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HomeMy WebLinkAboutJIMMIES ICE CREAM - FOOD i � F Jimmie's Ice Cream 40751 . Falmouth Rd. Cotuit__d40-03$ t� k ORMERLY: CHAD'S ICE CREAM 5 S A+ s 3 5, i , P f �rt x Town of Barnstable BOARD OF HEALTH John T. Norman Board of Health Donald A.Gaudagnoli,M.D. • DAWNsrABLE. F.P.(Thomas)Lee +$ 9+�a� m 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. A Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 324 Issue Date: 01/01/2022 DBA: JIMMIE'S ICE CREAM OWNER: KON LIMOUSINE SERVICES INC Location of Establishment: 4075 FALMOUTH RD, UNIT# B COTUIT, MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 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: $30.00 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 - For Office e Initials: oFtHElp�, Town of Barnstable �` Date Paid 61 [24,�zdv 2-911� � �AB�. ; Inspectional Services 2 " 3 -� "' 9� Public Health Division Check# ArEp �A C��q Thomas McKean, Director 0�0-032 _ G 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE �' ' .2 ) NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ..ILeJOVI L5 5 ,�t,.�� C le c=/Y A-\ ADDRESS OF FOOD ESTABLISHMENT: 4/6 1 ,'— r�A L!j1U✓ 7 cc, :AILING ADDRESS(IF DIFFERENT FROM ABOVE): /? E-MAIL ADDRESS: 'J14 456 C y wI TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( ) IT& - TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: ✓ DATES OF OPERATION: r -j'lGaO Yl 7W 2 NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: U yf SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. r ***OUTSIDE DINING REMINDER*** JUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? � IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) OBILE FOOD ;AROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) T_CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL, MOBILE & NEW FOOD ONLY*** r REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED ' PLEASE CALL 508-862-4644 0AApplication FormsTOODAPP 2020.doc I OWNER INFORMATION: G ,,IFULL NAME OF APPLICANT 7,A'M 6,1 G v 4 HA M VS.OLE OWNER: YE NO D.O.B L' 17 • G OWNER PHONE # J 6 8' 7 7 j I! :ADDRESS (? G . f� G Q �!¢ ✓!�/� Al — Q Z 6 'S n- CORPORATE OWNER: (CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least (1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment'. - Certified Food Managers Expiration Date Allergen Awareness Expiration Date o t s w" /am ` ZL_ 1. A�'1�s I✓ 'j� M L Z Z Pinu-lidbto - B-) I L a7 F- SIGNATURE OF tp P LICANT DATE I " I ***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. i FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, ith sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert ermit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a food establishment is prohibited. 4.'I `NOTICE: Permits run annually from January Ist to Dec. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN ' s I°'THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. 4 1• f i » Application Fonns\F'OODAPP REV3-2019.doc I T Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. 0A1v9rA8LF. : Paul J.Canniff,D.M.D. 4$ q 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: 324 Issue Date: 01/01/2021 DBA: JIMMIE'S ICE CREAM OWNER: JAMES NEEDHAM Location of Establishment: 4075 FALMOUTH RD, UNIT# B COTUIT, MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 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: FROZEN DESSERT: $30.00 Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: 614� Only: pa A For Office]Use Initials: °SIRE Town of Barnstable Date Paid Amt Pd$ MU AM. Inspectional Services v '�' Check# i63� `` Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL n NAME OF FOOD ESTABLISHMENT: J� VY11 L .�C-C_— C'C '�1 1 ADDRESS OF FOOD ESTABLISHMENT: G W�lj tJ�/ l� C MAILING ADDRESS(IF DIFFERENT FROM ABOVE): t0c) J o X kd U V(l l E. o a 6 E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (, - a TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO ✓ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: V DATES OF OPERATION: % J/Z/TO NUMBER OF SEATS: INSIDE: C� OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? !� IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? J TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) V ROOD SERVICE ETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) _ZOBILE 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 ,�,/ �3 ` N 144 m SOLE OWNER. YES NO D.O.B Z 7, (, OWNER PHONE# �U 0 7 7 b 2 ADDRESS O ` Qe, CORPORATE OWNER: X G N L P M G u'� >/u i� -L�c V/ C i=-:5, 3 C/ V( CORPORATE ADDRESS: JQ CG G J� [1 O �L ✓/ / C� YYI/�" G �4 Ste/ PERSON IN CHARGE OF DAILY OPERATIONS: Ve 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 17 2. A&g:00A in�e- t / ZZ SIGNATURE OF PLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. RAWMAKIM : Paul J.Canniff,D.M.D. 1 �. 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: 324 Issue Date: 01/01/2020 DBA: JIMMIE'S ICE CREAM OWNER: JAMES NEEDHAM Location of Establishment: 4075 FALMOUTH RD, UNIT# B COTUIT, MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 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: C,iA FROZEN DESSERT: $30.00 Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r Only* Initials: Town of Barnstable For Office Use "r Q' Date Paid 41 11' 426Amt Pd$ &MMSPABLE. : Inspectional Services 9.yA`e� Public Health Division Cheek# 14W �' 3a 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 3 G 2, 0 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: Z/� ►^-7 ADDRESS OF FOOD ESTABLISHMENT: 7 6 7 J— 64 L Yu r,u 711 CO� nqA a- 3 S_ MAILING ADDRESS(IF DIFFERENT FROM ABOVE): f� O , 0 6 X � `RO O-5 i V l I E MA C) E-MAIL ADDRESS: .v/A rnG3 E Ka nI l—l n'f 0 e G d'►'1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: S TOTAL NUMBER OF BATHROOMS: 1 WELL WATER: YES_NO--Z... (ANNUAL WATER ANALYSIS REQUIRED) i ANNUAL: SEASONAL: ✓ DATES OF OPERATION: / I 12 eTO NUMBER OF SEATS: INSIDE: G OUTSIDE: G TOTAL: C5 SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING.AND MEET OUTSIDE DINING REQUIREMENTS. / IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? N o 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 V/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 r f^ OWNER INFORMATION: FULL NAME OF APPLICANT /V7(: 3 14A WI (� SOLE OWNER: YE 2 — l-7 -6 OWNER PHONE ,- 7 /# 6 0 1 �3 S/ O D.O.B / ADDRESS po CORPORATE OWNER: A 6IJ 6EIQ 4.4.Yy) CORPORATE ADDRESS: G , Q 52 ✓111 PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date SIGNATURE OF APPLI ANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/al)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 I st to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. Q:\Application FormsWOODAPP REV3-2019.doc Town of Barnstable 1p BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. BARS-rABLL John T.Norman a+a F.P. Thomas Lee Alternate °©. � Q• .. 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstabte.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: 324 Issue Date: 03/01/2019 DBA: JIMMIE'S ICE CREAM OWNER: JAMES NEEDHAM Location of Establishment: 4075 FALMOUTH RD, UNIT# B COTUIT, MA 02635 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 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: $30.00 Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r. i o4SHe r�W For Office Use Only: Initials: Town of Barnstable 3_9-1 9 Date aid Amt Pd$ �BARM9'rABLE, Inspectional Services 1679. �m Check# 13 A'FGMA�A Public Health Division Thomas McKean,Director Alk 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: ADDRESS OF FOOD ESTABLISHMENT: �G 7 U Q T 1 f- /}1) d MAILING ADDRESS(IF DIFFERENT FROM ABOVE): P G• c-9 d X FG E-MAIL ADDRESS: A ryyL.S Kon/.,1,*) 0 • cc m TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (OF-) TOTAL NUMBER OF BATHROOMS: 2 i WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED)ANNUAL: SEASONAL: ✓ DATES OF OPERATION:s5—/_—/,&T0 `U/ /6/! M NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: 0 t 4 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 1tEQUIREMENTS. . IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? _ IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?__6�ZA- 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 i FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) -CATERING.- (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL,MOBILE &NEW FOOD ONLY*XX F REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED i Q:1Appiication Fomis1F00DAPPRL-V2018.doc e z l PLEASE CALL 508-862-4644 OWNER INFORMATION: i FULL NAME OF APPLICANT A C1 @ KU 0 -4/Y"0 CC 0,1 SOLE OWNER:(gJ NO D.O.B a/(7/6 / OWNER PHONE# d-O f 1 ADDRESS / i�o�L/,1/� D/Z 0 z V //4r-17 CORPORATE OWNER: 4= IFEDERAL ID NO. CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: f 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 Z Z 2. G- A 2 za r< 0 31 031 00/ . SIGNATURE OF A LICANT DATE ***FOOD POLICY INFORMATION*** f SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile hocks must be inspected by the Health Div. Prior to openine!! 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. f 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 httD•/hvw)v towiiofbai,nstable us/healtlidivision/applications.asp. C< 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. - j 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 I st. i Q:Vlpplication PormsTOODAPPREV2018.doc a l `oF1ME T TOWN OF BARNSTABLE.. .HEALTH.INSPECTOR,s Establishment Name: Date:' Page:,Of I 4 - OFFICE HOURS eARNsrAa�Eo PUBLIC 2 0 MAIN STREET s 30 4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3.30 4:30 P.M. mnss �r. MON.-FRI. �p ,639 .e HYANNIS, MA 02601 508-862-asaa No Reference R..-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT �3 �`.vf L UD� �' c1�C/�e ot Name . ' Date T e o TYpe of Insgection ` ! l M VH/I Routine i Address /�7 �/ Risk• Food Se Re-inspection �� Level a ail Previous Inspection Telephone Residential_Kitchen- Da Mobile o Pre erati Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint y� Person in Charge(PIC) Time Bed&Breakfast' HACCP:. Other In; ` Inspector Out: Each violation checked r quires 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) ❑ 1 3 _ - .Action as determined by the Board of Health. Allergen Awareness 590.009(G) oa im FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination-from Hands c ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ` ❑4.Food and Water from.Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control j et-44 ❑ 8..Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) - ' ❑ 9.Food Contact Surfaces Cleaning.and Sanitizing ❑ 21.Food and Food Preparation for HSPj_'4 G ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY V I � ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories - li Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations /J Critical(C)violations marked must be corrected immediately. (blue&red items) 4 Corrective Action Required: In No ❑ Yes Non critical(N)violations must be corrected immediately or Overall Rating 1 within 90 days as determined.by the Board of Health. ❑ Voluntary Compliance ❑ Employee.Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo Emergency Closure ❑ Voluntary Disposal ❑ Other. checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations-and no m , -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 P ( )( ) constitutes an order of the Board of Health: Failure to correct violations _ regardless of the number of critical,results in an F. B-One critical violation and less than 4non-critical violations 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation.of the food . Y p - if no critical violations observed,4 to 6 non critical violations-B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and waste__. (FC-5)(590.006) establishment permit and,cessation of food establishment operations. If - 27.Physical Facility (FC-6)(590:007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations a s than,9rion-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 obs d,7 to 8 n critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 8 non critical vi lations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector' ignature Print: c 31.Dumpster screened from public view. Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen'Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted- Y :. N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41'F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding ty. 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 EachIdentifying * 590.004(F) 7-101.11 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*P 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 Restriction-Presence and Use*its and Vegetables * 3-501.19 Time as a public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 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)DispositiRetumedon od and Rlated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition 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 Warewashdng-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* pe 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* SanitizationTemperatures* TIME/TEMPERATURECONTROLS 3-202.14 Eggs.and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1$ Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155'F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145'F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-001.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effie°"°°mrzooi 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 4-702.11 Frequency of Samtizahon of Utensils and Food 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* 3-401.11(A)(2) I Ratites,Injected Meats-155'F 15 sec* 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* Ratites-165`F 15 sec* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 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 Authority Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* RegulatoryAuthori[y 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 practiceRequirements.sshould be debited under#29-Special $ Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper.Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3,103.11(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 3-10L11 Food Safe and Unadulterated* 3-003.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A Cooling 3-202.18 Shellstock Identification ( ) g 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(1) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures 1 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 1 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Fonnback6-2doc *Denotes critical item in the federal 1999 Food.Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. THE Tp� TOWN OF BARNSTABLE ,, HEALTH INSPECTORS Establishment Name: \,� � Date: 2 Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. " 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 MON.-FRI.4644 No Reference R-Red Item PLEASE PRINT CLEARLY ArFO MP'�° 508-862- 110 FOOD ESTABLISHMENT INSPEC ION REPORT Name �YVI l,l. � Date 4 Type of T Inspection (� outine l �1!.��C��� Address Risk Zood Servi Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP c(.V �+'"�" In: Other J Inspector � ��� OutL 30 " `� /b Each violation checked requi es an explanation on the narrative page(s)and a citation of specific provision(s)violated. i p. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ 01 l� GEC Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ GHQ,/ Q 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 3.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS '✓1 YLC `/( G{/ ❑ 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) 104 ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating . ` C ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling k- � 19 ❑ 7.Conformance with Approved Procedures/HACCP Plans Dom-' HHot and Cold Holding ram} l -75 PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control �� (� t ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)®-T._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 tom" Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) 9 ^ 1 OL. Corrective Action Required: No Yes Non-critical N violations must be corrected immediate) or 4 ❑ ❑ ( ) y 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. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-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 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 Signat e Print: 31.Dumpster screened from public view Lo�� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signa _ Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N f� ..-t j •r'�.�.-... .--,_.- -...._ ..-�.<-..-..-. .-.-_..,_rr'• `z.- r-c.: "-._ _.. -:'.,!Y'r`.�..i..--.---.. --- ...+'4,rZ^Y-_..-.^-�r-'...«r-.-_l .,�./s• .rY.�..-. � .. .--�--..•�.-- _ �-......J�<'.yr._,...X-n.-� -K.. r..�!M�-J"-"-_ - - r a Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives 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* 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 Se azation-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* 1590.003(G). Reporting by Person in Charge. Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* - - 590.004 11 Variance Requirements * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q � - - - Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated Food- .- 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* ) 590.004 A-B I 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 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 Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water* "- 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* g PP Y Not Otherwise Processed to Eliminate Equipment* ( )( ) Pathogens* e 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * e nw urnom 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential. 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related[o 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* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail _ 3-401.11( )( )( ) 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 * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 16 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 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 � 5-205.11 Accessibility,Operation and Maintenance * 3-402.12 Records,Creation and Retention* Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 Labeling of Ingredients* Supplied with Soap and hand Drying Devices � 27. Physical Facility FC-6 .007 590.004(J) 9 9 Y tY 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 1.008 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. pF THE roy TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: JJ) n'1Wtj �L.°Q n Date: V-/--ZJ?j Page: of v� do -.y• OFFICE HOURS r'��=• PUBLIC HEALTH DIVISION 8:00-9:30A.M. RARNSTABLC ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 39• ��� HYANNIS,MA 02601 08-8 -FRI62-0644 6 508-8 . No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPETIO �1DrFD MPS°' N REPORT Name ' 1 Date Z lyoe of Tvoe of Inspection �. �J 1✓�1 \e S 1 O n s Routine S 1 ✓A7.2.1�!/Li Address z- Up( Risk Food Sery Re-inspection p J Level Retail Previous Inspection 'C Telephone Residential Kitchen Date: Mobile re-operatio Owner HACCP Y/N Temporary s Caterer General Complaint Person in Charge(PIC) f ��Ar Time Bed 8 Breakfast HACCP In: 3 ;, -P Other \ ,�'`L Inspector y`�� Out:� ;�0�+ l�iJ QD yy Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ f e C 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 �Handwash Facilities (. 0 EMPLOYEE HEALTH PROTECTION FROM CHEMICALS W �(��J l D� ✓"`��� ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals / �t✓��L. 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 I Accuracy of Ingredient Statements ❑ 18.Cooling l b ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding J PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Se aration/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 ❑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) l Corrective Action Required: ❑ No Non-critical(N)violations must be corrected immediately or Overall Rating �1 TO Yes within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ® Embargo ❑ Emergency Closure ❑ Voluntary Disposal El Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) Constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4npn-critical violations 9 )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other PATE OF RE-INSPECTION: Inspector's � ature Print: 31.Dumpster screened from public view 7 1 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N - (� #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' ' natur/�,y Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y IN Dumpster Screen? Y N V` Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 . Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 7-101.11 Identifying Information-Original Containers* 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 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-]02.1 l Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 F59"0.003(E) 0.003(D) Exclusions and Restrictions** 7-204.11 Sanitizers,Criteria-Chemicals* 3-306.14(A)(B)Returned Food and Reservice of Food* REQUIREMENTS FOR Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and - 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.1 I(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE 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* 3-401.11A(1)(2) Eggs-155°F 15 sec Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are 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* e111i-11112001 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401 A I(A)(2) Ratites,Injected Meats-155'F 15 sec* aces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009 A Chemical ( )-(D)in cater- Sources* Ratites-165°F 15 sec* in mobile food,temporary and residential 10 Proper,Adequate i S• P y Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* t 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 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g• g g 3-403.11(A)&(D) PHFs]65°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) ' Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 8 Tags/Records:Shellstock I 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible S 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 6-30L11 Handwashin Cleanser,Availability 27.8. Physical Facility FC-6 .008 7 Conformance with Approved Procedures/ g y 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1.009 i 3-502.11 Specialized Processing Methods* 30. 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. HEALTH INSPECTOR'S Establishment Name: Date: oF� row �/�/� �TOWN OF BAR STABLE Page: of OFFICE HOURS PUBLIC HEALTH DIVISION s:oo=saoA.M. BARNSTABLE.O` L/f D�- 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MA- g. MON.-FRI. �A ,619.p�m HYANNIS, MA 02601 sos-ss2 asaa No Reference R-Red Item PLEASE PRINT CLEARLY. rFDN1�` FOOD ESTABLISHMENT INSPECTION REPORT Name Date of Tyne of Inspection _� / O er s Routine - Address Risk ry Re-inspection Level Retail Previous Inspection 5, Telephone Residential Kitchen Mobile Pre-operatio Owner HACCP YIN Temporary ness Caterer General Complaint - Time Bed&Breakfast HACCP Person in Charge(PIC) eti} �Z In: Other Inspector Out: w Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ -G. Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ "� FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands / c ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 4 EMPLOYEE HEALTH PROTECTION FROM CHEMICALS Ak ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ALL . Aj ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals 3 FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) � ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures V V 9 ❑ 5.Receiving/Condition ❑ 17.Reheating l�l ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling !A ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control L&A it 5 J ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating. within 90 days as determined by the Board of Health. ❑ Voluntary Compliance. ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo Emergency Closure Voluntary Disposal Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more no violations, 24.Food and Food Preparation (FC-3)(590.(3104) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4npn-critical violations 9. )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9.non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) receipt within 10 days of recei t of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N 1 / Dumpster Screen? Y N 1 Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1 q Food or Color Additives Law Cooled to 41'F/45`F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 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 EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 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 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated on of Foam* 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 Fond* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* q Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.1 IA(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,Meats&Game Pathogens* eg°°°e rorzoot 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 p 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 3A01-11(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-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 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 145T* 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 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23.30) 3-202.11 Package Integrity ( ) Commercially Processed RTE Food-140'F Critical and non-critical violations,which do not relate to the foodbome * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 13 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140`F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41'F/45'F Item Good Retail Practices FC 590.000 TagsiRecords: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 Supplied with Soap and hand Drying Devices thin 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* 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:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Op IKE Tory TOWN OF BARNSTABLE, HEALTH INSPECTOR's Establishment Name. Date: Page: of ti OFFICE HOURS Ri�r'�Eo: PUBLIC 2 0 MAN STREEETSION 3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. mnss.. �r. MON.-FRI. �OTEu Mn+>�0 HYANNIS,MA 02601 508-862-4saa No Reference R-.Red Item PLEASE PRINT CLEARLY FOOD TABLISHME T IN T ON REPORT . Name Date a of Type of Inspection I y Operationlsl Routine Address JY Risk i Food Service Re-inspection ty _ �1// el Retail Previous Inspection A ^ Telephone I I Residential Kitchen Date: Mobile Pre-operation Owner 14ACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC Time Bed&Breakfast HACCP Other Inspector t• Each violation checked requires n explanation on the narra Ive pag (s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk actors(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 gel r 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 J FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HfSP) 0 ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 16.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories l 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 ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations..9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical, results in an F. 6=One critical violation and Less than 4 non-critical violations 9 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation.of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.water,Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility . (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than.9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in-writing and submitted to the Board of Health at the above address violations observed,7 to.8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements, (590.009) within 10 days of receipt of this order. violation,4 to 8nora-critical ViolaU,ns 30.Other DATE OF RE-INSPECTION: 1 ector's i re i P- 31.Dumpster screened from public view /. Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N ✓ i V #Seats Observed Frozen Dessert Machines: Outside Dining Y N I s Sig Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted, Y N Dumpster Screen? Y N - T Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination L14 Food or Color Additives '_ Law Cooled to 41°F/451 Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 . PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives - - Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) I 2 590.003(C) Responsibility of the Person-in-Charge to Other*._ * 3-501.16(A) Hot PHFs Maintained At or Above 140°F * 7-102.11 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* 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 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements Contamination from the Consumer 590.003(G)- Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* t 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Powders, Raw Seed Sprouts Not Served* P 2 1 Tracking P w r P Control 7 06. 3 ac o des Pest Co tro and g 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils an Eggs d 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* Eff&" 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and 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* Lit 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* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )(b) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45*F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 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-7 006 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °F�XE r TOWN OF BARNSTABLE .. HEALTH INSPECTOR'S Establishment Name InePage:. of OFFICE HOURS AR E PUBLIC 0HEALTHNST DIVISION 8:00=9:30A.M. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 2639. HYANNIS,MA 02601 M-8 -FRI. No Reference R-Red Item, PLEASE PRINT CLEARLY �°rEo MAC°�0 508-862�644 FOOD ESTABLISHMENT INSPE I REPORT Name / at e o Type of Inspection l Routine Address Risk �-ery� Re-inspection vel Retail Previous InspectionTelephone Real Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast UAWZOther P Inspector r t 1 4 Each violation checked requires an explanation on the narrative pages)a� 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) ❑ (91 L/ 1 0( Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ ` i ,F91OD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 11 T/"I PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 7T1 ?C EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures / ❑ 5.Receiving/Condition ❑ 17.Reheating / ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisdries 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 ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Per (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 (FCC 590.005 B=One critical violation and.less than 4non-critical violations 9 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=F is scored automatically if: no hot 27.Physical Facility (FC76)(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 violations observed, 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address .to anon-critic I violati s. If 1 critical refrigeration. 29.Special Requirements (590:009) within 10 days of receipt of this order. v' Ion, to 8non-critical Jiolatio =C 30.Other DATE OF RE-INSPECTION: In is Si r P t: 31.Dumpster screened from public view ' 7:5-/�, fi Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N q #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's lure Print: b, Self Service Wait Service Provided Grease Trap Size Variance Letter Posted, Y N /,ti r 0 Dumpster Screen? Y IN (1l I Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) ; FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives. Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives `•* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* - 19 - - PHF Hot and Cold Holding 3-501.16 Cold PHFs Maintained At or Below 41°F/45°F Contamination from Raw Ingredients 15 -or Toxic Substances B) EMPLOYEE HEALTH 3-302.11 A 2 Raw Animal Foods Separated from EachIdentifying * - 590.004(F) ( )O P 7-101.11 Identi in Information-Original Containers Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) F Responsibility of the Person-in-Charge to - 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 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 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) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals*_ _ REQUIREMENTS FOR , 3-306.14(A)(B)Returned Food and Reared or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces " 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of 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,Meats&Game Pathogens* sff°"ve iiirzom 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15. Molluscan Shellfish from NSSP Listed Chemical* Ratites-165'F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. * 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 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition 8. g g 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) 3-202.11 Package Integrity Y Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification g 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 * 5-205.11 Accessibility,Operation and Maintenance 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. °F1NE.or TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: �I ! U I J / / a e: Page: of 1 OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT C R Y p +639•s�o 508-862-4644 ) 'FON1A` FOOD E TABLISHMENT INSP, C ION REPORT . ® V Name ' Dat Doe o �e of Inspection . r O P Address 1 ' t'k d Servic Re-inspects Led el Previous nspection Telephone Residential Kitchen Mobile Pre-operatio Owner HACCP YIN Temporary Suspect ss IIICaterer General Complaint Person in Char a(PIC Time Bed&Breakfast HACCP Other- Inspect orZa frMiA 6s, WS154- 1 //V- J= Each violation'checked requires an explanation on the narrative age(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) ❑ J FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling 91-1 ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) (� ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories b J Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations ` Critical(C)violations marked must be corrected immediately. (blue&red items) a�(I Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled 0 Emergency Suspe C N Official Order for Correction:Based on an inspection today,the items Embargo Emer,_enc Closure Volunta Dis osal checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ q v n ry p ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriousl 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If y 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 violations observed,7 to 8 on- ritical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address n lation,4 to Snon-critical vi ls C. 29.Special Requirements (590.009) within 10 days of receipt of this order. ao = 30.Other DATE OF RE-INSPECTION: sp cto 's i atur 'nt: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N IC's Sig lure Print: / Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N 1 Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions w 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-contamination14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in--Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* - 3-302.11(A) Food Protection* P g * 20 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 PP P * 590.004(11) Variance Requirements 3-304.11 Food Contact with Equipment ment and Utensils * q p 7-203.11 Toxic Containers-Prohibitions* 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Resumed Food and 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 Warewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a HermeticallySealed Container*. Sanitization Temperatures* Raw Seed Sprouts Not Served* Pe 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* [460011 1.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 0 .114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* - Concentration and Hardness* 3 401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of .11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef cfi°11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency 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 Violations of Section 590.009 D cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* (A) (D) (A) ( )in Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 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 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g, g g 3�03.11(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 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retafl Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(•n Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures 1 6-301.11 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 1 Specialized Processing Methods* 130. 1 Other 3-502.12 1 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Fonnback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. e pp THE rok, TOWN OF BARNSTABLE - HEALTH INSPECTOR,s Establishment Name: �WaU Page: of ti OFFICE HOURS P q ° PUBLIC HEALTH DIVISION 8:00-9:30A.M. eA•RaNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. �r. _ MON.-FRI. . i6SS.per• HYANNIS, MA 02601 soa-8sz asaa No Reference R-Red Ite PLEASE PRINT CLEARLY ; FOQD ESTABLISHMENT INSPECTION REPORT 6 l Name Date Type o Type of Inspection Operation(s) Routine Address Risk Food Service Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint HACCP IL Person in Charge(PIC) Time Bed&Breakfast Other In: Other Inspector Out: Each violation checked requires 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) ❑ 1/7 Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ 1�_�V 1 \1&X1 YC'41 _ 41M Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS . ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. - ❑ Voluntary.Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils FC 4 590.005 B=One critical violation and less than 4 non-critical violations 9 ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If g p,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 C=2 critical violations and less than non-critical. If f critical water,sewage back-up, 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations to observed,7 to 8 non-critical iolat violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. viola' 4 to 8non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Insp ct 's S" t Print: 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 PI Ignat Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted, Y N Y N Dumpster Screen? "` y Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41'F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 1 g Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41'F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * 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 me as a Public Health Control 7-202.11 Restriction-Presence and Use* 20 Ti 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 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 Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 1590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Pe 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 Equipment 5-101.11 Drinking Water from an Approved System* gg* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective uinoot 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 Source3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min F Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155' 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 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165'F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 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-165'17 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23.30) 12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A 3-202.18 Shellstock Identification ( ) 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 E6-301.12 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 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* 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 I Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans Hand Drying Provision 29. Special Requirements 1.009 3-502.11 1 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. /, ate: v l Page: of oFv4Ero �, TOWN OF BARNSTABLE QU v L INSPECTOR'S Establishment Name, 'i' . .. � OIF ICE HOURS P ° PUBLIC HEALTH DIVISION 8.ob-9:30A.M. : �./ ° 3:30-4:30 P.M. -Critical Item F CORRECTION Date Verified • BARNSTABLE. • 200 MAIN STREET Item Code C DESCRIPTION OF VIOLATION/PLAN O MA55. g. HYANNIS,MA 02601 MON.-FRi. No Reference R-Red Item PLEASE PRINT CLEARLY �A .639•pia 508-862-4644 ` 'EON1P` FOOD ESTABLISHMENT INSP CT O REPOR Name Date Tvoe of Type of Inspection J Routine la I Address ood Serpic Re-inspection eve) Previous Inspection ' Telephone Residential Kitchen Mobile re perati Owner HACCP Y/N Temporary S Iness Caterer General Complaint Person in Charge(PIC) Time Bed 8 Breakfast HACCP In: Other t071XIV 7_o11]j(M14 = Each violation checked requires an explanation on the narrative age(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) ❑ J 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 N ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities / r 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 Potential) Hazardous Foods (Potentially ) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures 5.Receiving/Condition 17.Reheatin ❑ 9 ❑ 9 6.Tags/Records/Accurac of Ingredient Statements 18.Coolin ❑ 9 Y 9 ❑ 9 ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time Asa Public Health Control ckl IV ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) p ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY f O ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories ` 1���( A Ile, 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: I ❑ No ❑ Yes Non-critical N violations must be corrected immediately I O or `C l within 90 days as determined by the Board of Health. verall Ring ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: A checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. + B=One critical violation and less than 4 non-critical violations 9 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 2 if no critical violations observed 4 to 6rion-critical violations=B. Seriously Critical Violation F is scored automatically if: no hot 6 Water,Plumbing and Waste (FC 5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than.9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of violations observed,7 to 8rion-critical vio ations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violat' ns= 30.Other PATE OF RE-INSPECTION: I ctor's ignat re4rM Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed r Frozen Dessert Machines: Outside Dining Y N C's Signatur Print: Self Service Wait Service,Provided Grease Trap Size -Variance Letter Posted Y. N Dumpster Screen? Y N' ✓ l�1 i t Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) r' FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance 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. 1g 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 * gg Not Otherwise Processed to Eliminate Equipment ( )( ) Pathogens* � 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * Effective rruzoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 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 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 590.004(J) 9 9 y ' ty 7 Conformance with Approved Procedures 1 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °FIWE TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name:\ Date. Page:,of °kq OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSI'ARLE. • 200 MAIN STREET 3:30-4:30 P.M. Item � Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MON94, M639; `mil HYANNIS,MA 02601 - 64 508-862-4644 No Reference R_Red Item PLEASE PRINT CLEARLY 8-8 rFO MP'�A FOOD ESTABLISHMENT INSPf CIIIO14 REPORT Name Date e o Tvoe of Inspection Operation(s) Routine Addiri RiskFood Service Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation r j Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector12�L 1. � E S. Out: 1. 1- CQ a lanation a narrative page(s)and a citation of specific provision(s)violated. Each violation checked requir�s an Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ i Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑,3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations i Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils FC-4 590.005 6=One critical violation and less than 4npn-critical violations 9 ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9npn-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. within 10 days of receipt of this order. violation,4 to 8npn-critical violatio s=C. 29.Special Requirements (590.009) Y P 30.Other PATE OF RE-INSPECTION: In r 'gna re nnt: 31.Dumpster screened from public view �Ile /P1 wiz ell 14�1 Permit Posted 7 Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI 's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N 7y Dumpster Screen 7 Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* * 590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41'F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to _ 7-102.11 Common Name-Working Containers* * 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 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 horn the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a 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 Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective rruzoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 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 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* * Ratites-165°F 15 sec* in mobile food,tern or and residential Sources 10 Proper,Adequate Handwashing g' P Game and Wild Mushrooms Approved By 3 401.11(C)(3) Whole-muscle;In[ac[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 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity g g 3 403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70'F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item I Good Retail Practices FC 1590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection 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 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. i f - . er8r o 347 West Main Street k°` .r Hyannis, MA,02601 Termite,Pest andgemcn Turf508-771-5008 i Management �4 V �'r'^r�m a'IT�•I�� ••` f APPOINTMENT RECORD INVOICE Invoice# 26401 JIMMYS ICE CREAM Invoice Amount $350.00 PO BOX 80 Service Date May 14,2019 OSTERVILLE,MA02655 Account# 137421 Tech&License# Jackson Ellis Service Address 4075 FALMOUTH ROAD — - ----- — — — Commercial Pest Control Service-Initial Service Charge, Initial 1 $350.00 1 ( $350.00 NOTES Today I set wooden snap traps for mice and rats. Set traps in attic areas,basement, ' ,' • exterior,shed and a few in ice cream building. Most rat traps are inside square black boxes do not move boxes please. I will do 4 follow ups to check and reset traps. If a bi • monthly service or any baiting is required an addition fee will be required. Thank you. PRODUCTS USED _ - t rt RU Wood Trap-Rats 2 1,3,4,5 12 Each Hand Placement Wood Trap-Mice 1 1,2 _ 14 Each Hand Placement TARGETED PESTS 1-Mice,2-Other-See Notes AREAS TREATED 1-Attic,2-Bathroom,3-Exterior,4-Prep Area,5-Shed CUT HERE AND INCLUDE THIS SECTION WITH YOUR PAYMENT Please mail in your payment with this portion of your statement to ensure proper credit. JIMMYS ICE CREAM Current Amount Due:$350.00 Due Date:Jun 13,2019 Account#137421 Invoice#26401 Amount Enclosed$ Send Payments To Fowler and Sons Inc.347 West Main Street,Hyannis,MA,02601 Pay Online fowl erandsonsinc.briostack.com/customer Pay by Phone 508-771-5008 °FTNE r°jr, TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: Date: Page: of ti OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. �!. HYANNIS, MA 02601 _ MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY �p +bas• �e 508-862 4644 'FD1A" FOOD ESTABLISHMENT INSPECTI N REPORT Name Da VIA a of Type of Inspection g Routine Address Risk < Fbod Service e-inspection Leve tion Telephone Residential Kitchen Date: yl- Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP S In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. C� Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ l Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP J ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories 1 Violations Related to Good Retail Practices(Blue Itemsl 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. - I ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than 4vpn-critical violations if no critical violations observed,4 to 6npn-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address observed,7 to 8npn-critical iolations. If 1 critical refrigeration.v = 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 Signature Print: 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' Signature r t: Self Service Wait Service Provided Grease Trap Size Variance.Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) ' Assignment of Responsibility* 8 Cross-contamination 1q 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.