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'II » THE COMMONWE LTH OF MASSACHUSETTS
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Board of Health
FOQD ESTABLrSHME T INSPECTION REPORT T�,. ,��"��8'Z2 3( .�`��Z
Name Date Tyr�_of Ooeratlon(s) Type of Ins i n
,S � � a ❑ Food Service Routine
Address � I Rts ❑ Retail Re-inspection
Level ❑ Residential Kitchen Previous In�pection
Telephone ��j� ����� •^ ❑ Mobile Date:
0 "�
Owne� HACCP Y/N � Temporary re-operation
�� ❑'Caterer ❑ Suspect Illness
Person in Charge(PIC) ��f Time ❑ Bed/,&-B eakfast ❑ General Complairn
In: (,tr h.(!�',$�y¢�� ❑ HACCP
Inspector Out: Permit No. ❑ Other
Each vio ation checked'requires an expianation on the narrative page(s) and a citation of specific provision(s)
Vf018ted. Non�omplfance w/th:
Violations Related to Foodborne illness Interventions and Risk Factors (Red Items� Arrti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immedia#e corrective 590.009(E) ❑ sgo.00s�� ❑
action as determined by the Board of Health. �ocai�.aw ❑
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Gontamination from Hartds
❑ 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
❑ 4. Food ar�d Waterfrom Approved Source TIMFJTEMPERATURE CONTROLS::(Patentially.Hazardaus Foodsj
❑ 16. Gooking Temperatures
❑ 5. Receiving./Contlition
❑ 17. Reheating
❑ 6, Tags!Records/Accuracy ot Ingredient Statements
❑ 18. Gooling
❑ 7. Conformance with Approved Procedures/HACCP Plans
0 19. Hot and Cold Holding
PROTECTION FROM CONTAMINATION
❑ 20. Time as a Public Health Control
❑ 8. Separation/Segregation/Frotection
' REQUIREMENTS:FOR HIGHLY Sl18CEP7YBLE PORULATIONS(HSP)
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10: Pcopet Adequate Handwashing
❑ 21. Food and Food Preparation for HSP
. CONSUMER ADVISORY
❑ 11. Good Hygienic Practices ' ❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical (C) violations marked rriust be corrected To Foodborne Illnesses Interventions
immediatEly or within 10 days as determined by the Board and Risk Factors (Red ltems t-22):
of Health. Non-critical (N) violatior�s musf 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. _ 590.00U/Federal Food Code.This report, when signed below
�= � ` by a Board of Health member or its agent constitutes an
23: �Management and Personnel (FG2�(5so.003) order of the Board of Health. Failttre to correct violations
24. Food and Food Protection (FGs)(sso.00a� cited in this report rpay result i� suspension or revocation of
25. Equipment and Utensils �Fc-aj�5so.005� the food establishment permit and cessation of food
26. Water, Ptumbing and Waste ��c-5��sso.00s> establishment operations. If aggrieved by this order, you
27. Physical Faciliry �Fc-s��5so.00�> have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials �Fc-�l�sso.00s� and submitted to the Board of Health at the above address
23. Speciat Re�uirements �5so.00s� within 10 days of receipt of this order.
30. Other - DATE OF RE-fNSPE��t�N•
Inspector's Signature: ► print: �-
a ti
PIC's Signature: Print: Page�of�Pages
Reorders:Astro Data(781)246-2005 This form approved by the Massachusetts Department of Public Health.
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Vlo/ations Related fo Foodbome lllness �- " "
lnt+erventions and Risk Factors(Red Items i 22) PROTECTION FROM CONTAMINATION
8` Cross-contamination
- FOE)D`PRQT�ION MANAGEMENT � 3-302.11(A)(1) Raw Animal Faods Sepatated from , - §
. `` 5.90.003(A)' Assi ' ent of Res nsibilit * Coo�ed and.IrI'�n�i�ods.*_ � ":
590.003(B) Uemonscration of Knowled e*' _ '' Confaminat�on fiom-F�w M redienis `
2-103.11 �eison in Char e-Duties - 3-302.11 fA)(2) Raw Animal Foods Segaratied from Each {
Other* ,
�`EMPLOYEE HEALTH � Contamination from the Enviwnment
� 590.003(C) �-�esponsibility of the Person in Charge to 3-302.11(A) Ft�od Pretection* � -
require reporting by Food Eq�ployees and 3-302.15 Washing Fruits and Vegetables y
"�� Applicants* � �
�' 3.304.11 Food Gontact with Equipment and
590.003(F) Responsibility of a Fooci Employee or an , Utensils* �
Applicant to Report to the Person in Contamination l►'om the CbnSmmer
CharSe* -..
3-306.14(A)(B) Returned Food and Reservice of Food*
590.D03(G) ReporEing by Person in Charge* Disposition of Adulterated or Contaminated
590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discazding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE y Food Contact Surfaces
�; Food and Water From Regulated Sources 4-501.111 Manual Warewashiag-Hot Water
590.004(A-B) Compliance with Food Law* Sani6zation Tempetatures*
3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water :
3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures'� �
3-202.13 Shell Eggs* 4-501114 Chemical Sanitization-temp.,pH,
3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness*
3-202.16 Ice Made from Potable Drinking Water* 4-60111(A) Equipment Food ContactSurfacesat�d
5-101.11 Drinking Water ftom an Approved System* Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- i
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils*
Shel�sh and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Ute�ils and
3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization- Hot Water and
3-20115 Molluscan Shellfish from NSSP Listed Chemical*
Sources* �
i6 Proper,Adequate Handwashlr�g
: Game�nd Wild Mushrooms Approved by 2-301.11 Clean Condiuon-Hands and Arms* '
Regulatory Authority 2-301.12 Cleaning Procedure�`
3.202.18 Shellstock Identification Present* 2-301.14 When to Wash*
590.004(C) Wild Mushrooms* 11 ' Good HygieniC Practices ,
3-201.17 Game Animals* 2-401.11 Eadng,Drinking or Using Tobacco*
Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and
3-202.11 PHFs Received at Proper Temperatures* Mouth*
3-202.15 Package Integrity*
3-301.12 Preventing Contamination When Tasdng*
3-101.11 Food Safe and Unadulterated* ��; PrevenUon of Gontamination from Hands
` Taga/Records:Shelistock 59p.pp4(E) Preventing.Contamination from
3-202.18 Shellstock Identification* Employees* ',
3-203:12 Shellstock Identifica6on Maintained* 13' ' Handwash Facflities I
�ags/Records:Fish Products Convenientty Located and Accessib/e s ,
3-402.11 Parasite Destruction* ' S-203.11 Numbers and Capacides*
' 3-402.12 Records,Creation and Retention* 5-20411 Location and Placement*
590.004(n Labeling of Ingredients* - 5-205.11 Accessibility,Ogeration and Maintenance
CoMonnance wlth i4p�proved Procedures � Supplied with Soap and Hand Drying
MACCP Plans Devices
n � � �
3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availabikty,
3-502.12 Reduced Oxygen Pacltaging,Criteria* 6-301.12 Hand Drying Provision
8-103.12 Conformance�witti Approved Procedures*
+peaotes ctiticai item in the[ederal 1999 Food Code or 105 CMR 590.000.
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Violations Related to Foodborne lllness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures
Factors(Red liems 1-22) (Cont.) According to Law Cooled to
41°F/45°F Wi[hin 4 Hours.
i
PROTECTION FROM CHEMICALS 3-501.l5 Cooling Methods for PHFs f
I 14 ; Food or Color Additives 19 ; PHF Hot and Cold Holding
3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below
3-202.14 Protection from Una roved Additives* 590.004(F) 41°F/45°F*
;'15 ' Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140°E*
Containers* 3-501.16(A) Roasts Held at or above 130°E*
7-102.11 Common Name-Workin Containers* 20 : Time as a Public Health Control
7-201.11 Se aration-Stora e* 3-501.19 Time as a Public Health Control* �
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE '
7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP)
7-204.11 Sanitizers,Criteria-Chemicals* 21 < 3-80111(A) Unpasteurized Pre-packaged Juices and
7-204.12 Chemicals for Washin Produce,Criteria* Beverages with Warning Labels* '
7-204.14 D in A ents,Criteria* 3-801.11(B) Use of Pasteurized E s* ��
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.*
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.*
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
Z� ' ?-603.11 Consumer Advisory Posted for Consumption of ,
TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or
; 16 Proper Cooking Temperatures for not Otherwise Processed co Eliminate
PHFS Pathogens.* EHective 1/1/2001 �
3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* i
Eggs-Immediate Service 145°F 15 Sec.*
3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL RE�UIREMENTS
Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in r
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering,mobile food,temporary and
3-401.11(A)(2) Ratites,In'ected Meats-155°F 15 Sec.* residential kitchen operations should be
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections
Stuff'in Containin Fish,Meat, �
8 g above if related to foodborne illness �
Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors.Other
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail
145°F* practices should be debited under�129-
3-401.12 Raw Animal Foods Cooked in a Special Requirements. �
Microwave 165°F* i
3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETA/L PRACTICES '
17 Reheating for Hot Holding (Blue Items 23-30)
3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the
3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be
Time* found in the following sections of the Food Code and 105 CMR
3-403.11(C) Commercially Processed RTE Food- 590.00.
140°F* Item Good Retail Practices FC 590.00
3-403.11(E) Remaining Unsliced Portions of Beef 23. Mana ement and Personnel FC-2 .003
Roasts* 24. Food and Food Protection FC-3 .004
, �.g ;' Proper Cooling of PHFs 25. E ui ment and Utensils FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbin and Waste FC-5 .006 I�,
70°F Within 2 Hours and from 70°F 27. Ph sical Facilit FC-6 .007
to 41°F/45°F Within 4 Hours.* 2g, Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial Re uirements .009
�I Temperature Ingredients to 41°F/45°F 30. Other
� Within 4 Hours*
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
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