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HomeMy WebLinkAboutCOTUIT HIGHGROUND - FOOD (2) Cotuit Highground p2o "09 ' 31 Crocker Neck Rd. Cotuit _ _ I r Town of Barnstable BOARD OF HEALTH O John T. Norman Board OI Health Donald A.Gaudagnoli,M.D. BA.RNSTABLE F.P.(Thomas)Lee MA Daniel Luczko M.D. Alt. 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 280 Issue Date: 01/01/2022 DBA: COTUIT HIGHGROUND GOLF CLUB OWNER: COTUIT HIGHGROUND GOLF CLUB Location of Establishment: 31 CROCKER NECK ROAD COTUIT, MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 27 OutdoorSeating: 18 Total Seating: 45 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, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: i For Office Use Only: Initials: "'E' � Town of Barnstable Date Paid � $� Inspectional Services MAE& ►`� Public Health Division cheek# - Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: L d u;� 911 i wou vo C vW C/L'6 U ADDRESS OF FOOD.ESTABLISHMENT: 31 MAILING ADDRESS(1F DIFFERENT FROM ABOVE): 90 &x l S CO,u lr. M A o)-G 35 E-MAIL ADDRESS: COf_ -Crl-h n re>uNGI YA rI oo•co TELEPHONE NUMBER OF FOOD ESTABLISHMENT: U W - M,3 TOTAL NUMBER OF BATHROOMS: WELL WATER:YES_NO ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: 4/ DATES OF OPERATION: N / 01 TO / //S 1 ,2 NUMBER OF SEATS: INSIDE: OUTSIDE: t F TOTAL: y3 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? IV 6 IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) `'*-1 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 SOLE OWNER: YES/e D.O.B 1 5 C OWNER PHONE ADDRESS_ L &JC 00 . rj 6 b x- CORPORATE OWNER: 00�4,64 f1,��Irovpd boff C /V/ ANC CORPORATE ADDRESS: 'I" U Q b x l 3 C s t c 2 0 eke rs 6 3 s PERSON IN CHARGE OF DAILY OPERATIONS: ny v� J� • GUI e� 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. pa&j= 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will.result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at littp://www.townofbarnstable.us/healthdivision/applicationEm. 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 FormsTOODAPP REV3-2019.doc i Town of Barnstable BOARD OF HEALTH ILI John T.Norman a Board of Health Donald A.Gaudagnoli, M.D. 6Aw4sr,ABLE, Paul J.Canniff,D.M.D. a 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: 280 Issue Date: 05/13/2021 DBA: COTUIT HIGHGROUND GOLF CLUB OWNER: COTUIT HIGHGROUND GOLF CLUB Location of Establishment: 31 CROCKER NECK ROAD COTUIT, MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 27 OutdoorSeating: 18 Total Seating: 45 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: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I Town of Barnstable BOARD OF HEALTH John T. Norman Board of Health Donald A.Gaudagnoli,M.D. ¢an.-4srABm = Paul J.Canniff,D.M.D. M N AS& 200 Main Street, Hyannis, MA 02601 F.P Thomas Le 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: 280 Issue Date: 01/01/2021 DBA: COTUIT HIGHGROUND GOLF CLUB OWNER: COTUIT HIGHGROUND GOLF CLUB Location of Establishment: 31 CROCKER NECK ROAD COTUIT, MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 45 OutdoorSeating: 0 Total Seating: 45 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: ------ ----- - --- - - -- - MOBILE-FOOD: MOBILE-ICE CREAM: Q.n FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: i opINE t For Office Use Only: Initials: � Town of Barnstable pate Paid Amt Pd$off_ NRNSrABLE. : Inspectional Services 9c6 ,�y; �0�' � I Arf1639. Public Health Division Check# Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE.A/FOOD ESTABLISHMENT DATE `{ off-/ NEW OWNERSHIP RENEWAL V NAME OF FOOD ESTABLISHMENT: CO f a d l 11 t 9)q f b yY� &W C-1A ADDRESS OF FOOD ESTABLISHMENT:;� / CR o c_k L r S lye tl p d• C 6 7 V I M A O'Lt 3 -MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 20 S,A 136 t d?rd MA 0,6 3 S' E-MAILADDRESS: Ct7 tv r'f//eq�ACouNr/l y�d�DD ` COr"L TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (2 TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO ✓ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: L/ DATES OF OPERATION: 4/ 1 /d-) TO 1 1 l d 2 NUMBER OF SEATS: INSIDE: ? 5 OUTSIDE: i 8' TOTAL: `/3 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? IV D IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? F' TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) 'q 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:Wpplication FortnsTOODAPP 2020.doc I , OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/NO D.O.B 8 / 5C OWNER PHONE# SD ADDRESS 86 G rev S� �.c�.f�a x /pi'i! C d�U t� MA 0,l G 3 CORPORATE OWNER: CdjueT /req�grOUNC/ C a �� Clv�t cf►JC CORPORATE ADDRESS: O. AQd Ckt rS A A L d�✓.T �A O�G 3 J PERSON IN CHARGE OF DAILY OPERATIONS: Pp✓( M Hd/1 e R 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 I. SAW M. 4tji2 / a-3 /aa 1. Ad M. 'Welo- 2. Ji-Ohes jop 3 / a 3 lei i SIGNATURE OF APPLICANT DATE *=*FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen cesserts 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 htti)://www.townofbarnstable.us/healthdivision/applications.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.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Q:\Application FormsTOODAPP REV3-2019.doc c COTE MOGROWOcoll cou; 1, a � �9 WIN%PM 0635 _....__,�., _.......4 s'. .. ?. ...,Q......-�....�..., `t��..........�. ..._...........0�.�. �..i _........� , �....._......�..._........_.._.�-.. .�1..._......._.�........r.........�.�.. _��.._..._..,_�. ..._.aMo� k.J /�v+'II..�/t..�+L�'1 .� /`✓�(.�/�'/�('/� 4 , f ,� SuS- y���98G3 cow�cec�ouim roU coWE P:O,BOX136 vl� ai NUM I A 0 :0v I THE ip� TOWN OF BARNSTABLE _ HEALTH wsPECTOR,s Establishment Name: - Date: - Page:�_of ' / 4 OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified M A­9. - HYANNIS, MA 02601 - M-8 -FRI. No Reference R-.Red Item PLEASE PRINT CLEARLY �p a 508-862-4644 tED MPS FOOD ESTABLISHMENT INSPECTION REPORT -Name 7 Date �L Tvne of Type of Inspection g Routine - f r Address 7 I Gj l�� Risk Food Service Re-inspection Level e a Previous Inspection Telephone Residential Kitchen Date: Mobile P e-operatio ' l Owner HACCP Y/N Temporary ss Caterer General Complaint / - � Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector v Out: •�"'-C� � `ram=�2_ �--�.�✓`-• , Each violation checked req;Tres 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) ❑ )�j+,^(� �1/vt• Z(,/L - Z � �/ � Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) V ❑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 1^� 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 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 Embar o checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ Emergency Closure El Voluntary Disposal ❑ Other: 23.Management and Personnel . (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC 4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations g 2 .Water,Plumbing and Waste (FC-5)(590.00 ) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 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 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. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 t critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector' 7�,n,7', Print: 1131.Dumpster screened from public view r I J Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N pIC's na a Print: #Seats Observed Frozen Dessert Machines: Outside Dining Y N Self Service Wait Service Provided Grease Trap Size Variance Letter Posted. Y N Dumpster Screen? Y N Violation related to Foodborne Illness Violation 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* g * 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* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control Restriction-Presence and Use*7-202.11 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and 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 Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(1-)) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed 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* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(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-die 1112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* f Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Ho[Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* 10 P ing,mobile food,temporary and residential Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. * 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms ( )( )( ) 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 C CommerciallyProcessed RTE Food-140°F* (Blue Items non-critical 23-30) 3-202.15 Package Integrity ( ) 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* 1g 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* 1 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 1 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. °F.NE roy TOWN OF BARNSTABLE HEALTH INSPECTOR�s Establishment Name: (� !'�' 14 / c �`Date: 9 �3 2 Page: of 1 - - OFFICE HOURS PUBLIC HEALTH DIVISION -• 8:00-9:30A.M. BARNSTABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified y� MASS, a� HYANNIS,MA 02601 5os-862-4R I. a79• s44 No Reference R-Red Item PLEASE PRINT CLEARLY � prF°"""`� FOOD ESTABLISHMENT INSP CTION REPORT Name Date Type of T of Inspection q ) l Jb (� O outine t 3 �q tlV`1 v coo,/ c/OC�� Address 3 CrDCJ / e OC K_4, Risk ood Se is - ection " Level Retail Previous Inspection Telephone Residential Kitchen Dater Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness ,t` s Caterer General Complaint Person in Charge(PIC) > i ��� Time Bed&Breakfast HACCP In: I"16 Other Ins ector p � �d-v our 11 =40 Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. D-�-c f_`t7 ; Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ y 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) ❑ 1 FOOD PROTECTION MANAGEMENT ❑ 12Prevention of Contamination from Hands l ❑ 1.PIC Assigned/Knowledgeable/Duties DA.PHandwash 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.C ling ❑ 7.Conformance with Approved Procedures/HACCP Plans .Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.S paration/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❑ 11.Good Hygienic Practices ❑ n 22.Posting of Consumer Advisories I Ol�- `1� `�S ,� /� Violations Related to Good Retail Practices(Blue Items Total Number of Critical Violations C�fJMT r C`;' Obi Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or 111 Overall Rating within 90 days as determined by the Board of Health. ❑ ry Compliance Voluntary Com ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. I ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 6=One critical violation and less than o 6 non-critical violations 9 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i non-critical. If no critical " water,sewage 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 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008) 9 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:„ 31.Dumpster screened from public view V�in Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N pIC's Signature Print: #Seats Observed Frozen Dessert Machines: Outside Dining Y N g Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N t"�----•�.�--..-..�_.- .,._,�,f-�.,-^-1....-r��.,_...,-..:.-..-..s-..� -. _,....,^�.-..s...t. »r.t . .-ury�. ;n-� _,ram �.` �+._..._.+.«y-. ti��.t .� � _ _.�- ,.. - .` .. _� . .�,..r+,.-z,..-_.-,�. v- ��. i :. - - - �-r..R...-.:.-- :- -- - 3 -,a-,ram{--r.. . .. Violations Mated 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[0 41°F/45°F Within 4 Hours* 3-501.15 CoolingMethods for PHFs 590.003(B) 1.Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* Cooked and RTE Foods.* j 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from•Uriapproved 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 .11 Identifying Information-Original Containers 590.004(F) 7-101 * 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 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 7-202.11 Restriction-Presence and Use* t 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 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 Rlated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 1590.003(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* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 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* Equipment* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11,(A)(2) Comminuted Fish,Meats&Game Pathogens* E6­e�e mnooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.00§(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* 3-401.1](A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources 10 Proper,Adequate Handwashing _ g' P � 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* foodbome illness interventions and risk factors. 2-301.14 When to Wash* Other es should violations relating[o good retail 590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 see* 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 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140'F to 70°F 3-202.18 Shellstock Identification ( ) 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 t. 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) L' ing•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 1.008 HACCP Plans 6-301.12 Hand Drying Provision. 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Pickaging 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_ _ . r_ oF� roy TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: ` rt���YVA^A Date: 2� Z3 LI Page: of 1 4• OFFICE HOURS P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M. sArtNsrAarr. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS MON.-FRI. �prF,639. a HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT 1 , Name e�- , J Date'3 3 L Type of Type of Inspection , y��p�1/` 1 w At ra Routine vv�"'v�l. vt/( V� Address Risk Food Se�il e Re-inspection C'mLevel Previous Inspection Telephone nKitchen Zip 3 Mobile Owner HACCP Y/N Temporary C Jr Tc-e(A j Caterer General Complaint ,y._ ''�QQ I�,- n Person in Charge(PIC) �r�lJ �„ „ / Time /� Bed 8 Breakfast HACCP 1 Z db !� Q lS�+ _,�` V LJ� In: I F����r` Other p I Inspector SQ( Out: DAeL Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. j 19 , Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ � y� 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) 9- FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands a f 1.PIC Assigned/ned/Knowledgeable/eable/Duties / ❑ g g ❑ 13.Handwash Facilities 4`� f EMPLOYEE HEALTH PROTECTION FROM CHEMICALS i� ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives KOQ t0Aa,rS --Vb yv- t , e ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals �i n L (Jvl�, g_i2�� ®}_ FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) K 7 Cam~ 1714.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling c ❑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 17121.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) 3 ;N1X1 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 ® ar Emb o checked indicate violations of 105 CMR 590.000/Federal Food Code. g El Emergency Closure ❑ Voluntary Disposal El Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than 4npn-critical violations 26.Water,Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Si ature Print: 31.Dump r screened from public view Ilk (1c a Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y IN #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: [I ,t \ �� Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N �uu 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) [Demonstration gnment of Responsibility* 8 Cross-contamination 1q Food or ColorAdditives Law Cooled to 41°F/45°F Within 4 Hours* * 3-501.15 Cooling Methods for PHFs 590.003(B) of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 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 E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meals&Game Pathogens* Eg cNve iiinoor 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 r f ces Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources 10 Proper,Adequate Handwashing g' P � 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* 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.practices 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 foodbome 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 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. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Fomtback6-2doc *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. oFIHE TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: �� Date Page: of yip ° PUBLIC HEALTH DIVISION OFFICE HOURS® E 8:00-9:30 A.M. BARNSfABLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 9cbp ;39:s�0g HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY r fD M� 508 862 4644 FOOD ESTABLISHMENT INSPFCTIPN REPORT Name Dat lype of Tvoe of Inspection , er s Routine vi 41 Address Risk pod Servi Re-inspection Previous Inspection .ems52 Telephone Residential Kitchen Date: Mobile re- peration Owner HACCP Y/N Temporary ess Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP / Irk Other - Inspector t: F1 4-1 Each violation c ecked requires an explanatiod on the narrative p g (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) ❑ f 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) Ej FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable I 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 Q 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 LzCA ❑ 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 today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ® Embargo ❑ Emergency Closure Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. FC-4 590.005 B=One critical violation and less than 4npn-critical violations g 25.Equipment and Utensils ( )( ) 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 FC-7 590.008 be in writing and submitted to the Board of Health at the above address violations observed,7 ti 8 non-critic violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials ( )( ) 29.Special Requirements (590.009) within 10 days of receipt of this order. violation;4 to 8 non critical olatio =C. 30.Other DATE OF RE-INSPECTION: IMcr'snature Print: 2 - 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 IC's Sign re P np' : 1 J Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y IN 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 L14 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.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved 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 Pelson-in-Charge to 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation 8 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing 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 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 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 Pe 7-206.13 Tracking Powders,Pest Control and * 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* TIMEITEMPERATURE CONTROLS * 4-501.114 Chemical Sanitization-Temp., H. CONSUMER ADVISORY 3-202.14 Eggs and Milk Products,Pasteurized P�.P 18 Proper Cooking Temperatures for PHFs ! 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* Not Otherwise Processed to Eliminate Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * 8g Equipment 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* ep rme rnizoor 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 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 Surf 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)-41))in:cater- . 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165'F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under Game and cold Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodbome illness interventions and risk factors. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b)All Other PHFs-145'F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3403.11(A)&(D),PHFs 165'F 15 sec* Requirements. 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140'F* Blue Items 23-30) a Integrity* ( ) Y 3-202.15 Package e _ g 8nty Critical and non critical violations,which do not relate to the odborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140'F to 70'F 3-202.18 Shellstock Identification ( ) 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* P26. Management and Personnel FC-2 .003 5-204.11 Location and Placement*. 3-501.14(B) Cooling PHFs Made from Ambient Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F Equipment and Utensils FC-4 .005 3 402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices Physical Facility FC-6 .007 7 Conformance with Approved Procedures 1 + 6-301.11 Handwashing Cleanser,Availability Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision Special Requirements .609 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doe *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. o�z BOARD OF HEALTH Town of Barnstable v Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. t' BARNS'TABLE John T. Norman v 1—A16 F.P. Thomas Lee Alternate 0. 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections g g 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 280 Issue Date: 03/01/2019 DBA: COTUIT HIGHGROUND GOLF CLUB OWNER: COTUIT HIGHGROUND GOLF CLUB Location of Establishment: 31 CROCKER NECK ROAD COTUIT MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 45 OutdoorSeating: 0 Total Seating: 45 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - — -- — -- - - -- - - MOBILE-FOOD: MOBILE-ICE CREAM: a� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office �oFI►+e r you Town of Barnstable t (i Initials; r Da O-a- d l Amt Pd$ + 9ARMASS.LE, : Inspectional. Services �l,galls_ . y Mass. tb7p. Public Health Division Check# A)Fp Mpt A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Q I Office: 503-862-4644 Fax: 508-790-6304 i APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT i DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: C a v yr dl h rOvN d ?ll- ADDRESS OF FOOD ESTABLISHMENT: 3 1 C2a eker s Necj R,.0aj P4, A - 0 a-63 S MAILING ADDRESS(IF DIFFERENT FROM ABOVE): P© 'lJ O 136 MA A O a43 S E-MAIL ADDRESS: C D7 cc�`I"tl l�n �j rDE+NG� �/,61��a CoM TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (SUS) r - ,�63 TOTAL NUMBER OF BATHROOMS: 6 WELL WATER:YES NO X ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: x DATES OF OPERATION: Y l�lJI TO / l 1S I AD a NUMBER OF SEATS: INSIDE: ) s OUTSIDE: IF TOTAL: y 3 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 m REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? �/ F 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 02) 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\Applicatim Fornis1FOODAPPREV2018.doc A 1 py YA r { a r+ ' 9 :,- PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT JAL, / M . rho A e.R SOLE OWNER: YES NO D.O.B 1 S(, OWNER PHONE# S07- `- f 'y t ADDRESS 76 r ov t C, SII Cd 7�:1 /t 0 aG j lrtt CORPORATE OWNER: Li ✓b t FEDERAL ID NO. : / CORPORATE ADDRESS: '/' l b' I36 J CZD� �rS/V�e/l i�rrC CO?or��� O G 'S PERSON IN CHARGE OF DAILY OPERATIONS: Last(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. / AV M . 11tAa 2 i2 3 Ira 1. 901 M. llekk a- 2. J-ANie �k4 P) na�Jy— SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** 6 i SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. p1 jor to open inpl l 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 terns are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering o event. You must complete a catering notice found at http://ivwsv towiiofbarnstable us/healtlidivision/al)plications.asl). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January Istto Dec.31s1 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. gg �I Q:1Appfication Forms\F00DAPPREV2018,doc F. ro TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date: Page: of. .� kq OFFICE HOURS i AR"N'��Eo PU62 0 0 MAN STREETLIC HEALTH 3::30-- :30A.M. 4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �p Me3q:s�0� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY rF MPS 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name Dat a of Type of Inspection e Routine Re-ins ection Address Risk d Service P Level Previous Inspection _ Telephone Residential Kitchen Date' Mobile re-operation Owner HACCP Y/N Temporary Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP 41414 &AJ 4,g In: I Other InspectorVh-& 4M Out: � r. Each violation checked requires an explanation on he Five 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 � t EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 1 d 07 �C�V ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations RelatedTotal Number of Critical Violations(Blue Items Critical(C)violations marked must be corrected immediately. . (blue&red items) � to Good Retail Practices 1 Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating �SPA,� within 90 days f Health. Voluntary Compliance Restriction/Exclusion Re-inspection Scheduled Emergency Suspension as determined b the Board o e Employee ee ❑ p 9 Y p Y y � ❑ rY P ❑ P Y ❑ C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils. (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than 4non-critical violations 26.Water;Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 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 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation;4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view (AA Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert'Machines Outside Dining Y N PI s ignature Print: J 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* S 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.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved 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 590.003(C) Responsibility of the Person-in-Charge to 7-101.11 Identifying Information-Original Containers* * 2 Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* ` 7-201.11 Separation-Storage*Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* - REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated 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 HermeticallySealed 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* 3-801.11(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. 1 g Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 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* -W 11i"mrzoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11-' Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g �' 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165`F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential 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* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 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 PreventingContamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity* g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) RemainingUnsliced 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* 1g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. " * 5 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli, M.D. unNsrADLL + Paul J.Canniff,D.M.D. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate ONE 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: 280 Issue Date: 01/01/2020 DBA: COTUIT HIGHGROUND GOLF CLUB OWNER: COTUIT HIGHGROUND GOLF CLUB Location of Establishment: 31 CROCKER NECK ROAD COTUIT, MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 45 OutdoorSeating: 0 Total Seating: 45 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: QA FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office Use Only: Initials: Town of Barnstable K � Date Paid 3 a Loz MMWABLE, : Inspectional Services '�9 Public Health Division Check# g� �N3 '�En Mpv a Thomas McKean, Director t 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: C040lf 11jg1 jrQunld eo-J? CJv� ADDRESS OF FOOD ESTABLISHMENT: 31 C-?-Dck/c �-S AkdAol, Co,I wl A 0.1&3� MAILING ADDRESS(IF DIFFERENJT FROM ABOVE): 90 i3 6,4 l3 Co7v: /�1g pa�3� E-MAIL ADDRESS: 0&-rU z f-f�f iiq roulvc� (PYAA00• CO K TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (5og) ya _ R 8(3 TOTAL NUMBER OF BATHROOMS: a— WELL WATER: YES_NO')� ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: >C DATES OF OPERATION: `7�l I /yV TO l/Slao,2I NUMBER OF SEATS: INSIDE: OUTSIDE: /k TOTAL: 113 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? NO 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 QAApphcation FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT I ;4 SOLE OWNER: YES/e D.O.B fj 66 OWNER PHONE ADDRESS_ g4 C��UV`2'JS`�" OA63� CORPORATE OWNER: CK7U:7 1)idr^couMd( -Y) L1Z'NC . CORPORATE ADDRESS: f D �6X 31 C,2W-kek3 Need �d PERSON IN CHARGE OF DAILY OPERATIONS: ) Atli 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. 0AU /�I- gthLk la) 1. ArlM.��zR 2. J A _ 3 / a 7 SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/heaIthdivision/a1)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 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 l_ THE COMMONWEALTH OF MASSACHUSETTS AMOVED BOAR® OF HEALTH TOWN OF BARNSTABLE pit iripwiui Wurlw Tontitrnrfiun Permit Application is hereby made for a Permit to Construct ( ) or Repair ( n Individual Sewage Disposal System at: .......... ........... = ------------ -----------------------------------------------------------------------------------------------_-- Lk ' �ddress or Lot No. s� v . ..-----•-• ---r� S ----------------------------------------- ......... / O r Address Installer Address UType of Building Size Lot............................Sq. feet ,.., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons:-__--.-.----.----.------. Showers ( ) — Cafeteria ( ) dOther 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. 3 Seepage Pit No--------------_---- Diameter.---..--.----------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (14 Test Pit No. 2................minutes per inch Depth of Test Pit----................ Depth to ground water--...................... P4 •-•-•... ------------------------------------------------ ••--••......................................-.......---..........---......--•...----...........••---- ODescription of Soil........................................................................................................................................................................ x V •---••-•-----------------------------------------------------------------------------------------------------•--- ................ •...-••--•-- U Nature of Repairs or Alterations—Answer when applicable.-- -.- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance as be 'i sued by e board o health. �c��7 Signed ..... . .. i........................... ........................................ Date Application Approved By .............. ... -�D.- ................. Q...: 1... ..¢...- - Date Application Disapproved for the following reasons: .......... .............................. .......................................................................................... ................................................................. .............................. . ............. .................................................................. ..... -....................................... Permit No. ......(�. ...-.... �-�......................... Issued ................................... Date...... Date No...... .z3..: �?.7 F>sa. ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE t p Sul Mnrkii Tomitrurtiatt remit Application is hereby made for a Permit to Construct ( ) or Repair ( �— n I�' ndividual Sewage Disposal System at: ................:1......--- !u- - ------ ------------------ Loc�i'rn�:\ddmss or Lot No. �- -----......7r?.v.S.7 ............................ ....................................................... er Address Installer Address UType of Building Size Lot............................Sq. feet �-� Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------------------------------------------------•--•-•------. ---.._......----•-------------------....-----......--•-_..... 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rZo Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -----------------------•-------••--•---•••-•.....--•--•------------••------•---..........._.................................................................. 0 Description of Soil----------------------------------------•---.............-•---•------------•-------------------------------.....------•-----•--•........................................ x --- •----------------------------------------------------------------------------------------------- - - -- ---------A- ---------------------------------------- U Nature of Repairs or Alterations—Answer when applicable... , �_.>..._...._ f 1.lf ........................... •----•---------------------------------------------------------•--•------------.....-------•---------------....---------------------------- a .............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has XF issued by e board o health. Signed ...y..../ hL9 _........................ /...�a...a Da�e p Application Approved By ............. ...//7.... '.... f j Application Disapproved for the following reasons: ...... .......................................... .. ................................... ........................... ......... .......................... ................................::.......... . . ................................................................... ............................... ........................................ Dace Permit No. ...... :?��.7.. Issued .................................................. ...... . .... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF V'E BARNSTABLE rtifirate of VTT omplianre THIS IS T -ERTIFY, That the,Individual Sewage Disposal System constructed ( ) or Repaired Insrdlcr I d , at j/........ ....... .�......t./� ""---- .._ tea._...... a Q ...c/.d... ..................................- �..i ._........ > tom... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ------.?3 .....,-3'�-l.7_.... dated ......................................_...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. --�-� DATE..._.............. ...-.. .-....t....`7............--- -- -------._... Inspector ............... .,..... J....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c� TOWN OF BARNSTABLE �e, 0 O No.... `...5--b 7 FEE---•-•---•--•------•--. 19ispliar�arks- Ton trurtion "rrmif Permission is hereby granted /---- ... -a/. r ----------------------------------------------------------------------- to Construct ( ) or Repair ( an Individl al Sewage Disposal S stem atNo. = .............................. ` y Strect qqq as shown on the application for Disposal Works Construction Permit No._ .1_`j Z1.7 Dated...... f?. j.`i....9-3.._- ................................ =-.. ......................................................... q DATE................./ --.--- Board of Health � FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS TOWN �/O' F BARN SBLE LOCATIOI / 6V6 d bP -- a k SEWAGE VILLAGE a&4tASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.CIL) :SEPTIC TANK CAPACITY /e-4 0 LEACHING FACILITY:(type) i,7�.�� ��� �°;^-5 (size) NO. OF BEDROOMS !-- PRIVATE WELL 0 UUBLIC W BUILDER OR OWNER �L.r a-Will. - DATE PERMIT ISSUED: , .� DATE COMPLIANCE ISS ED: S ,3 VARIANCE GRANTED: Yes No Z._...._-- i C6/ all- �D i AaY �s�� c��,s� 36 WALL CAUTION: Electrical and plumbing connections should be made by a qualifiegig"a Person who will compiY with all available federal,state and local Health,Electrical,Plumbing,and Safety codes. w American Dish Service Z ` Mumilnc•fureis of Wnre Washinc7 Equipment •Manufacturer reserves the right 10 modify these u a w ` specifications in wmpliance with regulatory 7 a y agencies and manufacturing expediency. ur c p NS F r' �D Q1 V a Conned to upply Source using 10.12 AWG U Copper wireSs uaing non-time delay fuse of 20 J u amp rating or 20 amp circud breaker. 7 w -- - reET Series Specifications LL �; � I I poi I I p I 1 1/2'FDT.NLE I I I AT(3UT I OM ET-AF FAMILY MODELS I ET-AF ET-AF ET-AH ' NSF RATED CAPACITY(RACKSIHOUR) 30 24 20 WASH TIME(IN SECONDS) 45 60 75 RINSE TIME(IN SECONDS) 30 45 60 TOP VIEW DWELL(INSECONDS) 15 15 15 TOTAL CYCLE TIME(IN SECONDS) 90 120 150 u z z 25 IiZ INCLUDE v WATER TEMPERATURE OF SUPPLY WATER(NSF)120•F.MINIMUM FRONTiS1UE SWITCHES (Or 49°CELSIUS) .1 crl WATER CONSUMPTION (NSF RATED) . 1.7 GALS. PER CYCLE ENCLOSURE CLEARANCE, 11;15" '' j °' Or 6.4 litersicycle 801'I ON1OF 2.1.13116' r :ouvTEa {1 7 CIT. MOTOR RATING....................(1.125 KIN)1.5 HORSEPOWER n I ELECTRICAL RATING(NEC) 115 vac, 20amp breaks,5016OH7, 1 phase / RACK SIZE.. . STANDARD 19.75"X 19.75"(Or 50.2 X 50.2 cm) DOOR INTERLOCK I/ DOOR CLEARANCE`. 11"TALL X 22.25"WIDE(Or 27.9 x 56.5 cm) sVVI I CH -�_ WATER INLET......................................(Irv)F.P.T. _ DRAIN SIZE......................................(1.112^)F.P.T. L7 i 1:q "Ad HEIGHT OF STANDARD ET(ADJUSTER FEET NIL GIVE)MIN 33.5"-_.MAX 38" • .. ` Or 85.1 to 88.9 cm r1 ® HEIGHT OF ET-AF•3......MIN:36.5^_MAX:38"(Or 92.7 to 96.5 cm) Q WIDTH(OVERALL)............................. 24.a"(Or62.9cm) DEPTH(OVERALL) .. ) SHIPPING WEIGHT...................... 201 POUNDS(Or 91.2kg) N SHIPPING VOLUME(CRATED)..........38 CU.FT.Or 1.1 cu meters s:: f ELECTRICAL CONNECTION- '-th'ATER INI F- *Also available in a 3"Taller Version with 1"f DRAIN - 2q,8 cm 14' x 22.25"(35.8 x 57 cm)door clearance. 1!2"CONDUIT CONNECTION � 1!2 FPT Model ET-AF-3 FRONT VIEW SIDE VIEW Effective2/1102 t� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ELJ T L... .........OF....t /.?✓'l. :........... .............................. Appliration for Uiipnsal Worko Tondrnrtion Prrmi# Application is hereby made for a Permit to Construct ( ) or Repair (-') an Individual Sewage Disposal System at: o .................•-----. •. ...4 � 3ho dress ..... ..or Lot No------------------------------------------ Address wner ................................................... Installer Address Type of Building Size Lot............................Sq. feet V 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........ --••-••••.................. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................--. G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ...................................................................................••-••......•••--•......................................................... 0 Description of,Soil........................................................................................................................................................................ x U -•-••-•-•-••-•••-••----•-•--•••-•••...........•--•-.....-•-•----•••-......-•-•...............•••••-•...---•-.........-•••-••-•------•••--•-•••--•..............-••-•--••••-•-•---•---••-••-...........•. x ................-............................................. •--J U Nature of airs or Alterat' r�s—Ans er when applicable.......,0.2......_ ..rG_.1--...._...: ....... ._.. ... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'AI TLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ,nbe boar f health. Date Application Approved BY .. Z- - g Date Application Disapproved for the follow reasons:............•------------•-•-•-•-----•---------..........--•----•---------._.....••--••.........._....-•--••.. ....................•-••.._.......•------•--••-••---••-----•--••••--••• .............................................................................................................................. Date PermitNo................................................... Issued........................................................ Date IrNo...