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YE OLDE PEPPER COMPANIE - ESTABLISHMENTStniversal one. www.myuni,., .maop.com phone: 1-800-756-4676 UNV16162 MADE IN USA 4 -J 22 e(6r Stmq)- Commonwealth of Massachusetts ` City of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: File Number: BHF -2004-000360 Ye Olde Pepper Companie 122 Derby Street Salem MA 01970 LOCATED AT: 0122 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2011-0090 ,Ian 1, 2011 Dec 31, 2011 $280.00 Total Fees: $280.00 PERMIT EXPIRES 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR DAVID GREENBA uM, RS ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 40' FLOOR TEL. (978) 741-1800 FAx (978) 745-0343 DCRrEN13AUM(7t7 SALFN[. CONS 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT De %P�ID&6 TEL # ADDRESS OF ESTABLISHMENT /-?a1 �eABV FAX # MAILING ADDRESS (if different) EMAIL - Business' 7e!'41mf FEE (check only) Website: a)Muy less than 1000sq.ft. =$ 70 OWNER'S NAME ,Cp�l� =$280 TEL # =$420 -- - - -------------------------------------------------- RESTAURANT YES O -----------------------------_ less than 25 seats ---------- $140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats ADDRESS de,2 CITY o/r STATE .5" ZIP CERTIFIED FOOD MANAGER'S NAME(S) //// CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON CeA/Gj<Ns��r(% HOME TEL # 97� %�S X954' DAYS'OFOPERATION° +;Monday .' uesday I Wddhesday ,l >.:Thursday s'.s, ,'° Fnday= ; SaturdayM., wI .;,Sunday HOURS OF OPERATION /p Please write in time of dm dQy✓�JfM For example 1 lam-li�1 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -- - - -------------------------------------------------- RESTAURANT YES O -----------------------------_ less than 25 seats ---------- $140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) $100 YES NO $25 YES NO $135 YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax retum5,agd paid all state taxes required under the law. Ar Date Revised 10/7/11 F00DAP20I Ladm Check# & Date or .08/27/2008 14:47 FAX VE OLDS PEPPER COMPANIE 14TD dba SILVER SWEET CANDIES 522 ESSEX STREET LAWRENCE MA 01840 TEL (978) 557-101.1 FAX (978) 557-1017 FAX TRANSMITTAL PAGE TO: FROM:�O DATE: MESSACE: TOTAL PAGES INCLUDING TRANSMITTAL PAGE:-,7-'- Q101 AGE:-,7-'- QJ01 A-1 Exterminators P.O. Box 310 Lynn, MA 01903-0310 BOD -5254925 B01 -Tp: 127913001 YE OLDE PEPPER CO LTD 122 DERBY STREET SALEM. MA 01970 Service Slip I Invoice INVOICE: — 425475 _-- DATE: 07101M _ . ORDER: - 425175 WDA bn. [27913001 978.745.2744 LocalYE OLDE PEPPER CO LTD 122 DERBY ST SALEM. MA 01970 put ,hase Order Terme Last SsrvlCe Map Code Time Out • Chem" wtsWc1 p over 70 days bom the date d esrvios ale subjed to a 1%% FINANCE I nxaby adxadedpe lM eaoehwlaq ComP'*V" d as wekev rendered. and agree b pay tk CHARGE PER MONTH or mmual permntege rife of 19%. Cuslomer agrees to pay r Med met al femme ere apect0ed store. expwmB In the Brent at eolbdlal. x CUSTOMER SIGNATURE PLEASE PAY FROM THIS INVOICE Z0z %Yd L6:DT 900Z/LZ/90 A-1 Exterminators ,P.O. Box 310 Lynn, MA 01903-0310 BOG -525-4825 Bill -To: 127913001 YE OLDE PEPPER CO LTD 122 DERBY STREET SALEM. MA 01970 Service Slip l Invoice FINVOlte: ..._.- 417427 DATE: OBt0510B OROERt -- 417427 Worts 127913001 978-745-2744 Location- YE OLDE PEPPER CO LTD 122 DERBY ST SALEM. MA 01970 Work Data Time Target Peet lechniGan Time In OW05/05 1010 AM 005 Purchase Order. Tem1a Leat 9ervlcd Mep Code Timp Our ry. p yi I I i 101 1 ST A 2NO d BASEMENT REGULAR PEST CONTROL SERVICE 537.00 SUBTOTAL 537.00 TAA 50.00 TOTAL — --- - $37.00 AMT_ PAID S0,00 CMrpea oulatanding over 30 days from the dots d SWViw pre subpd to Is r%% PINANCE I hwby acA.wrddedpa d<uaAadery mmpteean d a0 aewien reAdered. aM apAe b pay Ura CHARGE PER MONTH or annual percentage rale A 1a%. Custamar agrees Is pay amrmed wet o1 sereicw of ipeceied sews, eapen#e M tae event of Wild m )( CUSTOMER SIGNA'(U� PLEASE PAY FROM THIS INVOICE Coo YYd 0:1?T 900Z/LZ/90 A-1 Ex10m11natore P.O. Box 310 Lynn, MA 01903-0310 500-325-4!15 Bill -To: )2791300) YE OLDS PEPPER CO LTD 122 DERBY STREET SALEM, MA 01970 Service Slip I Invoice INVOIBE: 40"' 1 DATE:, 05/08108.. ORDER: 109855 Werk 127913001 978-745-2744 Localiaw YE OLDE PEPPER CO LTD 122 DERBY ST SALEM. MA 01970 Work Date. Time Target Peat Technicion Time In� 101 REGULAR PEST CONTROL SERVICE BOB OR GEORGE -1ST & 2ND & BSMT-M122 a $37.00 SUBTOTAL $37.00 TAX $0.00 TOTAL 137.00 AMT. PAN $0.00 BALANCE $37.00 - Charyee wOrareling Peer 10 date hom Mc dale or service am subject b a 14A% FINANCE 1 he.eby arias cdae me saeeteUhry comPletlen of all mrAcea rendered. end aawe to Pay Me CHARGE PER MONTH or annual pncewe$e ww of 14%. CuPtoewr epwea to Pay acaued cost or omcos N $Mlr*d eae a. eepeneos in dos evert e1 uddecaan. X CUSTOMER SIGNATURE PLEASE PAY FROM THIS INVOICE too %Yd 16:DT 900Z/LZ/90 A-1 Erbartninptors P.CG Baa 310 Lynn. MA 01903-0310 ' SM525.4825 BX4To= (27913001 YE OLOE PEPPER CO LTD 122 DERBY STREET SALEM, MA 01970 Service Slip ! Invoice [DATTE:S E- 40'3133Ogf09lOB • 403133 WOOL /27913001 978-745-2744 Location: YE OLDE PEPPER CO LTD 122 DERBY ST SALEM. MA 01970 Work Oele Time Tergal Pevt Tachnicun Time In Map Code - Time Out Purchase Order To" Last Service 101 INSPECT AND TREAT AS NEEDED REGULAR PEST CONTROL SERVICE 537.00 SUBTOTAL 437.00 TAX $0.00 TOTAL i $37.00 AMT. PAID i0.00 BALANCE 537.00 Changes a teMmmftg over 30 days am the dere of some, are subject ro a I%% FINANCE I homey zc edge Ne sokefsctary completion of all eanieee rendered. and agree to pay Me CHARGE PEP MONTH M erRNM oafcanine rate of le%. CUHdmer agrase to pay ncruI4 agP pf aarvFaa as spece'xe weave. esPensea In the event of ee11ec110n. X CUSTOMER SIGNATURE PLEASE PAY FROM THIS INVOICE S0� Xtld 16�6T A-1 Exterminators P.O. Box 310 Lynn, MA 01903.0310 600-5254525 BIII-To: 127913001 YE OLDS PEPPER CO LTD 122 DERBY STREET SALEM, MA 01970 Service Slip 1 Invoice INVOICE: 397147 DATE: 03/04106 ORDER: 387147 Work [279/300) 978-745-2744 Location: YE OLDIE PEPPER CO LTD 122 DERBY ST SALEM. MA 01970 -. Work Dale .. TInw ''-Tergel Past ' T4ehn0sn SUBTOTAL $37.00 Jr $000 TOTAL $3700 - Titre Out - Purchase Order Terme Last Service Map Coda 101 I INSPECT AND TREAT AS NEEDED REGULAR PEST CONTROL SERVICE AMT. PAID $0,00 BALANCE $37.00 N • Charyryes outstanding over 30 days from ft am at senxe are subject to a i rix FINANCE I hereby ackb noodge the sob s/ader, cempleli of ea seM<es rendered. and agree m Par the CHMOE PEA MONTH or eenuel percentage rate of 10%. Cuetanter agrees to Pay aucamd cost of %"see as spocKed abom expenses In tae event of oWledlon X CUSTOMER SI NAI_U�— PLEASE PAY FROM THIS INVOICE 9018 %Vd L6!6T 800Z/LZ/80 $37.00 SUBTOTAL $37.00 TAX $000 TOTAL $3700 AMT. PAID $0,00 BALANCE $37.00 N • Charyryes outstanding over 30 days from ft am at senxe are subject to a i rix FINANCE I hereby ackb noodge the sob s/ader, cempleli of ea seM<es rendered. and agree m Par the CHMOE PEA MONTH or eenuel percentage rate of 10%. Cuetanter agrees to Pay aucamd cost of %"see as spocKed abom expenses In tae event of oWledlon X CUSTOMER SI NAI_U�— PLEASE PAY FROM THIS INVOICE 9018 %Vd L6!6T 800Z/LZ/80 A- tO 6 P. 310 Lynn, MA 01903-0310 800-5251825 Bill -To: 127913001 YE OLDE PEPPER CO LTO 122 DERBY STREET SALEM. MA 01970 Service Slip / Invoice INVOICE: 392759 DATE: 02105108 ORDER: .- - .. _392759 Work [27913001 978-745-2744 Location: YE OLDS PEPPER CO LTD 122 DERBY ST SALEM, MA 01970 101 INSPECT AND TREAT AS NEEDED REGULAR PEST CONTROL SERVICE Coda a ": "" - T110001 "lr Purchase Order Terme _ Leat Service Map TAX 10.00 101 INSPECT AND TREAT AS NEEDED REGULAR PEST CONTROL SERVICE Charge, eutsrandu g ever 30 ears nom 0m dam rd IcMeM ere subject be • 1 %% FINANCE I hereby acknorrleege the seglibet" COmpk(en M l0 serecee rendered. and agree W pay the CHARGE PER MONTH or annual pementags rvte of 18% Customer sgmea m ptn awed my of eervwe, ee aveeairM above. expenses In the event of wlwd m X CUSTOMER SIGNATURE PLEASE PAY FROM THIS INVOICE LOO %Vd 0:tT 900Z/LZ/90 577.00 i SUBTOTAL $77.00 TAX 10.00 TOTAL $37,00 AMT- PAID 10.00 BALANCE $3700 Charge, eutsrandu g ever 30 ears nom 0m dam rd IcMeM ere subject be • 1 %% FINANCE I hereby acknorrleege the seglibet" COmpk(en M l0 serecee rendered. and agree W pay the CHARGE PER MONTH or annual pementags rvte of 18% Customer sgmea m ptn awed my of eervwe, ee aveeairM above. expenses In the event of wlwd m X CUSTOMER SIGNATURE PLEASE PAY FROM THIS INVOICE LOO %Vd 0:tT 900Z/LZ/90 a 0122 Derby Street Telephone: 745-2744 +Owner. Robert Burkinshaw PIC: Amanda Leclerc Inspector: Elizabeth Salandrea Date Inspected: Correct By: 8/19/2008 Risk Level Permit Number: BHP -2008-0069 'Status: Open # of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) Ye Olde Pepper Companie City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation - Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comment: All food products should be stored at least 6.8 inches off the floor. Equipment and Utensils FAIL Non -Critical BLUE Comment: Fridge in back room needs visible, accurate internal thermometer. Other- See Notes FAIL BLUE Comment: Small amount of mouse droppings observed upstairs in bottom back corner of shelving opposite the stairs, and there were possible droppings downstairs in shelving under the counter at the end. PIC states extermination is taking place regularly and will fax invoices. Establishment to follow all recommendations of pest control operators, keep all areas thoroughly cleaned and sanitized, and immediately clean up any droppings found. PIC to notify Board of Health within one week that violations noted have been corrected. Please fax last 6 months' extermination receipts to the Board of Health within one week. 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. Aug 19,2008) Page I oft Item RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741.1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 19,2008) Page 2 oft .['�'�'a^"i . cX.c'c'F-�s.'�'�C'�+.+n'..,,,��.+..,:a ... .ny < „b •. rt _�-� iyx,:s:�ii � s h"f{ K �;y�r'�£ � �+ra +„"w` k'..� � ,yam,^. ,„➢ r ; . .- , ,..: ax•r "'' f_ ...tac .W^T".k ^".c«°a`U` * "AL ��,,.vw'"���5�� . Commonwealth of Massachusetts'51 CIty of Salem Board of Health Kimberley Driscoll 120 Washington Street, 4th Floor - Mayor - _ - SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 - ESTABLISHMENT NAME: File Number: BHF -2004-000360 Ye Olde Pepper Companie. 122 Derby Street Salem LOCATED AT: 0122 DERBY STREET SALEM, MA 01970 MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2008-0069 Jan 3, 2008 Dec:31, 2008 $280.00 Total Fees: $280.00 PERMIT EXPIRES IDecember3l,2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be postedin,:.. a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, orequipment changes are made,. all .... plans for such must be submitted to and approved by the Salem Board of Health. Page 45 of 46 - c ..t CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"' FLOOR 'I7EL. (978) 741-1800 KIMBERLEY DRISCOLL FAX (978) 745-03430 C `(lei g.,oA tl p /� �-q MAYOR ISCOTTaSALEM.COM JOANNE SOOTT, DEC 6 -2007 HEALTH AGENT CITY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT L�L®�i�P /MDQ �i� TEL # gV;or %�-A 7f5L ADDRESS OF ESTABLISHMENT /oZ.X�/i� �3 ., %!�6k/n FAX # MAILING ADDRESS (if different) EMAIL - Business': OWNER'S ADDRESS Website: A&W�/,)A Ve eZ4&2-D 4Ge/i1Ndt�. LD�I TEL # CITY STATE CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) _ C=$270S0` more than I0,000sq.ft. EMERGENCY RESPONSE PERSON /-'�fi�6i ���� i�i1Gs H19 HOME TEL # o / Af 25-99 seats DAYS OF OPERATION 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION /,0 10M' /p hW - /0 �97r/- /d fj%�7 /O AV /O 4/n - Please write in tme of day -1,177 s 10/01 v fPnr examnla l lam -11 nm1 TYPE OF ESTABLISHMENT RETAIL STORE ES NO -- ----------------- RESTAURANT YES NO (Outdoor Stationary Food Ca ; $210) -----------. K YES NO ------------- BED/BREAKFAST( CHILDCARE SERVICES ..._----------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) FEE (check onl less than 1000sq.ft. =$ 1000-10,000sq.ft. _ C=$270S0` more than I0,000sq.ft. =$420 ------------------------- less than 25 seats =$140 25-99 seats 4230 more than 99 seats =$420 --------------------------------------------- -------------- $100 YES NO $25 YES NO $135 YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fled all state tax return ts and paid all state taxes required under the law. Date ,3o9a 1?6 i Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Checkq & Date'�� 0122 Derby Street Telephone: 745-2744 Owner: Robert Burkinshaw PIC: Louise Olszewski Inspector: John Gehan Date Inspected: Correct By: 6/4/2007 Risk Level: Permit Number: BHP -2007-0021 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) Ye Olde Pepper Companie City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL BLUE Comment: All foods and food products must be 6.8 inches off of the floor. Equipment and Utensils FAIL BLUE Comment: Any refrigeration unit must have visible and accurate internal thermometer. Physical Facility FAIL BLUE Comment: Floor downstairs requires thorough cleaning. 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 04,2007 ) Page 1 oft y 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® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 04,2007 ) Page 2 oft CITY OF SALEM, MASSACHUSETTS RECEIVE® BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR DEC - 4 2006 SALEM, MA 01970 TEL. 978-741-1800 CITY OF SALEM FAx 978-745-0343 BOARD OF HEALTH W W W.SALEM.COM Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT al?, . B CSD TEL #%'1� �Ys �T7iL� Sunday /0 ADDRESS OF ESTABLISHMENT ZAA �24Ei ,gkl 5g � FAX # q�� 1017 more than 10,000sq.ft. Please write in time of day. MAILING ADDRESS (if different) _ EMAIL -- Business': Nb-, OWNER'S NAME Y& ADDRESS /_ S REET CERTIFIED FOOD MANAGER'S NAM Owner's: CITY TEL ST CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL O194(s, ZIP DAYS OFOPERATIOR Monday Tuesday HOURS OF OPERATION n% Wednesday i9m' Thursday Friday 10A"0_ /0 Aw , Saturday 1,4 AW Sunday /0 �0 /1 1� /}srI- 1D =$100 more than 10,000sq.ft. Please write in time of day. ---- T ------------ Y- ES - ----- NO - - - -- - - - - RESTAURAN - less than 25 seats =$100 IForexample Ilam 110m) =$150 more than 99 seats =$200 TYPE OF ESTABLISH FEE (check only) RETAIL STORE ES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ---- T ------------ Y- ES - ----- NO - - - -- - - - - RESTAURAN - less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 - - - ------- --- -- -- - - ------- BED/BREAKFAST YES NO B - - - ------------------------------ $100 ------------- ---- - --- -- ----- ------------- -------------------- --- --- ---- ---- ---- ----- -- ADDITIONAL PERMITS .......... ---- MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT (such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, hnutftled all state tax [eturns and paid all state taxes required under the law. ' // S Oto prr--✓Ci/of / � . Date Social Security or Federal Identification Number __/ --------------------- Revised 11/13/06 FOODAP2007.adm Check_ 8 Date �q_ 4.M(]l1_— J 1,71) , YE OLDE PEPPER COMPANY, LTD. dba SILVER SWEET CANDIES CITY OF SALEM FCSiecking - Northmark 11/30/2006 100.00 100.00 9249 Hea!th3��"`nr ..�vr�.� �, +d S¢ arc,,s ,+t•-:*r'.s�� v .> � 6 3:. N , , IGmbeiley Dnsc011 „*uw�w ti' x 120 Washington Street,,4th Floor x,�+ a F a M8 Of . RP .�w nrr �''.^'�'x�y ^"' Lw•.: i /�+ v6.nirnfio-`y .