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HomeMy WebLinkAboutBARNACLE TOO - CLOSED FOOD "Barnacle TOO I 974 Crai9ville Beach Rd: Centerville -22�Wo� rtr Town of Barnstable BOARD OF HEALTH Or John T.Norman Board of Health Donald A.Gaudagnoli,M.D. aaa�tisr��sc F.P.(Thomas)Lee 111 a'a5. 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: 281 Issue Date: 01/01/2022 DBA: BARNACLE TOO OWNER: BARNACLE ENTERPRISES INC Location of Establishment: 974 CRAIGVILLE BEACH ROAD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 20 OutdoorSeating: 0 Total Seating: 20 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE-ICE CREAM: Q� 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: Only outdoor seating. June 14, 2016 Board meeting granted variance for 20 seats with the following conditions: the restaurant will only be open during the hours that the Craigville Beach bathroom faciliities are open when using seating at the establishment . 1 r For Offic Iriiti8lS . Town of Barnstable 717 Date Paid AmLP 1 L= x Inspectional Services - `� Public Health DivisionP �'teCk# 1 ' 9 car, 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 .U'A NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: S ARM Ad fi 90ewR r st-S ADDRESS OF FOOD ESTABLISHMENT: 974 crd g&y t tt f 8e g,c.L RU MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �'` CJn 7G�. E-MAIL ADDRESS: ��A���G`�� w� s • a�+� TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: B WELL WATER:YES NOj ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: _DATES OF OPERATION: I / /AIFO /0/ NUMBER OF SEATS: INSIDE: © OUTSIDE: aS 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? 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) *** E & NEW FOOD ONLY*** _ SEASONAL.MOBIL REQUIRED TO CALL HEALTH DIV FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q\Application FormsTOODAPP 2020.doc . y OWNER INFORMATION: FULL NAME OF APPLICANT TmAl y A91 VA6G s SOLE OWNER: YES jV0 D.O.B r OWNER PHONE# ADDRESS PDT dq 3.1k)"T)1Y"A)1AP8 rf /1' A O a CORPORATE OWNER: I A� eaI�l N A� CORPORATE ADDRESS: �R�}1 Phi l�� � Cit, ,► I �1t �K O)WL ,j r PERSON IN CHARGE OF DAILY OPERATIONS: lDM I� NI Wtkk I 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 2. '7(� SI ATURE OF APPL ANT 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/henithdivision/appncations.ast). 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 APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q\Application FormsTOODAPP REV3-2019.doc `ofIME Tom TOWN OF BARNSTABLE - HEALTH INSPECTOR'S Establishment Name: Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 800:-9:30A.M. BAR ABLE, ARNSTABLE, 200 MAIN STREET 3.30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/-PLAN OF CORRECTION Date Verified MON.-FRI. A +679. ��� HYANNIS, MA 02601 No Reference R.-Red Item. PLEASE PRINT CLEARLY 508-8624644 'FON1P�� FOOD ESTABLISHMENT INSPECTION REPORT. Name Date Tyne of Tvoe of Inspection Routine Address /1 �, ; I Risk Food Re-inspection - 7\ L/ rivl Cy Level Retail Previous Inspection V GY Telephone Residential Kitchen Date: Mobile. e-operation Owner HACCP YIN Temporary SOspec ness Caterer General Complaint Person in Charge(PIC) Time Bed 8 Breakfast HACCP c In: Other Inspector 7 �v Out: V' " ` I I _ Each violation checked,r uires 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 Related 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) ❑ C ' 3r Action as determined by the Board of Health. Allergen Awareness 590.009(G) U4 I�0-U1_ &eA 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 /� a ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) & d. ❑ 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 ? _ C( ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for.HSP i ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories , d/ Violations Related to Good Retail Practices(Blue 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,the items ❑ Embargo ❑ Emergency Closure F] 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 B=One critical violation and less than 4 non-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 suspensi 9on 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) within 10 days of receipt of this order. violation,4 to 8 no"gal'gal violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Sig to a Pri t: j 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 Sig ature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N t— t IKE Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. awRN§eABM Paul J.Canniff,D.M.D. b r 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: 281 Issue Date: 01/01/2021 DBA: BARNACLE TOO OWNER: BARNACLE ENTERPRISES Location of Establishment: 974 CRAIGVILLE BEACH ROAD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 20 OutdoorSeating: 0 Total Seating: 20 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - - ----— MOBILE-FOOD: MOBILE-ICE CREAM: a� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Only outdoor seating. June 14, 2016 Board meeting granted variance for 20 seats with the folllowing conditions: the restaurant will only be open during the hours that the Craigville Beach bathroom faciliities are open when using seating at the establishment ptHE r Town of Barnstable For Office Onl Use y: Initials: �' Date Paid [Amt Pd$ � BAMSfABM Inspectional Services 16 9. `e� Public Health Division Check# P s � �fD MAC Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPrLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 330 �1 NEW OWNERSHIP RENEWAL C� NAME OF FOOD ESTABLISHMENT: BARN Ad f. EN��rPR t sus ADDRESS OF FOOD ESTABLISHMENT: 97j/ Cret i 4�t II f, 6ea G�► led MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: , n11317FNAL'G6 WMCAS I NG 1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: V7 - 3A49 TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO_j_ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: �C DATES OF OPERATION: / /�/TO /0/ / j NUMBER OF SEATS: INSIDE: © OUTSIDE: 75' TOTAL: o�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? 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) *** 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 +49Ny 4t9 1✓A6&1 SOLE OWNER: YES UO D.O�.B OWNER PHONE# ADDRESS Po8 lQ 3 PH ,.W►WT}�H�}A�/l��PD t 1 /� �A c a &3,- CORPORATE OWNER: /�A� �' �Qre/N A) CORPORATE ADDRESS: 1"I lilt &4c-, PjCiElt}�,ry I�t, l'1'll4 O��3� PERSON IN CHARGE OF DAILY OPERATIONS: lON 00 VltGI/ 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.— o 0 Ali piiv,44,t 15'/,ju 1. r SI ! ATURE OF APPL ANT 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/at)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.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FonnsT00DAPP REV3-2019.doc 4/28/2021 Rockland Trust Company Welcome back, CAROLYN NINIVAGGI TRUST Stop Complete tl- Stop Payment Successful Tracking ID 18270764 Process On 4/28/2021 Account FREE BUSINESS CHECKING Payee Name Town of Barnstable Health Dept Amount $250.00 eck N 1588 Check Date 4/14/2021 Close View In Activity Center https://www.rocklandtrustonline.com/rocklandtrustcompanyonline/Uux.aspx#/stopPayment t 1/1 4/28/2021 Rockland Trust Company - Welcome back, CAROLYN NINIVAGGI TRUST Single Transactions Recurring Transactions Mobile Deposit History Created date Status Transaction Type Account Amount FREE BUSINESS 4/28/2021 Processed Stop Payment-Tracking ID: CHECKING DDA- $250.00 18270756 XXXXX8226 Tracking ID: 18270756 Amount: $250.00 Created: 04/28/2021 10:04 AM Account FREE BUSINESS CHECKING DDA- Number: XXXXX8226 Created By: CAROLYN NINIVAGGI Authorized: 04/28/2021 10:04 AM Payee: Town of Barnstable - Health Dept Check 1589 Authorized By: CAROLYN NINIVAGGI Number: Will process 04/28/2021 Check Date: 04/14/2021 On: https://www.rocklandtrustonline.com/rocklandtrustcompanyonline/Uux.aspx#/transactions/activityCenter?page=l&query=sort%3DcreateDate%251Fd 1/1 4/28/2021 Rockland Trust Company ng Stop Payment Fee — $35.00 Pending Stop Payment Fee — $35.00 https://www.rocklandtrustonline.com/rocklandtrustcompanyonline/Uux.aspx#/account/967288?currentTab=transactions 1/1 p1FS Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. EARfMABM 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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 281 Issue Date: 01/01/2020 DBA: BARNACLE TOO OWNER: BARNACLE ENTERPRISES Location of Establishment: 974 CRAIGVILLE BEACH ROAD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 20 Outdoor5eating: 0 Total Seating: 20 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q.A FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Only outdoor seating. June 14, 2016 Board meeting granted variance for 20 seats with the following conditions: the restaurant will only be open during the hours that the Craigville Beach bathroom faciliities are open when using seating at the establishment , Initials: Town of Barnstable _ Date Paid Amt Pd$ BARNSTABLE. : Inspectional Services Public Health Division check# Thomas McKean,Director 4 S—Ob,dD 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 r: APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE d NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: V Y MAILING ADDRESS(IF DIFFERENT FROM ABOVE): /� E-MAIL ADDRESS: r fi C. 18�4901ftCI 9 (9`0 n&A . A.)Cr TELEPHONE NUMBER OF FOOD ESTABLISHMENT: at A-0- 3 OD TOTAL NUMBER OF BATHROOMS: WELL WATER: YES_NO--)C ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: J /tS3PTO V/ / 00 NUMBER OF SEATS: INSIDE: © OUTSIDE: TOTAL: a 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? 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) *** 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 t w 9 " J OWNER INFORMATION: FULL NAME OF APPLICANT TOpJ 4 id AM&-19l SOLE OWNER: YES lQ MOM OWNER PHONE# So 8- a�_311 ao ADDRESS PO J /9 3 ICJ e ST N y f31IJNti.omrfi CORPORATE OWNER: ^&is# CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: II / 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 Ton i n%an , 1�1,12a -r l ;3 1. 0AJ 3 / 30/ as SI ATURE O 9AP L a A*'NFT 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/heaIthdivision/a1)plications.as[). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. 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 1st. Q:\Application FormsWOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. BARNSTABLE � John T. Norman VA$% F.P. Thomas Lee Alternate +d39. , 200 Main Street,Hyannis, MA 02601 a 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: 281 Issue Date: 03/01/2019 DBA: BARNACLE TOO OWNER: BARNACLE ENTERPRISES Location of Establishment: 974 CRAIGVILLE BEACH ROAD CENTERVILLE MA 02632 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 20 OutdoorSeating: 0 Total Seating: 20 FEES _— FOOD SERVICE ESTABLISHMENT: $250.00 YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: - -- - - - MOBILE-FOOD: MOBILE-ICE CREAM: C�� 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: Only outdoor seating. June 14, 2016 Board meeting granted variance for 20 seats with the following conditions: the restaurant will only be open during the hours that the Craigville Beach bathroom faciliities are open when using seating at the establishment T LK r t} i% tJNE r Initials: °`"�° Town of Barnstable 3-� AD Date Paid 3 Amt Pd S a DMN6TABL£,yr Inspectional. Services q MAH9. W //��{/ /y{/0 1679. �m . . Check# _ ArEGMA�A 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 i DATE .3141 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: 77f eftai0I/46 Jeaei led. MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: Tffxy,&rNac l e—O dom eas 1 • ij'-T TELEPHONE NUMBER OF FOOD ESTABLISHMENT: f r} AV- 3�O TOTAL NUMBER OF BATHROOMS: i WELL'HATER:YES NO/— ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: �+/Ir14TO /Dl / /19 NUMBER OF SEATS: INSIDE: OUTSIDE: dO TOTAL: a 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 REQUIRE,MENTS. 1 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 5<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:1Apptication FomisWOODAPPRI:V2018.doc ' 4 PLEASE CALL 508-862-4644 OWNER INFORMATION: �) d FULL NAME OF APPLICANT SOLE OWNER: YES® D.O,B r --� ,519"'OWNER PHONE# .S49S-V1?&-3 qA9 r ADDRESS 8 I 3 I"� In� kfax0? CORPORATE OWNER: 4FEDERAL ID NO. : - D rr Q L4 IJ� CORPORATE A DRI; S: �/"Qt 41/'!��>� OG�t,L� �`� 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 r en Awareness Expiration Date ery tj%J Al I d(VA 6*t ®rf*7 2. 011-1 A? T v�ora yARBAu 3 �4 s . SIGNATURE OOPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!1 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•1/www towiiofbarnstable,us/healtlidivision/ai)plicatioiis.8sp. 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. i NOTICE: Permits run annually from January I st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC I st. Q:1Application FormsTOODAPPREV2018.doc C 1 5 oF.NE r TOWN OF BARNSTABLE .HEALTH INSPECTOR's Establishment Name: G `�c!t Dater `2/1,.Page: _of P� "Wo OFFICE HOURS BAR- Nsr"BCE. PUBLIC 200 MAN STREET 330-4:30 P.M. DIVISION - 6 0=9a0A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. •g HYANNIS,MA 02601 MON.-FRI. No Reference I R-Red Item• PLEASE PRINT CLEARLY .aaq•p. 508-862-4644 rF Y D P M FOOD ESTABLISHMENT INSPECTION REPORT - Name Dat 3 Z Tyoe of s ec i n racalautba-Y �T Address '? & p u� Risk Food S Re-inspection ill �'C ,/ Level Retail Previous Inspection Telephone U Residential Kitchen Date: 3 // � fGr Mobile Pre-operation r�_ Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast Other CP S)L4 C- - ILR a, � In: I Inspector Out: (I !3p 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) ❑ s S) C IpC FOOD PROTECTION MANAGEMENT ❑ 1 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 QG� //�� . 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 �.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 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) q i lb al Corrective Action Required: ❑ No El 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,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 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 non-critical violations if no critical violations observed,4 too 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 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 anon-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 ( )( ) within 10 days of receipt of this order. violation,4 to 8 critical violations=C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: Inspector' Ignatur Prinrl�ih) 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 s Signa Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y . N Dumpster Screen? Y N f .- :'a.....a.:,t .._.. .:-:.�- ..._ r.-.-� - - �. .. ._ •-� ._ -t .r . ..- ._ c 4-, .. - Y-ti "' ._, '- r .. .. a _ ,. .. ... r F Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Real 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 Additives 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'• * y 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 590.004(F)3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A5(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 3-501.16 A Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* ( ) 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 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 I 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* 3 590.003(D) Contamination from the Consumer Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Remmed Food and Reservice 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 Wazewashing-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. Proper Cooking Temperatures for PHFs CONSUMER ADVISORY Drinking3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 18 '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 5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff dive r/r/zoor 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 rf 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 Chem Ratites 165°F 15 sec* ical* ( )"( ) Sources* Mushrooms Approved By ing,mobile food,temporary and residential Authority 10 Peanon on-Hands an Arms*Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and 2-301.11 Cl Condition Hdd A * 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 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 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18I 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 5-203.11 Numbers and Ca acities* Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products P 24. Food and Food Protection FC-3 .004 3-002.11 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 t Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 Labeling of Ingredients* Supplied with Soap and hand Drying Devices 590.004(J) 9 9 - � 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 {J 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 590.00q. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. " oFIHF roh TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: L ,Z f Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ' r 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified :a q. p HYANNIS, MA 02601 MON.-FRi. No Reference R-Red Item PLEASE PRINT CLEARLY 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name �-� Date Z� Tvoe of Tyne of Inspection O n s Routine AddressCh l7L Re-inspection /„e( S W Level Retail Previous Inspection Telephone Residential Kitchen Date- Mobile �re-operati Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint �� `� Person in Charge(PIC) Time Bed&Breakfast HACCP In:-I;M A Other Inspector Out: ; S , i Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. ( ll tL „I 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 uji ❑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 vpK.tl ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved.Procedures/HACCP Plans ❑ 19.Hot and Cold Holding �p 1 PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control �� Ol cL ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) S`L"L( l! I I ❑ 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 r 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 illk 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 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 4npn-critical violations g ( )( ) 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 be in writing and submitted to the Board of Health at the above address violations observed,7 to 8npn-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8 non- violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Sign re Prin: 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.) 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding 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 ated 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* Require Reporting by Food Employees and Contamination from the Environment 7-102.1 I Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130`F* Applicants* * 7-201.11 Separation-Storage* 20 Time as a Public Health Control 3-302.11(A) FoodPro[ection 590.003 F Responsibility of A Food Employee or An 7-202.11 Restriction-Presence and Use* * O P y3-302.15 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 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*, 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* 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 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 y 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* 3-801.1 1(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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* 3-801.1 I(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* t 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.1 l Drinking Water from an Approved System* 4-60I.11(A) Clean Utensils and Food ContactEggs Surfaces of s-Immediate Service 145*17 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* rry rdw 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* 3-20L14 Fish and Recreationally Caught Molluscan Contact Surfaces 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155*F 15 sec* aces of Equipment* - Shellfish* 4 703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009 A - D Violations of Section 590.009 A Chemical ( ) ( ) ( )-(D)in cater- Sources* -- Ratites-165*F 15 sec* 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 1T 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 Conamination 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 I 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. 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 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. t HEALTH INSPECTOR'S Establishment Name: ,��1 Y �C J Date: � age: of `oF roi, TOWN OF BARNSTABLE t � � �P ~� PUBLIC HEALTH DIVISION OFFICE HOURS 800-9:30 A.M. �a+srne�E. = 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified mnss. g. MON.-FRI. 94, ,659.p�m HYANNIS,MA 02601 son as2 FRI. No Reference R-Red Item PLEASE PRINT CLEARLY . rEDN1P� FOOD ESTABLISHMENT INSPECTI� N REPORT op ✓✓✓ Name r Dat /vAl ipe of Tyi)e of Inspection tot Q1 g Routine Address Risk Food Seniice Re-inspection evel Previous Inspection ft Telephone Residential Kitchen Date: J Mobile a-oper Owner HACCP Y/N Temporary _�uspect llness i L Caterer General Complaint Person in Charge(PIC) O Time Bed&Breakfast HACCP 41 Other L Inspector f Each violation checked requires kn explanation on the narrative age(;)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 I Knowledgeable/eable/Duties g 9 ❑ 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 p 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 HS ❑ 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 Violation Critical(C)violations marked must be corrected immediately. (blue&red items) 2 2D 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,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 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 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 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 t anon-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 v�latio =C. ' 30.Other DATE OF RE-INSPECTION: In ctor s Signature int: 31.Dumpster screened from public view go, Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Ign ure Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N v 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 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* g3-501.16(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* * i 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 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* 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 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 Reared 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 Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served y P 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 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* 3-401.11A(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* E1hc"9e 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 IS sec* in mobile food,temporary and residential Sources g, P arY 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* 3-4 13.11(A)&(D) PHFs 165'17 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3403.11(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 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* is 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 3-203.18 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 to 41'F/45'F 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. 1 Poisonous or Toxic Materials FC-7 '008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1C.46miancewithApproved Procedures* S.590Formback&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. iihoF� roy TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Oo Date: Page: - of/ OFFICE HOURS BARNS'rAB1.E. ' PUBLIC 0 MAIN LSH DIVISION -s:3oA.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. MASS. `0 HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY �°rFD MPS° 508-862-4644 FOOD ESTABLISHMENT INSPEjCTION REPORT Name Da'- a of c io �jj Q11IM96iiM outi6e Address o d Sem ection e el Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation It 00, Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) ime Bed&Breakfast HACCP Other d Inspector u^ Each violation checked requires A explanation on the narrative p ge(s 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 Cq ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS Vr ❑ 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 1P ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding Ai PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control Lff-� ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIO�S(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSPI ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY n I ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Lli 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,the e 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) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 9 26.Water,Plumbing and Waste if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot g (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations l than 9 non-critical. If no critical water,sewage 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must s a less ga back-up,infestation of rodents or insects,or lack of ( )( ) be in writing and submitted to the Board of Health at the above address violations observed;7 iy 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 4 to 8 n-cri cal violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: In Ign u Print: -z-f 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 Sign re ,O Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N , I L L Dumpster Screen? Y IN p 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 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* 7-10211 Common Name-Working Containers* 3-501.16(A) 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* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage*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 Requirements 590. 3(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 00 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 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 3-801.11(C) I Unopened Food Package Not Re-Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 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* 3-401.1 IA(I)(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 I 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* sg°"1e 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 3-201.15 Molluscan Shellfish from NSSP Listed Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Chemical* F Ratites-165' 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 Requirements. radicsrho ld 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* Lu Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 3-501.14 A 3-202.18 Shellstock Identification 13 Handwashing Facilities ( ) Cooling Cooked PHFs from 140°F to 70°F hem 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* 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 I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1 1.009 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. _3//7`gyp IKE rok, TOWN OF BARNSTABLE VHEATH INSPECTOR's Establishment Name: Date: Page:.of v tia OFFICE HOURS PUBLIC HEALTH DIVISION 6:00-9:30A.M. BAR-STABLE. ) 200 MAIN STREET 3:30-430 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 0MON.-FRI. �p e39.a m HYANNIS, MA 02601 506-662-4644 No Reference R-Red Item PLEASE PRINT CLEARLY rFDMP+ FOOD ESTABLISHMENT INSPF JCT19N REPORT y Name /� Datebft a of o s e io C era ions Routine Address \ sk ood Service Re-inspection. evel Retail Previous Inspection Telephone Residential Kitchen Date: VU Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP n[ Other Inspector ? 0, ' Each violation checked requires an explanation on the narrative 'age(s)and a citation of specific provision(s)violated. IV 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 J EMPLOYEE HEALTH PROTECTION FROM CHEMICALS a ❑ 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 H$P _ ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY 1I✓O ❑ 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: IgNo 11 1 Yds Non-critical(N)violations must be corrected immediately or within 90 days as determined b the Board Health. Overall Rating y y ❑ 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 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 g )( ) 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 9non-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) within P within 10 days of receipt of this order. violation,4 to 8 non-critical violation =C 30.Other DATE OF RE-INSPECTION: Inspe to s Sig at e Q Pr' t: 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 514111 Print: Self Service Waft 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding 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 * P g 2 Other 7-102.11 Common Name-Working Containers** 3-501.16(A) 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* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 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 Requirements 3-304.11 Food Contact with Equipment and Utensils ( ) q 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) I 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* 4-501.111 Manual Wazewashing-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 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* 163AO1.11A(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* Effective mnooi 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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed , Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 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 Requirements. radicsrho ld 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* 2401.12 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* * (Blue Items 23-30) 3-202.15 Package Integrity* g g 3-403.11(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 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 16 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 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients[0 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 1 6-301.11 1 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 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. �p THE*ow TOWN OF BARNSTABLE .HEALTH INSPECTOR'S Establishment Name: - Date: Page: of OFFICE HOURS i BARNSfABLE.o� PUBLIC 200 MAN STREET 3:30-4:30 P.M. DIVISION : 0- :30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �A e3q. `0$ HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'FDN1P`p FOOD ESTABLISHMENT INSPECTION REPORT Name Dat Type o Xe o sec io O er Routine Address '7 Risk Fo S e ction Level a Previous Inspection l Telephone i Residential Kitchen Date: _� 15 !a";5 N Mobile Pre-operation Owner HACCP TIN Temporary Suspect Illness 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. l 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)a(G) Action as determined by the Board of Health. Allergen Awareness 590.009 i FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands \' i ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities . l ` C EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives (0 ❑ 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 G l ❑ 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 SUSCEPTIBL`E,POPULATIONS(HSP) e ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP 7t ❑ 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 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 toda ; 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 B=One critical violation and less than 4 non-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 t F is scored automatically o la 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 i 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 anon-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8raon-critical violations=C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Du7y- r 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 PIC's g t Print: t Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N -ro Dumpster Screen? Y N /V ✓✓ / /v V 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 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.1](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 390.004(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* Require Reporting by Food Employees and Contamination from the Environment 7-102.11 Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 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)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g � ) 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 F 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 Wazewashing-Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetically Sealed Container Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-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 . ean Utensils and Food Contact Surfaces of * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* 4-60111A) Cl Eggs-Immediate Service 145°F 15 sec Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff eye 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 12.1 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing Ratites-165°F 15 sec*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 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 t 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 3-403.11E Remaining Unsliced Portions of Beef Roasts* ( ) 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 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 hem 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 16-301.11 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. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* _ 8-103.12 Conformance with Approved Procedures* S:590Forrnback6-2doc *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. `oF*KE►o TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: ✓ .t� Page: of,, 'xP c OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 2679. .0� HYANNIS, MA 02601 MON.-FRI. No Reference R--Red Item - PLEASE PRINT CLEARLY � 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name Da Ee Tvoe of Inspection 0 ' RoutineAddress ` k erv' Re-inspection e el Previous Inspection JC Telephone Residential Kitchen Dat Mobile re-operaPo Owner HACCP Y/N Temporary uspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP U l 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 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 b the Board of Health. Overall Rating ry p ❑ ❑ p ❑ Y Y ❑ 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 (FC72)(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 4npn-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 2T.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 anon-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8 non critical violations=C. 29.Special Requirements (590.009 Y p 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view n� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N W #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sig to Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N e-�___ Dumpster Screen? Y N �" G�''��'�' l 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 1 q 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* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers* 3-501.16 A Roasts Held At or Above 130°F* Require Reporting by Food Employees and Contamination from the Environment * ( ) 7-201.11 Separation-Storage*Applicants* 3-302.11(A) Food Protection* P g * 20 Time as a Public Health Control 3-302.15 Washing Fruits and Vegetables Use 590.003(F) Responsibility of A Food Employee or An 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Applicant To Report To The Person In Charge* 3-304.11 Food Contact with Equipment and Utensils* 7.202.12 Conditions of Use* 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)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 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* 4-501.111 Manual Warewashin 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 3-801.11(C) Unopened Food Package Not Re-Served* 3-201.13 Fluid Milk and Milk Products 4-501.112 Mechanical Warewashing-Hot Water Monitoring 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 3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec CONSUMER ADVISORY Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are 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* PP Y Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg crave 1/12001 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 - ide in cater- * Ratites-165°F 15 sec* in mobile food,tem or and residential Sources g. P azY 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 Requirements. radicsshold 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) Critical and non-critical violations,which do not relate to the fvodborne 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 * 3-501.14 A 3-202.18 Shellstock Identification 13 Handwashing Facilities ( ) Cooling Cooked PHFs from 140°F to 70°F 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* Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. 9 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 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 I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 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. TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: "- Date: Page: _Of , �---- o OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BAR- N�rABLE. ) 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified v� MASS.. `m� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY °rF0 MPS° 508-8624644 FOOD ESTABLISHMENT INSP CTION REPORT Name Dat a j e oe of Inspection er t' s Routine Address sk ervice Re-inspection eveI Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP V,1 (, 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) ❑ tea Action as determined by the Board of Health. Allergen Awareness 590.009(G) c 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.Reheatingk CA mg ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding l PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control \ ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE P PULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ` ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY op ❑ 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 b the Board of Health. Overall Rating ry p ❑ ❑ p ❑ y y ❑ 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- (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 (590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than 4npn-critical violations 9 if no critical violations observed,4 to 6npn-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste 5 590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9npn-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility C-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxi (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. within 10 days of receipt of this order. violation,4 to 8npn-critical violations=C. • 29.Special Requ��eflts (590.009 y p 30.Other �f�e� ,� E_ C Inspector's Signature Print: 31.Du ster s�r�elr�fi"-Eu I Permit Posted? Y \/ N �(� Grease Trap Previous Pumping Date-tom= Grease Rendered Y N f #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' I t e pint: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N 4 110` t J AW Dumpster Screen 7 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) qu 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 1 q 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 d RTE Foods.* 19 PHF Hot and Cold Holding ooe an oo 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[0 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 Se aration-Storage* Applicants* 3-302.11(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* 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 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reared or of Food* 7-204.12 Chemicals for Washing 590.003(E) Removal of Exclusions and Restrictions g Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 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* 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 Control and * 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I 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* 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved S stem* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145'F 15 sec* PP Y Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 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 Shellflsh and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min Eggs:e 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 8 tiY 550.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources g. P aTY 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 foodbthe appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* Other 90 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* practices Other 590.hou violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements.o should 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) 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 3-202.18 Shellstock Identification ( ) 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 1590.000 * 23. Mana ement and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours 9 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 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Fonnback6-2doc *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: ICE GREY 4 , . t proudly p Y i p g.ur- Sea,6 Ice VANILLA D R FqZA BY THE SLICE I I STRAWBERRY 1 CHOCOLATE Regular 2.35 Small 1.85 I' COFFEE1 �1� CHOCOLATE CHIP COOKIE DOUGH Pepsi Diet Pepsi , . MINT CHOCOLATE CHIP Mountain Dew •.- Dr. Pepper __ •-_. _ 1. Mug Root Beer fl Sierra Mist rainbow sprinkles,chocolate sprinkles, Lemonade ; crushed oreo,whipped cream t . Iced Tea ; „ m e1 I n U Gatorade 2.75 c . Cool Blue �'� �` �,'� '•�� - • • • •• Riptide Rush + • • Fruit Punch Lemon-Limea. kP . ... .- •• . Apple Pear - Yumberr SUNDAY - THURSDAY,.J 11-6 Black and Blue . • FRIDAY - SATURDAY 111-6 Bottled Water 2.00 v�ti bD;2 K > b I BREN OVEN MZZA SOUP & SALAD BARNACLE CLASSICS Cheese Hamburger Alt Tomato sauce, mozzarella and parmigiano Clam Chowdah6 oz certified angus beef 7.45 Large- 11.95 l Small - 9.95 1 Slice-3.75 Garden . . Cheeseburgers One Topping Slice 3.95 Lettuce,tomato, onion and shredded6 oz certified angus beef 7.95 With Grilled Chicken 9.95 Hot Dog Antipasto - . • All beef grilled or deep fried 4.00 pepperoni • sausage • peppers • meatball Salami, mortadella, .• • • provolone, lettuce Toppings: lettuce,tomato, ketchup, mustard, onions • bacon . mushrooms . olives • spinach tomato, olives, oil and vinegar 7.95 pickles, onions and relish +.75 /each Philly Cheese Steak Certified angus beef with peppers and onion 8.95 Salad Chicken Tenders. . . . . . . . . . . . . . . . . . . . . . . . . . . , Raspberry 5 chicken tenders with choice of dipping sauce SV E top I A LTY P�Z Z A (ranch, bleu cheese or honey mustard) 6.95 Large- 14.95 1 Small - 12.95 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Margherita �L Tomato, mozzarella and basil � PAH�U��y S"'UnrN Hawaiian Ham, pineapple and cheese TEASERS OR "A Honey Cheese pizza topped with a honey glaze French Fries 2.95 Cap rese tZ Italian 1 Buffalo Mac and Cheese Mozzarella;fresh basil, Salami, mortadella, Pizza topped with mac and cheese,fried Barnacle Home Style Onion Rings 4.75 fresh tomato, prosciutto, capicola, provolone, chicken and buffalo sauce - Mozzarella Sticks balsamic glaze and olive lettuce, tomato, oil and Meat Lovers 5 mozzarella sticks served with marinara sauce 6.95 oil 7.95 vinegar 7.95 Cheese pizza topped with pepperoni,sausage, Fried Dough Eggplant Parmigiano Cheese BLT and bacon Topped with mozzarella Cheese, bacon, lettuce Topped withpowered sugar and cinnamon 3.75 pp Prosciutto 7.95 and tomato 7.45 Gorgonzola, red onion with balsamic vinaigrette Chicken Parmigiano Turkey fig drizzle 15.95 Topped with mozzarella Sliced turkey,cheese, 7.95 lettuce and tomato 7.95 Meatball Chicken Caesar _ _ placing your order,please inform your server if anyone Topped with mozzarella Grilled chicken tossed in in your party has a o, rawundercooked 7.95 a caesar salad 7.95 �t Barnacle Favoritemeat, - of borne illness especially if you have a medical condition. 