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BOSTON STREET LIQUORS - ESTABLISHMENTS basw St("f if-tvor3 . 6 uPbr Off LaPF universal one. www.myuniversalop.com phone: 1-800-756-4676 UNV16162 . MADE W USA J OR 1 1 Commonwealth of Massachusetts s City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/28/2011 ESTABLISHMENT NAME: Boston Street Liquors File Number:Bttr-2004-000096 Alto.Madgy A Ghaley 36 Upton Hills Lane Middleton MA 01949 LOCATED AT: 0018 BOSTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2012-0148 Jan 1,2011 Dec 31,2011. $70.00 TOBACCO VENDOR BHP-2012-0164 Jan 1, 2011 Dec 31,2011 5135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2011 Board of Health This Permitis not transferable,and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY Or SALEM, MASSACHUSE'l I'S B0ARD OF HEALTH 120 WASHINGTON STREET,4°' FI:.00R TEL_(978) 741-1$00 KINIBERLEY DRISCOLL FAN (978) 745-0343 NfAYOR iraxn Sin <alem com LARRY RANIDIN,RS/RI:l IS,(J JO, HFAl:flI 3(AINT - - 201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT o S I't" s/. 6�r h� rs TEL#-a ADDRESS OF ESTABLISHMENT 4 ( v5,--_{ r vx - $ le�.� /rff� a /9 o FAX# MAILING ADDRESS(if different) �Q 60 X q0 Q Acc Le}yK p2/4— a l e? EMAIL-Business': Website: OWNER'S NAME 1), rre TEL# 1 g_ 9q LJ ADDRESS I9 8Usd-rm .('{-iYhl} 4 a/q 'Ia 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 HOME TEL# PAY,SOFOPERATION. Mond Tues Wedn r7hursd u: w Fdd� Saturday Sunda HOURS OF OPERATION Please wrtle in tone of da/. 1 I - j . (For exainpe Ilam-ilpm) I � TYPE OF ESTABLISHMENT _ FEE Checkonly)--- RETAIL nl -__RETAIL STORE (YEJ NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 --- ------------------------ ----------- _. ...... RESTAURANT YES NO . ,._._ ._ .. _.._._._- lesst}5a .'..5 seats =$440 (Outdoor Stationary Foo!Cart$210) 25-99 seats =$280 more than 99 seats =$420 ----- ------ ....... ----- ------ BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICESfN(1RSING HOME.-•,.--_,•• ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO 2 TOBACCO VENDOR NO ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment Irl accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submltted 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 t,to my best knowledge and belief,have filed all state tax returns and paid a state taxes required under the law. - Signature Date (�1�� } Social Security orFederal Identification.Number Updated 523/1 l FODDAP201 l.adm Check#&DateT $ �{�,� CITY OF SALEM, MASSAcHusE-rrs BOARD OF HE,ALTH 120 W S1IINGION 5'TREET,4"°110OR hSMSI�;RLCY 17RISCOLL TEL. {.)78) 741-1800 MAYOR FAX O78) 745-0343 lramclinpsalemxom L ARRY RiA iNIDIN,RS/RF1 IS,(:I-10,CP-FS Hi•:al,rn AcI.Nr Th s .cur.pn vi51. be.col ected during your next Board of Health irfspeCtiolar. OUESTIONAIRE – GREASE TRAPS 2009 1. NAME OF ESTABLISHMENT: `96sl-n, PL�c/ L�rtie r 2. ADDRESS OF ESTABLISHMENT: (& 126S 4,t S Ss Ce �, mY% >! 3 2-0 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS —WZ—A 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? n Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Boston Street Liquors File Number:BHF-2004-000096 Attn.Madgy A Ghaley 36 Upton Hills Lane Middleton MA 01949 LOCATED AT: 0018 BOSTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0007 Jan 1,2011 Dec 31,2011 $70.00 TOBACCO VENDOR BHP-2011-0006 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $205.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health ______/L�y✓f This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in'a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS 'BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGRIENBAUM&Al.En1.COM DAVID GREENBAUM,RS ACTING HEALTH AGENT r 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 66oS+-aoi S,- reg f tzg&&" TEL# 4 RFs- 7YY - /76 ( ADDRESS OF ESTABLISHMENT($ /3aSi-oH 54-- Ste- m1i e /91-0 FAX# MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAME In 6LOdg TEL# 7k(- 7/Sr- fh. 3 ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) S}f CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# D"AYS;OF.OPERATION :`:.Monday '_•r, . Tuesday` Wednesda _I'.. Thursd ,r Fdda r>:Saturda 'Sunday; HOURS OF OPERATION i PoeasewaleintimeoFday. FRS^- 11pnr $an,_ //�,ti 8a.W_ttP, jgam _Npwjgaw._ Hpa. b"an�_ Ppm * ..,Ilap, — q,?- For example l lam-11 TYPE OF ESTABLISHMENT FEE (check only RETAIL STORE ES NO less than 1000sq.ft. =$7 1000-10,000sq.ft. = 280 more than 10,000sq.ft. =$420 ------------------------------------------------------------------------------------------------------------------------------------------ RESTAURANT YES NO less than 25 seats =$140 (Outdoor Statinnary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------------------------------------Y-------ES 146 ------ -----------------------------------------------------------------------------------$---10-------- BED/BREAKFAST/ NO 0 CHILDCARE SERVICES/NURSING HOM-- ----------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR (Z2:E�) NO 135 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid al st a taxes required under the law. Signature Date Social Security or Federal Identification Number ---------------- 7—r� - -- - — ------ Revised l0n1I I FOODAP201 Ladm Check#&Date ;.vim',{o.:r y_.,r.�;.,. -...,A N.Y".s6i�i:..irr.1'r*d61"a4+lwYrtl.'�{r+�'"^+v4,i.r4,Lr^4.'3"n'tT,A.+ e:.,M+♦ ;. r �`Y�r rrr 1?1R A�Mhe4v eA..tN�"'y�-,-�h,y'1'f T1l,r�M'�...enl'• �^/ "»+( Massachusetts Department of Public Health 120W Board SHealth Division of Food and Drugs SalSal Washington Strr eet, 4'" Floor em, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name ate Type of Operation(s) Type of Inspection y ❑ Food Service ❑ Routine Address �/� �l(�y Risk '$� Retail E] Re-inspection `� " Level ❑ Residential Kitchen Previous Inspection Telephone !1 (1 4L� ' (o , ❑ Mobile Date: Owner I HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PI ) 1 Time ❑ Bed& Breakfast ❑ General Complaint I AM in D �YD !S�. TiTe,,� ^� ❑ HACCP Inspector 1i �) Out:3.( � Permit No. ❑ Other Each violation checked requires an explanation on the narrative pag?(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),jT 590.009 action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT�'�'"'. „„„„ „, ,.�.`a ,;,„; ❑ 12. Prevention of.Contamination from Hands ❑ 1`PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH ` s p „ �� , ,. 1 PROTECTION FROM CHEMICALS � _; x Ik -7 � 1 F12. Reporting of Diseases by Food Employee and PIC1eWti N a ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals '"FOOD FROM APPROVED SO11RCE' ;,u,"a t..k..;"trw . a El4. Food and Water from Approved Source g TIMEREMPERATURE CpNTROLS(Poterrtialiq Hazardous Fonds) 'Ml 1,: ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating , ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling _-<PROTECTIOM FROM CONTAMINATIOH "�' � ' ❑ 19. Hot and Cold Holding 8"Separation/Segregation/Protection ❑ 20.Time As a Public Health Control E] 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMEN75 FOR HIOHCYSUSCEPI-IBLE POPULATIONS(HSP)'.. ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing , ❑ 11.Good Hygienic Practices m'CONSDAAEF3 ADVISORY_±, � ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related I Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N ` by a Board of Health member or its agent constitutes an 23. Management and Personnel (F -3),5 0,004)) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(59o.o67) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)159o.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:5XM1 PWF.m 14C /� /' ' 1 �CAO�itL� •n 1 Inspector's Signature: D Print: PIC'sSi nature: Pa e-LofC7�Pa e sG/2 Prink �Uh I7Utr c�n $ K Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F8 Cross-contamination 590.003(A) Assignment of Responsibility* 3-302,11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTS Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-3021.1(.A)(2) Raw Animal Foods Separated front Each EMPLOYEE HEALTH Other" 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employrxs and 3-302.11(A) Food Protection* a tlicants* 3-302.15 Washinit Fruits and Vegetables 590.003(F) Responsibility Of Food Employee Or An 3-304.11 Fuad Contact with Equipment and Applicant To Report'fo The Person In Utensils* Charge" Contamination from the Consumer 590.003(6) Reporting by Person inChane* 3-306.14(A)(,B) Rammed Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated- L190.0033(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE F"A* 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..111 Manual Warewashing-Hot Water 3-201.12 _Food in a Hermetically Sealed Container* Sanitization Temperatures* -- 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eiaas* Sanitization Tem eratures* - 3-202.14 Eggs and Milk Products,Pasteurized* 4-5(11.114 Chemiaat Sanitization-temp.,pH, 3-202.16 Ice Made Front Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water from an Approved System*tem" 4-601.11(A) Equipment Food Contact Surfaces and 590.006(4) Bnsils Clean affied Drinkin Water' Ute 590.006(B) Water Meets Standards in 310 CMR 22.0* ♦ 602'11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils.rod 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202AS Shellstock Identification Present* 2-30:12 Cieamn Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2-401.11 Eating,Drinkin♦or Using Tobacco* 3-202.11 PHFs Received at proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package hate it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 _Pm ventin Contamination When Tasting'; 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(1) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products I3 Handwash Facilities 7402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(5) Labeling of ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.t J Accessibilit ,O reration and Maintenance /HACCP Pians Supplied with Soap and Hand Drying 3-502.11. S eo:ialized Processin Metluttds* Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11, Haadwashiriv Cleanser,Availability 9-103.12 Conformance with Approved Procedures* 6-3(1.12 Hand Drying Provision °Denotes critical item in the federal 1999 r�1 Cade or 105 CMR 590,006. - CNITY OF SALEM I _ (� BOARD OF HEALTH Establishment Name: Z7)Sl7/t �('Pr i" n ,� . �1 /JDate: I Page: ('4- of_ j Item Code C-Critical Item vDESCRIPTION OF VIOLATION/PLAN OF CORRECTION *' Di e =^ No. Reference R-ReilRem PLEASE PRINT CLEARLY UT i ' j Dn In l M A A O A A .1 ,, -+ c) 0 I Lin i Discussion With Person in Charge: Corrective ActiomRequired: ❑ No t sq . Yes. t I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension I comply with all mandates of the Mass/Federal Food Code. I understand than;, noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 77/ 2)- !� o cnry - i t ❑ Voluntary Disposal ❑ Other: 1.4((',) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cowled to -" Factors(1teMs 1-22) (Cont) _ 41`F/45''F Within 4 Hours- 3-501.15 Conlin-Methods forPHFs PROTECTION FROM CHEMICALS lg PHF Hot and Cold Holding 14 Food or Color Additives �� - 3.501.16(B) Cold PHFs Maintained at or below 3-202,12 Additives 590.004(F) 410/450 F'_ 3-302.14 Protection from Unapproved Additives' - -- IS Poisonous or Toxic Substances 3-atl( 16(A) lint PH}=s Maintained at or above F-101.71 }c� !entifyin Infrnmation Onoinal Crintainelss` 3-501.161A)----- Rv ,ts Held at or.ilroce 130 t'.�' r-102.11 1 Common lame 0.otki i Con ain4r� �� _ ' Time as a Puhl+c Heatth Control L7 01.11 �SeLatmcn 5i'rn ate, F, ... Frm ss rPublic Health<ontrol' - 9ts�,D-itSi, t F .nr:eRr, to r_nent' 21E)II) ke t xt c n F r u nu "a](! U 7 0° 1 2 Condinon"of Us _�Y —_ REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 03.(1 1u- tc f n x unci Prolr hr c n POPULATIONS i r 2(kl.al Samnruti C'riteu Chu.uc dti F-7; -204.12 Charlie+Is for C i aa6a`� I L•� t'np i tau ned Pa o �}aged Juices and -- - }-r oD4 14 - - � 5d! Bevr s es uit) i < nn; te. .C l- ,rit 1lrH} I'c of Pu *cua rd 1 c _ '05.11 hxsd ni 1 t xxJ f untx , lad> cats _ , - - - ---I 11-11;'011,110))�ISt0. lir P-ntrall {iak ' Anuntl E=ixs! and 1 j�?OCtlt i,,.,i,.r disc Pc tcirf, .Ci tuij � i - Far S d ti coli( \c Sr rvc I I 1 J6.! Rcide 1' ntsi, r r - r- -. .� _s,C,! 1 r f , th, rr ed Isxd! r< ti.f R cr Hca. ,.:•0 0.l i l ,cki Q 'ust,le P r ajar ! and ---� - _ _ ,_.__,.__._.�._.�. -._. �I'rmwi rn" _ CONSUMER ADVISORY r "r3 1 ' ors})i c k n enr'os I o E ott ,aur,ti.(rn _ T'Ih9EJTEMPERATURE CONTROLS 3 of vrimr t i vol '171a Ere t , Under. kinc<f i IG �� - 1 Proper Cooking Temperatures tar 1 I Pf1Fs Not O[I<t a u I'n;c= t j..'it lir,lie tilLElltlq._..._ Fb 155 ' ISS ttftn�t i itmG:.d uc S r Az 1 E7 11 s,,�� )3iltS,bst ui. .c.Ravc41ui1- :. dt}LIc . }(�; C mnrntleurnh tic� ,. 6:)Inr G _-.- I. - __. ..-_. _.._..__.. _. _.__._ ln[m n, i5} ' 1SPECIAL REQUIREMENTS .nil r1}}rt, )F s '(qk r IB cRu t 1 ° 7 1 ` nsn" j htl.i( 1( (< rti !n'x. .. - F_I�. 1 `:4}.00'�)t;S)'f}) , Vi C 1a r ) tSetKl r-off,) fD)}t j ,!ringmohii r tea{ r ,:rpan ,r ..id r-401.HtA)-3) i'nurry Wild Game, S trcdPHF''. � 1 uvei nt sl kitchenol, t i crm [r�tld i'}� 4i `fnu i nn ❑ter I tit• 41 t. ' i china unkknr Shc 1y l,r r rn oy t c its 1 D?'t' 15 AU l� V":;', ... ( r i 1 i �t)l t1i tu(9 4 t .. .ill a' � i 4Y `.� �• .., y, � i7 H Peating for lint Hmdiiig __ � 1/10LATiONS RELATED :C G'?L?-' ' Ric TA IL PFAt"?'k'ES 103.11rir i1)) tett !n:"t ' a itews23-3f# 403.}1(b) 4lr tow.vc- Its FzMmuicSindinG, Ca„r rs dra" fTiltac! rt rti. nrrrtarn pw ca -=1hr �1nt ve" rn, ifl s r+ ri :arr rid tibfrr,trxlived abow, e.rtbe 3-403.11(C) f ( m,nereis l4 Pru, ctl iT }rand. i i,lir , of.:,r', >, ,wg t. w, , , c Fr c.d c od6,w. r lir. CMR i }{, F rfT tXt i-00>.! 1(l� I Inc m lair cp;Lnc ,c r Poi w»a ro!'Bcei , _(tam ' Good Road Practices _ FC 590.000 i nc i dP r )n PG E 00 _ I- Prope-r C-o-ounrd of PHFs 21 FoA dRxxo,c tto _ FC i o4- - y - i- -. _ t 2+ 3Nrrcn'andUra ss Fn "b taf,A7 C lr>nA t' PHI, tr rte l-1W F h' r-- •�,bm�ir1 .€e_ FC-5 006 -i L5 atet Pic 0017_ to,4 1'I `F W thin - H_ui _ ( 26 � r o s r gas ow ylalpiC'_ 7 002 PHEI Nbdv Font Ambient i I np,tantre ht,rcd cuts io 41 I�14i'F ; 3 )the Wabin 't) n�l.'.4 uYiC3t r ,M• y� r fol Fa:#, .dC of IGS.- rc`r}'r tiff(. r13't.l. ^^�...r...:^!.-v-...<.:yr�P�lA*.r i...l�,,ayf„R,44'•-f� •*.�. .:7�fv�r�•.,.v..+a-aw':''G�f":.'�yF:' >V.yii� ,r,.,.,,..ri'i�l t.-. .P::i*';K'ti - i Massdbhusetts Department of Public Health Salem Board of Health Division of Food and A` Drugs 120 Washington Street,41h Floor ,, 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT 4 ' Tel. (978) 741-1800 Fax (978) 745-0343 Name I ( Date II7r Gr TvoeooOeaon(s) Tvce of Inspection ❑ ®"Routine Address �5 Ask `. ® Retail [) Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephon � _ ❑ Mobile Date: l OwnerCt (t / �" HACCP YM E3 Temporary ❑ Pre-operation 0A ( V IG hl ❑ Caterer ❑Suspect Illness Person in Cha46(PJC) Time ❑ Bed&Breakfast ❑General Complaint In: 12031) ❑ HACCP Inspector Out.)741; Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors 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. FOODPROTECTIONMANAGEMENT _�„„; "" �� F. �:. °` °'.�`" ❑ 12. Prevention of Contamination from Hands )►. ❑ 1 PIC Assigned/Knowledgeable/Duties $ ❑ 13 Handwash Facilities � EMPLOYEE HEALTH PROTECTIONFROMCH,EMICAL8hx� ...3' :�_..�. ❑ 2. Reporting of Diseases by Food Employee and PIC3..Fa`�s , = u '• _ u • F� � t ❑ 14.Approved Food or Color Additives - ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals LFOOD FROMAPPROV bSOURCE ' RE I,TIMEITEMPERATUCONTROLS Patantiall'HaterdoueF'ooda El 4. Food and Water from--Approved Source �, � ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 1 B. Cooling PROTECTION FROMCONTI)MINATION dV!�17r�rTMXM ❑ 19. Hot and Cold HoldingKx la �-' W- -w....-, d -m..m.me�uN6hm$,ikmn f%31� F`f!W„mi4+6r�m5.d�slu�r�wC ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REp¢)Ri*M NfS FOR MIOk1Llf 8, usG P17aLE PpPULATIOt S„(HSP)„q, ❑21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ':CONSUMERADVISOFiI'. mL cF":-�j, r ;' El 22. Posting of Consuer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 7-125. Equipment and Utensils (FC-a)(5so.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 7. Physical Facility (FC-6)(590.007)' have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 5:5X ,dFw masa F) A „ Inspector's Signature: \ / ( , Print: PIC's Signature: / C^� ,,,�}-7� � Print: U h ti !)�-r�� w I Pag�_of�Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 I 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foals Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-1.03.11. Person in charge--duties , Contamination from Raw ingredients Raw Animal Foods Separated from Each 3-302.11(A)(2) EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3302.1I(A) Food Protection* applicants* 3-302.15 Washingis and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char e* Contamination from the Consumer 590.