� a a. s SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: File Number: BHF -2004-000360 LOCATED AT: Ye Olde Pepper Companie 122 Derby Street Salem MA 01970 0122 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2007-0021 Dec 19, 2006 Dec 31, 2007 $100.00 Total Fees: $100.00 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 28 of 29 07/24/2006 VE OLDE PEPPER COMPANIE LTD dba-SILVER SWEET CANDIES 522 ESSEX STREET LAWRENCE MA, 01840 TEL (978) 557-1011 FAX (978) 557-1017 FARC TRANSMITTAL PAGE TOTAL PACES INCLUDING TRANSMMAL PAGE;. laO1 0 07/24/2006 14:28 FAX A1AlLxxterminators INVOICE m8 DSTIIEET,LYM.IAADte02iU7 ® Tet -ase -1131 1-900-52S9M FAX 791.59 -?W Pest and Termite Control Professionals "�' 4i "' J. m DArT DAY TYPE DATE �1. ... _ CONTROL FOR COMMENTS 1.11`, :]!( •_.1_t, R�l.ii':.._ I1_ i ,. r'n%l: .. T n _, . COMMERCIAL SANITATION Floors—Clean ........ YES. ❑ NO - ❑ Counter Counter Surfaces — Clean ................. ❑ 0 ❑ Drain Areas — Clem ....... . . ............... ❑. float Rooms—Clean........................ ❑ U Dining Areas — Clean .............. . ...... ❑ ❑ Employee Areas — Chan ........... . ........ ❑ ❑.- Locker Areas — Clean ..... . ................. ❑ ❑ Storage A•^-" — Organized .................. ❑ n Comments APPLICATION OCCUPIED OR HOURS. :AS BEFORE THEY ARE CHILOREN.. OR. PETSON- IHEAIED SURFACES UNTIL CRY- CONTRACTING RY ACC. ND Z02 PLEASE REMIT PAYMENT TO: P.O. Box 310 Lynn, MA 01903-0310 CURRENT 30 DAYS 80 DAYS 1 90 DAYS 77 REli:j1?R 4G.a\!i —p SERVICECHARGE "-"n NUMBER- UNIT PRICE AMOUNT MOUSE GL BD MULTI -CT TRAP DATE PROTECTA CHECK NO. PROTECTA LP RTU BATT STA OMC ❑VISA CJ DISCOVER RAT GLUE. GD. ACCT. p EXP DATE SALES TAX C,O:D. p- CHD ❑ we ❑ TOTAL DUE TOTAL AMOUNT PD ADDITIONAL I RESIDENTIAL WARRANTY INFORMATION DWELLING TYPE 1 Family ❑' 3 Family ❑ 2 Family ❑ 8 Family ❑ WARRANTY YES NO'❑- 30 Days ❑ 60 Days n 90 Days ❑ 6 Mos. U REASON FOR NO WARRANTY I -Partial service requested............':...............................................................❑ -Poor sanitation ................................ ....... ........... .................. ....... .................. Q -Kitchen/bathroom cabinets not prepared ...... ............................................ Q' •Closats/turnkure not prepared ,.....:.............. ........................................ . _....❑ •Rodaot'prooting. needed.... .................... ......... ,......... .,,......... ....,..._._.......Q. -Other CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOODS AGRICULTURE'S PESTICIDE TIMEIN BUREAU CONSUMER SHEETS, WRITTEN STATEMENTS. POSTING NOTICES AND HAVE AGREED TO NOTIFY TENANTS 2.7 DAYS PRIOR TO APPLICATION TIME. THE ABOVE SERVICE HAS BEEN SATISFACTORILY COMPLETED.14, CUSTONR SIGttATURE -. — E - / TKA SEE REVERSE SIDE FOR PEFITINENT INFORMATION White— Office Copy Canary — Customer Copy pink — Remittance Copy 07/24/2006 14:28 FAX Alt INVOII 167 RD 51REF7, LYNN, M4 01802-ASB7 t ® 761 -SK -27M 1-Mo-W54aW FAX781-M-7841 Pest and Termite Cbntrol Professionals rF 1 I 1-17 F-, PP -P CONTROLFOR .. COMMENTS Nr_'3 I:1R `.a7i'.'jF.". ..;:T i': _.!•.IG n+ 1 AJ"-T n� J �z9•e.� p•c��.�c.L' �I�-1 COMMERCIAL SANITATION Idj 03 PLEASE REMIT PAYMENT TO: P.O. Box 310 Lynn, MA 01903-0310 CURRENT I 30DAYS I 60DAYS- 00 DAYS .-,.". i ACCT NO. AS! PE01 Oil. SERVICE CHARGE NUMBER UNITPRICE AMOUNT MOUSE GL BD MULTI-CTTRAP DATES 06 PROTECTA CHECK NO, PROTECTA LP RTU BAIT STA —T ❑ MC ❑ VISA ❑ DISCOVER RAT GL4EED �•. n • 7'� �"" ACCTn EXP DATE. - SALESTAX TE A, C.D.D. p CNG ❑ NIC E]TOTAL DUE TOTAL AMOUNT PD y "1 I iDDIT10NALCOMMENTS 4- 4 ` POST APPLICATION REQUIREMENTS OCCUPIED AREAS MUST BE VACATED FOR HOl{RS. DRV. PRIOR OR PETS ON DWELLING TYPE I �VYARRANTY YES ❑ NO CT I Famay. ❑. a Family. ❑ 30.OaIra ❑. 60 Days. ❑ 2 Family LJ 6 Family U90 Days f7 6 Mos. ❑` REASON FOR NO WARRANTY -partiatsenice.requested..............__...........-._..._............ _....... __ ... VES NO Floors —Clean ........................... U U. Counter Surfaces — Clean .... .... ......... ❑ ❑❑ Drain Areas — Clean ........................ -Other ❑ Rest Rooms —Clean ...... - - - <y.......... ❑ ❑ Dining Areaa — Chien ...... .............. ❑ 0 Employee Meas — Clean ............. . ...... U U Locker Areas — Clean ........ .............. ❑ Cl Storage Meas — Organized ... .............. ❑ ❑ Comments POST APPLICATION REQUIREMENTS OCCUPIED AREAS MUST BE VACATED FOR HOl{RS. DRV. PRIOR OR PETS ON DWELLING TYPE I �VYARRANTY YES ❑ NO CT I Famay. ❑. a Family. ❑ 30.OaIra ❑. 60 Days. ❑ 2 Family LJ 6 Family U90 Days f7 6 Mos. ❑` REASON FOR NO WARRANTY -partiatsenice.requested..............__...........-._..._............ _....... __ ... _..........Q, -Poor sanitation............................................................... ._............ ......___...❑ -Kitchen/bathroom cabinets not prepared..._......._.__..._._.__.._............_.E] •ClosetsRUmiture not prepared...... ... ......................... __._...................... _..E}. •Rodent proofing needed .............. __._.____........._.___......... _...................� -Other OF FOOD A AGRICULTURE'=C'2017' PESTICIDE.,. •TIME 1 _- RAVE AGREED TO NOTIFY TENANTS 2-7 /V? ISFACTORILY-COMPLSTEO� iNss-r , REVERSE SIDE FOR PERTINENT INFORMATION Wwte—Office Copy Canary — Customer Copy Phi, — Remittence Copy 07/24/2006 14:28 FA - PL RE IT'PAYMENT TO: ti AW tTrninYRors f i "" EEr LraR, MA01902-4597 010%, . P,O,; 310 kVll n, MA OI M-0310 ® 79,-692-77 1 1-RDD-525-aaa FAX 79,-592-T64, "Ik 47' Pest and Termite COM WI Professionals CURRENT I 130DAYS I 60DAYS r uLDI. ^EPF'L F i � 'i a Gc rjr ro1' :i i Z04 90 DAYS L' DATE..^��T .�'? •m.tas_w-r'-7}.4�1�.TF�'Fi7N05!i 11F, fa ;110E CONTROLFQR REGULAR PEST'-GRE)NTRQI_ $ERVICECNAIiGE- Floors — Clean - - . YES . . . .. . . ❑ 9'3-7 Counter Surfaces Clean ............ COMMENTS ❑ Drain Argas — Clean .. . . . . ❑ Cl Rest Rooms — Clean ...... .. .... . ... — ❑ ULl Dining Areas —Clean ..................... RShi —/4t i_'L. ❑ Employee Areas — Clean .................... ❑ ❑ Floors — Clean - - . YES . . . .. . . ❑ NO ❑ Counter Surfaces Clean ............ ❑ ❑ Drain Argas — Clean .. . . . . ❑ Cl Rest Rooms — Clean ...... .. .... . ... — ❑ ULl Dining Areas —Clean ..................... ❑ Employee Areas — Clean .................... ❑ ❑ Locker Areas—Clean ....................... ❑ ❑ Storage Areas — Organized .............. _ .. ❑- 0 - Comments - NUMBER' UNITIPACE EXP DATE a � ALES TAI( D.D.D. ❑ ' Cno p NIC ❑ - NOTAL DUE .•TOTAL.AMOUNT PD .1. �1491-14SItTlw"ITl:Tdail . i.T DWELLING TYPE 1 Famfly ❑ 3 Famlly ❑ 2 Famlly ❑ 6 -Family ❑ WARRANTY YES ❑ NO ❑ 30 Days ❑ 60 Days ❑ 90 Days ❑ 6 MO% 0 - AMOUNT REASON FOR 140 WAPRANTY I- •Panlal service requested ......... ........ ....... ............. ........................................ POST APPLICATION REOUIREME14TS•Poorsanitalion............................................................................................ 1:1. OCCUPIED AREAS MUST BE VACATED FOR ^ ` HOURS.-Kltchentbalhmnm cabinets not prepared ........................... .......... .............. ❑ THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE •Closets/fumiture not prepared ............................_..._ ....... I ......... ................ 0_ REOCCUPIED. 00 NOT ALLOW ADULTS. CHILDREN, OR PETS ON -Rodent proofing needed .................... :........................................................ .❑ TREATED SURFACES UNTIL DRY. -Other CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD 5 AGRICULTURE'S PESTICIDE ITIMEIN BUREAU CONSUMER SHEETS, WRITTEN STATEMENTS. POSTING NOTICES AND HAVE AGREED TO NRpTIFY TENANTS 2-7 - - DAYS PRIOR TO APPLICATION TIME THE ABOVE SERVICE NAS BEEN SATISFACTORILY COMPLM!D. ini SEE REVERSE SIDE FOR PERTINENT INFORMATION While — Office Copy Canary — Customer Capy Pink —Remmance Copy MOUSEGLSD - DATE ' I �� MULTI -CT TRAP -� , PROTECTA CHECK NO. PROTECTA LP RTU BAIT STA ❑ MC EJVISA ❑ DISCOVER FIATGYLUE BD ACCT. b EXP DATE a � ALES TAI( D.D.D. ❑ ' Cno p NIC ❑ - NOTAL DUE .•TOTAL.AMOUNT PD .1. �1491-14SItTlw"ITl:Tdail . i.T DWELLING TYPE 1 Famfly ❑ 3 Famlly ❑ 2 Famlly ❑ 6 -Family ❑ WARRANTY YES ❑ NO ❑ 30 Days ❑ 60 Days ❑ 90 Days ❑ 6 MO% 0 - AMOUNT REASON FOR 140 WAPRANTY I- •Panlal service requested ......... ........ ....... ............. ........................................ POST APPLICATION REOUIREME14TS•Poorsanitalion............................................................................................ 1:1. OCCUPIED AREAS MUST BE VACATED FOR ^ ` HOURS.-Kltchentbalhmnm cabinets not prepared ........................... .......... .............. ❑ THOROUGHLY VENTILATE TREATED AREAS BEFORE THEY ARE •Closets/fumiture not prepared ............................_..._ ....... I ......... ................ 0_ REOCCUPIED. 00 NOT ALLOW ADULTS. CHILDREN, OR PETS ON -Rodent proofing needed .................... :........................................................ .❑ TREATED SURFACES UNTIL DRY. -Other CONTRACTING ENTITIES HAVE RECEIVED ALL MASSACHUSETTS DEPARTMENT OF FOOD 5 AGRICULTURE'S PESTICIDE ITIMEIN BUREAU CONSUMER SHEETS, WRITTEN STATEMENTS. POSTING NOTICES AND HAVE AGREED TO NRpTIFY TENANTS 2-7 - - DAYS PRIOR TO APPLICATION TIME THE ABOVE SERVICE NAS BEEN SATISFACTORILY COMPLM!D. ini SEE REVERSE SIDE FOR PERTINENT INFORMATION While — Office Copy Canary — Customer Capy Pink —Remmance Copy 0122 Derby Street Ye Olde Pepper Companie City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT PASS LJ RED PASS PASS PASS U RED PASS 0 RED PASS L 745-2744 PIC Assigned / Knowledgeable / Duties Owner: RED PASS Non-compliance with: Robert Burkinshaw PASS ] Anti -Choking PIC: Tobacco Inspector: I EMPLOYEE HEALTH .John Gehan i Reporting of Diseases by Food Employee and PIC Date (Correct By: 17�P�f21@06 Personnel with Infections Restricted/Excluded Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source BHP -2006-0287 Receiving/Condition Status: Open Tags/Records/Accuracy of Ingredient Statements # of Critical Violations: Conformance with Approved Procedures/HACCP Plans 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) PASS LJ RED PASS PASS PASS U RED PASS 0 RED PASS L RED PASS 0 RED PASS 0 RED PASS ] RED 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 I of ' Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION RED Reheating PASS Violations Related to Separation/ Segregation/ Protection PASS PASS RED Foodborne Illness Hol and Cold Holding PASS RED Interventions and Risk Factors Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED (Require immediate corrective Food and Food Preparation for HSP PASS action) ' Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS ❑d RED Prevention of Contamination from Hands PASS ❑d RED Handwash Facilities PASS RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS RED TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods) Cooking Temperatures PASS ❑d RED Reheating PASS ❑d RED Cooling PASS ❑d RED Hol and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Posting of Consumer Advisories PASS ❑Q RED 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 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils FAIL BLUE Comments: Kettles require general cleaning. Bleach or quatanery sanitizing solution required for all prep areas. Simple green does not constitute sanitizing solution. Water, Plumbing and Waste PASS BLUE Physical Facility FAIL BLUE Comments: Prep room floor requires general cleaning. Dry storage area floor mequires general cleaning. Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other- See Notes PASS BLUE GENERAL COMMENTS: 702: 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 3 of I 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: IOra zMrI EMIexiIIESiY5111 Ye Olde Pepper Companie 122 Derby Street Salem MA 01970 LOCATED AT: 0122 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2006-0287 Jan 4, 2006 Dec 31, 2006 $100.00 Total Fees: $100.00 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 16 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 -EcE�vE I I CITY OF SALEM BOARD OF HEALTH 2006 APPLICATION FOR PERMIT TO OPERATEnnA FOOD ESTABLISHMENT NAME OF ESTABLISHMENT1,p�TEL # ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) Ce1rJ1011=1 . / 4-'J T E L # QW9�%�'o�- `i7 ADDRESS //9 �i�� /✓vim CITY /Y. � STAX10P ZIP O% CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) � EMERGENCY RESPONSE PERSON L ,Q,�%/Gi r<�i✓�/ HOME T E L # 14%1 i HOURS OF OPERATION: Mon./D-STue.tea—Wed./O-Sihu.jL, Fri./O at. /D-SSun TYPE OF ESTABLISHME FEE (check only) RETAIL STORE ES NO less than 1000sq.ft. 1000-10,000sq.ft.10 more than 10,000sq.ft. 50 RESTAURANT YES O less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 ----------- ..................................................... BED/BREAKFAST YES (,NO/ $100 ------------------------------------------------------------- --------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) !CE CREAM, YOGURT, SOFT SERVE YES N $5 TOBACCO VENDOR YES - $50 ALL NON-PROFIT (such as church kitchens) YES $25 3 9s6 *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. KWMQ Date Social Security or Federal Identification Number --------------------------------------------------------------------------------------------- V1140 40 -------------------------------------- Revised 11/03/05 FOODAP2.adm Check# & Date 11 E � -f /a ° 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 Datb / Type of Operationfsl Type of Inspection ❑Food Service Retail] ❑Routine Re -inspection nn J n I jd O _ Address Rlsk ' Level EJ Residential Kitchen El Mobile El Temporary Previous Insp9ction Date: c, /G �T ❑Pre-oeration Telephone _ Owner p HACCP Y/N ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person in Charge (PIC) Time In. OutL 3 Z Permit No. El HACCP EIOther Inspector �a� 1 vrvrauvir crreuneu� requires an expianatlon 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" ❑ B. 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 'ilimmediately 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 s5MnSp OFOm 14drc I Y / / /I ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS [:114. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURECONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control s"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. 2 DATE OF RE^INSPECTION: D 1 Inspector's Signature: \ Print: J PG. PIC's Signature: - - A Print:- r ) �. 1 N Page of- 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* 2-10311 Person in charge - duties EMPLOYEE HEALTH 2 590.003(C) charge Responsibility of the Person=,,,i'd Compliance with Food Law* 3-201.12 require reporting by food e 20113 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 Drinkinn Water from an Approved Svstem' 590.006(A) Chai gel, 590.006(6) 590.003(G) Reporting by Person in Char e* 3 1 590.0030 Exclusions and Restrictions* 3-201.15 590.003(F) Removal ol'Exclusions and Restrictions F0 C C IN '" Denote., critical item in the federal 1999 Food Ca)e or 105 CN1R $90,060. F-8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 P000i in a I-Iennetically Sealed Container* 20113 Fluid Milk and Milk Products* 3-202.13 ......' Shell Eggs* 3-202.1.4 __ Fgp and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinkinn Water from an Approved Svstem' 590.006(A) Bodledllrinkin Water* 590.006(6) Water Meets Standards in 310 CMR 22-0' Washine Fruits and Vegetables Shellfish and Fish From an Approved Source 3-20t.