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TOWN OF NORTH ANDOVER
BOARD OF SELECTMEN GENERAL LICENSE APPLICATION
Indicate if license is: ❑new ❑transfer kchange of dba ,other (°H"ee-
Check type of license you are applying for:
❑ Common Victualler Package Store
❑ Restaurant All Alcohol ❑Package Store Wine&Malt
❑ Restaurant Wine&Malt
❑ Club All Alcohol ❑Class I No.of vehicles for display:
❑ Annual Entertainment ❑Class II No. of vehicles for display:
❑ Sunday Entertainment ❑Class III motor vehicle junk license
❑ Electronic Games-list below: ❑Fortune teller
❑Vehicle for hire/taxi No: of vehicles:
❑ Jukebox
❑ Billiard Table-No: of tables
Name of Applicant: %US r qrV 1hA2kc7-IWC
Business Name: 7-;ye VlN 2p KINfW 1)4-n 74,�Tr€ aF Vie-
If business is a dba,please attach a copy of busine11py:certificate.
If business is a corporation or LLC,please attach
1. Certificate of Good Standing dated withi the last 6 months; and
2. Corporate Vote authorizing business at a stated location.
Address of licensed premises: 5 u �i4"APi 'r ,-r (*':r.� 414vc.q;r 71 79? 'TIIANP J)ae J)-d
Mailing address(if different from above): 3 Prywre-t-rwT
Business Telephone No: b bpi' SOUS Business Email:
F.E.I.N.: 2-06 3 1 9# 3 I
Please check one of the followings: ❑own r remises ease premises ❑property under P&S
Name and address of property owner if di ;erent from license holder:
slop Sh'o� S�P`Yt ��T Lac �~
Name Ahdress
If applicable,please attach a copy of the i ase or Purchase and Sal eeme
If applicable,please provide, on paper no larger than 8'/2 x 14:
1. Ei t(8)copies of the floor Ian of building(includin kitch an eatin ar }; ' d
2. Eigh (8)copies of the site pl n indic ting parking a�i� s an s� o t w y
If applying for a Cla s I,Class Il or Class III Ii,,e ses, lea t a I th �s o s:
p
1. The num r of vehicles on d pla
2. The exact cation of the ve cies f
3. Customer pa king
4. Office area
Proposed hours of operation:
Monday Pont - 11 Pm ThursdayL,2!'t
Tuesday g o9a. - 011., Friday 6 1.,K /I p /
Wednesday _ , f1M Saturday 19 .pi,t — /,, Prwr / Sunday /0 91n
(Specify liquor sale hours if different than regular establishment hours):
Has applicant operated a similar business? ` Yes ONo If yes,please provide:
Name of business:_ —/7-/C- 044-yianp
Address of business: 5 y -y,g yr f& - .
Federal Tax Number: Z003131-41
Do you currently hold a similar license?,kYes ❑No What type? s+m e OCtJ'%^��
Have you previously applied for a license?XYes ❑No
Have you ever had a license revoked? ❑Yes Lilo If Yes,please indicate why:
I hereby authorize the North Andover Police Department to conduct a fingerprint based national criminal
record check and provide said information to the local licensing authority.
�. /6. it
Signature Date
Pursuant to MGI.Chapter 62C, §49A and Chapter 40, §57,I hereby certify under the penalties of perjury
that all state tax returns have been filed and all state and local taxes have been paid.
8- je. a
Signature Date
I hereby certify that I have read the conditions included with this application,including the requirement to
submit to a fingerprint based criminal record check, and agree to comply with any further stipulations that
the Licensing Authority may from time to time approve. I also hereby authorize the licensing authority or
their agent to conduct whatever investigation or inquiry is necessary to verify the information contained
in this ap h ation.
• /8. 16
Signtuar' Date
In addition to the documents stated in the application,applicant must provide the following:
❑ ABCC Form A, if applicable
0 Certificate of Good Standing from the Department of Revenue
❑ Check for filing fee of$100.00 made payable to the Town of North Andover
❑ Reportort of the Technical Review Committee
❑ For corporations-certified copy of Articles of Organization from the Secretary of
Commonwealth's Office
❑ For corporations-a vote of the Board of Directors appointing a Manager
❑ For partnerships-copy of the Partnership Agreement
0 For transfer of a license-Form 983 or 983A
❑ Check for filing fee of$200.00 made payable to the Alcoholic Beverage Control Commission
0 Check for License fee- $3,000-Restaurant All Alcoholic Beverages
$2,000-Restaurant Wine&Malt
$2,200-Inn holder All Alcoholic Beverages
$2,000-Club All Alcoholic Beverages
$2,000-Package Stores All Alcoholic Beverages
$1,500-Package Stores Wine&Malt
$100.00-One Day All Alcoholic Beverages
$75.00 One Day Wine&Malt
$50.00 Fortune Teller
Please contact the Town Cleric's Office with any questions at(978)688-9501
The Commonwealth of Massachusetts Print Form
Alcoholic Beverages Control Commission
239 Causeway Street
Boston,MA 02119
www.mass.gov/ahcc
RETAIL ALCOHOLIC BEVERAGES LICENSE APPLICATION
MONETARY TRANSMITTAL FORM
APPLICATION SHOULD BE COMPLETED ON-LINE, PRINTED,SIGNED,AND SUBMITTED TO THE,LOCAL
LICENSING AUTHORITY.
