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DOWNTOWN BISTRO - CLOSED FOOD
DOWNTOWN BISTRO N7 13 - N STREET HYANNIS,MA. 02601 ✓ BOARD OF HEALTH Town of Barnstable John T.Norman Board of Health Donald A.Gaudagnoli,M.D. ¢AMNSTABLL F.P.(Thomas)Lee,. '$ s 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 663 Issue Date: 01/01/2022 DBA: DOWNTOWN BISTRO OWNER: SUNNY BOY INC. Location of Establishment: 372 MAIN STREET HYANNIS„ MA 02601 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 92 OutdoorSeating: 64 Total Seating: 156 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - MOBILE- FOOD: MOBILE- ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: OIL- Town of Barnstable Office rpk� For Oce Use Only: Initials: _ �. a Date Paid t oZ Am1 + BARN STABLE Inspectional Services g3 9 MASS. Check# Public Health Division Thomas McKean, Director ({' 200 Main Street, Hyannis,NIA 02601 l "I Office: 508-862-4644 Fax: 508-790-6304 / APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE /� L4 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: c.—vt ADDRESS OF FOOD ESTABLISHMENT: ,?7 Z � /� �� f�G`�►h�,� :�i MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 02 Grp G yr h l-s E-MAIL ADDRESS: 41 e�L(/ TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ) W? TOTAL NUMBER OF BATHROOMS: WELL WATER: YEES NOS ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: _,S�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)? S TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) c/FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING... (CATERING NOTICE.REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FornlsTOODAPP 2020.doc OWNER INFORMATION: ss�� A X FULL NAME OF APPLICANT �!�V' [5/�4-4-1'V16 SOLE OWNER: O D.O.B ' Z��� OWNER PHONE# � ADDRESS V 1-010W s��.1h LS CORPORATE OWNER: ►YyU / LPG/ `�/ CORPORATE ADDRESS: y�il -7 -7 � oZh PERSON IN CHARGE OF DAILY OPERATIONS: Jr�lic� GAGC List(2) Certified Food Protection Managers AND at least(1.) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date I. �rl Ia— M46A-ell Y Z- /Z 5- SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments, including mobile bucks 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.1owiiotbarrrstable.ns/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Pen-nits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION('S)AND REQUIRED FEES BY DEC 1 St. Q:\Application ForinsWOODAPP REV3-2019.doc i + BOARD OF HEALTH Town of Barnstable � John T.Norman Board of Health Donald A.Gaudagnoli,M.D. Paul J.Canniff,D.M.D. 200 Main Street, Hyannis, MA 02601 F.P. Thomas lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 663 Issue Date: 01/01/2021 DBA: DOWNTOWN BISTRO OWNER: SUNNY BOY INC. Location of Establishment: 372 MAIN STREET HYANNIS„ MA 02601 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 92 OutdoorSeating: 64 Total Seating: 156 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q,� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r' s. For Office Use Initials: TMETp Town of Barnstable �!` Date Paid' G�.�Pd$30� BARNSPABLE, : Inspectional Services �. - 1639. `` Public Health Division Check#1aa� prFC MAC a 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*40-?-d NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: n whc 5 f yz� ,7 ADDRESS OF FOOD ESTABLISHMENT: �v� ✓7'l�/h Z5 ��n'�S MAILING ADDRESS(IF DIFFERENT FROM ABOVE): l E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: �OUTSIDE: CD TOTAL: 640 SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LI ENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REOUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? �1 IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) /FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc 'f OWNER INFORMATION: FULL NAME OF APPLICANT � ' SOLE OWNER: /NO D.O.B "Z,-/—G 2-OWNER PHONE # d `� 2��✓���G� ADDRESS CORPORATE OWNER: --/-7V',y7 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 1. 1rl4n 7/ 1. p/`l�i� �� � l 13 l SI NATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments, including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC Ist. Q:\Application FormsWOODAPP REV3-2019.doc I - ; �pIKE Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. ®� E Paul J.Canniff,D.M.D. e , 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: 663 Issue Date: 12/10/2019 DBA: DOWNTOWN BISTRO OWNER: SUNNY BOY INC. Location of Establishment: 372 MAIN STREET HYANNIS, MA 02601 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 92 OutdoorSeating: 64 Total Seating: 156 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office Use Only: Initials: Town of Barnstable Date paid �� Amt Pd$ I BAW .,B,E, . Inspectional Services MASS. Public Health Division check# � Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 fig APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE���LL1� NEW OWNERSHIP RENEWAL L NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ,2 J / l'y /V` 40,4e3 E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (Oki - TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO>0 ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_ SEASONAL: DATES OF OPERATION:_/_/_ TO 9a 1 NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST. COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** 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 4 OWNER INFORMATION:,�� FULL NAME OF APPLICANT I I�►=D(��J �LlavL(/� / SOLE OWNER: q NO/ D.O.B OWNER PHONE# ADDRESS yX1,1-1t'►4S CORPORATE OWNER: CORPORATE ADDRESS: `TU L ✓J 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. Y must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date c 1. - 2. Al SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asi). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:Wpplication FormsTOODAPP REV3-2019.doc rtA Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. " Board of Health Donald A.Gaudagnoli,M.D. BARNSTABLL John T. Norman "A F.P. 200 Main Street, Hyannis, MA 02601 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: I Permit No: 663 Issue Date: 03/01/2019 DBA: DOWNTOWN BISTRO OWNER: TIMOTHY GAUDETTE Location of Establishment: 372 MAIN STREET HYANNIS MA 02601 Type of Business Permit: FOOD SERVICE Annual: Seasonal: YES IndoorSeating: 92 OutdoorSeating: 64 Total Seating: 156 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - - MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: .