1HE . pP rOy, DATE. * + FEE: fl 3 * BARMASS.NSTA LE, y MASS. �q �A i639• �� REC. BY { Town of Barnstable rQ SCHED. DATE: Board of Health z 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Wayne A.Miller,M.D. CA3 FAX: 508-790-6304 Junichi Sawayanagi Paul J.Canniff,D.M.D. VARIANCE REQUEST FORM LOCATION Property Address: �`'/�/�I�y/1li° ��e�( /e Assessor's Map and Parcel Number: Size of Lot: , Wetlands Within 300 Ft. Yes Business Name: ML l 9_'-7t_9Q No Subdivision Name: � r APPLICANT'S NAME--by y I�� R1 j►/�C t Phone _5 D a SIN 3 y Did the owner of the property auth rize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON • Name: ( Name: Address:. POt /`/ Address: Phone: Phone: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) a�,ge 14 E isTiN� d�i�,r�� P l h T rr►0(Mo5s Sire--T Rile- CVrf�il rr ?ffi(earcr vi re ScrrgN5 i ,� r c �f NATURE OF WORK: House Addition ❑ House Renovation ❑ Repair of Failed Septic System ❑ Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets. Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or registered sanitarian Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorised you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same ov.,ner/lessee only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed)) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne Miller,Chairman NOT APPROVED Junichi Sawayanagi REASON FOR DISAPPROVAL Paul J.Canniff,D.M.D. C:•\cache\Temporary Internet Files\OLKAE\VARIREQ.DOC _ VdMaG�� loo Meft� 17LI CRAB-vi/1c 13Q� 2n*rf7& -� �aGj; - ; l�ees�t �_�e�_�e s, Qo�rbg•eC � 's .-- � . � f � _ ,.M9 � �c•4e��e.t.-i—V`�-o�rr�4�n n�r_w l.e r�,a��. _. � s 4t _ _ tt �S�te JJ14-�OC4ACto j,.�s�ctar�.etc�1o«e .... _ . SM oo�►�e s + ���.- cp1a..�G J $L�u,v4�e,,j� �gs•�'vece�,. Aa�n,,,,�,�_�nan�p _ G tPy c.aa�esrne�on� �1,,e.-�as�.�uP f Gc e me 1��r,ot1L� 1 Q�blole.-.�ucv1 h i MQ�C�G Q' �„n Gln:c�,tt Te+t�-ecg o . - C�:Q O—cv.eri CeuSer C�eCe�alCe �- S4sa,,,hcrc� 2� cy 7�x t t 1 S�brGtr� 3f�T�I R K 1"R-FIE /,�-I OOh� Ml ;".. . x;,� ��v, y CIKE Town of Barnstable i �a 16 s639• Board of Health �� 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,DMD Junichi Sawayanagi June 15, 2007 Mr. Roger Ghanem Craigville Beach Grill 974 Craigville Beach Road Centerville, MA 02632 RE: Craigville Beach" Grill, Toilet Facilities Variances Dear Mr. Ghanem: You are granted a conditional variance from Section 322-4 to operate a food establishment with only one toilet facility. This variance will allow you to operate a food establishment, Craigville Beach Grill, at 974 Craigville Beach Road with the following conditions: (1) Touchless sensor operated faucets shall be installed at the restroom handwash sink and at the handwash sink(s) located in the food preparation area(s) before December 31, 2007. (2) Seating for patrons is not authorized inside the building. Only outdoor seating is authorized. (3) No more than 28 seats are authorized outdoors. (4) This variance may be revoked anytime the operator fails to comply with a condition of these variances or anytime unsanitary conditions are observed. . (5) This variance decision letter shall be posted on a wall adjacent to your food service permit in an easily accessible location for viewing by a health inspector during inspections. These variances are granted because the applicant stated that the there are no seats within the building. There are public bathrooms across the street at the Q:\W P FILES\Crai gv i lleB Eac hGri 112007.doc public beach. Therefore, the Board is not opposed to outdoor seating at this location. Your second variance request from the requirement to place the dumpster onto sandy soil instead of an impervious surface is denied. All outdoor refuse storage containers (dumpsters) are required to be placed onto nonabsorbent materials. The Federal Food Code, Section 5-501.11 specifically reads as follows: 'An outdoor storage surface for refuse, recyclables, and returnables shall be constructed of nonabsorbent material such as concrete or asphalt and shall be smooth, durable, and sloped to drain.' The Federal Food Code was adopted by the State of Massachusetts Department of Public Health. The local Board of Health does not have the authority to be less stringent than a State Code. Sin"your Wayne iller, M.D. Chairm n QAWPFILES\CraigvilleBEachGri112007.doc �/ �� r �i� �� �� �� ��� J �fZHE}r • DATE: N� C� FEE: t BARNSrABLE, 9 MASS. g 039. REC. BY Town of Barnstable SCHED. DATE: ,ZZ/ .Board of Health,o� 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX 508-790-6304 Sumner Kaufman,M.S.P.H. O Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION Property Address: L CiAgg,17g J ' , • �l Assessor's Map and Parcel Number: Size of Lot: Wetlands Within 300 Ft. Yes Business Name: No Sub n ame: C--4 APPLICANT'S NAME: Phone �� / Did the owner of the property at&orize you to represent him or her? Yes No n o PROPERTY OWNER'S NAME CONTACT PERSON b Name: A`fit90,V Al(r✓f'VA Ca t Name: '� � a) Address: /O 7`/► /4r/�w es7 A�dress: . v Phone6.5a Phone' �� Go ' ® r*i VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more ace needed r ra s 1� T .+� ,e s i G/U Ala l Fic e � S NATURE OF WORK: House Addition 0❑❑❑❑❑ House Renovation ❑ Repair of Failed Septic System 13 Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets. Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) , _ Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only], outside dining variance renewals [same owner/leasee only], and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) 4 Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne A.Miller,M.D.Chairman NOT`APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Susan G.Rask,R.S. Q:\HEALTH\Application Forms\VARIREQ.DOC SALADS GREEK SALAD CHICKEN SALAD TABOULEH SANDWICHES HAMBURGER CHICKEN FILET BURGER FISH BURGER HOT DOG SHISH KABOB Beef, Chicken and Shrimp MID-EASTERN COMBO CHICKEN, BEEF, SHRIMP, BABA=GHANOUSH, HUMMUS AND TABOULEH SIDE DISHES BABA-GHANOUSH HUMMUS CORN ON THE COB L I 1' I -------------- G Gl(�j�r f 0 T GQ.. �� nn Su�hS ) V �, flirt rva"C-P- Kid- ���, CX, l r _ ® 'Get �J C-eExr+ Town of Barnstable Regulatory Services Department M►ss. 200 Main Street,Hyannis MA 02601 ED MIS� APPLICATION FOR OUTSIDE DINING/SIDEWALK CAFE . LOCATION Property Address: Name of Establishment: . u4e.-51-�4 APPLICANTS NAME: Phone#�`� J?O "''e-gr SEATING �Q FACILIT AY EQUIPMENT Total#of Seats Existing .Z 0 #of Restrooms Provided ! Size of Grease Trap Total#of Seats Proposed _ Air Curtains(Yes or No) (Total means overall number of seats indoors and outdoors) Hose Bib (Yes or No) l Screens (Yes or No) .Brief Description of Seating Arrangement,Type of Furniture Proposed,Hours of Operation,Projected Opening and Closing Dates If I/we the undersigned certify that the above information which Uwe provided is correct. Uwe have d and fully understand the procedures as established by the Town of Barnstable in accordance with Chapt II, o Article 8,Section 2 of the General Bylaws and the Board of Health Regulation#14,and further ti understand that failure to comply with said procedures may result in the immediate revocation of s c-n permit. Signature ofApplicant(s): otJ Date: Date: IMPORTANT-PLEASE REMEMBER TO INCLUDE: 3 Copies of the Neatly'Drawn Sketch Plan of the Outside Dining Area Showing Separation istances to Curbing,Trees,Rubbish Containers and any other Obstacles in Pedestrian Walkway !��3 Copies of Pictures of the Proposed Outside Dining Location(Front and Side Views) Copy of the Menu THIS SECTION BELOW IS FOR OFFICIAL USE ONLY Town Manager Approval: Public Health Division: `t Licensing Board Approval: Certificate of Insurance: License Agreement: Comments: . t' C a ° IIN99919 o g&@M V � SALADS GREEK SALAD CHICKEN SALAD TABOULEH SANDWICHES HAMBURGER CHICKEN FILET BURGER FISH BURGER HOT DOG SHISH KABOB Beef, Chicken and Shrimp MID-EASTERN COMBO CHICKEN, BEEF, SHRIMP, BABA-GHANOUSH, HUMMUS AND TABOULEH SIDE DISHES BABA-GHANOUSH HUMMUS CORN ON THE COB ,�. '�', t �� �. � __ if7iM1 �! � i �` � - L� ���,. .- �, "' I -) tt1 � i � � ����� � �:�r.�l��l � � s. v r�r�,��� .. Mom' �_� r' Sid t I a ., � A!Uai u(!ta 8meq f .�- +.. .� ,_.�. �.�,�. f_ ._'_ ' ems' ...`�'_. .. `..� �i�i�."f'i � � a. � _ �I_1 _. . — -- ® jy� i / x ��� � � rrrw;,; ���, .,� � � l�►:r ,�: .., � y � ���, � �,� o. !� �► � i ������ ���111 1��,� L� J r71 J� r t .� r� tt �1 11 r �� r .. PypFSHE Tp�� Town of Barnstable + BARNSfA,BLE, 6 SS. Board of Health ArFD MAI A 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,DMD Junichi Sawayanagi June 27, 2016 Mr. Tony and Ms. Carolyn Ninivaggi The Barnacle Too P.O. Box 193 West Hyannisport, MA RE: Barnacle Too, 974 Craigville Beach Road,`Toilet`Facilities Variances Dear Mr. and Ms. Ninivaggi, You are granted a conditional variance from Section 322-4 to operate a food establishment with only one toilet facility. This variance will allow you to operate a food establishment, Barnacle Too, at 974,Craigville Beach Road with the following conditions: (1) Seating for patrons is not authorized inside the building. Only outdoor seating is authorized. (2) No more than 20 seats are authorized outdoors. (3) Seating shall not be provided whenever,the public restrooms located across the street, at 988 Craigville Beach Road, are closed. Seating may only be provided when those public bathrooms are available. (4) This variance may be revoked anytime the operator fails to comply with a condition of these variances or anytime unsanitary conditions are observed. (5) This variance decision letter shall be posted on a wall adjacent to your food service permit in an easily accessible location for viewing by a health inspector during inspections. This variances is granted because the applicant stated that the there are no seats within the building. A restroom is available inside this food establishment for patrons and employees. Also, there are public bathrooms provided across the street at the public beach. Therefore, the Board is not opposed to outdoor Q:\WPFILES\Barnacle Too Restroom Variance 2016.doex a seating at this location, with the understanding that the seats shall be removed whenever the public bathrooms across the street are closed or are not available. S' erAyou Wayn ill , M.D. Chair an Q:WP FILES//Barnstable Too Restroom Variance 2016.docx s ' 3" S • `S IME ray, DATE (« FEE: i BARNSTABLE, MASS. �A }� 9 1639. �0� REC. BY {ArFD MA't A M+ Town of Barnstable SCHED. DATE: Board of Health a 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Wayne A.Miller,M.D. W FAX: 508-790-6304 Junichi Sawayanagi Paul J.Canniff,D.M.D. VARIANCE REQUEST FORM LOCATION Z� C % Property Address: � f�rV/ �� Assessor's Map and Parcel Number: Size of Lot:Wetlands Within 300 Ft. Yes Business Name: —11-1,E � �AMC l - 1('-0 No Subdivision Name: Sha-62hJk a—w(seS APPLICANT'S NAME: )V y Phone S-0&' Did the owner of the property auth rize you to represent him or her? Yes No PROPERTY OWNER'S NAME ~ CONTACT PERSON Name: /10 4) LY V1/UV1Name: Address: Po l f I,, , l�y/�yj C r/ Address: _ Phone: 5 o0 r (-fo Phone: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) 2 CVrf' %n A)J 1-1 4i(e tii re Scr�;zNs , NATURE OF WORK: House Addition ❑ House Renovation ❑ Repair of Failed Septic System ❑ Checklist (to be completed by office staff-person receiving variance request,application) Please submit copies in 4 separate completed sets. Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or registered sanitarian Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or-local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/lessee only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne Miler,Chairman NOT APPROVED .lunichi Sawayanagi REASON FOR DISAPPROVAL Paul J.Canniff,D.M.D. C:.\cache\Temporary Internet Files\OLKAE\VARIREQ.DOC I MAIL-IN REQUESTS Please mail the completed variance application form to the address below. Also include four copies of engineering plans, house plans, authorization letter, etc. (see check-list below). In zp addition, please include the required fee amount (see fees at bottom of this page). Make -.. $95.00 check payable to: Town of Barnstable. Our mailing address is: r�s Town of Barnstable s r Public Health Division 200 Main Street �- Hyannis, MA 02601 Checklist _ Four(4)copies of the completed variance request foam _ Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or registered sanitarian _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) $95.00 valiance request application fee (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/lessee only], outside dining variance renewals [same owner/lessee only ,and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, you must mail the required $95.00 fee. Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. In addition, please mail four copies of engineered plans, house plans, authorization letter, etc. (see check-list below): Checklist _ Four(4)copies of engineered plan submitted(e.g.septic system plans) Completed seven(7)page checklist confirming review of engineered septic system plan by the submitting engineer or registered sanitarian _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) $95.00 variance request application fee (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/lessee only], outside dining variance renewals [same owner/lessee only),and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date For further assistance on any item above, call (508) 862-4644 Back to Main Public Health Division Page it f Town of Barnstable ` a l 6 "E Regulatory aFti Services Richard V. Scali,Director * A° "& Public Health Division STABLE 4 mass. �, �•�-��� 3659• prFO MP'�6 Thomas McKean,Director 200 Main Street]Hyannis,MA 02601 Offi= 508-862-4644 Fag: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: °/0 °I a NAME OF FOOD ESTABLISHMENT': ADDRESS OF FOOID ESTABLISHMENT: VAI E-MAILADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ago - �40 WiI IBER OF SEATS*: INSIDE: OUTSIDE: Ok® TOTAL: O _ X Note: If indoor seating provided,see Licensing regarding Common Victuallers License TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: !UF SOA)A L TYPICAL HOURS OF OPERATION MON-FRI:Al: TO :� DAYS CLOSED EXCLUDING HOLIDAYS (I.E.MONDAYS) NNNV, _ YF SEASONAL: APPROXIMATE DATES OF OPERATION: J/ , /ATO /01 y•_yA�JL'J17.CJl.L\ ✓Jl:1RyY�: SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE >CRETAIL FOOD BED &BREAKFAST CONTINENTAL BREAKFAST *IF SEATING: ALSO,MUST OBTAINT RESIDENTIAL EITCHEIV A COMMON VICTUALLER'S LICENSE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN.DAIRY DESSERT MACEONES CATERING OUTSME DMG (DYER) 3 ***REMINDER*** IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? J IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? kov#y &eisaetw' CONTACT INFORMATION: FULL NAME OF APPLICANT /V ads 1 SOLE OWNER: YES SO IAL SECURITY NO. ADDRESS PHONE#L� - IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION A FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.**PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E.SERVSAFE.) 1. EXPIRATION DATE: J / O l� EXPIRATION DATE: a // dO. EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR EVE IEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER {* PLEASE PUT THE NAME OF THE ESTABLISMAENT ON THE CERTIFICATE*** LIST THE NAME QF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF. L. EXPIRATION DATE: c/ l SIGN OF APPLICANT AND DATE QAApplica6on FonnsToodappldoc rj&Z U@s t o n e4w, we �- � 77 14 a151 WS-MS-S A $Mt S The Mt.Adams 5'oven features a door opening 29.75 inches wide x 10 inches high.The oven floor diameter is 52 inches, i resulting in a 15-square-foot cooking surface.A tensioned steel exoskeleton surrounding the hearth and dome perimeter ensures structural integrity and longevity.Wrapped in spun ceramic fiber insulation and requiring only a 1-inch side clear- ance to combustibles,the monolithic 4-inch thick cast-ceramic - x hearth and monolithic 4-inch thick dome rest on an open black painted steel stand.The oven body is finished with galvanized WS-MS-S model with optional Stainless Steel Mantle shown. steel and a stainless steel service panel is provided.The oven arrives completely assembled,ETL Listed,ready to install and is HEARTH CAPACITY made in the USA.Information about custom finishes,tools and 8"pizzas: 12-16 accessories can be found online at:woodstone-corp.com. 10"pizzas: 10-12 FUEL CONFIGURATIONS 12"pizzas: 8 GAS-FIRED ONLY:Configured to burn either natural gas(NG)or 16"pizzas: 5 liquid propane(LP).* Assuming 5-minute cook times,the approximate maximum hourly production capacity can be calculated bymultiplying O RADIANT FLAME(RFG):Heated by an easily adjust- the above numbers by 12.Cook times will also vary depending able radiant flame(105,000 BTU/hr max.NG)located in on"style"ofpizza. the rear of the cooking chamber.User control ensures the GUIDE TO MODEL NUMBERS ability to balance the ovens radiated top heat with the heat being conducted and radiated from the floor. q ❑RADIANT FLAME+UNDERFLOOR IR(RFG-IR): b i In addition to the radiant flame,a 83,000 BTU/hr(NG) N O m a o b thermostatically controlled infrared burner is mounted b v o p under the oven deck to ensure high production capacity �. Q� a c, `_ d with no heat recovery issues. __�. : ���d.._w WS-MS-S-RFG X -NG -LP µ ❑WOOD-FIRED(W):Wood-fired only. 105,000 94,000 n ❑WOOD WITH GAS ASSIST(W-IR):This wood-fired model is 105 000 94,000 ...-..__... _....__^..,..w�....a.._,........ �.�..�. _r._..._... .T _....� assisted by the additional BTU/hr of an Underfloor IR burner. WS-MS-S-RFG-IR x X -NG -LP Note:A wood fire is required with this configuration. 188,000 159,000 WS-MS S RFG IR,W F, x x 9 i x- NG -LP ❑COMBINATION(-W):Allows optional wood burning for 188,000 159,000 1ovens with gas burner configurations. Note:Adding wood to an WS-MS-S-W-IR X X -NG -LP 83,000 65,000 oven with an RFG burner will reduce available hearth capacity. ws MS-s W =fix .i *Gas type must be specified at time of order. REVISED:SUMMER 2015 ON 05'�Z Wood Stone Corporation An ongoing program of product 1801 W.Bakervlew Rd. improvement may require us to change t. 360.650.1111 specifications without notice. Bellingham,WA 98226 USA Intertek Intertek tf. 800.988.8103 info@woodstone-corp.com ANSI Z8b-2009 W 009 nNsuNSF sro a f. 360.650.1166 M S t o n e wood l CSA 1.8b2009 stone-corp.com 19 e er5 xXQ4 ,} � zx{7 9c aoy 4x e f b 4 � (. FACADE INFORMATION All facades or enclosures are by others. PLAN VIEW All MS ovens require a 1"side clearance and 14'!top.clearance to-combustible construction:; 64 v4' An constriction 6"to either side of the oven 2112' 1630mm Y � Gomm doorway and above must be non-combustible. Uo� Anyfacade or enclosure below the mantle of A Flue Collar 9' Gas-Fired or Combination ovens must allow for: 230mm B Mantle 4114' Unobstructed access for removal of 63ommservice/intakepanel. Flame Height Eas access to all controls. CControl Knob 7211262 Y1840mm158omm Sufficient combustion air for gas,burners;see Digital Installation and Operation Manual for details. DController E Forklift Here L210mm 14• B Electrical Connection 32114• 820mm Service Panel F or optional FRONT VIEW SIDE VIEW Storage Box 29 3/4' 12 3/4' G Gas 750mm 320mm r 21/2' Connection � A 11114' 90mm A __60mm 280mm Must Be Left ' Removable for Service 10• 250mm D•Not 76112' 1940mm Facade or Cover _ B B 47 3/4' 1210mm 7839 C /D rC 2000mm I 361/C 30 3/1r ZIG+ 920mm 780mm 440m TOE KICK 6 311mm E E m �970mm_� 130mm 461/2' 1180mm UTILITIES SPECIFICATIONS VENTING INFORMATION GAS ELECTRICAL The Mt.Adams can be direct connected to a power- 3/4 inch gas inlet(FNPT) Gas-Fired Only and Combination ventilated,grease-rated chimney or can be vented with 120 VAC,1.1 A,50/60 Hz a Listed Type 1 exhaust hood,or one constructed in BTU/hr Requirements Connection made beneath oven accordance with NFPA 96 and all relevant local and See table on previous page as shown. national codes.The oven must be vented in accordance with all relevant local and national codes,and in a Wood-Fired Only manner acceptable to the authority having jurisdiction. 120 VAC,2 A,50/60 Hz Note:A 10"ID flue adapter is included with Connection made to readout box. ovensD ovens ordered without a hood to facilitate connection to a round duct(adds 3"to height). Ship .00 REVISED:SUMMER 2015 Wood Stone Corporation An ongoing program of product 1801 W.B3k2tVI2w Rd. improvement may require us to change t. 360.650.1111Bellingham, spec fications without notice. '• WA 98226 USA Intertek Intertek tf. 800.988.8103 info@woodstone-corp.com S t O n eee� ANSI 283.11b2009 ANSYNsr Sron f. 360.650.1166 ' p, cSA1.se-2009 woodstone-cor com 20 q7,q CRAlivi/!f- j 1 1 4e-��e.t_,._N�_oo_rr��.,n_ne_w-�-t�er�o��� _ t.`.go4lol Wdaec_ ##Fm I_. �.QQ�e Juiw�ocanyc_;�•`�,c�r-4rl�eTc_Y..S,,ec.t. -- -_-- _ F i SMOO.'�lC S - _ L�eet'y, !-,J ct'fA 31�0_Qas�6ecP t (ac at1 tcrvlG F - F i " - E l F i ........_.� ... _.-t.. .._.. .-... f 1 f ( 5 �a�oi1,�5au5�t9el8acsn�Wtca��pall�oil�anS� �CQ i `1ewtoc-At &,Ss' _. cV-e nl Te A i Ot�lOh a.�Rq t I t •n P�� ,. JLCI�cJ�G�s 'f Sub c �" CaeCeSG G�.:ck.e.�l'Qaz�NI 1 - - C"NOC,n i I 1 ti Cs�'YtE i _j L t l t i S�rG� 3f+T►�Rvo u , f i S ton a VT A•A STONEOVEN may' `¢�.Y,���3 • WS-MS-S & The Mt.Adams 5'oven features a door opening 29.75 inches wide x 10 inches high.The oven floor diameter is 52 inches, 3, resulting in a 15-square-foot cooking surface.A tensioned 1 steel exoskeleton surrounding the hearth and dome perimeter ensures structural integrity and longevity.Wrapped in spun ceramic fiber insulation and requiring only a 1-inch side clear- ance to combustibles,the monolithic 4-inch thick cast-ceramic hearth and monolithic 4-inch thick dome rest on an open black painted steel stand.The oven body is finished with galvanized WS-MS-5 model with optional Stainless Steel Mantle shown. steel and a stainless steel service panel is provided.The oven arrives completely assembled,ETL Listed,ready to install and is HEARTH CAPACITY made in the USA.Information about custom finishes,tools and 8"pizzas: 12-16 accessories can be found online at:woodstone-corp.com. 10"pizzas: 10-12 ii FUEL CONFIGURATIONS 12"pizzas: 8 GAS-FIRED ONLY:Configured to burn either natural gas(NG)or 16"pizzas: 5 liquid propane(LP).* Assuming 5-minute cook times,the approximate maximum El RADIANT FLAME(RFG):Heated by an easily adjust- hourly production capacity can be calculated bymultiplying the above numbers by 12.Cook times will also vary depending able radiant flame(105,000 BTU/hr max.NG)located in on"style"ofpizza. the rear of the cooking chamber.User control ensures the GUIDE TO MODEL NUMBERS ability to balance the ovens radiated top heat with the heat being conducted and radiated from the floor. CU ❑RADIANT FLAME+UNDERFLOOR IR(RFG-IR): x a In addition to the radiant flame,a 83,000 BTU/hr(NG) w o v b ;. thermostatically controlled infrared burner is mounted b v b p b under the oven deck to ensure high production capacity .,rtl ,F..._, Q'.H a.w with no heat recovery issues. WS-MS-5-RFG X -NG -LP ❑WOOD-FIRED(W):Wood-fired only. 105,000 94,000 El WOOD WITH GAS ASSIST(W-IR):This wood-fired model is 1os o00 94 000 : assisted by the additional BTU/hr of an Underfloor IR burner. WS MS-5-RFG-IR X X -NG LP Note:A wood fire is required with this configuration. 188,000 159,000 q WS MS'S RFGIR-W X. X::'!., fN.G -i P ❑COMBINATION(-W):Allows optional wood burning for 18s 000 159,000` ovens with gas burner configurations.*Note:Adding wood to an W5 MS-5-W-IR X X NG LP 83,000 65,000 oven with an RFG burner will reduce available hearth capacity. WS-MS-s W x *Gas type must be specified at time of order. REVISED:SUMMER 2015 om Wood Stone Corporation An ongoing program of product cus 1801 W Bakery ew Rd. improvement may require us to change t. 360.650.1111 specifications without notice. Bellingham,WA 98226 USA Intertek Intertek tf. 800.988.8103 infoCa?woodstone-corp.com ANSI83.11b-2009 nrsunsF STD a csA 1 .820 f. 360.650.1166 Stone woodstone-corpcom l - 19 ♦ D ♦ STONE " • FACADE INFORMATION All facades or enclosures are by others. PLAN VIEW All MS ovens require a 1"side clearance and 14".top clearance to combustible construction. 641/4' 21/2' 1630mm Any.construction 6"to either side of the oven 60wn doorway and above must be non-combustible. Any facade or enclosure below the mantle of A Flue Collar.'` 9 171 f l Gas-Fired or Combination ovens must allow for: 230mm I$G I I 6411C Unobstructed access for removal of B Mantle T 1630mm service/intake panel. C Flame Height'" I I I I Ea access to all controls. Knob Control Kb 721IY I I I I 62' 1840mm 1580mm Sufficient combustion air for gas burners;see Digital I I Installation and Operation Manual for details. D Controller L J A L J 240rrnm E Forklift Here::: ;...•... 8114'Electrical 210mm B Connection �321/4' 820mm Service Panel F or optional. FRONT VIEW SIDE VIEW Stordge.Box. - 29 314' 12 3/4' G Gas 750mm 320mm 3112' 21/2' 11 114' Connection -{ A 90mm� A r_f-60mm 280mm .Must Be Left. Removable :. for Service` 10' 250mm 76112' _ r 1940mm • B I B 47 3l4' 1210mm 278 000m C �C 000mm 36114' 30 314' //G+ 920mm 780mm 17112' TOE KICK 6314' E E 440mm 170mm 38' -�� 130mm �46112' •- 970mm 1180mm UTILITIES SPECIFICATIONS VENTING INFORMATION GAS ELECTRICAL The Mt.Adams can be direct connected to a power- 3/4 inch gas inlet(FNPT) Gas-Fired Only and Combination ventilated,grease-rated chimney or can be vented with 120 VAC,1.1 A,50/60 Hz a Listed Type 1 exhaust hood,or one constructed in BTU/hr Requirements Connection made beneath oven accordance with NFPA 96 and all relevant local and See table on previous page as shown. national codes.The oven must be vented in accordance with all relevant local and national codes,and in a Wood-Fired Only manner acceptable to the authority having jurisdiction. 120 VAC,2 A,50/60 Hz Note:A 10"ID flue adapter is included with Connection made to readout box. ovens ordered without a hood to facilitate connection to a round duct(adds 3"to height). Ship . 11 lbs REVISED:SUMMER 2015 Wood Stone Corporation An ongoing program of product L om improvement may require us to change s 1801 g BakWA 98 Rd. specifications without notice. t. 360.650.1111 Bellingham,WA 98226 USA ANSIZ83rto-2009 ANsvNsr e�k tf. 800.988.8103 info@woodstone-corp.com CSA 1.86-2009 f. 360.650.1166 woodstone-corp.com 1 1 S t o n el ZO 4 NMI e.)Pdyr jop V e-66 0— ro coal; AxY Gomav ICKty lwQ-Stt� .. t t- Ypur ©ivy _X� ,� vts t�lv A) lzree., — w r47 �s pAeoi ep E14 r,.t"P I !9'N su�3 Rye Sub SU� �lj 7 jtC, L # mv(d a L O CAT IO,N SEWAGE. PERMIT ..`_N0 VILLAGE INSTA LLER'S NAME i ` ADDItLsS, d U,;I,L D E R OR OWNER '' *. DATE PERMIT ISSUED DATE COMPLIAN.C'.E. ISSUED r� { IV 1 N � � N A `y WALL dC SERVICE L 1 P.O.Box 771 • Harwich Port,Massachusetts 02646 508-432-4908(Harwich) • 508-778-4908(Hyannis) • Fax(508)430-1510 1 1-800-281-4908 INVOICE T0: Dar OF SERVICE: t SEPTIC TANKS,CESSPOOLS GREASE TANKS&TRAPS PUMPED,CLEANED&REPAIRED i SEWEROOTER SERVICE TITLE 5INSPECTIONS&CERTIFICATIONS JOB,SITE ---- LICENSED DRAIN LAYERS CALLUS FOR NEXTSERVI t , DESCRIPTION ' CHARGES BALANCE ; BALANCE BROUGHT FORWARD Cesspool pumped&cleaned g Septic tank pumped&cleaned t rease tank pumped&cleaned Leaching facility pumped&cleaned f Tight tank pumped&cleaned I Sewerooter service Extra hose Extra labor Extra locating&uncovering time }. L own Disposal Fee .+ ri Inspection of septic system Miscellaneous _ JOB DESCRIPTION:" e s SALES AMOUNT ON ACCOUNT ✓ Signature A finance charge of 2%per month(24%annually)will be applied to BALANCE DUE 4y----C unpaid balances.Arty collection fees,legal fees or court costs to be paid by customer. Uha nk C�Qu TERMS: PAYMENT DUE UPON COMPLETION OF SERVICE. By placing an order for service, the customer acknowledges that Wall Septic Service will hold no t responsibility for conditions unknown or not reasonably identifiable at the time of service, including but not limited to damage to underground sprinklers, or utilities when locating and/or digging. --_----.-_--__.---..._. G CO TH OF MASSACHUSETI'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 974 Craiqville Beach Rd. Centerville Owner's Name: - Zelechowski Owner's Address: Box 736 Barnstable Date of Inspection: Name of Inspector:(please print) Wi 1 1 i am F._ . Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number:—(508 1 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Se�ction,15.340 of Title 5(310 CMR 15.000). The system: vPasses l Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �/„f Date: 2 b- 9 n The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRhvr DEP)within 30 days of completing this inspection.If the system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing authority. Notes and Comments ****This report only describes conditions at the time of inspection sad under the conditions of use at that time.This inspection does not address how the system will perform in the future under the saute or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 1 Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 974 Craiqville Beach Rd. Centerville Owner: zelechowski Date or inspection:0 3•-!U,;7-— o 's! - Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. =have sses: ot found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Sy tem Conditionally Passes: ne or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic'tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatin that the tank is less than 20 years old is available. ND expl : servation of sewage backup or break out or high static water level in the distribution box flue to-broken or obstruct pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approva of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND ex lain: e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass in pection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is mwvod ND xplain: R r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address974 CraiUv l l P RP;rh -rd. Centerville Owner: Zelechowsk i Date of Inspection: 6.1— a — O -z— C. F rther Evaluation is Required by the Board of Health: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing o protect public health,safety or the environment. 1. Sy tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sys em is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Sys inwill fail unless the Board of Health(and Public Water Supplier,if any)determines that the system ifunctioning,in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a sur cc water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frocfi a private water supply well".Method used to determine distance "This system passes if the well water analysis.,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM PART A CERTIFICATION(continued) Property Add ress:974 Craiqville Beach 1qd. Cent-Prot 1 le Owner: 7.P1 Qchotw�ski Date of Inspection: a - - D. S stem Failure Criteria applicable to all systems:. You m st indicate"yes"or"no"to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert duc to an overloaded or clogged SAS or cesspool ` Liquid depth in cesspool is less than 6"below invert or available volume is less than''/:day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is:free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To considered a large system the system must serve a facif ity with a design now of 10,000 gpd to 15,000 gpd• You ust indicate either"yes"or"no"to each of the following: (The ollowing criteria apply to large systems in addition to the criteria above) yes io the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well . If you ave answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"i Section D above the large system figs failed.The owner of operator of airy la:gx system considered a signifi ant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.30 .The system owner should contact the appropriate regional office of the Department. i 4 Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:974 aiQui l le coach rd. Cent�i 1 ie Owner: Zelechc=ski Date of Inspection: 3 —U 7--01 2— Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes —o /Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? (/Has the system received normal flows in the previous two week period? t/Have large volumes of water been introduced to the system recently or as part of this inspection? c/_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) t/ Was the facility or dwelling inspected for signs of sewage back up V — Was the site inspected for signs of break out? l/_ Were all system components,excluding the SAS,located on site? r/_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? -�/- Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. !✓/ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 i Page 6 of l l * • -' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:974 Craigyill_e Beach rd. Centerville Owner: Zelechawsk i Date of Inspection: 3—d'2—o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual)://O DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents:_C Does residence have a garbage grinder(yes or no):/-/ Is laundry on a separate sewage system(yes or no):.,�,Q [if yes separate inspection required] Laundry system inspected(yes or no)./ D Seasonal use:(yes or no):Ye-s Water meter readings,if available(last 2 years usage(gpd)): 2001 27 ,00 0 gal. Sump pump(yes or no)A, J 2000 8,000 gal. Last date of occupancy:_ AO v t CO MERCIAL/INDUS�T rRIA�L Typ of establishment: Desig flow(based on 310 CMR 15.203): gpd Basis f design flow(seats/persons/sgft,etc.): Greas trap present(yes or no):_ Indus 'al waste holding tank present(yes or no): Non-s,nitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 9 9'J —6 o 0 :7 0 a d Was system pumped as part of the inspection(yes or nc)�. O If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: fTY�TYP OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no);� 6 I � 'Page'7 of 11 • E�NIENTS OFFICIAL INSPECTION FORM—NOT FOR YES NTARY SS FORM SUBSURFACE SEWAGE DISPOSAL C SYSTEM INFORMATION(continued) (`ra;ayi_11S Beach Rd. Property Address: Centervi�— ' 1e owner:. Ze1��11QWski Date of Inspection: BULL ING SEWER(locate on site plan) Depth Blow grade:--------— _on 40 PVC other(explain): Matey' is of construction:—cas uweli or suction line: Dis ce from private water supp y evidence of leakage,etc.): Comments(on condition of joints,venting, SEPTIC TANK: "locate on site plan) _— . I Depth below grade:_L— ___polyethylene Material of construction:._concrete metal____fiberglass es or no):_ (attach a copy of othes(met ain) is age confirmed by a Certificate of Compliance(y I{tank is metal list age:_ y v certificate) ,� U Dimensions-. , t Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: V Distance from top of scum to top of outlet tee or baffle: �� Distance from bottom of scum to bottom of outlet tee or baffle:1� it liquid levels Now were dimensions determined: 1211 Comments(on pumping recommendations,inlet and outlet tee or baffleY condition,struct al integrity, as related to outlet invert,evidence of.leakage,etc.): >~ l GR E TRAP:(locate on site plan) Depth b low grade:_ of eth lone other Materia of construction: concrete metal_fiberglass Y Y (explain : Dimens ons: Scum t ickness: Distan a from top of scum to top of outlet tee or baffle: Dista a from bottom of scum to bottom of outlet tee or baffle:Date f last pumping: condition,structural integrity,liquid levels Co ents(on pumping recommendations,inlet and outlet tee or baffle as r lated to outlet invert,evidence of leakage,etc.): I 7 Page 8 of l l ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 974 Craiqville Beach Rd. Centerville Owner: Zelechowski Date of Inspection: 7•—O A—O 2--- TIG or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth low grade: . Mated of construction: concrete metal fiberglass=�olyedrylene other(explain): Dimen ons: Capaci gallons Design low: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date o last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PU CHAMBER: (locate on site plan) Pum in working order(yes or no): Al s in working order(yes or no): Co s(note condition of pump chamber,condition of pumps and appurtenances,etc.): i 8 Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:974 Crajairille Beach Rd. (',pntarvi 1 1 a Owner: 9.a1 echowski Date of Inspection: a—d z— O 1 � SOIL ABSORPTION SYSTEM(SAS): V (locate on site plan,excavation not required) If SAS not located explain why: Type 1loaching pits,number:_ ✓leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): n 6 . b C MCA 1 /Z C SPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Nu er and configuration: Dep —top of liquid to inlet invert: Dept of solids layer: Depth of scum layer: Dimen ions of cesspool: Materi is of construction: Indicati n of groundwater inflow(yes or no): Comm is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PR (locate on site plan) Mate ials of construction: Dim nsions: Dep of solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 974 Craiayille Beach Rd. Centerville Owner: Zelechowski Date of Inspection: : —o.3_-6 2 SKETCH OF SEWAGE DISPOS AL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. .w ^i X3 10 II `Page 11 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 974 Crai vq ille Beach Rd. Centerville Owner: Zelechowski Date of Inspection: S-02-- 0 2, SITE EXAM Slope Surface water Check cellar Shallow wells t Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design flan reviewed: =Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 roc V THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Allpfiration for Diipnsal Works Tons rnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( kj"'an Individual Sewage Disposal System at: y 7 . 0,0 ..q---U.4 - - _- ....A.4d------------- ....... cation- ddress 0 .......................................... or Lot No. a Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------- •--- -------------------•-------------------------------------------------------- •-••---------..-.-.--._.._-.. w Design Flow............................................gallons per person per day. Total daily flow........._............._............._......gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________-___-_- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.............I............................................................ Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ----------------------------------------------------------------------------------------------------------------------------------------------•--._.._....... 0 Description of Soil....... ............ w -•-••••••......-•---•......-- --•--. � ...•..._.... -------------------------------------------- x ..................-.......-......................................................................... ------------------------------------ ---------------------------------- - -------.---- ------- U Natfre of Repairs or Alteratio —Answer when applicable..1.-162.Q____6�_ dP)---1�.AVk............ .710.49...___. e - . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issue by e board of health Signe ....�....._ l . •--•-- D Application Approved By............. ------- Date Application Disapproved for the f ollowi re ns• ---•-•-•-•--•-•----••-•••-••-•-•--••--...-•---•----•-•-•-----••--•---•-•--------••-••......................... ..............•-----......................•-------------•-•-......-----.. __ ..................................... ..... ----_........_---•------- -------------------------------------------------------- Date PermitNo......................................................... Issued....................................................... Date No ...!. Fss..�....._............ ..�, ®� 't THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r'"' Appliratiun for Disposal Works Tonstrnr#iun rerun# Application is hereby made for a Permit to Construct ( ) or Repair ( 010an Individual Sewage Disposal System at: ... ._ Al.. ............... 041.1 ._. ..---- � . � .....-6 . .. ...................... Location-Address or Lot No. ... .. .................................. .............................................................---.............. ..... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Shcwers ( ) — Cafeteria ( ) � Other fixtures .------••--•------------------------------••----•-•--. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width_............. Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching a rea....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY-•--••--••-•--•--••...................•-•--•-•-•-•----••-••-••...I......... Date......................................... ,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ............................................................................................................................................................ O Description of Soil....... . ............ -_........ --------_-_-------------•-------•-------------------------------=----- txj ---•----------------------•-----.... � �., `• W --------------------•-----_-•---- x -- ----------------- -----------•-•--------•---•-•-----••--------------•-•--•-••--•--- ... --- - ,,a ---------------- ---------------- U Nature of.Repairs or Alteratii s—Answer when a livable "1 1jf�_... � ._. f t ___..___._./t"IU ....__.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.1 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issue by.4ke board of heatt i Signe __......._ Application Approved BY -----------------------=---•---------••-•••-- -------��?-...................... Date Application Disapproved for the followi re ns. -----•---------------•-----•--•------•------•-•-----•-•---••--------•--•---•--•------------•---•--•---•-----. ....•-•................................••••--•----••----•-••---•-----•-• -•- -•----•-•-•.._...----•-•------•-•-•--••---•..-•--•---••--•-••-•--•----- s ;,A Date PermitNo......................................................... Issued_...............................!k.............. Date I Apo � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... '�ri ✓.............OF....../,"s" �i� l... ............................. f�rr#if irtt�r of f�uirtixlittnr�e TIj,S T ERTIFY, That the In 'vidual Wage Disposal System constructed ( ) or Repaired by......�Z ._ .._._ 4..: ! -.. .._..... °' '.... - .'.-••....................................................................................... d' 11!K I,�11 all . has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.................................,_........ . dated__..._._...._....___.____._..._._...._..___..... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRI! AS A GUARANTEE THAT THE SYSTEM WILL NCTION SATISFACTORY. DATE--(--ly__t�...........................•-•-•-••------..._....--•---. Inspector-- - --------•-•-•--•---•---------------•-••----•---------•--------------•-•---- r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w- ! No._.._._..... Disposal Works Tuntr ion rrmit Permissionis hereby granted............................................................................................................................................... to Constr Repair ( �an In•ividual ewagD'sposal System at No.-- ... �`' f`.__ f�% �� r-cam` ---------------------•--------........ Street - - ' - Street as shown on the application for Disposal Works Construction Permit N. ___ar':_:_________ Dated.......................................... -- ............... ----• --- ----------------•---•-•---••---_... Board_of:Health DATE.. -•------••-•-•----•----•--...................... FORM t255 A. M. SULKIN, INC., BOSTON