(X)3(6) Re ortin 'b Person in Char Vie* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.11 I Manual Warewashing-Hot Water 3-201.12 Foci in a Hermetical) Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tent eratures* 3-202.14 E =s and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Drinking Water from an Approved roved S stem* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* , - 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.1 l Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1Q Proper,Adequate Handwashing Regulatory Authority Game and uMushrooms Approved by 2-301.1.1. Clean Condition-Hands and Arms"' 3-20218 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11 Eatin=,Drinking or Usin Tobacco* 3-202.11 PRFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Ivlouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventin Contamination When'Fastin " 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em kt ecs* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible - 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.11 Location and Placernent* 7 Conformance with Approved Procedures 5-205.11 Accessibility,O reration and Maintenance /HACCP PlansSupplied with Soap and Nand Drying 3-502.11 Specialized Processing methods* Devices 3-502.12 Reduced ox en packaging,criteria* 6-301.11 Handwashin an = Cleanser, Availability 8-103.12 Conformance with A. roved Procedures" 6-301.12 Hand Drying Provision *Denotes cridad item in the federal 1999 Fond Cade or 105 CMR 590.000. i - CITY OF SALEM i BOARD OF HEALTH Establishment Name: Date: Page: 1_ of item Code- c -critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION 6 Date n No. Reference R "Red Item 9 > , - - -- f > Verified tt °` sryd.a..., v 1!�:k_ t `s PLEA EPRINT CLEARLY R`" _.5 _ _.:_ ,. :Y .-,. 'a d: C(On , �) !a -lin A rlz, A4( hl)�rc4 C r\ Uclt 5 avr, cru< Le JI ov. r, r7.f e 16--i C O'cPct erg dt� (if), 4- of } e 1 I k 1 4 i Discussion With Person in Charge: Corrective Action Required: ❑ No ¢e--Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension C with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ��'� ❑ Voluntary Disposal ❑ Other: Ytid ort Tem-- — perature F,7; t �7 Vtoadicas Related to Foodborne illness Interventions and Risk i"coreding to La" Cooled to Factors(Items 1-22) (Cont.) LiLE456WtC&tn4Hauts PROTECTION FROM CHEMICALS 5 Coolim,Methods for PHFs LL4_ 19 Food or Color Additives 1 PHF Hot and Cold Holding 3-50'A6(B'1 Cold PHI s Maintained at ow beftla, Adllivoa;* -1-2012,i2 S9}.004F) 4£`145°F� 3-302,14 Protiection from lfruia)pEoled ��dilivSL, ab Vc LL5- Poisonous or Toxic Substances 3-50i.16(A) flot IIIJFv zMameirred at ce us��,w -101.1 1-1 —Original 146"F, 09 0 iciontifying hifoa inalion Ro;isys Held at ornbove 13001i, mve 13 20 Time as a Public Health Control 7-102,11 i Contractor Name-- lKorking Cont airien�* L 19 -L -Iime as a Public Health Control' 7-2iTi I I vacianceR i-202.11 Restrictic,n -Prest-jace and 1-,e" 7 202.Y2 Cond lone of uso* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE —, —-T< .. ...riers-Pr Shiba-��03 POPULATIONS IRS 1 7 -204.11 Sannizerq.Criteria -cheroicals. - '7-'?(14.1° chonlicats for Washine,llrsidnccC gitsc[7— 21 I >r802,1 I(A) UnIxNteurized,Pee-paocl.agcd Juices and ftereraee' with Uc (a'Pa,licurized losa�,c '1-20,5,1 i Incidernal Fosid Ctiruavt� LAinicainci* �1-801 1413) 3-h0l.11(D) Ilosel or Paris all,,Ccaak<�,d Animal Ford all(] 1 7-206,11 Resinco'd Use pe'ticideo;�critelial — Raw 7-206.12 RalQ111 Edit StaliolM —7f�-- - Lgf—D Is,Kz- L-T 570-6�-3 aC�,nTp,,,d,,s pest C,,rrr(, 'I and MonihniniL—, CONSUMER ADVISORY TIMErrEMPERATURE CONTROLS 161,F�l i -Census rer Advisory Poa'ie.d for Cat ssnout ion of Raw. Undercooked is o�r-Cookmg Temperatures tQr� Nos,01heroise PrraeeseA to E.1ijamate J_�Hles E --7TPr,_ I I I At I iC7— I air ,nn I I I A(l) I _5 S'c 15 _ , c. '55 3-31,)2.)3 FTI &-SK'rosofuie Jos [crow Shell L�L IlLirij� rare I L Servicv 145'Fl5sec, C"ayne Anituals- 155'T 15 sec. SPECIAL REQUIREMENTS 3-461.1 1(13)0)f2) Por), and lit�cfftoasl 10t' 12! rs Ratites,lr�a%led Mciris - 155'F 15 59605()(A) tD) 7iolatt ser catering, rsrofiihRaid,temporary and resident al kitchers operations Aicould he 3 40 1�I I tA)(3) Poishr), Wild Game, Stuffed fol-lFs, Stuffing Containing Fish t bleat, oobitcd under the appropriate sections Poultry or Raines 165'F.15 scc. above if related to fc<Aboorle illness 7 -4011 I iCr�j lholemug cic, Intact Beef Steaks owes ventions, and -I sk factors, Other 145F 590,009 violatious, relafirso to void retail practices hould he debited wider#29 - 1-401 12 Raw:Amoral Rx,I,Comlicil In a — — Miicao%ave 165'F* -.--- sfo'!cud Requirements. All Other PIIFs-- 145'V 15 Sec. L17Reheating for Hot Holding VIOLATIONS RELATER?TO GOOD RETAIL PRACTICES 3-i F3.I F(A)& I)) pf&l 165'F 15 scc. (Itetins 23-11I) 3-40331(B) Microwave- 165F 2 Moore Standing Cir6ccsl teod non-(ritical viok'tion'i' ii'lach do nare'are, r's she Tinsel filadborne i'lrxss iur,'a vearoonv and nA-fiufol,s Lvoed above, (on be 3-403.11(C) Commermuiv Processed RTE Food found in the Jtrtr ra urX se r rrns of the Food Code aid 105 CMR • - --------- 3-400"1.I(E 1 Remaining Uraliced Persians(if Ficef It Good Retail Practices FC 5(70 000 Roasts* ni 23� Manageent and Personnel Proper CoolingofPHFs 24 Footrand Food Proleciao-ri-- -F-G.--3- -,004— To—-,c-�i-;aa-�t e,T i s ; FC - 4 3-501.14(A) C(s:,4iag Cooked PHI-s from 14WIF to _� _qu�ipm , - '005-- 26 006 -VV _q�o�d W risle 5 '()'F Within 21 fours and From 7,1)'1-' povs-cal Fmai FC,-6 _I 007 to 4 I'TAY F Willa or 4 floau. 2E -Vo3sonow or Toxic Matff ats 363 3 501.1413) Cooling PI-IFe Made From Asubienteras 009 -.��Pqdal Raottrem --- Temprature lagredieraq t(,410f'/45'F Within 4 Ihonr�!� 5 - Commonwealth of Massachusetts r City of Salem tGmbertey Drist:oli Board of Health Mayor 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/11/2010 ESTABLISHMENT NAME: Boston Street Liquors File Number:BHF-2004.000096 Arm.Madgy A Ghaley 36 Upton Hills Lane Middleton MA 01949 LOCATED AT: 0018 BOSTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions t Notes RETAIL FOOD BHP-2010-0224 ,Ian 4,2010 Dec 31,2010 $70.00 TOBACCO VENDOR BHP-2010-0225 ,Ian 4,2010 Dec 31,2010 $135_00 Total Fees: $205.00 i PERMIT EXPIRES FiDe�mber 31,2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS i * BOARD OF HEALTH 120 WASHINGTON STREET,4n'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOL.L FAx(978) 745-0343 x MAYOR DGREENBAUM&ALEM.COM oe C7 DAVID GREENBAum, �ZQo9 ACTING HEALTH AGENT �Y 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL# %7F_ 7VY- /7G / ADDRESS OF ESTABLISHMENT-/F ?3os4o .S/'y Salew{w+ � ��4�° FAX# MAILING ADDRESS(if different) _ Pd /,sok 9y`( 114,dN /P lym, /n-Al- ° l 5 y F EMAIL- Business': Website: OWNER'S NAME lnjg,6 L 4. t,-17 rr gQ TEL# V-/- 711' - ?Y6 3 �r—r ADDRESS36 (42hjH ki' it Ln) 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 HOME TEL# �DA1S"OF,OPERATION'�"`� Monday��T"�I, ',�,Tuesday �,W,ednesdaytT,hursday,�" ,�'>�Fritlzy", ' jk, ;Satutday�A, *�,Stirftiayw.:4 =.: HOURS OF OPERATION j Please write in time of day. aam Itpm ?Aw- prn I J4M- hpm I Jam- Npm ; /1 Pm I12pm- For example 11 am-11 m TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. _$70 1000-10,000sq.ft. 80 more than 10,000sq.ft. =$420 R---E--S--T--A---U--R---A--N---T----------------------------Y-------------NO---------------------------------------------le-s's'th-a-n---2-5...s-e-a-ts------------------$'1'4"0'.... (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 (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR <21D NO $13 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax retume and paid all state taxes required under the law. #y-3SyYooj Signature Date Social Security or Federal Identification Number. R-evised 424-0—FO--DA-P-08adm Chck#&Date — $ , -o-, qa ------------- Irk CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH - _ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 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: Liquor Store Name of Establishment: Boston Street Liquors: .