HOURS OF OPERATION: Mon. ✓Tue.y Wed. e --Thu. (— Fri. �at. ✓Sun. t/ TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than I000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO J less than 25 seats =$100 25-99 seats x$1501 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR �i -1—o �Y S� NO 50 ALL NON-PROFIT (such as church kitchens) C 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 best knowledge Signature Revised 11/03/03 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my have filed all state tax returns and paid all state taxes required under the law. Date Check# 8 Security 9_`/ Number 4 1 Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4`" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name r as ,T 15 Date ds T 0 erasion s TVDe of Insoection rem Food Service ❑ Retail ElResidential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. ❑ 5outine Re -inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint ❑ Other Address Risk Level /47 Telephone Owner I v ff&,eJNrA/_#ir/vi HACCP Y/N Person in Charge (PIC) Time Out: Inspector F � oacn violation GneCKeU requires an expiananon on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION" ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C„ N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S: 590Mn fFo1m 14dol [112. 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 REOUIREMENTS FOR HIGHLY. SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY, ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature- j Print: PIC's Signature: Print: Page % of 2Pages Violations Related to Foodborne Illness interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(0) Assignment of Responsibility" 590.003(8) Dcrnonsuation 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 repotting by food employees and 3-201 13 Fluid Milk and Milk Products* applicants* Shell Eggs'h 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To ReportTo "Che Person In Drinking Water from an Approved Svsfern* 590.006(A) Charge* 590.006(8) 590.003(G) Re orting b Per on in Char *e " 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(F) Removal of Exclusions and Restrictions C 5 C C '" Denotes critical item in the federal 1999 (rood Code or 105 Ch[R 59(1,(100. 4 .- t •s • g Food and Water From Regulated Sources 590.004(A -1D Compliance with Food Law* 3-201.12 Food in a Hanneticall Sealed Container* 3-201 13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs'h 3-202.14 ks gs and Milk Products. Pastem9zed- 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved Svsfern* 590.006(A) Bottled Drinking Water* 590.006(8) Water Meets Standards in 370 CMR 22.0* Washing Faits 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 Gains and Wild Mushrooms Approved by Re ulato Authority 3-202.1.8 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 Packa ge 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 Destrnction* 3-402.12 Records, Creation and Retention"` 590.004(J) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of F, ui Ement* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Prccessin = Methods* 3-502.12 Reduced oxy=en packaging, criteria - 8 -103.12 Confonnance with Approved Procedures* '" Denotes critical item in the federal 1999 (rood Code or 105 Ch[R 59(1,(100. 4 .- t •s • g Cross -contamination 3-302.11(A)(1) Raw \mmatFoods Separated front Cooked and. RTF F otuls" Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.1.1(A) Food Protection` 3-302.15 Washing Faits 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 Contarrdnated Food 3-701.11 Discarding or Reconditioning unsafe Food" 9 Food Contact Surfaces 4-501.111. Manual Waewashing- flot Water Sanitization `I' em eratures* 4-501.112 Mechanical Warewashirtg-Hot Water Sanitization Tern teratm:es* 4-501.114 Cheuueal Sanitization- temp., pH, concentation and hardness. 1' 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Fitensds* 4-702.'11 Frequency of Sanitization of Utensils and Food Contact Surfaces of F, ui Ement* 4-703.11 Methods of Sanitization - HotWaterand Chemical^' Io Proper, Adequate Handwashing 2-301-11 Clean Condition -- Hands and Arms" 2301.12 Cleaning Procedure* 2-301.14 When to Wash* Ll Good Hygienic Practices -I 2-401.11 Fat'in , Drinking or Clsing Tobacco` 2-401.12 Discharges From the Eyes. Nose and Mouth* 3-301.12 Preventing Contamination When Tastin ,* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em bytes' 13 Handwash Facilities Conveniently Located and Accessible 5=203.I t Numbers and Ca asides'^ 5-204.11 I-ocation and Placement* 5-205.11 Accessibi�on and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser. Availability 6-301.12 L Hand Drvin,Pr� CITY OF SALE BOARD OF HEALTH Establishment Name: /✓oi'ctsAr9X q-zX ,e Date: /A%4c Page: 2- of Z Item Code C - Critical Item ' DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Fi5afe No. Reference I R —Red ItemVerified eeec ooiur ri veof v ._.. A Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to obsery II conditions as described, and to LlRe-inspection Scheduled ElEmergency Suspension comply with all mandates of the Mass/FederrfFod Code. I understand that noncompliance may result in daily fines oft my -five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. Ao�_� 0 Voluntary Disposal 1 0 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 I5 16 18 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives'" - 3 -30114 Protection from Unapproved Additives* ;3 Poisonous or Toxic Substances 7-101.11 Identib4tiglnformation - Original Containers* 7-102.11 Common Name - Workim, Containers' 7-201.11 Separation - Swine* 7-20111 Restriction- Presence and Ilse* 7-202.12 Conditions of Use* 7-20=3.1.1 'roxicContainers- Prohibitions" 7-204.11 Sanitizers. Criteria - Chemicals* 7-20412 Chemicals for Washing Produce, Criteria* 7-204.1.7 Drvin guts. Criteria* 7-205.11 incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides. Criteria* 28. Rodent Bait Stations* r!!:: Tracking Powders, Pest Control and Monitann- TIME/TEMPERATURE CONTROLS "Demotes critical item in iha Cuieral 1999 Food Codo or 105 C MR 590,000. Proper Cooking Temperatures for PRFs Received t'lenwTatures Ac cordm„ to Law Cooled to 4FFt45 FWithin4Horus. Coolima Methods for PHFs PHFs 3-401.11A(1)(2) Eggs- 1.55°F 15 Sec. ;3 E>gs-InmediateService 145°F15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(A) Annuals - 155°F 15 sec. * 3-401.1 l(B)(1)(2) Pork and Beef Roast - I3(PF 121 min* 3-401.11(A)(2) Ratites, Injected Meats- 155'F 15 Equipment and Utensils sec. 3-401..11(A)(3) Poultry, Wild Game, Stuffed PRFs, Time as a Public Health Control* Stuffing Containing Fish, Meat, 590.004(H) Poultry or Ratites -165"F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks Physical_Faciliti 145°F 3-401.12 Raw Animal Foods Cooked in a 28. Microwave 165'F * 3- 401..11(A)(1)(b) All Other PHFs-145`F'15 see. * .008 Reheating for Hot Holding 3-403.11(A)&{p) PHFe 165°F 15 sec. * 3-403.11(B) Microwave- 165' F 2 Minute Standing 30. Timed' 3-403.11(C) Commercially Processed RTE Food - 1.40°F* 3-40311(E) Retraining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501_ W(A) Cooling Cooked PHFs from 140'F to 7WF Within 2 Hours mid From 70'F to 41'Fl45'F Within 4 Hours. * 3-501. i4(B) Cooling PHFs Made From Ambient Temperature Ingredients to 4101-,/45'F Within 4 Hours" "Demotes critical item in iha Cuieral 1999 Food Codo or 105 C MR 590,000. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 � 3 -SOL I I (A) I Unpasteurized steurized Pre-packaged Juices and Beverages with Warning labels" 3-801.11(D) Raw or Partially Cooked Ant ml Food and R rw Seed Sprouts Not Served.* 3-801.11(IU Unooened Food Package Not Re- served- " 2 3 -SOI 14(C) 3-501 I5 PRFs Received t'lenwTatures Ac cordm„ to Law Cooled to 4FFt45 FWithin4Horus. Coolima Methods for PHFs 19 590.000 PHF Hot and Cold Holding ;3 3-501.16(B) 590.004(F) Cold PPIFs Maintained at or below 41`745°F* .003 3-501.16(A) Hot PHFs Maintained at or above 14WR * FC 3-501.16(A) Roasts Held at or above 130`F.* 20 Equipment and Utensils Time as a Public Health Control - 4 3-501.19 Time as a Public Health Control* Water, Plumbing and Waste 590.004(H) Variance Re uirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 � 3 -SOL I I (A) I Unpasteurized steurized Pre-packaged Juices and Beverages with Warning labels" 3-801.11(D) Raw or Partially Cooked Ant ml Food and R rw Seed Sprouts Not Served.* 3-801.11(IU Unooened Food Package Not Re- served- " 2 3-603.1 t Consumer Advisory Posted for Consumption of 590.000 Annual Foods'phat are Raw. Undercooked of ;3 FC Not Otherwise Processed to Eliminate .003 24. Path6�enS.* ene11,1e aszooi FC 3-302.13 Pasteurized Eggs Substitute for Raw Shell 25. Equipment and Utensils 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 alcove if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Rccluiiements. Ul"al+ (items 23-34) Crorml and non-critical violations, which do not relate io the foodborne illness ituervennons and rcrk-jn(tors luted shove, (on be found in the follotoing sections of the Food Code and 105 CMR 590.000. Item Good Retail Practices FC 590.000 23. Mana ament 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 2/. Physical_Faciliti FC - -6 - - ' .007 28. _...- Poisonous or Toxic Materials FC - 7 .008 29. S ecial Re uirements .009 30. _ __ Other ___ ____ I Wiran;12d", • w Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name / Dat ! T e of O enation s T of Ins ection Food Service El Retail Routine ElRe-inspection f ! Qy Address f� Risk Telephone? Level El Residential Kitchen Previous Inspection 7!7 At ❑ Mobile El Temporary Date: [IPre-operation Owner HACCPY/N f J Lt I ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) s Time In: Out: Permit No. [I HACCP E-1Other 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 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 Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate, Handwashing El11. 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) 4. Food and Food Protection (FC -3)(590.004) 2 . Equipment and Utensils (FC -4)(590.005) 6. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S 590MVWFom 14.do IWA ❑ 12. Prevention of Contamination from Hands X13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMErrEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling [119. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY. SUSCEPTIBLE POPULATIONS (HSP) -. ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ., ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: / C - Inspector's Signatu Print: PIC's Signature: YJ - Print -s o / 1 y Pagel of� Pages r Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT I 590.003(A) Assi mment of Responsibility" �� 590.003(B) Demonstration of Knowledge* 2 103 1 1 Person in charge -- duties EMPLOYEE HEALTH 2 590.0030C) Responsibility oftheperson incharge to Compliance with Food Law* 3-20 L 12 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 'A-202.16 ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved Svst'ern* 590.006(A) Chw gc* 590.006(.B) 590.003((3) Reporting by Person in Char e* 3 59(L003(D) Exclusions and Resu ictions* 3-201.15 590.003(E)___LRemoval of Exclusions and Restrictions C I® C ••• c•.� a �::• ►� a :'I knote, enfical uen in the federal 1999 Food Code or 105 CNIR 590-X1(10. .r - • g Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-20 L 12 Foci 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* 'A-202.16 ice Made From Potable Drinking Water* 5-1.01.11 Drinking Water from an Approved Svst'ern* 590.006(A) Bottled Drinking Water* 590.006(.B) Water Meets Standards in 310 CMR 22.0* Washln y Froits 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 Reoulatory 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 PI -[Fs Received at Proper Temperatures 3-202,15 Package Lttc ity* 3-10111 Food Safe and Unadulterated TagsfRecords: Shellstock 3-202.13 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* TagsfRecords: 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 E ui anent* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized processing Methods* 3-502-12 Reduced oxygen packaing, criteria' 8-703.1.2 Conformance with A xoved Pnacedures" :'I knote, enfical uen in the federal 1999 Food Code or 105 CNIR 590-X1(10. .r - • g Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods` Contamination from Raw ingredients 3--02.11(A)(2) Raw Animal Folds Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection" 3-302.15 Washln y Froits and Vegetables 3-304.1.1 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"` 9 Food Contact Surfaces 4-501-111. Manual Warewa0ung-HotWoter Sanitization Tem. erattnes* Mechanical Warewashing- Hot Water Sanitization Temperatures* ffli Chemical Sanitization- temp., pH, concentration and hardness, Equipment Food Contact Surfaces and Utensils Clean*" Cleaning Frequency of EquipmentFood- Contact Surfaces and Utensils* 4-702.'1 1 Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui anent* 4-703.11 Methods ofSanitization-Hot Water and Chemical, Ip Proper, Adequate Handwashing 2-301.11 Clean ConditionHandsand Arms* 2-301.12 Cieanim* Procedure* 2-301.14 When to Wash* I I Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges Froin the Eyes. Nose and Mooth* 3-301.12 Preventine Contamination When Ti stir ,* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em levees" 13 Handwash Facilities Conveniently Located and Accessible 5-203.1.1 Numbers and Ca acities" 5-204-I1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Ilandwashina Cleanser. Availability 6-301.12 hand Diving Provision CITY OF SALEM BOARD OF HEALTH ' r Establishment Name: A110 I� r nAIy r `�uj Date: Page: 2 of Rem Code C - criticai item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION' Date No. Reference R — Red Item Verified _. PI GGSF PRINT CLEARLY - e_ If 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 nderstand that noncompliance may result in daily fines of twenty-five dollars r spension/revocation of your food permit.' Corrective Action Required ❑ Voluntary Compliance ❑ Re -inspection Scheduled ❑ Embargo ❑ Voluntary Disposal No I ❑ Yes ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: Violations Related to Foodborne fitness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 16 17 v 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 - Workim* Containers* 7-201.11 Separation - Storage" 7-202.11 Restriction - Presence and User 7-202.12 Conditions ofI-Ise* 7 -?03.1.1 Toxic Containers - Prohibitions* 7-204.11 Sanitizers,Criteria- Chemicals" 7-204.12 Chemicals for Washing Produce, Criteria's 7-204A4 Dc in� A tints. Criteria" 7-205.11 Incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stations* 7 -?06.13 Tracking Powders, Pest Control and Monitarina* * Denotes critical Sem is tha IMeral 1999 Food Code or 105 CNIR 590:000. U Proper Cooking Temperatures for E3-501.15 PHFs 3-401.11A(1 )(2) Eggs_ 155'F 15 Sec. 24, E gs-bumediateService 145'Fl5sw 3-401.11(A)(2) Comminuted Fish, Meats & Game 20 Anirnats - 155°F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast - 130°F 121 nun" 3-401.11(A)(2) Ratites, Injected Meats -155'F 1.5 FC -5 sec. * 3-401 1 I (A)(3) Poultry, Wild Game, Stuffed PHFs, _ FC -6 Sniffing Containing Fish, Meat, 26. Poultry of Ratites -165'F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 28. 145°F �: 3-401.12 Raw Animal Foods Cooked in a _ 30, Microwave 165°F * 3-401.11(A)(1)(b) All Other PHFs-145'F'15see. Reheating for Hot Holding 3-403.11(.9)&(D) PHFs 165`T 15 sec. * 1403.11 (B) Microwave -165° F 2.biimne Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140 Ft 3-403.11(E) Remaining Unsliced Portions of Bee( Roasts* Proper Cooling of PHFs 3-501..14(A) Cowling Cooked PHFs from 140`F to 70'F Within 2 Homs and From 70'F to 4t'Ft45°F Within 4 Hours. t. 3-50t.14(B) Cooling PI-IFsMade ,From Ambient Temperature Ingredients to 41'Pl45-F Within 4 hours' * Denotes critical Sem is tha IMeral 1999 Food Code or 105 CNIR 590:000. U s 21 3-501.34(0 PHFs Received at Temperatur" Aca)rding to Iaw Cooled to 4F F/4Y F Within 41 -lotus. E3-501.15 Coaling Methods for PHFs19 ( FC - 2 PHF Hot and Cold Holding 24, 3-501.16(8) Cold PRFs Maintained at or below 590.004(F) 41145' F* Not Otherwise Processed to Eliminate 3-501-160) Hot PHFs Maintained at or above 140°F-* 20 3a01.16(A) Roasts Heid at or above 130'F. Time as a Public Health Control FC 4 3 901.19 Time as a Public Health Control* Pasteurized Eggs Substitute for Raw Shell 590.004(H) VarianceRe wrement s 21 3-501.11(A) Linpastendzed Pre-packaged Juices and Bevecaaes will, Warning Libels* Consumer Advisory Posted for Consumption of ,-901,11(B) Use of Paste11197e1 Eeas* ( FC - 2 3-801.1. t(D) Raw or Pm tialty Cooked Animal Food and Raw Seed S )routs Not Served. " 24, 3-801.11(C) Umi tined Food Packa e Not Re -served. 