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL/To Appliratiun fur Uigpuutt1 Workii Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (04 l an Individual Sewage Disposal System at: ........ 1 ..... ...:..... ?"...'.�.... �c �. ........................ ............................................. o dress IV or Lot No. ••......•• •.. ................. - '..... ........................•••.... wner Address ..........................•----•--••---------.......-•-•--•--•--.........._............_.......... a Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms________________________________ _____Expansion Attic ( ) Garbage'.Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria Other fixtures -------------------------------- - . . Design Flow____________________________________________gallons per person per day. Total daily flow.............................................gallons. W.W Septic 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.......................................................................... Date........................................ aTest Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water_.___._.._.__..__._____. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --••--------------------------------------•-----...._._..----------....-•-•-•---..._..-----------••.......................................................... 0 Description of Soil........................................................................................................................................................................ •---•--------------- ---------------------------------------------------------------------------------------------------------------------------•- ............................ - -----•------••-- Nature of ��,airs or Al erati Ans er when applicable _.___._'€3' . . U PP . -• •• ..._•--- Agreement: v� 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 been is b�t�e boarf health. , Date Application Approved By........................ .-----• -_..i . .. .. •--•� �2--................ ate - Application Disapproved for the follow reasons-------------•---------•---------............................................................................. -----•--•-----•.................................•-•--••-•-----•-•. .............................•----•---.....-•--•-•.....•--•--•...___...........•--------------•-•....... ......--•-•-. Date PermitNo..... --....---.._.. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �!.. � ..... -OF... ................................. Trrtifirate of Tomplittnrr T CIS, .0 CE FY, That the Individual Sewage Disposal System constructed ) or Repaired by. ...e�. R =�.cC.c� �..'....................••--•--•-----------------• ..............._.R..-►.... .. ( ..... at: ...._.1 ! _•---•-• -- _... . ,' 's` ----•---.........._ .......-•.................... .............•------ has been"'installAd in accordance with the provisions of TITLE 5 of The State Sanitary Code described in the applietion for Disposal Works Construction Permit N.o._____ __'l1 ? dated_.-. 1�:2:" (.. ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUINCTION SATISFACTORY. �. DATE.......... ... 7 - ... ..... Inspector.----.. a/-------------------••-----._----••-•--•-••--•----------•--••-----_--. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE L H No.........................3 ' '.. ...............OF . .._. . .............--•.•___ ................................ . F$E ...... Disposal Works Tonotrurtion Prrmit Pirmission is hereby granted-............... 1<7 :- ....... LCV.I... .......................................................................... at No........ .:_(- •) �� Individual Serge Disp st to Construct or Re air an I ..... Street as shown on the application for Disposal Works Construction Permit No �. _1 D _________ ....... Z. -•►.-.- _----•_--__------•-- ---- DATE.•--•--••--- T,. L FORM 1255 A. M. SULKI INC., BOSTON TOWN OF BARNS LE XL I LOCATION le.��ri4 t�'� CL,k 1 01 SE AGE # �✓ VILLAGE (�p_7—� f" ASSESSOR'S MAP & LOT�f� a INSTALLER'S.NAME&PHONE ND. ,� •— WA e OA>Q SEPTIC TANK CAPACITY t'' �� /000 e �� LEACHING FACIL171Y (type) -Zerl5vl5rmze) Z6� 14 NO.OF BEDROOMS / f 'y S y BUILDER OR OWNER PERMITDATE:�-- , COMPLIANCE DATE:�,7 �2 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A ®� 1 �/ ✓I� rntv Bellaire, Dianna From: Soto, KatCkhryn OC 6DL I Sent: Thursday, May 13, 2021 10:17 AM To: Bellaire, Dianna Cc: McKean, Thomas Subject: Cotuit Highground Hello Dianna, I spoke to Tom about adjusting the seats for Cotuit Highground so they can have outdoor seats on their permit. Currently they have a total of 45 seats inside only on their permit. Tom approved the change of seats on the permit to say 27 inside and 18 outside (27+18=45). You are all set to adjust the permit to these numbers and send the owner a copy. I have a copy of the floor plan and letter to request the change from the owner that I will place in the file tomorrow. Thanks, Kathryn Health inspector Town of Barnstable 200 Main St Hyannis, MA 02601 508-862-4639 l The information containe.cl in this electronic transmission 'e-mail' ,Including any attachment the"Information"),may be confidential or otherwise exempt from disclosure.it:is for the addressee only.This Inforrrration may be privileged and confidential work-product or a privileged and confidential communication.The Information may also be deliberative and pre-decisional in nature.As such,it is for internal use only.Tile Information may not be disclosed without the prior written consent of the Director of Public Health and/or the own Attorney's Office of the.I"awn of Barnstable.If you have received this e-mail by rni=.ake, please notify the sender and delete it from your system.Please do not copy or forward it. Thank you for your cooperation. 1