HomeMy WebLinkAboutFood Establishment Inspection ReportTHE COMMONWEALTH OF MASSACHUSETTS
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FOOD ESTABLISHMENT INSPECTION REPORT
Board of Health
Name
Date
Type of Operation(s) v
Type of Inspection
C'eGth h47S
G/z(�/ba_
❑ Food Service
El Retail
Routine
❑ Re -inspection
Address ��
Risk
•5 -e-
Level
❑ Residential Kitchen
El Mobile
Previous Inspection
Date:
Telephone (7 . .- 3 Ct .. a 3
�/
❑ Temporary
❑ Pre -operation
Owner
HACCP Y/N
❑ Caterer
El Bed & Breakfast
❑ Suspect Illness
El General Complaint
Person in Charge (PIC r i`
Time
l h l
In:
Out:
Permit No.
❑ HACCP
III Other
Inspector 7z-•e4m
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)
violated. Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑
action as determined by the Board of Health. Local Law ❑
FOOD PROTECTION MANAGEMENT l
❑ 1. PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted / Excluded
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source
❑ 5. Receiving / Condition bl(
❑ 6. Tags / Records / Accuracy of Ingredient Statemeh#S
❑ 7. Conformance with Approved Procedures / HACCP Plans
PROTECTION FROM CONTAMINATION
❑ S. Separation / Segregation / Protection
❑ 9. Food Contact Surfaces Cleaning and ti ' g
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices (Blue
Items) Critical (C) violations marked must be corrected
immediately or within 10 days as determined by the Board
of Health. Non -critical (N) violations must be corrected
immediately or within 90 days as determined by the Board
of Health.
C N
23. Management and Personnel (FC-2)(590.003)
24. Food and Food Protection (FC-3)(590.004)
25. Equipment and Utensils (FC-4)(590.005)
26. Water, Plumbing and Waste (FC-5)(590.006)
27. Physical Facility (FC-6)(590.007)
28. Poisonous or Toxic Materials (FC-7)(590.008)
29. Special Requir e�ts (590.0
30. Other /1 1
Inspector's Signatuge• � _�/� I Print:
PIC's Signature: , /1;29 r f Print:
❑ 12. Prevention of Contamination from Hands
❑ 13. Handwash Facilities 6
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color dditives
❑ 15. Toxic Chemicals
TIMEITEMPERATURE CONTROLS (Potentially. Hazardous Foods)
❑ 17. Ptehes3tirrtl'-
❑ 18. Cooling„
❑ 19. t ar1fild Cold Holding
❑ 20. Time as a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
❑ 21. Food and Foo ee4o�HSP
CONSUMER ADVISORY
❑ 22. P dvisories
Number of Violated Provisions Related
To Foodborne Illnesses Interventions
and Risk Factors (Red Items 1-22):
Official Order for Correction: Based on an inspection
today, the items checked indicate violations of 105 CMR
590.000/Federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
the food establishment permit and cessation of food
establishment operations. If aggrieved by this order, you
have a right to a hearing. Your request must be in writing
and submitted to the Board of H Itch at the above address
within 10 days of receipt of this e'
DATE OF RE -INSPECTION:
,e 0,)
^ I
Page-L-of o2-Pages
Reorders: Astro 1Xta (781) 246-2005 This form approved by the Massachusetts Department of Public Health.
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