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c, Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
SAWNSTABL- Paul J.Canniff,D.M.D.
MAC F.P. Thomas Lee Alternate
s9. 1e 200 Main Street, Hyannis, MA 02601
Phone: (508)862-4644 Fax: (508)790-6304
www.townofbarnstablems
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: 517 Issue Date: 01/01/2021
DBA: SEA COAST INN
OWNER: DEVANG PATEL
Location of Establishment: 33 OCEAN STREET HYANNIS, MA 02601
Type of Business Permit: BED AND BREAKFAST
Annual: Seasonal: YES
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
'FEES ----------- - - - -
FOOD SERVICE ESTABLISHMENT: YEAR. 2021
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: $30.00 ----•-- - - -- -- - - -- -
MOBILE-FOOD:
MOBILE-ICE CREAM: C,��
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
9 For Office Use O� • Initials:
OpfME iq� Town of Barnstable� V2ji24AmtPd$
BARNSPABLE. : Inspectional Services
�pi i639,s`�� Check# � Cash ��
EpMp,l Public Health Division
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 19J NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT: L c eGd� Min
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ,K
E-MAIL ADDRESS: Sea CDOIcC'�b�'G'D���3n'1���•�
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 17.S
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YES NO ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: ✓ DATES OF OPERATION:®4/Ot 121 TO N l 31 /-2
NUMBER OF SEATS: INSIDE: -R� OUTSIDE: TOTAL:
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)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
4FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
{{A�BED&BREAKFAST
[CONTINENTAL BREAKFAST r -
"''''VVVVVV 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
L
Y
t/
OWNER INFORMATION: ��
FULL NAME OF APPLICANT �J(%V 4+ n Q1 �� I
SOLE OWNER: CE)S/NO D.O.B OWNER PHONE# T1�" -
SIC) &eon 4
ADDRESS r O cj t ne.l C-N
CORPORATE OWNER:
CORPORATE ADDRESS: (�
PERSON IN CHARGE OF DAILY OPERATIONS: PJV C�n
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
1.
2.
If
2
SIG ATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to openinlz!! 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/applications.asi)www.townofbarnstable.us/healthdivision/applications.asi).
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.3 V 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
t J
MAIL-IN REQUESTS
Please mail the completed application form to the address below. Also include copies of your employees'
food protection manager training certificates (at least two) and food allergen awareness training certificate (at'
least one.) In addition, please include the required fee amount (see fees at bottom of this page). Make check
payable to: Town of Barnstable. Our mailing address is:
Town of Barnstable
Public Health Division
200 Main Street
Hyannis,MA 02601
FOR FAXED REQUESTS
Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax copies of your
employees' food protection manager training certificates (at least two) and food allergen awareness training
certificate (at least one.) In addition, you must mail the required fee amount(see box below). Please make the
check payable to: Town of Barnstable. The check must be mailed to the address listed above.
FEES: Bed&Breakfast Permit=$55; Food Service Permit 0-49 seats=$250; 50 or more seats $300;
Continental Breakfast= $30; Retail Food (only TCS Foods)= $20; Retail Food Store—Less than 8,000 S.F. _
$100, more than 8,000 S.F. = $285; less than 1,000 S.F.; Retail Food Combo/Limited Prep. - $200.00; Cottage
Food Industry= $75;Mobile Truck=$50; Mobile Ice Cream Truck=$35; Frozen Dessert License= $30;
Additional non-refundable Fee for New Establishment or New Ownership=$100-$500(see staff), Late Fee=
$10
Q\Application FonnsTOODAPP REV3-2019.doc
is
i
1
--r6t,� k
r
pfi Town of Barnstable BOARD OF HEALTH
�Y John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BAKNWAFUZ : Paul J.Canniff,D.M.D.
NAM 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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: S17 Issue Date: 01/01/2020
D BA: SEA COAST I N N
OWNER: DEVANG PATEL
Location of Establishment: 33 OCEAN STREET HYANNIS, MA 02601
Type of Business Permit: BED AND BREAKFAST
Annual: Seasonal: YES
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: $30.00
MOBILE-FOOD:
MOBILE-ICE CREAM: QA
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
lie Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
' errrasL� 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, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 517 Issue Date: 01/01/2020
DBA: SEA COAST INN
OWNER: DEVANG PATEL
Location of Establishment: 33 OCEAN STREET HYANNIS, MA 02601
Type of Business Permit: BED AND BREAKFAST
Annual: Seasonal: YES
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: $30.00
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:
Town of Barnstable BOARD OF HEALTH
ti Paul J Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
BARNST,BLL John T.Norman
\, MAs F.P.(Thomas)Le Alternate
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: 517 Issue Date: 04/01/2019
DBA: SEA COAST INN
OWNER: DEVANG PATEL
Location of Establishment: 33 OCEAN STREET HYANNIS, MA 02601
Type of Business Permit: BED AND BREAKFAST
Annual: Seasonal: YES
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR: 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: $30.00
MOBILE- FOOD:
MOBILE-ICE CREAM: GQ�
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:
a
1
oFrHME toys Initials:
Town of Barnstable
Date Paid / )Ff
Amt Pd
9BAMMAN.ST"LE•� Inspectional Services1619.
Public Health Division
Thomas McKean,Director Ldi(
200 Main Street,Hyannis,MA 02601 �JJ
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: L'o '* CC,)S rT
ADDRESS OF FOOD ESTABLISHMENT:
MAIMING ADDRESS(IF DIFFERENT FROM ABOVE):�
E-MAIL ADDRESS: Q v q hJ 74 Z l9 2 l.!L`� Q Vx UU CO
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS: ac
WELL WATER: YES NO �.. (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: TO 70./ 01 11
NUMBER OF SEATS: INSIDE: Q OUTSIDE: TOTAL:
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)?
TYPE 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)
TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL, MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
Q:\Application FonnsT00DAPPREV2018.doc
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT �� J C'
SOLE OWNER: YES/NO D.O.B i OWNER PHONE # 19? Y/
ADDRESS_ 153 -� C k?c D'O P Y j✓Iv f S l'v! - UZ G all
CORPORATE OWNER: 1�d FEDERAL ID NO. :
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS: S ,j
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
IV2 0-
2.
SIGNATURE OF APPLICANT 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/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1st to Dec. 31'each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st.
Q:\Application FormsTOODAPPREV2018.doc
t
MAIL-IN REQUESTS
Please mail the completed application form to the address below. Also include copies of your employees'
food protection manager training certificates (at least two) and food allergen awareness training certificate (at
least one.) In addition, please include the required fee amount (see fees at bottom of this page). Make check
payable to: Town of Barnstable. Our mailing address is:
Town of Barnstable
Public Health Division
200 Main Street
Hyannis,MA 02601
FOR FAXED REQUESTS
Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax copies of your
employees' food protection manager training certificates (at least two) and food allergen awareness training
certificate (at least one.) In addition, you must mail the required fee amount (see box below). Please make the
check payable to: Town of Barnstable. The check must be mailed to the address listed above.
FEES: Bed& Breakfast Permit= $55; Food Service Permit 0-49 seats=$250; 50 or more seats $300;
Continental Breakfast= $30; Retail Food (only TCS Foods) = $20; Retail Food Store—Less than 8,000 S.F. _
$100, more than 8,000 S.F. = $285; less than 1,000 S.F.; Retail Food Combo/Limited Prep. - $200.00; Cottage
Food Industry= $75; Mobile Truck= $50; Mobile Ice Cream Truck=$35; Frozen Dessert License=$30;
Tobacco Sales Permit=$85; Additional non-refundable Fee for New Establishment or New Ownership=
$100-$500(see staff), Late Fee=$10
Q:\Application FormsTOODAPPREV2018.doc
OF IKE roW TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: -��� J Y,n Date: 1a� �,-� age of
OFFICE HOURS
PUBLIC HEALTH DIVISION 8,00-9:30 A.M.
BARNSTABLE. • 200 MA►N STREET 3:M N.-FP.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS,MA 02601 More.- RI.508$62-4644 No Reference. R-Red Item PLEASE PRINT CLEARLY
FOOD ESTABLISHMENT INSPECTION REPORT
Name Date Tvpe of Tyne of Inspection
3 Operation(s)M- Routine
�Address , � Risk e Re-inspection
Level Retail Previous Inspection
Telephone Residential Kitchen Date:
Mobile < Pre-operation'
Owner HACCP Y/N Temporary Suspect 111ness
Caterer General Complaint
Person in Charge(PIC) Time Bed&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) 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 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 IL-
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations I ^
Critical(C)violations marked must be corrected immediately. (blue&red items) VI (;/�/" Corrective Action Required: ❑ 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/Exclu n ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items Embargo Emer enc Closure Voluntary Disposal
checked indicate violations of 105 CMR 590.000/Federal Food Code. ® 9 ❑ 9 y ❑ ry P ❑ 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 6=One critical violation and less than 4Hon-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
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.Special Requirements (590.009) receipt within 10 days of recei t of this order. violation,4 to 8 non-critical violations=C.
30.Other DATE OF RE-INSPECTION: In pector' ' n t e rint:
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
r t,
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* F 8 Cross-contamination 14 Food or Color Additives I 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)
*
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 7-201.11 Separation-Storage* 3-501.16(A) Roasts Held At or Above 130°F
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*
3-304.11 Food Contact with Equipment and Utensils
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11) Variance Requirements
q
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)Returned Food and Reated 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 Fg 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 Wazewashin Hot Water 7.206.12 Rodent Bait Stations
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. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3401.11A(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
5-101.11 Drinking Water from an Approved System * g8 Not Otherwise Processed to Eliminate
Equipment ( )O Pathogens*590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * e ecnve mrzoor
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*
Sources* 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* 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 PHFs 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 Commercial] Processed RTE Food-140'F* Blue Items 23-30)
3-202.15 Package Integrity ( ) Y 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
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
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( )
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
5-20411 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* 1 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 6501.12 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.
I
IME Tp� TOWN OF BARNSTABLE ,HEALTH INSPECTOR's Establishment Name: - �! Date: .I Q /�;qjlsPage: Of
4 OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00'-9:30A.M.
BARNSTABLE. ` 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS. g. MON.-FRI.
94, ,639.p HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEA 2LEA SE PRINT C LEAq LY
'EDN1P' FOOD ESTAB ISHMENT INSP CT N REPORT
Name Date" e o T section If
r Routine
Operations)
Address Risk Food Service Bq n ction
Level Retail Previous Inspection
Telephone Residential Kitchen Date:
Mobile Pre-operation _
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complai
Person in Charge(PIC) Time Bed&Breakfast HACCP \ f
Other 01 9 / r
Inspector
re an explanation on the narrative pages nd.a citation of specific provision(s)violated.
Each violation checked requiViolations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009
(m
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ /ffrj�tsj
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ LLI
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ,
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities - KIN
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS A '
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives , /�7 f-
/^ 01
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially H ous Foods)
❑4.Food-and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating l
❑ 6.Tags/Records/Accuracy of Ingredient Statements 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans 19.Hot and Cold Holding \ 9. 1 /
PROTECTION FROM CONTAMINATION ❑ 0.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) 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
( ) dlately or Overall Rating
within 90 days as determined by the Board of Health. g ❑ 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. ❑ ❑ 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 6=One critical violation and less than 4non-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 g p,infestation of rodents or insects,or lack of
27.Physical Facility )( ) gg y y 9 g q C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,y y (FC-6 590.007 a rieved b this order, ou have a ri ht to a hearin Your re uest must violations observed,7 to 8non-critical vi lations. 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 viol lion,4 to 8non-critical viol oIc i .
29.Special Requirements (590.009) within 10 days of receipt of this order.
Q
30.Other DATE OF RE-INSPECTION: In p tor' gnature a nt: _
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 P C's Signa ure 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.)
_FOOD_ PROTECTION MANAGEMENT _ PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) jAssignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
3-501.15 Coolin Methods for PIK
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12_._ Additives* g
Cooked and RTE Foods.* * __ _ .. _ .1.9_ __ PHF Hot andCold Holding_
2-103.11 Person-in_Chazge Duties - - - 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 1 5 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below'41°17/45°17
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* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
.- - - - 7-10211 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*- -- -- - - -- - --' - 3-3D2.T1-(A)-- Food Protection* p g 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 3-304.11 Food Contact with Equipment and Utensils*Person In Charge* t 7.202.12 Conditions of Use* -590.004 fl_ Variance Requirements
590.003(G) Reporting by Person in Charge* ___ _ _ 7-203.11 Toxic Containers-Prohibitions*
( ) q
- Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* ,° .,7-204.11 Sanitizers,Criteria-Chemicals* _ REQUIREMENT.S.FOR.
_ _ 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) I Removal of Exclusions and Restrictions _ g 1
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 Fiom Regulatod"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* * 3-801.11(D) Raw or Partially Cooked Animal Food and
_ ( ) P - -- - - _ - - - - 4-SO1-.1-1"1- - Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations
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* -' - - - 4-501.11-2 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 Dririking 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
5-lOL.l1 _ Drinking VVater_from.an Approved System* _ gg
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* El/cti e 11112001
4-602.1 L . 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 590.009(A)-(D)in cater-
Sources* Ratites-]65°F 15 sec* ing,mobile food,temporary and residential
�0 Proper,Adequate Handwashing 3AOI.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* foodborne illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 * Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )(b) All Other PHFs-145°F IS sec
�� Good Hygienic Practices practices should be debited under#29-Special
3-201.17 Game Animals* yg 17 Reheating for Hot Holding 9
Re uirements.
$ 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)
3-202.15 Package Integrity* Critical and non-critical violations which d not relate t the dborne
o e e o e a
* 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts*
3-101.11 Food Safe and Unadulterated ( ) g 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
* 13 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( ) g r27.
Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F
Tags/Records:Fish Products
5-203.11 Numbers and Capacities* Within 4 Hours* Management and Personnel FC-2 003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient. Food and Food Protection FC-3 004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* Water,Plumbing and Waste FC-5 .006
590.004(1) Labeling of Ingredients'
Supplied with Soap and hand Drying Devices
Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability - Poisonous or Toxic Materials FC-7 1.008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009
3-502.11 Specialized Processing Methods*
30. 1 Other
3-502.12 Reduced-.Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures*
PP 5:590Formback6-2doc
*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.
.J
0 0� TOWN OF BARNSTABLE J/� �'py'l1`I HEALTH ICE H EURSR s Establishment Name: s'k-�/ ! U Date: Page:.of
Y�• O J /(�' V J'� O O
PUBLIC HEALTH DIVISION J 8:00-9:30 A.M.
v
spnr+srpeLe. � 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF ORRECTION Date Verified
MON.;FRI.
'qp t6)q.A�0 HYANNIS,MA 02601 No Reference R-Red.Item PLEAS P RLY
rF0 MP'� 508-862-4644
FOOD ESTABLI T INSP TON REPORT
Name Date e o o Ins c ion
Operationlsl ou in
Address Risk Food Service
Re-ins ction
Level Retail sous Inspection AV 0
Telephone Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
General Complaint
Person in Charge(PIC) _ Time
Be &Breakfast HACCP
Other
Inspector
Each violation checked requires an explanation on the narrative page )and a citation of specific provision(s)violated.
r
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 Hazar nods)
❑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
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
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
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo F] Emergency Closure Voluntary Disposal El Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below b a Board of Health member or its agent
24.Food and Food Preparation (FC-3)(590.004 p g y g A=Zero critical violations and no more than anon-critical violations. F=3 or more critical violations.9 or more non-critical violations,
constitutes an order of the Board of Health. Failure to correct violations 6=One critical violation and less than 4non-critical 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 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)(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-critic violat• ns. If 1 critical refrigeration.
viol
29.Special Requirements (590.009) within 10 days of receipt of this order.
n, to 8 non-critical violatio =C.
30.Other DATE OF RE-INSPECTION: Insp s Si nat
31.Dumpster screened from public view
i
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N Pi6j' Signature / , Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted •Y N `�/ /)�, 6 r
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions t
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 1 g 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
Other* 7-102.11 Common Name-Working Containers* 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 Emits and Vegetables 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* ( ) q
- 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 Reservior 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*
q 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 Warewashin 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 Contiol 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
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(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
Equipment
5-101.11 Drinking Water from an Approved System* * Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* effe°"°e vtrzooi
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*
Sources* 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.
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
$ 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 Commercial] Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome
* 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts*
3-101.11 Food Safe and Unadulterated (E) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 8 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification g
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
* 3-501.14 Coolin PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* 5-204.11 Location and Placement (B) g
* 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 I FC-7 1.008
HACCP Plans 6-301.12 Hand in Provision
Drying 29. 1 Special Requirements 1.009
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.