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YOUR NEIGHBORHOOD MARKET - ESTABLISHMENTSYour neiyh�olh�Ba fi��ke} !� �; San�91 Stt�1F universal onew www. myuniversalop.com phone: 1-600-756-4676 UNV16162 MADE IN USA Commonwealth of Massachusetts � 4 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 -2004-000363 Your Neighborhood Market 103 School Street Salem. MA 01970 LOCATED AT: 0103 SCHOOL STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2011-0092 Jan 1, 2011 Dec 31, 2011 $280.00 TOBACCO VENDOR BHP -2011-0091 Jan 1, 2011 Dec 31, 2011 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KINIBERLEY DRISCOLL NIAYOR DAVID GREENBAum, RS ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON S'TREE r, 4T°' FLOOR TEL. (978) 741-1800 FAZ (978) 745-0343 DG FJ-,NBAutif&ar,eN+. CONI 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT VOUL-Z, WAK1 TEL# ADDRESS OF ESTABLISHMENT loo? sut L 1 i S Lt A FAX#_ MAILING ADDRESS (if different) EMAIL -Business': I Website: ( l OWNER'S NAME TEL# ADDRESS. QIO I,&F&k C6gj e SALEM N h a STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) /% CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) (q EMERGENCY RESPONSE PERSON Pthl()OC 1 , 1 e OCtU�EE A HOME TEL# \ a`i�) �$ 3L 410 i Please write in time of day. TYPE OF ESTABLISHMENTFEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 3 more than 1 0,000sq.ft. =$420 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 CHILDCARE SERVICES/NURSING HOM--------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE $25 TOBACCO VENDOR ot $135 ALL NON-PROFIT (such as church kitchens) $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 Revised lonli l FOODAI'MI Ladm Check# & e WW (2160 4 1lr�— —' kI S ) C k;w Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 03/29/2010 ESTABLISHMENT NAME: File Number: BHF -2004-000363 UI1ZK�1 Y �f17:� IA Your Neighborhood Market 103 School Street Salem MA 01970 0103 SCHOOL STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2010-0206 Jan 4, 2010 Dec 31, 2010 $280.00 TOBACCO VENDOR BHP -2010-0205 Jan 4, 2010 Dec 31, 2010 $135.00 PERMIT EXPIRES Total Fees: $415.00 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 KIM BERLEY DRISCOLL MAYOR DAVID GREENBAum, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 DGREENBALIM&ALEM. COLI �3lybll�,�Cy_�i[�P13�]i7��l�iZoZ�77�7�i�13�Zd7��fs_1-3�F�Gh�il��i NAME OF ESTABLISHMENT \'jUkVL tS tGFi iFOl) 1AAAKMI TEL# (9-10141-040k ADDRESS OF ESTABLISHMENT 10 ?, SC I Ful) ST, SAI-Ftvt m A , FAX # (TTQ 741- 0 6 MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'S NAME_ LLLW&- TEL # (ql j) 3ai N- 47/a ADDRESSa[0 LAEAF ETTt� S1iNi SALEM mA Olgw STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON PRU NCr I L N)6rU YCtJ HOME TEL #1 =FOPERATIQN „ r{vtpndif *N4,TTsd ue'; a' �. kWes[ng-s ay `Thusday _Fnday ; `";Sat ay j' k Sunday? HOURS OF OPERATION Please write in time of day. - gam -9P0 Xafn-gpm,1 gam -gpmj gam-gpMj Bram- Ipm! gam -qpm kk7n-8'pm For example Ilam-llpm I. TYPE OF ESTABLISHMENT RETAIL STORE YES NO FEE (check only) less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sci t. =$420 RESTAURANT YES Q0 less than 25 seats =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 -------------------------------------------------------- --------------............ BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS _----------------- --------------------------------- ................................................................................. ............. MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE S - $25 TOBACCO VENDOR YES NQ $135 ALL NON-PROFIT (such as church kitchens) YES QOD $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. Date��1-11, Social Security or Federal Identification Number i'nuL --it--11 n -C Revised 424/07 FOObAP2008.adm Check#&Date Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000363 IGmberley Driscoll Mayor Your Neighborhood Market 103 School Street Salem MA 01970 LOCATED AT: 0103 SCHOOL STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2009-0212 Dec 23, 2008 Dec 31, 2009 $280.00 TOBACCO VENDOR 13HP-2009-0213 Dec 23, 2008 Dec 31, 2009 $135.00 PERMIT EXPIRES Total Fees: $415.00 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 01 KIMBERLEY DRISCOLL MAYOR JANET DIONNE, ACTING HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4` FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 . JDIONNE e SALEM. COM 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT (OUR I\11Q- tPYi;-b2ftM0 M{ WZT TEL # C- IA ! It{ I- 0140,6 ADDRESS OF ESTABLISHMENT 10) SC -%Q-- Sig SALEIA MA 0 H7r) FAX# 6W )7It, I-01406 MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'S NAME_ _/_UisoC— H-, tJG--uyF-� TEL# (r41�) Llli- Ic(90 ADDRESS _ 03 yUia G Sl i-QAI.E:A( RA. a 0 I g 7 o STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) (Required in an establishment where potentially hazardous food is prepared) CERTIFICATE#(S) EMERGENCY RESPONSE PERSON HOME TEL ,DAYS:OF OPERATION Monda Tlidstla Wednesda , Thursda • w? PHONE AREA CODE NUMBER EXTENSION • FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASECALL CAME TO SEE YOU WILL CALL AGAIN'. WANTS TO SEE'. YOU RUSH -- RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED 1 ' I I r , I I 1 1 I 1 1 ' I I r , I I i i l 0 Establishment Name: -�OQX Item ? Code ` "' C Critical Item a" No. .Reference: R Red ltemr �>3r rc.r 1t SNS CITY OF SALEM BOARD OF HEALTH /i✓_kU-VAVJ6 4N3 -Xy A/\Q,( K VT Date: I Ili I16 Ic �a H DESCRIPTION OF -VIOLATION /,PLAN OF CORRECTII 0" pl ;eFzASFF PRINT C_ LE ARLY P•'n`z nGr ,g R Page: of Vended s A f Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re -inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. (n ❑ Voluntary Disposal ❑ Other: L> A Violations Related to FoDditarric illness Interventions and Risk Factors (1havar 1-22) (Cont) PRnTFr'nON FROM rNEMICALS 1=4 Food or Color Additives -2 �2 12 1 "("lives,* 7502714 ProedAddiiives, T40 1 TI (A)(2) Poisonous or Toxic Substances -IOIAI identifying Intio tnaliori -- Orii,inal 3 401.11(9}(1;(21 Containers" 7-102.11 s Common Name, - Workim, Conuiliner,* 7-201.17 Srlaarafiiar 7-2011 t Restriction - Presence and Use* 7-1'02.12 Condition ion, of Use. 7-i(rf, [I Toxic Contairlin" - Prolubition0c 7-204.11 sanili7els, Critei in - 01cmicak, 7-204. E— , 6tel;a;;I� T1-11=1111cal—sfol wash Produce c --� —1 7204.14 -o D -ii , l �rjitsl Criteria" F--+T''6dc-mal ii fail (Avict, Ulkiltcants* 7-206.!T- I R 7-206.12 Rodent Boil Svntons' 7-216.'93 1 Tracking Powder, Pest Control and 74 03.11(b) onit21 LjL,— gg Proper Cooking Temperatures for PHFs 3-;}01.11 A(ll(2) Fg&s- 155 F 15 Scc- I S16(,V; W launediate Servict, 145'F I 5sec T40 1 TI (A)(2) Comminuted Fizh, Meats & Game Animals JWF 15 sec. 3 401.11(9}(1;(21 Pork and I3 et kwg - 130Y 121 rain4 -401.11(A)(-'S I Raines, InJecicti Meats - 1 5-'F 15 3-401.11(A)0) Sloffirm, Ccannining, Fish,Meet, �awei_L6LF 1,1,sec 3-401,11(C)(3) — _Lloultr�orl whole -nnn"Mo, Intact Beef Steaks 1452+' 1401.12 Raw AAtrial Faxis Cooked ilia Miciowaw 105T 7-4D,11(Aff(I)Hn All Cather PliFs -- 145°F 15 sec 17 Reheating for Hot Holding 5 sec, FHF165"F I5 74 03.11(b) NIiCA)WaVC- 165"F 2 MoRill Standing, I I liale, 1 3-403 . I I (C) ConiTnei6ally Pioeesital RTF. Food - 140'F" Unsireed Portions 3-44311(E) Rentaniun, of (�ef � Roasts* Ig -ira—Wr Cooling of PHFs 7501 14(A) . C 0i ilin 70"F Within Hours, and From "Iff ti)4J'F/45FWdlon4Hours. 3-501.14(9) Cooling PHFs Made Front Atnblent Temperature n, 4J OFY45"F1 I L Hours* - Dcn,les ai=il item, m 1he 1994 Food C,Aeor 105 (AR 590 (M) '-501.14(0) 1 PHFs Rectnved,:it'Femperaturet; According, to Lav, Cooled in .F/4Y"IF Within 4 How,, C , t" IF —'- fit" ijoliw, Ime"dixi, to, iiFs Time as a Public Health Control a, �,Pubfie�Fl, if Control - .i -801.1)(A) ! Unpe,neurizcd Pic -pack, aged Juices mid qeier�ves with warnill 4 I1(B) 1 Lac of Pa_ ctnlA Ein" z 801 I I (D) Raw or Painad),, Cooked Annual Food and Raw S 22 1 34)0-', 11 j Cominner Adisori, Posted for Conuniption of Anis it Fiod,That irc Raw. Undeaciiiiked in uol (7tnrrwnie Prot�essed to Eliminate Pade ... en, 3021 11, poqteenzecl Eau; sublioule tor RAW Shelf SPECIAL REL UIREMENTS calering.mobilo biod, temporary v and remdenual kitchen operations should lie dchited under the appropriate settions atiuve if related to ftK)dhorne illness traervennons and risk fin -tors, Other 590.4)09 violations relating to goal retall practices,iliould be debited under #29 - Spccial Rrafuircruonts. (Itents, 23-30) Cwwal vookin,mc winch (1f) tall re4te in lite ftvdhorne d1ness naervenoons and riskjaclors lived above, coxa be, found in tht, f4ownig wcoioris of iiii, Rind Code wid 105 CXlR 59doi)o, PH C01411 PHIMaintained at 590,004(F) - 410/47F �Hilt I S16(,V; W PHFs %famranted at or above lmov Time as a Public Health Control a, �,Pubfie�Fl, if Control - .i -801.1)(A) ! Unpe,neurizcd Pic -pack, aged Juices mid qeier�ves with warnill 4 I1(B) 1 Lac of Pa_ ctnlA Ein" z 801 I I (D) Raw or Painad),, Cooked Annual Food and Raw S 22 1 34)0-', 11 j Cominner Adisori, Posted for Conuniption of Anis it Fiod,That irc Raw. Undeaciiiiked in uol (7tnrrwnie Prot�essed to Eliminate Pade ... en, 3021 11, poqteenzecl Eau; sublioule tor RAW Shelf SPECIAL REL UIREMENTS calering.mobilo biod, temporary v and remdenual kitchen operations should lie dchited under the appropriate settions atiuve if related to ftK)dhorne illness traervennons and risk fin -tors, Other 590.4)09 violations relating to goal retall practices,iliould be debited under #29 - Spccial Rrafuircruonts. (Itents, 23-30) Cwwal vookin,mc winch (1f) tall re4te in lite ftvdhorne d1ness