22 3-603.11 Consumer Advisory Posted for Consumption of ----------- Management and Personnel ( FC - 2 Animal Foods ,rhat are Raw, Undercooked or 24, Food and Food Protection Not Otherwise Processed to Eliminate .004 25. Pathobens.* Ehecu�a rroaooi FC 4 3-302.13 Pasteurized Eggs Substitute for Raw Shell Water,Plumbing and Waste FC -5 -EEs'" SPECIAL REQUIREMENTS 5901)09(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and 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. r&X0r*1#M.•T:W-U1 (items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risd,facters listed above, can be found in the followilig sections of the Food Code and 105 CMR 590.000. Item Good 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. Water,Plumbing and Waste FC -5 ,006 27. Physical Facility_ _ FC -6 _ .007 26. Poisonous or Tonc Materials FC - 7 .008 28. S ectal Re uirements '� ,009 _ 30, Other s:>pnro"wwt� zao< A CITY OF SALEM BOARD OF HEALTH r Establishment Name: (n//GYIfY /1"c1f Date: Page: 3 of 3 Item Code C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R — Red Item Verified PLEASE PRINT CLEARLY _V Ile IF / PAX") vze- Indat-. (K..r FsL 13 X� kc_ t at-./ Altf(i Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion as described, and to violations before the next inspection, to observe all conditiIT, ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Codenderstand that noncompliance may result in daily fines of twenty-five dollr suspension/revocation of ❑ Embargo ❑ Emergency closure your food permit. 0 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 .y Denotes critical item in tit ta9eral 1999 Food Code or 105 CMR 590.1X)0. Food or Color Additives 3-202.12 Additives* - 3-302.14 Protection from Unapproved Additives* FC-2 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers" 7-102.11 Common Name - Working Containers* 7-1-01.11 1 Separation - Storage': 7-202.11 Restriction -Presence and Ilse* 7-202.12 Conditions of Use - 7 -203.11 Toxic Containers -Prohibitions' 7-204.11 Sannizers. Criteria-Chenucals* 7-204.12 Chemicals for Washine Produce, Criteria" 7-204.14 Drvin A eats. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides. Criteria* 7-206.12 1 Rodent Bait Stations"` 7-206.13 Tracking Powders, Pest Control and Morntoriq* .y Denotes critical item in tit ta9eral 1999 Food Code or 105 CMR 590.1X)0. Proper Cooking Temperatures for PHFs Received at Temperatures PHFs 3-401.11A(1)(2) Eggs- 155'F 1.5 Sec. FC-2 Eggs- hmiediatc Service 145'FI5sec*' 3-401.11(A)(2) Comminuted Fish, Meats & Game _ 3-501.15 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 3-50tA6(B) sec. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 41"/45'F* Stuffing Containing Fish, Meat, 3-501. 160) Poultry or Ratites -165'F J5 sec. " 3-401.11(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 PRFs-- 145'F 15 sec. 3-501.19 Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 sec. * 3-403.11(B) Microwave- 165' F2 Minute Standing. Time" 3-403.1.1(C) Commercially Processed RTE Food - 140'F 3-403. LI(E) Remaining thislieed Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140"F to 702E 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 hrgredients to 41 °F/45'F Within 4I3ours" .y Denotes critical item in tit ta9eral 1999 Food Code or 105 CMR 590.1X)0. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 4-501.14((') PHFs Received at Temperatures Animal Foods ifiat are Raw. Undercooked or 3-801.11(,B) According to Law Cooled to FC-2 3-801.11(D) 41'Ft451,F Within 4 Howl. 3-302.13 Pasteurized Eggs Substitute for Raw Shell _ 3-501.15 Cooling Methods for PHFs 19 _ _ Equipment and Utensils PHF Hot and Cold Holding .005 3-50tA6(B) Cold PI1Fs Maintained at or below FC 6 FC -6 FC - 7 590.004(F) 41"/45'F* _ _ Other 3-501. 160) Hot PHFs Maintained at or above 140'F. * 3-501.16(A) Roasts Held at or above 110'F. 20 Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H) VarianceRe uirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpastem�ized Pre-packaged Juices and _Beverages with Wat'atn* Labels* Animal Foods ifiat are Raw. Undercooked or 3-801.11(,B) Use of Pastotlrized Eggs* FC-2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed S nuts Not Served. 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-80 I H (C) Una erred Food Pucka >e Not Re -served. 22 3-603.1 I Consumer Advisory Posted for Consumption of FC Animal Foods ifiat are Raw. Undercooked or 23.M Not Otherwise Processed to Eliminate FC-2 Pathogens,* em ` uvea" _ 24. 3-302.13 Pasteurized Eggs Substitute for Raw Shell FC -3 E ie* orcG iAL"CuLa"rivIG1V is 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary aid residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relafing to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Ctiticaland non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be .found in rhe follondug sections of the Food Code and 105 CMR 590.000, Item Good Retail Practices FC 590.000 23.M anagement and Persoim_e_I FC-2 .003 _ 24. Food and Food Protection FC -3 .004 _25_ _ _ Equipment and Utensils FC - 4 .005 26 27. 28. 29. Water Ponta and Waste Physical Fa_cillty_ Poous or Toxic Materials ison S eciai R uirements FC 6 FC -6 FC - 7 _006 1.007 .008 .009 30. _ _ Other __ __ -- ssw�m�nn..es zr,� n q STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS s BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Witch's Brew Cafe Address of Establishment: 156 Derby Street Owner's Name: Spiro Kounsalieh Restrictions: Application Date: 12/1/2003 Permit for Food Establishment 53-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 13-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS ' L BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 --- NOV 26 2003 C.I IY CCW -ALEM BOARD OF HEALTH STANLEY USOVICZ, R. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1`.t7 t'Irr-kA C+g W4 -EL # C] 5- 71,14�73iLaj ADDRESS OF ESTABLISHMENT I C—o(,?— STC2 --f MAILING ADDRESS (if different) ' OWNER'S NAME 1'SP\<tiD N<00t.3-5,6L_ICJA TEL# C ADDRESS 1'� C, —Z)o CITY�Y�r�C I✓�_ I mo— 'LIP C) \ � __ CERTIFIED FOOD MANAGER'S NAME(S) 5Prd0 KooAj ALL b CERTIFICATE#(s) 7L4 38C (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON ),(K,o �6�?SHC t£.1-( HOME TEL ## %,-/y" 73& G HOURS OF OPERATION: Monl6-1 Tue./0-1 Wed!O-/ Thu/04 Fri./o-I Sat./6-( Sun.! 1- 12 TYPE OF ESTABLISHMENT RETAIL STORE YES RESTAURANT ESI NO BED/BREAKFAST YES %O 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 =$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. Pursua L Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best k I e and belief, have filed all st to tax returns and paid all state taxes required under the law. i tt �(� Gr Ot 1 Ia% o i Signa Date Social Security or Federal Identification Number -------------------------------------------------------------- Revised 11/03/03 F ODAP2.adm Check# & Date P" OPSFORM 4009 MAGE IN U.S.A. IMPORTANT MESSAGE FOR M •3B P. . PHONE AREA CODE ❑ FAX O MOBILE AREA CODE -- 3'6 9 EXTENSION NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE 671--/yisS C�sr/rrre9ri 1&11-4, c9�,6� /aMelo"ar— SIGNE OPSFORM 4009 MAGE IN U.S.A. CITY OF SALEM BOARD OF HEALTH Establishment Name: -l/r.e W 4 e,4 's l�rrt.J Date: Page: of Item No. Code Reference C — Critical nem R — Red Item - DESCRIPTION OF VIOLATION / PLAN OF CORRECTION - PLEASE PRINT CLEARLY Date Verified r i n v,ces 1 ex ooin4n:71 s l , gee 017 1r'7 C4 6 .3 Gdc/c% a/ 5�ar fs 0 I O a f vl/'10 dP Qr///, o dVvl D /Q s Ci h vE / 7>-( rl Gf1 s� v 4 / Ca4,%s• _ oro i Psl /�,PCS�P n' i fel nA� ' IS _ r f Q r ZZ !.V carr/ rt'/ihrl 't.he a l- Discussion With Person in Charge: have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observerconditions as described, and to comply with all mandates of the Mass/Federa Code. I understand that _noncompliance may result in daily fines oft a ty-five dollars or suspension/revocation of your. food permit. Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 17 TIMEITEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection frorn Una roved Additives'" 3-501..75 Poisonous or Toxic Substances 7-101.11 Identifymg,Information -Original Coutainers', 7-102.11 Coalition Name - Working Containers* 7-201.11 Separation - Storage* 7-20111 Restriction - Presence and Use" -- 7-202.12 Conditions of Urex 7-203.11 Toxic Containers - Prohibitions' 7-204.11 Sanitizes s. Criteria - Chemicals* 7-204_'1_' Chemicals for Washing Pnxtuce. Criteria' 7-204.14 Ih: ing Agents. Criteria* 7-20511 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 Moniuxine TIMEITEMPERATURE CONTROLS Denote, critical item in the federal 1999 Food (ode or 1W CMR 590,0011. 20 3-501.1$(0 Proper Cooking Temperatures for 3-801.11(B) PHFs 3-401.11A(I)(2) _ Eggs- 155°F 15 Sec. 3-501..75 E -s- Immediate Service 145'Fl.5sec* 3-40L I I(A)(2) Comminuted Fish. Meats & Game 3-501.16(B) Animals - 155"F 15 sec. s` 3-401.11(6)(1)(2) Put kand Beef Roast -130'F121.min" 3-401.11(A)(2) Ratios, Injected Meats- 1.55'F 15 Watipment Plu and Lijaoin�and Waste-. sec. * 3-401.11(A)(3) Poultry, Wild Game. Stuffed PHFs, 27. Stuffing Containing Fish, Meat. 3-501.14 Poultry or Ratitcs-165'F 15 sec. 3-401:11(C)(3) Whole -muscle, Intact Beef Steaks Poisonous or Toxic Materials 145°F "` 3-401.12 Raw Animal Foods Cooked in a _ 29 Mictowa ve 165°F 3-401.11(A)(I)(b) .All Other PHFs -- 145'F 15 sea .008 Reheating for Hot Holding 3-4011 I(A)&(D) PHFs 165'F 15 sec. * 3-403.11(13) Microwave- 165' F 2 Minute Standiq, Time* 3-403.11(C) Commercially Processed RTE Food - 140'F 3-403A 1(E) Remaining Unsliced Portions of ,Beef Roasts„ Proper Cooling of PHFs 3-501-14(A) Cooling Cooked P1lFs from 1401°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 4111--/45`F Within 4 Hours* Denote, critical item in the federal 1999 Food (ode or 1W CMR 590,0011. 20 3-501.1$(0 PHFs Received at Temperatures 3-801.11(B) According to Law Cooled to 3-801.1.1(D) 41'F/45'F Within 4 -Hou s. 3-501..75 Cooling Methods for PHFs 3-302.1.3 PHF Hot and Cold Holding 3-501.16(B) Cold PI1Fs Maintained at or below 590.004(F 41c'/45' F* 3-501.16(.A) Hot PIlFs Ma9ntained at or above Watipment Plu and Lijaoin�and Waste-. 140°F-* 3-501.16(A) I Roasts Held at or above 130'F. 27. Time as a Public Health Control 3-501.14 Tfine as a Public Health ControPr 590.004(14) Val ianceRequirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.1](A) Unpasteurized Pre-packaged Juices and Beverages with Wavting'fabels* 3-801.11(B) Use of Pasteurized Egg* 3-801.1.1(D) Raw or Partially Conked Animal Food and Raw Seed Sprouts, Not Served. * 3-80L 1.1(C) Unopened Food Package Not Re -served. +' CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked or 590.000 Not Otherwise Processed to Eliminate Management and Personnel Pathogens.* e"- " "' 3-302.1.3 Pasteurized Eggs Substitute for Raw Shell 24. EO JS* Violations of Section 590.009(A)-(10) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness uitervenrions and riskfactors listed above, can be found in thefollowing secrionv of Ute Food Code and 105 CMR 590.000. Item Good Retail Practices 590.000 23- Management and Personnel --Ac FC - 2 .003 24. Food and 6. Watipment Plu and Lijaoin�and Waste-. 1 -FC 5006 27. i Physical Facility - I FG -6 .007 j 28 Poisonous or Toxic Materials I FC -7 .008 _ 29 S ecial Requirements_ .008 f30 Other 5690ta2 dog Massachusetts Department of Public Health Rivislon 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 W T a,i f C e Datio G n s Type of inspection ooOerve Retail Elp outine Re -ins ection Address PPS Risk `S� Telephone Level� ElResidential Kitchen Previous Inspection C/_ 7 3 57 EI Mobile ❑ Temporary Date: ❑ Pre-operation Owner / HACCP Y/N ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) Time In: Out: Permit No. El HAC ElO hem- Inspector i Each vroiatlon cnecxed requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C " N'? 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S' 590Mn lForm 14AW ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS - ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods)`,;. ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions 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: In ectis Signature: - punt (PI % 's Signature: - Print: I Page of r -Pages 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 Knowledge" 2 1-03,11 Person in ch uge - dents 2 590.003(C) Responsibility of the person in charge to Compliance with FoodLarv* 3-201.12 require, reporting by'food employees and 3-201.13 Fluid Milk and Milk Products* ap licants* Shell Eggs* 5c 03(F) Responsibility Of A Food Employee Or An 3-202.16 ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System'* 590.006(A) Charge" 590.006(B) 590.003(0) Re orcin by Person in Charge* 3 590.003(1?) E.xclumons and Restrictions* 3-201.15 590.003(E) Removal of F.xclnsions and Restrietiims in C •i G • u= : i . • '* Denote; critical rein In the federal 1999 food Code or 105 CNIR 590.000. g Food and Water From Regulated Sources 590.004(A -B) Compliance with FoodLarv* 3-201.12 Food in a Hermetical) Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-223.14 Iii =gs and Milk Pralucts. Pasteurized* 3-202.16 ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System'* 590.006(A) Bottled Drmkine 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 Re Mato Authait 3-2021.8 Sheilstock Identification Present* 590.004(C) Wild Mushrooms' 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-20111 PF[Fs Received at Proper Tenn perann eg* 3-201t5 Packaelnte it.,, 3-10111 Food Safe and Unadulterated Tags/Records: Sheilstock 3-202.18 Shellstock identification * 3-203.12 ShellstockIdentification 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 ±1- f E4-703.11 conformance with Approved Procedures lHACCP Plans 3-502.11. S ectalized Processin� Methods* 3-502.12 Reduced oxygen packaging, criteria* 3-103.12 Conformance with A p proved Procedures* '* Denote; critical rein In the federal 1999 food Code or 105 CNIR 590.000. g Cross -contamination 3-302.11 (A)( 1) Raw Animal Foods Separated from Cooked and RTF. F Foods* Cortamoafion from Raw Ing, edents 3-302.1 1(A)(2) Raw Animal Foods Separated from Each Otfiu* Contamination from the Envlronmenf 3-302.11(A) Food Protection` 3.302-15 1 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501,111. Manual Warewashing - EIot Water Sanitization Tem eratnres* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures"' 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. "` 4-60L I I (A) Equipment Food Contact Surfaces and Utensils Clean* 4-60211. Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils" 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces ±1- f E4-703.11 4-703.11 MethodsofSanitization-HotWaterand Chemical* 10 Proper, Adequate Handwashing 2301.11 Clean Condition - Hands and Arms"` 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco" 2-401,12 Discharges From the Eyes. Nose and Mouth* 3-301.12 Preventing Contamination When Tasting," 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Enn lovees* 13 Handwash Facilities Conveniently Located and Accessib,'e )A Numbers and Capacities* -5-20' 5-204.11 Location and Placement" 5-205.1.1 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Flandwashing Cleanser. Availability 6-301.12 Hand Drying Provision `-,CITY OF SALEM ' //�J BOARD OF HEALTH Establishment Name: "I-xrs &&o L 0 re Date: 6-3-0 4F Page: a of Item No. Code Reference C - Critical nem R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Verified 9R/i,49 / P/ vs E ow* 11VA7%he— G s L �A nUdd& r-TeetrilaL4 9-h6C rvvJC� u 022 a4fd OX la-LJ41 s Ye f a YY � 2n � 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 dollar ension/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: 0 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) 14 3-202.12 Food or Color Additives Additives* PHFs 7302.14 Protection from TJna r roved Additives* 15 Eggs- limnectiate Service 145`1715sec* Poisonous or Toxic Substances Comminuted Fish, Meats & Game 7-101.11 Identif}ging Information -Original Containers* 3-401.11(8)(1)(2) 7-102.11 Common Name - WorR n, Containers* Ratites, Injected Meats -155'F 1.5 7-201.11 Separation - Storage* 3-401.11(A)(3) 7-202.11 Restriction - Prescnce and User Stuffing Containing Fish, Meat, 7-202.12 Conditions of Use* 3-401.11(C)(3) 7-24311 Toxic Containers - Prohibitions* 1450F ': 7-204.11 7-204.1.2 Sanitizets, Criteria - Chemicals" Chemicals for Washing Produce. Criteria* _ 7-204.14 DrVin : guts. Criteria* All Other PHFs - 145'F 15 sec. 7-205.11 Incidental Food Contact. Lubricants* 3-403.11(A)&(D) 7-206.11 Restricted Use Pesticides. Criteria* Microwave- 165° F 2 Minute Standing, 7-266.12 Rodent Bait Stations* 3403.11(0) 7-206.13 Tracking Powders, Pest Control and Monitoring* 17 18 TIMEITEMPERATURE CONTROLS ' Denotes critical item m the 6-,iexal 1999 Food Code or 105 CMR 590.000. 