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 Reculatort, Authorit 3-202.15 Shellstock Identification Present* 590.004(C) Wild MnShrOORI5* 3-201.17 Gane Animals* 3-701.11 Receiving/Condition 3-202.1 1 PI-IFs Received at Pro or Tem ieratures'r 3-20215 Package Integrity* 3-101.11 Food Safe and Unadulter Tags/Records: Shellstock. 3-202.13 Shellstock Identification * 3-203.12 Shellstock Identification Maintainedt Tags/Records: Fish Products 3-402.1't Parasite Destntction* 3-102.12 Records. Creation and Retention* 590.00401) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui rnenY* Conformance with Approved Procedures /HACCP Plans 502.115 L3t)2 ecializedProce .12 Reduced oxv�en acka<rin-,ori tecta" 103.12 Conformance with A xoved Ptoeedtues" '" Denote., critical item in the federal 1999 Food Ca)e or 105 CN1R $90,060. F-8 Cross -contamination 3-302.1 1(A)(1) Raw Animal Foorts Separated fiom Cooked and I2TE Foods* Contamination from Naw Ingredients 3-30111(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washine 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 Reseraice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Foal* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water San itization'1'cm>eratnres* 4-501-1.12 Mechanical Warewashing- Ilot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp-, pH, concentration and hardness. 4-601. f I (A) Equipment Food Contact Surfaces and Utensils Clean' 4-602.11 Cleaning Frequency of Equipment Faod- ContaCt Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui rnenY* 4-703A 1 Methods of Sanitization - Hoe Water and Chemical* 10 Proper, Adequate Handwashing - 2-301.11. Clean Condition - Hands and Arms" 2-301.12 Cleanims Procedure* 2-301.14 When to Wash* ll Good Hygienic practices Eating, Drink'im, or Using Tobacco* _2-401.11 _ _ 2-401.12 Discharges From the Eyes, Nose and Mouth* 3 301.12 Preven n� Contain not ou When 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em lovees* 13 Handwash Facilities Conveniently Located and Accessiblo 5-203.11 Ntftnbers andCa 5-204.11 Location and Placement* 5-205-1 l Accessibility, O oration and Maintenance. Supplied with Soap and Hand Drying Devices 6-301-11 fl tndwashinc tyle user. Availability 6 :SOl to lIand ng Provision r+ CITY OF SALEM /� BOARD OF HEALTH Establishment Name: �(1 O�� �e�% i l :).,,-,iq Date: C%� Page: C;z of Item No. Code Reference C - Critical It6m R — Red Item DESCRIPTIONOF VIOLATION / PLAN OF CORRECTION -. "PC SE PRINT CLEARLY --- Date Verified f t QA 1 .P r i (,C /J Discussion With Person in Charge: 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 enty-five dollars or suspension/revocation of noncompliance may result in daily fines of twenty-five your food permit. Corrective Action Required: ❑ No Yes volunta y Compliance ❑ Employee Restriction i Exclusion Ll 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 15 17 18 TIME)TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection front [7na> roved .Additives* FC -2 Poisonous or Toxic Substances 7-101..11 Identifying Iniormation -Original Containers* 7-101I1 Common Name - Working Containers* 7-201.11 Se ..cation -Stora e"` 7-202-'t t Restriction - Presence and Use 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions" 7-204.11 Sanitizers.Criteris- Chenucals* 7-204.12 Chemicals for Washint 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 Mont toeing* TIME)TEMPERATURE CONTROLS "Denotes' critical item in the federal 1999 Foal Code. or 105 CMR 590.000. F3-501.15 Proper Cooking Temperatures for PHFs Received at Temperatures According to Iaw Cooled to 41`�F/45'F Within 4 Hours. " Cooling Methods for PHFs PHFs 3-401.1IA(1)(2) Eggs- 155'F 15 Sec. FC -2 E'gs-Immediate Service 145°F75sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 1-501.16(A) Animals - 155'F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 nvn* 3-401.11(A)(2) Ratites, Injected Meats- 155°F 15 26. sec. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Time as a Public Health Control* Stuffing Containing Fish, Meat, 590.0040-1) Poultry or Ratites -165°F 15 see. "= 3-401.11(C)(3,) Whole -muscle, Intact Beef Steaks FC - 7 f8:7077: 145°F * 3-401.I2 Raw Animal Foods Cooked in a Microwave 165'F * 3-401, 1 l(A)(1)(b) All Other PHFs -- 145'F 15 sec. Reheating for Hot Holding 3-40111(A)&(I)) PHFs 165'F 15 sec. x 3-403.11(B) Microwave- 165' F 2 Minute Standing Time" 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.1.1(E) Remaining Unshced Portions of Beef Roasts* Proper Cooling of PHFs 3-501_ 14(A) Cooling Cookcd PHFs from 140`F to 7WF Within 2 Hours and From 70-F to 41.°F/45°F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Tempetatme Ingredients to 41 "17/45°F Within 4 Hours* "Denotes' critical item in the federal 1999 Foal Code. or 105 CMR 590.000. F3-501.15 3-501.14(0) PHFs Received at Temperatures According to Iaw Cooled to 41`�F/45'F Within 4 Hours. " Cooling Methods for PHFs 19 3-$01.11(B) PHF Hot and Cold Holding FC -2 3-501.16(B) 590.004(F) Cold PHF, Maintained at or below 41V45" F* Food and Food Protection 1-501.16(A) Hot PHFs i4taintained at or above 140'F.* 25. 3-501.16(A) Roasts Held at or above 130+. 20 26. Time as a Public Health Control FC -5 3-501_19 Time as a Public Health Control* _ Physical Facility --- 590.0040-1) Variance Re nirement REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 2'1 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.QQ0 3-$01.11(B) Use of Pasteurized Egs* FC -2 3-801.11(D) Raw or Partial1v Cooked Animal Fotxf and Raw Seed Sprouts Not Served.:u Food and Food Protection 3-801.11(C) Una erred Food Package NoC Re -served. CONSUMER ADVISORY 22 3-693,11 Consumer Advisory Posted for Consumption of 590.QQ0 23. Animal Fords That are Raw. Undercooked or FC -2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC --3 Pathogens.* Eae;*•.a ,: i.rei 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005_ 26. Eggs" Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating tri gc)od retail practices should be debited under #29 - Special Requirements. (items 23-30) Critical and non-critical violations, which do not relate to the foodborne illness interventions and risd-fa(rorc listed above, can be. found in the following sections of the Food Code and /05 CMR 590.000. Hein Retail Practices FC 590.QQ0 23. Management and Personnel FC -2 .003 24. Food and Food Protection FC --3 .004 25. Equipment and Utensils FC_ -_4_ .005_ 26. _ Wa_ter,PIumhing and iNaste FC -5 006 27. _ Physical Facility --- C - 6 .007 28. Poisonous or Toxic Materials FC - 7 f8:7077: .008 29. S ecial Re uirements �-_bog 30 Other S: S, of.,, 6:. Mx Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4th Floor Division of Food and Drugs � Salem, MA 01970-3523 ' FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name I Dae / Type of Operation(s) Type of Inspection ❑ Food Service 43 -Retail ❑ Residential Kitchen ❑ Mobile ❑Temporary [-ICaterer ❑ Bed & Breakfast Permit No. Routine . Re -inspection Previous Inspection Date: ElPre-operation ❑ Suspect Illness ❑ General Complaint El HACCP ❑ Other Address ( .. 1 Kl Risk ' Level C _ Telephone Owner HAC0Fl,1fJN Person in Charge (PIC) Time In I Out. ,. 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 Risi-®ctors 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. Gr _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 ss0M=KIFO��14da n /.�) ❑ 12. Prevention of Contamination from Hands t ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMErrEMPERATURE CONTROLS (Potentially Hazardous Foods) [116. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP), [121. Food and Food Preparation for HSP CONSUMER ADVISORY - -- ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related ❑ _ To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate. violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: 5 ;4�,+kK, 3Q. ao0j Inspector's Signature: `WElf Print: �- i PIC's Signature: Print: t t .. 1 Kl Page= of�ages I pi Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) U 3 4 6 F&19-0 -: f •T.71TF-1Z PW4 iti14LNIfI 590.003(A) Assignment of Responsibility"` 590.0030 Demonstration of Knowledge" 2-103.1.1 Person in charge -- dutiw( EMPLOYEE HEALTH 59q.003(C) Responsibility of the person in charge to 590.004(A -B) require teportrng by food empioyces and 3-201-12 applicants* 59Q003(F) _ Responsibility OfA Food Employee 01 An 3-202.13 Applicant To Report To The Person In 3-202.14 Charge* 590.003(G) Reporting bPerson in Charge* 590.003(1)) Exclusions and Restrictions* 590.(103(E) Removal of Exclusions and Restrictions ' Denotes critical item in the wdo.ral 1999 Food Code of 105 CMR 590.000- - g Food and Water From Regulated Sources 590.004(A -B) Cont liance with Food Law* 3-201-12 Food in a Hermetically Scaled Container* 3-201.13 Fluid Mill: and MilkPr(Aucts* 3-202.13 Shell Eggs* 3-202.14 F, aS and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-1.01.11 Drinking Water from an Approved roved Svetem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0` Washing Fruits and VcEtabies 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 Auihorit 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms` 3-201.17 Game Animals" 3-701.11 Receiving/Condition 3-202.11 PRFs Received at Pr(iltal ut reratures* 3-202.15 Package lnte it .m, 3-101.1.1 Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstook Identification 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Par.rsiteDestruction* 3402.12 Records. Creation and Retention* 590.004(,1) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui hment* Conformance with Approved Procedures /HACCP Plans 3-502.11 1 Specialized Processing Methods* 3-502.12 Reduced oxy, ,en packagging, criteria* 8-103.12 Conformance with Approved Procedures" ' Denotes critical item in the wdo.ral 1999 Food Code of 105 CMR 590.000- - g Gross -contamination 3-302.11(A,)(1) Raw Animal Foods Separated from Cooked and RTE Fitods" Contamination from Raw Ingredients 3-302,11(A)(2,) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302A I(A.) Food Proloccion* 3 302,15 Washing Fruits and VcEtabies 3-304. 11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(13) Returned Food and Rescivice 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 eraaues* 4-501.112 Mechanical Warewashing-Flet Water Sanitization Temperatures' 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. '' 4-601.A I(A) Equipment Food Contact Surfaces and tltensits Clean* 4-6102.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702, 11 Frequency of Sanitization of Utensils and Food Contact Surfaces of E ui hment* 4-703.11 Methods of Sannization -Hot Water and Chemical* 16 Proper, Adequate Handwashing 2-301.71 Clean ConditionHandsand Arms* 2-301-12 Cieain,Procedure` 2-301.14 When to Wash" 11 Good Hygienic Practices 2401.11 Fatin , Drinking or Using Tobacco* 2-401.12 Discharges Froth the Eyes. Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Prevendn, Contamination from Em hl0 ;ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.1.1 Numbers and Capacities, 5-204.11 Location and Placement" 5-205.11 Accessibility, 0eration and Maintenance. Supplied with Soap and Hand Drying Devices fi-301.(1 Handwashing Cleanser. Availability 6-301.12 Hand Drvin > Provision f t ;:'O' 1 �W t ' �= CITY OF SALEM BOARD OF HEALTH r� Establishment Name: 2 Date: l Page:_ of O<,i Item Code I C—Critical Item IIESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference ` R —Red Item [ /. Verified ececc omur rceoi v . .. I l z_ f ra , M I Discussion With Person in, Charge: �= Corrective Action Required: O No Yes I have read this report, have had the -opportunity to ask questions and agree ie -correct all ❑ voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to Exclusion P Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twen y five dollar or susp/s,/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �, �� i� �� ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness interventions and Risk Factors (items 1-22) (Cbnt.) PROTECTION FROM CHEMICALS 14 15 16 18 *Denotes critical itemin the Federal f� 1999 Food Code or 105 CMR 590 000. � , i Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-801.11(0 Poisonous or Toxic Substances 7-101.11 Identifying Information - Ong nal Containers, 7-102,11 Common Name - Working Containers* 7-201.11 Se aration - Stora 0 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 Washine 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* *Denotes critical itemin the Federal f� 1999 Food Code or 105 CMR 590 000. � , i Proper Cooking Temperatures for 3-801,11(B) PHFs 3-401.1 1A(1)(2) Eggs- 155'F 15 Sec. 3-801.11(0 E cgs- hnmediate Service 145'.Fl 5sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game Equipment and Utensils FC -4 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 Ph sisal Facili FC -6 SeC. 3-401.1',I(A)(3) Poultry, Wild Game, Stuffed PHFs, 20 Stuffing Containing Fish, Meat, ' Poultr or Ratites -165°F 15 sec. 3-401.11(0(3) Whole -muscle, Intact Beef Steaks 145`F * 3-401.12 Raw Animal Foods Crooked in a Microwave 165`F * 3-401,11(A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165'F 15 sec. 3-403.11(B) Microwave- 165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140`17 to 70'F Within 2 Hour and From 70'F to41'F/450F Within 4 Hours. * 3-501.14(B) Coling PRFs Made From Ambient Temperature Ingredients to 41'F/45°F Within 4 Hours* *Denotes critical itemin the Federal f� 1999 Food Code or 105 CMR 590 000. � , i 21 3-801.11(A) 3-50i.14(C) PHFs Received at Temperatures 3-801,11(B) According to Law Cooled to 3-80E11(D) 41.'F/45'F Within 4 Hours - 3-801.11(0 3 -501.15 5Cooling Methods for PHFs 19 PHF Hot and Cold Holding Equipment and Utensils FC -4 3-50'1,16(Ii) Cold PIIFs Maintained at or below 26. 590.004(F) 410/45' F` Eggs Substitute for Raw Shell 3-501.16(A) Hot PHFs Maintained at or above Ph sisal Facili FC -6 140'F * 28. 3-501.16(A) Roasts Held at or above 13011% 20 Time as a Public Health Control S eclat Re uirements 3-501-19 Time as a Public Health Coun-ol* 30, ­Other 590904('H) variance Ra uirement 21 3-801.11(A) Unpasteurized Pre-packagedJmices and Bevemees with Warnine Labels* 3-801,11(B) Use of Pasteurized Eggs* 3-80E11(D) Raw or PartialtyCooked Animal Food and Raw Seed Sprouts Not Served. * 3-801.11(0 Unopened Food Packa>e NotRe-served. x, CONSUMER ADVISORY 22 3-603.1 I Consumer Advisory Posted for Consumption of 23. _ Mana ement and Personnel FG -2 ------- ---------- -----.-TC Animal Foods'Pliat are Raw, Undercooked of 24. Food and Food Protection - 304 Not Otherwise Processed to Eliminate 25 Equipment and Utensils FC -4 Pathogens.* `'vee"s vvzoar 26. 3-302.13Pasteurized Eggs Substitute for Raw Shell 27. Ph sisal Facili FC -6 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 1129 -- ,.,Special Requirements. (Items 23-30) Critical and non -c. ritical violations, which do not relate to the foodborne illness intenvenrions and risk factors listed above, can he found in the following,sections of the Food Code and 105 CMR 590.0(10. Item Good Retail Prac(ices FC 590.000 23. _ Mana ement and Personnel FG -2 ------- ---------- -----.-TC .003 24. Food and Food Protection - 304 .0 25 Equipment and Utensils FC -4 .005 26. _ Water, Plumbiral and Waste FC -5__ 27. Ph sisal Facili FC -6 r .007 28. _ Poisonous or Toxic Materials FC - 7 .008 29. S eclat Re uirements .009 30, ­Other - - -__ . 