REVENUE CODE: RETA
CHECK PAYABLE TO ABCC OR COMMONWEALTH OF MA: $200.00
(CHECK MUST DENOTE THE NAME OF THE LICENSEE CORPORATION,LLC, PARTNERSHIP,OR INDIVIDUAL)
CHECK NUMBER:
IF USED EPAY,CONFIRMATION NUMBER:
ABCC LICENSE NUMBER(IF AN EXISTING LICENSEE,CAN BE OBTAINED FROM THE CITY): 082600036
LICENSEE NAME: Tuscan Market,Inc.,d.b.a.The Vineyard
ADDRESS: 554 Turnpike Street
CITY/TOWN: North Andover STATE MA ZIP CODE 01845
TRANSACTION TYPE(Please check all relevant transactions):
F1 New License ❑ New Officer/Director ❑ Pledge of License ❑ Change Corporate Name
F1 Transfer of License ❑X Change of Location Pledge of Stock []Seasonal to Annual
Change of Manager Alteration of Licensed Premises Transfer of Stock E]Change of License Type
n Cordials/Liqueurs Permit New Stockholder Issuance of Stock QX Other Change d.b.a.Name
n6-Day to 7-Day License Management/Operating Agreement E] Wine&Malt to All Alcohol
THE LOCAL LICENSING AUTHORITY MUST MAIL THIS TRANSMITTAL FORM ALONG WITH
THE CHECK,COMPLETED APPLICATION,AND SUPPORTING DOCUMENTS TO:
ALCOHOLIC BEVERAGES CONTROL COMMISSION
P.O.BOX 3396
BOSTON,MA 02241-3396
' The Commonwealth of Massachusetts
Alcoholic Beverages Control Commission
239 Causeway Street
Boston,MA 02114
wwov.mass.gov/abcc
PETITION FOR CHANGE OF LICENSE
0826-00036 North Andover
ABCC License Number Cityrrown
The licensee Tuscan Market,Inc. respectfully petitions the Licensing Authorities to approve the
following transactions:
❑ Change of Manager ❑ Alteration of Premises 0 Change of Corporate Name/DBA
❑ Pledge.of License/Stock ❑ Cordial&Liqueurs a Change of Location
❑ Change of License Type(§12 ONLY,e.g."club"to"restaurant`
❑ Change of Manager Last-Approved Manager:
Requested New Manager:
❑ Pledge of License/Stock Loan Principal Amount:$ Interest Rate:
Payment Term: Lender:
XQ Change of Corporate Name/DBA Last-Approved Corporate Name/DBA: FTh7eV!neyard
Requested New Corporate Name/DBA: A Taste of the Vineyard
❑ Change of License Type Last-Approved License Type:
Requested New License Type:
❑ Alteration of Premises:(must fill out attached financial information form)
Description of Alteration:
Description of Premises:
I
❑X Change of Location:(must fill out attached financial information form)
Last-Approved Location: 554 Turnpike Street
Requested New Location: 757 Turnpike Street
J.0 An
Signature of LicenseeZ10.4i $I Date Signed !V-/ 7
fa'Corporatbn/l1C,byIts authorized repres tative)
Y �y
THE COMMONWEALTH OF MASSACHUSETTS
•s TOWN OF NORTH ANDOVER 1600 Osgood Street Suite 2035
d
North Andover,MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH Nor ,Massachusetts 01845
Division of Food and Drugs Phone-978.688.9540
FOOD ESTABLISHMENT INSPECTION REPORT Fax-978.688.8476
e-mail: healthde t@to wnofnorthandover.com
Name of Establishment p Date Type of Operation(s) Type of Inspection
T V V �'C 2L 4 -CY-I E] Food Service Q Routine
Address c- Risk Level ® Retail ❑Re-inspection
Telephone
El Residential Kitchen Previous Inspection
06S ❑ Mobile Date:
Owner HACCP: ❑ Temporary ❑Pre-operation
IBJ Y / N ❑ Caterer ❑ Suspect Illness
Person-in-Charge(PIC) r Time V ❑ Bed&Breakfast ❑ General Complaint
E], HACCP
In.
Inspector ��2 Out:1200 ❑
Year: Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective action as Tobacco 590.009(F) ❑
determined by the Board of Health. Allergen Awareness 590.009 (G)❑
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwashing 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 and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition [116.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans [:118.Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control
REQUIREMENTS FOR HIGHLY-SUSCEPTIBLE-POPULATIONS(HSP)
❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑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 Practices(Blue Items) Number of Violated Provisions Related To
Critical (C) violations marked must be corrected immediately Foodborne Illnesses Interventions and Risk
or within 10 days as determined by the Board of Health. Factors(Red Items 1-22):
Non-critical (N) violations must be corrected immediately or Official Order for Correction:Based on an inspection today,the items
within 90 days as determined by the Board of Health. checked indicate violations of 105 CMR 590.000/federal Food Code.This
C N
23. Management and Personnel (FC-2)(590.003) report,when signed below by a Board of Health member or its agent
24. Food and Food Protection (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
aggrieved by this order,you have a right to a hearing.Your request must
27. Physical Facility (FC-6)(590.007) be in writing and submitted to the Board of Health at the above address
28. Poisonous or Toxic Materials (FC-7)(590.008) within 10 days of receipt of this order.
29. Special Requirements (590.009) DATE OF RE-INSPECTION:
30. Other
Inspector's Signature:' Vd, Print: G`� a
ICs Signature: Print: Page C of ages
�� h
Violations Related to Foodborne Illness Interventions and Risk Factors
(Red Items I-22)
FOOD PROTECTION MANAGEMENT
1 590.003(A) Assignment ofRes onsibilit * PROTECTION FROM CONTAMINATION
590.003(B) DemoustrationofKnowledge* 18 Crass-contamination
2-103.11 Person in charge-duties 3-302.11(A)(1) Raw Animal Foods Separated front
Cooked and RTE Foods*
EMPLOYEE HEALTH Contamination from Raw Ingredients.