-- 4 0i ME ro�� For Office UsOnly. Initials; i Town of Barnstable LoBIs:Pai J � Amt.Ed$ BARN6TABLE, Inspectional Servicesoc //�� ��r� � V`� k A1FO Mph"� Public Health Division Check# Thomas McKean,DirectorO� 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 i APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: ?-2,2 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: �!�'� �ZCd! G-� �Con— TELEPHONE NUMBER OF FOOD ESTABLISHMENT: .2`7- -77C6 TOTAL NUMBER OF BATHROOMS: . . o WELL WATER:YES O ... (ANNUAL WATER ANALYSIS REQUIRED) � SEASONAL: DATES OF OPERATION: / / TO ANNUAL: .�._..� } NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: Zy SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ,s i a ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST I3F APPROVED BY THE HEALTH DIV,AND LICENSING_,_AND MEET OUTSIDE DINING V REQUIREMENTS. : IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CHECK ALL THAT APPLY BELOW TYPE I'ESTABLISHMENT: (PLEASE ) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) k BED& BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING... (CATERING NOTICE REQUIRED BEFORE EVENT(SEEPAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL,MOBILE &NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED@ Q:1Application ForniAPOODAPPMV2018.doe i ¢A k i �i PLEASE CALL 508-862-4644 OWNER INFORMATION: i FULL NAME OF APPLICANT 6 ce SOLE OWNER• YES -NO D.O.B ? (,�—OWNER PHONE# ADDRESS S:2 7Ve / CORPORATE OWNER: -J 1122 I/AMDERAL ID NO. : CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS:Certified Food Protection Managers AND at least 1 Allergen Awareness Certified Staff List(2) Cert � ( ) g f 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 ler en Awareness Expiration Date z. rit,,'7 SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** k SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile hocks must be inspected by the Health Div, prior to openinul! 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. i r 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:/hvww,townofbarnstable,us/heaItiidivision/ai)piicatiolis.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited, TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. 1 1 NOTICE: Permits run annually from January Istto Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC I st. t r III I Q:1Application FormsTOODAPPREV2018,doc i i E `pp iME row TOWN OF BARNSTABLE HEALTH IWSPECTOR,s Establishment Name: Date: v Page: of. PUBLIC HEALTH DIVISION OFFICE HOURSs:00-9:30A.M. BARNSfABLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified a3 v. �0� HYANNIS, MA 02601 MON.-FRI. No Reference' lk-Red Item PLEASE PRINT CLEARLY prfD MP�a• 508-862-4644 _ FOOD KSTABLISHMENT INSPFECTION REPORT fl Name Z Date T e a of I s ectio �+ °�,M era ion s o4ne �ls �C✓' C- A% Address Risk ction P 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 Ak In: Other Inspector Out: ; r Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. 4 Allergen Awareness 590.009(G) �l lo FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands Li !is'l ii 1.PIC Assigned/Knowledgeable/Duties - ❑ 9 9 ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS, �J ❑ 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(F /�r;!((r��y `y�� I f ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures `-' o`. �" V I L( ems ❑ 5.Receiving/Condition ❑ 17.Reheating - ( 5 " 1 ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling s ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding J (�y PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) It - ❑ 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 yl Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations���• ..JJJ lJ_J Critical(C)violations marked must be corrected immediately. (blue&red items) ^ ^.1 Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating mil!✓a within 90 days as determined by the Board of Health. lid ❑ 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 b a Board of Health member or its agent 24.Food and Food Preparation p g y g A=Zero critical violations and no more than anon-critical violations. F=3 or more critical violations.9 or more non-critical violations, p (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils B=One critical violation and less than 4 non-critical violations 9 (FC-4)(590.005) cited in this report may result in suspension or revocation er 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 )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. { 28.Poisonous or Toxic Materials (FC-7 590.008 9 = Y 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8non-critical violations C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N I v` #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* * 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information_Original Containers* 590.003(C) Responsibility of the Person-in-Charge[0 Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 7-]02.11 Common Name-Woiking.Containers* 2 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 7-201.11 Separation-Storage* 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 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* z 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 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed Sprouts Not Served* 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 TrackingPowders,Pest Control and p 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1 g 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 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 37401.11(A)(2) Comminuted Fish,Meals&Game Pathogens* eg cnwc iiuzom 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* - Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 37201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and a ide in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004 C Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( ) practices should be debited under#29-Special 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding 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* 2401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercial -Commercially Processed RTE Food 140°F* (Blue Items 23.30) 3-202.15 Package Integrity* Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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 * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 5-20511 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* . , Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S: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. o`TKE roh TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of 1 OFFICE HOURS BARNSrABLE� PUBLIC 2 0 MAIN LTH STREEET 3:30-4:30 P.M. DIVISION � : 0- :30 A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MONHYANNIS,MA 02601 508-8 -FRI.62-0644 No Reference R-Red Item PLEASE PRINT CLEARLY 8� FOOD ESTABLISHMENT INSPECTION REPORT Name Dateg yoe of T sec' n p outin Address Risk oodSe mod-- ens Level etaifT I 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 In: Other Inspector Out: r y 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) ❑ C Action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS (��J ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives �J ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardo s 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 - 1= 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: ® Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined b the Board of Health. Overall Rating Voluntary Compliance y y ❑ ry ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today, a items ® Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal F d Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils FC-4 590.005 B=One critical violation and less than 4non-critical violations g ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 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 o la hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of ( )( ) 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 Snon-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N 1 #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Anature ` Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N ��)j �p B � 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* L 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* g7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* P g Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* q Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual 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* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical 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 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Eggs 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 ctwe 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 ui * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source Equipment* Pment 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 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) Commercially Processed RTE Food-140°F* Blue Items 23-30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* B) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F 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 I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °p IKE,°� TOWN OF BARNSTABLE _ - HEALTH INSPECTOR,s Establishment Name: 1p /n'w+��l Wn fSf�I _ DaterIt/ 11AP Page:_�of ti OFFICE HOURS 7� PUBLIC HEALTH DIVISION 8:00-9:30 A.M. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified •BARNSfABLE. 200 MA IN STREET MASS. MON.-FRI. ,639. v Mn+°0� HYANNIS,MA 02601 soe-as2-asaa No Reference R Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT r :E3 AA Name / lrb Date n Tyoe of Ro section Address ^n Risk (Food Servic Re-inspection m� v 1��� �^ Level Previoy1pt,on GTelephone Residential Kitchen Date: ,Mobile Pre-op Owner HACCP Y/N Temporary Suspect Illness e a '' Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP E' _ In: Other tol` \ Le Inspector vj J sn Out: f P v n 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) ❑ Ale- Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ c FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 6C bf 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 iq ]EA E FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) V a ll ❑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 .VY� ❑ 11.Good Hygionic Practicos ❑ 99 Pnstin0 of f:nnciimar AriviSnries Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations �1 Critical(C)violations marked must be corrected immediately. (blue&red items) I'I Corr Clive 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. `V�'.1-d' 6Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on a 44inspection today,the terns F] Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management.and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical, results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 9 if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27..Physical Facility (FC-6)(590.007) aggrieved by this order,you'have a right to a hearing. Your request must 2 Water,Plumbing and Waste (FC-5)(590006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less thari 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 vi to observed,7 to 8non-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. v` lation, o on-critic I violations=C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: Ins or's Sign t e Int: 31.Dumpster screened from public view _� dl VI �. S ✓1 - Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert-Machines: Outside Dining Y N PIC's Si ature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N t S"Ci- r , Violations related to Foodborne-Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F)- EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 7-102.11 Common Name-Working Containers* 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance 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 Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004A-B Compliance with Food Law* * 3-801.11(D) Raw of Partially Cooked Animal Food and ( ) liance 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 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg cd-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 cy 4-703.11 Methods of Sanitization-Hot Water and StuffingContainingFish,Meat,Poultryor 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D).in cater- - * Ratites-165°F 15 sec* in mobile food,tern and residential Sources 10 Proper,Adequate Handwashing g' temporary Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special KE Eatin Drinkin or Usin Tobacco* * Requirements. 5 Receiving/Condition g. g g 3-403.11(A)&(D) PHFs 165°F 15 sec3-202.11 PHF's Received at Proper Temperatures* Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23.30) 3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F12 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 riskfactors listed above,can befound in the g Tags/Records:Shellstock . 4(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs fallowing 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 • Ma nagement and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Mana 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 9 of Ingredients* Labeling In * Supplied with Soap and hand Drying Devices 590.004(J) 9 - 27. Physical Facility FC-6 .007 Y tY 7 Conformance with Approved Procedures/ 6-301.11 1 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 1 Hand�Yin Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* s 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. opVE roh TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: / fD Date: 2k2sia Page:_ of OFFICE HOURS i pRN�rAe�Eo PUBLIC 0 MAIN STREET SION 8:00-9:30 A.M. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ,HpSG, g, MON.-FRI. 'gyp ,e79.a e HYANNIS, MA 02601 508-862�644 No Reference R-Red Item PLEASE PRINT CLEARLY 'FOM FOOD ESTABLISHMENT INSPECTION REPORT F--� Name Date T e LDf oftEIEMbspection !1 l� a'p RoDow! u' f Address Risk Food Service e-inspection n � r Level Previous Inspection Telephone Residential Kitchen Date: N�- L, . v Mobile Pre-operation c Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Char a(PIC) Time Bed&Breakfast HACCP 0 N, C t �� ` In: Other C 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) Oft C4 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 JPA EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved food or Color Additives W�SA, 4 Q-e- ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals I 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) Cor7 ctive Action Required: ❑ No es Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. 4 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 4non-critical violations 9 )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t F is scored automatically lack of 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 la 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations obs rved,7 to 8non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violati o non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspec is Sign re Ph 31.Dumpster screened from public view 11 , A14 ��W& U V'r1 w- Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N / #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC'S ure Pri nf Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N J--- I b ^ Q r Dumpster Screen? Y N r- 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 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.* Protection-6 - - 19 PHF Hot and Cold Holding. 2-103.11 Person-in-Charge Duties - ' '- 3-302.14 om 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 * -- EMPLOY 590.004(F) Other*EE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*7-201.11 Separation-Storage* * 2 3-501.16(A) Hot PHFs Maintained At or Above 140°F 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* - - 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 3302.15 �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 * ( ) 9 590.003(G) Reporting by Person in Charge*- 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR, 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g � ) Disposition of Adulterated or Contaminated ----- - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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 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 1 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. 10 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 Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 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 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 g. 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) 3-202.15 Package Integrity Y 12 Prevention of Contamination from Hands '-� Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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 WiUrin 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* 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. °FiK rE TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: 01t!V+4-PvJ^ �;J f� Date: -5 /0 Page: 1 Of _ 1 OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. 6ARN57'ABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified � MO -FRI.HYANNIS,MA 02601 sos-8s2-asaa No Reference R-Red Item PLEASE PRINT CLEARLY rFOMrt FOOD ESTABLISHMENT INSPECTION REPORT dd {Su„U 1 U ^� 0 vpr Name Date Type of Type of Inspection x. ( 777 . Routine JI ! - Address n/� - Risk Food Se Re-inspection y I b 04 3 71 'Y`N� - 'd � Level a trevooperatus Inspectio rn I� VL v u It Telephone Residential Kitchen 1'��1 f. { { , )15 r Mobile ' Owner (\/'l (� HACCP YIN CateTemrer General Complaint p I Person in Charge(PIC) Time Bed&Breakfast HACCP , t In: Other Inspector; S Out: ,,t G 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) ❑ �( (� �v Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands G ❑ 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 p• ❑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 S C- ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling Gil f r ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) , Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ 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 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxic Materials. (FC-7)(590,008) be in writing and submitted to the Board of Health at the above address violations observed, to anon-critical violations. If 1 critical refrigeration. violation 29.Special Requirements (590.009) within 10 days of receipt of this order. , c itical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's ignatur Print 31.Dumpster screened from public view VVj 4k"-- CAVI) Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Si ure Print_ Self Service Wait Service Provided Grease Trap Size Variance Letter Posted - - Y N Dumpster Screen? Y N V _ Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F Applicants* * 7-201.11 Separation-Storage 20 Time as a Public Health Control PP 3-302.11(A) