HomeMy WebLinkAbout0022 RICHARDSON ROAD - HOSPITAL/NURSING HOMES (2) 2.c �1 -o 1
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p¢� Towh Of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D. `
:STABLE, F.P.(Thomas)Lee,.
+gd2 FAA tl.
200 Main Street,'Hyannis, MA 02601 Daniel Luczkow M.D. Alt.
Phone:`(508) 862-4644 Fax: (508)790-6304
www.townofbarnstable'us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 559 y Issue Date: 01/01/2022
DBA: HARBOR POINT OF CENTERVILLE
OWNER: KRE-BSL,HUSKY CENTERVILLE LLC.
Location of Establishment: 22 RICHARDSON,ROAD CENTERVILLE„ MA 02632
Type of Business Permit: FOOD SERVICE ` M
Annual: YES Seasonal
,IndoorSeating: 65 OutdoorSeating.`` 0 Total Seating: 65
FEES r -
FOOD SERVICE ESTABLISHMENT: $300.00 ` :YEAR. 2022
RETAIL FOOD:
n
COTTAGETOOD OPERATION: Permit Expires: 12/31/2022
B&B- FULL BREAKFAST: 3
CONTINENTAL BREAKFAST: a
MOBILE—FOOD:
"MOBILE-ICE CREAM: P a�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
F FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED'IN CONJUNCTION`WITH A COMMON VICTUALER LICENSE
Restrictions: `
x.
For Office Us.n-1-1 Initials:�t ' �.o Town of Barnstable Il
Date Paid 24 Amt PdPd 0- c
MASS. Inspectional Services 106 1 Dr7 9 7
039. Public Health Division check#
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: mrha/L t-4( e4
ADDRESS OF FOOD ESTABLISHMENT: ::;?A /`C1e11,a,26&eA0 .�c d, W`l arms
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): /
E-MAIL ADDRESS: &,--4L Q7 Wendt
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS: �,5
WELL WATER:YES NO...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: i/ SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: S OUTSIDE: a TOTAL: 6,5
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING IV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING:AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF.SERVICE DOOR(S)?
TYP&OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
- COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE &NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application FormsTOODAPP 2020.doc
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OWNER INFORMATION:
FULL NAME OF APPLICANT S 6, le % r
SOLE O �R. O D.O.B OWNER PHONE#_ �fl- IX991-' 7/00 X�/�
q _
ADDRESS d �/ ��D�P��� -7/p!` 1W A*,Sl
CORPORATE OWNER: 7777Ll0,AO.5
CORPORATE ADDRESS: .ClY 001 A,0Sf: .dW-5-1 i
i
PERSON IN CHARGE OF DAILY OPERATIONS: e /J L,hls7" l.2EGTOQ—
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health:Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
a
2. /32 en da.,
SIGNATURE OF LICANT DATE
***FOOD POLICY.INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to oyenine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Diva Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/appfications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product:by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec. 31".each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 sf.
i
�A lication FonnsTOODAPP REV3-2019.doc. ..
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Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
Ha. :�ce� Paul J.Canniff,D.M.D.
�• 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
_ Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 559 Issue Date: 01/01/2021
DBA: HARBOR POINT OF CENTERVILLE
OWNER: KRE-BSL HUSKY CENTERVILLE LLC.
Location of Establishment: 22 RICHARDSON ROAD CENTERVILLE„ MA 02632
Type of Business Permit: FOOD SERVICE/SENIOR
Annual: YES Seasonal:
IndoorSeating: 65 OutdoorSeating: 0 Total Seating: 65
FEES
FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2021
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM:
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
For Office Use 0 nly: Initials:
Town of Barnstable
Q` Date Paid
9&UNSrABLE,O Inspectional Services DOb
MASS.
pTf�Mp�A Public Health Division Check
10-
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE
� NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: 1161/2/jDJ2.
ADDRESS OF FOOD ESTABLISHMENT: AU 166I 'AWSON /6'a
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: h,57C eeh Cd, /�`/E'/?G`t�?d d`C�GLCt ll t�/ r LOGYI IX
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (.S—o,�77Y - a311
TOTAL NUMBER OF BATHROOMS: _
WELL WATER:YES NO ✓ ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: ✓ SEASONAL: DATES OF OPERATION: /_/_ TO
NUMBER OF SEATS: INSIDE: (,,,5 OUTSIDE: O TOTAL: 6 S' le�Tj
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TY/FOOD
E OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED)
CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL, MOBILE& NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application FormsTOODAPP 2020.doc
OWNER INFORMATION:
FULL NAME OF APPLICANT /�i�E� flol5e��/ �rjrerd/��� (J�etiot�l5 LCCiL��,r/lay//aint' iNl�le
SOLE OWNER:/NO D.O.B OWNER PHONE # 7/0 U K
ADDRESS �Q/ c/0/It°,5 4JA"ACc.M /9i4• 06-75/5/
CORPORATE OWNER: e aja
CORPORATE ADDRESS: U/ Jon es &U n)V51
PERSON IN CHARGE OF DAILY OPERATIONS:
List(2) Certified Food Protection Managers AND at least (1) Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
ti
2. r�ul�P�. 1=�� 2 d,9, 09 /20,11
SIGNATURE OF AP P CANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments, including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/a1)plications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FormsTOODAPP REV3-2019.doc
ee- vssvj-1
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board Of Health Donald A.Gaudagnoli,M.D.
oAnvSrAaLL " Paul J.Canniff,D.M.D.
11 6 9. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 559 Issue Date: 03/11/2020
DBA: HARBOR POINT OF CENTERVILLE
OWNER: KRE-BSL HUSKY CENTERVILLE OPERATIONS LLC.
Location of Establishment: 22 RICHARDSON ROAD CENTERVILLE, MA 02632
Type of Business Permit: FOOD SERVICE/SENIOR
Annual: YES Seasonal:
IndoorSeating: 65 OutdoorSeating: 0 Total Seating: 65
FEES ---
FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: ----- -------- _ - --- - ----
MOBILE-FOOD;
MOBILE-ICE CREAM:
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
j FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions: a-
t K;
�k p+k1� Town of Barn Stable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BARwrA.uL.K '. Paul J.Canniff,D.M.D.
�1,659 F.P. Thomas Lee Alternate
lw 200 Main Street,.Hyannis, MA 02601
Phone: (508) 862-4644 -fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 559 Issue Date: 12/10/2019
DBA: HARBOR POINT OF CENTERVILLE
OWNER: BENCHMARK SENIOR LIVING LLC
Location of Establishment: 22 RICHARDSON ROAD CENTERVILLE, MA 02632--
Type of Business Permit: FOOD SERVICE/SENIOR
Annual: YES Seasonal:
IndoorSeating: 65 OutdoorSeating: 0 Total Seating: 65
FEES
FOOD SERVICE ESTABLISHMENT:. $300.00 YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: 0
FROZEN DESSERT: Thomas A. McKean, RS,`CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
•
Ear Officr Ilse Only- Initials:
Town of Barnstable .
S� jZate Paid IO � � $
t � Inspectional Services
1F��17
Check 4
Osq.
Public Health Division
Thomas McKean Director.. . :
200 Maim Street,Hyannis,MA 02601
Office: 508-862-4644 Fax:.508490-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE :NEW OWNERSHIP RENEWAL—.
NAME OF FOOD ESTABLISHMENT:
i
e.
ADDRESS OF FOOD ESTABLIS..HMENT: Z? K �Aardsow dohtt _7ew;&1 llle_
f
MAILING ADDRESS(IF DIFFERENT FROM:ABOVE): • Da�3a
E-MAiL.AD.DRESS:
J
TELEPHONE NUMBER OF FOOD ESTABLISHMENT. (S o�h
TOTAL NUMBER OF BATHROOMS-.
a.
WELL WATER:YES (ANNUAL WATER ANALYSIS REQUIRED) . . . . .. .
i
ANNUAL: SEASONAL. DATES OF OPERATION:
-- T --'
-
:NUMBER OF SEATS: INSIDE: . � OUTSIDE:
TOTAL: S
SEATING• MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING
REQUIREMENTS. /
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? N
IS AN AIR CURTAIN PROVIDED:AT WAITSTAFF SER. CE DOOR(S)?
TYPE OF ESTABLISIMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD:SERV ICE
i
_RETAIL FOOD-ONLY re cared_for TCS foods foods requiring refrigeration/freezer)
BED&BREAKFAST:
CONTINENTAL.BREAKFAST
_COTTAG.E FOOD INDUSTRY:(formerly residential kitchen)
MOBILE MOOD
FROZEN DAIRY DESSERT MACHINES....(MONTHLY LAB ANALYSIS REQUIRED)
_CATERING ... (CATERING NOTICE REQUIRED BEFORE.EVENT(SEE PAGE#2)
. . SEASON MOBILE&NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 5084624644
Q:\Application:F6rms\FOODAPP202O.doc.
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ff
OWNER INFORMATION:
FULL NAME OF APPLICANT 1,A L bAk Wo I YVl(
SOLE OWNER: .YES Y NO . D.O.B ' S S :OWNER PHONE# SIJ�"TT �3 t l
ADDRESS R 11 f /
CORPORATE.OWNER. g&6 NUSKV_f'�n RrutIle bcepSee a-C
�1 r
CORPORATE ADDRESS: 0 IlT 4ry l' a C Q �6aro3�
PERSON IN:CHARGE OF DAILY OPERATIONS: e1< _b1
List(2) Certified Food:Protection Managers AND at least(1)_Allergen Awareness.Certified Staff. .
AII:FOOD ESTABLISHMENTS must:have 1 Certified Food Protection Manager PER SHIFT: t
**ATTACH COPIES OF CERTIFICATES** The Health Diva will NOT use past ears' records.You
must.provide new copies:and:POST THE CERTIFICATES at your food:establishment.
Certified Food.Managers ExnirationDate Allereen Awareness Expiration Date
.. .. .. .. -. .. .. .. .. .. .. � .. is:.
:
z. c3�:: re,e:; i� I
t
SIGNAT OF APPLICANT DATE
f:
***FOOD.POLICY INFORMATION***
SEASONAL FOOD SERVICE All seasonal food establishments,including mobile trucks must be irispected by.the.Health Div, i
prior to ouenine!! Please call Health:Div.at 508-862-4644 to schedule your inspection: Please call at least(7)days in advance.
FROZEN DAIRY.DESSERTS: Frozen desserts must be tested by a_State Certified lab prior to opening and monthly thereafter;'
with sample.results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are.met. : 3
CATERING POLICY: Anyone who caters within the Town of Barnstable:must notify theTown by-fax or mail prior to catering
event. You must complete a catering notice found at.htto://www.town6fbiiriistable.us/healthdivision/apnlications.asp. i
OUTDOOR COOKING: Outdoor.cooking,preparation,ordspaay of any food product by a food establishment is prohibited. q
NOTICE: Permits run annually from January Im to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st:
Q;�Applica(ion FortnAFOODAPP REV3-2019:doc
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h e ,`below; verifies.that . :.
T e Education ter C n
' eveUe
.: has successfullycomple' ted' he knowledge and=skill evaluations for the .'
_._ -
Emergency-tare & Safety.:Institute Course.
Adult,Child,Infant CPR&AED March arch 21,2018,
Marsh 21,2020 O THLOWW KOEH::'.
.. Course:Name Course etro ec e 1 D
C Com 1 '
- o P � a nt tto r
e Date R ommend d Renewa to Studs Authorize ' n Numbs
Cape Cod CPR&First Aid Training 508-3844750
J ewi anet:Radzl ¢ JC912FHOQXLA
Education Center Education Center Phone Number Instructor Name
Instructor
Info@CapeCPR.eom:..... .... .:..... ID Number
This certificate does nat guarantee any future performance or suggest any Form of licensure.Skills deteriorate rapidly-when not
Education Center Email _ used.Periodic retraining is strongly recommended.
Cut along the dotted line at the bottom of s , c 'Student,Authorization,q .THLOVMOKOEH
the certificate and along the:dotted lines:around Education Center.* Cape Cod:CBRB'First Aid:T►aining.
"
the course completion card.,Fold the card in half. ';Educatlon Center Email:Jnro®CapeCPR,cam::'
Education Center Phone'q 508-364 4750
;."
...
Instructor,Name:,JanetRadzleWl¢ i
8•.JC912FHOOX LA
Instructor ID
,.
' The Education Center vedfles"that the above has successfully::"
completed tho Mnowledge.and skill evalunUons for the
_.
Q s
Emergency Care&Safety Institute:Course:.
March 21,2010,
"March 21"2020
Co n D _ -
Course Complatio ate Recommended Renewal Date .
..
s.
.. ... ..
... (ail .. .. s - .. .. ... .. .. .. ... .. .. ... .. .. .. ... .. ..
IME ro�4 TOWN OF BARNSTABLER.,, ,:,,..,,. z..•,. .HEALTH,INSPECTOR'S Establishment Name: - Date:' .. _ _Page.k.:... .� :... .of.'
� .. .....,:. e:.• ..,., ... 'OFFICE HOURS - -. ..-
° PUBLIC HEALTH DIVISION,.;'. . . . 9:00-9:3o`UR
BARN LE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS. g MON.-FRI.
,63v .0 -r HYANNIS,MA 02601 No Reference R. Red Item PLEASE PRINT CLEARLY
"FOOD
.- ... 508-862-4644 -.
.w. v ,
FOOD ESTABLISHMENT INSPECTION REPORT �� � `ba� - C� r
Name t� Dat Tvoe'of Inspection /1
Routine lJ v
Address 7/ Risk Food Service Re-ms ection
"' evel Previous Inspection
Telephone `: Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) .S Time Bed&Breakfast HACCP
In: Other
Inspector ��� Out:
Each violation checked req Tres an explanation on the narrative page(s)and a citation of specific provision(s)violated. b
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 Tobacco 590.009(F) ❑
Action as 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.Handwash Facilities
.. I .. c ..
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
.❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 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 1
❑ 11.Good.Hygienic Practices ❑22.Posting of Consumer Advisories -
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) . �'. Corrective Action Required: El No ❑ es
Non-critical(N)violations must be corrected immediately or Overall Rating
9
within 90 days a s deter h Board of Health.mined b the oa d
Y - Voluntary Compliance E ' I ee Restriction/Exclusion Re-inspectionheduled Emer Emergency Suspension
Y ` LI ❑ rY p ❑. mp oY ❑ Sc ❑ 9 Y p-
C N Official Order foe Correction:Based on an inspection today,the items
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo Emergency Closure Voluntary Disposal Other:
23.Management and Personnel. (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils . B=One critical violation and less than 4 non-critical Violations 9
(FC-4)(590.005) cited in this report may result.in suspension or revocation of the food if no critical violations observed,4 to 6 no violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Specia Requirements. (590.009) within 10 days of receipt of this order. violation,4 to 8von-critical violations=C.
l
30.Other DATE OF RE-INSPECTION•
Inspec Si ure Print:
31.Dumpsptt screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed I Frozen Dessert Machines: Outside Dining Y N PIC's Ignat a Print:
Self Service `Wait Service Provided Grease Trap Size Variance Letter.Posted Y N
Dumpster Screen? Y^ - N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) i
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)
590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* *
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
* 7-201.11 Separation-Storage*
Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11) Variance Requirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions*
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Resumed Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of
3-202.16 Ice Made From Potable Drinking Water* 3-401.I IA(1)(2) Eggs-155°F 15 sec
Raw,Undercooked or
5-101.11 DrinkingWater from an Approved System* 4-601-11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are U o0
PP Y Not Otherwise Processed to Eliminate
Equipment*
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) CuuuuinuLed Fish,Meals&Game Pathogens* xbe4"Oe 1111eow
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
faces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
* 2-301.14 When to Wash* 3 401.11 A 1 All Other PHFs-145°F 15 sec* practices Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )(b)
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements,d be debited under#29-Special
5 Receiving/Condition 2-401.11 - Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2 401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercially Processed RTE Food-140°F* Blue Items 23-30)
3-202.11 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F[0 41°F/45°F _
Tags/Records:Fish Products
5-203.11 Numbers an P
d Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
.
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
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4
°F�Ns r TOWN OF BARNSTABLE. HEALTH INSPECTOR-s Establishment Name: Date: Page:. Z Of
OFFICE HOURS
a ° PUBLIC HEALTH DIVISION 8:00-'.9:30A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item - Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS,MA 02601 _ MO -FRI. No Reference.;;.R-Red Item PLEASE PRINT CLEARLY.,,.-
prE°Min° FOOD ESTABLISHMENT INSPECTION REPORT s0a-8 s2asaa
Name _VA'_
Date ( Type of T e f Inspection D
outine
Address Risk ood S e-inspection
Level - Retail Previous Inspection 01 190 Q S
Telephone Residential Kitchen Date: L
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector { Out:
t '
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
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 Tobacco 590.009(F) ❑
Action as 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.Handwash Facilities + ''
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS j V
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE: TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) r /n M� a7
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures co a-eo
t Es
❑ 5.Receiving/Condition ❑ AT�
17.Reheating � '.