* * 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 *- - - - - EMPLOYEE HEALTH 3-30211(A)(2) Raw 590-.004(F)- Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of-the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-201.11 Separation-Storage* 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* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An _ 3-302.15 __. Washing Fruits and Vegetables *7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* - - 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for 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 Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* I 13-801.11(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 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* Ef°eve 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* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from N$SP Listed _ Chemical* Stuffing Containing Fish,Meat,Poultry or 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 Shellstdck 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 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition 8. g g 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 * (Blue Items 23-30) 3-202.15 Package Integrity O Commercially Processed RTE Food 140°F Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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 * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retell Practices FC 590.000 3-203.12 Shellstock Identification Maintained Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 :008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria*_ 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. `Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. TOWN OF BARNSTABLE �fTNErO� OFFICE OF i DA"STABL i BOARD OF HEALTH MASS& i639• 367 MAIN STREET �o YAY k' HYANNIS, MASS.02601 March 16, 1994 Albert Crocker, Jr. 44 Mountain Ash Road Marstons Mills, MA 02648 RE: Chad's Ice Cream/variance Request 4527 Falmouth Road, Cotuit Dear Mr. Crocker: You are granted a conditional variance on a trial basis from the Board of Health "Revised Supplement to Minimum Sanitation Standards for Food Service Establishments" Regulation _.. . 10 that requires a minimum of a 1000 gallon grease interceptor at all food establishments, at 4527 Falmouth Road, Cotuit, with the following conditions: (1) Only the scooping of hard ice cream is authorized. No other foods are authorized to be prepared at this site. (2) Only disposable single service paper, plastic, and other disposable dishes and utensils are authorized. (3) You must install an under-sink grease interceptor under the triple compartment sink approved by the town's plumbing inspector. (4) This grease interceptor shall be cleaned monthly (instructions enclosed). (5) You must install a water flow restrictor device at the triple compartment sink approved by the plumbing inspector. (6) All other regulations contained in 105 CMR 590.000: State Sanitary Code, Chapter X - Minimum Sanitation Standards for Food Establishment and of Town of Barnstable Board of Health sanitation regulations shall be strictly adhered to. (7) You shall install an additional bathroom to be utilized by the employees of the food establishment. This conditional variance expires April 1, 1995. This variance is not transferable, and will be voided if the establishment has a change in use, change of ownership, or leased to a party other than an applicant. Very truly yours, J seph C. Snow, M.D. cting Chairman BOARD OF HEALTH TOWN OF BARNSTABLE JCS/bcs enclosure cc: Edward Glazul 17 1991 June , Albert Crocker, Jr. 44 Mountain Ash Road Marstons Mills, Ma 02648 RE: Chad's Ice Cream/Variance Request Dear Mr. Crocker: You are granted a conditional variance on a trial basis from the Board of Health"Revised Supplement to Minimum Sanitation Standards for Food Service Establishments" Regulation 10 that requires a minimum of a 1000 gallon grease interceptor at all food establishments, at 4075 Falmouth Road, Cotuit, with the following conditions: (1) Only the serving from one (1) soft-serve ice-cream machine and the scooping of hard ice cream is authorized. No other foods are authorized to be prepared at this site. (2) Only disposable single service paper, plastic, and other disposable dishes and utensils are authorized. (3) You must install an under-sink grease interceptor under the triple compartment sink approved by the town's plumbing inspector. (4) This grease interceptor shall be cleaned monthly (instructions enclosed). (5) You must install a water flow restrictor device at the triple compartment sink approved by the plumbing inspector. (6) All other regulations contained in 105 CMR 590.000: State Sanitary Code, Chapter X - Minimum Sanitation Standards for Food Establishment and of Town of Barnstable Board of Health sanitation regulations shall be strictly adhered to. (7) This conditional variance expires December 31, 1991. This variance is not transferable, and will be voided if the establishment has a change in use, change of ownership, or leased to a party other than an applicant. Very truly yours, Ann Jane Eshbaugh Chairman BOARD OF HEALTH TOWN OF BARNSTABLE AJE/bcs enclosure 0 • lit) DATE 3- I I -I cf tN TOWN OF BARNSTABLE FEE ��' w i� ♦� OFFICE OF n RECEIVED l eA'»rnec►.PAIR 1 BOARD OF HEALTH °o 1639 3e7 MAIN STREET o re+ HYANNIS, MASS. 02601 VARIANCE REQUEST FORM All variances must be submitted FIFTEEN (15) days prior to the scheduled Board of Health meeting.NAME OF ,APPLICANT TEL. N0. 11120 ` 146) ADDRESS OF APPLICANT NAME OF OWNER OF PROPERTY SUBDIVISION NAME / DATE APPROVED ASSESSORS MAP AND PARCEL NUMBER 0 2 9 D 3 /� LOCATION OF REQUEST SIZE OF LOT ,0 81 q�;e� _SQ• FT. WETLANDS WITHIN 200 FT. OF PROPERTY: Yes No VARIANCE FROM REGULATION(List Regulation) REASON FOR VARIANCE(May attach letter if more space is needed) PLAN - rua COPIES OF PLAN MUST BE SUBMITTED CLEARLY OUTLINING VARIANCE REQUEST. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPROVAL Susan G.Rax% Joseph 0.Snow,M.D. Brian L tlr* ol-V c crc lo{ ST 1 PQ2� mo�s�v� Wi a - l5z I ems• � j el" U h �a_ � _. vLo KI - Old � oc� i� � ! 3 To WA) Gva44.0 ... - - . Ctrs _-�-.� C.t�►+� - - __. � �►-1 t�.� Pam'2$C.o-ru,rr 1 S'FORAGE'. u Pj,iKE' 1-.- r I 4064 VA'LY WALLED : x1+�Sli• C'D�m�-72. itl�t,41T1�1)� s� M etE� - .. t. For office use only TOWN OF BARNSTABLE b Qjl-5. Sa of nat azc11 Received y . THE T OFFICE OF Date BOARD OF HEALTH moo i6 q �' 367 MAIN STREET f j �Fa MAY�� HYANNIS.MASS.02601, r VARIANCE REQUEST FORM A11 variance requests must be submitted fifteen (15) days prior to the scheduled Board of Health Meeting, OF APPLICANT TEL�i� ~ NAME ADDRESS OF APPLICANT NAME OF. OWNER OF PROPERTY DATE APPROVED SUBDIVISION NAME ASSESSORS..MAP & PARCEL NUMBER. LOT. SIZE. LOCATION OF .REQUEST VARIANCE FROM REGULATION (List Regulation) REASON FOR VARIANCE (May attach letter if more space is needed) PLAN POUR COPIES OF PLAN MUST BE SUBMITTED CLEARLY OUTLINING VARIANCE REQUEST. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPROVAL . Ann Jane Eshbaugh, Susan G. Ras Joseph C. Snow, M.D. MAY - 3 2991 BOARD OF HEALTH TOWN OF BARNSTABLE ` ` ` F' � +• f ti � .. a C� a5 I.'. +' 4 �• • + r� + •• •' ` ,. •:, ti - r },• ;A v rt �' "K, � ;� .•� - •r t ` ,gam ' • - `+./ �� •` i , C Abl Abi ZIAti, •V. ..s,�,iy ' �� Y n '• fU� ..�. • 'e -{" .. ey 'ice. '''��, �► �I ; y ol=.I - 1lMri•yvw.M�Jr.-nllewwwMnn•Y�YweM.•rvw.nw•�5w. .,� 5 j �[j(�` f • ` � ' +r , • ' 3.• .• • �/ !r , • j�, fAp� , ., a •'•. •' , q� 5.. t J ,• .. A -S `5r .f •° - ` � r. a i• a•5 � - �_. . . w_ -apatxecxsm,eaax+iwrwswcu�v�. wexv.wmwienivwJecw.awr - .sslz¢cwrr+x�w-eowv✓. _ .�.tar'::,uiiaNe'�x+mma.,uw�sauw.s( " `'• t ♦' - vi •y� ^, ,' �.+•+ ,•. -. - • �' ..- - - ' �. Syr:,. - �, � � �,�. �L ���... _•�, -os �=C�"..��. ,� . • . - . fir/• ,([� �y�•"" o t s ii Oil � d I -ZI Z 75 t i f i 4 a { A r M 4 ; v / r MAR-14-2006 14:31 KILROY -AND WARREN 15087757526 _ P 01f11 C0MM0NW1;111.,1'II t,)1?MA,S,SACHLISl:—l'S EXLCUME OPIPICE OF E NVIIt(INMENTAL Ajia IIItS ' DIt P AIn'Mr,,N7't)j� UNV1I[t3NM1'31q°I'AL FI,tU'I'II;CTION a; t 10PICIIA►L IMM"EC rION APORM -NO I' FOR VOLUNTARY ASSIr"S411�LNT SUBSURFACE SEMAGE DISPOSAL SYSTEM F0 11M PART A GIJI�'I't�'IGA'I'ttlN Property Address; � �1 � 1, l..- S Owner's Flame: Owners Address. i _ - bate of lrrxpextlon: Name of leraprclor.(pleaie prliri) Ctrrtillan}'Altlttece (J 'I clrirhanr f�unrbt t: -'OU-716 CEIx' -IFICATION s jr VrEMEN_'r 1 ecniry tltat 1 havc peFSOM111y 412117eeted01c 4c%vvgc dialrasnl system et ihie address and dint the inforntalion reponvi below is true.aeeurntc And complete ris or the bone orthe itl9l,ecti0n.'rhe inspe tlott eras ncrrurmcct based oil my training aid experience in the proper Atttetrvrt and malutenaucc oron site seivo r dispasul systems.I an,a VLP approved Mlem iospertur pernu»nt to,,5actihn 15.340 of'ritle 5(310 CAIR The s,YSccm: Passe g C:nndilit+nnll�V hassca _ Ntrxh Furthcr I:vniuptiun hy the Local Apprcvfig Awharily Fails Inapecler'S Sk vatttrs.. Date: ( � ci 'Mtc system impvc(or shall submit s copy or this insncctlon rcl9ort tt)titc Aplsrvving Aurharity(I)ayard�,f 1 l�hts or DfUP)within 30 days orcotttpleting this insptotion.Irthe sniem is a shared syslctir or has a+icsigu now or IU,000 -_-- igpd ar greater.dtc in3pector and tie system 0MIcr$11,111 submit OWreport to tilt nppropriatc rrgivnal oftcc yr ilic _ _ . . •1'.?lac origloiRl S)oeutrf Eic sent tb lltC SySlr:tit owner anti copies�ttet trr ihti�1ryLr�'Tf slipTtai�ie,rnd tht:�IY�ov9gg ' --- .. ;lUtltsrri(y. Notes and Gnnt,ncins •**'Thfv rrlrorl only tics ribas can flint. This inspectionsloro ual ntl wider the tl$lslht7ry loci oyrtt•m will izre rt rym inctbr!tttrrM un�dl110S OF tlororsttnresc t that vmdl l ipg qP USc. i Title 5 lrrspettitm 1•"tfrrn d/131W0U0 - p,�c 1 r MAR-14-2006 14:31 KILROY AND WARREN 15087757526 P.02i11 r ` lrngc 2 yr 11 E l SP 0 i;[v-'sS'v135URVAc SkAG POSALa�SiE,1,j 1NEC1 1 ORnj PART A CaNlt'I'1llriCATION lettmitnicih Pruperty Address.- 1)slle or 1n.I'vetitln:_ [nzlpcctltan`FUlnntsry: creez�k n,rl,rr,l>err k:l ALWAYS'rnmptc(o all ur SeTtIolt 1) A. eSySleva )'asses; �•�.1 havc m,t rpunel tray htrcm mOun viuelt b►dic,9tts 111111 ntty of ilte failurc Criteria described in 110 Chllt lS,3tr]ur in 310 CMR 1.5.304 exist.Any raiiurc critcrtt 11111 avalulned arc indic,aled below. Comments: It.� .1,F, m te f �rru9)iNan,trla•f�,�,�rar� r One yr nmorc system Cullilipncnti as tlescriilyd in lire"t;t,ezJitiona!i'ast"i t' rcpalred-711t:syst Uptrrt eunt(tli tins or the relrtpselneut err rclotr�r,as sillttvvCtl ion need tp be rcubecd t r Y Ure 1391rJ of i~lcalth,will pass, uz t yes,no or not drtcrreliricd(y,N,tVI explaill, �)In tht` fur tic t9flinvine 5lalcmenis. If•'ltot ifmmlineV laicise c�tpl , 7',a septic laths exhibits sull:ita nu3U11 nad vvcr 20 years aide unsnulld '31 Of llle septic taf,k(wileiber lnctal or nett)is structurally 1111tz1 initllration or Catrjllratioll or talik rallpre is itlimil it.System will pass hispection irthe eAlslin$tank is replaced with a canipiyfag septic tank as aNllrtrvrJ by the hoard arl lealelt. 