20 3-501.14(C) Proper Cooking Temperatures for 3-54L15 PHFs 3-401,1 1A(1)(2) _ kgs- 155F 15 Sec. 3-501.16(B) 590.004(F) Eggs- limnectiate Service 145`1715sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(A) Animals - 155'F 15 see. * 3-401.11(8)(1)(2) Pork and Beef Roast - 130'F 121 mm* 3-401.11(A)(2) Ratites, Injected Meats -155'F 1.5 590.004(11) sec, * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC - 6 Poultry or Ratites -165'5 15 sec. 3-401.11(C)(3) Wlrole-muscle, Brtact Beef Steaks FC - 7 1450F ': 3-401.12 Raw Animal Foods Cooked in a _ Microwave 165'F * 3-401.11(A)(1)tb) All Other PHFs - 145'F 15 sec. _ Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165'F 15 sec. * 3-403.11(2?) Microwave- 165° F 2 Minute Standing, Time'' 3403.11(0) C,rnrntordally Processed RTE Food - 140'F' 3-403.11(F) Renlaioing Unsliced Portions of Beef Roasts Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 1,10'F to 70°F Within 2 Hours mid From 70'F to 41.'F145'F Within 4 Hours. * 3-501.14(13) Cooling PHFs Made From Ambient Temperature Ingredients to 41'17/45'F Within 4 Hours* ' Denotes critical item m the 6-,iexal 1999 Food Code or 105 CMR 590.000. 20 3-501.14(C) PRFs Received at Temperatures According to Law Cooled to 41'F1451 F Within 4 Hours. 3-54L15 Cooling Methods for PHFs 3-801.11(13) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PFIFs Maintained at or below 41°!45°F* 3-501.16(A) Hot PRFs Maintained at or above 140'F. * 3-501.16(A) Roasts Held at or above 130°F. Time as a Public Health Control 3-501.19 Time as a Public Health Ccimrolx 590.004(11) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.1i(A) Unpasteurized Pre-packaged Juices and Beverages with W'atningLabels* ------- 590.000 3-801.11(13) Use of Pasteurized lie�s* FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Kaw Seed S lttxrts Not Served. 'r Food and Food Protection 3-801.1 1(C) Unopened Fant Package Not Re -served. CONSUMER ADVISORY 22 3-(i{)3.11 Consumer Advisory Posted for Consumption of ------- 590.000 23. Animal Foods Hurt are Raw. Undercooked or FC - 2 .Oo3 Not Otherwise Processed to Eliminate Food and Food Protection __ FC -3 1'atho cns.* E'1 c11s vvzoai 3-302.13Pasteurized Eggs Substitute for Raw Shell .005 26. E gs" mt:uulKt:mtN 15 590.00r,W-(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. WSX00417 i*,A►i1 (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 followbrg sections of the Food Code and 105 CAM 590.000. item ------------ Goad Retail Practices - FC ------- 590.000 23. Management and Personnel---- FC - 2 .Oo3 24. Food and Food Protection __ FC -3 .004 _ ui ment and Utensils _ FC - 4 .005 26. Water, Plumbing and Waste FC -5 .006______ 27. Ph sical Facile FC - 6 .007 28. _ _ Poisonous or Toxic Materials FC - 7 .008 _ 29. S ecial R uirements ,009 30. Other _ S:11ofm'b C,2 d- Ma0anhusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street, 4'h Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT )( Tel. (978) 741-1800 Fax (978) 745-0343 Name/� yi a, e/v (rtF2 Date G-/-Oil T e of O eration s Type of Inspection Food Service El Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer El Bed & Breakfast Permit No. Q utine Re -inspection Previous Inspection Date -/_a7-0 r4 ❑ Pre-operation ❑ Suspect Illness El General Complaint El HACCP El Other Address J ?Je (3 U i Risk Level Telephone /G �� J 7v C/ - /7 3 6 9 Owner q / // / P HACCP Y/N Person in Cl arge (PIC) ! Time In: Out: Inspector %ar/n7�/ / �Wyn tacn 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 ❑ 12. Prevention of Contamination from Hands [1] 13. Handwash Facilities .... PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives [115. Toxic Chemicals ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved, Procedures/HACCP Plans PROTECTION FROM CONTAMINATION" ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C_I 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) I/ 29. Special Requirements (590.009) 30. Other S : 5so1ns dFmm 14.d. r \ 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 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: I cfroF's• 'Hato / //,/',/ Print: (Pi vs Signature: Print: Pagel of Pages u 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* 2-103.1.1 Prtaonmcharge-duhcs 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 3-201.1.3 Fluid Milk and Milk Products* a,.nyrlicants* Shell Eggs* 590.003(F) Responsibility Of A Fait Employee Or An 202.16 Ice Made From Potable Drinkine Water* Applicant To Report Tone ,Person In Drinking Water from an Approved System* 590006(A) Cha g -e* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 1 590.003(1)) Exclusions and Restrictions* 3-203.15 590.003(E) Removal of Exclusions and Restrictions 4 C Fe C ' Denote, critical ileoi in the federal 1999 Food Code or 105 CMR 590.006. PROTECTION FROM CONTAMINATION 8 Food and Water From Regulated Sources 590,004(A -B) Compliance with Food Law" 3-201.12 Food in a Hermetical) Sealed Container* 3-201.1.3 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202-14 Bees and Milk Products, Pasteurized" 202.16 Ice Made From Potable Drinkine Water* 5-1.01.1 1 Drinking Water from an Approved System* 590006(A) Bottled DrinkineWiter * 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fmits and Vc,,&ables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-203.15 Molluscan Shellfish from NSSP fasted Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Regulatory Authority 3-202.16 Shellstock Identification Present* 590.004(0) Wild Mushtamms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PIFs Received at Pro per Tem neratuces'" 3-202.15 Package tnte>rit * 3-101.11 Fond Safe and Unadulterated 'k Tags/Records: Shellstock 3-202.16 Slnefistock Identification * 3-203.12 Shellstock Identification Mainnuned* TagslRecords: 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 Food Contact Surfaces of E ui ment* Conformance with Approved Procedures IHACCP Plans 3-502.11 Specialized Processin> Methods* 3-502-12 Reduced ox >en ackagine, criteria* 8-103.12 Conformance with Approved Procedures* ' Denote, critical ileoi in the federal 1999 Food Code or 105 CMR 590.006. PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.11(A)(1) Rai- Animal Foods Separated from Cooked and RTF Foals" 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 Fmits and Vc,,&ables 3-304.11 Food Contact with'Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(13) Retut tied Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food"` y Food Contact Surfaces 4-501.111 Manual W'arewishing- HotWater SanitizauonTetn eiatures* 4-501.1,12 Mechanical W:•u-ewashing- [for Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pR, concentration and badness- +' 4-60I f I (A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702-'11. Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui ment* 4-703.11 Methods of Sanitization - Hot Water and Chemical' 10 Proper, Adequate Handwashing 2-301.11. Clean Condition -- Hands and Arms" 2-301-12 Cleaning Procedure* 2-301.14 When to Wash* II Good Hygienic Practices 2=101.11 Sating, Drinking or Usin * TabaccoT 2-401.12 'Discharges From the Eyes. Nose and Month* 3-301.12 1 Preventing Contamination WhenTastin,,* 12 I Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em lovees* 13 Handwash Facilities Conveniently Located and Accessibic 5-203.11 Numbers and Ca acities* 5-2041 11 Location and Placement* 5-205,11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.21 Handwashing Cleanser. Acailabilit 6-301.12 I4and Drvm r Provision CITY OF SALEM ' 1 BOARD OF HEALTH / Establishment Name: i JI l C V 1 S �i�l) ( / Date: ro I ' 0 �-I Page: 07 of o2 Item No. Code Reference C - Critical nem R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION ' PLEASE PRINT CLEARLY Date Verified o.l b ii 3 n 'R i l' f r - I 1 ' . h711 7- LI/a c rJf ss . o - 0S a c O Mwo fa4ew s ca re s y of 47 Discussion With Person in Charge: I have read t is report, have had the opportunity to ask questions and agree to correct all violations before-th ne ext -ins inspection, to observe all conditions as described, and to P 1_ comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 Food or Color Additives 3-202.12 Additives* 3-302.14 _- Protection from Unapproved Additives* IS Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers - ontainers*7-102.11 F102 11 Common Name - Working Containers' 7-201.11 Se aration-Storage* 7-202.1.1 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* 7-206.11. Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* 16 17 18 TIMEfTEMPERATURE CONTROLS * Denotes critical item in 1110 FAeral 1999 Food Code or 105 CMR 590 000. Proper Cooking Temperatures for PHF% Receivedat'i'emperatures According to Law Cooled to 4ff/45°F Within 4 Howl. " PHFs 3-401-IlA(l )(2) Eggs- 155°F 15 Sec. 19 Eggs- linntediate Service 145'Fl5sec* 3-401.11(A)(2) comminuted Fish, Meats Sc Game 3-501.16(B) 590.004(F) Animals - 155°F 15 sec. 3-401.11(B)(1)(2) Pork. and Beef Roast - IXT 121 min* 3-401.1I(A)(2) Ratites, Injected Meats- 155°F'1.5 3-5011.6(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 Poultr or Ratites -165".F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks Variance Re uircment 145gF " 3401.12 Raw Animal Foods Cooked in a Microwave 165`F * 3-401.11(.A)(1)(b) All Other PHFs -'145°F15see .* Reheating for Hot Holding 3-403.11(A)&(D) PHFs 1650F 15 sec. * 3-403.11(B) Microwave -165" F 2 Minute Standing Time"' 3-403.11(C) Commercially Processed I2TE Food - 140°F* 3-403.11(E) Remaining Unslieed Portions of Beef Roasts" Proper Cooling of PHFs 3-50114(A) Cooling Cooked PHFs from 140'F to 70°F Within 2 hours and From 70°F to 41°F/45'F Within 4 Hovis, s 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45`F Within 4 IIours`f * Denotes critical item in 1110 FAeral 1999 Food Code or 105 CMR 590 000. e 2'1 3-50114( , PHF% Receivedat'i'emperatures According to Law Cooled to 4ff/45°F Within 4 Howl. " E3-501.15 _ Gaoling Methods for PHFs 19 3-301. f 1(D) PHF Hot and Cold Holding 25. _ 3-501.16(B) 590.004(F) Cold P61Fs Maintained at or below 41'/45° F" 26 - 3-501.16(A) ]-lot PHFs Maintained at or above 14WE * 27. 3-5011.6(A) Roasts Herd at or above 130°F. * 20 Poisonous or Toxic Materials FC - 7 Time as a Public Health Control 29 3-501'19 Time as a Public Health Control * 30,O-_, 590.004(H) Variance Re uircment e 2'1 3-801.1 I(A) Unpasteurized Prc-packaged Juices and Beverages with Warning Labels* 23. 3-801..11(B) Use of Pasteurized Egg=s* 24. 3-301. f 1(D) Raw or Partially Cooked! Animal Food and Raw Seed Sprouts Not Served.* 25. _ 3-801.11(C) Unopened Food Package Not Re -served. i 22 3-fiO3-1 1 Consumer Advisory Posted for Consumption of 23. klaractement and Personnel FC - 2 Animal Foals That are Raw. Undercooked or 24. _ Food and Food Protection_ F_C--3 Not Otherwise Processed to Eliminate 25. _ _ Eclulment and Utensils FC -4005 Pathogens.' "I"aJ41 26 - 3-302.13 Pasteurized Eggs Substitute for Raw Shell 27. Physical FacBlty _-___- FC -6 007-- 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 1/29 - Special Requirements. G (items 23-30) Critical and non-critical violations, which do not relate to tate .foodborne illness interventions and risk -factors listed above, can be found in the follonrzng sections of the Food Code and 105 CM'@ 590.000. Iteir Good Retail Practices FC 590.000 23. klaractement and Personnel FC - 2 .003 24. _ Food and Food Protection_ F_C--3 604 25. _ _ Eclulment and Utensils FC -4005 26 - Water, Plumbingand Waste FC -5 -1_ _.005 .006 27. Physical FacBlty _-___- FC -6 007-- 28. Poisonous or Toxic Materials FC - 7 .008 29 Special Requirements1 .009 30,O-_, ----t-- --- r.wnm �+wxAo� Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Hea\hta 120 Washington Street, 41h Floor Salem, MA 01970-3523 T,el. (978) 741-1800 Fax (978) 745-0343 Name Date ofOSeratieo: ns eInspection PIC's'Sign Lure:i I /� .O rvic LJ Retail t eFa Rout ElRe-inspection Address Risk Telephoney^ Level ❑ Residential Kitchen ElMobile Previous Inspection 3 ❑ Temporary ❑ Caterer Dater�i•�aas� ❑ Pre-operation ❑ Suspect Illness Owner rploo HACCP WN LA u S .L16 fi ❑ Bed & Breakfast A General Complaint Person in Charge (PIC) Time In: Out: Permit No. ❑ HACCP ❑ Other Inspector's v eacn vioiatlon cnecxea requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT -- ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags%Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTIONFROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection 9'9. Food Contact Surfaces Cleaning and Sanitizing [110. Proper Adequate Handwashing [111. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board 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) 9. Special Requirements (590.009) 30. Other 35XInspedFom -14. e ❑ 12. Prevention of Contamination from Hands ®F13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE .CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)" ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions a �, and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Pect�r' i natute;.._ /' Print: PIC's'Sign Lure:i I /� Print: ge__L 0f '7 Pages i Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) A.ssigument of Responsibility" 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* 3-201.12. require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shot[ Eggs* 590.003(F) Responsibility OfAFood EmployccOrAn 3 -202.16 Ice Made Froin Potable Drinking Water" Applicant To Report To The Person In Drinkin',; Water from an Approved Svstem* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge" -3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(.E) Removal of Exclusions and Restrictions 4 in C C s• *+tMIUMME110JIM ' Uunole critical item in the federal 1999 Pond Code or 105 CMR 590,000. a $� Food and Water From Regulated Sources 590.004 A -B) Compliance with Food Law* 3-201.12. Food in a Henneticalty Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shot[ Eggs* 3-202.1.4 13 gs and Milk. Products. Pasteurized - 3 -202.16 Ice Made Froin Potable Drinking Water" .5-101.11 Drinkin',; Water from an Approved Svstem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0' Washing Fruits and Vegetables Shetifish 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 RegulatoryAuthors 3-202.18 Shellstock Identification Present* 590.004(0) Wild Mushrooms* 3-201-17 Game Animals' 3-701.11 Receiving/Condition 3-202.11. PI Fs Received at Proper Tem teratures` 3-202.15 Packave:lincuity" 3-101.1.1 Food Safe and Unadulterated Tags/Records: Shelistock 3-20113 Shelistock Identification * 3-203.12 Shellstock Identification Maintained" Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3402.12 Records. Creation and Retention" 590.0040) Labeling of Ingredients` Frequency of Sanitization of Utensils and Fond Contact Surfaces of E ui pment" Conformance with Approved Procedures IHACCP Plans 3-50'2.11 1 Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria` 8-103.12 Conformance with An roved Procedures" ' Uunole critical item in the federal 1999 Pond Code or 105 CMR 590,000. a $� Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RIF Foods" Contamination from Raw Ingredients 3-3(72.11(x1)(2) Raw Animol Foods Separated from Each Other" Contamination from the Environment 3-302.11(A) Food protection* 3-30115 Washing Fruits and Vegetables 3-304.1.1 Food Contact with Equipment and Utensils* 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' F-9-1 Food Contact Surfaces 4-501-111 Manual Warewashing - Hot Water Sanitization Tem eramres* 4-501-112 Mechanical Warewashing- Hot Water Sanitization Tetn tcratures^ 4-501114 Chemical Sanitization- temp., pH, concentration and hardness. " 4-601_'11(A) Equipment Food Contact Surfaces and Utensils Clean' 4-602.11 Cleaning Frequency (if SquipmmuFood- Contact Surfaces and Utensils" 4-702.11 Frequency of Sanitization of Utensils and Fond Contact Surfaces of E ui pment" 4-703.11 Methods of Sanitization -- Hot Water and Chemical'" Ig Proper, Adequate Handwashing 2-301-11 Clean Condition -- Hands and Arms': 2-301.12 CleaninProcedure*. 2-301.14 When to Wash"` n Goad Hygienic Practices 2=401.11 Eafin , Drink;in L or Using Tobacco* 2-401.12 Discharges From the Eyes. Nose and Month* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands (E) Presenting Contamination from Em plovees* 13 b5-2O3,11 Handwash Facilities Conveniently Located and Accessible NumbecsandCaacities'" 1 Location and Placement' 5-205.12 Accessibility, O erasion mod 44aintenance Supplied with Soap and Hand Drying Devices 6-301.11 FlandwaslnnE Cleanscr.Availabihty 6-301.12 Hind Drvin g Provision i CITY OF SALEM BOARD OF HEALTH Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) 14 Food or Color Additives 3-202.12 Additives* - - - 3-302.1.4 Protection from Una t moved .additives* 1j 7-101.11 Poisonous or Toxic Substances Identifying Information - Original Containers* 7-102.,11 Cotmnon Name- Working Containers" '-20 1.11 7-202.1 1 Se aration-Storage* _ Restriction - Presence and Use" 7-202.12 7-203.11 Conditions of Use, "ToxicContainers -Prohibitions"° 7-204.11 Sanitizets.Criteria- Chemicals* 7-204.1.2 Chemicals for Washing Produce.,Criteria"' 7-204.14 Drying Agents, Criteria'* 7-205.11 Incidental Foot) Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations" 7-266.13 Trackin�� Powders, Pest Control and Monitorin �* 16 17 i7l�tf:llftl��5t:7�if \i1f:i�d�}. Yisi�14.9 +Denies critical corn in the federal 1999 Food Code or 105 CMR 590.000. IMM 20 21 3-501.14((,) . Proper Cooking Temperatures for 3.50 L 15Ca)lIn PHFs 3-401.11A(I)(2) Eggs- 155'F 15 Sec. 3-501.16(B) 590.0(f4(F) Eg" s- Immediate Service 145'Fl5sec, 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-%1.16(A) Annuals - 155'F 15 sec. ", 3-401.11(B)(I)(2) Pork and Beef Roast - 130'F 121 nun* 3-401.1 L(A)(2) Ratites, Injected Meats- 155'F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game. Stiffed PHF6, 27, Stuffing Containing Fish, Meat, FC -6 Poultry or Ratites -165'F 15 sec. 3-401.1 I(C)(3) Whole -muscle, Intact Beef Steaks FC -7 145"F * 3-40LI2 Raw Aminal Foods Cooked in a Microwave 165"T * 3-401.11(A)(1)(b) All Other PHFs -- 145'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165•'F 15 sec. 3-403.11(B) Microwave- 165' F 2 Minute Standing, Thee* 3-403.L1(C) Commercially ProcessedRTE Food - 140'F* 3-403.11(E) Retraining Unsllced Portions of Reef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Conked PHFs from 14WF to 70`F Within 2 Hours and From 70'F to 41 °F/45"F Within 4 Hours. s 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41'Ft45`F Within 4 Hours* +Denies critical corn in the federal 1999 Food Code or 105 CMR 590.000. IMM 20 21 3-501.14((,) . PHFs Received at Temperatures According to Law C(x)led to 41'F145'F Within 4 Hours. " 3.50 L 15Ca)lIn Methods fur PRFs 3-801.1.1('D) PHF Hot and Cold Holding 3-501.16(B) 590.0(f4(F) Cold PWa Maintained at or below 41^145'I 3-501_ 16(,h) Hot PHFs Maintained at or above 140'F. 3-%1.16(A) Roasts Held at or above 130'F. 'k • 25. Time as a Public Health Control 3-501.19 Time as a Public Health Control" 590.004(H) Vatianeeft�(uire.ment REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 3-801.11(A) Unpasieurizx d Pre p rckaged Juices and Bereiaaes with Wantinnlabels* 3-901.1'1(B) Use of Pasteurized Egg" 3-801.1.1('D) Raw or Partially Calked Animal Food and Raw Sced Sp pouts Not Served. * 3-80 L I I (C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 23, Animal Fouls that are Raw. Undercooked or '.. FC - 2 .003 Not Otherwise Processed to Eliminate and Food Protection _ _ FC -3 Pathocens.* rrreceoe rruznai • 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 �I 26. guess 590.009(A) -(D) Violations of Section 590.009(.4)-(D) in catering, mobile food, temporary and residcntia 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 - Specizl Requirements. (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne ittness interventions and risk,factots listed above, care be f6und in the follon•ing se(tians 2f the Food Code and 105 CMN 590.000. Item Good Retail Practices Fc 590.000 23, Management and Personnel '.. FC - 2 .003 --2-4,-__Food and Food Protection _ _ FC -3 .004 • 25. { Equipment and UtensilsFC-4 ---- -...._ .005 �I 26. 1 Water. Plumbing and Waste ---------- I FG -5 DO@ I 27, Physical Facility FC -6 .007 28 Poiserous or Toxic Materials FC -7 .008 _ 29 Special Requuanents .009 30 Other J1J1 CITY OF SALEM � /_ n BOARD OF HEALTH Establishment Name: M,A?-h S` Btfw Cade Date: 5'6_9 L{• 0 g Page: 3 of _ Item No. Code. Reference C - Critical Item - DESCRIPTION OF VIOLATION /.PLAN OF CORRECTION R — Red Item PLEASE PRINT CLEARLY. Date Verified. E -Fe Ad no4 /. n ,u , s a vt s/ g ax n fZc d a �2 -( D F or Prcc duos s rP(y on �qoop' i2 aQr CILq Surd e S e l God f° U f Ar 0c 10-C r f o� S o n4 divppmas were S zridjea-Agg r 5 e h n An -T, 7ha p h re , crFo • G oGl clebvrs Qn c hl an r:riuc b (,9- ,r)c W • Shei ices xFun covers had cpm -1Lian of She/t-es rl Api covers e Fh ate.. a5 r f iss ' v1s►b rate oMkljtr, VI'S 6te aeovi-a tt rr, 4e a aI- el020ty be IaC(d (n unz{, a C l bor e CabIntl Ln tva def LL 010 a - rrdeK-f d� Jn05 Uere_ b Cil r 1 sod 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 con dit ns as described, and toExclusion comply with all mandates of the Mass/Federal Food Cogy I understand that noncompliance may result in daily fines of twenty-five ¢¢ s or suspension/revocation of your food permit. 1 11 Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Li Re -inspection Scheduled ElEmergency Suspension ❑ Embargo Z)Emergency Closure ❑ Voluntary, Disposal ❑ Other: , —Z;� \ Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 18 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Adi itkes'r 3-302.14 Protection ftom Unai ruved Additives* 3-401.1IA(1)(2) Poisonous or Toxic Substances 7-101..11 Identifying Information - Original Containers'" 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Stora O 7-202.11 Restriction - Presence mid Use* 7-202.12 Conditions of Use, 7-203.1.1 Toxic Contruneo,- Prohibitions" 7-204.11. Sanitize",, Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-2(4.1.4 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 "Denotes critical item lir the federal 1999 Food Code or 105 CN1R 590:000. 3-501,14(C) PHFs Received at Temperatures According to Law Cooled to -41°F(45'F Within 4 Hours. *, Proper Cooking Temperatures for 3-501-15 Cooling Methods for PHFs 19 PRFs_ 3-401.1IA(1)(2) 3-501.16(B) Cold Plus Maintained at or below 590.004(F) 41V45' F* Eggs- 155°F 15 Sec. 3-501.16(A) Hot PHFs Maintained at or above 14W * 3-801.11(C) E =gs- hnmedtatt Service 145°F15sec'^ 3-401.11(A)(2) Time as a Public Health Control Comminuted Fish, Meats r& Game 3-501.19 Time as a Public Health Control* 28. Animals - 155°F 15 sec. 3-401.1l(B)(1)(2) Pork and Beef Roast - 130°F 121 nnn* 3-401.11(A)(2) Ratites, Injected Meats - 155°F 15 sec. 3-401..11(A)(3) Poultry, Wild Game, Stuffed PHiFs, Stuffing Containing Fish, Meat, 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 (looked in a Microwave 165`F * 3-401,11(A)(1)(b) All Other PHI's -- 145°F 15 sec. * Reheating for Hot Holding 3-403.11(A)ht(D) PHFs 165°F 13 sea 3-403.11(23) Microwave -16.5° F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unslieed Portions of Beef Roasts* Proper Cooling of PRFs 3-501,14(A) Ca7hng 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 lir the federal 1999 Food Code or 105 CN1R 590:000. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-501,14(C) PHFs Received at Temperatures According to Law Cooled to -41°F(45'F Within 4 Hours. *, Unpasteurized Pre-packagedluicesand Beverages with War amg,Iabels* 3-501-15 Cooling Methods for PHFs 19 PHF Hot and Cold Holding FC -2 3-501.16(B) Cold Plus Maintained at or below 590.004(F) 41V45' F* Raw or Partially Cooked Animal Food and Kew Seed S xouts Not Served. 3-501.16(A) Hot PHFs Maintained at or above 14W * 3-801.11(C) 3501.16(A) Roasts Held at or above 130°F. 20 Time as a Public Health Control FC -6 3-501.19 Time as a Public Health Control* 28. 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-90LH(A) Unpasteurized Pre-packagedluicesand Beverages with War amg,Iabels* Animal Foods Mar are Raw. Undercooked or 3-801.11(13) Use of Pasteurized E,, FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Kew Seed S xouts Not Served. 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-801.11(C) Uno icited Fund PackaLc Not Re -served. 22 3-003.11 Consumes Advisory Posted for Consumption of FC Animal Foods Mar are Raw. Undercooked or 23, Not Otherwise Processed to Eliminate FC -2 Pathogens,* r`'Bza•,e r.vaoor 24i 25 26 3-302.13 Pasteurized Eggs Substitute for Raw Shell FC -3 FC 4 FC -5 .004 _ .005 .006 _ �re�,rrt�newenrservretvta 590.009(A){D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited wider the appropriate sections above if related to foodborne iliness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under !/29 - Special Requirements. I:I tlt(4w*1 (Items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be fiound in the following sections of the Food Code and 105 CMR .5.90-O()0. Item Good Retail Practices FC 590.000 23, Mana�cemen[and Personnel FC -2 .003 24i 25 26 Food and Food Protection --RC-4 Equipment and Utensils ]Nater, Plumbinq and Waste FC -3 FC 4 FC -5 .004 _ .005 .006 27. Physical Facility FC -6 .007 28. Poisonous or Toxic Ivan_ ials FC 29. 30 Spcx;ial. Requirements ----..----- _ Other i .009 s>�o[o�Lama-z.unc CITY OF SALEM BOARD OF HEALTH Establishment Name: 1 Sare Date: S',;) Qq Pager / of 4 Item No. Code Reference C — Critical Item R —Red Item •; 1/ DESCRIPTION OF VIOLATION /PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Verified and tea Q eYYYI l ✓? �6P h)on4-Gls or//-) vvicc S) 21 P chi A14 1A Si60-4 c S / a r Gvlll cis P 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 - r suspension ocation 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: �ffi Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 16 17 18 ItlIT] I!AI tG13 7 Fopd or Color Additives 3-202.12 Additives'" 7302.14 Protection from Una t roved Additives* 3-801.11(C) Poisonous or Toxic Substances 7-10 L I I Identifying Information - Original Containers* 7-102.11 Common Name - Workin., Containers - 7 -201.11 Separation - Stojam* 7-202.1.1 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 Prodnce, Criteria* 7-204.74 Dr Ina A eats, Criteria' 7-205.11 Incidental Food Contact, Lubricants* 7-206.14 Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stationv 7-206.13 Tracking Powders, Pest Control and Monitoring* ItlIT] I!AI tG13 7 ' Denotes critical item in the faleral 1999 Food Code or 105 CNIR 590.000. Proper Cooking Temperatures for PHFs Received at Temperatures According to Iaw Cooled to 41'Ft45°F Within 4 Hours. Cooling Methmc for PHP"s PHFs 3401.11A(l)(2) Eggs- 1.55°F 15 Sec. 3-801.11(C) Eggs- immediate Service 145'FI5sec* 3-41 Comminuted Fish, Meats & Game 3-501.16(A) Animals - 15YF 15 sec. * 3-40111(B)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats - 155"F 1.5 FC -5 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. 3-401.1.1(,C)(3) Whole -muscle, Intact Beef Steaks _ 29:__ 145`F a 3-401.12 Raw Animal Foods Cooked in a 30. Microwave 1650F 3-40111(A)(1)(b) All Other PHFs- 145"F 15 sec. Reheating for Hot Holding 3-403.11(-4)&(D) PHFs 165'F 15 sec. 3-403.11(B) Microwave- 165'F2 Minute Standine 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) Cowling Cooked PHFs from I40cF to 70`F Within 2 Hours and From 70'F to 41'F(45"F Within 4 Hours. 3-501.14(B) Coolim, PFIFs Made From Ambient Temperature Ingredients to 41 °F145'F Within 4 Hours` ' Denotes critical item in the faleral 1999 Food Code or 105 CNIR 590.000. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 3-801.11(X) 3-SOSJ=4(C} 3-501.15 PHFs Received at Temperatures According to Iaw Cooled to 41'Ft45°F Within 4 Hours. Cooling Methmc for PHP"s 19 3-801.1.1tD) PHF Hot and Cold Holding 3-801.11(C) 3-501.16(B) 590.004(,F) Cold PRFs Maintained at or below 41'(45° F* .004 3-501.16(A) Hot PHFs Maintained at or above 14WF. * - FC -4 3-501. M(A) Roasts Held at or above 130T. 2R FC -5 Time as a Public Health Control 27. 3-501-19 Time as a Public Health Control* '.007 590.004(H) variance Re uirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 3-801.11(X) Unpasteurized Pre-packaged Juices and Beceraees with ama mong Iabois* 3-801.11(B) Use of Pasteurized ELes* 3-801.1.1tD) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 3-801.11(C) Una ened Food Pucka e Not Re -served. 1 22 3-603-I 1 Consumer Advisory Posted for Consumption of Mata emy�ent and. Personnel FC -2 Animal Foods That are Raw. Undercooked or 24. --- Food and Food Protection Not Otherwise Processed to Eliminate .004 25. Padalens. * ree:n:e vwzoo - FC -4 302.13 Pasteurized Eggs Substitute for Raw Shell Wa_ter,P_lumbin and Waste FC -5 EggO 59(1.004(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 /F29 - Special Requirements. FAWIF#i (items 23-30) Ctilical and non-critical violations, which do not relate to the ,foodborne illness itueiventionsand riskfacrors listed above, can be found in the follows ng sections of the Food Code nru7105 CMR 590-0110. Ito m 4:306141:10211-a FC 590.000 _----------- 23. Mata emy�ent and. Personnel FC -2 .003 24. --- Food and Food Protection - FC - 3 .004 25. ----- Equipmentaod Utensls - FC -4 .005 26. Wa_ter,P_lumbin and Waste FC -5 .006 27. Physical Facility--_. FC -6 '.007 28. __ _ Poisonous or Toxic Materials FC -- 7 .008 _ 29:__ S ecial R uirements .009 30. _ Other _; ssvuro,r,maw-zao� FO DATE �JJ�'"�� TIME4L'4 M OF 05 PHONE AREA COOE NUMBER EXTENSION O FAX ❑ MOBILE AREA CODE N MBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU -RUSH RETURNED YOUR CALL Witt FAX TO YOU SIGNED ®Vp. NOTES �l ,r :j� May -05-04 03:03pm . From -D P N FOOD AND DRUG F�#X 617-863-6770 T-675 P, 01/02 F-411 Massachusetts Department of Public Health Food Protection Program 305 South Street Jamaica Plain, MA 02130 Phone: 617 983-6765 Fax: 617 983.6770 TO: Salem BoH FROM: Diane Bemazzani Food Safety Specialist Fax Number. 978-745-0343 Pages (excluding cover) 1 Phone: Date: May 5, 2004 Re: Complaint No. 04-082 CC:. ❑ Urgent 11 For Review Q Please Comment [I Please Reply C) Please Advise e Comments Please conduct an inspection of theestablishment and forward a copy of the inspection report to this office. Thank you! May-05-04 03:03pm . From-D P X FOOD AND DRUG 617-983-6770 T-675 P.02/02 F-411 r Massachusetts Department of Public Health Division of Food and Drugs 305 South St. Jamaica Plain. MA 02130 Ph (617)983-6712 Fax (617) 983-6770 Complaint Number 04082 Date of Complamt 51512004 — Foodoorne amass' ❑ if rve Fei out limaaome nmess Form Form of Complaint. Telephone Source of Complaint Consumer :omplarnant Name Anonymous Address. ❑ OK to give out Phone. Name/4 to company Notes Description of Complaint: Caned in., Bon several times about the restauram'Wrtanes Brew Cafe- in Salem. MA and they don't seem to do anything about the rodent problem andidtny conditions. Nawra of Complamt: infested (mse,.ts. rodent droppings) end Filthy D u,siiaa Health Care Provider V,s;t Date: NameofProvWer Product Brand Name, Praouei Name Product Size/We,gnt San By Date ExprtauonlBusl U6ed Date Date of Purenase- Product Information Category: Product Code/Senal Number. Pacnage Type UPC Code. C Imported Product LI Product used Date used. Amount Remammg ESfabl,Snmenl Where Purchusud Manufactured By. w,tches Brew Calti 156 Derby Street Salem MA Phone, Complamt Roeewea By: Dane BeriallIMIN Phone Number (617) 9838765 Comments DQsposil,on Warrens To BOM Page 1 of 1 Dsumuted By Phone. ? CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT Facsimile Transmittal To: Qt AwtF 60449Z7ANI Fax# 61-7 ^ 983-6770 RE: W) f-t9d r ktEW Date : Board of Health News Office Hours: Effective September 12, 2003 Page(s): including this cover # `1 - Your Information 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 Do Salem Residents Know ? - The Board of Health meetings are held the second Tuesday of the Month. CITY OF SALEM //�� BOARD OF HEALTH Establishment Name: iy-lrirs )C 19_-e t r Date: y e) Page: / of / Item No. Code Reference C - Critical item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION R — Red Item PLEASE PRINT CLEARLY Date Verified �AS� oN c t4l07_ AN lN4 CTsc�/J (,eA P CaN:h/ Txsq y o (W6CA �c Ds n4 N#-4 J t"Ai-, u �O rT! t s e0o &A/3" DLu PfA1 S' Wrff 4C OATOATAje VA ID I >f TW s G vac (/J Q n r,- f'z VWF e4, ems. 0vrd-49/— WV ( r✓>ii- )f v I'D C-49AN- 4t4D . tv19)2 & 11- t I� C rJNs �a�t�J� l� Ocl�,� C vs� ef% Mc d dr �e/3r+� �` � � r �✓� � ,Yr s 672 iscussion 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-fiv ars or suspension/revocation of your food permit. Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension C3 Embargo Li Emergency Closure ❑ Voluntary Disposal 13 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (teems 1-22) (Cont.) PROTECTION FROM CHEMICALS 10 16 17 1S TIMElTEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Una raved Additives* 3-501.16(B) 19l).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* 7-20111 Restriction - Presence and Ilse" 7-202.12 Conditions of Use - se*7-203-11 7 -203- I I 'roxicContainers -,Prohibitions* 7-204.11 Smnitizers. Criteria-ChemicalsT 7-204.1.2 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" TIMElTEMPERATURE CONTROLS Denotes ethical item in the federal 1999 Food Crile of JW CMIt 590.000. 19 3-501.14(C) _ Proper Cooking Temperatures for 3-501.15 PHFs_ 3-40LIIA(1)(2) Eggs- 1557 15 Sec. 3-501.16(B) 19l).004(F) Eggs- immediate Service 145'F15sec 3-4011 I (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 - 1.55'F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game. Stuffed PHFs, Stuffing Containing Fish, Meat. 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 Hot Holding 3-403,1 1(A)&(D) PIIFs 165'F 15 sec. " 3-403.11(B) Microwave- 165' F 2 Minute Standing Time* 3-403.11(CI) Commercially Processed RTE Food - 140'F* 3-403A IiE) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501-14(A) Cooling Cooked PHFs from 140`F to 70'F Within 2Hours and Front70'F to 41'F145IF Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41 ".F745'F Within 4 Hours* Denotes ethical item in the federal 1999 Food Crile of JW CMIt 590.000. 19 3-501.14(C) _ PHFs Received at Temperatures According to Law Coaled to 4l'F145'F Within 4 Hours -'w 3-501.15 ConlingMzthodsfor PHFs 3-8W I I (B) PHF Hot and Cold Holding 3-501.16(B) 19l).004(F) Cold PI-tFs Maintained at or below 41'145° F" 3-501.16(A) Hot PHFs Maintained at or above 140'F-* 3-501.16(A) Roasts Held at or above 1.30'F. FC - 6 Time as a Public Health Control 3-501.19 Tons as a Public Health Control* 590.004(H) VarianceRecuirement k 21 3-801.11(A) Unpasteurized Prc p ukaged .iuices and Beverages with Warning L-ibels' ' Management and Personnel f Food and Food Protection 3-8W I I (B) Use of Pasteurize ] Eg s* 25._+ 26. 3-801.11(D) Raw of Partially Coked Animal Food and Raw Seed Sprouts Not Served. .005 .006 3-801.1.1(C) Llna. cued Foal Package Not Re -sensed. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of ' Management and Personnel f Food and Food Protection FC- 2 FC - 3 Anunal Foods `That are Raw, Undercooked or 25._+ 26. Euq ipment and Utensils Water, Plumbin and W- aote Not Otherwise Processed to Eliminate .005 .006 27. Pathogens. s; FC - 6 3-302.13 1 Pastewtzed Eggs Substitute for Raw Shell Poisonous or Toxic Materials '.., �ecial Requirements I Other -_- FC - 7 Eg g,* A1-EWAL "ZVuR1GYICIN 1J 590 -009(A) -(D) Violations of Section 590.009(A) -(U) 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. re1�rrtttr3zTrti�rax9 (Items 23-30) Critical and non-cmical violations, which do not relate to the ,biodborne dares interventions and rink factors listed above, can be found in the following sections of the food Code and 105 CMR 590.00(3. Item Good Retail Practices FC 590.000 j- 23.. 24. ' Management and Personnel f Food and Food Protection FC- 2 FC - 3 .003 .004 25._+ 26. Euq ipment and Utensils Water, Plumbin and W- aote FC 4 FC - 5 .005 .006 27. 1 Physical Facility FC - 6 _ .007 28 29 30 Poisonous or Toxic Materials '.., �ecial Requirements I Other -_- FC - 7 .008 009 _--_J I,):)!. A-, 2 1 ��MPORTANT MESSAGE i -OR _ ' A.M. DATE �Q //TIME- OF PHONE AREA CODE NUMBER EXTENSION ❑ FAx O MOBILE AREA CODE NUMBER BER TIME TO CALL TELEPHONED. r PLEASE; CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE. YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU SIGNED -= fIVPS. ra m �r_yl_G_ t ?14 - WON M - a %5s - TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH' RETURNED YOUR CAL WILL FAX TD YOU w c ■IJ ('1''315 I '955.Maclorce _... .,,•..: FG lrsect BartMydrameMyMoli) 10% xs-. oaeaa-w 0.y F s� a�t47. I Niban BaNNibari FG BaD (Cnhoaorkeild)5%F"<'i4 '.w.:=. a :> ar1,. 04 NFBorO(D'soDium OCMDarete TretieAydrate)98%�9P`s-j 'tF J -4tnp 84405-8{.:.«', a ❑Rool.�'� � �a3 � �•�%'%(r xve�'y, „�^smp 48 ". 4 i OExtarim Pdl at "' j(3. a}tea <.` 4�—. ta.iS I '955.Maclorce _... .,,•..: FG lrsect BartMydrameMyMoli) 10% xs-. oaeaa-w -n' x' -�zt5 :Is:A" tSR. ?!yt ;' ❑Ga6t Paan 3 i � GWd4�"(,••. 1- 380 Niban BaNNibari FG BaD (Cnhoaorkeild)5%F"<'i4 '.w.:=. a :> .147.. NFBorO(D'soDium OCMDarete TretieAydrate)98%�9P`s-j 'tF J -4tnp 84405-8{.:.«', a ❑Rool.�'� � �a3 � �•�%'%(r xve�'y, „�^smp 48 ". Nylar C -C prnYj4en),:00.01MAE11 dA2%.., sk':- H. .w- °:E71715�007:57079 ^' OExtarim Pdl at "' j(3. a}tea <.` 4�—. ta.iS '. /9 OrMene,Turf; Tree.3 SFmN VJP (Acephate175% r :c <k'Rt w -. ',� 59839-2aZA:' ❑teMecepea aeeee,'t�e °a '�:' :.3.ie a Pre-Emp1 Roadi Gel Bak Qmidadopn� 2.15% a r ._ '$�*;' ;. ',g^.3125325 •:.- ,. ❑ lnemrg DodUlLvn�jster`"Yhi „ ' , V4` 98.'Pr Orthene Aerosol WoePhate11.0%'1 .' .,10..' :;:ups.•"r.sk ,'.Ww 499.373 .W ,}- .. r •.,. ,.: ,. Oalia i ^P+ -r N2`.' i4'.+0.+t d+•.4yi(:T''. 151 -PT -Kkk'Aeroeol CY (Cy9uMxn)0.1%>rt:?, xi.,,.,F fP'ir,wmt5a;+, 499-470. sr.. ...2 .» •:.• .,:.": 70 Fr Cy-KICKCS(CYeutlab) 0.025% 0.05% 01% �:-'fi 49a304,;..r Precautions ^ .-: f.yrf a t f Nt '� r5'lf 312' or Avert Gel SOtftemectin Bl) 0.05%t vy�'w, ,y y,'-'�...+„ •� 498,410 ,. _ Keep an aireeph of WlereeaM Paley ,j t� i y� Mey °'i "y r'Tia,' _ q PT 585 Plue XLOAerosol rine)0.25%ld-7ans Allethrin)025% 14, 498310 wme eye. raee, Mmat; or x4n Ir4te9an T,.': } e'� 189 Pr.TnDIe MICroPro Aerosd (Slilea AerogeQ4%(Pyrethrins)0.3% 499.395 - Avdd bnemtrg velwia mlete, or Eiata. xeimfm tteweloeatl Dempengr 121 SusPer ISC BameMrin)..00.01%i.00.03%' 00.08% . —;7 432-783. .t.e Wete. a Do not amps v4 m widen plepemerte .k m�`'$ 81 Tempo 20WP(Cyfluthdn) 00.025% 0005%'00.1% :3125.377/3125380 p,. Do not onvn to mam unt0 etoo MftUon y k- 83' Tempo SC Ultra( uMrin).0.025% ..s . r': a+: 3125-498 - Do not Wo beea4 erua unla Ory •; ,. 81 ULD BP 100 ULV (PYMMMs)1.0% �. Fo, nee eeetmmtk remeln e t oo area y e mJmmum of kur twno, ' is ULD 8P 300 ULV (PyreMrirrs)3.0% ', d'Sr 499-452/11540.9 - 4994W11540.1 T-6-4d�OtlO R/07: C=Crecka C)evke Y=Vab-;"t;:o= 1 Merbbk XT Bak lBroollecoum)0.005% - 10182339 a=Spot =ext DC-DlWe4Canbrx 0 3 BmtiJ ' 6P: S-rnsp�,xl - --k°•• r: C ntmc 81" Bell (BromaDlolone) 0.005% e- 120.5579 E9U0ment Do4e15/CI:'.. CB=Comp. Nr Sprayer t'�"7�=Trap ta PT=Pm rT..We tY F UAVx PbsUn95etNce StlCkeYJO>S ` Yw Ad ft Superviso75 Comments: ,�.. s,+ 'vy y.•• - '. :'" , . I T`19T ♦3 �. TICE' `� t 5 r3 ci ., n Tnl4.c"`+fir Y45 b T 4 �RUACHCR/MICE r, aGA C MERS SIGNA ` AMOUNT PAID r v UNRESOLVED OROBLEMSI �_: k 1CUSTOMER INFORMATION Y9f R 4# BREW '� t eroA 43 'HES A. DCRBY, ST t .' 'rJA AM/N/X ,. .x. %MI)MA .01970 �g.y A.+. Icpe Area`s=Activity and Conditions Observed .. Y- {Lx ;' _� ryjW •J # a'`x xr` }'n i T. ..�.� _A _ ., >L j1rr�-� 'a • 0.:. Y .a,v/ } ry nA:-YF>' J$ •h r IPMtreport detai{s�where Peels were found in and around the facility. The report also {fists those steps you'can take to help limit or nize'pestin iasions. For each of the areas listed below, numbers represent the type of$ests found in the rea, and lettere represent onditions present that may be contributing to a current, or possibly a future, pest infestation fE ,° "'": . ;' ', '"• ems- S,rt`Y. Irpit deriorAreas Pests Conditions Food Areae Pests `Conditions' _ S 9 Argentine Ants ❑ Cff ces r _ - '` ❑ Dining Area LaL'bb y/Public Areas O Stove/Oven Une - Ent a s -- - ❑y El Food Sto're'room ,I . 1 EtResULocker Rooms % " " ❑ Dishwashing Area OsJanitorClosets ' - ^-� ❑ Deli/Bakery t❑ Launtlry - ..❑ Processing Area a ,- d` t0`B29er/Furnace Room ,, .p' Packaging Area t �StorageUtdity O A, r; e t ,O Produce Area � - K _ Oi Warehouseh—{� � ; Cl,Meat/Seafood Shop -�X a a Basement¢sg 4 -Exterior Areas r i t O Patient Rooms- r god Debris Under Appliance,, , �' p�EMenor Walls -North Cti 1t'% cf - IC +t 4 �' OU Extenor Walls�outh ❑ Unen,Storege Rooms,; ; ` <+ O EMenor h , �❑ ht � � -r, IGtclienettes �`" ElNuri es�Stations vase Deposits on Floor --° O Guest Rooms �,, .. "Sy. Q ❑ Dum kY4.S 1.4j4 A O+BannueVMeetinc Rooms . — , . x .. -``r r„5ad:,.,m< .,fi . >., __7d ` „Y'k;,' �r . ;• .: .x•iy .p mlan Cockmachep _. .. us 6:Phareoh Ants ':” mc,a ax i1 ,yy; Sit :Occasional lnvaifers "°y£ i` sayn R.tx . ✓16 rRals nt nencan Cockroaches r,'-. ,k Ants ... Al2.Hunhng Spidersna}"o"3t-7i*$'ice,yet`.`�;�i+e,.fi' :'ya cental Cockroaches `;"mob �ry �`7Pavement 8 Fire Antsl - '-v 13 :Web -Building Spiiiers �.�isinn s� ,,..18 "Stor46 Product Pests��e-+ * Adoor Cockroaches S 9 Argentine Ants x.14 - Bmwn RecWseSpiders yr �'° 19 Other Iverfish q i 10 Ants. 16.'• Black Widow Spiders.+#".-'st'ai^ 20 Other "�^ t}�'.. sin Clogged/Dirty : "¢,�.'t.,'t I. ,. Paper/Litter :,.. s O Poor Storage PmchCes i'°r x Y3 Move Dumpster Away Frain Bldg cod Debris Under Table ,'T ° J. Water leak. .� R' Repar Wa[er Damaged Wood Z Dumpster Area Needs Cleaned',*._ god Debris On Shelf m K. Mops ImProPedy Stored S�, .al 6ctedor CracksMoles" M� Mercury Vapor Lights Outside "'�*E"t god Debris Under Appliance,, "` L Trash Containers Need Cleaning .,:Trim Back Tree/Shmb Branches �;, BB Keep Doors Closed fi at Organic Matter inCmcks x " M. Heavy Dust/Dirt Deposits U. Remove Pile of Debns xa "; A '^�" CC Repair Door/Screen �Z` vase Deposits on Floor --° w N. Numerous Cobwebs Present - .V.',Cut Tall Grass/Weeds�At y DD.,:Replace DoorWeatherstnppingl. ease Deposits on Equipment � O.. Repair FloorMles/WaIVCedmg , W Improve Outside Drainage w: x EE Poor Outdoor Storage Practices )iled Dishes Left Over Night % P. Se4bN#QejckS in Walls -' k Install Gravel Foundation Barrier''- _ nments s i1 'csJ�, ols >• :� �" �s r r � s� a oiiL�� a � � c ::. h+ ID :1�r1 a•,d-P y o .. . alp Printed 1 i/04.. 107y 978Y745-'8,717 bAl E' ys.l'7, B. a� 45 r 00 3/1.7/04 <t f " 66 x069 70 3WE zt ,; 1 SFRG�EaPRil _ BFtfiNCH I'S BREW �'' iLRM1:NIX INTERNATIONAL 1 f_RBY ST 130 RUMFORD AVE STC_ 113 MA0:197{? NI WT(:li�;MA 02466 t*, (61.73969...1.7:1.3: R NAME & CERTIFICATION NUMBER SUPERVISOR NAME & CERTIFICATION NUMBER FGHEE I1AN FISLER, ARTHUR H. 598 �176'5 U Gannon Cemvmcnes �'i''T1'�kD� a"ts �•Cadvoalms 2' 77l :f. L) Flats '0°-S[ae4 Materials 4uam 4k buena 1. 45 0,9osiders 820 WIND=UP TRAPS 0 aural p. N9ePWe-Ante KB ,l Protlw4 Perm ❑ Odenml Cd4mA`'�4, - p 5e(uro ,', ❑ surerab µ't `. O I OBa 400. Insect Monitors"' 870 TIN CATS ,.40O Traps 845 Rol Bait Stations- Ft°t ❑ Oma Cai Ivoadi� t#`iip Od"er�A�""h ❑ Flka„pjOmer WTI ouse 640 MBad StMons - ntrol Materials Useday� }tea _} .'8 EPA eg Y` T7C EJC ynn our t; R If a Traps . 655 ❑and Bart Sta ons f rice Granular AM Baft(AbeciamBt)0011% - ..i. 499-370 �{i `s are as Inspected angor Tfaated `I restconrrdmergnseimdudimreaM'mCss mvn5vmre2 ince Duel ChoiceArd Bait lSWPaan"Itl)Q576_ •i 499459 x( - ,.7 'rid Fue AM Bafl lAbancecbn 87)0.071% ( 4. r':r 499-370''_t 't i, ,`.=a” e�gm"9 A"em ❑ usWev areas ❑lyL4/°a�'"'�S'mO11Br FlO01n �-, ie"�. ..- .. ..r n /\ola9aNYf4y, fi` p' _ t & ' ` �s '�-: [Roach.BaOStatbns.(A<ametm1005%4 F--•.499-467 :s r "nce 388BAnt .Gel Bad(Baat85.4%» a { ., =� t 499-092 +;-4, Al and CSgambda-cyhabNnn)'^.po015%a 0003% ❑006% " lo182-381tftMaa tGWd 0(Dmmmethnn)006% ;. `+iF. E k 432-838 :J I aBdk Dusl.(SOica 40%Q%yreNrms)10% 499-429 .ml EC (Hydmpram) 0 O6% ; `,p' "'` ` ..f' r 2724-351 .. n -+. oration MW Blocks Bad Q3fleihiabre)00025%4� 7173-218 ': =r EC(Pyremdns) ❑005%,?001% 002 ! 4818-1145_: r " Y TO%II Bart Ium Safl,ol ' 01 % " 1 v t2455lt+ Y t .•. ' 7 farce FCAoecli Bart StaBono(Flpon10 • '';• 64 4&1t 432-125 ]'pdgBgnt Raame s.;p-++�tl'• ' ^ k ...•. ,: s q :'•._ . U( Rooms- ORoo s - - ❑F:'txw ve"mretx .. Olergscepeo Arem Y:. •.. ' force'FC AM Beg Slatlons Qlpron9J001%- :`' r. `6434&10/432-1256 1 > foke FC'Mt Get Ba(FiprodQ 0.001% 64248-214 32 1 2 8 4 :...- -{ �'^ fameMR68d Sot ON %'. ; ^ , '; .. 64248-14743&1259 1 t -da. fome FG Imect.Baft(F AM*lh*bh) 10% "t'^' - 6424&19/432-1262 m BaEG Bart (Qthoboric a605%„ ` ':'� + 64405-2 3- aDQ3isodkm Oetaborale TrahaAY,lmte)98%.." 6905-8 . -1171&307-57079' v EC(Py'dpmayfer0,.U0.015%`90.02%„- ;.'' f . 'Precautions., 'aria Tuif;Tree; B:ShruDWP ... (ALrepha1e175%)k'�'” �'.:.. '. .. 59639-2&ZA Empt Roach Gel Bat QmWac Wr4215%T:a-:,. 3125-5257432-1385 kftm'Awosol (Apaphate)1.0% 499-373 y-WokAemsd(Cyflilhnn)0.1%• 499-470; Keep w4ofiaad"dtl4lde" and Pab." JOcKCs y (C'AAdn):0.025%0.05%Oh%^ - 49&304 MaY vasa sy4 nose, u""wl.aslan mitetlpn. r A:nW Sreemm9 vapes mua. or 4usra ifem"Im 4s4alkee4' J .. ,�,�-,��- Im to emiwla ... sued Gel Bag (Abameclm B7).0.05% ;r: 499-410 AS PW XLO AemsolQ'yrethdris)OS% F+ :.499-290' Al ie Aemsd(Silica Aeluge04.8% Oyrethma)0.6% -499-385 wim "odenikia pNcementi . Oo m irewmto mom w"w art�vanubum. Do&toem"heme4aeazufttdq.. -. . Fa eea teem "re, remain oa treetetl e"�bemlw"m""ot (awhwuaawul my. WWSC(Deltarnethdn)- 00.01%" 00.030A U0.06% 4322763 pp Ulha WP(C•jfluthdn)-❑0.025%A&p5%x400.1%': 3125-482/432-1357, p0SCUIba(Cyfldhr1n) 0.025% 3125498/432-1363 - Te�iinxrt cane fT/c0: taeWm v=VOW 0=Ganem I BP 100 ULV (ayrsihdns)1.0% T- 499-452/11540.9 ,(:=Dremca s=spot.- OT=Bait 'DC=drectaCContam' 13=3'B SP=Space IN=1nsp4plpn '. Equ]mMCO ffM: CS=Comp.wSpmta ?=Trap B6=Bert StMon '" HD=H Wste A'=Ammtl B BG=MG P! f TreaMatt t F ULV F' " BP 300 ULV QjveNdns) 3.0% 4. 499-Wl 1640-1 Itherblok Xr Bail(Bm Wacoum)0.005% „ - .. 10182339. •frac Bb%Bort Q3romadiobne)0.005%.('' 12455-79 T .4'.. S -_K: {, ,• Y' :- ,* Pwrtn9 serVk& srmaen t ❑ r k, ❑ rw.a>.+yy -u Vis. J k �2i BUPBrYISOTBCWIIRIBRIS Fq ;# p-. eti f y,3'0: Shad "}�� e „PriGr`�©alanrcee, ,� 00 t'L y� fq i Y w T4y1i $Y yE� A Amit il� ,_ „L 4x7�44r'/eJ) k z� 1 4 1 G ewA Tax Chat �;t CiS . r ti6i. BP s c iNsrnucnUNsOEM RA3 F TT i" .Rr- .h h F, S 'p. W "-. ♦ yh d AES/M al ) h a tf Yp 'Ha I` T / i - -•'?'M tan '� t rim -s. dtg *L+/:�y, .. 1 E 1 A 7! .r T 1 p' t is 4�). bl4 4 H Y 4p `I is ' r:°"'4" 45140.'.. 3 FRcM 'AMOUNTPAID p.Totalue' TIT,' cN ,c,r�� he .5 " F UNRESOLVEDPROBLEMS4ffi; �sGNATu E, DAt� -4 t»CALLf1-800-TERMINIX.(1-800-837-tf464�' / saw. .; �..>..::_.� _"'-• ._ . CIS}''` •�c` r• ___ W.:. _ . <. .. ' -' '___ ..... �. .r .._ _:�� ..,_,,.. -.. _........ w..:v..,..y,.:.»=;j t..................-a+-�-.•=.�-s.�,Y..sv,,,wRr,r..r,.�.•a.;-.,•rrd .1ri61,v,1�• •. _ �r.s.,r..$,....,.n�.�.a.,,e.r.m...�r.e.�..r....r..,;�•,w+,-«...,�,w+aa.•.aYl 7., 01 ? x W% vmii, rests, wnonuoms. rum. 0 '�R:Ibining Area.' 4 -,Z) Stove Oven Line O. Lobby/Public Areas j , , -7. 1 -1,- lkl-�� r, -tr Food Storeno"Orn' - 'O'Ent�. �'s . ryvvays.�a, _'191 Dishwashin4kea %5-Resttt_ocker Rooms At l JenitorCloset DeIVBakery d Processing Area .,11U Laundry9 1. ❑ ikabtri� Bofi4i'Fuma .Q Oac rk Storage Utility Produce Area L1 Meat/Se' o -IJ - *Q Warehouse at or S 'A - i zo - r�? i. ' n Exterior Area .7 Bas�'6nf' ri i�U, Patient Roo Ell E;derlor Wal sr 4We] a &r ti, a ICU � A. -N Ext It ' Unen Storaga ooms El ExteriorWatils-East :C3 Kitchenettes 6 k Exterior Walls -West Q'Nuribi Sttions El Loading Dock on 4,1 A x 16. Rater r V12. Hunting Spiders 17Mice Pa-ven ent Ants . V American 61�kmec j' 13 'Web -Building Spiders, 8. Fire Ants- 18., Stored Product Posts 4:!OutdoorCoc g.Argentinektts '_;Brown141 BWn Recluse Spiders S. Silverfish `)Jt 10'�';' Ants.' Widow Spiders 20. Other A. DminGlogged/Dirty 1.,,PapeeAjfter l Q. Poor Storage practices Y. Move Dumpstsr'Avray Ftom 13k Area Needs Cleaner B. Food Debris Under Table �.,dAeWaterlsak A. Repair Water Damaged,Wood _�L Z. Dumpsterl "Ak Mercury Vapor Lights Ourtside _6ps Improlpe ly died s K'fA r 6t C. Food a S. Seal Exterior Crad Debri' On Sh'ff 6, ontainers Need Clewing, T Tirim i Closed E. Wet Organic Ma D. Food Debris Under Appliance L Tnesh C Back Tree/Shrubl3rahches BB. Keep Door tter In Cracks M.IReavy WittDirt Deposits 13 U. Remove piles of D CC?Vepair Door/Screen r Grease Deposits 6rfFloor Av Nupterous Cobwebs Present.- V. Cut Tall Grass/Weeds DD. Replaceboorweatherstrippinc G. Grease Deposits onEquipment epair Ecor/TilesMall/Ceilin , g W.mprove Outside Drainage EE. Prior Outdoor Storage PracticeH. Soiled Dishes Left Over Night gee 1616i/Cmks hi Wells X :nstall Gravel Foundation Barrier FE Other VQ-/ Ar_Mm lellll nil Comments 3- 4, - 41 A q, 7 VQ-/ Ar_Mm lellll nil KRA I IRTOMER-8130PY `il`.,, *n4f KAM' TBA4 kt� PRODUCTION11110TIMEIN W VxA0Couw Vf%t L 0 RWT AW )AJLSDAYj#,M X397A 9 4 87 � , 11 -1 ul 4500 8206; '7� $T K, rar SZ, --RACE ZANLIff:i�mw -e tl� 4, 4 MT WITCHMME , I. - . t . .. 04� TERX -i" WTEAAhn-bNA1 : r . . 'A 156,' DEWBY,�- 1�1,' 'T, 1.30 --'0 RD AVE STEN,113 SAL'EM MA�0-1970 N E W T 0 MA 02466 NZA-k (617) 9-17131 (�6 OPERATOR NAME& CERTIFICATION NUMBERF SUPERVISOR NAME & CERTIFICATION NUMBER JOHN F :6HEEHAN 97625th F):SL. R,'.ARTHUR 1+,; 159 8 E ;Gennan� E3 Target .1 1knta Materials-"- l#,tl.;d POStS " U Ao�� 6, 450InSJ&M�rr, o#;,P-1620WND-UPTRA 400 Insect Mwhmf! i,i%7,I 6100IN CATS 0 oiorta_� :,:.0 F.Anter. 71 : 410 Pheronvo T1 646r Fiat Bait statioi '.4A _u Foes 10_5�1:3, tBsAReBTIC E/C lArnounit PestjControl Materials Used �zjSYa 60 MouseSaft St 16W 494 Areasinipected and/or 7veiww S3 -A&vahoa Granular AM Bait obamectin 87) 0011% *.43r, 4WVO 295 Plane Dual Choice AM Baf(Suffluianimc) 0.5% -Tfj;'A99-4S C4 77777 315 -ASCOW Fos Ant Bait Pbamedn E11) 0.011% &9wA-- 1116KA499-370r",,2� v W5 Acharce WB AM Gel Bert 499492N _ A' �7 ,� is, I AU A ft-" '15 othim) �(30.0159fii6CI0.03%4U0.D6%V1- .:e�—J0182-%141001? Dernaid CS Umbdia-cylial 210 DebGadGPebMeftM)G05%,,*1W_ 91581 WID BA Dust (Silica GOO 40%PYiethine) 1.0% fa n: A Bait 0- ❑ 'Ell _Roon,41� 43 K1&WECFyTeWm)v00.05%'UG.I% 002%",414 A i ' .55D 'WUITOX 11 Bait Piwdlum Sal of Dtphaolivoii-91 0 2 4N-1, W�VQ 259Z #A .1 ,wit. FC Ant Be Sta=(Rpmorplo"19 '�'6424001432-1256' mq,�P, M,�LW)doxm F.0 AM Gel Bait Flieonil)9.001% r'"6424&21/432-1264 01i Ft., 354%4AMdowceFCRWCh Bak Gel (Rpmh[I) 0.01 64248-141432-1259 Y ',t:055 MagoiceFGinsect8aft(Hydrainefthilm6n) t:64248-19/432-1262 -a is ,�W, NbanBaftNbMEGBahPtt�6&46%-,�'�I 644�W�2_of W.v_ 1i Ni-BwXp)igodiumOctaboWeTmUahydrati)98% 6" jN),171 7- 462.N&EGFynWorjf@o)zU0.015%' 5-30 57079 i . u 'n,; 2 �tligms 26 ZA,:: "9_26_ZA':. 9349'OrMmTufTr6e,&ShrubAVP_PtaphdaI 380 Pre-Empt Roach W 80 Ornklaclop� 2.15%125-5251432-1395 4Is_373 -65 PT Calibres Aerosol Onephsle)'�To% . ... .. Precaution1 - PT Cy -Kick Aemsol (eyflLdhrin) -1,4 Aevcbt votV 499-470 70 FrCy40ckCS(Cykftn) 0.025% OM% 0.1% �WO 499-304 �c "oois'% on I. 'A�dbieathin,�nusbi..dusfti. 312 PT Ay&t Gel Bait Obaineatin BI) 0.05% 499_410 69PT%5Pks)L0ASmwIFpftrins)0.5% Aen,904A IS9 PTTflDaA0Wd(S,IiCe O�6 121 Suspend SC n) C)0.01% 0.061 432-763 "00;r _my{ 81 TenipotiftraWPICAft" DO.M% 00.05% 00A% �oa C too (Cylludmin) 0.025% 31254W432 -1m LF T;.6��(vq c 91 L7LDSA0U0 ULV pyretnins) 1.0% ) 499-45W1540-9 S=sw jar -sea _D, d=� 15 *-r 102 ULD BP 300 ULV Pyrethrins) 3.0% 4991 ,4 X . IH=lnmp��,. I %.L v SM Weathedhlok XT Bait proffilmootirn) 0.005% 10152-331 EqW�Wc--�iq :. FiAr T- %1— 9 620 Contras . Saft (Brormadidone) 0= 24V 5% 7 ft W_eeks-pf°Nar�4 A Posing Service Stiloar? 0 Y" f Eli 'ki fiS Stip�arwilades:bbmn*96; Pr fk b 8 s Amt_ a 2 Tax + V ��FIE (�,iAMO GWIPAID ! �7 MS? RE, ME !�� DE (I aW RMI- -837 N 41, I IRTOMER-8130PY `il`.,, / 1 �x S . 1REW .IRBY ST f + N�1�a\°� >~ e �1 s >: y can take to help limit or as, and letters represent i. R StorageUtlhty't ; roduceArea r Warehouse %reas4etwlty and Conditions Observed ❑ Meat/Seafood Shop report details where pests were found in and around the facility. The report also lists those stepsyou pest invasions. For each of the areas listed below, numbers represent the type of pests;found in•tlte,ar dons present that may be contributing to a current, or possibly a future, pest infestation:', V :wApt,t basement 01 p-— :error Areas Pests Conditions Food Areas Pests Otfices�'. Dining Area _ Lobby/Publio Areas '' lil Stove/Oven Line -- • �— Entryways { Q Food Storeroom �.— ,ResULocker Rooms _ , )5l Dishwashing Area .' Janitor Closets_ ElDell/Bakery— Laundry - - O Processing Area — Boiler/Furnace Room -, ' 0 Packaging Area - — y can take to help limit or as, and letters represent i. R StorageUtlhty't ; roduceArea r Warehouse ❑ Meat/Seafood Shop V :wApt,t basement 01 p-— EdenorAreas, Patient Rooms ` 1 ❑� Exterior Walls -North — ICU ? L jf Walls-- South Walls-outh - ,. . Linen Stora a Rooms 9 []"Exterior xded - N — Kdchenettes _ � ❑kExtenor WaIIs-West Nurses Stations '• O'Loading D&k 40 - - 66 me ElL DumRg —,,.' ,rr Display Aisles # x E3 Roof r Other (—. y. g r tLV�iTtfie' Other t5R ''.. I�Dishas 6 Pharaoh Ants 11 ,o= tonal invodgrs Y^t:r anCocTPavement Ants X12.`,Hun[Ing SPrders 4 Cockroa8. Fre Ants ' - '13. -Building Soli11 18:• Stored Product Pests Cockroaches 9. Agentine Ants `14. Brown Recluse gg)/rdersh . :•+10.,.,Ants. „15.. Black Widdw SpAlersAogged/Dirly �: - I. Paper/Litter 'O. Poor Stora'g'e Practices e'', ` Y.: Move Dumpster Away From Bldg. ebels UnderTeble J. Water leak. R. Repair Water Damaged Wood,'..:- Z;'Dumpster Area Needs Cleaned .ebris OnShelt K Mops Improperly Stored S. Seal Exterior,CracksrHoles. i.AA- Mercury Vapor Dghts Outside- ebds Under Appliance ` L Trash Containers Need Cleaning T. Tdm Back TreslShrub Branches- BB. KeepDoore Closed genic Matter in Cracks M. Heavy Dusf/Dlrt Deposits U. Remove Piles of Debris : CC. Repair Door/ScreenDeposits on Floor N. Numerous Coti�ebs Present V. Cut TEJI,Grass/Weeds: + DD. Replace Door Weatherstripping YDeposits on Equipment O. Repair FloorRles/wall/Ceiling W. Improve Outside Drainage EE. Poor Outdoor Storage Practices Left Over Night P. Seal Holes/Cracks in Walls X. Install Gravel Foundation Barrier, FF. Other ' nts 1 y Yxttill tg�Vl .y�M} Flve'"t "veM I4x a,r r �>y"a``a'�""'�," Iu x *y'.i'"}, `1F i•.,. fT� 1 a 9 . ,M�� S�d'A y �1V ...,%M�.h `F,.3 vF r"r iiif^ 1l'r^:9p i [d �K�i' . F r - � a ;ei . y y A � "�. +� !lyjj[ 1 °.:�'"rgAktM� 1t }�('d rc ^5 �•y�� d �� i` .. g s` Signature ` ¢" 3ery le Pro ±k�`� TERM/NN CGMMERC/AL June 4, 2004 Witches Brew 156 Derby St. Salem, Ma 01970 Account # 662063 This letter is to confirm that Terminix is currently servicing your property at 156 Derby St Salem, Ma 01970 and will be servicing them on a Semi-monthly basis. The account has been active with Terminix since September of the year 2000. > r pW E al ems i�'t ort Any questions please feel free to contact our office. l3d6l s Thank you, � (h /%��r/[. , Melissa Branch Pest Control Bookkeeper Terminix International 130 Rumford Ave. 4113 Newton, Ma 02466 800/ 491-3768 JUN 1 7 2004 CITY OF SALEM BOARD OF HEALTH IMPORTr..{. MESSAGE FOR DATE 5 PHONE AREA CODE NUMBER EXTENSION 0 FAX 0 MOBILE AREA CODE NUMOER 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 iff®psFORM MADE IN MR Mass�ach`llsetts Department of Public Health Salem Board of Health 120 Washington Street, 4'h Floor Division of Food and Drugs � Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT MTel. (978) 741-1800 Fax (978) 745-0343 Name nn Date Tyue of Operation(s) Type of Inspection ❑Food Se vice ❑ Retail ❑ Routine ❑ Re -inspection A 1 /{ -Address S Risk ElResidential Kitchen Previous Inspection TelephoneLevel rj Lf (f '7 J7 � � El Mobile [I Temporary E] Caterer EJBed &Breakfast Date: ❑ Pre-operation Q uspect Illness General Complaint Owner '7O/ it A L si HACCP YM Person in Char a (PIC) Time e" In: Out: Permit No. El HACCP ❑ Other " Inspector �� (/ cP (LEO Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT _ - ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE _, ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION " "" "' ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C A. 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 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 s501nVo rFo,,,a14.d0 Inspector's ❑ 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 [117. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding [120. 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): El Official Order for Correction: Based on an inspection A 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: Print: Pagel of Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) ASsi--iunentofResponsibility* _ 590.003(B) 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 En s* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water" Applicant To Report To The Person In Drinkin Water from an A roved S •stem" 590.006(.A) Charm* 590.006(B) 590.003(G) Re orcin b Perstm in Charge* 3 590.003(D) Exclusions and Restrictions* 3 -20 1. 15 590.003(E) Removal of Exclusions and Restrictions 4 C 6 C Denotes critical item in the federal 1999 Faid Code of 105 CN -IR 590.090. 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 En s* 3-202.14 _ Fggs and Mrlk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water" 5-101.1.1 Drinkin Water from an A roved S •stem" 590.006(.A) Bottled Drntk[n Water* 590.006(B) Water Meets Standards in 310 CMR 22.04' Contamination from the Environment Shel ish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish - hellfish*3-203.15 3 -20 1. 15 Molluscan Shellfish from NSSP Listed Sources* Washing Fruits and Vegetables Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Packs e tette grit y* 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* 3-402.12 590.004(7) Records. Creation and Retention' 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 Faid Code of 105 CN -IR 590.090. PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.11(.A)(]) Raw Animal Foods Separated Prom 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 3-302.1](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 Rescrvice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding of Reconditioning Unsafe Food,: 9 Food Contact Surtaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.11.2 Mechonicril Wurewashmg Hot Wates Sanitization Tem aratnres* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. " 4-601.11(A) FAluipment 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 tt3 ment* 4-703.11 Methods of Sanitization - Hot Water and 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* 11 Good Hygienic Practices 2-401.11 'Satin , Drinking or Usin Tobacco" 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventin Contamination �Vhen'I'astind* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em p gees* 13 Handwash Facilities Conveniantiy Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 1 -ovation and Placernent* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Mand Drying Devices 6-301.11 Handwashin Cleanser, Availabilit 6-301.12 Hand Drvin, Provision 4 CITY OF SALEM �J BOARD OF HEALTH Establishment Name: �l/iir�o� CJcP�v �.,At c Date: �'� �` 04 Page: � of 2 � Item No. Code Reference C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION R" - Red item - - - PLEASE PRINT CLEARLY Date Verified s .H E rs SvcT of r9 c 4 ,Mf !L = cccl vi res /I M .A�cr, u a/ tN-Aj CurVQU�-{'a 4 V-741— t lea-. /J,y- s x'140 IngArt rJ4-_r2!, Nt�atr c v M •^ c r 7�-� /1 -� G C irG- iRN AM I M M. Pv f P-,4&4 J1 04f4t& L&LEr^ 70 1 Pr- uFF— GtaJ r7fti 14Ls4_P U r f- s Ur- n �D GsC - Eitfi�S �r -SON t Discussion With Person in Charge: I have read this report, have had the opportunity to ask uestions and agree to correct all violations before the next inspection, to observe all " d41ons as described, and to p comply with all mandates of the Mass/Federal Fyyo Code. I understand that noncompliance may result in daily fines of twefity-fi dollars or suspension/revocation of your food permit. Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness interventions and Risk Factors (items 1-22) (Cont) PROTECTION FROM CHEMICALS 14 Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unat roved Additives'" 15 Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11 Common Name - Working Containers'" 7-201.1.1 Separation - Storage' 7-202.11 Restriction -Presence and Use* 7-202.12 Conditions of Use" 7-203.11 'Toxic Containers - Prohibitions* 7-204.11 Saintizers, Criteria - Chemicals* 7-204.12 Chemicals for Washin Pnx4tce, Criteria* 7-204.14 Drying Agents. Caitetia* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted UsePestieides, Criteria* 7-206.12 Rodent Bait Stations" 7-206.13 Tracking Powders, Pest Control and Monitoring* Nu 17 18 TIMEITEMPERATURE CONTROLS * Denotes critical iter) in the federal 1999 Food Code or tq5 CMR 590.000. 19 20 3-501.14(0) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.1IA(1)(2) Eggs- 155°F 15 Sec. 3-501,16(B) 590.004(F) E-�s- Immediate Service 145`F15sec 340111 (A)(2) Comminuted Fish. Meats & Game 3 -SOL 16{,q) Animals - 155'F 15 sec. " 3-401.11(B)(1)(2) Pak and Beef Roast - 130'F 121. min* 3-401.11(A)(2) Ratites, htjected Meats - 1.55'F 15 590.004(H) sec. 3-401.11.(A)(3) Poultry, Wild Gaine. Stuffed PHFs, Stalling Containing Fish, Mea[. Pouttry or Ratites -165'F 15 ,sec. 3401.11(C)(3) Whole-muscte,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. * 3-403.11(6) Microwave -165' F 2 Minute Standing ]'into* 3-403.11(C) Commercial lyProcessed RTE Food - 140'F* 3-403.11(E) Remaining Unsliced Portions ofBeef Roasts" Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs front 140°F to 70'F Within 2 Homs and From 7WF to 41.'F14VF Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient - Temperature Ingredients to 41"F45"F Witton 4 Hours' * Denotes critical iter) in the federal 1999 Food Code or tq5 CMR 590.000. 19 20 3-501.14(0) PHFs Received at Temperatures According to Law Coaled to 4'1'F(45'F Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-801.11(6) „ PHF Hot and Cold Holding 3-501,16(B) 590.004(F) Cold P111 s Maintained at or below 41°14511 F` 3-501.16(A) Hot PHFs Maintained at or above 140"F. * 3 -SOL 16{,q) Roasts Held at or above 130'F. 27. Time as a Public Health Control 3-501.19 Time as a Public Health Control 590.004(H) Variance Reeuhentenl' s •. 21. 3-801.11(A) Unpasteurized Pre-packaged .Juices and Beverages with Warn uo L-ibels* F23Good 23._Management 3-801.11(6) Use of Pasteurized Eggs* 24, 3-801.11(D) Raw or Paurially Cooked Animal Food and Raw Seed Sprouts Not Served. 25, 26. 3-801.11(0) Una coed Food Package Not Rc-serve(. CONSUMER ADVISORY 22 3-603.11. Consurner Advisory Posted for Consumption of F23Good 23._Management and Personnel FC -2 Animal Foods That are Raw. Undercooked or 24, j Food and Foci Protection FC - 3 Not Otherwise Processed to Eliminate 25, 26. Equipment and Utensils FC 4 _ - Water, Plumbin and Waste, FC -5 Pathogens-°' FaeC""a "'700: 27. 3-302.13 Pasteurized Eggs Substitute for Raw Shell 28 _1 C 29 30 Poisonous or Toxic Materials _ '', FC - 7 Special Re guirements Other 1 Eg s* af`Cl IAL ncan.nncmcry t a 590.009(A)41)) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be eb,ic,; .fader the--, iciL A dJ � rr- r - 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 (Items 23-30) Critical and non-critical violations, which do not relate to the foodhorne illness interventions and risk factors listed above, can be, found in the following sections of the Food Cade and 105 011? 590.000. Retail Practices FC 590.000 F23Good 23._Management and Personnel FC -2 .003 24, j Food and Foci Protection FC - 3 .004_ 25, 26. Equipment and Utensils FC 4 _ - Water, Plumbin and Waste, FC -5 .005 ....... _-...--------- -006 27. Physical Facility FC - 6 .007 28 _1 C 29 30 Poisonous or Toxic Materials _ '', FC - 7 Special Re guirements Other .00$ .009 APPROVED VARIANCE GABRIEL PETINO LOT COVERAGE OF DESIGN - EXISTING + PROPOSED ADDITION =,807 SALEM HISTORIC (EXCEEDS ALLOWABLE LOT COVERAGE) APPROVAL EXISTING RESTAURANT IS NON—CONFORMING CONSTRUCTION USE IEmwS PROPOSED DINING ROOM ADDITION FOOTPRINT ffl ECT WILL BUILT TO PROPERTY LINE AS DIMENSIONED TO: (EXCEEDS FRONT, SIDE & REAR SETBACKS) CAFE EXISTING NUMBER OF PARKING SPACES WILL BE SALEM, MA REDUCED PROPOSED ADDITION (DOES NOT CONFORM TO PATRON/PARKING RATIO) SCHEME A _ scALe zl HtUECT W. YI U `I m W N W � Q y I W I Vl EXISTING STRUCTURE O PROPOSED ADDITION PROPERTY LINE --- --- u A IMCT: GABRIEL PETINO ARCHITECTURAL DESIGN - DRAWINGS FOR SALEM HISTORIC COMMISSION APPROVAL NOT FOR CONSTRUCTION N MCWTON DATE IEmwS AflpfITEC15 ST'W-: ffl ECT PROPOSED ADDITION TO: THE WITCH'S BREW CAFE DERBY STREET SALEM, MA 3 MT TITLE PROPOSED ADDITION FLOOR PLAN SCHEME A _ scALe 1/8" = V- 0" HtUECT W. pRAWTK' NO A- 9/24/03 9 D O a 1 ❑ INITIAL SERVICE ® REGUEXTRA SERVICEICE �IVA O EXTRA SERVICE ry nrlq CITY of SALEM BOARD OF HEALTH COMMERCIAL. INSPECTION REPORT{. ;BRANCH t� ACCOUNT a'"";a RT �*; "-y-iEIBF70NE--n?,'°• ;»;GRID S.D,WJ!F; T' t,'PRODUCTION ,, ,;;': +, TIMEIN'e-`+* .J".TIME TIME OUTi`°.''' • SERVICE TROPE" Ax,,W s, s,£ ; i � ` 4�x,�'z . i~k�,ya^��"°y,. x BRANCH�N«a-��'; �A Q.iG� C,Cs� , 4AA . c 14 :;i0 s OPERAT R NAME & CERTIFICATION NUMBER SUPERVISOR NAME & CERTIFICATION NUMBER q1s! I�ctes Target Pests ❑ ❑ Pa'�m•^ ❑ ❑ �l in' U ❑ a9anma Mrs _�y M. ❑ Gmred Pmduct Pests U aieinel cackmachss ❑ F Ams O silvaf¢h ❑ Omer Cl Dlher Cockmeches ❑ Oma41s 0 Fles ❑ Omer Materials .need .u. 450 Insiders 620 WIND-UP TRAPS 400 Insect Monitors 610 TIN CATS Phemmone Tm 645 Rat Batt Stations Pest Control Materials Used EPA Reg. 0 Tic Etc Amount ODY Glue Traps 640 Mouse Bait Stations 630 Sna 7m 655 Liquid Bad Stations Areas Inspected and/or Treated Post ConeDl metentls uad"'e'r'reenymaes 7nvn bstatm 293 Advance Gmnular Ant Salt t4bameclin 81) 0.011% -499-370 285 Advance Ddal Choice Ant Bad (SuHlummid)0.5% 499-459 315 Ascer Fire Ant Bad(Abamectin B1)0.011% 499-370 9 ❑� 89 t ❑ PUN. 4eslA 1c R. U oc'l'y Arena �""^rym41mf QOO"' OxStomgeAlNdy Q, ❑.wamtauseNea. ;• . - . _ :, ....... UPmcess;og seas ❑ Pedem Rpp� ❑Gait Roans Cl em Gcr4 ❑ Roo1 L) B* ora .ter ❑ �'bs"D� ❑ tuaai"0 °°sx/a'mDnvv U Omer 309 Avert Roach Bait Stations (Abammfin) 0.05% 499467 365 Advance 3888 Ant Gel Bad (Borex)5.4% 499492 15 Demand CS (lambda-cyhalothrin) 00.015% ❑ 0.03% ❑ 0.06% 10182-361 210 DetteGald G (Detamethnn) 0.05% 432-836 158 TnDle Bulk Dust (Silica Gel) 40%(Pyrethrins) 1.0% 499429 41 GeMml EC (Hydmpmm) 0.06% 2724.351 'y Generation Mini Blocks Bait (DMIII lone) 0.0025% 7173-218 T❑ 43 Kicker EC(Pyrethnns) 00.05% 00.1% 002% 4816-1145 550,..U0ui x ll Bart (Disopium Sad of Diphadnarce) 0.106% - .r.... -... : o- 12455-81.. _ - -- 352 MaxforceFC7loach Beit Statiods (Flpmhit)0.05% .' 64248-11/432-1257 351 Maxforce FC Ant Bart Stations (Fipmnip 0.01 % 64248-10/432-1256 357 MaWome FC Ant Gel Bait (Rpronill 0.001% 64248.21/432-1264 354 M FC Roach Bait Gel (Rprani00.01% - 64248-14/432-1259 355 Maxfome FG Insect Bait (HydIen0hylnon)1.0% 64248-19/432-1262 360 Niban Bw Miban FG Batt (Orthoboric add) 5% .64405-2 147 Ni-Bor D(Dlsokum Odabomle Trebahydnne) 98% 64405-8 46 NylarEC (Pynpmxyfen) 00.015% U 0.02% 11715.307-57079 49 Odhere Turf, T., & Shmb WP (Acephate) 75% 59639-26-ZA 380 Pre-Empt Roach Gel Bait (Imidaciopm0 2.15% 3125-525/432-1365 65 151 70 PT OdMne Aemsol(Acephate) 1.0% PT Gy -Kick Aemsol(Cyllulhdnl 0.1% PTC -Kick GSC idhdn 0.025% 0.05% 0.1%04 Y l Y6 ) 499-373 70 Precautions Keen a4Mrmd,Mch,Hmn'md Dab Mav rause ave. nolo. miosl;astdn lmUdm. Avoid creamioq vaDae mI.. or ausm. HanMul if sxe1b , GamDa�9r5nules to enivate. 312 PT A"n Gel Bait (Abamedin B1) 0.05% 10 69 PT 565 Plus XLO Aerosol( Pyrethrins) 0.5% .F"90 159 PTTri0ie Aerosol(Sili.Aemgo4.8%(Pyiethrins)0.6%85 mrrot tamtt aim mdentmida paieo,ems. m mt,etum to mom un61 atter veemaeon. m trot touch treated areas noel dry. 121 Suspentl SC (Dettamethnnl ❑ 0.01% ❑ 0.03% ❑ O.Ofi%63 E31254B2/432-1357 81 Tempo Uttra WP(CyfiWhnn) 00.025% 00.05% U0.1%32-135783 Tepa SC U9ra(Cyfluthrin) 0.025% 32-1363 TmaunentCodaNC): c=Grace&Cmvice v=von G=Gereml G=Spot eT=Ban IX'.=D:utalConon 9-TI3 ,I W=Spar»92 IN=mspectian 91 ULDBPIDOULV(PyrethAm)1.0% 11540-9 ULD BP 300 ULV(Pyre mr )3.0% 11540-1 591 Weatherblok XT Bak (13mddamum) 0.005% 10182-839 E9uianeM Code (TnT: CS =Come. PL BDmyer T=Trap e$=Rat Station NG=HaM taster A=Aerosol aG=Bait Gun R=Powe Treatment F-ULV 520 Contme Blox Bait (Bmmadiolom) 0.005% k. 12455-79 r - - - Poseng Semce Sticker? ❑Yes ❑No Supervisor's Comments: UNRESOLVED PROBLEMS? 4 vnuuuv 14 onn_R17_ndndl ^Ar r trj.Mdr{`%•..SpLR,I'AL'6EFMCEjP1s1Tlucnoss.,i, '., e' -. A"•.x==•'•vy. .�4a ;.. { II { C ro SIGNATURE AMOUNT PAID CASH SE TE HNICI¢H5 - TUBE DATA CUSTOMER INFORMATION TERM/N/X Service Areas -Activity and Conditions Observed This IPM report details where pests were found in and around the facility. The report also lists those steps you can take to help limn or minimize pest invasions. For each of the areas listed below, numbers represent the type of pests found in the area, and letters represent any conditions present that may be contributing to a current, or possibly a future, pest infestation. 1 Interior Areas Pests Conditions Food Areas Pests 11. Occasional Invaders ❑ Offices y- _ -a Dining Area /Cpondittocs C� fZJ t ❑ Lobb /Public Areas - y - O. Entryways �] Stove/Oven Line 'O Food Storeroom < . 9 13. Web -Building Spiders L? Rest/Locker Rooms i O Dishwashing Area X21 14. Brown Recluse Spiders ❑ Janitor Closets f ❑ Deli/Bakery 10. Ants. 15. Black Widow Spiders ❑ Laundry ❑ Processing Area _ i ❑ Boileb Furnace Room`'A Y. Move Dumpster Away From Bldg. ❑ Packaging Area B. Food Debris Under Table J. Water leak ❑Storage Utility Z. Dumpster Area Needs Cleaned ❑ Produce Area C. Food Debris On Shelf K. Mops Improperly Stored ❑ Warehouse AA. Mercury Vapor Lights Outside ❑ Meat/Seafood Shop — L. Trish Containers Need Cleaning di BSsement L y Exterior Areas E. Wet Organic Matter in Cracks M. Heavy Dust/Dirt Deposits ❑ Patient Rooms CC. Repair Door/Screen ❑ Exterior Walls -North F. Grasse Deposits on Floor •�� LI ICU DD. Replace DoorW%therstdpping ❑ Exterior Walls -South G,,.Grease Deposits on Equipment 0. Repair Floor/Tiles/Wall/Ceiling ❑ Linen Storage Rooms EE. Poor Outdoor Storage Practices ❑ Exterior Walls -East H. SOIIedPishes Left Over Night (' yI ❑ Kitchenettes FF. Other ❑ Exterior Walls -West _ ;I ❑ Nurses Stations .I — El Loading Dock — ❑Guest Rooms ❑ Dumpster ❑ Barjquet/Meeting Rooms _.' . '❑ •i _ LI Exterior Storage Rooms., — Di.,splay Aisles if r � _. -`• ❑Roof ... ;i ❑ Other ❑ Other ❑ Other ❑ Other _ i a 1. Gartman Cockroaches 6. Pharaoh Ants 11. Occasional Invaders 16. Rats 2. American Cockroaches 7. Pavement Ants 12. Hunting Spiders 17. Mice 3. Oriental Cockroaches 8. Fire Ants 13. Web -Building Spiders 18. Stored Product Pests i 4. Outdoor Cockroaches 9. Argentine Ants 14. Brown Recluse Spiders 19. Other f 5. Silverfish 10. Ants. 15. Black Widow Spiders 20. Other . f A. Drain Clogged/Dirty I. Paper/Litter 0. Poor Storage Practices Y. Move Dumpster Away From Bldg. B. Food Debris Under Table J. Water leak R. Repair Water Damaged Wood Z. Dumpster Area Needs Cleaned C. Food Debris On Shelf K. Mops Improperly Stored S. Seal Exterior Cracks/Holes AA. Mercury Vapor Lights Outside • D. Food Debris Under Appliance L. Trish Containers Need Cleaning T. Trim Back Tree/Shmic Branches BB. Keep Doors Closed ._;. E. Wet Organic Matter in Cracks M. Heavy Dust/Dirt Deposits U. Remove Piles of Debris CC. Repair Door/Screen I F. Grasse Deposits on Floor N. Numerous Cobwebs Present V. Cut Tall Grass/Weeds DD. Replace DoorW%therstdpping G,,.Grease Deposits on Equipment 0. Repair Floor/Tiles/Wall/Ceiling W. Improve Outside Drainage EE. Poor Outdoor Storage Practices . H. SOIIedPishes Left Over Night (' : ?Seel Holes/Cracks in Walls 1'i rMstapGrevpl Fpyndation,BaMer ;- FF. Other e _ - a w Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name ateT e of O erasion s T f Inspection D.t �S O 10 Food Service C3 Retail Routine lie -inspection Address FOOD FROM APPROVED SOURCE Risk n P . Level El Residential Kitchen Previous Inspection _ Telephone 1 g I ❑ Mobile El Temporary Date: ElPre-operation Owner HACCP Y/N ti a r ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ElGeneral Complaint Person inie arge (PIC) O Time i In El HACCP Inspector �,.c Out: Permit No. ❑Other Each violation checked requires a exexpianation on this narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Antl-Choking Tobacco Violations marked may pose an imminent health hazard`and,[!!?uire immediate corrective 590.009( E)'to 590.009 (F) action as determined by the Board of Health. ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION . ,.. t ❑ 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) J� 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 Prevention of Contamination from Hands Handwash Facilities ❑ 16. Cookin( ❑ 17. Reheati CHEMICALS • ,� . !,o or or Color Additives ❑ 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 (' CO_NSUMER ADVISORY 022. 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_a�_(U 5: 5901wpegFomi&10.tla\c- �j � 0 p • i)1C)\(ITunt� �Rt�tno�crX �Rt� ��nlX lm ii2i., Inspector's Signature: Q, r�.•�-� 13. EMPLOYEE HEALTH_ - - - - --- -- �\ PROTE ❑ 2. Reporting of Diseases by Food Employee and PIC 0 14. ❑ 3. Personnel with Infections Restricted/Excluded Print: FOOD FROM APPROVED SOURCE TIMET ❑ 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 . ,.. t ❑ 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) J� 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 Prevention of Contamination from Hands Handwash Facilities ❑ 16. Cookin( ❑ 17. Reheati CHEMICALS • ,� . !,o or or Color Additives ❑ 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 (' CO_NSUMER ADVISORY 022. 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_a�_(U 5: 5901wpegFomi&10.tla\c- �j � 0 p • i)1C)\(ITunt� �Rt�tno�crX �Rt� ��nlX lm ii2i., Inspector's Signature: Q, r�.•�-� Print 1 PIC's Signature: ( Print: 12 1' % Page I 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* r2-103.11 1 Person in charge -- duties EMPLOYEE HEALTH 2 59'0k03(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 tem* Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions im 6 FOOD FROM APPROVED SOURCE '* Denole5 critical item in the federal 1999 Food Cade or 105 CMR 590.000. C PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermeticall • 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* 5401.11 tem* Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22,0* Frequency of Sanitization of Utensils and . Few Contact Surfaces of Equipment* Shellfish and Fish From an Approved Source 3-20114 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 ReceivinglCondition 3-202.1.1 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-10[.11 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.1.2 Shellstock Identification Maintained* 12 Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.0040 Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures iHACCP Plans 3-502.11. Specialized Processing Methods* 3-502.12 Reduced oxygen Rackaging, criteria* 8-103.12 Conformance with Approved Procedures* '* Denole5 critical item in the federal 1999 Food Cade or 105 CMR 590.000. C PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.1.1(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.111 Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated front Each Other* Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(.A) Food Protection* 3-30215 1 Washing Fruits and Vegetables 3-304.11 Food Contac[ with Equipment and Utensils* 4-602.11. Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and . Few Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3 ?01.11 Discarding or Reconditioning Unsafe Fuad* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water - Sanitization Temperatures* 4-501.1[2 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chenucal. 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* 4-70111. Frequency of Sanitization of Utensils and . Few Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.1.1 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2A01.11 Eatin , Drinkin or Using Tobacco* 2401.12 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* 11 5-205E6_301 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices Handwashin Cleanser, AvailabilitHand Drying Provision CITY OF ✓SALEM nn I`I BOARD OF HEALTH Establishment Name:u)A /) is 04 fj Q. Date: R - a to n n Page:_, of Ram No. Code Reference C -tem Critical Item R - Red RedR� SCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date. Verified - U �l .P ,OA n 1`_�=Q A _ o n v ;, Q i 7 6i> Qu�� Qst r/Lk- /a /J� X /l '0 G f-3> ,_ , �L U.rn -4) l (i , 7 A4 d <n Discussion With Person in Charge: 1 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 o twenty-five dollar r suspension/revocation of your food permit. Corrective Action Required: ❑ NoI ❑ 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 16 M 18 TIMEMEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-50L16(B) 59UO4(F) Polsonous 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 Wishing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 1 Rodent Bait Stations" 7-206.13 Tracking Powders, Pest Control and Monitoring* TIMEMEMPERATURE CONTROLS Denotes critical hens in the federal 1999 Food Cade or 105 CMR 590.000. C 20 3-50f,14(C) Proper Cooking Temperatures for 750 L 15 PHFs 3-401.11A(1)(2) Eggs- 1557 15 Sea 3-50L16(B) 59UO4(F) Eggs- Immediate Service 145*FlSsec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3501.16(A) Animals - 155F 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. * 3-401A I(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, PC-6 Poultry or Ratites -165'F 15 see. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks FC -:7 145'F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3.40LI I(A)(1)(b) All Other PHFs -145'F 15 sec. _-�_- Reheating for Hot Holding 3-403A I(A)&(D) PHFs 165F 15 sec. 3-403.11(B) Microwave- 165` F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140'F* 3403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PRFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70'F Within 2 Hours and From 70'F to 41'F/45'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* Denotes critical hens in the federal 1999 Food Cade or 105 CMR 590.000. C 20 3-50f,14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Hours. 750 L 15 Cwbng Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-50L16(B) 59UO4(F) Cold PIFs Maintained at or below 410/45' F* 3-501.16(A) Hot PHFs Maintained at or above 140'F. * 3501.16(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 3-80L H (A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels_* 590.000 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3-801,11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts No Served. * Food and Food Protection 3-801,11(C) Unopened Food Package No Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 223. Animal Fools That are Raw, Undercooked or FC - 2 .003 .I No Otherwise Processed to Eliminate Food and Food Protection FC - 3 Pathogens.* "Y" T" 25. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell .005 26. 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. (Items 23-30) Critical. mid non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in she follox¢ng sectionsof the Food Code and 105 CMR 590.000. lien I Good Retail Practices I FC 590.000 223. Manaztement and Pamonnel FC - 2 .003 .I 24. Food and Food Protection FC - 3 .004 J 25. Equipment and Utensils I FC -4 .005 26. Water. Plumbing and Waste FC -5 .006 I 27. Physical Facili PC-6 .007 28. Poisonous or Toxic Materials FC -:7 .008 29. Special Requirements ,009 30. Other _-�_- Swl�12 e a* CITY OF SALEM BOARD OF HEALTH Establishment Name. r Date: Page:_ of 4-4,— Item Code C -Critical ttem DE gCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R -Red Item VerRied PLEASE PRINT CLEARLY t I A ct� A AQ AAA -PAA rlyvy'v) u _p _ .i P - r .f 0�, /V / ,,. e I/ A n ., C� I n i � � /VI,AA/ � 1.1 n ,/ !M2 i r _ -.. A�.� P(�n,r / n� /ic_l '- MA OUe.l�Oi 71C _ /\2400A, 1- r n / L�An Y\ AXE C `/, /1- 1 A n x Dt rAAO A 41)_ ^ten n I I"), I� `, n /y D 1V o n Discussion With Person ir1 C arge: DCorrectivuAction Required: ❑ No (} Yes 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 copditions as described, and to Exclusion comply with all mandates of the Mass/Federal Foo ode. I understand that Re-inspe9tion Scheduled ❑ Emergency Suspension ` noncompliance may result in daily fines of twe -five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. t 11 Voluntary Disposal ❑ Other: 7 Violations Related to Foodborne Illness Interventions and Risk Factors (item 1,22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 17 18 TIMEITEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-30214 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 Conainers* 7-201.11 Separation - Storage* 7-20111 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 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 hent in the federal 1999 Foci Cale or 105 CMR 590.000. 20 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-401.1IA(1)(2) Eggs- 155F 15 Sec. 3-501.16(B) 590.004(F) E gs- Immediate Service 145'F15sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals - 155'F 15 sec. * 3401.11(13)(1)(2) Pork and Beef Roast - 1.30'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC -6 Poultry or Ratites -165'F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks FC -7 145'F 4' 3401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3.4013) (A)(1)(b) All Other PHFs - 145'F 15 sec. "- ' Reheating for Hot Holding 3-40311(A)&(D) PHFs 165'F 15 sec. * 3-403.11(B) Microwave- 16.5' 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 hent in the federal 1999 Foci Cale 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 PRFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 410/45' F* 3-501.16(A) Hot PHFs Maintained at or above 140'P. * 3-501.16(A) Roasts Held at or above 1300F. 25. Time as a Public Health Control 3 501.19 Time as a Public Health Control* 590.004(H) Variance I uuement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULAnDNsHS( P) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels* 530.000 3-801.11(B) Use of Pasteurized Eggs* FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Na Served * Food and Food Protection 3-ROIAI(C) Unopened Food PackaNot Re -served. CONSUMER ADVISORY 22 SPECIAL 3-603.11 Consumer Advisory Posted for Consumption of 530.000 23. Animal Foods That are Raw. Undercooked or FC -2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC -3 Pathogens,* em"e"o" 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. s* Eggs - SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section .590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness intenentions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000. Item I Good Retail Practices I FC 530.000 23. 