« Address of Establishment: 18 Boston Street Owner's Name: Magdy A. Ghaly Restrictions: Application Date: 11/12/2003 Permit for Food Establishment 002-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 001-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT * a s CITY OF SALEM, MASSACHUSETTS hJ i' 11 BOARD OF HEALTH 1 3 w 120 WASHINGTON STREET, 4TH FLOOR NOV 12 2003 SALEM, MA 01970 TEL. 978-741-1800 CIT`( OF SALEM FAx 978-745-0343 BOARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ' Ll, TEL#9_2:�� L4 ADDRESS OF ESTABLISHMENT /'R Qr7�tLZ^yl� �n� I✓JjI i, MAILING ADDRESS (if different) UDt6 ia /19f(`/� k Icky AA 0I0)L/9 OWNER'S NAME M12 0 ,�I� � r] C/ TEL# `:S/ ADDRESS CITY STATEAA 'Lb ZIP CERTIFIED O MANAGER'S NAME(S) CERTIFICATE#(s (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON C i HOME TEL# 'T 1� 9,(3 HOURS OF OPERATION: Mon.91LTue.R--1 l Wed. g- I Thu. S=f Fri. A-( ISat.Z j 1 Sun.jLLg C4 TYPE OF ESTABLISHMELIT FEE check only RETAIL STORE YES NO 6Da'o less than 1000sq.ft. _$ 50 1000-10,000sq.ft. $1 00 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 YES NO $5 �� p TOBACCO VENDOR YES NO $50 / ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL hapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowled e a lief, have filed all state tax returns and paid all state taxes required under the law. 3 t7 Signature - ate Social Security or Federal Identification Number ��Signature�-� Date 11/03/03 FOODAP2.adm Check#&Date .90.,Z_f�/ - 4-3 Massachusetts Dery S Deportment Of Public Health Salem Board Health M 120 Washington Street,0 Floor Division of Food and Drugs f Salem, MA 01970-3523 FOOD-ESTABLISHMENT INSPECTION REPORT t Tel. (978) 741-1800 Fax(978) 745-0343 Name Date Tvide of O eration s T e of Inspection O 7 6°1 Food Service Routine Address l Risk ❑ Retail ❑ Re-inspection Sf �� Level ❑ Residential Kitchen Previous Inspection Telephone / J el- ElMobile Date: Owner / HACCP Y1N 171 Temporary ElPre-operation M1 d ❑ Caterer ❑ Suspect Illness Person in Charge PIC) /� L Time 71Bed&Breakfast [I General Complaint In: [IHACCP Inspector i/,. fi ,.'s kis Out: Permit No. ❑Other_ Each vlolation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. i Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. `FOOD PROTECTION MANAGEMENT , ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH - "PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded [] 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ,. - TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY .. �. ❑ 11.Good Hygienic Practices ❑22, Posting of Consumer Advisories Violations Related to Good Retail Practicas Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses interventions { immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2)(560.003} order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 28.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility i (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements & (590.009) within 10 days of receipt of this order. 30. Other j DATE OF RE-INSPECTION: S.59glnspecMror 14d.c i _��T Inspector's Signature: .ofd Print: PIC's Signature: Print: t Page of c�Pages r c Violations Related to Foodborne Illness ~ interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 11 5W.003(A) Assignment of Re onsibilita* 3-302.11(A)(1) Raw Animal Foods Separated from 590.6031 J Demonstration of TCnowledge* Cooked and RTE Foods* �2-703.1'1 Person in charge--duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection'" a plicants"` 3-302.15 Washiu Fruits;and Ve<,etables 590.0(13([) Responsibility Qf A Food Employee Or Aa 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char<*e* Contamination from the Consumer 590.003(G) Reverting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food' Food and Water From Regulated Sources `) Food Contact Surfaces 590.004(A-B) Compliance with Food Law" 4501.11, Manual Warcwashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem Aeratures* 3-20113 Fluid,Milk and Milk Products* 4-501.112 Mechanical Warewashin„1-for water 3-202.13Sanitization Temperatures* Shell ER s* 3-202.14 Ev ls and Milk Products.Pasteurizzd'� 4-501-114 Chemical Sanitization-temp., pH, 3-202.16 Ice Made Ficin Potable Drinkine Water" concennatpon and hardness. 5-101.1.1 DrinkingWater from an Approved S•stens` 4-601-71(A) Equipment Fond Contact Surfaces and Utensils Clean, _ 590.006(A) Bottled Drut Water" 4-602.11. Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces aid Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan F<wd Contact Surfaces of E ui nrent+` Shellfish* 4-76311 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP.Listed Chemical* Sources" 10 Proper,Adequate quale --..-... Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Re ulato Authorit 3-202.18 Shellstock Identification Present* 2-307_12 Cleaning Proccdnre* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* it Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinkin or Using Tobacco" 3-202.11 PHFs Received at Proper Tem eratures* 2-401-12 Discharges From the Eyes,Nose and 3-202.15 Pack i e htte it,,, Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting"Tags/Records:Shellstock 32 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 540.004(E) Presenting Contamination from 3-20112 ShellstockIdentification Maintained" EntAlovees* Tags/Records: Fish Products 13 Handwash Facilities 3402.11 Pm_astc Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibilit OAeration and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11S ecialized Processing Methods' Devices 3-502.1.2 Reduced oxygen Aacka rine.criteria* 6-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with A roved lkocerhves" 6-301.1.2 Hand Drying Provision IDenoles critical item in itis federal 1999 Foal Cculc of 105 Cs9R 590.000. r' CITY OF SALEM r BOARD OF HEALTH Establishment Name: Date: / q d !�K Page: a of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION *DateNo. Reference R—Red Item PLEASE PRINT CLEARLY 1Oild.ES' 4 / '�7/ Al O�l�R(I / S �-/ S S1v AIT /3 o f r t ` s 7 cthr w m� ai ,e - L. 71- de s Lvvic'/� p /f 9::e/'_0 4!51 C/ t "Y P ' t C i t Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes 'i 4 have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of LlEmbargo LI Emergency Closure your food permit. �� Qt ❑ Voluntary Disposal ❑ Other: r - ' 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 4'1`Fl45°1`Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cixding Methods for PHF 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501..16(.B) Cold PhIFs Maintained at or below 3-202.12 Additives* 590.004(F) 4I'145°F* 3-302.14 Protection from Unapproved Additives* 3.501.16(A) Plot PHFs Maintained at or above 15 Poisonous or Toxic Substances 7-101.11 I'dentif}ring Information-Original 3-501.16(A) I Roasts Held at or above 130°F. Containers" 7-102.11. Cornrnon Name-Working Containers'' 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-20111 Restriction-Presence and Use* 590M04(H) Variance Rck uireme at 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-,Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals POPULATIONS(HSP) 7-204.12 Chemicals forWashin=Produce.Criteria* 21 3-801.11(A) Unpasteurized Fre-packaged Juices and Beverages with Warnin-Labels* 7-204.14 Dr in, Agents.Criteria* 3- 80t.11 B) Use of Fasteurtzed Egos* 7-205.1.1 Incidental Food Contact,Lubricants* 7-206.11. Restricted Use Pesticides,Criteria" 3-801'11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served x 7-306.12 Rodent Bait Stations" 3-80111(C) Uno cited Food Packa re Not Re-served. 7=206.13 Tracking Powders,Pest Control and Monitorin** CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603,11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs rr •,6 r2oor 3-401.1-1A(i)(2) LR s 195°Fls Sec. Pathof"'cas F....s-Immediate Service 145°1715sec'k 3-302.13 Pasteurized El,rya Substitute for Raw Shell 3-401.1.I(A)(2) Comminuted Fish.Meats&Game B s* Animals- 155'F 15 sic. "` 3-401.11(13)(1)(2) Pork andBeef Roaat-130'F 121. mill SPECIAL REQUIREMENTS 3-401.11(A)(2) Rah.tes, Injected Meats- 159°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in Sec caterme mobile food temporary and 3-401.11(A)(3) Poultry,Wild Game-Sniffed PHFs, residential kitchen operations should be stuffing Containing Fish,meat. d>b;i:_; wader the a;;pr«tpriai Poultry or Ratites-165'F'15 sec." above if related to'foodborne illness 3-401.11(C)(3) Whole-muscle.Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under##29- Microwave 1.65°F* Special Requirements. 3-401.11.(A)(1)(b) All Other PHFs-145'F'15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-103A I(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403,11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time" foodborne illness interventions and risk factors listed above, cart be 3-403.11(0) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 5,90.000. _ 3-403.'11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* 23 1 Management and Personnel 1 FC-2 .003 1g Proper Cooling of PHFs Food and Food Protection FC-3 _ -.24. -_-_ 004 25 Equipment and Utensils - ----1-FC-4- .005 26. 3-501.i4(A) Cooling Cooked PHFs from 140'F fa Water Plumbin _ and Waste FC o 006 _ 70'F Within 2 Hours and From 70'F 27. ! Physical Facility FC-6 .007 to 47°F145"F Within 4 Hours. ^` 28__ Poisonous or Toxic Materials FC-7 .008 1 3-501.14(13) Cooling PHFs Made From Ambient 29, Special Requirements .009 Temperature Ingredients to 41'F/45'F 30. _LOther _-_ Within 4 Hours"` s , <•-z,e. 'I)enote-a eriticrilitzna in the federal 1999 Food Code or 10;I C411d 590.000. IMPORTANT MESSAGE FOR_& J' DATE - TIME M OF PHONE A--/ 74 - 53p,�L3 AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED JRU7SH E:GALL CAME TO SEE YOUALL AGAIN WANTS TO SEE YOURETURNED YOUR CALLAX TO YOU MESSAGE SIGNED( J. MAADRE IIN U#3 � rY NOTES - I I I 4 Commonwealth of Massachusetts F City of Salem Board of Health ' Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: Boston Street Liquors File Number:BHF-2004-000096 Atm.Madgy A Ghaley 36 Upton Hills Lane Middleton MA 01949 LOCATED AT: 0018 BOSTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0122 Dec 23,2008 Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0123 Dec 23,2008 Dec 31,2009 $135.00. Total Fees: $205.00 PERMIT EXPIRES December 31, 2009 Board of Health , .,_ hl1 14 This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Paye 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"r FLOOR TEL. (978) 741-1800 �- CC KIMBERLEY DRISCOLL FAS(978)745-0343 MAYOR IDtONNE sALent.COM V�L OEC - 2009 JANET DIONNE, ACTING HEALTH AGENT 13V .. ,O OEA4 OF TIt 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT B6 ILZJI TEL# �7-9 —"; 4 LF 6 ( ADDRESS OF ESTABLISHMENT $,4 2 FpvY MAILING ADDRESS(if different) T /*11V � u 4 EMAIL-Business': Website: OWNER'S NAME z4 TEL# 5!jZj1 :3-jB ,7963 0 ADDRESS 144,4O/ LFT STREr=T CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) /V /A CERTIFICATE#(S) WIA (Required in an establishment where potentially hazardous food is prApared) EMERGENCY RESPONSE PERSON HOME TEL# DAYSOFOPERATION -L Monday',, I ` Tuesd '!Wednesda " .; •Thursda . 'Fdd Saturday Sunda: HOURS OF OPERATION Please write in time of day. ! 1 8 —(( $ —\\ $ \\ For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -------------------------- 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-------------------------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO 25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid II s to taxes required under the law. V( ejeg OL(— 35' LIL4 3 O Signature Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date 5�2 I(�Q $ �QS Commonwealth of Massachusetts City of Salem Board of Health lGmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Boston Street Liquors File Number:BHF-2004-000096 Attn.Madgy A Ghaley 36 Upton Hills Lane Middleton MA 01949 LOCATED AT: 0018 BOSTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0023 , Jan 3,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2008-0044 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES (December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all - plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 15 • e 3� 1 QTY OF SALEM, MASSAC HUSEM c BOARD OF HEALTH g 120 WASHINGTON STREET,4' FLOOR TEL. (978) 741-1800 KI]iaERLEY DIUSOOLL FAX 03 ( 978) 745- 3 3 RECEIVE[) MAYOR JOANNE SCOTT, DEC 4-2007 HEALTHAGENT CITY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT oSt ��x � fYct � L/ y,uvTEL# ADDRESS OF ESTABLISHMENT 13' 1Ou s4-ate S f • Su l e,, rnva FAX# MAILING ADDRESS(if different) Azo ?WY, 969 Asr'eWekk7' MAq- 0 /9 `/ EMAIL-Business': Website: OWNER'S NAME &L ct_g aCc1 /i-4kOL4 TEL# y -� 18 - 9963 ADDRESS 74 t -nn /////S Ln/ 0 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) N 114 CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION I Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION p" Please write in 6me of day $�-At fr"AI ,, $ Al-(If 344-k�l',` B ,AtA-V\ AI IAt",4PM -;ZAA v1 Q)1'Yi 12-flA�'r (For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. _$70 1000-10,000sq.ft. 80 more than 10,000sq.ft. =$420 --------------------------- ---.. .. ------------------------------ - ----- - -- - - ---------------------.-- RESTAURANT ES§ NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------- - -- --------- ------------------------------------------------ . ------ BEDIBREAKFAST/ YES NO $100 CHILDCARE SERVICES. - ----�- ---------------------- -- --------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y NO TOBACCO VENDOR Y NO $135 ALL NON-PROFIT(such as church kitchens) YES NO 5 '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 a. state taxes required under the law. Irl-)V-1 Signature Date Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Check#&Date S � 0018 Boston Street Boston Street Liquors City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-1761 Food and Food Protection FAIL Critical BLUE j Owner: Comment:the following items removed,outdated: 11 slimjims,1 pickled sausage.closely monitor all expiration dates. Magdy A. Ghaly GENERAL COMMENTS: ,PIC: Dan Piotrowski no other health code violations noted at this time. t l nspector. Elizabeth Salandrea Date Inspected:Correct By: i 1/14/2008 'Risk Level `Permit Number: BHP-2008-0023 :Status: I SIGNED OFF I#of Critical Violations: 11 jTime IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 14,2008 ) Page 1 oft Item Status Violation Critical Urgency Violations Related to I Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) j?O Cityof 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. Jan 14,2008 ) Page 2 oft CITY OF SALEM, MASSACHUSETTS BOARD OFHEALTH E C E I\IPSE D 120 WASHINGTON STREET,4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 DEC — 4 2006 FAx 978-745.0343 KimberleyDriscoll WWW.SALEM.COM CITY OF SALEM Mayor JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT—So5kfol f4re.e '- L/srctkr-_S TEL# `7'4 _ ��`✓- I ADDRESS OF ESTABLISHMENT C S i c m,* FAX# MAILING ADDRESS(if different) ,rT! 'Z6, QMJ CSid1(4r1�t tnAl- C I EMAIL--Business:: Owner's: OWNER'S NAME .171a,6,14i _)/_TEL#-M/-/ 711 —I2 S ADDRESS :3G ��f9 �, f/i� .S 1-41- /41/dd/e4h /ham 0/5r STREET CITY STATE —Zrp CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# BATS Of OPERATION Monday Tel Ltleduesday _ Thursday Friday Saturday Sunday HOURS Of OPERATION Please write in time of day. 5nw+ 11pr, yar» _ ///ym a„ _tt/sn �'an _11 n 'a. !/ 2r rj n _tlJr� 12j»,r_9R tforexample ttam-flnml TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE ES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ------ - ... -- - - ..._..... iess than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 . . . ... .......... r�...---..... ...........---....-......_...__....._._..........__....._-----_-----....._.....- BED/BREAKFAST YES (O $100 i ----- .---- ----- --------- _----- --- ---------- ----- ..... --- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVEY S `NO $5 TOBACCO VENDOR YE NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 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 allstate taxi returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number ------------------------------------------------ ------ ------_.-------�---C-'-p--� ----__ j,-Y------------5-----�------------ ._.-----------------------------_.----.-_ Revised 11113/06 FOODAP2007.adm Check#&Date�Y_t�_.�L. .� �_•L'3 t x s�• � + �-.�'� �� ,� �, �,� Commonwealth of Msssachusetts� � �" • • i �a p .v 1x rNBoaI d of Health �t n a, gra W 120 ashington Street,4th Floor 7 Ki!nberfey Ddsooll az .• ,:,,• ..t a Mr SALEM,MA .01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Boston Street Liquors File Number:BHF-2004-000096 Ann.Madgy A Ghaley 36 Upton Hills Lane Middleton MA 01949. . LOCATED AT: 0018 BOSTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0062 Dec 19,2006 Dec 31,2007 $50.00 RETAIL FOOD BHP-2007-0095 Dec 19,2006 . Dec 31,2007 $50.00 TOBACCO VENDOR BHP-2007-0084 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES ;December 31, 2007 Board of Health �� 6 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 5 of 24 0018 Boston Street Boston Street Liquors City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-1761 Handwash Facilities FAIL Critical ❑d RED Owner: Comment: Hand wash sink found obstructed. Keep hand wash sink clear and accessible at all times. Magdy A. Ghaly GENERAL COMMENTS: PIC: Dan Piotrowski 1003:Establishment sells a limited quantity of pre-packaged candy, chips and snacks. Inspector: No other health code violations cited at this time. David Greenbaum Date Inspected:Correct By: 11/21/2006 Risk Level Permit Number: BHP-2006-0018 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) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 22,2006 ) Page I oft 1 Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 22,2006 ) Page 2 oft P •�.. . ,r+,- ....,:.,,„.n-n..•,,_«..-...fs.n5..7- . ..Y,...r.. ,rr^._.. ...:."i-w. - .. k. .. .. +,..�.s..k....... n�,... . .*.wr- , a , .. .. s'4 ' Massachusetts Department of Public Health Salem Board SHealth p 120 Washington Street,4'h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978)745-0343 Name Date T e of f Operations Type of I e eD coon ( �Jr � UG CJ Food Service '� Routine Address Isk Retail ❑ Re-inspection Level F1 Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: 1/40!5' Owner t I MACCP yJN ❑ Temporary ❑ Pre-operation 4 ❑ Caterer ❑Suspect Illness Person in Charge{PIC) Time ❑ Bed&Breakfast El General Complaint r'l In: AS ❑HACCP Inspector r Outs Permit No. ❑Other Each violation checked re uires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. 4 FOOD PROTECTION MANAGEMENT -. ❑ 12. Prevention of Contamination from Hands . ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE'° - TIMEiTEMPERATURE CONTROLS(Potentially.Hazardous Foods)', ❑ 4. Food and Water from Approved Source _ E] 5. Receiving/Condition El 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION -" ❑ 19.Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control [1 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP [110, Proper Adequate Handwashing CONSUMER ADVISORY _. El11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/tederai Food Code.This-report, when signed below 123. by a Board of Health member or its agent constitutes an Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations . Food andFood Protection (Fc-3)(590.004) cited in this report may result in suspension or revocation of . Equipmentand Utensils (FC-4)(590.005) the food establishment permit and cessation of food .Water, Plumbing and Waste (FC-5)(590.006) establishment operations. if aggrieved by this order you . Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing . Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address . Special Requirements (590.009) within 10 days of receipt of this order0. Other DATE OF RE-INSPECTION: l/ 1 V\-/ 5:5XJIn earor 140. Inspector's Signature: print: PIC'sSignaturetM-��,.�-. �, /,'� Print:^,�. �7.✓,� �� pag -of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination I 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(8) Demonstration of Knowledge* Cooked and RTE Foods` 2-103.11 Person in char e--duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw-Ani Separated from Each EMPLOYEE HEALTH Other' 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3302.11(A) Food Protection* applicants* 3-302-15 Washing Fioils and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.1.1 Food Contact with Equipment and Applicant To Repots To The Person In Utensils* Charge" Contamination from the Consumer 590.003(6) Re mrihh"b Person in Char e' 3-306.14(A)(8) Returned Food and Reservice of Fiord* 31 590.003(D) Exclusionsand Restrictions'° Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe, FOOD FROM APPROVED SOURCE Food` q 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-8) Compliance with Food law". 4-501,111 Manual Warewashing-Hot Water 3-201..1'2 Food in a Hermetically Sealed Container* Sanitization'1'em.erataues' 3-201.1.3 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 E gs and Milk Products 4-501.114 Chemical Sanitization-tenhp-pH, concenuntion and hardness. * 3-2021(5 Ice Made From Potable Drinking,Water 4-601.1 1(A) Equipment Food Contact Surfaces and 5-101.11 Drinkinu Water from an A roved System* Utensils Clean' 590.006(A) Bottled Drinkine Water' 590.006(8) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-70211 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces oI13 ui nhent* Shellfish* 4-703.11 Methods of Sanitization-- Hot Water and 3-201.15 Molluscan Shellfish train NSSP Listed Chemical* Sources* to Proper,Adequate Handwashing Came and Wild Mushrooms Approved by Regulatory Authority 2_301.11 Clean Condition-Hands and Anns'` - 3-202.15 Shellstock Identification Present* 2-301.12 Cleanin' Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Prober Tem eratures'" 2-401.12 Discharges From the Eyes.Nose and 3-202.15 Package Inte it°" Mouth* 3-101.1.1 Food Safe and Unadulterated" 3-301.12 Preventing,Contamination When Tustin,* 6 Tags/Records:Shellstock 12I Prevention of Contamination from Hands 3-202.13 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em lo•ees* TagstRecords:Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11 Parasite Destruction* 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and edeas* 590.004(,1) Labeling of Ingredients' 5-204.77-205.11. Location mid Placement* 7 Conformance with Approved Procedures 5Accessibility, Operation aid Maintenance. /HACCP Plans Supplied with Soap and Hand Drying 3-502.1 i Specialized Processing Methods* Devices 3-502.12 Reduced oxygen hacka<gins;,criteria* 6-301.11 Handwashin*Cleanser,Availability 3-103.12 Conformance with Approved Paacednres* 6-301.12 Hand Driving Provision *Denotes critical item in ilie federal 1999 food Code or 105 CMR 596.000. CITY OF SALEM ' ) L BOARD OF HEALTH Establishment Name: Date: / Page:_ of Z� Item Code C—Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified - -:--PLEASE PRINT CLEARLY ro Ls C kQe ( P H c>.!z J 3D 2, i 17o n K-- 1n (n Y i y r A AV-0d A4R-AA9q A - n- f Discussion With Person in Charge: Corrective Action Required: ❑ No Yes 1Voluntary Compliance ElEmployee Restriction/ r 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 Exclusion P Ll 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/r vocation of ❑ Embargo ❑ Emergency Closure your food permit. } ❑ Voluntary Disposal ❑ Other: e i - NJ M nK 1 t.� 3-501.14(C) PHFs Received at'temperatures Violations Ro/ated4c,Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) _ 41'F/451F Within 4 Homs. PROTECTION FROM CHEMICALS 19 3-501.15 Coohna Methods for'PHFs 14 Food or Color Additives PHF Hot and Cold Holding 3-SO'1.16(B) Cold PRFs Maintained at or below 3-202.12 Ad sectio* 590.6040 41`/45°F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 40'F. * 7-101.11 ldentifyinv Information-Original 3-50W 16(A) Roasts Held at or above 130°F. Containers* 7-102.11 Common Name-Workim�Containers* 29 Time as a Public Health Control 7-201.11 Separation-Storage" 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H)590.004(H) Variance Requirement 7-202.12 ConditionsofUse" ~REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP} 7-204.11 Santnzers,Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 21 3-801.11(A) Cnpasteunzed Pre-packaged Juices and 7-204.14 Dr•in=A ants,Criteria* Beverages with Warning 11bels- 7-205.11 Incidertt;nl Food Contact. Lubricants 3-801.11(13) Use of Pasteurized E s* 7-206.11 1 Restricted Use Pesticides. Criteria 3-801.11(D) Raw or Painalty Cooked Animal Focal and Raw Seed Sprouts Not Served. * 7-206.12 Rodent Balt Stations* 3-801,11(0) Uno erred Food Pack, e Not Re-served. 7-306.13 Tracking Powders,Pest Control and I Monitorin-* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of lfi Proper Cooking Temperatures for Animal Foods'Fhat are Raw.linderamkedor PHFs Not Otherwise Processed to Eliminate 3-40Y.L1A(1)(2) Eggs- i5S'F'LSSec. Pathogens.* Fc'oL"vva0or Fggs-hmnedtate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute'Cor Raw Shell ro 3-401.11(A)(2) Connnfnuted Fish,Meats&Gaine Egg Arnmals-155'F 15"sec. 3-401.11(13)(1)(2) Pork and Beef Roast-130"F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. ; catering. mobile food, temporary and 3-401.11(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr y or Ratites-165°F 15 sec. "' above if related to foodborne illness 3-40111(C)(3) Whole-muscle,Intact'Beet Steaks interventions and risk factors. Other 1453174; 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under N29- Microwave 165°'F* Special Requirements. 3-40 L 11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165'F 15 sea * (Iterns 23-39) 3-403.11(B) Microwave-165'F 2 Minute Standing Critical and non-critical viaintions, which do not relate to the Time* foodborne illness interventions and rick fcrc-tors listed above. can be 3-403.11(C) Commercially Processed RTE Pond- found in the following.sections of the Food Code and 105 CMR 140°F` - 590000. 3-40111(fi) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 58D.000 Roasts* 23. Management and PersonnelFO-2 .003 1g Proper Cooling of PHFs _24. Food and Food Protection __FC--3 .004 25 __ _Equipment and Utensils FC 4 _ .005 3-501.14(A) Cool Cooked PFIFs from 140`F to 26 `,Nater,Plumbing and Waste FC 5 .006 70°F Within 2 Hours and From 70"T p7, ph sical FaciiltY __- FC-6 .007 to 41.'F/45'F Within 4 Howl. * 28. Poisonous or Toxic Materials FG-7 .008 3-50L 14(B) Cooling PHFs Made From Ambient _29. S eeialRe uiremsms - 009 -}= Temperature'ingredients to 41`F/45"F 30. ___,_Other Within 4 Rotas)' szroro,ve.av-zoo, *Denotes critical item to 1110 ioderal 1999 Find Code or 105 CMR 590000. 3 47.'!:`-` Commonwealth of Massachusetts +� City of Salem e Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2006 WHO'S PLACE OF BUSINESS IS: Boston Street Liquors File Number:BHF-2004-0096 36 Upton Hills Lane - Middleton MA 01949 LOCATED AT: 0018 BOSTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0018 Jan 1,2006 Dec 31,2006 $50.00 TOBACCO VENDOR BHP-2006-0019 Jan 1,2006 Dec 31,2006 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health C 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 14 of 18 r CITY OF SALEM, MASSACHUSETTS v BOARD OF HEALTH (LSC 3 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970V 4 TEL. 978-741-1800 OFo 0 STANLEY J. USOVICZ, JR. FAX 978-745-0343 eo�yn �F ®?0Df MAYOR WWW.SALEM.COM Ad 3 JOANNE SCOTT, MPH, RS, CHO Op 444sj HEALTH AGENT N 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT SOK S4- ZjgDu-t'S TEL# ADDRESS OF ESTABLISHMENT 19 BOs�orc S'b-ee—f Sglesn_ 0/4'716 MAILING ADDRESS (if different) Qn . /30x (09�M ��h InI-7- dl9`/% OWNER'SNAME " 42Q L, Gka ll TEL# ADDRESS 36 UPAVP #1115 LN CITY A7) {1 STATE /n R- ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Ma84 6 64,z4l HOME TEL# &/-�l�- ?93 HOURS OF OPERATION: Mon9�Tue.9A/ 'Wed -i( Thu.,?-r/ Fri. 9&Sat. 9-/i Sun./.I TYPE OF-ESTABLISHM T FEE check only RETAIL STORE'j Y NO less than 1000sq.ft. - 5 ^0 /1 more than =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 --------------- ------------------------------------------------------- $00---------......------------------------ ---------------- BED/BREAKFAST YES NO $10 ADDITIONAL PERMITS ---------------------------------------------------------------------------------------------------------------------------- MAKE (not just serve) ICE CREAM, YOGURT, SOFT cERVE YES NO $5 TOBACCO VENDOR �Q^6 (ZaV NO 50 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. P 21 $-1,0.5 oc/-3SYgco/ Signature Date Social Security or Federal Identification Number ----------------------------------------------------------------L---------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date ,/ /CZ"1__05 CITY OF, SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 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: Boston Street Variety Address of Establishment: 122 Boston Street Owner's Name: Tuan Nguyen Restrictions: Application Date: 9/14/05 Permit for Food Establishment 322-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 70-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT p CITY OF SALEM, MASSACHUS tom" u LSP' r BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 - FAX 978-745-0343 CITY OF SALEM STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR - HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �&S` 011J STRtE_f� EL# 4d-�- `ISI• 22o I ADDRESS OF ESTABLISHMENT 12 Z JRQ MAILING ADDRESS (if different) OWNER'S NAME •�VA-t N(��N / TEL# 95 5, 22-(z, ADDRESS (22 'ROe-M h,) j . 41=. Z CITSTATE IL4A zip © Y (— CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) � EMERGENCY RESPONSE PERSON bA-N)h-I llk9LX(fw HOME TEL# Jyt Z51�• AN N Am .Ok Mt W k+- d{ 0 FF! #0"I PM HOURS OF OPERATION: Mon.(o �j Tue.t�Wed.4j Thu.6-4 Fria-9 SatSun.* —(f TYPE OF ESTABLISH M T FEE check only RETAIL STORE ES NO less than 1000sq.ft. 1000-10,000sq.ft. =$100 n � 00 more than I0,000sq.ft. =$250 RESTAURANT YES NO ✓L, 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 rf' $50 ALL NON-PROFIT(such as church kitchens) �a'��, 'rEt (�D $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 bet mow dge and belief, have filed all �t�t�e��ax returns and4pn'idI all state taxes required under the law. -- 1W____A d'�aL� gnaw Date Social Security or Federal Identification Number ---------------------------------------------------------------------------- ------------------------------------------ Revised 11/03/03 FOODAP2.adm Check#&Date 11�('S /� / v-o Massachusetts Department of Public Health Salem Board Health p 120 Washington Street, Street,4�" Floor Division of Food and Drugs Salem,MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978)745-0343 Name Date Type of Operation(s) T e of Inspection or l &r othe /9 d�� Ro Service Routine Address Riskh1 Retail ❑ Re-inspection " jdaird-Ij ff LevelL ❑ Residential Kitchen Previous Inspection Telephone E] Mobile Date: HACCP YtN ❑ Temporary E] Pre-operation Owner l lltf 0' ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint f In: ❑HACCP Inspector R Out: Permit No. ❑Other- out. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. revention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities EMPLOYEE HEALTH PROTECTIONFROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC " ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE TIMENEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 21. Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing ❑ CONSUMER ADVISORY 11. Good Hygienic Practices - [122. Pasting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related / Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions t immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below F-CN by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2}(990.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:5900,wFom -74,d. Inspector's Signature l Print: K: x PIC's Signature: Print: 0 / - -""^ Page o Pages r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crass-contamination 1 590.003(A) Assignment of Responsibilsty* 3-302.11(-AN 1) Raw Animal Foods Separated hoot 590-003(11) Demonstration of Knowledge* Cooked and RIE Foods* 2 103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Othcr* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1 I(A) Food Protectloo applicants- 3-302,15 Washing Fruite and Veetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char o* Contamination from the Consumer 590.003(G) Reporting b•Person in Charge* 3-306.14(A)(I3) Returned Food and Reservice of FkKKI* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11. Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Fora* 4 Food and Water From Regulated Sources 1:97 Food Contact Surfaces 590.004(A-R) Compliance with Food Law's 4-501.111 Manual Warewashin;-Hot Water 3-201.12 Food in a Hennetieally Sealed Container* Sanitfiation Temperatures'; 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashino[lot Water 3-202.13 Shell E,,,,s* Sanitization Temperatures* 3-202.14 E sand Milk PratuctS.Pasteurized" 4-501-114 Chemical Sanitization-temp.,pH, 3-202.1G Ice Made From Potable Drinking 4-601,11A g Water" concentration and hardness.Surfaces and "` 5-101.11 Drinkin Water from an Approved Svstem* ( ) Equipment Food Contact S 5909 ,06(A) Bottled Drinking,Water* Utensils Clean" 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Snrfaces of F: ui ment* Shellfish" 4-703.11 Methods of Sanitization--Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.1 1 Re ulatoAuthcnt Clean Condition-Hands and Arens"` 3-202.18 Shellstock Identlficaiian Present" 2-30112 Cleanim*Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wasli* 3-201.17 Game Animals* 1.1 Good Hygienic Practices g Receiving/Condition 2-<401.11 Eating,Drinkinor Using Tobacco 3-202.11 PHFs Received at Pro ner Tem>eratures's 2-401.12 Discharges From the Eyes.Nose and 3-202.15 Package Imc grit y* Mouth* 3-101.11 Pood Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* L6 TagsiRecords:Shellstock Lz Prevention of Contamination from Hands 3-202.18 Shellstock identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Desttnction* Conveniently Located and Accessible 3-,102.12 Records.Creation and Retention* 5-203.11 Numbers and.Ca acities* 590904(11 Labeling of Ingredients* 5-204.11 Location and Placement', - 7 Conformance with Approved Procedures 5-205.,11 Accessibilif",O enation and Maintenance /HACCP Pians Supplied with Scap and Hand Drying 3-502.11 S ecialized Promssin Methods` Devices 3-502.12 Reduced oxv en sling ng,criteria" 6-30111 I3andwashing Cleanser,Awdlabilit 8-103.12 Conformance with Approved Procedures"` 6-301.12 Eland Drvin Provision "Denote;critical item in the federal 1999 Food Code or 105 CMR 590,000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 6-4s"o S'ywdr U tot's • Date: 11//7jok Page: 2- of 2 Item Code C-Critical nem .. DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item. Verified 'PLEASE PRINT CLEARLY - t a:d fuAw Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollar or suspension/revocation of ❑ Embargo ❑ Emergency Closure r� your food permit. �� ❑ Voluntary Disposal ❑ Other: r Y . r� - 3-SOLId(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to, Factors(items 1.22) (Cont) 41 F/45-F Within 4 Hours. PROTECTION FROM CHEMICALS 3-50'1.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding ?-501.16(12) Cold PHFs Maintained at or below 3-202.12 Additive,* 590.004(F) 41°745°F* 3-302.14 Protection from Una t roved Additives* 't-501.16(A) flot PHFs Maintained at or above IS Poisonous or Toxic Substances - O' A17. 7-101.11 Identifying Intin'mation-Origlnai Roasts Held at or above 130°F. 7102 11 7-102.11 Common Name--Workin«Containers" 20 Time as a Public Health Control 7-201.11 So oration-Storage" 3-501.19 Time as a Public Health Counts'* 7-20211 Restriction-Presence and Use` 590.004(H) Variance Require cut 7-202.12 Conditions of Use* 7203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 San9tizets,Criteria-Chemicals* POPULATIONS(HSP 7-204.12 Chemicals for Washin¢Produce,Criteria"` 21 3-NOl.i I(A) Unpastew�ized Pre-packaged Juices attd 'Beverages with Warning Labels- 7-204.14 Dain A>ents,Criteria* -- 7-205.11 Incidental Food Contact.Lubricants* 3-S01.11(B) Use of Pasteurized Eggs* 3-SOLll(Dj Raw or Partially Cooked Annual Food and 7-20611 Restricted Use Pesticides.Criteria* Raw Seed S Croats Not Served. 7-206.12 Rodent Bait Stations* 3-Sp1.11(C) Unopened Food Package Not Re-served. 7-206.13 'Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMElTEMPERATURE CONTROLS77pathogens. *Consumer Advisory Posted for Consumption of Animal Foods'Thai.are Raw,Undercooked of PHFsI6 Proper Cooking Temperatures for Not Otherwise Processed to'Eliminate ocnxa_a vriaoor 3-401.11 A(l)(2) Eggs- 155 e 15 seg. E=gs-hnmediate Service 145°F15sec* 3-302.t3 Pasteurized Eggs Substitute for Raw Shell 3-401.11(!1)(2) Comminuted Fish,Meats&Game E 's* Animals- 155°F 15 sec. 40 1.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, injected Meats- 155`17 15 590�009(A){D) Violations of Section 590.009(A)-(D)in see,* catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Staffed P,IfFs, residential kitchen operations,should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr or Rafrtes-165°.1715 s� above if related to foodborne illness 3-401.11(0)(3) Whole-nmscle, Intact Beef Steaks interventions and risk factors. Other WSF* 590.009 violations relating to good retail. 3-401.12 Raw Animal Foods Cooked in a practices should be debited under #29- Microwave 165`F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. I7 Reheating for Hot Holding VIOLATIONS RELATED TO G60D RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°.F 15 sec.* (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness hnerrenlions and ris&}'actors listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the jblG>wntg sections of the Food Cade(asci 105 CMR '140'F* 590.000. --- - -- ----_.. 3- ng.403.1 I(E) RemaitriUnsheed Portions of Beef ht-emGood Retail Practices FC 580.000 Roasts* 23. Manareanent and-PersonnelFC-2 903 Ig Proper Cooling of PHFs 24 Food and Food Protection _ FC-3 .004 25 _ _ Equipment and Utensils FC 4 ---005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26 Water Plumbin and Wasie FC 5 .006 1(FF Within 2 Flours and From 70°F 27. Ph sic rI Facill FC o .007 to 41°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29_ Spacial Hegniremenis --- -009 Temperature Ingredients to4l°17145°p 3a, Other _-- Within 4 Hours'a ssoonn,„nr_ec-za� -`Denotes critical ilea in ilia Weral 1999 Food Code or 105 CMR 590000. -u -4 -A I . CITY 01F . ACHUSETTS ARD OF HEALTH 120 wASHINGT0ON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Liquor Store Name of Establishment: Boston Street Liquors Address of Establishment: 18 Boston Street Owner's Name: Magdy A. Ghaly Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 140-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 034-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSE `m E}OARD OF HEALTH 120 WASHINGTOTI STREET, 4TH FLOOR NOV 2 4 2004 SALEM, MA 01970 TEL. 978-741-1800 CITY OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT /5(1-S f-tl iv) Ll'e TEL# ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) 3 rrjh L!f/ /y/iela(`��y- /nom olg� OWNER'S NAME Aa,JYy 9k TEL# ADDRESS /�J �fJyl �/��S LN LNC :, STATE_ zip CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON / <(�� HOME TEL#-7:E -99l3 HOURS OF OPERATION: Mon. t/ Tue. z/ Wed. G✓ Thu. // Fri. !/ Sat. // Sun. y TYPE OF ESTABLISHMENT FEE check only RETAIL STORE O less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO I b d� less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR �f 3 �S �E NO $50 ALL NON-PROFIT(such as church kitchens) 1 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 knowloNge and belief, have filed all state tax returns and paid all state taxes required under the law. 1� z2- v5` Sign Date Social Security or Federal Identification Number --------------------------------------------------------------------------------------------q-'--/------------------------------------- Revised 11103103 FOODAP2.adm Check#&Date 359,3 rco CITY OF SALEM, MASSACHUSETTS �'J'�( J BOARD OF HEALTH 120 WASHINGTO,N. STREET, 4TH FLOOR SALEM, MA 01970 ✓,p�,c,� TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner ' s Name : Magdy A. Ghaly Name of Establishment : Arge ' s Liquors, Inc . Address of Establishment : 18 Boston Street Type of Establishment : Liquor Store Application Date : 12/19/2002 Restrictions : Permit for Food Establishment 82-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 20-03 These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. q72ALTH .AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 a FAX 978-745-0343 STANLEY USOVIC7, J R, MAY JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD; ESTABLISHMENT ;NAME OF ESTABLISHMENT S4, k/ /- qA -' TEL# Q - 7Y ADDRESS OF ESTABLISHMENT Asa MAILING ADDRESS (if different) mak Mills 4-A.11, OWNER'SNAME t4lo-Vy 4,I.a Ly TEL#_?- ADDRESS-3L. - -n -T iTY WWAP4"si, -cTAXEP4- ZIP 0/9 Y9 CERTIFIED FOOD MANAGER'S NAM—E(S) CERTIFICATE#(s) (required in an establishment where potentially—hazardous food is prepared.) EMERGENCY RESPONSE PERSON- LL HOME TEL#74S-/ 7/9-,9,9 HOURS OF OPERATION: Mon. ✓ Tue. ✓ Wed. Thu. i/ Fri. C, ''Sat. ✓ Sun. 74 TYPE OF ESTABLISHMt! -T 7-71\ FEE check only RETAIL STORE No "zo less than 1000sq-ft. I! 506 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 S $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE Y NO (gSb ( ' 3 TOBACCO VENDOR ES NOAO 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,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge,a;ed belief, have filed all state tax returns and paid all state taxes required under the law. ow-- 3g CO- I Date Social Security or Federal Identification Number Revised 11125102 FOODAP2,adm Check#&Date,-2s'3 fi(,- 1"2