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding !�
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control.
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 1
❑ 9.Food Contact Surfaces Cleaning and.Sanitizing ❑21.Food and Food Preparation for HSP �� j� .�
❑ 1b.Proper Adequate Handwashing CONSUMER ADVISORY Y /�
❑ 11.Good Hygienic Practices ❑22..Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations ` �/ C/lV✓
Critical(C)violations marked must be corrected immediately. (blue&red items) +. Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or g Overall Rating
within 90 days as determined by the Board of Health. r- "mb
ompliance. ..❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the itemschecked indicate violations of 105 CMR 590.000/Federal Food Code. _' ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:'
23.Management and Personnel (FC-2)(590.003) This report;when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9-or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 6=One critical violation and less than 4'non-critical violations
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6uon-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility )( ) aggrieved y y 9 g q C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
y y (FC-6 590.007 a rieved b this order,you have a right to a hearing. Your request must
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non critical violations: If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. _
30.Other DATE OF RE-INSPECTION Inspector's ig re P in1
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' atur Print: „
Self Service Wait Service Provided Grease Trap Size - Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions 4
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
* * 3-501.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives
Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
7-102.11 Common Name-Working Containers*
590.003(C) Responsibility of the Person-in-Charge[0
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* 7-202.11 Restriction-Presence and P g Use*
20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11) Variance Requirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions*
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed S routs Not Served*
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and P
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 3 401.11A(1)(2) Eggs-155°F 15 sec Ice Made From Potable Drinking Water*
Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* 4 601,11(A) Clem Utensils and Fond Contact Surface of Eggs=Immediate Service 145°F 15 sec*
g PP Y Not Otherwise Processed to Eliminate
Equipment* 3-401.11 A 2 Couwuuuted Fish,Meats&Game * eg ctme 1nl2001
590.006(Aj Bottled Drinking Water* ( )O Pathogens
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
faces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary
and a ide in cater-
* Ratites-165°F 15 sec* in mobile food,tem or and residential
Sources g, P
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165*F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
( )( )@)
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Packa a Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
gCritical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities Cooling Cooked PHFs from 140°F to 70°F 3-501.14(A)
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* y Within 4 Hours* 23. Management and Personnel FC-2 .003
Tags/Records:Fish Products 5-203.11 Numbers and Capacities*
5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
.
3-402.11 Parasite Destruction* Temperature Ingredients to 41"F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
`Op IKE r TOWN OF BARNSTAB,LE HEALTH INSPECTOR'S Establishment Name: - Date:, - Page:,of
"r OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BAFINSTABLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
619. �•� HYANNIS,MA 02601 MON.-FRI. No Reference .R: Red,ltem PLEASE PRINT CLEARLY=,
prEO MPS p' 508-862-4644
FOOD ESTABLISHMENT INSPECTION REPORT
Name �{ Date` Tyne of Inspection
Routine _ lfvY t
Address Risk Food Servi Re-inspection
Level Retail Previous Inspection
Telephone Residential Kitchen Date: 1
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: h„ Other
Inspector Out: ►'_1 1/
4' c
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.. V
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 Tobacco 590.009(F) ❑
Action as 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.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures.
❑5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time Asa 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) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items Embargo
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations re 9
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
y y (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must -
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
violation,4 to 8 non-critical violations=C.
natu Print:3 .Other DATE OF RE-INSPECTION' Inspector's Sig ,
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions _
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) 4
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 33 590.004(F)
02.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16A 7-102.11 Common Name-Working Containers* ( ) Hot PHFs Maintained At or Above 140°F*Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
3-302.11(A) Food Protection*
7-201.11 Se aration-Storage*
Applicants* P g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
590.003(G) Reporting by Person in Charge*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11) Variance Requirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 1590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Reservicr of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 163-401.11A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System gg Not Otherwise Processed to Eliminate
Equipment*
590.006(A) Bottled Drinking Water* 3 401.11(A)(2) Animals-1d Fish,Mean&Game Pathogens* Eff°n e iiuzooi
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
* Ratites-165°F 15 sec* in mobile food,tem ora and residential
Sources g. P t'Y
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* When 3-401.11 2-301.14 Wh to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
practices( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23.30)
12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41'F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
IIEl TOWN OF BARNSTABLE . HEALTH INSPECTOR'S Establishment Name: Ott ! 1 Page of
'OFFICE HOURS
� PUBLIC HEALTH DIVISION -.- a:ao-9:30 A.M.
BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS. MON.-FRI.
'639 �� HYANNIS,MA 02601 508-862-4644 No Reference _R-Red Item.• PLEASE PRINT CLEARLY
MP�a FO D ESTABLISHME, T INSPECT I N REPORT
D
Name Date i -Type of of Ins ec ion
O ation s Routin
Address I isk ood Sery ecti'n
I eve[ . it Previou s�e
Telephone Residential Kitchen Date.
Mobile Pre-ope t' Zrg
Owner HACCP YIN Temporary Sus pe Ilness t
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP lef
r - Other - , i
Inspector' t: i
Each violation checked requires an explanation on the parr ive page(s)and a citation of specific provision(s)violated.
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 Tobacco 590.009(F) ❑ f
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
AA a
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities \ /.014 _`�•
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS )er v
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) r
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures.
❑ 5.Receiving/Condition ❑ 17.Reheating
i
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling I /,/ ,1;• "
❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑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 Advisorie
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations /
Critical(C)violations marked must be corrected immediately. (blue&red items) ) � Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately.or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance. ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today, e i ms
checked indicate violations of 105 CMR 590.000/Federal Food'Code. ❑ Embargo , '❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of HealtWmember or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. 6=One critical, Failure to correct violations re
and less itical violations regardless of the number of critical,results in an F.
violation than 4,non-cr
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B.
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically,if: no hot
27.Physical Facility (FC-6)(560.007) aggrieved by this order,you have aright to-a hearing. Your request must C=2 critical violations and less than 9 non-critical. If ho critical water,sewage back-up,infestation of rodents or insects,or1ack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-criti al violations: If 1 critical refrigeration.
violation,4 to 8 non-critics iolatio sa C.
29.Special Requirements (590.009) within 10 days of receipt of this order. .
30.Other DATE OF RE-INSPECTION: In cto natyre ® Print:
31..Dumpster screened from public view. J J
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N J t
#Seats Observed Frozen Dessert Machines: Outside Dining Y N IC's Sig ture Print: r
Self Service Wait Service Provided Grease_ Trap Size Variance Letter Posted. Y N `�
Dumpster Screen? Y N 333 VVV
Violations related to Ftiodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12-- Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties �- - � 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7`101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F*
7-20
Require Reporting by Food Employees and Contamination from the Environment 7-101.11.11 Separation-Storage*
Common Name-Working Containers* 3-501.16(A) Roasts Held At or Above 130°F*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
( ) P 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed S routs Not Served*
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and p
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served
3-202.13 Shell Eggs* Sanitization Temperatures* TIMErfEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System* ) Eggs-Immediate Service 145°F 15 sec
4-601.11(A Clean Utensils and Food Contact Surfaces of * Animal Foods That are Raw,Undercooked or
,
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Coum iauted Fish,Meats&Gaiue Pathogens* Ef°&° 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary
and a ide in cater-
* Ratites-165°F 15 sec* in mobile food,tem o and residential
Sources g. P rar3'
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 b All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail
( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under 929-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* '18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 3-501.14 13 Handwashing Facilities Cooling Cooked PHFs from 140°F to 70'F
(A) 8
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70'F to 41°F/45°F Item Good Retail Practices FC 590.000
* Within 4 Hours* 23. Management and Personnel FC-2 .003
Tags/Records:Fish Products 5-203.11 Numbers and Capacities 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient
* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
FTC r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of
OFFICE HOURS
BARN STABLE PUBLIC
200 MAIN STREET
- . 3:30-s:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
3:30-4:30 P.M.
mAss. g.�A ,e3y.ate• HYANNIS,MA 02601 MON.-FRI.508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY .
FOOD ESTABLISHM NT 1NSPE TI N REPORT
Name MINT Date yoe of Ins ectio
a 0�1
- outiAddress isk nspe ionLevel Previous ns io
Telephone Residential Kitchen Date: t
p Mobile Pre-opbr i I
Owner HACCP Y/N Temporary Suspect I HessrT
Caterer General Complaint y
Person in Charge(PIC) Time Bed&Breakfast HACCP
n, Other -11�0 IN
Inspecto f ,
0 s
Each violation checked requires an explanation on the narrat' a page(s)and a citation of specific provision(s)violated. J /
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ �N A Vo
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ -
Action as 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.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures "
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 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
FM
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue 8,red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,th de s ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils FC-4 590.005 B=One critical violation and.less than 4 non-critical violations 9( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F.is,scored automatically if: no hot .
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical: If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a`hearing. Your request must
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non ritical violations. If 1 critical refrigeration. _
29.Special Requirements (590.009) within 10 days of receipt of this order.
on,4 to 8Hon-critical lions G.
30.Other DATE OF RE-INSPECTION: I spe ctor's ig atur - O Print: As-
31.Dumpster screened from public view t
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N IC s Print:
Self Service Wait Service Provided Grease Trap.Size Variance Letter Posted Y N
Dumpster Screen? Y N
ILI
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
* * 3-501.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.1-2_. Additives
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding -
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 1 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
590.004 Variance Requirements
* 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* (I1) q
590.003(G) Reporting by Person in Charge - Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rlated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed Sprouts Not Served*
3-201.12 Food in a Hermetically Sealed Container Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* e�cri-11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140'F* Blue Items 23-30)
12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402. Records,Creation and Retention* p Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied witthh Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8403.12 Conformance with Approved Procedures* +c S:590Formback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
HEALTH INSPECTOR'S Establishment Name: Date: Page: / of
°FINE Tp� TOWN OF BARNSTABLE . _ . . -
q OFFICE HOURS
PUBLIC HEALTH DIVISION, - 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
y MASS. �+ MON.-FRI.
�A 659•p`0 HYANNIS,MA 02601 No Reference R-Red Item- PLEASE PRINT CLEARLY
508-862-4644 A
FOOD ESTABLISHMENT INSPECTION REPORT s
Name
Date of Tyoe-o#Inspection
/� n /
O eration .
Address Risk .� Eood Service a m'spection `
Previous Inspection
Level _y
Telephone Residential Kitchen Date: G 6e
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness AI
Caterer General Complaint
Person:in Charge(PIC) Time Bed 8 Breakfast HACCP / ;' ��
In: Other / '
Inspector , ' Out: /
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items f .> r �
) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ X 1,0ree .i,
Action as 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.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS. !/ /f/ " i `� �i i✓
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ,/�
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals //
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ({
❑4.Food and Water from Approved Source. ._ ❑ 16.Cooking Temperatures � / � ' I •'
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding rJ
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control /
i
❑ 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 ADVISORYo
t
❑
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories ".
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical.Violations
Critical C violations marked must be corrected immediate) . blue&red items "�
( ), Y ( ) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating 1
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other.
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations..9 or more non-critical violations,
24.'Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations re gardless of the number of critical,results in an F.
6=One critical violation and less than 4 non-critical violations
25.Equipment and Utensils (FC 4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to-6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no-critical ' water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials. (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8rion-critical violations=C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.D ip rr screened from public view
Permit•Posted N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N Plus Signat Print:
4
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives. Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12- Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* * -� 19 PHF Hot and Cold Holding _
2-103.11 Person-in-Charge Duties 3-302.14._�, Protection from Unapproved Additives
Contamination from Raw Ingredients Poisonous or Toxic Subs tances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
15
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* -590.004(F) - --* -- - - - -
2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
P y7-102.11 Common Name-Working Containers* *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
Storage*
-
Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) - Variance Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* - -REQUIREMENTS-FOR
3-306.14(A)(B)Resumed Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discatding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance.with Food Law* 4-501.111 • Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* _ Sanitization Temperatures*. TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* - Concentration and Hardness* 3-401.11A(1)(2) Eggs-1 ook 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean iite.nc;lg and Food Contact Surfaces of Eggs-L55*F late Service 145°F 15 sec'. Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water front au Approved System* * gg Not Otherwise Processed to Eliminate
Equipment
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Cuauuiuuied Fish,Meats&Game Pathogens* eb cnve 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
faces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Ho[Water and Stuffing ContainingFish,Meat,Poultryor590.009(A)-(D)3-201.15 Molluscan Shellfish from NSSP Listed _ Chemical* g Violations of Section 590.009(A)-(D)in cater-
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources g, P
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices L.17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 * (Blue Items 23-30)
3-202.15 Package Integrity Tti (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. `Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
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