1 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 WasteFC - 5 1 .006 I 27. PhysicalFaci6 FC -6 .D07 28. Poisonous or Toxic Materials FC -7 .008 29. Specid Requirements ,009 30. i Other ' 5Wo z Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4'" Floor Division of Food and Drugs Salem, MA 01970.3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name l o \ C ' a Date - - T e of O eration s T f Inspection Routine Re -inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness ElGeneral Complaint ElHACCP Food Service Retail ❑ Residential Kitchen El Mobile El Temporary ❑ Caterer ❑ Bed & Breakfast Address t pr S isk Level Telephone OwnerHACCP ( Print Y/N Person in Ch rge (PIC) Time In �:J Inspector Out p Permit No. ❑Other tacn violation checked requires-anexplanatlon 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)�] 590.005 (F) action as determined by the Board of Health. r n 1 -- - - F i00 PROTECTION MANAGEMENT .__. ❑ 12. Prevention of Contamination from Hands 'ji 1. PIC Assigned / Knowledgeable / Duties _ ❑ 13. Handwash Facilities 77 L ❑ 2. Reportng of Diseases by F o - - --- PROTECTION FROM CHEMICALS Food Employee and PIC "' ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded I FOOD FROM APPROVED SOURCE t,.- - _- �' 1a " E34. 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 ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentlalty Hazardous Foo_ds)' ❑ 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 CCQQNSUMEFIADVISORY 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 I 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)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC -3)(590.0044)) ) cited in this report may result in suspension or revocation of V 25. Equipment and Utensils (FC -4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC -5)(590.006) establishment operations. If aggrieved by this order, you �\ 27. Physical Facility (FC -6)(590.007) have a right to a hearing. Your request must be in writing V 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, semrep�ra, 14, p _v1 Inspector's Signature: Print: t% \ PIC's Signature: Print O 1 Pagej of3 Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(.0) oResponsibility' 590.003(B) Demonstration of Knowledge* 2-103.11 I Person in charge - duties EMPLOYEE HEALTH 2 590d103(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 tlicams* Shell Eggs* 590,003(F) Responsibility Of A F(xxl 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 C C FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Food Cade or 10 CMR 590.000. op PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* _ 3-201.12 Focxf in a Hermetical l y 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* 5-107.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* ShelNish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory AuthgLlty 3-202.18 Shellstock identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated Tags/Records: Sheilstock 3-202.18 Shellstock Identification 3-203.12 Shellstoek Identification Maintained'k 12 Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(J) Labeling of Ingredients' Handwash Facilities Conformance with Approved Procedures 1HACCP Plans 3-502.11. S mialized Processin Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Food Cade or 10 CMR 590.000. op PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.1l(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.1.1 I. Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other' Mechanical Warewashing- Hot Water Sanitization Temperatures* em eratures*4-501.114 Contamination Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 1 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Uumsils* 4-602.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-701. It Discarding or Reconditioning Unsafe Food.* 9 Food Contact Surfaces 4-501.1.1 I. Manual Warewashing - Hot Water Sanitization Temperatures* 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.,11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Arms* 2-301..12 Cleaning Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2-401.1 I Eating, Drinking or Using Tobacco* 2-401.12 Discharges. From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(F,) _ Preventing Contamination from EtnFlo ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-2(15.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwaihing Cleanser, .Availability 6-301.12 Hand Drying Provision ITY OF SALEM BOARD OF HEALTH Establishment Name:( 9),t-PAol,:�) r 31 -L. Date: Page: 3 of _ Item No. Code Reference C — Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION PLEASE PRINT CLEARLY Date Verified I l � \ - �y r v ItiroJr ) J S v rLs V'\ 1 U Vke, — l P 1-t L Q �111_,P ip _ 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 cond' ions as described, and to p comply with all mandates of the Mass/Federal Food. I understand that ,noncompliance may result in daily fines of twenty,-,fKe dollars or suspension/revocation of your food permit. _ Corrective Action Required: ❑ No ❑ Yes ❑t''Voluntary Compliance ❑ Employee Restriction / % Exclusion O! Re nspeclion Scheduled ❑ Emergency Suspension ', l ins, 1 ❑ lEmbargo ❑ Emergency Closure 0 Voluntary Disposal ❑ Other: Viotetfons Related to Foodborne Illness Interventions and Risk Factors Mems 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 Food or Color 15 C 17 18 01MATT _u: ,. ..�. Additives 3-202.12 TAdditives* 3-302.14 Protection from Unapproved Additives" .003 . .004 ! Poisonous or Toxic Substances 7-101.11 identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Stn * - 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 hicidentat Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitorm * C 17 18 01MATT _u: ,. ..�. * Denotes critical item in the federal 1999 Foci fade or 105 CMR 590.0X 3-501.14(C) PHFs Received at Temperatures According to Law Coaled to 41'F/45'F Within 4 Hours. * Proper Cooling Temperatures for 19 PHFs 3-401.11A(1)(2) Eggs- 155F 15 Sec. .003 . .004 ! Eggs- Immediate Service 145'F15=1 3401.11(A)(2) Comminuted Fish. Meats & Game 3-801.11(C) Animals -155°F 15 see. * 3-401.11(B)(1)(2) Pork and Beef Roast - 130°F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 j PhsicalFacili sec. 3-401.1 I(A)(3) Poultry, Wild Game, Stuffed PHFs, Poisonous or Toxic Materials Stuffing Containing Fish, Meat, .008 Poultry or Ratites -165'F 15 see. 3401.11((2)(3) Whole -muscle, Intact Beef Steaks .009 145°F * 3-001.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs - 145F 15 sec. Reheating for Hot Holding 3-403AI(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 3-50IA4(A) Cooling Cooked PifFsfrom 140°F to 70°F Within 2 Hours and From 70`P to 4VF/45°F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41017/45°F Within 4 Hours* * Denotes critical item in the federal 1999 Foci fade or 105 CMR 590.0X 3-501.14(C) PHFs Received at Temperatures According to Law Coaled to 41'F/45'F Within 4 Hours. * Cold PRFs Maintained at or below 3-.501.16(A)j Roasts Held at or above 130'F. ! Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-501.15 Conlin Methods for PHFs 19 p}}F Hot and Cold Holding Cold PRFs Maintained at or below 3-.501.16(A)j Roasts Held at or above 130'F. ! Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-80LH(A) Unpasteurized Pre-packaged Iuices and :Beverages with Warning Labels* 590.000 3 801.11(6 Use of Pasteurized Eggs* .003 . .004 ! 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served- * FC - 4 3-801.11(C) Unopened Food Package Not Re -served, CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 'I 23. I Manatiament and Personnel 24. Food and Food Protection Animal Foods That are Raw, Undercooked or .003 . .004 ! 125. Not Otherwise Processed to Eliminate 1 FC - 4 7= I Pathogens.' �` ,n,�n TEquiprnent Water. Plumbing and Waste 3-302.13 Pasteurized Eggs Substitute for Raw Shell 27. j PhsicalFacili Eggs* SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Speeial Requirements. VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES (Items 23-30) Crifical and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the fallowing sections of the Food Code and 105 CDM 590.000. 1 Item 1 Good Retail Practices j .FC 590.000 'I 23. I Manatiament and Personnel 24. Food and Food Protection .- FC -2 1 FC -3 .003 . .004 ! 125. and utensils FC - 4 7= I ! 26. TEquiprnent Water. Plumbing and Waste _i FC -5 .006 27. j PhsicalFacili FC -6 .007 . 128. Poisonous or Toxic Materials FC -7 .008 ~29. Special R uiremer4s .009 ' 30 i Other 1 ssw:c�.,�aaz s, �1� CITY OF SALEM BOARD OF HEALTH Establishment Name:�T�iZ j � f,y- ' Date: h —�z Page: c)-" of Rem Code C - Critical ItemDESCRIPTION OF VIOLATION / PLAN OF CORRECTION lel- Date No. Reference R - Red Item j \ A I Ij I 1 PLEASE PRINT CLEARLY Verified u ��, �"` � , ks�(��`., n_ 1 }��: i`i,/S-✓ �•i;i/ ( L�-j � �y,u � 7+/ rt �_ rl l A i . 01" r � n �6C.U/ n re ',.r � O' m A) 1,fY t�?1 Ra { t OIY��il O' L I �_�_1/ v iv l v Discussion With Person in Charge: Corrective Action Required: ❑ No IY 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 FY Re-inspec't.io•n ❑ Emergency Suspension comply with all mandates of the Mass/Federal oo Code. I understand that ^S^creduled L1❑ YL ,noncompliance may result in daily fines of t enty- ive d Ilars or suspension/revocation of Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: VloWlons Related to Foodbarne illness. Interventions and Risk Factors (!toms 1-22) (Cont.) EiIi...• t lfala;;Fsln�� lin Food or for 15 16 17 - TIMEITEMPERATURE - Additives 3-20 2.12 Additive&..._...... .....---- 3-30.2.14 Protection from Unapproved Additives`" 3-501.16(6) 590.004(F) Poisonous or Toxic Substances 7-101,11 Identifying Information - Original Containers* 7-102.11, Common Name - Working Containers'r 7-201AI 1 Separation - Sto 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toric 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 Relent Bait Staticrosfi 7-206.13 Tracking Powders, Pest Control and onitorin * Monitoring* TIMEITEMPERATURE CONTROLS - Proper Cooking Temperatures for 3-501,15 PRFs 3-40LIIA(I)(2) Eggs- 155`F 15 Sec. 3-501.16(6) 590.004(F) Eggs- immediate Service 145°Fl5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3.501.16(A) Animals - 155°F 15 sec. * 3401.11(B)(1)(2) Pork: and Beef Roast -130°F 121 min* 3-401.11(A)(2) Ratites, Injected Mane; -155°F 15 590.004(H) sec. * 3-401-11(A)(3) Poultry-, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, , FC -8 Poultry or Ratites -165'F 15 sec. 3-101.11(C)(3) Whole -muscle, Intact Beef Steaks " FG� 7 145°F 4' 3401.12 Raw Animal Foods Cooked in a - Microwave 165F * 3-401A I(A)(1)(b) All Other PRFs -145*F 15 sec. � Reheating for Hot Holding 3403.11(A)&(D) PHFs 16S F 15 ice. * 3-40111(B) Microwave --165` F 2 Minute Standing Time* 3401 I I(C) Commercially Processed ATE Food - 140°F* 3403.11(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 Hours and From 70°F to 4FF/45'17 Within 4 Hours. * 3-501.14(6) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 Hours* * DernNes critical ivem in the L -doral 1999 Food Caie or 1004R90-000- s 3-501.14{C) PHFs Received at Temperatures According to law Cooled to 41°F/45°F Within Hours. 3-501,15 Coohng Methods for PHFs 3-801.11(6) PHF Hot and Cold Holding 3-501.16(6) 590.004(F) Cold P1IFs Maintained at or below 4101450 F* 3-50 L I6(A) Hot PRFs Maintained at or above 1400F. * 3.501.16(A) Roasts Held at or above i300F. 25. Time as a Public Health Control 3-501.14 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.17 (A) Unpasteurized Pre-packaged Juices and Beveraxes with Warning Labels* 590.000 3-801.11(6) Use of pasteurized Eggs* FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served, * i Food and Food Protection 3-801.11(C) Unopened Food E2ELaE Not Re -served. 22 3-603.11 Consumer Advisay Posted fir Consumption of 590.000 23.__ Animal FuocLs That are Raw, Undercooked or FC -2 .003 Not OtherwiseProcessedto Eliminate 1 i Food and Food Protection ( FC -3 Pathogens.' "* l?" 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. EMS?, 5Ft:t;tAL Violations of Section 590.009(A) -(I)) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590,009 violations relating to good retail practices should be debited under #29 - Spec:ial Requirements - (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk- factors listed above, carr be found in the folle»ing sections of the Food Code and JOS CMR 590.000. t Nem 1 Goad Retail Practices _FC 590.000 23.__ ; Mangoement and Personnel FC -2 .003 i 24. i Food and Food Protection ( FC -3 .004 25. 1 Equipment and Utensils 1 FC -4 .005 26. 1 Water. Plumbing and Waste ' rC-5 -56i- 0827. 27. i Ph stcal Faci" , FC -8 .007 128. Poisonous or Toxic Materials " FG� 7 .008 X29. Special Requirements - .009 30. 1 other � S59Cfoa�ivAG2bc Commonwealth of Massachusetts City of of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Temporary Food Permit DATE PRINTED: 07/19/2011 ESTABLISHMENT NAME: File Number: BHF -2004-000357 LOCATED AT: Witch's Brew Cafe 156 Derby Street Salem MA 01970 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes TEMPORARY FOOD BHP -2011-0538 Jul 24, 2011 Jul 24, 2011 EVENT: HSI fundraiser LOCATION: Freindship Dockside FOOD TO BE SERVED: Hummus plater and clam chowder Total Fees: PERMIT EXPIRES my 24, 2011 Board of Health Page 1 Jul 10 11 03:48p Microsoft KIMBERLL'Y DRISCOLL MAYOR L=Y RANII)K 16%11 I J IS, GI f0, CP -Fr Flr'lm iAcrjwr al:TE101117Ciir7' CITY OF SALEM, NLkSSACHUSETTS BOARD OF HFuTH 120 WASHINGTON STREET, 4'T FLOOR Tri. (978) 741-1800 Rix(978) 745-0343 Iramdip@salmn.com m APPLICATION FOR A TEM RARY FOOD SERVICE PERMIT FEE: 1-3 = $3 ON -PROFIT = $LS 4-7 DAYS = 600 AVER % D - 7 DIVIDED BY 7 X 6OO =THE AMOUNT DUE. (E E: 14 DAYS DIVIDED BY7=2%600=$1200) NAME OF EVENT f+S-F F1-ie/1 tySh( ,a nLOCATION ��1e n d S� t 0 - DATE(S) OF EVENT a n '7 jaA1 NAME OF APPLICANT TELEPHONE# NAME OF BUSINESS ', `/ I �C.[/! r? 5' Y✓�P ICJ TELEPHONE#�S' e7 7 � � II J :. • : f tt� � 6? v +ZQ/ CERTIFIED FOOD MANAGERS NAME LN 1>° �OS P CERTIFICATION# Ce Is 8 ©O A PLAN OF THE EST ISHMENT IS: I OSED DRAWN ON THE BACK TYPE OF GERATION: ICE RY ICE OTHER iM S _C/,Fept d n C M OD FOR COQ4WG/ OT HOLDING: S _O I METHOD FOR SANITIZING: _ CHEMICAL OTHER Sans �[2.tn4 Sfabon a6a8P4 Ship; also S,n� SOUR -_E OF Ft)OD: NAME:-?.DDRwS `JJ FOODS TO BE SERVED iNCLUDING INGREDIENTS AND METHOD OF PREPARATION: _k 1 f(� m r/,S I HAVE READ THE BOARD OF HEALTH, 'REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS"I HAVE HAD THE OPPORTUNITY rO ASK QUESTIONS - REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM, AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY7EMPORARY FOOD ESTABLISHMENT PERMIT. PURSUANT TO MGL C62C, S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I, TO MY BEST KNOWLEDGE AND BELIEF, HAVE FILED ALL STATE TAX RETURNSAND ALL STATE TAXES REQUIRED UNDER LA DATE SOCIAL SECURITY OR FEDERAL ID # CHEW & DAM EXAM FORM NO. 4474 CERTIFICATE NO. 6680055 ServSafe@ Certification for successfully completing the standards set forth for the ServSafe® Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). 9/24/2009 DATE OF EXAMINATION 9/24/2014 DATE OF EXPIRATION Local laws apply. Check with your local regulatory agency for recertification requirements. i filluilludift ® David Gilbert Chief Operating Officer, National Restaurant Association #0655 Executive Director, National Restaurant Association Solutions 02009 National Restaurant Association Educational Nuneaton. All rights reserved. SewSafe and the SarvSafe logo are registered trademarks of the National Restaurant Associabon Educational Foundation, and used under license by National Restaurant Association Solutions, LLC, a wholly owned subsidiary of the National Restaurant Association. This document cannot be reproduced or altered. 08121102 v.0908 NATIONAL l RESTAURANT ASSOCIATION®