'A dletal scptir A will pass inspection it h is s1111ctuMily sound•not leaking alai ira Ccrtiflcatc orCiitrtpliancc indicating that the ttmk i$ Itss tluntl 20 years old is nvailablC. ND c/xlylaiu: �.✓ observotina Of sowagc backup or,brcak 0114 or high static%vatlevel 06atructcd►ripe(s)or due to a broken,Stilled or unt:Yett diSlributiou box $y$tof i 'lie 411 i tri60021SS box i tuib dite-to broken or amtovai orpoerd ofileahh); brukCn pipe(s)ere rt gamd tabstrut:timll 6 mfitove tribtltion btl"fevded orizplaccJ N1)catplain: The system required pumping more thail d times 9 year due to brokcii or ubstructet!pilm(s). The syst t11 will pass i"speeNva ir(whii nri,rv,z!Of the Voard ilrilcaltlr), broken i11pe(s)arc emplaced Obatrtrction is retttvvcd NO explain: z MAR-14-2006 14:32 KILROY AND WARREN 15087757526 P:03i11 Paht 3 or l l OFFICIAL INSPECTION voiyvi-rwr FOR VOLUNTARY ASS,CSSMENTS SUBSURFACE SEWAGE I?ISPOSAL SYSTEM IN4PEC;TIOT4 Po]tM PART A C:,F'RI-11Irlt*;AV'iON(euntirmtQ? Proprrly Address: Owe4r pale of in laian: - i:orther Evaluation Is Required by the lluarvl pf llealltl: _ Cunditiu:ts exist which requirc further cvaluailtitt by the Iloard or 1leal►11 In order to detennine if the sysicln is failing to protect pURC health,$1lfcly of tilt etrvilvilusent- 1, $rllaw will peas unless Ittlnrd of IIcaltlt dairrmiues in eccurdnttec 1sit11 310 CMR 15.303(1)(b)that lbr system Is"at fagc(lunhtg lu to Innnncr Which will jlroleel public hrallh,safety and the environmen(; Cesspool or privy is within 50 reef Afar Aurrucc venter -� Cess"OF privy iS within all feet urn tbt rdetinb vegctatctt wrtland or a sah ntarsll 2. SyMent%v111 fall ullieas the Ban"of Ilealtll(11141 Public Wstcr Sulrlttier,if any)drterlullies that(lie trystcm(S fgnctiaplp in a fnpllfler that pt•vlstts the public heelfh,safety and euvlrarimcut; The system has p seplie e211k atut mil absorpiicrtt system(SAS)altcl the 5A3 is within 100 feet of a surface Waler w rply or tributary to a surface water supply. The sysittlr lilts a septic ta►rk vild SAS mid the SAS is vrl(hin n lone 1 *[a putllk water supply, 1 1e Mtctn has a Scptic tank and SAS rued 1114 SAS k vvidun St)reci of a privalc water supply well. "he syslem has a septic tank mid SAS and dic SAS is less Ill-all 100 feel but 50 feat or more front a rrrivaic water stipple well",Mrthr+d used w tictonlline tiislance *0111is sysical riasaes irthe well water annlysit,llerrvnned fit ft IVP ec"iPcd latporatat7,far colifortq trtlt:tcria ohd volatile organic cornpounds iitdieates(hat the well ie free 00M Pollution korn that facility mid [Ile prr-$cncc of dinmonia nilrogen and nitrate nitrogen is equip to or less Man S ppin,provided th81 Mt Other failure crilcria am 164gered_A cony of the t111aly3113 must be attached to dila roan, 3 Other: ... _.. - - - .--- ......--...... — MAR-14-2006 14:32 KILROY AND WARREN 15087757526 P.04i11 F P#v•1 fir I I OFFICIAL INSPECTIoN yOJtM—NOT pelt VO LUNTARY ASSESSMENTS St►IiSURFACt SEWAGE 1)ISPOSAt.tiYS'I'N M INS1'I;(:1-10N JCC)ll m PART A CI��#t'1-fM�iCA`I7f)N(at,rnintrttll 1'r'trperty gddress: Owner: �.....�_._. Vote of ino ctinrl; f7_ Sysleai Failure Ctlrerin nplillcaiilt to all syttentA: 1'vu ust Indictitc«yes^or"no"to c,acli ul'thC ft11I(rwinl;tier all iusiicl'liuiis: Yes N IZ flackletx ofSCWogc 111to facilily or syAlcm eonilmllenr(1(10 111 uvel'hintled or l ssxpgol cbarge Or poil"T Of emircrit(n the surface t)rtiie ttrowi()ar murrase wnter$d,c all l SAS vv�s),drJ or Clogge(i SAS or eossimo! �. c3s 'hylrid level ill file dts,i'lliUttpil lSpx ab(,VC oullct it}vClt(IIrC 19 all QVcrloadcd Or C1099C4 SAS or ccasplipol Liquid depth is tes"ol is loss than 0"WOW inverl fir available valtntle is less tlhfill y,day flow Required 111,mping 111Lyra than 4 lilacs in lift last teat I t VQj of tunes p(fniped ,t C I(y rl(,i,gc(t or obstrat;lcd pipcM,Number �. Any port of tl,o- , Any lyu cesspool ur privy Is Ww1w high ground eater cicvetlptl, r rtion edn of CCUPoal or privy is within tOU ftcf orn surffiec~valet supply or tributary tea surface ► alcr StrpJAY. s ` - k Any pvfiitln ore et;spirol or privy is tvitliln u 7,tirrc i ufA politic�vct1, �* „� Any portion of a cesspool or privy iS wlllfin 50 fcct of a private water suirply well. AnYporllon era ccsaiiopot or privy is Ices t11nr1 i00 rest trit greater than 50 feet from a privarc w.Ilcr Simply well tvith no aetept$ble Water(lunilly Allillysig, (Tills SyRtcrn Passts if the well Walk,-tanalysls, irt'rfortnetl at a DEP ceniffc(l labvrgtory,fur colifernt bacteriq load volatile organic c0111119und3 ludicates that lilt well is free rrurn pollnllvn from(hat rucility and it►e presence of rirrimonly flltrtrgrn Rlld nitrate nitrogen Is equal to or less than"blink,provided that no other(allure critcriar are triggered. q cupy of the analysis tmrs(be i(ttached to 111115 fornl.1 711t Mien,jam, 1 have determined that site or(pore or Ilse;ttypvc r►lllurc criteria exist as cribrd in 7 10 CMIi 15.303,tlfererare file systems fills. Tiie system owner Should contact die Board or health to dcicralinc wltal will be"C"M50ry 1n correct the roliure, L Large Systems- Top lye copsldered a large systeln tilt$y&tetra 111110 AErvc a rltt'ilily with a design 119w Of 10,ggt)Clod to 15iopo d You mast indiealc chllcr"yes"WIWI to each of the fbilowiag: {'rite foliowing criteria airply to large sysle,e)s in u(idid(yr►tv Ute ctitcriti a(iuvc} yes lop . the gystcni is tvithin dt1Q fact ore surfhcc drinkillig twitter supply ^_the systC11 iS Within 200 teat urn trilwtary to a surface drinking water supply the systertt is loafed In a nitrogen Sensitive firm(11110ri 11 Welylcad PrafcCtipri Area-lMIA)or a mapped one 11 ar®public•vmcr supply weft ll ywf haYC pMStverod"ya3-t0 arty t111C%tiun in$Ccriun E the systt;eti is C(nlsidcrCrl a sigttitelotft direst,pr aifStwcreJ "3,cs in section 0 above the large 3y%lctn has riiilcd.7'he otvttcr or upcttttir of any large SCAM(1111CM,C0 is c>+11 a sigiliflcarit threat under Section Ir or Ailed folder Section t)sliali upgrade file systen,In cccvrdalue with 310 CMR 15.304-T11C syslenl Invncr shv(lld t:OH14ct the Aliprpitrlete regiynnl ufflce or the I?epantnent. 4 MAR-14-2006 14:32 KILROY AND WARREN 15087757526 P.05i11 Pagel of I I OFFICIAL INSPECt`ION IPOPM—ND'r F01t VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE I)1SP0,5AL SYSTEM INSPECTION DORM PART 11 CHECKLIST Property Address: Owner- >Uatc tr(i1t ccliats: ,� Chcrk if the ralkiwing have bccn done.you ntn.l ltrdicMI:" cs"Or"it)"a8 to Melt orllte falJnwln ; Y No Pumping ioformadofi was ptvviJccl Uy the atn►cr,ncett}►xnt,nr�taard oC!Icvlllt tf/ Were any of the System romponcuts humped out in the prcvlr,us nvu weeks? Has the System rccciv0d fmnnal flows Ili(lie prcvious twQ week licriod r/ ✓ I lave large volumes of water been introduced tt►(ht systct►t recently or as part of this insjwrtipn? Were as built pinrss orthc systetri oWvil1Cd and examined?(Irthey were not available nolc at NIA) Was the facility or dwelling inspected ray sigm orat:wnge back up V/_ Was the site{psricc(cd for slggs ttrbrCak nut' I/ Were all system epmMientg,culuding the$AS,Jvcawd on sits - Were the uplic tautk manholes umvverc►l,almocd,and the intrriur of dtc tank inspected fur the condilion ortltt:baffles or lees,materini orconsimttion,dimensions,dertli of liquid,del►tit of sludge anti depth of scum? _ —,"/— Was the facility owner(and octupahts if different from owner)provided wltft iuranitation an Me profit r maintenance of sirbsurP,ce sewage dispoul%y4lcros:'? The size mad location of tht Sail Absarptlun SYstent(SAS)Oki(Ftc cite has teen detemtluad bau ed*A: yt: nu _ existing Information_For example,a plan at Ilse ueaw ur i leallh. betermined in the Ctcid(if any or the roillrrc criteria related to I'an C is at isxuo approximation of distance is unscceplablc)()IQ CMIt MAR-14-2006 14:32 KILROY AND WARREN 15087757526 P.06/11 4� i r 01TICIA►L MpEcrm FORM—NOT I FOR VOLUNTARY ASSESSMENTS SUBSUIMACE M-WAGJ; DISPOSAL 5�'S'I'I{M XNSI'LC3'tpN l~�OItM PART G F SYS-1 ,M 1NVORMA'1.J(: M I`rnnerty Atldress:��� ,��. r)atc#alas crlt$n; It�SrI)LN`l°IA r, i<�.t)�t,�`�,ci�tt)rrlulvs Number or bedrooms(dcsfga,).. Ne,mlrcr oncnd+oursrs(actrtal); DESIGN liow based on 31t)CMIL!5.703(far ex;itnpic: 1!q glnl x 1!nt ltcdr~xkm5). Number urcurrent reslllet►L%: t 0C.-t Ics!<kllce have It l trrbaic l_t�ifwer(yes or no): Is 17undry on a selrarnre sc%vggc sy_1lcnt()(CS pl flay):-�_� (!Ives sclr>+rrite inspcctivl4 rr[luirCd) I.nundry systom inspetltd(yes or anal): Scas011a!Ilse:(yes or no); Watcr meter readings. !f available(last 2yc;rts usn(;c Surnll pluttn(Yes or 1+0): Last date vrgctlryj,ncy.. Ct)MMMICIAL nNI)U 'iTypttht., rk-0 "flooir"obrlsl1r:fenG l7cslget ll�.tY(tla9e4 on 31 Basis or dcs?V fkw SCnts/ (• t�►suutrfsyft,ctc.); Grease trap ltrescrlt(yes yr tndtlstrlal waste hulling tvnk)IrcScnt (Y cs Or r Non-snni r y w -•• � astc discha r ctl 1 the ' +) tlic Water net 8 T sy.�tefn(yeS tr fu . rchitin $s, rlavalla(s14, fS 42.Ot? py 4v QGj 1_•0(lyric or ticcupancy/ugc: �,���'"��, r (TPI it<tt(describ{); Pulgping HVCQf41s GENCHAL INFORMATION St7UfC@UIItlfdrtlt�U(llr; �_,r.-l�/�y+w Was 5ysterir)lumped as[Ittet or the inn ccti _�!!r1, .4�,pt►+N` ,�J'ULj. P on(yes ar Its). _ jr yes,vale trumped:,.,"�gOHMS--1.10%�Was qusnsity Utintpcd dcicrtninctl7 Rmun tut pumping: 7'YA O!r MTEM LL -,G SOPIrc lm*,dlstribtrtierl Vax,soil absUgltiun systclrt Siugle ceectlool overflow CCSapaOl Njvy Shalvd gySrcul(yes or 110)((ryes,aitreh previous inShe4ltUrr recurd9, if,,,y) _InpcvaOYe/Allerrmative lechnology,Attach a cypy erillc currenl uperatigll ynd 111*tentrl1ce Ctliltratt(to be Obtained train System Owner) Tig(rt.t,'rnk —Allach a copy of d►a J3Cs)'nttlnY,vaf Other(describe): _ Approxi"Inf0 age 17fall cornpOnGnfs,dale irrsfeltad(ifketewri)and 6errrrte utry,forma4iun: WCM 50-080 00M tfciccted►whoa Arrlvlrrs at fl,c sire(Yvs MAR-14-2006 14:33 KILROY AND WARREN 15087757526 P.07i11 OFFICIAL iNS!'EMON FORM—NOT I,Ui( VOLUNTARY ASSESSMEN'M �SUDWRFACG UWAGE 01S1't 1SAL SYti')FAI INSPECTION FORM 11A10'C - SY�'11'Irl��( (l`tl'C)fti�'IA'1'If1N{�t�tltinurtt) Properly Addrem t?►Yl►cr: -_ 1tUtl 1)11'1(;SEIYt;Ii(lucnte on site plan) Depllt below gratle: Materials pf evnsfruelion:cast iron AQ I+V(' other(r.aptAitt): 170umcc IMin private water supply wclr nr"tictit0l lint•; Cantrneats(oil WHO ion of jvinis,venting,evidence of Icahag,tic.): Mvric TANK: +!{locate CHI site Itfitin) Delith bcluw grade: 1 Material of cpnatruceiutt: uncrele . metal 11l+crgln4t Iwtyatttytcnz [flank in metal fist ege:_- _ Is age wi+ttirmetl�t►y n C'ertitic:nte{+i'C:uuyrlinnre�(yra e+r+try); „(r+nael►,ropy of ccrtificale) 011imnsion3: b , Sludge deptll: Distance fro+n top of sludge to bottom of chic,we yr _- Sculn thickness: y nistancs from top ttfecu+n t4 to,.,of outlet tee t,r wimj>if t1 Distance Irvin builuni of scum to Ito�t of outict ice ur ltollic; I low►verC dimensions detentilned: Conmtenis(on pumping reepatmendgllo 9, Inlet nneJ t+uclet Ire or tsatlte con+litio+e,stntctuml hake-rity, lkluld laveib as r letted 10 ottilet inrce.cviticttt a of,lcakn rc,etc.): LAM Cr qAaj'V VL A&AA" aue,�. c�vea GREASK TRAP:.,,,,, •(I=te on site plait) Depth below gmcle: Malerfat orcpnstruction: concrete tttctal Cltergtass_ IMdyetltyrcnc _ _outer (explain): „_-- w...., -- MIXICtts10111t: . . .+;um Ilticknt:$g; Distance 0oin top orscam to top ofouttel tee or ImMc; _..., Uistattec(IxNu bottom of Settut tp ttOttons csf tuagcl lair ttr ttattle:� Date of UST Pumping: _ Corr+menft(oA pumping rrxa..v,+c»r)atioris,iltial nrui rwttel Ira 1rr crime rc}+rtiiaitvt,-oniclurei imcgrily,liquid 1cr"els as relator to vUtltt lr yvm evidence oricskage,cio: 7 MAR-14-2006 14:33 KILROY AND WARREN 15087757526 P.08/11 OFFICIAL 1NS11j:C:1.jaN PORM NOT lt()lt Vo l,UN-1'ARY AS,SIf;;;5tV1>;iY_ (Jll 'ClltlrACJ Slr.tiYA(ilr, 1)1,SPO-SAL SYSTEM INSN;f-11(7pi Fo lth.1 PART(': 5Yti'1'EM 1Ntrol(NIA-I'I()Ntefustirtuctll l"roperty Atltlre:<s: a �_ A,tte of Itts Tertiuo: 'I'M T or 11pW)lNQ TANK: (fiink nttr tf be pnttll+cd m ifnrrr tnr etlrt+ccrltm)(tncate pit slic plan) bcpdi bclply Vdc: Mnterial UPGan�truttitm:�,,,t:tinGrcle_. . �gttlal , •.,..(FhcrGlass. , ..tn,h-r-tlrvit►re� ,..,.aftirr(c.claL-riill: �fll►AClfry: •—.+-. .,.�. •..l{LtlltrllS "�....,...,_ ....�_, 1Scsi�lT F�it�.r: • .•. r 111{Nt}/�lii�+ Alami prescftt %. - � ._i•� /Ugtirt Jcvcl: _ Alarni in Workiti n ititler Ome of last pinit�in�r;_ Cvca ttr uti}; Corrpnallta tn+.+aNffarn aP«1Anu n+fd lissnn Nsrlir;6nr;.Ct+.): VINTRIBUTIorl ljoX;Y_(if prescig 11111Sl Jrr ullt`itetl)(lttctrte i�1 C11r plan) VgAlt of(iquit)icvci Abcvc untict if)vcrt. + _ Commeills(rTp1e Irbpa is icvcl and di5[rllntfttnt 10 Wtlicis ctpial,in)+cvidcnec ftf 3viitla c7rf)vvcr,ant}+c vidcttec of laaka c iiftt►or Otis of bD.N,c1c.); )'Vftll+C11011)F.1t: (lucatc,oil 3ilc plan) hifnllrs it,working orilar(Yes or no): Aldnns in Working ortler(ycs or uo)., Coirttttcrtts(110tc egntlit;on of puiltp d1711 bcr,comJ11i9n of lnuutpc arltl yPlTurtcTtatitcts,ens.); P, MAR-14-2006 14:33 KILROY AND WARREN 15087757526 P.09/11 risc9orrli OFr+1CtAL INSPECTION FORM—NOT FOR VOLUNTARY ASSMMENTS SUDSVRFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0Ft M PART C SYSTEM INFORMATION(viniint:ett) Proptrty Address: owner: Date of in eatton: SOIL ABSORPTION SYS11M (Pliaatc vn Rite plan,sreavatiun riot tcquttctt) !f SAS not located explain wlty; Tyre lettthing pits,number: I (P b6 teaching chambers,number: ieachlog galleries,number; 1Caching trenches,number,lenpllu _---lCuEbing(ie*numb",dimensions_,." ovcr(]ow CeMpool,number:_ —tnnovativdailicrnativc systcitt 'fypelnonle of tcchnalogy: _ COMInews(noto Condition ofsail,signs ofhydraulir raiiurc,lcvci trf tRmding,dmnt+iail.condition of vegctartotf, etc. : •r .1— , - CE'SS OOLS: cesspool'ntust be pumped Pi part orh�)(t(tsttC Ulf site ptan) Number anti conflgtiratiVn_ Depth—top of liquid td inlet invert: Depth of solids layer. Mpth of scum ipyer: Dimrnsions of cCSSjfobl: - Matcrials of constructlort:_ Indication of grpt wwitler inflaw(yes or no): Conmrems(note condition of soil,signs of hyttrauitc titilure,level of"wing,condition of vegetation,etc.): Materials of construction: Depth ofsolid9: Can-fonts(note condition oPao 1,sl—gns olllA.aulic failure,level orimaing,condition arvegesotion,ere.): 9 MAR-14-2006 14 33 KILROY AND [BARREN 15087757526 P.10i11 vagr to4rli ' OF ICIAL INSPECTION FORM -1401'Jr-t?I( N'0J,VM'ARY A5SCSSMrM-,,5 SU13SYJRPACB SI;wAcr VISPOSAL SYS-17.M INSPECTION F011M i'A HT C 8VSTEN1 INFORMATION(r��ntin�►epT I'rvnortr AAdrt$s- 440,2$ 7 Owner, Date Of In.licrfi1m.m e_ $Xr"t'CII OIL SPWAM DISPOSAL SYSTEM Provide a Actch of ilia setvar disposal systcua tncjudilix tics to at least In s�tt�ym�ncn!1 CrcrrllCe IaruhtinCkS orb t^ne(tnlarks, [.static all wells mlitl►in I(l()Poet, I't►ratc�ufttr� +ubtk +a f l mcr f+ipltty Cnicts tI1C Uttifcfiltg_ ,JDA A OAAC. Z45L J � dam" � � IQI f 3 33-3 ♦ 3 53' MAR-14-2006 14:33 KILROY AND WARREN 15087757526 P.11i11 lagctiorli • , , .0FIFICIAL IN.NPEC ION FORM—NOT FOR VOLUNTARY A$SES31v ENTS 5UJ3.5URrnCr SEWAG 1a18110SAL SYS'J'I,M INSPECI'IoN F0101 PART t:• SYSTEM1(VI'OR MATION(crMilintiad) Property Addnast 7 Owner: IMIR of In eetiba: l - sari,cxAm Slope Surrace water Check cellar Shallow wells �eirnaird dctilli to grottnd ranter 11�rrol Please indicate(dick)ill rodhods used it)determine tlrc high gr(nintl water clevution: _Obtained from aystein design plans on rccon'l-If checked,dwe o(ftsign pin„reviewed;_ `Obscmd silt(abutting pmperty/ubwyatiert hole witllie, 150 fcol of SAS) Clic-eked with local Board of I Icalth•expttrirt,»-�-�_ Checked with local cuavalors,installers-(attarlt da�vrucrrtatio yT`w�-� Accessed USOS dalabase-explain; -Cjd.( C&4ry . YOU most describe how yvu cstabliAcd[tic high ground water r1tvaiion, II TnTC1 O 41 McKenzie, Marybeth ` V From: McKenzie, Marybeth Sent: Wednesday, May 16, 2018 1:22 PM To: 'Richard tinory' Subject: RE:Jimmy's ice cream back storage area flooring Hello James Needham and Richard Tinory, I conferred with my colleagues because the specifications states" light commercial use and residential". The problem with these floors being used in an area that requires a lot of cleaning and water use is that they tend to buckle and are not a clean washable surface. This floor surface will be allowed with the following conditions: *No food prep will be done, only storage, in the area that it is installed. * If the floor buckles, at any time, and becomes a non-cleanable, it will have to be replace with a smooth washable flooring. If you have any questions please contact me. Food may not be bnsite during the construction time and a preop inspection must be done after the work and before bring food on site. Please refer to the check list that was given to you last year. Regards, Marybeth Mackenzie R.S. From: Richard tinory [ma i Ito:tinoryconstruction@hotmail.com] Sent: Wednesday, May 16, 2018 10:08 AM To: McKenzie, Marybeth Subject: Jimmy's ice cream back storage area flooring Hi Mary Beth please look at the technical data it says commercial warranty 5 years in the product is the newest on the market and supposably is waterproof 100% and anti-microbial Sent from the Check for Hotmail app i ifeproo i� TECHNICAL DATA SHEET . .i . h . ...• •� .•- -,y,. Construction 6.5mm Gauge/6mil Wear Layer—Multi-Width Plank Extruded Vinyl Core 4.Omm(0.157")Rigid Core i Top Layer 1.5mm(0.059")LuxuryVinyl Tile(LVT) Pre-Attached Undedayment 1.0mm(0.039")HDPE with Ultra-Fresh ! Use Light Commercial&Residential 3 SizesAAridths: 1 Size 4.25"x 47.64"(108mm x 1'210mm) 5.59"x 47.64"(142mm x 121Omm) 9.84"x 47.64"(250mm x 1210mm) J Wear Layer Emil(0.15mm) E Edge Detail Square Edge i Urethane with Enhanced 1 Finish Ceramic Bead(ECB)&Ultra-Fresh Embossing(s) Natural Timber,SawcuY Gauge 1 6.5mm(0.256") s Pieces/Carton 9(3 Pieces per Size*3 Sizes) E Varies with Size: 4.25"x 47.64"(108mm x 1210mm)=1.406 Sq.Ft.(0.131 Sq.M.) Coverage/Piece 5.59"x 47.64"(142mm x 1210mm)=1.849 Sq.Ft.(0.172 Sq.M.) 9.84"x 47.64"(250mm x 1210mm)=3.255 Sq.Ft.(0.302 Sq.M.) I Coverage/Carton ( 19.53 Sq.Ft.(1.815 Sq.M.) � l Limited Warranty 5-Year Light Commeraal/Lifetime Residential , Standard I Description Requirements Results ASTM E648 ( Radiant Panel(Critical Radiant Flux) I Class I:z 0.45 W/cm2 Passes Requirements ASTM E662 Smoke Density Flaming&Non-Flaming<_450 1 Passes Requirements ASTM D2047 Coefficient of Friction(Slip Resistance) N/A z0.6(Dry) ASTM F970 Static Load $ ±0.005",250-Lbs.Load Passes Requirements SIM Test Static Load Limit ) Test to Limit 1 2t5001bs. ASTM F2199 Dimensional Stability <_0.020"/Linear Foot Surpasses Requirements ASTM F925 i Chemical Resistance No more than"Slight Change" ( Surpasses Requirements ASTM F1514 Resistance to Heat Average&Max DE<8.0 ; Surpasses Requirements ASTM F1515 Resistance to Light Average&Max AE<8.0 ( Surpasses Requirements ¢ ASTM G21' Antifungal Activity N/A I Top:0-1;Bottom:0-1 ASTM F963 , Heavy Metals Refer to Standard Passes Requirements ASTM D7823 I Phthalates Refer to Standard I Meets CPSIA Guideliines Standard Description i Class 1 Class 2 Class 3 __ _ Class 4 Meets (Residential) " s (Light Commercial) ; (Commercial) (Heavy Commercial) Requirements Section 3.2 Thickness Swell 518% :516% k 516% :512% Classes 1-4 Section 3.52 Large Ball IR >800mm/31.5" - , >1,000mm/39.4" >1,200mm/47.3" >1,400mm/55.1" Classes 1-4- Section 3.62 f Small Ball IR >200mm/7.9" i >200mm/7.9" >350mm/13.8" >500mm/19.7" :Classes 1-4. Section 3.10 Surface Bonding 1 N/mm2 s 1.25 N/mmZ 1.225 N/mm2 ( 1.5 N/mmZ Classes 1,,,4 a Effective:July 11,2017 Page 1 of 2 (866)843-8453 1 homedepot.com TM M I ifeproo TECHNICAL DATA SHEET Standard € Descriptton Requirements rResults. ASTM E90&ASTM E413 Airborne Sound Transmission Loss i Sound Transmission Class(STC)z 50 STC 59(Surpasses Requirements) � ASTM E492 8 ASTM E989 LImppct Sound Transmission Impact Insulation Class(IIC)>_50 IIC 65(Surpasses Requirements) 1.J.:1r►sJ OFIN • ,. _ Standard(s) ' Description FloorScore® I This product is FloorScore®Certified (SCS FS-02874)and has thus been found to comply with the volatile organic compound CHPS 01350 (emissions criteria of the California Section 01350 standard. Footnotes 1) ASTM G21:Top Surface(LVT)and Bottom Surface(Undedayment)scored 0-1(No Growth to Traces of Growth;0-<10%Growth) 2) NALFA Sections 3.5&3.6:Tests for Impact Resistance(IR) Ultra-Fresh is a registered trademark of Thomson Research Associates,Inc. Effective:July 11,2017 Page 2 of 2 (866)843-8453 1 homedepot.com