11111","11-2 d- STANLEY J. LISOVICZ, JR. MAYOR CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745.0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Ye Olde Pepper Companie Address of Establishment: 122 Derby Street Owner's Name: Robert Burkinshaw Restrictions: Application Date: 1/21/2004 Permit for Food Establishment 270-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 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 Jan,14 04 11,: 19a r a a STANLCY usovicz, JR, MAYOR Joanne Scott Salem BOH 979 745 0343pr�q�J�q p.2 "j�zti11`�. CITY OF SALEM, MASSACHUSETTS;5 BOARD OF HEALTH JAN 202004 120 WASHINGTON STRE.Er, 4TH FLOOR SALEM, MA U191U 2004 APPLICATION NAME OF ESTABLISHM TEL 978.741-1800 FAX 978-745.0343 JOANNE SCOTT, MPH, RS, CHO HrALTH AGEN'i' Cl I Y Ul bALEM BOARD OF HEALTH OPERATE A FOOD ESTABLISHMENT TEL ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME_,,, 4,&ggt 9,1G2!'in�.f ¢sJ CERTIF TEL #— (required in an establishment where potentially hazardous food is prepared.) — EMERGENCY RESPONSE PERSON�,2Ai61 4 J HOME TEL HOURS OF OPERATION: Mon. 6=STue /O 15r Wed. Af✓✓ Thu. le- ✓'Fril8at. /4 S Sun. w-? TYPE OF E$T BLI H -0 RETAIL STORE ES NO a''� RESTAURANT YES NO BEDIBREAKFAST YES NO FeE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 less than 25 seats =$100 25.99 seats =$150 more than 99 seats =$200 $100 ADDITIONAL„PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO Vt NDUR YES NO $GO 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 reiaovcd upon change of ownership. The permit mutt 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 1, to my Inp wlep g n elie have 'ded II Stat to returns and paid all State taxes required under the taw. ture ate Social Security or Federal Identification Number .-- - - - -.......-------------- Revised 11(03103 FCODAP2.adm Check# 8 Date . [ G _ D ?# Ali- STANLEY LISOVICZ, JR. MAYOR January 15, 2004 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT Robert Burkinshaw, Owner Ye Olde Pepper Companie 122 Derby Street Salem, MA 01970 Dear Mr. Burkinshaw: In November the Salem Board of Health sent you an application for your 2004 Food Permit. Included in that mailing was a cover letter stating that you were required to return the application by December 4, 2003. In addition, on January 5, 2004, you were sent a ticket for not returning the application. To date we have not received your application, application fee, or ticket fine. You are operating your establishment without a permit in violation of the State Sanitary Code Chapter X: Minimum Sanitation Standards for Food Establishments, 105 CMR 590.000, Section 8- 301.11. Therefore you are ordered to close your establishment on Friday, January 16 2004 if the above mentioned application, fee, and fine, are not received in this office by 7 PM today, January 15, 2004. Sincerely yours, -�-6C oanne S ott Health Agent JS Hand delivered by Inspector & regular mail 01/15/2004 16:90 FAX ~Jan 14 04 11,9198 Joanne Scott Sale■ BON 970 745 0343 bM P.2 Clw of SAL_ cm, M.%"AL:MU9L-TTG BOARD OF HEALTH 120 WASHINGTON STReal'. 4TH F60001 5^1.6.04, MA UIV IV TEL. 918-141- 1600 0 F^R 976-745-0343 STANLEY USOVICZ, JR. JO^NNe SCOTT, MPH. P', CMO MAYOR HrALTM AOCNT 2004 APPLICATION FOR PERMFTITO OPERATE A FOOD PSTABUSHMEhIT NAME OF ESTABLISHMENT &-,,,��TEL A 0,70 9l`r--'? yEA�l ADDRESS OF ESTABLISHMENT MAILING ADDRESS (I dddi fvoi Q _ OWNER'S NAME-. ay CERTIF frequirod in an estehhshment where Potentially ha mdoos loon is ompitad.) EMERGENCY RESPONSE PrRSONL_8,0.'4- &A'ar"Oysy —HOME TEL u HOURS OF OPERATION: Mon.dt-S�Tw,.=4'sysp /A=�Thu..m' Fri. /Ff3aL Ar'LSun. TYPE OF ESTMLISJj RETAIL STORE ES NO RESTAURANT YES NO BEDOREAKFAST YES NO love Ow 1000 flag . `$ >f0 1000-10.Mq.R. ea100 more than /0,WOsq,1t, MGM less MW 25OWS R51oo 25-998011ft 6S1ti0 more than 99 seats •5200 8100 AOITIONAL PERMITS j f M (rust just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO 66 TOBACCO V IWUUN YBS NO $Go ALL NOAI-PROFTT(such as church Ithchamtl YES NO us Phase pay toleh with one cheat pools to the City of Salem This Permit 18 not transhMde and must im missued upon shards of ownership. The Permit must be posted In a prominent locaVon In the EtiubtishmeN. In sase►denoe with the Stela Tenlrary Cade, belare my rer oWWORA, knpne rMenM 9requlPmen1 changes aro made, as plena far such must be submitted to and npprvYod by the Salem Board of Health. Pursuant to MGL Chapter 62C. Saatiw 49A.1 certify under rhe team and peneides of pagury Ihat 1, to sty lie have ed I sta rat ons ono Paid ell state faxes roqubW under 9x6 law. odeir— oar-_3m9��� nature ate Social Security or Federal himfiftellanr P,crerl IIMM FOOOWteem Crew a Om / YE ObP01/15/2004 F49 UUMMANIt, L 162. CITY OF SALEM VIOLATION CHG. Chocking • I"= Bank ®muacrmsm, - 1Nm9mNu ..eeuese.me YE OLDE PEPPER COMPANIE, LTD. CITY OF SALEM Checbm - taxwo Bmk Roou¢euem Se i.eooamww �aue.mm..mm 1114/2004 1!142004 l&3 4470 125.00 125.00 4469 (00.00 100.00 01/15/2004 16:90 FAX r YE OLDE PEPPER COMPANIE, LTD. America's Oldest Candy Company 122 Derby Street Salem, Massachusetts 01970 Telephone: (508) 745-2744 Fax: (508) 744-1201 FAX TRANSMITTAL PAGE TO: .JJ.9.e6P 1 FROM: DATE: /•/5' o MESSAGE: 7�a�/�_,aiar�� Co-:.ldearq e:r1 OUR FAX 9 IS (508) 744-1201 TOTAL PAGES INCLUDING TRANSMITTAL PAGE: Z01 SINCE law Makers of the Original Salem Gibralters and Black Jacks Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4* Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name Date (04.4 Type of 0 eration(s) Tvpe of Inspection ❑ Food Service LT Retail ❑'Routine ❑ Re -inspection Address'('U �, Y� Risk Telephone \ , a ^l, / . i`Y Level /t'( El Residential Kitchen El Mobile [I Temporary ❑ Caterer ElBed & Breakfast Previous Inspection Date: ElPre-operation ❑ Suspect Illness ElGeneral Complaint OwnerHACCP ./ o jd W -tom v, Au y`144(a YM Person in Charge (PIC) ,L� Time QtJi Permit No. EIHACCP ❑ Other Inspector, ( �{� hacn 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) E]n 590.009 (F) `j 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. 01 'N '+ 23. Management and Personnel (FC -2)(590.003) . Food and Food Protection (FC -3)(590.004) 5. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S: 5901nn IFo1m6-N,tl \ A 1 ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities lie 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: t gna ure: -int: "pector;s a PIFs Signature: � r Print: 41- Page of c� Pages A �, J G Q lA rk r m' '1 11 Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT I 590.003(A) Asci mment of Resp 590.003(B) Demonstration ofKnowledge* 2-103.1.1 Person in charge -duties EMPLOYEE HEALTH 2 590.003(01 Responsibility of the person in charge to 590,004(A B) require reporting by food employees and 3-201,12 applicants - tlicants--590.003(F) 590,003(F) Responsibility Of A Food Employee Or An 3-202.13 Applicant To Report To The Person In 3-202.1.4 Chm-"c* 590.003(G) Re orcin b Person in Char e* 3 590.003(1)) Exclusions and Restrictions* 590.003(E) Removal of Exclusions and Resteictions 4 C I * Denotes critical item in the federal 1999 Food Code or 105 CMR 590At)o. g Food and Water From Regulated Sources 590,004(A B) Com liance with Food Law* 3-201,12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Es* 3-202.1.4 Eggs and Milk Products. Pastemizetf* 3-202.16 Ice Made Froin Potable Drinking Water* 5-101.11 Drinking Water from an Approved Svstern* 590.006(A) 'Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 229* Washing Fruits and Vegetables Shelffish and Fish From an Approved Source 3-201.14 Fishand Recreational lyCaught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Reguiptoty Authority 3-20218 Shellstock Identification Present* 590.004(C) Wild Mushrooms' 3-201.17 Game Animals* 3-701.11. ReceivingtCondition 3-202.11 PRFs Received at Pro er Tetn endures* 3-202.15 Pac;ka ge lute sty" 3-101.11 Fixed Safe and Unadulterated Tags/Records: Shelistock 3-202.18 Shellst'tx.k Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Desb:uction* 3-402.12 Records. Creation and Retention" 590.0040) Labeling of Ingredients' lvequency of Sanitization of Utensils and Food Contact Surfaces of Er ui jjj * Conformance with Approved Procedures IHACCP Plans 3-50211 Specialized Processing Methods" 3-502.12 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures" * Denotes critical item in the federal 1999 Food Code or 105 CMR 590At)o. g � Cross-contametation 3-M2.11(A)U) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302,11(A)(2) Raw Animas Foods Separated from Each Other* Contamination from the Environment 3-30211(A) Food Protection* 3-302.15 1 Washing Fruits and Vegetables 3-304.11 Food Contact with Equipment and Utensils` r Contamination from the Consumer 3-306.14(A)(3) 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 - flot Water Sanitization 'Fent eranues* 4-501..112 Mechanical Warewashing- Not Water Sanitization Tem �ezatures* 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 ofEquipmentFood- Contact Surfaces and Utensils" 4-70111 lvequency of Sanitization of Utensils and Food Contact Surfaces of Er ui jjj * 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms' 2-301.12 Cleaning Procedure* 2-301.14 When to Wash° 11 Good Hygienic Practices 2-401.11 Eating, Drinking orUsing Tobacco - 2 -401.12 Discharges From the Eyes. Nose and Month" 3-301.,12 Preventing Contamination When Tastin �* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.1.1 Nmnbeis and Capacities 5-204.11. Location and Placement* 5-205.11 Vicessibility, 0 oration and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 lkindwaqhing Cleanser. Availabilit 6-301,12 Hand Drvin g Provision CITY OF SALEM BOARD OF HEALTH Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 17 18 TIMEITEMPERATURE CONTROLS Food or Color Additives -� 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* FC - 2 Poisonous or Toxic Substances 7-101..11 klenti(prig Information -Original Containers* 7-102.11 Common Name - Working Containers" 7-201.11 Se aration-Storage" 7-202.11 Restriction - Presence and Use'w 7-202. IT Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11. Sanitizets, Criteria - Chemicals" 7-204.12 Chemicals for Washing Produce. Criteria" 7-204.14 Drying encs. 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 T Denotes critical item in tine Wend 1994 Food Code or 105 CNIR 590000. Proper Cooking Temperatures for Unpastewized Pre-packaged Juices and Beverages with Warnin Labels* PHFs 3-401 11A(1)(2) Eggs- 1.55`F15Sec. FC - 2 Eggs- Immediate Service 145'Fl5sec* 3-401.11(A)(2) Cona ninuted Fish, Meats & Game 3-801.11(C) Animals - 155'F 15 sec. '" 3-401.11(13)(1)(2) Pork and Beef Roast - 130"T 121 an 3-401.1f(A)(2) Ratites, Injected Meats -155'F15 28. sec. 3-401. 1 I(A)(3) Poultry, Wild Game, Stuffed PI -7T'&, LLIJ Stuffing Containing Fish, Meat, Poultry or Ratites -165'F IS sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks 1450F 3401.12 Raw Animal Foods Cooked in a Microwave 165'F s 3401.11(A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165".F 15 sec. * 3-403.11(B) Microwave- 165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 14WF* 3-403.1.1(F) Retraining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) ('noting Cooked PHFs from 140'F to 70°F Within 2 Hours and From 70'F to 41°F/45°F Within 4 Homs. 3-501.14(13) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* T Denotes critical item in tine Wend 1994 Food Code or 105 CNIR 590000. a 1 r -21 Pi- 3-501.14(C) PRFs Received at Temperatures Unpastewized Pre-packaged Juices and Beverages with Warnin Labels* According to Law Cooled to 3 -SO 1. 11 (B) 41'F/45`F Within 4 Hours. FC - 2 3-501.15 Cooime Methods for PHFs 19 PHF Hot and Cold Holding 3-801.11(C) 3-501 16(B) Cold PHFs Maintained at or below 25._Equi 26. _ 27. 590.004(F) 41V45'F* Pasteurized Eggs Substitute for Raw Shell 3-501.16(A) 1lot PHFs Maintained at or above 28. 140'F.* FC - 7 3-50116(A) Roasts Held at or above 130°F. LLIJ Time as a Public Health Control 3-501.19 Time as a Public Health Control* 30. 590.0041-11) VarianceReouiremeat a 1 r -21 Pi- 7-�� 3-801. Li(A} Unpastewized Pre-packaged Juices and Beverages with Warnin Labels* 590.000 3 -SO 1. 11 (B) Use of Pasteurized Eggs* FC - 2 3-801.11(D) Raw or Partially Cooked.9ninnal Fail and Raw Seed Sprouts Not Served. Food and Food Protection 3-801.11(C) Unopened Food Packa e Noe Re -served, " 1 !• 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 23. Anunal Foods That are Raw. Undercooked or FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC - 3 «rue -visor Pathogens.* cn ; 25._Equi 26. _ 27. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .007 28. Eggs* 590.t)09(A)-(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited ander the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retait practices should be debited under #29 - Special Requirements. IOX00100114 "i (Items 23-30) Crilieal and non-cri'cal violations, which do not relate to the firodborne illness interventions and risk factors listed above, can be found in rhe following sections of the Food Code and 105 CMR 590.0(10. Item Good Retail Practices FC 590.000 23. Mana einem and Personnel FC - 2 .003 24. Food and Food Protection FC - 3 .004 25._Equi 26. _ 27. mens and Utensils Water, Plu_mbirnq and Waste Ph sical Faci(i ___ FC 4.005 FC -5 j_.006 FC -6 .007 28. Poisonous or Toxic Materials FC - 7 .008 29. S uciai Re uiremenis .009 30. Other y.cco(rneAgAfr2Wac CITATION NO. CITY OF SALEM PD d 4 0 VIOLATION NOTICE r .L1 NAME (LAST, FIRST, INITIAL) STREETADDRESS CITY/TOWN STATE . ZIP is 61 Sr . -s 171m, , h r/7,7 -- LICENSE NO. LIC. EXP. DATE DATE OF BIRTH OWNER'S NAME (LAST, FIRST, INITIAL) ST EETADDRESS - CITY?OWN. STATE ZIP REGISTRATION NO. /STATE EXP. DATE I MAKERYPE I YEAR COLOR DATE OF VIOLATION TIME EIAM/ DATE CITATION WRITTEN PERS NA INJURY ONO LOCATION OF VIOLATION ElNNFFORCINGD. PVF t rip f . �eAv -s7 ,c �dZ! t OFFENSE CHAP. SECT. FINES �d/ Lt/e C }� 08�ZF/A/ tai B gooef eU/CN �ih/ C OFFICER I.D.NO. '% TOTAL /� L j� !�(i4S�,%/7 I�FINE DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ❑ IN HAND X ❑ BY MAIL DO NOT MAIL CASH - PAY ONLY BY POSTAL NOTE, MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM, MA 01970 TEL. (508) 745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED, AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT INTHIS ENVELOPE, PEEL -AND SEAL .I -4m9W!"a 'NP.M au M., 04,E fist �qTL J t � le w a w ♦ ♦ r r i r = Q ' 11 i =0m r �I 4 ¢OD r W t ul r r w w ' w r w ' r r a w r w w r w a u ;O r .J, s w Ld w r Z 4 Q r r d w o - 0 >- w 2 C .. V>m awn .W.a� a O lr� •W �Nm N = w o IL w �iyw�� w � wW��n 0 o W UUM�rn w } F p C v Orw O >- 0 0 � Cfi CMW IOD S. N m cc c0 Er cc O cc Er N O m a O 0 N l S O O I CO,UfR DOCKETNO. - -- CITATION NO. CITY SALEM PD llbdl VIOLATIO1O N NOTICE i7 NAME (LAST; FIRST, INITIAL) -J' ... .. G .:.. 67n 400 STREETADDRESS CITYROWN STATE LP LICENSE 140. P. DATE DATE OF BIRTH OWNER'S N L /l BBQ/ SrEEi ADDRE�S�S CITY OWN STATE ZIP A JGee . REGISTRATION NO, STA7E EXP. DATE MAKE/IYPE YEAF R DATE OF VIOLATION TIME DATE CITATION WRFITEN KRBpNR' / 0 P IWU /roS--off LOCATION OF VIOLATION tqo pn[YE Ey50pCING OE F 120 SfL 'JfY OFFENSE'.