2 590.003(C) Responsibility of the person in charge to 3-302.11(A)(2) Raw Animal Foods Separated from Each
require reporting by food employees and Other*
applicants* Contamination from the Environment
590.003(F) Responsibility Of A Food Employee Or An 3-302.11 A Food Protection*
Applicant To Report To The Person in 3-302.15 Washing Fruits and Vegetables
Charge* 3-304.11 Food Contact with Equipment and
590.003(0) Reporting by Person in Charge* Utensils*
3 590.003(D) Exclusions and Restrictions* Contamination from the Consumer,
590.003(E) Removal of Exclusions and Restrictions 3.306.14 A B Returned Food and Reservice of Food*
Disposition ojAdulterated or
FOOD FROM APPROVED SOURCE Contaminated Food
4 Food and Water From Re ulatcd Sources 3-701.11 Discarding or Reconditioning Unsafe
590.004 A-B Compliance with Food Law* Food*
3-201.12 Food in a Hermetically Scaled Container* 9 Food Contact Surfaces
3-201.13 Fluid Milk and Milk Products* 4-501.111 Manual Warewashing-Hot Nater
3-202.13 Shell Eggs* Sanitization Tem eratures*
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.112 Mechanical Warewashing-Hot Water
3-202.16 Ice Made From Potable Drinking Dater* Sanitization'fens eratures*
5-101.11 Drinking Water from an Approved System* 4-501.114 Chemical Snnitization-temp.,pll,
590.006(A) Bottled Drinking Water* concentration and hardness.*
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-601.11(A) Equipment Food Contact Surfaces and
Shellfish and Fish From an Approved Utensils Clean*
Source 4-602.11 Cleaning Frequency of Equipment Food-
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces and Utensils*
Shellfish* 4-702.11 Frequency of Sanitization of Utensils and
3-201.15 Molluscan Shellfish from NSSP Listed Food Contact Surfaces of Equipment*
Sources* 4-703.11 Methods of Sanitization-Hot Water and
Ganre awl Wild Mushrooms Approved by Chemical*
RegulatoryRegulatoty Authorit y 10 Proper,Adequate Handwashin
3-202.18 Shellstock Identification Present* 2-301.11 Clean Condition-Hands and Arms*
590.004(C) Wild Mushrooms* 2-301.12 Cleaning Procedure*
3-201.17 Game Animals* 2-301.14 When to Wash*
S Receiving/Condition 11 Good Hygienic Practices
3-202.11 PHFs Received at Proper Temperatures* 2-401.11 Eating,Drinking or Using Tobacco*
3-202.15 Package Integrity* 2-401.12 Discharges From the Eyes,Nose and
3-101.11 Food Safe and Unadulterated* Mouth*
6 Ta s/Records:Shellstock 3-301.12 Preventing Contamination When Tasting*
3-202.18 Shellstock Identification* 12 Prevention of Contamination 111.0111
3-203.12 Shellstock Identification Maintained* Hands
590.004(E) Preventing Contamination from
Ta s/Records:F7sh Products Pre Employees*
3-402.11 Parasite Destruction* 13 H ployees Facilities
3-402,12 Records,Creation and Retention* ConvenientlyLocated and Accessible
590.004(J) 5-203.11 Numbers and Capacities*
Labeling of Ingredients* 5-204.11 Location and Placement*
7 Conformance with Approved 5-205.11 Accessibility,Operation and Maintenance
Procedures/HACCP Plans Supplied%with Soap and Hand Dtying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availabili
8-103.12 Conformance with Approved Procedures* 6-301.I2 Hand Drying Provision
*Denotes critical iteir in the federal 1999 Food Code or 105 CMR 590.000.
THE COMMONWEALTH CF
MASSACHUSETTS ?
TOWN OR CITY OF
Establishment Name: Date: Page:
of
Item Code C-Critical Item DESCRIPTION OF VIOLATION /PLAN OF CORRECTION Date
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
tv ; a
Discussion With Person in Charge: Corrective Action Required: No ❑ Yes
�
L3 Voluntary Compliance Ll Employee Restriction/
►° U r ^1 -"'_ Exclusion
,t I ❑ Re-inspection Scheduled ❑ Emergency Suspension
40
❑ Embargo ❑ Emergency Closure
d I��
OA� `, C�l ❑ Voluntary Disposal ElOther:AJ
Form 734 B A.M.Sulkin Co..Boston,MA L
Violations Related to Foodborne Illness
Interventions and Risk Factors(Red Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT t3 Cross-contamination
1 590-003(A) Assignment of Responsibility* 3-302.11(AXI) Raw Animal Foods Separated from
590.003(13 Demonstration of Knowledge* Cooked and KIT.Foods*
2-103.11 Person in charge-duties Contamination from Raw Ingredients
3-302.11(Ax2) Raw Animal Foods 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 3-302.11 A Food Protection*
applicants* 3-302.15 Washing Fruits 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*
Charge* Contamination from the Consumer
590.003(G) Reporting 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
590.003E Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Fes*
4 Food and Water From Regulated Sources 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 Tem atures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*
3-202.14 Eggs 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 System* 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* 4-602.11 Cleaning Frequency of Equipment Food-
Sheffish and Fish From an Approved Source Contact Surfaces and Utensils*
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* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulat Autho' 2-301.11 Clean Condition-Hands and Arms'
3-202.18 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
5 Receiving/Condition 21101.11 Eating,Drinking or Using Tobacco*
3-202.11 P111 s Received at Proper Temperatures* 21101.12 Discharges From the Eyes,Nose and
3-202.15 Package Irate *_ Mouth*
3-101.11 Food Safe and Unadulterated3-301.12 Preventin Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contarnination 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 Facilitles
3402.11 Parasite Destruction* Conveniently located and Accessible
3402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility, tion and Maintenance
/HACCP Plans Suppled with Soap and Hand Drying
3-502.11 Specialized Process' Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision
'
Denotes criticai item in the federal 1999 Food Code or 105 CMR 590.000.
t
THE COMMONWEALTH OF MASSACHUSETTS
* TOWN OF NORTH ANDOVER 1600 Osgood Street, Building 20; Suite 2-36
North Andover,Massachusetts 01845
*'••.=-;'* Phone-978.688.9540 Fax-978.688.8376
*a+�cxusEs4� FOOD ESTABLISHMENT INSPECTION REPORT e-mail: healthdept(&townofnorthandover.com
Name of Establishment t,� Dat' Tvpe of 0peratLgLs) Tvpe of Inspection
V/^ ax ❑ Food Service rurboutine
Address l Rik Level Retail Re-inspection
CI�Telephone Residential Kitchen Previous Inspeclion
El Mobile
Owner HACCP: ❑ Temporary ❑ Pre-operation
Y / N ❑ Caterer ❑ Suspect Illness
Person-in-Charge(PIC) Time
Bed& Breakfast 1-1
General Complaint
1'� ❑ ❑ HACCP
p In: 1 3D ❑ Other
Inspector M f Out: 12 Year:
Each violation the ed 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 59o.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
corrective action as determined by the Board of Health. Allergen awareness 590.009 (c)❑
FOOD PROTECTION MANAGEMENT
❑ 12.Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH ❑ 13. Handwashing Facilities
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 and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans [:118.Cooling
PROTECTION FROM CONTAMINATION F-1 19.Hot and Cold Holding
❑ 20.Time as a Public Health Control
❑ 8.Separation/Segregation/Protection
REQUIREMENTS FOR HIGHLY-SUSCEPTIBLE-POPULATIONS(HSP)
❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑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 Practices(Blue Items) Number of Violated Provisions Related To
Critical (C) violations marked must be corrected immediately Foodborne Illnesses Interventions and Risk
or within 10 days as determined by the Board of Health. Factors(Red Items 1-22):
Non-critical (N) violations must be corrected immediately or Official Order for Correction:Based on an inspection today,the items
within 90 days as determined by the Board of Health. checked indicate violations of 105 CMR 590.000/federal Food Code.This
C N
23. Management and Personnel (FC-2)(590.003) report,when signed below by a Board of Health member or its agent
24. Food and Food Protection (FC 3)(590.004) 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
25. Equipment and Utensils (FC-4)(590.005)
26. Water, Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
aggrieved by this order,you have a right to a hearing.Your request must
27. Physical Facility (FC-6)(590.007) be in writing and submitted to the Board of Health at the above address
28. Poisonous or Toxic Materials (FC-7)(590.008) within 10 days-of receipt of this order.
29. Special Requirements (590.009) DATEOFRE-INSPECTION:
30. Other
Inspector's Signature: Print: f
P1Cs Signature: Print: t Page I-of Zpages
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodbome Illness Interventions and Risk According to Law Cooled to
Factors(Red/tems 1-22) (Cont) 41°F/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
ld Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives* 3-501.16(B) Cold PRFs Maintained at or below
3-302.14 Protection from Unapproved Additives*
590.004(F) 410/450 F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140°F.*
Containers* 3-501.16(A) Roasts Held at or above 130°F.
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
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 for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents,Criteria* -Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-851.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.1 1(D) Raw or Partially Cooked Animal Food and
7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. *
7-206.13 Tracking Powders,Pest Control and 3-801.11(C) i Unopened Food Package Not Re-served.
Monitoring*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*H/edNe11112001
Eggs-Immediate Service 1450FI5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.11(A)(2) Comminuted Fish,Meats&Game
Animals- 155°F 15 sec.* SPECIAL REQUIREMENTS
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. catering,mobile food,temporary andresidential kitchen operations should be
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections
Stuffing Containing Fish,Meat, 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#29-
3-401.12 Raw Animal Foods Cooked in a Special Requirements.
Microwave 165°F
3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec.* VIOLATIONS RELATED TO GOOD RETAIL 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
found in the following sections of the Food Code and 105 CMR
Time* 590.000.
3-403.11(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000
140°F* 23. Management and Personnel FC-2 .003
3-403.11(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004
Roasts* 25. Equipment and Utensils FC-4 .005
18 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 .006
3-501.14(A) Cooling Cooked PHFs from 140°F to 27• Physical Facility FC-6 1 .007
28. Poisonous or Toxic Materials FC-7 .008
70°F Within 2 Hours and From 70°F 29. Special Requirements .009
to 41°F/45°F Within 4 Hours.* 30. 1 Other
3-501.14(B) Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/45°F
Within 4 Hours*
•Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
THE COMMONWEALTH CF MASSACHUSETTS
TOWN OR CITY OF ��� A�� t
Establishment Name: Date: /Ca �1.� Page: of 2.
Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
8 C%
Discussion With Person in Charge: � 1 A. _. Corrective Action Required: No ❑ Yes
l� ❑ Voluntary Compliance ❑ Employee Restriction/
f � Exclusion
❑ Re-inspection Scheduled ❑ Emergency Suspension
��. -z�. r
❑ Embargo ❑ Emergency Closure
i.
❑ Voluntary Disposal ❑ Other:
Form 734 B A.M.Sulkin Co.,Boston,MA
Vlolations Related to Foodborne Illness
Interventions and Risk Factors(Red Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT LL Cross-contamination
1 590.00.1(A) Assignment of Re nnbili * 3-302.11(AX 1) Raw Animal Foods Separated from
590.0031 13Demonstration of Knowledge* Cook(A and R11 Foods*
2-103.11 Person in charge-duties Contamination hnm Raw Ingreefents,
3-302.11(Ax2) 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*
applicants* 3-302.15 Washing Fruits 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*
Charge* Contamination from the Consumer
590.003{G)----- Reporting 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
590.003E 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* 4-501.111 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 Eggs* Sanitization Temperatures*
3-202.14 Eggs 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 System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Botiled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food-
She9lish and Fish From an Approved Source Contact Surfaces and Utensils*
4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of W ent*
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 2-301.11 Clean Condition-Hands and Arms*
Regulatory Autho'
3-202.18 Shellstock Identification Present* 2-301.12 Procedure'
590. Wild Mushrooms' 2-301.14 When
hen to Wash'
3-201.17 Game Animals* 11 Good Hygienic Practices
1 5 ReceivinglCondition 2 401.11 Eating,Drinking or Using Tobacco*
3-202.11 P11Fs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and
3-202,15 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated3-301.12 Preventing Contamination When Tasting*
6 TagslRecords:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em to ees*
Tags/Records:Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction* Conveniently Located and Accessible
31302.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement*
Conforrnance with Approved Procedures 5-205.11 Accessibility, tion and Maintenance
MACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Provision
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
. MRRRReR
RECEJEDon,
THE COMMONWE LTH OF MAS
JUN 2
TOWN OF NORTH ANDOVE o Osgood street,Building 20; Suite 2-36
* * TOWN OF NORNorth Andover,Massachusetts 01845
* .�;,•'# HEALTH DE -978.688.9540 Fax-978.688.8476
��da�cxusE`1� FOOD ESTABLISHMENT INSPECTION REPORT e-mail: healthdept(&townofnorthandover.com
Name of Establishment- ) Date Type of Operation(s) Type of Inspection
' C 1�P a�C� • -1"f pL ❑ Food Service Woutine
Address Risk Level P Retail ❑ Re-inspection
Telephone ❑ Residential Kitchen Previous Inspection
❑ Mobile
Ownert HACCP: El Temporary ❑ Pre-operation
y N El Caterer
le� El HACCP: Illness
/
Person-in-Charge(PIC) Time2C ElBed& Breakfast a HACCP General Complaint
In:
InspectorE04 JA^1_1 Out: `16 Year: ElOther
Each violation ch ked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
corrective action as determined by the Board of Health. Allergen Awareness 59o.009 (G)❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑13. Handwashing 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
FOOD FROM APPROVED SOURCE ❑ 15.Toxic Chemicals
❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 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
REQUIREMENTS FOR HIGHLY-SUSCEPTIBLE-POPULATIONS(HSP)
❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑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 Practices(Blue Items) Number of Violated Provisions Related To
Critical (C)violations marked must be corrected immediately Foodborne Illnesses Interventions and Risk
or within 10 days as determined by the Board of Health. Factors(Red Items 1-22):
Non-critical (N)violations must be corrected immediately or Official Order for Correction:Based on an inspection today,the items
within 90 days as determined by the Board of Health. checked indicate violations of 105 CMR 590.000/federal Food Code.This
C N
23. Management and Personnel (FC-2)(590.003) report,when signed below by a Board of Health member or its agent
24. Food and Food Protection (FC-3)(590.004) constitutes an order of the Board of Health.Failure to correct Violations
25. Equipment and Utensils cited in this report may result in suspension or revocation of the food
(FC-4)(590.005) establishment permit and cessation of food establishment operations.If