naervenoons and riskjaclors lived above, coxa be, found in tht, f4ownig wcoioris of iiii, Rind Code wid 105 CXlR 59doi)o, 4 0103 School Street Telephone: 741-0406 Owner: Your Neighborhood Market PIC: Luong Nguyen Inspector: David Greenbaum Date Inspected: Correct By: 8/21/2008 Risk Level: Permit Number: I BHP -2008-0070 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) Your Neighborhood Market 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: There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. All other violations citede in the 8/15/08 inspection report have been corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 25,2008 ) Page I oft a CI RED: ;Violations Related to Foodborne Illness Interventions and Risk Factors (Require I immediate corrective action) _ Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 25,2008 ) Page 2 oft 0103 School Street Telephone: 741-0406 Owner: Your Neil PIC: Tien Ngu Inspector: Your Neighborhood Market City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency PROTECTION FROM-CONTAM I NATION Handwash Market I TIM David Greenbaum Date Inspected: Correct By 8/15/2008 Risk Level: Permit Number: BHP -2008-0070 Status: PARTIAL COMPLY # of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) Hot and Cold The restroom is missing paper towels. Provide d CONTROLS (Potentially Hazardous Foods) 9 The Hussman wall unit has a temperature of 46°F >lations Related to Good Food and Food Protection FAIL Critical towels in the restroom at all times. FAIL Critical unit to maintain a temperature of 41°F or below. FAIL Critical RED RED BLUE Comment: There are many price labels obscuring expiration/sell by dates. Do not obscure any expirationtsell by dates with price labels. The following items removed outdated: 4. Ortega pizza kits 2 - Uncle Ben's Rice 1 -Miracle whip 14 - Del Mo to Vegetables 3 - Sha -N-Bake 3- Ids Chiken Biscits 2 -Crunch -N -Munch 4 - Fiddle Faddle 14 - cookies 20 - Cabot cheese 2 - Petersons Shrimp Closely monitor all expiration dates to insure no expired product is out for sale. Equipment and ensils FAIL Non -Critical BLUE m nt: The Hussman freezer has a broken thermometer. Provide a new, visible, accurate thermometer in this freezer. oth ice cream freezers have an accumulation of frost. Thoroughly defrost both ice cream freezers. Reinspection on 8/21/08, all violations to be corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 18,2008) Page 1 oft ,k ,o RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 18,2008 ) Page 2 of CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 \ FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT This Form will be collected during your next Board of Health inspection. QUESTIONAIRE - GREASE TRAPS 2008 1. NAME OF ESTABLISHMENT: XOUR QrctiG--i4\'xl-RRJMn R -A K:t 1 2. ADDRESS OF ESTABLISHMENT: 103 StBtUL Sn, L U 1 h/1 ar 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? I1l0 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 6. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? a?``...a� � • a,,t+ w. t A.. � -+ �a ir97 " . , `- �..''y .. .. . xa CommonwealthLLof Massachusetts' ` • City of Salem Board of Health 10mbe11ey Driscoll 120 Washington Street, 4th Floor Mayor SALEM; MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: File Number: BHF -2004-000363 Your Neighborhood Market 103 School Street Salem MA 01970 LOCATED AT: 0103 SCHOOL STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued . Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2008-0070 Jan 3, 2008 Dec 31, 2008 $280.00 TOBACCO VENDOR BHP -2008-0107 Jan 3, 2008 Dec 31, 2008 $135.00 Total Fees: $415.00 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 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 46 of 46 " CITY OF SALEM, MASSAC HUSEM BOARD OF HEALTH 120 WASHINGTON STREET, 4"' FLOOR TEL (978) 741-1800 KIMBERLEY DRISOOLL FAX (978) 745-0343 RECEIVED MAYOR ISCOTTna SAt E COM JOANNE SCOTT, Nov 2 9 2001 HEALTH AGENT CITY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT *- 1t, a6GrINM-P M MK�,l TEL # ADDRESS OF ESTABLISHMENT 103 Z,&VL ej�. S L&m HA. FAX # MAILING ADDRESS (if different) EMAIL - Business': Website: OWNER'S NAME UAWC—, �1CT(1� t / TEL# l 97lgti — (g610 ADDRESS oZ1Ql�� f� i1� �t� sAi-am MA, STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in aniestablishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON T)}AtJFI T. hiiLI II rr \ 1J HOME TEL#l� [_�t7X 2g3 —S-10 DAYS OF OPERATION 1 Mondlay I Tuesday Wednesday Thursday Fdday i Saturda Sunda HOURS OF OPERATION I=°A,M,'I-1±A.14,11 — i`,I4< Please write in time of day. (Forexample Ilam-ttpm) 12 Ivl P. M.: J)•111 7—v{t.M I^ f1.Nt.' I Ii,IN.':—>V,If� 9 P M O I)-kG TO P-w(oi TYPE OF ESTABLISHMENT RETAIL STORE YES NO FEE (check only) less than 1000sq.ft. 7-0 1000-10,000sq.ft. $280 more than 10,000sq.ft. -------------------- ------ - -- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart $210) 25-99 seats =$280 more than 99 seats =$420 -----'-----'-'-------' §V---------*--'--------------------------------------------------------------------`--.........-. BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR YES NO $25 YES NO $135 ALL NON-PROFIT (such as church kitchens) YES NO '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, orequipmentchanges 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 Revised 4/24/07 FOODAIP2008.adm ChcckH & Date lJ -1 9 -_ I > I _ Social Security or Federal Identifict 0103 School Street Telephone: 741-0406 Owner: Your Neighborhood Market PIC: Inspector: David Greenbaum Date Inspected: Correct By: 6/26/2007 Risk Level: Permit Number: BHP -2007-0022 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) Your Neighborhood Market City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: F� Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Physical Facility FAIL Non -Critical BLUE Comment: There are gaps at the bottom of the front doors. Provide sweeps on both doors. GENERAL COMMENTS: All other violations cited in the 6/18/07 inspection report have been corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 26,2007 ) Page / of y Item RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Status Violation Critical Urgency j- — 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 26,2007) Page 2 of 0103 School Street Telephone: 741-0406 Owner: Your Neighborhood Market PIC: Inspector: David Greenbaum Date Inspected: Correct By: 6/18/2007 Risk Level: Permit Number: BHP -2007-0022 Status: VIOLATION # of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) Your Neighborhood Market City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency PROTECTION FROM CONTAMINATION GoZHygiemcmctices FAIL Critical ❑d RED nt: The front True Pepsi reach in has employee food stored with food for sale. Employees must store their personal food in ated employee refrigerator to prevent cross contamination. Handwash Facilities FAIL Critical ❑d RED ment: The side hand wash sink in the side restroom is missing soap and paper towels. Provide soap and disposable paper towels in the restroom at all times. The wash sink in the bathroom behind the counter has food and dishes stored in it. Hand wash sinks must be kept clear and ccessible and used for hand washing only. 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 19,2007 ) Page 1 of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food P tection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require C merit: There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price abet immediate corrective action) ome expiration dates appear to be scratched off. Do not tamper with any expirations dates. The following items found outdated at the time of inspection: 1 -Frosty Cheerios 2 - Quaker oatmeal crunch 6- Townhouse toppers 4 - White cheddar cheez its 1 - Ritz bits 1 - Saltines 31 - Pringles 20 - Nat res valley granola bars 14 - C ibou Granola bars 1 - etty crocker cake mix -Pasta roni 3 - Chow mein with shrimp 16 •Betty Crocker bowl appetite 1 - Wishbone salad dressing 21 -Kraft BBQ sauce 3 - Grey poupon 4 - Campbell's sports pasto burger soup 3 - Old EI Paso fajita dinner kit 13 - Cambells's Select soup 3 - Progresso soup 5 - Uncle Ben's rice 8 - Rice a roni 2 - Miracle Whip 1 -Thomas's english muffins Owner must closely monitor all expiration dates to insure no expired product out for sale. These violations are critical repeat violations and may be subject to monetary citatiions. Equipment a d Utensils FAIL Non -Critical BLUE omment: The walls at the slush machine have an accumulation of food spills and splatter. Thoroughly clean the walls. e Ii fixtures throughout the store are missing covers. Provide protective covers on all light fixtures. I bat it fixtures in the side bathroom need a thorough cleaning. op found stored in the bucket. Clean mop and store mop head down not touching any surface to air dry. The%Frffe 7 - Up reach in neeeds a thorough cleaning, including all shelves. KePeps! reach in needs a general 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 19,2007) Page 2 of Item True Coke unit needs a thorough cleaning. :al Facility Co ent: There are areas of water damage on the ceiling. c mg. Status Violation Critical Urgency FAIL Non -Critical BLUE Investigate the source of the leak and repair. Repair and repaint the Z- There are gaps at the bottom of the front doors. Provide sweeps on both doors. �Te missing floor tiles in the back storage area. Replace all missing floor tiles. GENEI7MENTS: Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street, 4th Floor SALEM MA 01970 (978) 741-1800 GeoTMS® 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 19,2007) Page 3 of CITY OF SALEM, MASSACHUSETTS RECEIVED o BOARD OF HEALTH DEC - 4 2006 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 CITY OF SALEM TEL. 978-741-1800 BOARD OF HEALTH FAx 978-745-0343 W W W.SALEM.COM Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT UQ h i t1 RSt> �MIkIKE l TEL #�/�I7}� 7 q b d ADDRESS OF ESTABLISHMENT F02 SA f±n I KA, FAX # t R] 74 1 —O'6 C MAILING ADDRESS (if different) EMAIL -- Business': Owner's: OWNER'S NAME L-A ILjl� _TEL# Jg1L -ILF� - Iol o I G rrwrw ADDR 111 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) g /A— CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL OAYSOFOPERATION Monday I Tuesday I Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION �fi M,� $/{.Wl— 8 $�f. •— BfF. gfEoH_ BA.M— Please write intime otdall. h IN IU �• Iv1 !. 