// A ltdl ZV,& CHAP. SEQ. FINES Tt706talAl Q�2 B C OFFICER I.D. NO. TOTAL ry� $ laur Y' ausne%� FINE ia.cn \.on I Int," UUF'Y GIVEN TO VIOLATOR X ElIN HAND ❑ By MAIL DO NOT MAIL CASH - PAY ONLY BY POSTAL NOTE, MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK - CITY HALL 93 WASHINGTON STREET SALEM, MA 01970 TEL (508) 745-9595 X 251 I -HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON - REVERSE, CONFESS.TO THE OFFENSE CHARGED, AND ENCLOSE PAYMENT IN THE AMOUNT OF S SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL STANLEY USOVICZ, JR. MAYOR January 15, 2004 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL, 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT Robert Burkinshaw, Owner Ye Olde Pepper Companie 122 Derby Street Salem, MA 01970 Dear Mr. Burkinshaw: In November the Salem Board of Health sent you an application for your 2004 Food Permit. Included in that mailing was a cover letter stating that you were required to return the application by December 4, 2003. In addition, on January 5, 2004, you were sent a ticket for not returning the application. To date we have not received your application, application fee, or ticket fine. You are operating your establishment without a permit in violation of the State Sanitary Code Chapter X: Minimum Sanitation Standards for Food Establishments, 105 CMR 590.000, Section 8- 301.11. Therefore you are ordered to close your establishment on Friday, January 16 2004 if the above mentioned application fee and fine are not received in this office by 7 PM today, January 15, 2004. Sincerely yours, ;oa"nne Sof tt Health Agent JS Hand delivered by Inspector & regular mail TF^ -n STANLEY J. USOVICZ, JR. MAYOR F " YY lyr.s OF,SALEM, MASSAckusE BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Ye Olde Pepper Companie Address of Establishment: 122 Derby Street Owner's Name: Robert Burkinshaw Restrictions: Application Date: 12/6/2004 Permit for Food Establishment 184-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CS In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Ye Olde Pepper Companie Address of Establishment: 122 Derby Street Owner's Name: Robert Burkinshaw Restrictions: Application Date: 12/6/2004 Permit for Food Establishment 184-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUWal,( BOARD OF HEALTH _ a 120 WASHINGTON STREET, 4TH FLO DEC111���111...111fffAAA a o SALEM, MA 01970 UEC = 2 2004 TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH .MAYOR HEALTH AGENT 2005 APPLICATION �FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT�� O/� yPD O j Zr-b TEL # I ZY /_\HH:f �.�.Y�] � X.9/_1:7 69.h�i1�►11 MAILING ADDRESS (if different) OWNER'S NAME ZJd,0,62!� &), TEL # 0%7 97S Off y CITYA 4iy'b014aC- STATE sell ZIP O/0"/5 CERTIFIED FOOD MANAGER'S NAME(S)N7/� CCERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON, _. ,Ie, 2i L41(S 0 M) HOME TEL # HOURS OF OPERATION: Mon/6- S Tue./6-r Wed. /O---5-T-hu. Id -5- Fri. Sat. iD-s Sun. /0 TYPE OF ESTABLISHM RETAIL STORE ES NO RESTAURANT YES NO BED/BREAKFAST YES NO FEE check only less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 5 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 YES NO $50 ALL NON-PROFfT (such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Social Securitv or -Federal Identification Number 11/03/03 FOODAP2.adm Check# & Date 6'el(O / STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Your Neighborhood Market Address of Establishment: 103 School Street Owner's Name: Luong H. Nguyen Restrictions: Application Date: 11/24/2004 Permit for Food Establishment 69-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 017-05 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. Jrt HEALTH AGENT CITY OF SALEM, MASSACHUSETTS y BOARD OF HEALTH HIIV3HL1 120 WASHINGTON STREET, 4TH FLOOR 30 QOVba c I p SALEM, MA 01 970 W3lVS 3O A110 a TEL. 978-741-1800 FAX 978-745-0343 *2E Z n0'N STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO c MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTA � f'�IY'I NAME OF ESTABLISHMENT YOILIR MEXT TEL # (q14) lM - 01f6 b 4 ADDRESS OF ESTABLISHMENT I03 SCUM, `Yt e Sfl ZM MA e C) t91 MAILING ADDRESS (if different) OWNER'S NAME �,1()�G o j��Gu�� 11 TEL# (q701gq—lq ,0 ADDRESS Atl� CITY J&t'2 —Yut STATE MA s ZIP ()1C1(-1 Ci CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) r EMERGENCY RESPONSE PERSON �{{ (�L�I l , 1�(CTLIY ISI HOME TEL # 1 Gf Te) 14 q —1q'70 HOURS OF OPERATION: Mon7- ld Tue.l-O Wed.]-IbThu.1 -tO Fri.7-10Sat.7_ID Sun. S' -,P TYPE OF ESTABLISHM N FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 ✓ more than 10,000sq.ft. =$250 RESTAURANT YESNO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR srlt 6� YES NO $50 ALL NON-PROFIT (such as church kitchens) NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date Il�z1t' Social Security or Federal Identific3lion Number . �4 nt- z — 1 z — -11')v Revised 11/03/03 FOObAP2.adm Check# & Date 34y c2 II / 2 Z Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name ] m n Date V - Type of Operation(s) ❑Food Service Retail FResidential Kitchen ❑ Mobile [I Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. T f Ins tion Routine Re -inspection Previous Inspection Date: ElPre-operationn ❑ Suspect Illness ❑ General Complaint ❑HACCP El Other AddressJ J C `'��" `n RP Telephone (\ �/ !� i 16 rl 1 I "I t 7t Risk Level Owner 0_8 Pn ) u n iA S0 UtAi HACCP YM Person in Charge (PIC) / , _ - _ inspector n- lit v Y�a� QA tJv i Time I ' Out: Each violation checked requires an exp anation 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 1 Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) 590.009 (F) (F)V I action as determined by the Board of Health. Q ,t �7 1� �/�� � FOOD PROTECTION MANAGEMENT _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEEHEALTH'_" . •": , ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded ❑ 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 ' I ❑ 8. Separation/ Segregation/ Protection 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygie/� nic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within,1.0,days as determined by the Board of Health. Non-critical (N) vidlations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.o03) 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. 5WIRSPe Fw 14W ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS - ❑ 14. Approved Food or Color Additives 5. Toxic Chemicals TIM EMPERATURE 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 1 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 ,off 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 t _ a 3-70 Inspector's Signature:t� Print G Cl. PIC'sS guatare: i v�. 0 l i 1 r Prmt9 )� �rA ✓ Page of 2Pages �RU C/' 1\ NCU Ve U (U. q(l� aAO C'e) r f \�L �i0j P 1 \� Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(A)Assig nment of Res onsibility* 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* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinkin Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590,006(B) 590.003 G) Re ordn b Person in Char e* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(F,) Removal of Exclusions and Restrictions Im C C C FOOD FROM APPROVED SOURCE - Denotes critical item in the federal 1999 Fold Cate or 105 CMR 590A00. $ 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* 3-20213 Shell Eggs* 3-202.14 .F, gs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinkin Water* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590,006(B) Water Meets Standards in 310 CMR 22.0* 1 Washing Fruits and Ve retables Shellfish and Fish From an Approved Source 3-20114 Fish and RecreaLionally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wiid Mushrooms Approved by Re ulato Authortt 3-202.1$ Shellstock.Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Inte itv* 3-101.11 Food Safe and Unadulterated Y Tags/Records: Shelistoek 3-202.1$ Shellstoek Identification * 3-203.12 Shellstock Identification Maimained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.0040) Labeling o1 Ingredients* Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Conformance with Approved Procedures /HACCP Plans 3-50211 S ecialimd Processing Methods* 3-5021.2 Reduced oxygen packaging, criteria* $-103.12 Conformance with Approved Procedures* - Denotes critical item in the federal 1999 Fold Cate or 105 CMR 590A00. $ Cross -contamination 3-302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other" Contamination from the Environment 3-302.11(A) Food Protection* 3-30215 1 Washing Fruits and Ve retables 3-304.11. Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* _ 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and - Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 47702.11 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 2301.1.1 Clean Condition - Hands and Arms* 2-301..1.2 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.1 t Eating, Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-30'L'12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 59lB(14(E) Preventing Contamination from Pan to es* - 13 Handwash Facilities Conveniently Located and Accessible 5-203.11. Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.1 L Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision OL� /Yun a� ��V t Ems. i � 2 A(�iu Q — Z/ e(2 5 . CITY OF'SALEM BOARD OF HEALTH Establishment Name:gP 0(Arl �o r non l ->>, mnAea Date: Io— L, '1 t� Page: o�of Item No. Code C - Crnieai nem Reference R - Red Item- - _ bESCR1P 10N OF VIOLATION / PLAN OF CORRECTION Date. �J PLEASE PRINT CLEARLY VVerified�Qy _ _ r/5 / + o / y -y PA -PA /� vnA i/. 7i — 1(/'+� l� �P.(Q P- C -IX n 0-. [.{4_ Ir v ` a f IA 1,196, Op n O yup PO vl D ♦ �V Y\i /IAP nnn 144 _ U [��/7O� nn A Y tit \ O _ _ )-.,,J)v �.. _ /! c— V A'7 O D . A n ♦ A --in n 1466 1,(" �/ ( Tom/ n j/ n \ !j ` n 7/� /� - , /� VC /) OAA/r� "-h" P', } l/OAe & V%r_bAl r An�..s_,n �11A1_ .a 4 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 EV voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and toRe-inspection Exclusion comply with all mandates of the. Mass/Federal Food Code. I understand that Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. \ c3voluntary Disposal ❑ Other: �J7 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 17 18 TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 _ Additives*' 3-302.14 _ Protection from Unapproved Additives* FC - 2 Poisonous or Toxic Substances 7-101..1.1 Identifying Information - Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Storae* 7-202.11 Restriction -Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Satntizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 - Restricted Use Pesticides, Criteria* 7-206.12 1 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS * Denotes critical item in the federal 1999 Fnod Cade or 105 CMR 590.0(10. } 3-501.14(C) PHFs Received at Temperatures - Aceording to law Cooled to 41 °F/45°F Within 4 Hours. * Proper Cooking Temperatures for 19 PHFs_ 3-401.11A(1)(2) Eggs- 155°F 15 Sec. FC - 2 JIM- Immediate Service 145°Fl5sec* 3401.11(A)(2) Comminuted Fish. Meats & Game 3-801AI(C) Animals -155°F 15 sec. * 3401.11(B)(1)(2) Pork and Beef Roast - 130°F 121 min* 3.401.11(A)(2) Ratites, Injected Meats -155°F 15 26. sec. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC - 6 Poultry or Ratites -165°F 15 sec. 340Lll('C)(3) Whole -muscle, intact Beef Steaks 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3401,11(A)(1)(b) All Other PHFs -145°F 15 sec. I Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165°F 15 sec. * 3-40311(B) Microwave -965° F 2 Minute Standing Time* 3-403.11(C) Conmtercially 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 Ambieni Temperature Ingredients to 41°F/45'F Within 4 Hours* * Denotes critical item in the federal 1999 Fnod Cade or 105 CMR 590.0(10. } 3-501.14(C) PHFs Received at Temperatures - Aceording to law Cooled to 41 °F/45°F Within 4 Hours. * 3-50L16(B) Cold PHFs Maintained at or below 3-501.16(A) I Hot PHFs Maintained at or above 3501 Time as a Public Time as a Public Variance Rennin REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 21 3-501.15 C x' Methods for PHFs 19 PHF Hot and Cold Holding 3-50L16(B) Cold PHFs Maintained at or below 3-501.16(A) I Hot PHFs Maintained at or above 3501 Time as a Public Time as a Public Variance Rennin REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 21 3-80.1.11(A) Unpasteurized Pre-packaged Juices and .Bevera s with R�anring Labels* 590.000 3-801Pasteurized) Use of Pasteurized E FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * Food and Food Protection 3-801AI(C) UnopenedFoodPacka Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 23. Animal Foods That are Raw. Undercooked or FC - 2 .003 - .I Not Otherwise Processed to Eliminate Food and Food Protection (.. FC- 3 Pathogens.* £kacere 1/1 It 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 26. _ Water. Plumbing and Waste t`]�t_r1 Violations of Section 590.009(A) -(D) in catering, mobile food, temporary, and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000. #am Good Retail Practices .FC 590.000 23. Man cement and Personnel FC - 2 .003 - .I 24. Food and Food Protection (.. FC- 3 .004 25. Equipment and Utensils. I FC -4 .005 26. _ Water. Plumbing and Waste I FC -5 A06 27. Physical Facies FC - 6 _007 . 28_ Poisonous or Toxic Materi 29. _ S ectal Requirements .00B 30. I Other I 0122 Derby Street Telephone: 745-2744 Owner: Robert Burkinshaw PIC: Amanda Leclerc Inspector: Elizabeth Salandrea Date Inspected: Correct By: 3/4/2010 Risk Level: Permit Number: BHP -2010-0274 Status: SIGNED OFF # of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) Ye Olde Pepper Companie City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comment: Chocolates on counter are left out overnight; provide a cover for the chocolates overnight. Employee items are being stored in soda fridge. Employee items must be stored separately to prevent cross contamination: PIC states new mini fridge for employees is being obtained. Several mouse droppings were observed on a lower storage shelf upstairs. Any droppings observed must be cleaned up & the area thoroughly sanitized. Exterminations are taking place monthly as required. Equipment and Utensils FAIL Non -Critical BLUE Comment: Soda refrigerator needs visible, accurate internal thermometer. Physical Facility - FAIL Non -Critical Comment: There are several areas of floor in the kitchen that are damaged. Repair floor to be intact. There is a hole in the wall upstairs behind the storage shelves opposite the stairs. Seal hole so wall is intact. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 BLUE GeoTMS® 2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 08,2010 ) Page 1 oft RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency a/ily,/J IMC City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 08,2010 ) Page 2 oft r Commonwealth of Massachusetts s i City of Salem Board of Health IGmberley Driscoll 120 Washington Street, 4th Floor Mayor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000360 Ye Olde Pepper Companie 122 Derby Street Salem MA 01970 LOCATED AT: 0122 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2009-0185 Dec 23, 2008 Dec 31, 2009 $280.00 PERMIT EXPIRES Total Fees: $280.00 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIMBERLEY DRISCOLL MAYOR JANET DIONNE, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4n' FLOOR TEL.. (978) 741-1800 FAX (978) 745-0343 JDtONNE&.aLEM COM 9 ?f1nA DECD. 2009 APPLICATIONi FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Z De% YeDDA.g TEL # ADDRESSCFESTABLISHMEh�e/>�/,� FAX#�1� ✓'�S7-/d�7 MAILING ADDRESS (if different) EMAIL - Business': Website: &,W60 �e a 1�E 2id�PP�A /Dy en .rr OWNER'S NAME /�f✓eeZ Z59,61�/AlSI14-eJ TEL# OW9�-s=���� ADDRESS //Or ��r�eAN .%!4' . ///-`JMNdC2 ,// ®/?W STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) _ EMERGENCY RESPONSE PERSON_ 1_"1eX1497 GGe/r/NS// % HOME TEL # 97f DAYS OF OPERATION 1. , Mond - . Tuesda - Wednesda , ! •=: Thursda - . P Fi da - Saturday, ''Sunday HOURS OF OPERATION d• �p. Qf/� /p /p. /o: Please write in time of da . y �J /, p>y, ! ,o � x"y soil �DJ 25 i (For example Ilam-11pm) f fes% J. � J�• , ..5�' .� TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE OENO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 --- ----------------------------- ---------------------------------------------------------------------I RESTAURANT YES NO ----------------------------------------- less than 25 seats ----- =$140 (VUwoor Stationary Fcod Cart $210) 25-99 seats =$280 more than 99 seats =$420 BEDBRAKAST/ -------------------YES ------146-------------------------------------------------------------------------------$-1--0-0-- ----- CHILDCARE SERVICES MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT (such as church kitchens) YES NO $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location In the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. 424/07 FOODAP2008.adm Check# & Date soctat �,ecunty or reaerai wenti c tio Nrl)e,I� 4 �' ? KiIV^ DATE PRINTED: Commonwealth of Massachusetts City of Salem IGmherley Driscoll Board of Health Mayor 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit 01/12/2010 ESTABLISHMENT NAME: File Number: BHF -2004-000360 LOCATED AT: Ye Olde Pepper Companie 122 Derby Street Salem II MA 01970 0122 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHF -2010-0274 Jan 11, 2010 Dec 31, 2010 $380.00 PERMIT EXPIRES Total Fees: $380.00 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 • + CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TM FLOOR TEL. (978) 741-1800 i{iiviBEFiZ Ef ^uRISC01 FuY (978) 745-0343 MAYOR DGREENnAUN12SALEM. CONI DAVID GREFNBAUIII, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT lm �f �C,g�B2 Co TEL# 97,f- 7s/S=-1 74js ADDRESS OF ESTABLISHMENT /A -z �e4 J� . Schen IWO/%FAX # .'Y7f— s S7 —/a 1,7 — MAILING ADDRESS (if different) EMAIL- Business': 9401- eona Website: aleWII&oV aee"k�xly.eo-q OWNER'S NAME Z,2je&- TEL 97� �/P.��� 7 ADDRESS STREET ,,/ 2 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) /U// CERTIFICATE#(S) (Required in an establishment where potentially hazardous food'iis prepared) EMERGENCY RESPONSE PERSON 4!U416 ,irjGl W IY51d-60 HOME TEL# %SSS AYSOFOPR©TIQNA�naTrsdayF' nay. Waturda (,„Sunday HOURS OF OPERATIONI , o _' Please write in time of day.I Forexam allam-11 m S Q� d SPS TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$2801 /171, more than 10,000sq.ft. =$420 kff§f;0��:r -------------------------- RESTAURANT YES NO --------------------------------------- less than 25 seats ---- =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 ---------------------------------------------------------------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES/NURSING HOME---------------------------------------------------------------------------------- -- ------------------------------------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT (such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health, Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax relurn3.an0 paid all state taxes required under the law. C �Ae44, , d i2ao� f / Sign ure Datd Social Security or Federal Identification Number -------------------------- ---- -- ----- Revised 424/07 FOODAP2008.adm Check# & Date- — O $ 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 Nam to �( Type of Operation(s) Food Service ❑ Retail Tvoe of Inspection ❑Routine ❑ Re -inspection ( Addrisa) 1 ( Risk ^ Teleptio'ne r Level ❑ Residential Kitchen ❑ Mobile Previous Inspection n El Temporary Date: ❑ Pre-operation v OwnerYM HACCP .SV) r f"- ❑ Caterer ❑ Bed & Breakfast El Suspect Illness ❑ General Complaint Person in Charge (PIC) Time In: Out: Permit No. El ❑ Other Inspector A Each violation cnecKea requlre,� an explanation on the narrative page(s) and a citation of specific provis)on(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_ �- 2. Prevention of Contamination from Hands ❑ -i.- PIC Assigned / Knowledgeable / Duties x'13. Handwash Facilities ❑ 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. l 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) N� 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) PR29. Special Requirements (590.009) 30. Other ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Fomes) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding [120. Time As a Public Health Control (_❑Q1. Food and Food Preparation fo HSP lcPGPULATIONS_(HSP) [�CO UMER ADVISORY. .' '- Q22. 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: S, semnspecFo,me-�a.aa n X F(Lt'" _ vv\ C/M -iy \9&-- Q Wl Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* 590.003(8) Demonstration of Knowledge" 2-103.11. Person in charge - duties EMPLOYEE HEALTH 2 590.003(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 Egos* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System*_ 590.000(A) Charge* 590.006(B) 590.003(G) Re ord ng by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(F,) Removal of Exclusions and Restrictions 4 C C IN FOOD FROM APPROVED SOURCE 4 Denoles critical item in the federal 1999 Focal Code or 1t)5 Cl,4R 590.000. n PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Egos* 3-202.14 F, gs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101..11 Drinking Water from an Approved System*_ 590.000(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* Shelrrsh 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 Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 Receiving/Condition 3-202.11 PRFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated TagstRecords: Shellstock 3-202.18 Shellstock Identification 3-203.12 Shellstock Identification Maintained* 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* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* 4 Denoles critical item in the federal 1999 Focal Code or 1t)5 Cl,4R 590.000. n PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 4-501..111 Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foals Separated from Each Other* Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(A) I Food Protection* 3-302.1.5 Washut Fruits and Vegetables 3-304.11, Food Contact with Equipment and Utensils* 4-602.1.1. Contamination from the Consumer 3-306.14('A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-701..11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501..111 Manual Warewashing - Hot Water - Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.11.4 Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1. Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition -Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2.401.11. -Eating, Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 -Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em to ces* - 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Suppled with Soap and Hand Drying Devices 7301.11 Handwashing Cleanser, Availability 6-301..1.2 Hand Drying Provision a0 VIS G`' _. f ITY OF SAL BOARD OF HEALTH Establishment Name_O nLAX ZaA l ,//V -K s -J sM a Date: Page: o of� Rem Code I C - Critics Item V3 DESCRIPTION OF VIOLATION /.PLAN OF CORRECTION Date No. Reference R - Red•item PLEASE PRINT CLEARLY.. -r�M Verified 'IU ,n a t 0 frln stxc U �pEppER 1D N. Uco Jr , ,061, , � � /i. L CANES ANIS NO AM AJA i i/Y�4-G%'J—� ��QrcarvoY� Y a C t 'A <�P /A 0 A .. k XA i Zr f lQQPk aP�'0 D o — 01 6n rL.Lr I _ — r,^OjA \I — ..',A- .—- An � nn Al r Lk Discussion With Person in Charge: U C rrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all V�untary Compliance ❑ Employee Restriction / �/ Exclusion violations before the next inspection, to observe all conditions as described, and to P ❑ Re -inspection Scheduled ❑ Emergency Suspension. comply with all mandates of the Mass/Federa Food Code. I understand that ". noncompliance may result in daily fines we t-fivlta�'s or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. � ❑ Voluntary Disposal ❑ Other: • / Vlolations Related to Foodborne Mass& Interventions and Risk Factors tftems7-22) (Cont) 15 16 Im m TIMErTEMPERATURE CONTROLS Food or Color Additives 3-202,12 1 Additives' 3-302.14 _ Protection from Una xoved Additives'% 3-501,16(B) 590.004(F) . Poisonous or Toxic Substances 7-101,11 Identifying Information - Original Containers* 7-102.11, Common Name - Working Containers* 7-201.11 Separation - Stora * - 7-202.11 .Restriction - Presenceand Use* 7-202.12 Conditions of Use* 7-2033.11 Toxic Comttiners - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 hicidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 - Rodent Bait Stations* 7-205.13 Tracking Powders, Pest Control and Monitoring* Im m TIMErTEMPERATURE CONTROLS ' Denotes critics. Dem in the L -doral 1999 Fuad Cade or 105 CMR 590.000. 3-501.14(0) Proper Cooking Temperatures tar 3-501,.15 PHFs 3401.1IA(t)(2) Eggs- 155`F 15 Sec. 3-501,16(B) 590.004(F) . Eggs- Immediate Service 145'Ft5sec* 3401.11(A)(2) Comminuted Fish. Meats & Game 3 -SOI. f6(A) .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 15 590.004(H} sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, Physical Facility Stuffing Containing Fish, Most, .007 Poultry or Ratites-I65'F 15 sec 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks .Oc18 1 145°F * 3-401.12 Raw Animal Foods Cooked in a -009 1 Microwave 165'F * 3-401 A I(A)(1)(b) All Other PHFs - 145'F 15 sec. " Reheating fm Hof Holding 3-403,11(A)&(D) J 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* 3-403.1I(E) Reimining 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(5) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/456F { Within 4 Hours* ' Denotes critics. Dem in the L -doral 1999 Fuad Cade or 105 CMR 590.000. 3-501.14(0) PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Haus. 3-501,.15 Cooling Methods for PHFs _ 3-801.11(B) PHF Hot and Cold Holding 3-501,16(B) 590.004(F) . Cold PRFs Maintained at or below 410/450 F* 3-50L16(A) Hot PHFs Maintained at or above 140`F. 3 -SOI. f6(A) Roasts Held at or above t30'F. 25. i Equipment and Utensils Time as a Public Health Control 3-501.19 Time as a Public Health Control* 590.004(H} Variance Requiter 21 3-801,11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels* 69tJ.tI00 l _ 3-801.11(B) Use of Pasteurized E0* FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and Rain Seed Sprouts Not Served. * 1 Food and Fuad Protection 3-801.11(0) Un2llencd Food Package Not Ra -served. CONSUMER ADVISORY 22 3-603.11 ConsumerAdvisory Pasted for Consumption of 69tJ.tI00 l Animal Foods That are Raw. Undercooked or FC - 2 A03 Not Otherwise Processed to Eliminate 1 Food and Fuad Protection FG -3 Patlro ns.* e4e"""narr 25. i Equipment and Utensils 3-302.13. Pasteurized Eggs Substitute for Raw Shell ! 26. ? wale. Plumhing and Waste 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. (hem 23-30) Critical., mrd non-critical violations, which do not relate to the foodborne fitness intenentions and risk factors listed above, can be found in the following sections of the Food Code and 105 OUR 590.000. Item Good Retail Practices ; .FC 69tJ.tI00 l Management and Personnel FC - 2 A03 j 24. 1 Food and Fuad Protection FG -3 .044 I 25. i Equipment and Utensils I FC -4 -1 .005 ! 26. ? wale. Plumhing and Waste FC -5 .006 ; 27. Physical Facility 1 1 .007 28. 'Poisonous or Toxic Materials FC- 7 .Oc18 1 1 29. Speda3 R uitemems ! -009 1 30. 1 Other A y 1 b . 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 Date G TVDe of Ooeration(s) ❑ Food Service ®Retail Type of Insoection �7Routine �l Re -inspection Addre Rlsk Telephone Level �] Residential Kitchen ❑ Mobile ElTemporary ❑ Caterer ❑ Bed & Breakfast Previous Inspection Date: El Pre-operation ❑ Suspect Illness ❑ General Complaint Owner HACCP YM Person in Charge (PIC) Time In:l i ��� Out: Permit No. El HACCP ❑ Other Inspector Each violation checked requires an ex ion on the narrative page(s) and a citation of specific provision(s) violated. vNoncompliance 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( EE,)L�l 590.009 (F) E action as determined by the Board of Health. FOOD PROTECTION M ❑ 12. Prevention of Contamination from Hands 1 PIC Assigned / Knowledgeable / Duties _EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE _ __ _, 4. Food and Water from Approved Source 5..Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION " ❑ 6. 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 (s9o.009) 30. Other ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMffEMPERATURE CONTROLS (Potentially Hazardous Foode) ❑ 16. Cooking Temperatures [117. Reheating ❑ 16. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control [REQUIREMENTS FOR_HIGHLY $lJSCEPTIB.LE R0PULATIONS(HSP)' ❑ 21. Food and Food Preparation for HSP CONSUMERADVISORY>* - **H+* �ti .^ 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:___i,Z;t/_ aoI I S, 5WMm pecvr-omb 14,e /10 0 101 - Inspector's Signature: ' t: PIC's Signature: l R Print: 'I% U f' .� Page of�Fag2s V�oc" v 4v,s a� r .r Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FRnM cnfaTAMINATlnm FOOD PROTECTION MANAGEMENT 1 590.003(A) Assi�tment 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 3201.13 Fluid Milk and Milk Products* applicants* - Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.0(6(B) 590.003 C) Re ertin b Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C C I FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 rood Cade or 105 CMR 590.006. C Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.1.4 Eggs and Milk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.0(6(B) Water Meets Standards in 310 CMR 22.0" Frequency of Sanitization of Utensils and Food Contact Surfaces ofEquipment* 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* Proper, Adequate Handwashing Game and Wild Mushrooms Approved by Re u/ato Authortt 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 Fond Safe and Unadulterated Tags/Records; Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* 12 Tags/Records:Fish Products 3402.11 Parasite Destruction* 3402.12 Records. Creation and Retention* 590.004(1) 1 Labeling of Ingredients* Handwash Facilities - Conformance with Approved Procedures /HACCP Plans 3-502.11. S ecialimd Processing Methods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-10112 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 rood Cade or 105 CMR 590.006. C 9 Cross -contamination 3-302.11(A)0) Raw Animal Foods Separated from Cooked and RTE Foals* 4-501..1.11 Contamination from Raw Ingredients 3-302.1 l(A)(2) Raw Animal Foods Separated from Each Other* MechanicalWarewashing-Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.1.1(A) - Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 - Food Contact with Equipment and - Utensils* 4-602.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and Food Contact Surfaces ofEquipment* Disposition of Adulterated or Contaminated Food 3-701..11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501..1.11 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 MechanicalWarewashing-Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH; concentration and hardness. 4-60 Ll 1(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 ofEquipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 30 Proper, Adequate Handwashing 2-30111 - - Clean Condition -Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 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 Handwashing Cleanser, Availability - 6-301.12 Hand Drying Provision F SALEM (� BOARD OF HEALTH 1 Establishment Name:CAo C�ie, �Yi_�iw�-- Dater Page: of 9=111�111119m= 22111111111 �� . 7. '•�. . . . . . A_ .. �O -- / ..'� •-_ :. , . d' :_iw�Y/sld�l r' ' _wy�-� 070 �216' �� 11i9i�V����L� •. i L.`WR �_ a �.� It _ �� WWI Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions an d agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that *noncompliance may result in daily fines of twenty -f ive dollars or suspension/revocation of your •.• permit.o ■ voluntary Compliance ■ Employee Exclusion L] Re -inspection Scheduled 11 Emergency Suspension E) Embargo a Emergency Closure Voluntary ... ■ Other tliolations Related to Foodborne Illness. Interventions and Risk Factors (Hems 1-22) (Cont.) im Fa 18 for Additives Food or Go 3,202.12 Additives...__.. ......_, *. 3-302.14 Protection from Unapproved Additives* 3-501A(i(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11, Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 . Restriction -Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Tonic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals fur Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria" 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7?06.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* Fa 18 Dinotea aiticat iwm in the f -demi 1999 Foal Code 01 105 CMR 590.000. I 20 3-501.14(0 Proper Cooking Temperatures for . 3-501..15 PHFe 3-401.11A(I)(2) Eggs- 155F 15 Sec. 3-501A(i(B) 590.004(F) E gs-immediate Service 145'F15sec* 3401.11(A)(2) Comminuted Fish. Meats & Game 3-.501.16(.0) .Animals -155'F 15 sec. * 3.401.11(B)(1)(2) Pori: and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155*F 15 590.004 H) sec. * 3401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, i -B Poultry or Ratites -165'F 15 sec, 3.401.11(0)(3) Whole -muscle, Intact Beef Steaks FC -7 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F * 3-401.11(A)(1)(b) All Other PHFs - 145F 15 sec. # i_ Reheating for Hot Holding 3-003:11(.0)&(D) PHFs 165-F 15 sec. * 3-403.11(B) Microwave -165` F 2 Minute Standing Time* 3403.11(C) CommerciailyProcessed RTE Food - 140'F 3-403.11(E) Remaining Unsli<ed Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from W'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* Dinotea aiticat iwm in the f -demi 1999 Foal Code 01 105 CMR 590.000. I 20 3-501.14(0 PHFs Received at Temperatures According to Law Cooled to 41'9/45'F Within 4 Hours. 3-501..15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501A(i(B) 590.004(F) Cold PHFs Maintained at or below 410145' F* 3-50116(A) Hot PHFs Maintained at or above 140'F. * 3-.501.16(.0) 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 Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 27. 3-80L II (A) Unpasteurized Pre-packaged ]nice& and .Beverages with Waning Labels* 590 -DW 3-801.11(B) Use of Pasteurized Eggs* ! FC - 2 3-801.1 I (D) Raw or Partially Cooked Animal Food and Ravi Seed Sprouts Not Served, Food and Food Protection 3-801.11(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.I1 Consumer Advisory Posted for Consumption of 590 -DW . Animal Foods That are Raw. Undercooked or ! FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection I FC -3 Path n$.*ERp:tiv*J//2pCI 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 i 26. Eggst. 590.009(A) -(D) Violations of Section 590.009(A) -(D) .in catering, mobile fel, 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 gooil retail practices should be debited under #29 - Special Requirements. (Items 23-34) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 OUR 590.000. fferrr i Good Ratafl Practices FC 590 -DW . 1 Management and Psrsonnnl ! FC - 2 .003 423 Food and Food Protection I FC -3 .004 25. Equipment and Utensils I FC -4 .005 i 26. Water Plumbing and Waste ^i FC -5 -FC _ .006 f 27. PlutsicalFacili i -B .007 28. Poisonous or Toxic Materials FC -7 .008 ' X29. .S ecial R uirements .009 i. 30_ I..Oiher i_ CITY OF SALEM t BOARD OF HEALTH Establishment Name:(A� (�J PMUA3pnjW(0`lAA , Date: (— oZ0 — 1,2 Page:_ of ___'SES&IPTION OF VIOLATION / PLAN OF CORRECTION PLME PRINT CLEARLY - AMP 0 - - - :. � ,_, -_ .• ter, ...._• � _1�11���� ___._, _r:.-_ FAWMM, "AM II 11110K 0 0.1 �-1 .. _ • • • • . • • • _ ••911 • • - • • • • • • r . WIN your food permit. ■VoluntaryCompliance ■Employee Exclusion El Re -inspection Scheduled Li Emergency Suspension C3 Embargo u Emergency Closure Violations Related to Foodborne Illness. Interventions and Risk Factors Meats1-22) (Cont.) PROTECTION FROM CHEMICALS 14 IM .16 17 k fly, 111141111;14 s Food or Color Additives 3-202.12 Additives*_ 3-302.14 _ Protection from Unapproved Additives* ; - 2 Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11. Common Name -Working Containers* 7-201.11 1 Separation - Storage* 7-202.11 . Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sandtizers. Criteria - Chemicals* 7-204.12 Chemicals for WashiM Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-306.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Fest Control and Monitardn k fly, 111141111;14 s * Dmotrs criticat vers in the federal 1999 Foci Cade or 105 CMR 590.000. 3.501.14(C) PHFs Received at Temperatures Accouling to Uw Bled to 41'F145'F Within Hours. * Proper Cooking Temperatures for 19 PHFa 3-401.11A(1)(2) Eggs- i55`F 15 Sec. ; - 2 Eggs- Immediate Service 145'Fl5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-801.11(C) Animals - 155'F 15 see. * 3.401.11(13)(1)(2) Pork and Beef Roast - 130'F 121 mio* 3-401.11(A)(2) Ratites, Injected Meats -155`F 15 ?6. sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat. I FC --6 Poultry or Ratites -1650.17 15 sec. 3-401.11(C)(3) Whole -muscle, intact Beef Steaks 1 FC - 7 1450F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165F * 3-40LI I(A)(1)(b) All Other PHR - 145'F 15 sec. Reheating for Not Holding 3-403AI(A)&(D) PHFs 165°F 15 sec. * 3.403.11(B) Microwave -165` F 2 Minute Standing Time* 3-403.11(0 Commercially Processed RTE Fuel - 140"F* 3-4031l(E) Remaining Unsliced Portions of Beef Roasts" Proper Cooling of PRFs 3-501.14(A) Cooling Cooked PRFs from 140`F to 70'F Within 2 Hours and From 70'F to 41'F145'F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature ingred lents to 41'F/45'F ltiikhin 4 Hours* * Dmotrs criticat vers in the federal 1999 Foci Cade or 105 CMR 590.000. 3.501.14(C) PHFs Received at Temperatures Accouling to Uw Bled to 41'F145'F Within Hours. * 3-501,16(13) Cold PHFs Maintained at or below 590.004(F) 410/450 F� 3-50116(A) Hot PHFs Maintained at or above at or above 130'F.* Time as a • s- ual 61; , 21 3-501..15 Coling Methods for PHFs 19 PHF Hat and Cohd Holding 3-501,16(13) Cold PHFs Maintained at or below 590.004(F) 410/450 F� 3-50116(A) Hot PHFs Maintained at or above at or above 130'F.* Time as a • s- ual 61; , 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 590.000 j 23. Use of Pasteurizes ; - 2 .1 3-801 l (D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * i Food and Food Protection 3-801.11(C) Unopened Food PackageNot Re -served. 22 3-603.11 Con comes Advisory Posted for Consumption of 590.000 j 23. Animal Foods That are Raw, Undercooked or - ; - 2 .003 Not Othemse Processed to Eliminate i Food and Food Protection FC - 3 Patbo *em.* axeaav* rn " 1 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 ?6. Egge Violations of Section .590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited ander the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to goad retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sectionsofthe Food Code and 105 CMR 590.000. I item !Good liafail Practices i .FC 590.000 j 23. i Management and Personnel ; - 2 .003 1 24.. i Food and Food Protection FC - 3 .004 1 25. Equipment and Utensils FC - 4 .005 ?6. 1 Water. Plumbinq and Waste _ 1 FC -5 .00_6 ; 27. 1 Phi sisal Facift I FC --6 .007 1_28. Poisonous or To)dc Materials 1 FC - 7 .008 29. - ecial Requirements .009 30. i Other S.sgffo,mRc:43 t:: raYZ Uri .1 Crn re-'sSor- YA 3rus� eco d- �✓c�uut�n es� `11 _ �Purc6,S eA SvtoV Vac, av� A S5 u P rou�iV-�e, 5�4u-12 fore csN (+\ aV"�y .C��briS q�C��or 0-0-- k, I i k 11 J 1�Pow4 t\Jcx l S4or� �(�O� feIACi� qV, (z)ose_ � / �a rods T�aS�� barre_� r�P�a�ed �tT� U�1t wtt�1�0. A ovt�iV\e Me_r �h Course, gvla Posed e. rewkoved Qe�.WL t w1� 1 S��k t� Waroc�n'i [s tc be ret (Qc�� �h�s wee-. kad �)owl2Vv-r a���r Prairl(Ay- veS�� at inoas beev� Ue-,o--m�1PP k�a s bees) Olocrode�, �2Yov�c� itn avid uuk'l� �� r� �0. Le -QA Tteec� In��W\�eC Il be- ; n soda P j 1 � USsf_SS Or k, g�Je- e5` (- A/L0,�� GVd w ; t T v3 +(3 l o cate 5V'le-e- cA �'O r v 1 1 r� t�uLCJeC eva I lc� ton h00� 0 ���t l ons k `�1 N ­'. J. ' ' N N vi e- Vi c v e_ f e-vvvov e -A bel 6 . krjiv\� �o (or-aAf IF -�I X Jc-W\0.q 2s a'�2c� s, We - p iQpq`r I T to�loW It�q ` That Uv)C ,LA, Y) 1111 f I �J II '' f W th i1 2 n 1, a W e2r\ w� 6A ace -c A y so1C ,1 ej rc-PQ, r, CR +� t- Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of FOOD FSTARt ISHMFNT INSPFCTION RFPORT Address: Tnl Name Dat Type of Operation(s) Type of Inspection e Jrig 13 Food Service 1�kResidential ❑ Routine Re -inspection Address Risketail Telephone w Level Kitchen ❑❑ Mobileora Temporary ❑ Caterer ❑ Bed 8 Breakfast Previou Inspection Date 1411 per tion ❑ Suspect Illness ❑ General Complaint Owner r / �^ HACCP YIN Person -in -Charge (PIC) Time In*Z ❑ HACCP Inspector Out Permit No. ❑.Other each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. FOOD. PROTECTION MANAGEMENT' ❑ 1. PIC Assigned/Knowledgeable/Duties 'EMPLOYEE HEALTH- ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOODIFROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans .PROTECTION FROM CONTAMINATION ❑ 8. Separation/Segregation/Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices_ (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Noncritical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2X590.003) 24. Food and Food Protection (FC -3X590.004) 25. Equipment and Utensils (FC -4X590.005) 26. Water, Plumbing and Waste (FC�5X590.006) 27. Physical Facility (FC -6X590.007) 28. Poisonous or Toxic Materials (FC -7X590,008) 29. special Requirements (swoog) 30. Other s e-aa� Anti -Choking 590.009 (E) ❑ Tobacco 590.009 (F) ❑ Allergen Awareness 590.009 (G) ❑ ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM'CHEMICALS,,, ❑ 14. Approved Food or Color Additives r ❑ 15. Toxic Chemicals TIMFJTEMPERATURECONTROLS (P.otantially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATtONS;(H$P).�. ❑ 21. Food and Food Preparation for HSP ,CONSUMERADVISORY, [122. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Connection: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION - Inspector's Signature: Print. / Page_ of Pages PICS Signature -Print: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assigrtment of Responsibility* 590.003(6) Demonstration of Knowledge" 2-103.11 Person in charge -duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of. the person in charge to Compliance with Food Law* 3-201.12 require reporting by food employees and 3201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.1.6 Ice Made From Potable Driakml Water* Applicant To Report To The Person In Drinking Water from an Approved System*_ tem* 590.006(A) Charge* 590.006(B) 590.003 G Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 _ 990.003(E) Removal of Exclusions and Restrictions C 15 6 FOOD FROM APPROVED SOURCE Denotes critical new in the federal 1999 rood Code or 105 CMR 590.000, n PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically ° Sealed Container* 3201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products. PaLteurzed* 3-202.1.6 Ice Made From Potable Driakml Water* 5-1.01..11 Drinking Water from an Approved System*_ tem* 590.006(A) Bottled Drinking Water` 590.006(B) Water Meets Standards m 31.0 CMR 22.0* Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 _ Molluscan Shellfish hint NSSF Listed sources* Proper, Adequate Mardwashing Game and Wild Mushrooms.4pproved by Requiatory Authority - 3 -202.18 Shellstock Identification Prescm* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 2-301.14 ReceivingrCondition 3-202.11 PHFs Received at Proper Tem rahues* 3-202.1.5 Package hue it * 3-I 01i.1 I _ Food Safe and Unadulterated _ 7ags/Reco7ds: Shelistock 3-202.18 Shellstock Identification * 3-203.1.2 Shellstoek identification Maintained'" 12 Tags/Records:'Fish Products 3402.11 Parasite Destruction* 3-40212 Records, Creation and Retention* 590.004(J) Labeling of Ingredients' Handwash Facilities Conformance v/hh Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Metb(xls* 3-50212 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* Denotes critical new in the federal 1999 rood Code or 105 CMR 590.000, n PROTECTION FROM CONTAMINATION 9 Cross -contamination 3-302.11(A)(1,) i Raw Animal Foods Separated from Cooked and RTE Foods* 4-501.1.11 Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Mechanical Warewashing- Hot Water Sanitization Temperatures* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11 FoodContactwith Equipment and Utensils* 4-602.11 Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Frequency of Sanitization of Utensils and - Food Contact Surfaces of Equipment* Disposition of Adulterated or Contaminated Food 3-701..11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.1.11 ManualWarewashing - Hot Water Sanitization Temperatures* 4-501.112 - Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanifization- temp., PH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Fond - 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 Mardwashing 2-301..1. I. Clean Condition - Hands and Arms* 2301..12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11. Eatin , Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventin Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* 13 Handwash Facilities Conveniently Crated 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 Handwashin Cleanser,Availabflit 6-301.12 Hand Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: T)l A, pczJg_ Cz, L r o Date: 6.L,1/ L,1/13 Page: ; of nem No. Code Reference C -Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date - PLEASE PRINT CLEARLY Verified _C n f.S pp � L C/✓ /� r /. - -a�-zti V1' I AJ ✓M 4 {'L �LI U✓ —k,f01J4 With Person in Charge: this report, have had the opportunity to ask questions and agree to correct all efore the next inspection, to observe all conditions as described, and to p h all mandates of the Mass/Federal Food Code. I understand that ce may result in daily fines of twenty-five dollars or suspension/revocation of permit. i FFnoncompliance Corrective Action Required: ❑ No es ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne 111ness interventions and Risk Factors (items I -W) (Cont.) 0 to IT I a 114 lin IM 16 Im so ._.-..__ Food or Color Additives 3-202.12 Additives*' 3-302.14 Protection from Una roved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101,11 Identifying Information -Original Containers* 7-102.11. Comaron Name - Working Containers* 7-201.11 Se aration - Stara * 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* 7-205AI 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 * Demxec critical imm in the federal 1999 Foal Code a' 105 C&i& 590.000, m NO 3-501,14(C) Proper Cooking Temperatures tar 3-501.I5 PHFs 3-40LIIA(1)(2) _ Eggs- 155`F 15 Sec. 3-501.16(B) 590.004(F) Egg-, Immediate Service 145'F15sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3.501.16(M Animals - 155'F 15 sec. * 3.401.11(11)(1)(2) Pak and Beef Roast -130'F 121 mm* 3-401.11(A)(2) Ratites, Injected Meats - 155'F 15 590.004(H) wcc * 31101.11(A)(3) Poultry, Wild Game, Stuffed PHFs, i 27. Stuffing Containing Fish, Meat, FC -6 Poultry or Ratites -1650F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks FC -7 145'F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165F * 3-401.11(A)(1)(b) All Other PHFs - 145'F 15 sec. Reheating for Hot Holding 3-103.11(A)&(D) PHFs 165'F 15 sec. * 3-403.11(B) Microwave - 165' F 2 Minute Standing Time* 3-403.11(C) Camenercially Processed RTE Foal - 140'F* 3-40331(E) - Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-50IA4(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* * Demxec critical imm in the federal 1999 Foal Code a' 105 C&i& 590.000, m NO 3-501,14(C) PHFs Received at Temperatures According to Law Cooled to 41'F145'F Within 4 Hours. 3-501.I5 Cooling Methods for PHFs 3-ilDI A I(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PRFs Maintained at or below 410/45' F* 3-501.16(A) Hot PRFs Maintained at or above 140'F. 3.501.16(M Roasts Held at or above 130'F. 25. Time as a Public Health Control 3-501,19 Time as a Public Health Control* 590.004(H) Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 59a0w 3-ilDI A I(B) Use of Pasteurized Eggs* , FC -2 3-801-II(D) Raw or Partially Cooked Animal Food and Raw Seed S ns Not Served. * Food and Food Protection 3-801.11(C) Unopened Foal Package Not Re -served. 22 3-603.11 ConsumerAdvisoryPasted for Consumption of 59a0w 23. Annual Foods That are Raw, Undercooked or , FC -2 .003 Not Otherwise -Processed to Eliminate Food and Food Protection FC -- 3.604 Pathogens.' 25. 3-302.13. Pasteurized Eggs Substitute for Raw Shell .005 1 i 28. 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 ander #29 - Special Requirements. (Items 23-30) Critical, and non-critical violations, which do not relate to the jeodbonte illness interventions and risk factors listed above, cnrrbe found in the following sections. of the Food Code and 105 CMR 590.000. ' item j Good Retail Practices .FC 59a0w 23. ' Management and Personnel , FC -2 .003 24. Food and Food Protection FC -- 3.604 25. Equipment and Utensils 1 FC -4 .005 1 i 28. i Water. Plumbinq and Waste _ i FC -5 .W6 ! i 27. i PA ical Fasi' FC -6 28. Poisonous or Toxic Materials FC -7 .008 29. 1 �jecial R uiremems .009 X30. 1 Other SwMnm3c�:v..' me Massachusetts Department of Public Health Division of Food and Drugs City/Town of FOOD ESTAFU ISHMFNT INSPFCTION RFPART Salem Board of Health 120 Washington Street, 4"' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Address: Tnl Name ve `)i Co.t Dat Type of Operation(s) Type of Inspection i --d Print: Food Service Retail Routine ' Re -inspection Address Ris ( Level Residential Kitchen Previous/Inspection Telephone _ Z24 El Mobile 31 P Date:S ` EI Temporary [IPre- peration Owner HACCP YIN L ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person -in -Charge (PIC) Time In: Vl�- ❑ HACCP Inspector Out: cir I Permit No. ❑.Other each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti -Choking 590.009 (E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009 (F) ❑ Allergen Awareness 590.009 (G) ❑ corrective action as determined by the Board of Health. ,FOOD;PROTECTION MANAGEMENT;.. _ _ _ . ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties (.EMPLOYEE HEALTH .... _ - _.._... .. ... .._ ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOODTROM APPROVED SOURCEF] 4. 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 CONTAMINATIONEl 8. 8. Separation/Segregation/Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices_ (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Noncritical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C 9- 23. Management and Personnel (FC -2x590.003) 24. Food and Food Protection (FC -3x590.004) 25. Equipment and Utensils (FC -4x590.005) 26. Water, Plumbing and Waste (FC5x590.006) 7. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FC -7x590.008) 29. Special Requirements (590.009) 30. Other ❑ 13. Handwash Facilities PROTECTION FROM_CHEMICALS_ ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEREMPERATURE"CONTROLS(PotentlalrykazardousF.00d_s) _ ❑ 16, Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control -, REQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATIONS';(HSP).` ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: Print�- ,,-,�, Z'u Page-Lofages PICS Signature: --d Print: Violations Related to Foodborne Illness.. Interventions and Risk Factors (Items 1-22) _ FOOD PROTECTION MANAGEMENT I 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 Complhmee with Fold. Law* 3-201.1.2 require repotting 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) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions I® 6 C FOOD FROM APPROVED SOURCE * Denotes critical hent inthe federal 1999 Paxl Code or 105 CMR 590.000. C PROTECTION FROM CrINTAMIMATtnii Food and Water From Regulated Sources 590.004(A -B) Complhmee with Fold. Law* 3-201.1.2 Food in a Hermetically Sealed Container* 3=201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and lAilk Products. Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved S stem* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CIVI 22.0* Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Cnuv.,ht Molitmean Shellfish* 3-201.15 Molluscan Shellfish from NSSF Iasted Sources" 4-703.11 Game and Wild Mushrooms Approved by Re ulato Authorit 3-202.13 Shellstrwk identification Present* 590.004(C) Wild Mushrooms* 3-201. 17 Game. Animals* Receiving'Condition 3-202.1.1: PHFs Received at Prc r Temperatures* 3-202.15 Package htte ,rit * 3-101.1 i Safe and Unadulterated _Food Tags/Re=ds: Shelistock 3-202.18 Shellstock Identification * 3-203.4.2 Shellstock Identification Maintained* Tags/Records; Fish Products I 3-402.11 Parasite Destruction* 3-402.12 Records. Creation and Retention* 590.004(n Labeling of Ingredients' Conformance with Approved Procedures IHACCP Plans 3-502.11. Specialized Pra:essin g Methods* 3-502:12 Reduced oxygen packaging, criteria* 8-103.42 Conformance with Approved Procedures* * Denotes critical hent inthe federal 1999 Paxl Code or 105 CMR 590.000. C PROTECTION FROM CrINTAMIMATtnii 2-301..11 . I Clean Condition - 2401.11 Eatin , Drinkin or UsingTobacco* 2-401.12 Discbarges. From the Eyes, Nose and Mouth*- - .. 3-301.12 Preventing; Contamination When Tas 590.004(E) Emnlovees* Handwash Facilities Conveniently Located ana Numbers and Capacities Location and Placement' Hand and Crass-contamtnabon 3-302.1.1(A)(1) I Raw Animal Foods Separated from Cooked and RTE Foss* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302AI(A) Food Protection* - 3-302 .15 WashingFruits 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 -?01.I t Discarding or Reconditioning Unsafe Food* 2-301..11 . I Clean Condition - 2401.11 Eatin , Drinkin or UsingTobacco* 2-401.12 Discbarges. From the Eyes, Nose and Mouth*- - .. 3-301.12 Preventing; Contamination When Tas 590.004(E) Emnlovees* Handwash Facilities Conveniently Located ana Numbers and Capacities Location and Placement' Hand and Food Contact Surfaces 4-501..111 Manual Warewasbing - Hot Water Sanitization Temperatures* - 4-501.1 t2 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization- temp., pH, concentration and hardness. * _ 4-601.,11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 > Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and 2-301..11 . I Clean Condition - 2401.11 Eatin , Drinkin or UsingTobacco* 2-401.12 Discbarges. From the Eyes, Nose and Mouth*- - .. 3-301.12 Preventing; Contamination When Tas 590.004(E) Emnlovees* Handwash Facilities Conveniently Located ana Numbers and Capacities Location and Placement' Hand and J ITY OF SALEM BOARD OF HEALTH Establishment Name: 2 ( 1 7W Date: Pager of Item Code No. Reference C - Critical ltem R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Dete verified LEASE PRINT/CLEARLY t C , P/1 r /fLAel r G , 35 9 c /s _ �t "5 , nr UI,�I G of <> .1- U�(fL fl v/6 c S n rn i cL r r J 0 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 PLYes ❑ Voluntary Compliance ❑ Employee Restriction Exclusion spection Scheduled ❑ Emergency Suspension ` ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors(ltems 1-22) (Cant.) PROTECTION FROM CHEMICALS 14 Food or Gator M IN law 18 TIME/TEMPERATURE CONTROLS Additives 3-202.12 Additives* 3-302.14 Protection from Un coved Additives" 3-50136(13) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Storage* - 7-202.11 . Restriction - Presence and -Use° 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitize". Criteria - Chemicals* 7-204.12 Chemicals fare Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria' 7-205.11 Incidental Foci Contact, Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitoring* IN law 18 TIME/TEMPERATURE CONTROLS ' Denotes critical item in the federal 1999 FooA Cole or 10 CMR 590.000. FEE 3-501.14(C) Proper Cooling Temperatures for 3-501,15 PHFs_ 3401.1IA(i)(2) _ Eggs- 155°F 15 Sec. 3-50136(13) 590.004(F) E gs- immediate Service 1450F15se_ c* 3-001 _II(A)(2) - Comminuted Fish. Meats & frame 3.501.16(A) Animals -155'F 15 see. * 3.401AI(B)(1)(2) Pork and Beef Roast -130-F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155`F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHF's, 27. _ Stuffing Containing Fish, Meat, i FC -8 Poultry or Ratites -165°F 15 sec, 3401.11(C)(3) Whole -muscle, Intact Beef Steaks FC -7008 1450F 7' 3-401.12 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* 3-103.11(C) Commercially Processed RTE Food - 1400 3403A I(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 41`F/45'F Within 4 Hours. * 3-501.14(.6) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'F Within 4 Hours* ' Denotes critical item in the federal 1999 FooA Cole or 10 CMR 590.000. FEE 3-501.14(C) PHR Received at Temperatures - According to Law Cooled to 41'Fi45'F Within 4 Hours. 3-501,15 Cooling Methods for PHFs _ PHF Hot and CoUl Holding 3-50136(13) 590.004(F) Cold PHPs Maintained at or below 410145° F* 3-501.16(A) Hot PRFs Maintained at or above I40`F. 3.501.16(A) Roasts Held at or above 130'F. ' 25. Time as a Public Health Control 3-50IA9 Time as a Public Health Ccwtrcl* 590.004(H) Variance R uiremem REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-80L 11(A) Unpasteurized Pre-packaged iuices and .Beverages with Warning labels* 590.000 3-801.11M Use of Pasteurized Bgas*_ '.' FC - 2 3-301-II(D) _ Raw or Partially Cooked Animal Food and Raw Seed Sprotits Not Served. * Food and Food Protection 3-801.11(0) Unopened.Food Package Not Ro-served. 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 23. Animal Foods That are Raw, Undercooked or '.' FC - 2 .003 Not Otherwise Processed to Eliminate Food and Food Protection FC -- 3 Patbogens.* El'o"'/" 25. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .005 ! 26. Eggsa 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 gaol retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical.and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000. Rom I Good RetailPractices FC 590.000 23. 1 Manacement and Personnel '.' FC - 2 .003 i 24. Food and Food Protection FC -- 3 .004 25. Equipment and Utensils 6G - 4 .005 ! 26. Water. Plumbing and Waste I FC - 5 .006 , 27. _ Physical Facility i FC -8 Ao7 i 28. Poisonous or Toxic Materials FC -7008 ' 29. S ecial R uirements .009 30. I Other _L 55un'n.mv:4.. m< Establishment Name: Y �e cl A . -t � DAQJ LTA CITY OF SALEM BOARD OF HEALTH S Page:_ of �r Date: L/' ( tet -6 � Item No. Code Reference C — Critical Item R — Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date Verified PLEASE PRINT CLEARLY oc Pall h2ec L A) —iL A AT 5 G - J J.l c CrV !Al In tJ ,L.a t C S.nv_ 4 0 612 a� lot Lw r Discussion With Person in Charge: F I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. azfd � f A��� Corrective Action Required: ❑ No Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion e -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: "I— Viefellons Related to Foudborne fliness, Interventions and Risk .. Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 LM Food or 16 17 18 TIMEITEMPERATURE CONTROLS Color Additives 3-20212 Additives*' 3-302.14 Protection from Una roved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11, Common Name - Working Containers* 7-201.11 Separation - Storage* 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers, Criteria - Chemicals' 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Fowl Contact, Lubricants* 7-206.11 Restricted Use Pesticides,' Criteria* 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and Monitorin * TIMEITEMPERATURE CONTROLS - Denotea critical iwnr in the federal 1999 Fend Cade or 105 CMR 590.000. IN 3-501.14(C) Proper Cooking Temperatures for 3-50L15 PHFs 3-401.11A(1)(2) Eggs- 155`F 15 Sec. 3-501.16(B) 590.004(F) Egos- immediate. Service 145°Fl5sec* 3-401 A I(A)(2) Comminuted Fish. Meats & Game 3-501.I6(A) Animals - 155°F 15 sec. * 3-401.11(8)(1)(2) Poi: and Beef Roast -130°F 121 mm* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 590.004(Hi sec. * 3401.11(A)(3) Poultry, Wild Game; Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC-& Poultry or Ratites-165OF 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks FC - 7.008 145OF * 3401.12 Raw Animal Foods Cooked in a Microwave 165°F * 340LII(A)(1)(b) All Other PHFs - 145°F 15 sec. i Reheating for Hot Holding 3-403.41(A)&(D) PHFs 165T 15 sec. * 3403.11(8) Microwave- 165` F 2 Minute Standing Tom* 3403.11(C) Commercially Processed RTE Foal - 140°F* 3-403.11(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 4t`F/45°F Within 4 Hours. * 3-501.14(B) Cooling PRFs Made From Ambient Temperature Ingrerlirnts to 41°F/45°F Within 4 Hours* - Denotea critical iwnr in the federal 1999 Fend Cade or 105 CMR 590.000. IN 3-501.14(C) PHF- Received at Temperatures According to law Cooled to 41'F/45*F Within 4 Hours. 3-50L15 CoolmE Methods forPHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PI117s Maintained at or below 41°/45°F"° 3-50L16(A) - Hot PHFs Maintained at or above 140°F. * 3-501.I6(A) Roasts Held at or above 230°F. 25. Time as a Public Health Control 3-501;19 Time as a Public Health Control* 590.004(Hi Variance Requirement REQUIREMENTS FOR HIGHLY SUSCEP nBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Juices and :Severs Jes with Warning labels* 59A.tW0 ; 3-801.11(B) Use of Pasteurized Eggs* '. FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Spreads Not Served * Food and Food Protection _ 3 -SOL I I(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 59A.tW0 ; 23. Animal Foods That are Raw, Undercooked or '. FC -2 .003 No Otherwise Processed to Eliminate Food and Food Protection _ FC -3 Patbo . * F"°`D1B 14amr 25. 3302.13. Pasteurized Eggs Substitute for Raw Shell .005 1 26. E SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile ford, 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 -crit cai violations, which do not relic to the foodborne illness interventions and >isk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000. t11 ----- Good Retail Practices ------ ;.FC 59A.tW0 ; 23. I Management and Personr*l '. FC -2 .003 24. - Food and Food Protection _ FC -3 .004 25. Equipment and Utensils iFC-4 .005 1 26. Water. Plumbing and Waste - FC -5 .OW 27. I Ph sisal FaciO FC-& ,�� 1 28. Poisonous or Toxic Materials FC - 7.008 ' 29._ - Special Requirements .009 '30. i Other i