26. Water, Plumbing and Waste (FC 5)(590.006) aggrieved by this order,you have a right to a hearing.Your request must
27. Physical Facility (FC-6)(590.007) be in writing and submitted to the Board of Health at the above address
28. Poisonous or Toxic Materials (FC-7)(590.008) within 10 days of receipt of this order.
29. Special Requirements (590.009) DA TE OFRE-INSPECTION:
30. Other
Inspector's Signature: Print: i
PICS Signature: Print: I �� Page / of ages
k..,---:a: ..t._ -..,._. .-v ..��a, �. �.^..Svt ._._.�:i.....-...-+...._.o....�P�s�-..-.,,..._ ..:-n---« f+
3-501.14(C) PHFs Received at Temperatures
Wo/adons Related to Foodborne Illness Intervendons and Risk According to Law Cooled to
Factors(Red Items 1-22) (Cont.) 41°F/45°F Within 4 Hours.•
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
1d Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below
3-302.14 Protection from Unapproved Additives*
590.004(F) 410/450 F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140°F. *
Containers* 3-501.16(A) Roasts Held at or above 130°F.
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use*
7-203.11 Tokic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP)
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents,Criteria* Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. *
7-206.13 Tracking Powders,Pest Control and 3-801.11(C) 11 Unopened Food Package Not Re-served. *
Monitoring*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*11 0-
Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.11(A)(2) Comminuted Fish,Meats&Game
Animals- 155°F 15 sec.* SPECIAL REQUIREMENTS
3-401.1 l(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. catering,mobile food,temporary and
* residential kitchen operations should be
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections
Stuffing Containing Fish,Meat, 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#29-
3-401.12 Raw Animal Foods Cooked in a Special Requirements.
Microwave 165°F
3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. * VIOLATIONS RELATED TO GOOD RETAIL 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) foodborne illness interventions and risk factors listed above, can be
( ) Microwave- 165°F 2 Minute Standing found in the following sections of the Food Code and 105 CMR
Time* 590.000.
3-403.11(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000
140°F• 23. Management and Personnel FC-2 .003
3403.11(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004
Roasts* 25. Equipment and Utensils FC-4 .005
18 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 .006
3-501.14(A) Cooling Cooked PHFs from 140°F to 27• Physical Facility FC-6 .007
28. Poisonous or Toxic Materials FC-7 .008
70°F Within 2 Hours and From 70°F 29. Special Requirements .009
to 41017/450F Within 4 Hours.* 30. Other
3-501.14(B) Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/45°F
Within 4 Hours*
•Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
THE COMMONWEALTH CF MASSACHUSETTS
TOWN OR CITY OF
Establishment Name: Date: II Page: 'Q of o�
Item Code C-Critical Item DESCRIPTION OF VIOLATION /PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
r
Discussion With Person in Charge: Corrective Action Required: LJ No El es
)—Ci r i t} i" zJr� 2v+�
❑ Voluntary Compliance ❑ Employee Restriction/
15 h f f I Q E7 Exclusion
/G f
El Re-inspection Scheduled ❑ Emergency Suspension
Z' arJv�.�o ci ,�
- El Embargo ❑ Emergency Closure
JLl
❑ Voluntary Disposal ❑ Other:
Form 734 B A.M.Sulkin Co.,Boston,MA
3-501.14(C) PHFs Received at Temperatures
V/o/adons Related to Foodbome Illness Interventions and Risk According to Law Cooled to
Factors(Red7tems 1.22) (Cont.) 41°F/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
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
3-302.14 Protection from Unapproved Additives*
590.004(F) 410/450 F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140°F.*
Containers* 3-501.16(A) Roasts Held at or above 130°F.
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
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 for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents,Criteria* Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. *
7-206.13 Tracking Powders,Pest Control and 3-801.11(C) 11 Unopened Food Package Not Re-served.*
Monitoring*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*enea 11,211
Eggs-Immediate Service 1450F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.11(A)(2) Comminuted Fish,Meats&Game
Animals- 155°F 15 sec.* SPECIAL REQUIREMENTS
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. catering,mobile food,temporary and
* residential kitchen operations should be
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections
Stuffing Containing Fish,Meat, 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#29-
3-401.12 Raw Animal Foods Cooked in a Special Requirements.
Microwave 165°F
3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec.* VIOLATIONS RELATED TO GOOD RETAIL 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) foodborne illness interventions and risk factors listed above,can be
( ) Microwave- 165°F 2 Minute Standing Found in the following sections of the Food Code and 105 CMR
Time* 590.000.
3-403.11(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000
140°F* 23. Management and Personnel FC-2 .003
3-403.11(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004
Roasts* 25. Equipment and Utensils FC-4 .005
18 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 .006
3-501.14(A) Cooling Cooked PHFs from 140°F to 27• Physical Facility FC-6 .007
28. Poisonous or Toxic Materials FC-7 .008
70°F Within 2 Hours and From 70°F Y9. Special Requirements .009
to 41°F/45°F Within 4 Hours.* 30. Other
3-501.14(B) Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/45°F
Within 4 Hours*
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
,a
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF NORTH ANDOVER
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
Name Date Tvoe of Oaeration(s) TvDe of inspection
r U1 ❑ FnM Service outine
AddressRisk ['Retail ❑Re-inspection
Telephone I Level ElResidential Kitchen Previous Inspection
a�1S g g 6 ❑ Mobile Date:
Owner HACCP YIN ❑ Temporary ❑Pre-operation
❑ Caterer ❑Suspect Illness
Person in Charge(PIC)' Time ❑ Bed&Breakfast ❑General Complaint
In: ❑HACCP
Inspector �' _ } Out: Permit No. ElOther
Each violation ch eked requires an explanation on the narrative page(s) and a citation of specific provision(s)
violated. won-c mpgarm wa:
Violation R� plated to Foodborne Illnas Intrsrventions and Risk Enctors(Red Ibsms) Arid-CTOGO
Violations marked may pose an-imminent health hazard and require immediate corrective w0•0°e(� ❑ 50'0°e ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑13. Nandwash 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 and Water from Approved Source TIMEREMPERATURE CONTROLS(Potentially Hardous Foods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Re=ds/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 HIGHILY WXCB"ILE POPULATIONS(HSP)
❑ 10. Proper Adequate O21. Food and Food Preparation for HSP
e9 Handwashin 9
❑ 11. Good Hygienic Practices CONSUMERADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Red Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an in pection
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)(S9o.00s) ober 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)(590.006) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (Fc s}(Sso.00s) establishment operations. If aggrieved by this order, you
27. Physical Facility (Fc-6)(590.000 have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials (Fc•7)(590.006) 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 REaNSPECTION:
Inspector's Signature. Print
PIC'S Signature: Print: r ti qPagL of�-'Pages
FORM 734A A.M SULKIN CO.
L
Violations Related to Foodbome Illness
Interventions and Risk Factors(Red Items 1-22) i
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003 A Assignment of Responsibility* 3-302.11(AXI) Raw Animal Foods Separated from
590.003liDemonstration of Knowledge* Cook(A and R1T Foods*
2-103.11 Person in charge-duties Contamination from Raw Ingredients
3-302.11(Ax2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other* .
2 590.003(C) Responsibility of the person in charge to Contaminadon from the Environment
require reporting by food employees and 3-302.11 A Food Protection*
applicants* 3-302.15 Washing Fruits 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*
Charge* Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.14 A B Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* Dispostion of Adulterated or Contaninated
590.003E Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Fes*
4 Food and Water From Regulated Sources 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 Eggs* Sanitization Temperatures*
3-202.14 Eggs 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 System* 4-601.11(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 C1 Frequency of Equipment Food-
590.006 B Water Meets Standards in 310 CMR 22.0* Cleaning y
__ SheB6sh and Fish From an Approved Source Contact Surfaces and Utensils*
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* 1p : Proper,Adequate Handwashing
Game and VWd Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms*
Regulatory Auth "
3-202.18 Shellstock Identification Present* 2-301.12 Cl Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienk Practices
5 ReceivinglCondition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PIIFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and
3-202.15 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tast' *
t; Tags/Records:Shelistock 12 Prevention of Contamination from Hands
3-202.18. Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Ha Employees*Facilities
TagslRecords:Fish Products 13
3402.11 Parasite Destruction* Conveniently Located and Accessible
302.l2 Records,Creation and Retention* 5-203.11 Numbers and C cities*
590.0(}4 J Labeling of Ingredients• 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility, tion and Maintenance
IHACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Process Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with ved Procedures* 6-301.12 Hand Drying Provision
*Demotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OR CITY OF DJ'w✓
Establishment Name: Date: (P 1-7111 Page: of �—
Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
OLA
w, o
Discussion With Person in Charge: Corrective Action Required: CIO No ❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
❑ Re-inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
Form 734 B A.M.Sulkin Co.,Boston,MA
3-501.14(C) PHFs Received at Temperatures
Wo/adons Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Red kerns 1.22) (Cont) 41°F/45°F Within 4 Hours.+
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
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
3-302.14 Protection from Unapproved Additives*
590.004(F) 410/450 F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140°F. *
Containers* 3-501.16(A) Roasts Held at or above 130°F.+
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
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 for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents,Criteria* Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. *
7-206.13 Tracking Powders,Pest Control and 3-801.11(C) 11 Unopened Food Package Not Re-served. +
Monitoring*
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PRFs Not Otherwise Processed to Eliminate
3-401.11A(l)(2) Eggs- 155°F 15 Sec. Pathogens.*Enecrrvevfaoot
Eggs-Immediate Service 145°F15sec• 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.11(A)(2) Comminuted Fish,Meats&Game
Animals- 155°F 15 sec.* SPECIAL REQUIREMENTS
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. catering,mobile food,temporary and
* residential kitchen operations should be
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections
Stuffing Containing Fish,Meat, 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#29-
3-401.12 Raw Animal Foods Cooked in a Special Requirements.
Microwave 165°F
3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. * VIOLATIONS RELATED TO GOOD RETAIL 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
3-403.11B foodborne illness interventions and risk factors listed above, can be
( ) Microwave- 165°F 2 Minute Standing found in the following sections of the Food Code and 105 CMR
Time* 590.000.
3-403.11(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000
140°F* 23. Management and Personnel FC-2 1 .003
3-403.11(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 1 .004
Roasts* 25. Equipment and Utensils FC-4 1 .005
18 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 1 .006
3-501.14(A) Cooling Cooked PHFs from 140°F to 27• Physical Facility FC-6 I 007
28. Poisonous or Toxic Materials FC-7 1 .008
70°F Within 2 Hours and From 70°F 29. Special Requirements .009
to 410F/450F Within 4 Hours.* 30. Other
3.501.14(B) Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/45°F
Within 4 Hours*
•Denotes critical item in the federal 199.9 Food Code or 105 CMR 590.000.
7A e kv
NqaUY
February 2, 2010
Susan Y. Sawyer, REH/RS
Public Health Director
Health Dept.
1600 Osgood Street ,'w .. J
Building 20, Ste.2-36
North Andover, MA 01845 TOWN N� TMENT
mij-rM DEPAR
Ms. Sawyer,
In response to your cease and desist letter received on February 1st, you will find enclosed The Vineyard's
2010 food license renewal application and payment of$185. We apologize for not getting these in by the
12/31/2009 deadline, but we did not receive the renewal notice in the mail as we have in past years. As a
result, we missed the deadline and would like the opportunity to dispute the$185 penalty fee.
Thanks,
Kerry Dwyer
General Manager
554 Turnpike St., North Andover, MA 01845
Phone: 978-688-5005 Fax: 978-688-5424
www.thevineyard.com
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF NORTH ANDOVER FRECEVTEDI
Massachusetts Department of Public Health N 2 8
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT FNORT
Name . Date Type of O f Ins action
11Z,10k [ 'Food Service outine
Address �" 'sk ❑ Retail ❑Re-inspection
Telephone Level E] Residential Kitchen Previous Inspection
�i-- AdJ^._ S'-60�' ❑ Mobile Date:
Owner HACCP YM ❑ Temporary ❑Pre-operation
❑ Caterer ❑Suspect Illness
Person in Charge(PI ) Time ❑ Bed&Breakfast ❑General Complaint
In: "S"s ❑HACCP
Inspector �--A S,re,1/O Ou($'rZa Permit No. ❑Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)
violated. Non-aMpHowe WO:
Violations Rolated to Foodborne Illness Interventions and Risk Factors(Red Items) And-Cho" Tobaseo
Violations marked may pose an imminent health hazard and require immediate corrective NO.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
[313.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
FOOD FROM APPROVED SOURCE ❑ 15.Toxic Chemicals
❑ 4. Food and Water from Approved Source TIMElrEMPERATURE CONTROLS Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Re=ds/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding 380
❑ S. Separation/Segregation/Protection ❑20.Time As a Public Health Control
REQUMMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
[3 9. Food Contact Surfaces Cleaning end Sanitizing
❑ 10. Proper 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 must be corrected To Foodborne Illnesses Intwventions
immediately or within 10 days as determined by the Board and Risk Factors(Red 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)(seo.00s) 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-0(5so.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 RF-INSPECTION:
Inspector's Signature: Print: 1?11_)11,2-A122w_1e110 ]
PIC's Signa tn Print: IPage/of;gas
FORM 734A
Violations Related to Foodborne Illness
Interventions and Risk Factors(Red Items 1.22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT g Cross-contamination
1 590.003(A) Assigninent of Responsibility* 3-302.11(AX 1) Raw Animal Foods Separated from
590.003 li Demonstration of Knowledge* CookLd and RTE,Foods*
2-103.11 Person in charge-duties Contamination from Raw Ingredients
3-302.1](Ax2) Raw Animal)bods 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 3-302.11 A Food Protection*
applicants* 3-302.15 Washing Fruits 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*
Charge* Contamination 6om the Consumer
590.003(G) Reporting 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
590.003E 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* 4-501.111 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 Eggs* Sanitization Temperatures*
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drmkmg Water* concentration and hardness. *
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 Cl Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0* Cleaning y *
Contact Surfaces and Utensils
SheAlish 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* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by Auth 2-301.11 Clean Condition-Hands and Arms*
Regulatory
3-202.18 Shellstock Identification Present* 2-301.12 Cl Procedure*
590.004 C Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
5 ReceivinglCondition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PI EFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and
3-202.15 Package Integrity* Mouth*
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em to ees*
Tags/Records:Fish Products 13 Handwash Facilities
3402.11 Parasite Destruction* Conveniently Located and Accessible
3402.12 Records,Creation and Retention* 5-203.11 Numbers and C cities*
590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement*
Confomtance with Approved Procedures 5-205.11 Accessibility, tion and Maintenance
IHACCP Plans Suppled with Soap and Hand Drying
3-502.11 Specialized Process Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision
*Denotes critical hem in the federal 1999 Food Code or 105 CMR 590.000.
THE COMMONWEALTH CF MASSACHUSETTS
TOWN OR CITY OF 4Z 45�;'
Establishment Name: ::Z6 L22 e- C1�'� Date: / Page: 'Z of �--
Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
l!(_ c°.
'09-4z_ 8/2
Discussion With Person in Charge: Corrective Action Required: WrNo 0 Yes
❑ Voluntary Compliance 0 Employee Restriction/
Exclusion
❑ Re-inspection Scheduled ❑ Emergency Suspension
0 Embargo ❑ Emergency Closure
❑ Voluntary Disposal 0 Other:
Form 734 B A.M.Sulkin Co.,Boston,MA
3-501.14(C) PHFs Received at Temperatures
Wo/atlons Related to Foodborne Illness Intervendons and Risk According to Law Cooled to
Factors(Red7tems 1-22) (Cont) 41°F/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
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
% 590.004(F) 410/450 F*
3-302.14 Protection from Unapproved Additives*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140°F.
Containers* 3-501.16(A) Roasts Held at or above 130°F.
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
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 for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents,Criteria* Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. *
7-206.13 Tracking Powders,Pest Control and 3 8-01.11(C) Unopened Food Package Not Re-served--7-1
Monitoring*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*Eftcli 1/112"
Eggs-Immediate Service 1450F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.11(A)(2) Comminuted Fish,Meats&Game
Animals- 155°F 15 sec.* SPECIAL REQUIREMENTS
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. catering,mobile food,temporary and
* residential kitchen operations should be
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections
Stuffing Containing Fish,Meat, 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#29-
3-401.12 Raw Animal Foods Cooked in a Special Requirements.
Microwave 165°F*
3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. * VIOLATIONS RELATED TO GOOD RETAIL 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
foodborne illness interventions and risk factors listed above, can be
3-403.11(B) Microwave- 165°F 2 Minute Standing found in the following sections of the Food Code and 105 CMR
Time* 590.000.
3-403.11(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000
140°F* 23. Management and Personnel FC-2 .003
3-403.11(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004
Roasts* 25. Equipment and Utensils FC-4 .005
18 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 .006
3-501.14(A) Cooling Cooked PHFs from 140°F to 27• Physical Facility FC-6 1 .007
28. Poisonous or Toxic Materials FC-7 1 .008
70°F Within 2 Hours and From 70°F 29. Special Requirements L.009
to 41°F/45°F Within 4 Hours.* 30. Other
3-501.14(B) Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/45°F
Within 4 Hours*
•Denotes critical item in the federal 199.9 Food Code or 105 CMR 590.000.
} _v-
r THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF NORTH ANDOVER
Massachusetts Department of Public Health
Division of Food and Drugs
FOOD ESTABLISHMENT INSPECTION REPORT
Name >//� Date Type of Operations) Type of Inspection
C vd�� I C9� ❑ Food Service [3'Routine
AddressRisk [-tetail ❑ Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone /
❑ Mobile Date:
E] Temporary [IPre-operationOwner / llm lwt ��/ � HACCP Y ❑ serer ❑Suspect Illness
Person in Charge(PIC) vV Time ❑ Bed&Breakfast ❑General Complaint
In
Inspector f `dS Permit No. El Other
CP
outr
/��i�'� � J/� • , Z.
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)
violated. Mon-compgance wM:
Violations Rolated to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking Tobaeeo
Violations marked may pose an imminent health hazard and require immediate corrective 00.009(E) ❑ 680.008(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT
❑ El1. PIC Assigned J Knowledgeable/Duties 12. Prevention of Contamination from Hands
❑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 and Water from Approved Source TIME/TEMPERATURE CONTROLS(PoWnti ft Hazardous Foods)
❑ 5. Reoeiving/Condition [116.Cooking Temperatures
❑ 8. Tags/Reoords/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling /
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding 2e6 17r 6
❑ S. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONS1MER ADVISORY
[122. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Red 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 x by a Board of Health member or its agent constitutes an
23. Management and Personnel {Fc-2)(s9o.o03) order of the Board of Health. Failure to corned violations
24. Fond and Food Protection (F Ccited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(90.004)-4)(590.00S) the food establishment permit and cessation of food
26. Water, Plumbing and Waste {Fc e;>(5eo.aos) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(5e0.007) 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 REaNSPECTION:
Inspector's Signature: Print:
PIC's Signature Pant: / Paged oft Pages
FORM 734A
ti
Violations Related to Foodborne Illness
Interventions and Risk Factors(Red Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT $ Cross-contamination
1 590.003(A) Assignment of Responsibility* 3-302.11(AXI) Raw Animal Foods Separated from
590.003 13 Demonstration of Knowledge* Cookexl and R7T Foods'
2-103.11 Person in charge-duties Contamination from Raw Ingredients
3-302.11(Ax2) 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*
applicants* f• 3-302.15 Washing Fruits 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'
Charge* Contamination from the Consumer
590.003(6) Reporting 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 orContaminated
590.003E Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Fes*
4 Food and Water From Regulated Sources 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 Eggs* Sanitization Temperatures*
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
concentration and hardness. *
3-202.16 Ice Made From Potable Waters 4..6p1.11(A) Equipment Food Contact Surfaces and
5-101.11 Drinking Water from an Approved System*
590.006(A) Bottled Drinking Waters Utensils Cleans
590.006(B) Water Meets Standards in 310 CMR 22.0' 4-602.11 Cleaning Frequency of Equipment Food-
She?ftsh and Fish From an Approved Source Contact Surfaces and Utensils*
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 Chemicals
Sources* 10 . Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Re ulat Auth 2-301.11 Clean Condition-Hands and Arras*
3-202.18 Shellstock Identification Present* 2-301.12 Clemiing Procedure*
590.004(C Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienk Practices
5 ReceivinglCondition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PllFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and
3-202.15 Package Integrity* Mouth*
3-I0I.I I Food Safe and Unadulterated
s 3-301.12 Preventing Contamination When T *
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em to ees*
Tags/Records:Fish Products 13 Handwash Facilities
31302.11 Parasite Destruction*
Conveniently Located and Accessible
3402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement*
Conformance with Approved Procedures 5-205.11 Accessibility, tion and Maintenance
IHACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Process' Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OR CITY OF �, Y�/��'Y
Establishment Name: /�� �/i/�El�ll Date:, " 7��d Page: Z of z
Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION.` Date
No. Reference R-Red item - Verified
PLEASE PRINT CLEARLY
Discussion With Person in Charge: Corrective Action Required: o ❑ Yes
❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
❑ Re-inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other:
Form 734 B A.M.Sulkin Co.,Charlestown,MA
rr
r
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne llness Interventions and Risk According to Law Cooled to
Factors(Red Items 1-22) (Cont) 41°F/45°F Within 4 Hours.*
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
14 Food or Color Additives LEE PHF Hot and Cold Holding
3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below
3-302.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F*3-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances
7-101.11 Identifying Information-Original 1400F.*
Containers* 3-501.16(A) Roasts Held at or above 1300F.*
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
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 for Washing Produce Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drying Agents,Criteria* Beverages with Warning Labels*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served.*
7-206.13 Tracking Powders,Pest Control and 3-801.11(C) I Unopened Food Package Not Re-served.*
Monitoring*
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*Effective 1/1/2001
Eggs-Immediate Service 145°F 15 sec.* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.11(A)(2) Comminuted Fish,Meats&Game
SPECIAL REQUIREMENTS
Animals- 155°F 15 sec.*
3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 sec. catering,mobile food,temporary and
* residential kitchen operations should be
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropraite sections
Stuffing COntaining Fish,Meat, 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#29-
3-401.12 Raw Animal Foods Cooked in a Special Requirements.
Microwave 165°F*
3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec.* VIOLATIONS RELATED TO GOOD RETAIL 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 noit relate to the
foodborne illness interventions and risk factors listed above,can be
3-403.11(B) Microwave- 165°F 2 Minute Standing found in the following sections of the Food Code and 105 CW
Time* 590.000.
3-403.11(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000
140°F* 23. Management and Personnel FC-2 .003
3403.11(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004
Roasts* 25. E ui ment and Utensils FC-4 '005
18 Proper Cooling of PHFs 26. Water Plumbina and Waste FC-5 .006
3-501.14(A) Cooling Cooked PHFs from 140°F to 27• Physical Facility FC-6 .007
70°F Within 2 Hours and From 70°F 28. Poisonous or Toxic materials FC-7 29. Special Requirements 009.008
to 41°F/45°F Within 4 Hours.* 30. Other
3-501.14(B) Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/45°F
Within 4 Hours.*
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.