8 ��<I'yl . ' (For examplellamttum) TYPE OF ESTABLISH_ T FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 - - -- _ ----- - ------- ------- ---- ---- ------ RESTAURANT YES NO ------- ----- less than 25 seats ------------- =$100 25-99 seats =$150 more than 99 seats =$200 - -------- -- - ----- - - ---- --- - -- - BEDIBREAKFAST YES NO - g100------ ----------- -- ----- ------ --- ---------- --- - - - PERMITS - - -- - -- ----------- ---- -- - --- ----------- ADDITIONAL PERMITS ------ $5 MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE NO $50 TOBACCO VENDORYES NO NO I✓ $25 ALL NON-PROFIT (such as church kitchens) `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be pasted 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 l3-131- I Social Security or Federal Identification ------------ -------------------- Revised 11113/00 FOO DAP2007.adm Check# 8 Date J / �3 —___fi n/ (2 $ L Gn-00 t; fGmbetiey a,.'" t x 120 Washington Street, 4th Floor , Maya y. IMF), .__ .� ,.- Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: File Number: BHF -2004-000363 Your Neighborhood Market 103 School Street Salem MA 01970 LOCATED AT: 0103 SCHOOL STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2007-0022 Dec 19, 2006 Dec 31, 2007 $100.00 TOBACCO VENDOR BHP -2007-0042 Dec 19, 2006 Dec 31, 2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 29 of 29 ti CITY OF SALEM, MASSACHUSETTS RECEIVED o BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DEC - 7 2006 TEL. 978-741-1800 CITY OF SALE^4 FAx 978-745-0343 BOARD OF F.,: TH 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 Young World Academy TEL # 97 i1 74/5 - (o kV ADDRESS OF ESTABLISHMENT Salem, MA 01970 FAX # 42 S-711 - 053 y MAILING ADDRESS (if different) EMAIL -- Business': Owner's: p6 t to dT oS OWNER'S NAME if jr-VAaU ( 20vV1 i Mot) �I t) �ATEL ADDRESS U 1511: 11 // /'1� r CERTIFIED FOOD MANAGER'S NAME(S) fi`rn ��4 \'J� nc }_CERTIFICATE#� a hill -I! //7 - chin+��tR J (Required in an establishment where potentially hazardous food is prepared) ��p J EMERGENCY RESPONSE PERSON 1'1)YI ilE�CD-,15—r%i— HOME TEL# 79L--T`�o�'7/TJ OAYSOFOPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday flea:HOURPOP meoN 7-� PleasewntelnUmeofday. If or eaamale )lam 110m) TYPE OF ESTABLISHMENT RETAIL STORE YES NO c�OD L 1 beL' jccvl, --- ------ -- --- RESTAUR-ANT YES NO BED -/BR-EAAKFAST ------- YES-_ NO -- -- ------- -------- -- ----------------------------------- ..--- ----- --- - ---- --- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE TOBACCO VENDOR ALL NON-PROFIT (such as church kitchens) FEE (check only) less than 1000sq.ft. -$50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. 0 ------------------------------------------------ less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 ----------------- ----------------------- - $100 _ - ------- ------------ ----- ---------- YES NO $5 YES NO $50 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. Signature Chapte/rr//62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, tax r rns,and�paid all slate taxes required under the law. ` Date / Social Security or Federal Revised 11/13/06 FOODAP2007.adm 'Checkq & Date $/6040 Number Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: File Number: BHF -2005-000045 LOCATED AT: Young World Academy 24 Valley Street SALEM MA 01970 0003 GREEN LEDGE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes FOOD SERVICE BHP -2007-0133 Dec 20, 2006 Dec 31, 2007 $100.00 ESTABLISHMENT PERMIT EXPIRES Total Fees: $100.00 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 8 of 8 t ,Nla 'sachusetts 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 Print: - II PIC's Signature: D e Type of Operationfs) Tvpe of Inspection 'L „1 (l ❑Routine ® Re -inspection Previous Inspection Date: ElPre-operation ❑ Suspect Illness [I General Complaint El HACCP ❑ Other ❑Food Service 1!!� Retail ❑ Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer El Bed & Breakfast Permit No. Address I (� ^ Risk 4 Level Telephone Owner HACCP Y/N Person in harge (Pig) v Time In: Ou3 3r J Inspector Each violation checked requires an explanation on the narrative Pages) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. r FOOD PROTECTION MANAGEMENT,.'„„"' .111 r; m„„ El i. PIC Assigned / Knowledgeable / Duties EMRLOVEE HEALTH' �"� ` ` p ` rr �� K -e -t °� ' n i_e. .�.�t_�..a r €.w,? a.;.i-k-. � 4 [' -r, a uwmw,.P r_1 2. Reporting of Diseases by Food Employee and PIC ❑ 3.. Personnel with Infections Restricted/Excluded d; FOOD FROM APPROVED SQURCE!j_ �n ,g„'r ,""2411F ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans TPROTECTION FROM CONTAMINATION.- ❑ y8. 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 p N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007)' 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S. 5901Wu (For 14. o I ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS a, ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals 11 TIME/TEMPERATURE CONTROLS (Pptemlally Hazardous Foods) 4 ❑ 16 Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control :REQUIREMENTS FOR HIGHLY SUSGEP,TIBLE POPULATIONS (MSP) r ❑ 21. Food and Food Preparation for HSP ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: ` I Print: - PIC's Signature: Print: Page oft Pages :�7 11 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of Responsibility* 590.003(B) Demonstration of Knowledge" 2-103.11. Person in char e - duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Thinking Water* Applicant To Report To The Person In Drinkin Water from an Approved System. 590.006(A) Char e* 590.006(B) 590.003(G) Reportina by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C 6 C FOOD FROM APPROVED SOURCE * Denotes, critical item in the federal 1999 Food Code or 105 CMR 590 000. .i PROTECTION FROM CONTAMINATION $ Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.1.2 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.1.3 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Thinking Water* 5-101-I1 Drinkin Water from an Approved System. 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Re ulato Author' 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11. Food Safe and Unadulterated Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction - 3 -402.12 Records, Creation and Retention* 590.004(1) Labeling of Ingredients` Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxygen packaging, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes, critical item in the federal 1999 Food Code or 105 CMR 590 000. .i PROTECTION FROM CONTAMINATION $ Cross -contamination - 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(02) Raw Aminal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) - Food Protection* . 3-302.15 Washing Fruits and Vegetables 3-304.1 t 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 Tern eratares*- 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.11.4 Chemical Sanitization- temp., pH, - concentration and hardness. * 4-601.1'[(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 of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.1.2 Cleanina Procedure* 2-301.14 When to Wash* 1.1 Good Hygienic Practices 2401.11 Eating, Drinking or Using Tobacco* 2401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventin Contamination When Tasting* .12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em rlo ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-20511 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11. Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision CITY OF SALEM = ' BOARD OF HEALTH aT_ Establishment Name: M Date: dL8LC. Page: oZ of Item Code C - Criticallitem `DESCRIPTION' OF VIOLATION / PLAN O CORRECTION Date No. Reference R -Red Item a ee1r Verified 0 I I I I A\.,to ,./- H1, cLf. M(_kil, , «CAjri�)ip.4- -ic^nn k Discussion With Person in Charge: O 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. f 1 ❑ Voluntary Compliance ❑ Re -inspection Scheduled ❑ Embargo 0 Voluntary Disposal ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure 0 Other: Violations Related to Foodborne fitness Interventions and Risk Factors (Items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 17 "Denotes critical heal in the lufetnl 1999 Food Code or 105 CMR 59(7.000. Food or Color Additives ---I 3-202.12 Additives" 3-302.14 _---- Protection front Unaproved Additives` k3-501.15 Poisonous or Toxic Substances 7-101..11 Identifying Information -Original - Contwrers* 7-1.02.11 Corntnon Name-Workin"Con[ainers* 7-201.11 Se natation - Slut age 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of IJ,, - 7 -203.11 Toxic Containers - ProfidudonO 7-204.11 Sanitizets, Criteria - Chemicals - 7 -1204.12 Chenueals for Washing Produce, Criteria'` 7-204.14 Drvin t encs. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria* 7-206.12 Rodent Bait Stations` 7206.13 Tracking Powders, Pest Control and Monitorinv*" "Denotes critical heal in the lufetnl 1999 Food Code or 105 CMR 59(7.000. Proper Cooking Temperatures for 3-SOLII(B) PHFs 340'LLIA(1)(2) Eggs- 155'F15Sec. k3-501.15 Eggs -Immediate Service 145'F75sec* 3-401.11(A)(2) Corntninuted Fish, Meats & fume _ _ _ _ _ _- Equ1Umentand Utensils FC -4 Animals - 155'F 15 sec. * 3-401.11(13)(1)(2) Pork'. and Beef Roast - 130`F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 Physical Facility _ FC -6 sec. * 3-401 -11 Poultry, Wild Game, Stuffed PHFs, 20 Stuffing Containing Fish, Meat, S ecial Re uirements Poultry m Ratites -1650F 15 sec. 3401.11(0)(3) Whole -muscle, Intact Beef Steaks 145'F * 3401.12 Raw Animal Foods Cooked in a Microwave 165`F * 3401.11(A)(1)(b) All Other PHFs- 145'F 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 Foci - 140°F* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PRFs 3-501..14(A) Cooling Cooked PHFs from 140'F to 70"F Within 2 hours and From 70"F to 41.':Fl45'F Within 4 Hours. * 3-501.'14($) Cooling PHFsMade From Ambient Temperature Ingredients to 41'F145`F Within.4 Hours* "Denotes critical heal in the lufetnl 1999 Food Code or 105 CMR 59(7.000. 21 3-80IfI(A) 3-501.14(0) PHFs Received ar Temperatures 3-SOLII(B) According to Law Cooled to 3-801.1 1(D) 4 1'Ft45'F Within 4lioms. k3-501.15 Cooling Methods for PHFs 19 PHF Hot and Cold Holding _ _ _ _ _ _- Equ1Umentand Utensils FC -4 3-501_16(13) Cold PHFs Maintained at or below 26_ 590.004(17) 41V45` F" 006 , . -006_ 3-501. I6(A) Hot PHFs Maintained atorabove Physical Facility _ FC -6 140°F.` 28. 3-501.16(A) Roasts Held at or above 130`17. 20 Time as a Public Health Control S ecial Re uirements 3-50119 Time as it Public Health Ct)ntrol* 30. 590.004(H) Variance Requirement 21 3-80IfI(A) Unpastcurized,Pre-packaged Juices and Beverages with Warning Labels* 3-SOLII(B) Ilse of Pasteu� 3-801.1 1(D) Raw or Partially Citoked Animal Faxl and Raw Seed S Croats Not Served. 'w 3-80'1.11(0 Uno coed Fcxxi Package Not Re -served. 22 3-603.11. Consumer Advisory Posted for Consumption of 590.000 Anunal Foals That are Raw. Undercooked or anacternent andPersonnel FC -2 Not Otherwise Processed to Eliminate _ 24. Pathogens. " 3-302.13 Pasteurized Eggs Substitute for Raw Shell _ _ _ _ _ _- Equ1Umentand Utensils FC -4 E rs'l 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 1/29 - Special Requirements. PJGT[ai/fii�C19 (itetns 23-30) Critical' and non-critical violations, which do not oclate to the ,foodborne illness inrervemlona and risk-fnetars Bated above, can be found in the fallowing sections of the Food Code arul 105 CMR .590.000. Item Good Retail Practices FC 590.000 23. anacternent andPersonnel FC -2 .003 _ 24. Food and Food Protection FC 3 .004 25. _ _ _ _ _ _- Equ1Umentand Utensils FC -4 ,005 26_ -----------...--- W it, Plumt?inq and Waste FC - 5 006 , . -006_ 27. Physical Facility _ FC -6 1 .007 - -- 28. Poisonous or Toxic Materials FC -7 1 .000 _ 29. S ecial Re uirements .009 30. Other -- --__-- >s;rom";m�a.a�zm< Massachuseks Qepartment ofPublic 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\\' jj V I i/f Dat 3 Dc IyP2 of Operations) Tvoe of Inspection [� Routine ❑ Re -inspection Previous Inspection Date: ❑ Pre-operation ❑ Suspect Illness ❑ General Complaint ❑ HACCP ❑ Other ❑Food Service Retail Residential Kitchen ❑ Mobile ❑ Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. Address I ( Risk Level Telephone _ 7G Owner J p HACCP Y/N Person in Charge (PIG) Time In: a. ar Out:3 Inspector ` n Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. [ FOOD PROTECTION MANAGEMENT,' },�,,,�6.6.Iei., ❑ 1. PIC Assigned / Knowledgeable / Duties "EMPLOYEE HEALTH ',-l"�E„'=a'"tw$'"d,; ,' g ❑ 2 Reporting of Diseases by Food Elloyee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SQURCE m...'-"3�:e,�yAa;,„,®,��m®"�",{�;�.. ❑ 4. Food and Waterfrom Approved Source �IS Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 12. Prevention of Contamination from Hands Print: a) ❑ 13. Handwash Facilities PIC's Signature: w E PROTECTION FROM- ( _ .a �bor C1�.e�m.,a5,,.,a,m..,„ ❑ 14. Approved Food olor Additives ❑ 15. Toxic Chemicals i r: TIM,E/TEMPERATURE CONTROLS (Potentially Hazardous Fuads) `"' �❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling 5 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION `� .c y ❑ 8. Separation/ Segregation/ Protection ❑ 20. Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. c" fir° 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S. ssa,nspecrFa,me-,a.em REQUIREMENTS FOR HIPHLY susdEP,TiaLE POPULATIONS (HSP), A El 21. Food and Food Preparation for HSP CONSUMER'ADVISORY'' _,`,-a , 3,3„' '°'� ,µt.'.�".' ❑ 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 CLtjhF�ailure s eport, when signed below by a Board of Health mer s agent constitutes an order of the Board of a to correct violations cited in this report ma ul ' suspension or revobTtion of the food establishment p a d esssat'ibn of food- establishment operatio . If ag ieved by this order, you have a right to a hearing. Your requ st must be in writing and submitted to the Board of Health a�the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: /1 Inspector's Signature: t \ Print: a) PIC's Signature: w Print: ( Page of ages Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) FOOD PROTECTION MANAGEMENT 1I 590.003(A)Assig ment of Responsibility' 590.003(B) Demonstration of Knowledge* 707 nowled e* 03.11 1Person in charge - duties . EMPLOYEE HEALTH 2 590.003(,C) Responsibility of the person in charge to Compliance with Food Law* 3-201.1.2 require reporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions C C C C FOOD FROM APPROVED SOURCE * Denotes critical item in the fedef ni 1999 Food Code or 105 CMR 590.000. to S Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.1.2 Food in a Hermetically Scaled Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made From Potable Drinking Water* 5-101.1.1 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Vegetables She/llLsh and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Reoulatory Author" 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.1.1 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11. Food Safe and Unadulterated Tags/Records: Shellstock 3-20218 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention" 590.004(J) Labeling of Ingredients' Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures /HACCP Plans - 3-502.11 Specialized Processing Methods* 3-502.1.2 Reduced oxygen packa 'ng, criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the fedef ni 1999 Food Code or 105 CMR 590.000. to S Cross -contamination 3-302.1.1(A)(1.) - Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients - 3-302.11(A)(2) Raw Anlrnal Foods Separated from Each Other* Contamination from the Environment 3-302.11.(A) Food Protection* _ 3-302.1.5 Washing Fruits and Vegetables - 3-304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Resemce of Food* DisposRfon of Adulterated or Contaminated Food 3-701.1.1 Discarding or Reconditioning Uneafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Teta eratures* 4-501.112 Mechanical Warewashinb Hot Water Sanitization Tem eratures* 4-501.11.4 Chemical Sanitisation- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301.11. Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-30112 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Em to •ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacifies* 5-204.1.1 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 - HandwashiriR Cleanser, Availability 6-301..1.2 Hand Drying Provision CITY OF SALE 9 BOARD OF HEALTH Establishment Name: 1 d n It I In �,�� ,� r1 PO/`1(po Date: l�� /_ Pager of'17 Item No. Code Reference C -Critical Item R - Red Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date Verified PLEASE PRIN CLEARLY f l o lI q AM.T- I _ I J9P MCIA G. _ / , _ �Q I Gn as �_ \ �r U % �- t 4 40T t k \'C. a�t. _ " ir JA / Discussion With Person in Charge: I,hdve 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. I Corrective Action Required: ❑ No Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion / �Re-inspection Scheduled ❑ Emergency Suspension v ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: l►J Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 16 18 TIMEITEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives"' 3-302.14 Proncelion front jjna a L)aroved Additives* 3-501.16(A) Poisonous or Toxic Substances 7-101.11 -T Identifying Information -Original Containers- 20 CommonName- WorkingContainers, 7-201.1 I Separation - Stela e" 7-202.11 Restriction - Presence and Use* 7-202.12 Conditions of Use* 7-203-11 Toxic Containers - Prohibitions' 7-204.11 Sanitizers, Criteria-Chennicals* 7-204.12 Chemicals for Washing Produce, Criteria" 7-204.14 Dain A=ents.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 Monitorinn* TIMEITEMPERATURE CONTROLS s Denotes critical item in tlae ordeal 199917ood Code or 105 CMR 590 000. .a 3-50 L 14(C) E3-501.15 Proper Cooking Temperatures for 19 PHFs 3-40 1.1 Eggs- 1.55`F 1.5 Sec. 3-501.16(A) Eggs- Immediate Service 145'Fl5sec' 3-401.11(A)(2) Comminuted Fish, Meats & Game 20 Animals - 155'F 15 sec. * 3-401.1 1(B)(1)(2) Pork and Beef Roast - 130°F 121 mine 3-401.11.(A)(2) Ratites, Injected Meats- 155'F 15 Equipment and Ulensiis _ _ _Water, Plumbiral and Waste Pb sisal Facili sec. 3-401..1.1(A)(3) Poultry, Wild Game, Stuffed PHFs, Poisonous or rests; Materials Stuffing Containing Fish, Meat, - 7 Poultry or Ratites -165'F 15 sec. s' 3-401.11(C)(3) Whole -muscle, 'Intact Beet Steaks 145°F * 3-401.12 Raw Animal Foods Cooked in a Other Microwave 165`F 3-441.11(A)(l)(b) All Other PHFs-- 145'1- 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 Fail - 140'F* 3-403.1.1(1,) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140°F to 7001- Within 2 limits 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/43'F Within 4 Ilours* s Denotes critical item in tlae ordeal 199917ood Code or 105 CMR 590 000. .a 3-50 L 14(C) E3-501.15 PHFs Received at T'emperat�kres According to I :iw Cooled to 41'F/45`�F Within 4 Hours. Cowline Methods for PHFs 19 PHF Hot and Cold Holding 3-501.16(B) 590-004(P) Cold PHI, Maintained at or below 41'145' F* 3-501.16(A) Hot PHFs Maintained at or above 3-501.16(A) Rcaists.Held at or above 130°F. * 20 Time as a Public Health Control 3-501.19 Timc as a Public Healdi Control* 590.004(H) Variance Re nirentent REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(A) Unpasteurized Pre-packaged Jtuces and Beverages with Wartime Labels* 3-901AI(B) Use of Pasteurized'E*gs* Mara ement and Personnel 3-801.11.(13) Raw or Partially Cooked Animal Food and Raw Seed S )routs Not Served. .003 3$0'1.11 (C) Unopened Food PackageNoC Re -served. " 22 3-603.11 Consumer Advisory Pouted for Consumption of 530.000 Animal Foods That are Raw. Undercooked or Mara ement and Personnel FC Not Otherwise Processed to Eliminate .003 _ 24. Pathogens.* E"*.."e,n;aom FC 3-302.13 Pasteurized Eggs Substitute for Raw Shell 25.__ 26. _ 27. Equipment and Ulensiis _ _ _Water, Plumbiral and Waste Pb sisal Facili E gs* a ?`MI.IAL MMLtUMM VII -141 a 590.009(A) -(D) Violations of'Section 590.009(A) -(D) in catering, mobile food, temporary acid 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 /029 - Special Requirements. L'1�F��}fslttkl.'tS1�i�;aTii3s�e�+I►77 (,Items 23-30) Critical aid non-critical violations, which do not relate to the foodborne diness interventions orad risk- factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000. item Good Retat7_Practices FC 530.000 23. Mara ement and Personnel FC - 2 .003 _ 24. Food and Food Protection_ FC -- 3 .004 25.__ 26. _ 27. Equipment and Ulensiis _ _ _Water, Plumbiral and Waste Pb sisal Facili FC - 4 FC -5 FC -6 .005 .006 .007_-- 28. Poisonous or rests; Materials FC - 7 '..008 29. -S29 Requirements .009 30. Other S.'.'ulNm�bskfi-gds CITY OF SALEM BOARD OF HEALTH Establishment Name: Ur A)QtrV 0( A nj Mrar / D� Wa Date: ��x/� l Page: of Item No. Code Reference C — Critical Item�;.:. R — Red Item _ DESCRIPTION OF VIOLATION / PLAN O F CORRECTION Date Verified PLEASE PRINT CLEARLY - {1 _. M zip 14A4 f; }7i lJ _I(y ( J / 3noLA O T- / ZI I � rt P tel - 8 O G t F a� Djhgcussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to p comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twe _ ty-five dollars or suspension/revocation of your food permit. Corrective Action Required: ❑ No s ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion 4-"-Re-inspection Scheduled ❑ Emergency Suspension /' ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: r Violations Related to Foodborne Illness Interventions and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 15 16 17 18 11110i4i3o5IIJ : ►r Food or Color Additives 3-202.12 Additives'" 3-302.14 Protection front Una roved Additives* cme t and Personnel Food and Food Protection__-- -__--_ Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers" 7-102.11 Common Name - Workinrr Containers` 7-201.11 Separation- Stora e"' 7-202-1.1 1 Restriction - Presence and User - 7-202.12 Conditions of U'se* 7-203.11 'Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria -Chemicals* 7-204.12 Chemicals for Washin¢ Produce, Criteria, 7-204.14 D 'in ,- ants, Criteria* 7-205.11 Incidental Food Contact. Lubricants* 7-206.11 Restricted Use Pesticides. Criteria* 7-206.12 Rodent Bait Stations* 7-206.'13'c'rack'ing Powders, Pest Control and Momtortn�* 11110i4i3o5IIJ : ►r I Denotes critical item in the Federal 1999 Food Code or 105 CMR 590,000. J Proper Cooking Temperatures for 14 PHFs 3-401.11A0 )(2) Eggs- 155'F 15 Sec. cme t and Personnel Food and Food Protection__-- -__--_ E cgs -Immediate Service 145°F15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 2g Animals - 155'F 15 sec. 't -401.1I(B)(1)(2) Pork and Beet Roast - 13(PF 121 mm* 3-401 .11 Ratites, Injected Meats -155'F15 FC sec. 3-401.11(A)(3) Poultry, Wild Game, Stuffed PRFs, S calci R uiremenfs Stuffing Containing Fish, Meat, Poultry or Ratites -165'F 15 sea. " 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks _ 145"F * 3401.12 Raw Animal Foods Crooked in a Microwave 165`F * 3401.11(.A)(1)(b) All Other PHFs -1.45'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 1650F 15 sec. * 3-403.1 I(B) Microwave- 165' F 2 Minute Standing Times' 3-40311(C) Commercially Processed I2TE Food - 140°F* 3-403.1.1(E) Remaining Unsliced Portions of lice Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 1,10'F it 707 Within 2 Fn {ot rs and From 70' to 41"F/45'F Within 4 Hours. * 3-501.14(}3) Cooling PHFs Made From Ambient Temperature Ingredients to 41 `F/45°F Within 4 Hours'° I Denotes critical item in the Federal 1999 Food Code or 105 CMR 590,000. J 21 3-501, k,(C) FRFs Received at Temperatures According to Iaw Cooled to 41'F/45°F Within 4 Homs. -3-501 14 15 Cooling Methods for PHFs PHF Hat and Cold Holding 590.000 3-501.16(B) Cold PHFs Maintained at or below 590.004(17) 41'/45° F° cme t and Personnel Food and Food Protection__-- -__--_ 3-501,161 A) Rot PRFs Maintained at or above 140"F.* Not Otherwise Processed to Eliminate 3-501.16(A) Roasts Held it or above 130°F. 2g Time as a Public Health Control _ FC - 4 FC -5 FC -6 3-501.19 Time as a Public Health Conti 1 Pasteurized Eggs Substitute for Raw Shell 590.004(H) Variance Requirement 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* Consumer Advisory Posted for Consumption of 3-801.11(B) Use of Pasteurized Eve*s* 590.000 3-801.11(D) Raw or Partially Conked Animal Foci and Raw Seed Snouts Not Served. z cme t and Personnel Food and Food Protection__-- -__--_ 3-801.11(C) Unopened Food package Not Re -served. CONSUMER ADVISORY 22 4-603.11 Consumer Advisory Posted for Consumption of 590.000 Animal Foods That are Raw, Undercooked or cme t and Personnel Food and Food Protection__-- -__--_ FC FC_- Not Otherwise Processed to Eliminate A03 .004 25. 26. 27. PathOl-enS.* c0aanva maroon _ FC - 4 FC -5 FC -6 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Poisonous or Toxic Materials FC E gs* CIV 1 5 Violations of Section 590.009(A) -(D) ,in catering, mobile food, temporary and residential kitchen operations should be debited wider the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. 17f*J (.Items 23-30) Critical and non-critical violations, which do not relate to the ,foodborne illness interventions and riskfactca's listed above, can be found in the fotlnndng sections of the Food Code and f05 CMR 560.000. Item Good Retail Practices FC 590.000 23.Mata 24. cme t and Personnel Food and Food Protection__-- -__--_ FC FC_- --2 3 A03 .004 25. 26. 27. _ Equipment and Utensilsand Utensils Water, Plu_mbin and Waste Phsiaal Facility _ FC - 4 FC -5 FC -6 .005 .006 .007 28. Poisonous or Toxic Materials FC - 7 _ .008 29. _ S calci R uiremenfs ._009 30. ___ Other _ ,rswr ,co10-2a90 Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street, 4th Floor SALEM, MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2006 WHO'S PLACE OF BUSINESS IS File Number: BHF -2004-0363 Your Neighborhood Market 103 School Street Salem MA 01970 LOCATED AT: 0103 SCHOOL STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions / Notes RETAIL FOOD BHP -2006-0289 Jan 4, 2006 Dec 31, 2006 $100.00 TOBACCO VENDOR BHP -2006-0290 Jan 4, 2006 Dec 31, 2006 $50.00 Total Fees: $150.00 PERMIT EXPIRESDe tuber 31, 2006 A Board of Health I , 7 This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 18 of 20 STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT D ,yXI v qqp pF �Oos �. OAy�4F'Ll 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT�'Qutg MR4U1 TEL# 010-1441-OL+O'G ADDRESS OF ESTABLISHMENT 1(13 Sc -t -n l- 04A,- 0(c)10 MAILING ADDRESS (if different) OWNER'S ADDRESS -Q- 10 t_KFAH -c I T CITY .3A1- t" STATE MA = ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERT TEL # -1(] (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Ti!h THAni t �Czt V ENI HOME TEL # (W) a23 - S 10 ( HOURS OF OPERATION: Mon.1-9 Tue._1L9,_Wed.i_ c Thu.] -Fri. 7- ID Sat.'f-10 Sun. g- Fe TYPE OF --ESTABLISH EN FEE (check only) Y CRETAIL STORE'I YES NOD �� less than 1000sq.ft. 1000-10,000sq.ft. =$ 50 =$100 ✓ more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 .. ............................................................................_.--$100------- BED/BREAKFAST YES ND - ... -------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE -(not ICE CREAM, YOGURT SOS SERVE �(�S (100 $5 -just serve) TOBACCO (p Y�ES� NO / $50 -VENDOR, ALL NON-PROFIT (§-uch as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature „ v v+ -t ' — 15 t -- Date Social Security or Fedi Identification Number ----------- 11/ -- 03/05 -------FOODAP2.adm ------------------------Check#---------&--Da---te-- --- Revised - - ------------------------------------------------------------- %��; 0103 School Street HACCP: ❑ Telephone: =741-0406 Owner: Your. Neighborhood Market PIC - N Tien Nguyen David Greenbaum 912012005 Risk Level: Permit Number: BHP -2005-0135 Statu_s.' s t VIOLATION # of Critical Violations: 2 k Time IN -Time OUT Your Neighborhood Market City of Salem RETAIL FOOD - Food Establishment Inspection Item Status Violation Critical Urgency Nature of problem or correction Non-compliance with: Not Done Anti -Choking PASS ❑ Tobacco PASS ❑ FOOD PROTECTION MANAGEMENT Not Done PIC Assigned / Knowledgeable / Duties PASS RED -_ EMPLOYEE HEALTH Not Done Reporting of Diseases by Food Employee and PIC Personnel with Infections Restricted/Excluded PASS PASS Q ❑d RED RED FOOD FROM APPROVED SOURCE Not Done ❑d RED Food and Water from Approved Source Receiving/Condition Tags/Records/Accuracy of Ingredient Statements Conformance with Approved Procedures/HACCP Plans PASS PASSd❑ PASSd❑ PASS RED RED RED - Notes: 307: Reinspection in one week- all items to be corrected Urgency Description(s) BLUE: _ _ Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within,10` GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc ( Rev. Sep 21,2005 ) Page 1 of 3 0103 School Street days)(Non-Critical vlolatlons�" PROTECTION FROM CONTAMINATION must be Corrected immediately. Separation/ Segregation/ Protection x within 90 days) F; RED RED . v ❑J violations Related to Food Contact Surfaces Cleaning and Sanitizing Foodborne Illness Interventions RED and Risk Factors (Require Proper Adequate Handwashing Immediate corrective action) :v Good Hygienic Practices Prevention of Contamination from Hands Handwash Facilities Not Done FAIL RED PASS D RED PASS Approved Food or Color Additives RED PASS ❑J RED PASS ❑D RED FAIL Non -Critical Q RED Your Neighborhood Market fees food stored in a freezer with I for sale. Employee food must be in an "Employee Only" freezer to I cross contamination. room needs a sign stating yes must wash hands before to work." PROTECTION FROM CHEMICALS Not Done Approved Food or Color Additives PASS ❑d RED Toxic Chemicals PASS RED TIMEITEMPERATURE CONTROLS (Potentially Haz Not Done Cooking Temperatures N/A RED Reheating N/A RED Cooling N/A RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP NIA ❑O RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories NIA RED GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 21,2005 ) PaQe 2 of 0103 School Street Your Neighborhood Market Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE 8 items found expired on the store helves. Owner must closely minitor all ex ation dates to insure that product out f sale is not expired. here are many price labels covering expiration/sell by dates. Do not use price labels to obscure expiration/sell by dates. NOTE: It appears that price labels are being used to cover expiration dates on expired product. Owner must stop this prat Equipment and Utensils FAIL Non -Critical ❑ BLUE Universal Nolan and Hershy ice cream freezers need visible, accurate thermometers. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non -Critical ❑ BLUE -\,All light fixtures are missing protective covers. Provide protective covers on all light fixtures. AXooring and shelving needs a thorough cleaning. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other- See Notes PASS ❑ BLUE Upon reveiw of past reports some violations cited are repeat violations. Monetary fines of $25.00 per repeat violation will be issued. Fine will be mailed. GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 21,2005 ) PaQe 3 of 0103 School Street Telephone:�r 741-0406" Owner: Your Neighborh PIC: Tien Nguyen Inspector: Is David' Greenbau )ate Inspected: a 9/28/2005 Risk Level HACCP: ❑ T -ect By:, Permit Number: BHP -2005-0135 t Status. _ SIGNED OFF A # of Critical Violations: 6 i Time IN: Time OUT: �i 3ency Description(s) UE a ilations Related to Good m" tail Practices (Critical lations must be corrected mediately or within 10 vs)(Non-critical violations Your Neighborhood Market City of Salem RETAIL FOOD - Food Establishment Inspection Item Status Violation Critical Urgency Nature of problem or correction Non-compliance with: Not Done Anti -Choking PASS ❑ Tobacco PASS ❑ FOOD PROTECTION MANAGEMENT Not Done PIC Assigned / Knowledgeable / Duties PASS ❑d RED EMPLOYEE HEALTH Not Done Reporting of Diseases by Food Employee and PIC PASS RED Personnel with Infections Restricted/Excluded PASS RED FOOD FROM APPROVED SOURCE Not Done Food and Water from Approved Source PASS RED Receiving/Condition PASS ❑d RED Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED . Conformance with Approved Procedures/HACCP PASS RED Plans PROTECTION FROM CONTAMINATION Not Done Separation/ Segregation/ Protection PASS [ RED Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED Proper Adequate Handwashing PASS - ❑Q RED Good Hygienic Practices PASS ❑J RED Prevention of Contamination from Hands PASS ❑J RED Handwash Facilities PASS 0 RED GeOTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 28,2005 ) Page I oil GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 28,2005) Page 2 of 0103 School Street Your Neighborhood Market must be Corrected immediately PROTECTION FROM CHEMICALS Not Done or Within 9O days) .. Approved Food or Color Additives PASS ❑d RED RED -_ Violations Related to Toxic Chemicals PASS ❑� RED Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS (Potentially Haz Not Done and Risk Factors (Require _ Cooking Temperatures N/A RED immediate corrective action) Reheating N/A ❑d RED Cooling N/A RED Hot and Cold Holding N/A 0 RED Time As a Public Health Control PASS Q RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP N/A RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other- See Notes PASS ❑ BLUE All violations cited in the 9/21/05 inspection report have been corrected. GeoTMS® 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 28,2005) Page 2 of NAME (LAST, FIRST, INITIAL) v STREETADDRESS CITY/TOWN STATE ZIP 103 kkn-, m ol9')4b LICENSE ^ C. EXP. DATE DATE OF BIRTH d, OWNER L) NC,vyEN 1.�t� �i• STREETADDRESS CITY/TOWN STATE ZIP 103 sc"Awl. SS $Yi1zm+ MT-) 011143 REGISTRATION NO. STATE I EXP. DATE MAKEI YPE I YEAR COLOR OF VIOLATION TIMEDATE ORATION WRITTEN RUIRIRwYNPL DATE '7 -i(i Orj Z kPM l'Z305 OYES ONO LOCATON OF VIOLATION ENFORCING DEPT. 1 a3 456"00L OFFENSE CHAP. SECT. FINES A EX?12�� QJDTII-T bS 0.O 13?ZO C LA -)i-\-< C44w1�1b ORR I.D. NO. TOTAL FINE $ SQ DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOH ❑ 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 j 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 k SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE, PEEL AND SEAL CITATION NO. CITY OF SALEM PD Q37� VIOLATION NOTICE NAME (LAST, FIRST, INITIAL) )6uZ �3EtCrN ARli(3o,-�' P)PXY,ti' STREETADDRESS CITV(TOWN STATE ZIP LICENSE NO. LIC. EXP. DATE DATE OF BIRTH OWNER'S NAME (LAST, FIRST, INITIAL) NGvylEN , 1.Qc*-!(c H. STREETADDRESS CITY/TOWN STATE ZIP 103 SCIAWL Si sf)k- � In" otq'vo REGISTRATION NO. STATE EXP. DATE MAKE/TYPE I YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL wuar q _�± 0,5 OAMp Z QPM l'�30i LINEIYEO LOCATION OF VIOLATION ENFORCING DEPT. 146 5LilOOL Sr Be d OFFENSE CHAP. SECT. FINES B c OFFICEft I D NO. � TOTAL FINE tQ. 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 IN THIS ENVELOPE, PEEL AND SEAL STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM. MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: 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. Vft%Xcl '144� HEALTH AGENT w n � STANLEY J. USOVICZ, JR. MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 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: 11/12/2003 Permit for Food Establishment 006-04 Frozen Desserts/Ice Cream Permit for the Sale.of Tobacco Products 005-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 41 d W HEALTH AGENT e STANLEY USOVICZ JR CITY OF SALEM, MASSACH BOARD OF HEALTH 120 WASHINGTON STREET, 4TH F SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 USETTS o LOOK P NOY 12 2003 CITY OF SALEM JOANNE SCOTT, MPH, RS, CHO BUAKQ OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT"/0 MI R NEJ67-d WR-Ho09 H TEL # 0� -3141-0#06 ADDRESS OF ESTABLISHMENT In SGHOO L ST- . S-A Lem � MA N-1-0 MAILING ADDRESS (if different) / OWNER'S NAME WO&C, -44 . /t/CU`�F/V TEL# ADDRESS -�10 CITY_ Sd> t yvl STATE M N r, ZIP o(�`l U CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food isprepared.) EMERGENCY RESPONSE PERSON I IFN /VG fA y EN/HOME TEL # qI B HOURS OF OPERATION: Mon..-�-q:iiOTue:� -q %aNed.1--l�'0fhu.�t -9.30F6.3--IA6at.+-/0:3r0un. 9-9 TYPE OF ESTABLISHMENT, RETAIL STOREES NO � FEE check only less than 1000sq.ft. =$ 50 ZO �� 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YESNO $5 / TOBACCO VENDOR YES $50 ✓�v ALL NON-PROFIT (such as church kitchens) S NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. SignatureDate I( It O- Social Security ore general Identification ation Number Revised 11/03/03 FUDDAP2.adm Check# & Date 117 S ;ie/-v.6V Massachusetts Department of Public Health Division of Food and Drugs FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4'h Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Name / JO utl t' IG of l4wa Ki Dat & �2 0, Tvoe of 0 eration(s) T e f Inspection L❑� Fo�od Service v2 Retail outine ❑ Re Address Risk 403 SCttd L rr -inspection Telephone P 7�! t�o yo6 Level ►� El Residential Kitchen EI Mobile Previous Inspection Date: TemporE Caterer ❑ Bed & Breakfast ElPre-operation ❑ Suspect Illness ❑ General Complaint Owner Ltetj14-�, 1 if U t HACCP Y/N Person in Charge (PIC) Time I In: Out: Permit No. El HACCP ❑ Other Inspector/lAIV "4fW Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009( E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED. SOURCE - ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/ Segregation/ Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 5. Equipment and Utensils (FC -4)(590.005) 26. Water, Plumbing and Waste (FC -5)(590.006) 27. Physical Facility (FC -6)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other S 5901nVWFOm 14,tl ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS - ' -- ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS (Potentially Hazardous Foods)-= ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time As a Public Health Control ,. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP),. ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Items 1-22): v Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature• Print: PIC's Signature:I 12L�� Print: �) �/ y Page of Pages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) in FOOD PROTECTION MANAGEMENT EMPLOYEE HEALTH 2 yi on AssDemonstration 5590.003(A) �90.003(B) Dcmonstrtaon of Knowledge* of Knowledge* L 2_103.11 Person to 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 - illicants*590.003(F) Shell Eggs* 590.003(F) Responsibility Of A Food Employee Or An 3202.16 Ice Made Front Potable Drinking Water* Applicant To Report To The Person In Drinking- Water from an Approved System* 590.006tA) Charas" 590.006(H) 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© C [® C "Denote, critical rein in the federal 1999 Food Cade or 105 CMR 590.000. g Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-203.14 P. *es xnd Milk Products, Pasteurized* 3202.16 Ice Made Front Potable Drinking Water* 5-101.11 Drinking- Water from an Approved System* 590.006tA) Bottled Drinking Water* 590.006(H) Water Meets Standards in 310 CMR 22.0* Washine Fi iR and Vegetables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved by Re Mato Authon 3-202.18 Shellsta:k Identification Present* 590.004(0) Wild Mushrooms* 3-201.17 Gatne Animalsr 3-701..11 Receiving/Condition 3 202.11 PHFs Received at Proper Temper alures* 7202.15 Packaee Inte i.t ,s. 3-101.11 Food Safe and Unadulterated " Tags/Records: Shellstock 3-202.18 Shellstock Identification * 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3=102.1'1 Parasite Desnaictionl' 3-402.12 Records. Creation and Retentions, I, 590.0(.4(.1) Labeling of Ingredients` Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* Conformance with Approved Procedures fHACCP Plans. 3-502.11 Specialized Processing Methods* 3-102.12 Reduced ox mn packaginz, criteria - L8 Conformance with Approved Procedures* "Denote, critical rein in the federal 1999 Food Cade or 105 CMR 590.000. g Cross -contamination 3-302.11(A)(1) Rate Animal Foods Separated from Cooked and RTF E oodss-. Contamination from Raw Ingredients 3-302,11(A)(2) Raw Animal Foods Separated front Each Other* Contamination from the Environment 3-302-11(A) Food Protection" 3-302.15 Washine Fi iR and Vegetables 3-304 11 Food Contact with Equipment and Utensils '# Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701..11 Discarding or Reconditioning Unsafe Food* 9 Food Contact Surfaces 4-501.111 Manual Warewashing- [lot Water San iniationTem eratures* 4-501..1.12 Mechanical Warewashing-,Hot Water Sanitization Tent teratures'" 4-501.11& Chemical Sanitization- temp., pH, concentration and bardneas. * 4-601.tl(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4702.11 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 P,(,c d r 2-301.1,4 When to Wash* I1 Good Hygienic Practices 2-401.11 F-atinn, Drinki❑ or CJsing Tobacco^' 2-401.12 Discharges From the Fycs, Nosy and Mouth* 3-301.12 Preventing Contamination When Tustin =" 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination fiom Em to ees' 13 Handwash Facilities Conveniently Located and Accessible 5-203.1.1 Numbers tmd Ca rallies* 5-204.11 Location acid Placement" 5-205-11 Accessibi(it, O oration and Maintenance Supplied with Soap and Hand Drying Devices 6-30'1.11 Idandwashine Cleanses Availabilit 6-301.12 @land Drying Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: Atne- NlIC1406'sk 14,560 ,Mtt' - Date: 64ky Page: 2-- of Z Item No. code Reference C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION R — Red Item - PLEASE PRINT CLEARLY Date Verified `� 2 7 ( O LW tN f�►fr ro#fu a eAr A r Pt rt 7t, SY1 t w w¢ ^ to - #WJ1 (N Z& 4010 QS 1 - wtr ML-* AttMb � Mv9f Me N4 P A6) r6 rLQ "L 2V4 L ,M e r is ► t Sly n S utt s vPPr r.ta� 5t Sva<. Q�` R d f 1N� -M l .,t -►.r -r i -n. Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that ,noncompliance may result in daily fines of twenty-five ollars or suspension/revocation of your food permit. ,v Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency closure ❑ Voluntary Disposal ❑ Other: V Violations Related to Foodborne Illness Interventions and Risk Factors (items 1.22) (Cont.) PROTECTION FROM CHEMICALS 14 16 17 18 TIME/TEMPERATURE CONTROLS Food or Color Additives 3=202.12 Additives* 3-302.14 Protection from 'U'ria> roved Additives* 3-501.168) 590.004t(F) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11 Cotmnim Name -Working Containers* 7-201.11 Se aiation - Storage* 7-202.1.1 Restriction - Presence and Use* 7-202.12 Conditions of (Ise* 7-203.1.1 Toxic Containers - Prohibitions'` 7-204.11 Sanitizers,Criteria- Chemicals' 7-204.12 Chemicals Por 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' cracking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS " Denotes critical item in Lha rMeml 1999 food Code of 105 CMR 590-600. 19 20 3-501.14(C) Proper Cooking Temperatures for 3-501.15 PHFs 3-40'1.IIA(f )(2) Eggs- 155'F 15 Sec. 3-501.168) 590.004t(F) E>¢s-htnnediateService 145°F15sec* 3-401.11(A)(2) Comminuted Fish, Meats & Game 3-501.16(A) Anianda - 155'F 15 sec, s 3-401.11(B)(1)(2) Pork and Beef Roast - 130'F 121 mins` 3-401.11(A)(2) Ratites, Injected Meats -155'F 15 590.004(H) see. 3-401.1 [(A)(3) Poultry, Wild Game, Stuffed PHFs, 28. Stuffing Containing Fish, Meat, FC -- 7 Poultry or Ratites -165°F 15 sec. 3401.II(C)(3) Whole-niusele,Intact 'BeefSteaks 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-401.11(A)(I)(b) Alt Other PHFs -145'F 15 sec Reheating for Hot Holding 3-403.1 I (A)&(D) PHFs 165'F 15 sea * 3-403.11(B) Microwave- 165' ,F 2 Minute Standin , Time" 3-403.11(0) Commercially Proceswil I2TE Food - 140'Fr 3-403.11(2) Remaining Unsliced Portions of Reef Roasts* Proper Cooling of PHFs 3-501.14(A) Coiling Cooked PHFs from 140°F to 70`F Within 2 Flours and From 70'F to 41'F/45'F Within 4 Hours. * 3-501,14(B) Cooling PHFs Made From Ambient Temperature higredients to 41cF/45`F Within 4 Hours* " Denotes critical item in Lha rMeml 1999 food Code of 105 CMR 590-600. 19 20 3-501.14(C) PHFs Received at l'emperatures According to Law Cooled to 41'F/45°.F Within 4 Hours. 3-501.15 _ Cooling Methods for PHFs -801,11(B) PHF Hot and Cold Holding 3-501.168) 590.004t(F) Cold PRFs Maintained at or below 41 V45° F- 3 -501.16(A) Hot PHFs Maintained at or above 140,2 * 3-501.16(A) Roasts Held at or above I'WF. 25. 26 Time as a Public Health Control 3-501.19 Time as a Public fleaith Control* 590.004(H) variance Re erirenrent 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warnin � Labels* -59-0.0-00---- -801,11(B) Use oPPasteurized Ee,,s* 1 FC -2 LI ;;1;( (D) Raw or Partially Cooked Animal Fool and Served. _ _ Food d Food Protection an C) Unopened Food Package Not Re -served. * CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of Aninnl Foods That are Raw, Undercooked or Not Othervtse Processed to Eliminate o.,mN., z rrece�� r car 3-302.13 1 Pasteurized Eggs Substitute for Raw ZWMILAAL KtZUUlHtMt:N I b 590.009(,X) -(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. �>e7eTii/(N7.9 (Items 23-30) Critical amid non-critical violations, which do not relate to the foodborne illness interventions and risk -odors listed above, can be fimatnd in the following .sections of the Food Code and 105 CMR 590.000. item ' Good Retail Practices FC -59-0.0-00---- 23. Manaclernent and Personnel 1 FC -2 .003 24. _ _ Food d Food Protection an FC -- 3 .004 25. 26 E ui ment and Utensils Water Plumbinq and Waste -F0-4-.----,-005 FC5 .006 27 Ph sical Faciiit FC -6 j .007 28. _ Poisonous or Toxic Materials FC -- 7 .008 29. S eciai R uirements 30. Other t:5a9Lm0ack52doc STANLEY J. USOVICZ, JR. MAYOR April 12, 2004 Your Neighborhood Market 103 School Street Salem, MA 01970 Dear Owner, CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01 970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT On March 27, 2004 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17 -year-old male purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Your Neighborhood Market is in violation of Section III(A) of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section, the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of ONE hundred dollars ($100) for the FIRST offense. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore, you are ordered to pay a fine of $100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street, 4th floor, within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sin e�rs, anne Scott Health Agent JS/bas Cc: North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman City of Salem - Board of Health Violation Notice - Tobacco Sale to Minors N2 2174 This notice is to inform you that during a tobacco sales compliance check, your establishment violated the Salem Board of Health regulation #124 prohibiting the sale of tobacco products to persons under 18 years of age. C'-- sr Date of sae Time of sale Minor' aQe/eender Minor's I>r Narrative report of incident and description of seller by adult supervisor who will testify at the Salem Board of Health meeting including a description of the seller: I affirm, under the pains and penalties of perjury, that the above report is true to the best of my knowledge Adult supervisor (Signature,) Adult supervisor (Print name) VENDOR STATEMENT: I acknowledge I received this Violation Notice on Z — }g L L7p.L at[� YY (&M and I am being given a carbon copy of this notice. I also acknowledge that I have been told that a letter regarding Board of Health follow-up to this violation will be mailed to me at the above address. 4 If vendor refuses this Notice or if Adult Supervisor feels unsafe in delivering it, an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information, contact the North Shore Tobacco Control Program at 978/741-5646. Board of Health-white/NSTCP-yellow/Establishment-pink --?,i r--��cst.....--,+✓.r-..-arri...-q,------------ ............. '1MMI'Mown'..'�+.i.....M1rR.xa..r...u...._+...-...=.Y.;�--Nti..,�... y THE COMMONWEALTH OF MASSACHUSETTS -,CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Cooking Temperatures ❑ 17. of Operation(s) Un i on Cooling P.4 of.44O Hot and Cold Holding ❑ Fgod Service etail Routine ❑ Re -inspection Address /� Id L I" P e TI/Type ❑Residential Kitchen ❑ Mobile Previous Inspection Date: Telephone , ❑ Temporary ❑Pre-operation Owner ❑ Caterer ❑ Bed & Breakfast ❑ Suspect Illness ❑ General Complaint Person In Charge (PI � In: Out: Permit No. HACCP ❑ Other Inspector �� u Each violations the� �kerT{ requ�ies an explanation on the narrative page(s) and a citation of specific provision(s) violated. �Grr/l vG C� / e e., <1/1( Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned / Knowledgeable / Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted / Excluded FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures / HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation / Segregation / Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health..N,on-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) to 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 7 / /.v ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION FROM CHEMICALS ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20.. Time as a Public Health Control REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of 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 REINSPECTION: Inspector's Signature• Print: / -Z, PIC's Signature: Print Page ! of AJ FORM 734A HOBB5 a WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) FOOD PROTECTION MANAGEMENT j', 590.003(A)Assi nment of Responsibility* 590.003(6) Demonstration of Knowledge* 2-103.11 1 Person in Charge - Duties EMPLOYEE HEALTH 2 590.003(C) Responsibility of the Person in Charge to Compliance with Food Law* 3-201.12 require reporting by Food Employees and 3-201.13 Fluid Milk and Milk Products* Applicants* Shell Eggs* 590.003(F) Responsibility of a Food Employee or an 3-202.16 Ice Made from Potable Drinking Water* Applicant to Report to the Person in Drinking Water from an Approved System* 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in Charge* 3 ` 590.003(D)Exclusions and Restrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrictions 4' 5 6 FOOD FROM APPROVED SOURCE * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 8 Q 12 13; PROTECTION FROM CONTAMINATION Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Food in a Hermetically Sealed Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and Milk Products, Pasteurized* 3-202.16 Ice Made from Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Source 3.201.14 Fish and Recreationally caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed Sources* 4-501.111 Game and Wild Mushrooms Approved by Regulatory Authority 3.202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 4-602.11 Receiving/Condition 3-202.11 PHFs Received at Proper Temperatures* 3-202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 2-301.11 Tags/Records: Shellstock 3-202.18 Shellstock Identification* 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records, Creation and Retention* 590.004(J) Labeling of Ingredients* Conformance with Approved Procedures /HACCP Plans 3-502.11 Specialized Processing Methods* 3-502.12 Reduced Oxygen Packaging, Criteria* 8-103.12 Conformance with Approved Procedures* * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 8 Q 12 13; PROTECTION FROM CONTAMINATION Cross -contamination 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* Food Contact Surfaces 4-501.111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing - Hot Water Sanitization Temperatures* 4-501.114 Chemical Sanitization - temp., pH, Concentration and Hardness* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization - Hot Water and Chemical* Proper, Adequate Handwashing 2-301.11 Clean Condition - Hands and Arms* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Employees* Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser, Availability 6-301.12 Hand Drying Provision Establishment CITY OF SALEM BOARD OF HEALTH Date: C Page: 2 of Item No. Code Reference C - Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION R — Red Item PLEASE PRINT CLEARLY Date' Verified C on, ! 1. F Uv r>n)% APE"— F2-C3t uor }� L stet (^ ADL L 2 4 !' 12--f F — &4 — Svla� iti n�f �Lc(JI s6G f LL r r, .� tfc ti(�7 r— UA4 y 1`S " N V -Ur e -4r— v F J Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all 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. L C q _ Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion ❑ Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal 0 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 17 Em TIME/TEMPERATURE CONTROLS Food or Color Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-501.16(6) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information - Original Containers* 7-10111 CorumonName -Workin- Cantainers* 1-20L I l I Separation - Stora e"` 7-202.11 Restriction -Presence and Use" 7-202.12 Conditions of Use' 7-20',II Toxic Containers - Prohibitions^ 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals lot Washing Produce, Criteria* 7-204.14 Drving Agents. Criteria* 7-205, 11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides, Criteria" 7-206,12 Rodent Bait Stations* 7-206.13 Trucking Powders, Pest Control and Monitoring* TIME/TEMPERATURE CONTROLS * Denotes critical aete in the federal 1999 Food Code or 101 CMR 190,0011. 3-50114(C) Proper Cooking Temperatures for _ 3-501,15 PHFs 3-401.11A(1)(2) Eggs- 155'F 15 See, 3-501.16(6) 590.004(F) EL -s- Immediate Service 145"F15wc" 3-401.11 (A)(2) Comminuted Fish. Meats & Game 3-501.16(A) Animals - 155°F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast -130°F121mill* 3-401.11(A)(2) Ratites, Injected Meats - 155'F 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game. Shifted PHFs, 29. Stuffing Containing Fish, Meat, Poultry or Ratites -165°F 15 sec. 3-40L'il(C)(3) Whole -muscle, Intact Beef Steaks '.. -- 145"F " 3-401.12 Raw Animal Fais Cooked in a Microwave 165'F 1-401.11(A)(I)(b) All 011 er PHFs - 145°F '15 see, Reheating for Hot Holding 3-403.11(A)&(D) PIIFs 165"F I5 sec. " 3-403.11(B) Mici owave- 165' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140"F* 3-403.11(E) Remaining Cnsliced Portions of Beef Roasts" Proper Cooling of PRFs 3-501.14(A) Cooting Cooked PHFs from 146°F to 70'F Within 2 Hours and Front 70°F to 41 T/45°F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature ingredients to 41 `F/45'17 Within 4 Hours* * Denotes critical aete in the federal 1999 Food Code or 101 CMR 190,0011. 3-50114(C) PHFs Received at Temperatures Accordin to Law Cooled to 41 'F/45'F Within 4 Hems. _ 3-501,15 twlin Ca Met]tods for PHFs 19 PHF Hot and Cold Holding 3-501.16(6) 590.004(F) Cold PHFs Maintained at or below 41'/45° F* .3-50 t.16(A) _ Hot PHFs M:tinrained at or above 146°F. 3-501.16(A) Roasts Held at or above. '130°F. 20 Time as a Public Health Control 3-501.1.9 Time as a Public Health Control"Recuuetnen 590.004(H) variancet 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Bever t es with W wain Lab ls* 3-801.11(B) Use of Pasteurized h,�s* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. °' 3-80'L 11(C) Unopened Faxi Package Not Re -served. A 22 3-603.11 Consumer Advisory Posted for Consumption of 590.6100 '� Animal F'oods'I'hat are Raw. Undercooked or FC -2 FC -3 .003 004 Not Otherwise Processed to Eliminate UP -- ti and Waste -4 FC Patho;ens.* Fe.,.r.,aror� 27. 3-302.13 Pasteurized Eggs Substitute for Raw Shell .007 28, Eggs* 590.009(A) -(D) Violations of Section 590.009(A) -(ll) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Speeial Requirements. ([terns 23-30) Critical and non-critical violations, which do not relate to the foodborne illness islerventions and risk factors listed above, call be ,found in the following sections of the Food Code and 105 CMR 590.O00. Item Good Retail Practices FC 590.6100 '� erlt nd Personnel Food-aridFood Protection FC -2 FC -3 .003 004 26 UP -- ti and Waste -4 FC '005 ..._. 27. Ph sisal Facilit _FC FC -6 .007 28, Poisonous or Toxic Materials FC - 7 .008 29. Special Requirements .009_,. 30. Other '.. -- 45v0;onroIlf 2 dr s> • KIMBERLEY DRISCOLL MAYOR LARRY RAMDIN, RSIREHS, CHO, CP -FS HEALTH AGENT Date: S' Z-7 - Complaint Number: 0856 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TEL. (978) 741-1800 FAX(978)745-0343 LRAMDINQSALEM.COM COMPLAINT INTAKE FORM Time:J.' "30 Received By: If . 1, Complainant T\)At4 n'1? --.J) r -q Address: Phone: 3Y7 , Z(A -0?9 ) irwbL rs�l(aNe3dst�a�,?� h-�I[�� aa+ St,y�t S'R�� s S�L�1•-'la �R�G? -IA�-' 1-3 ovS o"s t;eo ori' pgvor'c' A 0 WA4ZA'LZ- fVyy'ky, r� U Investigated By: Property Owner/Occupant Name 0 Date: Telephone #: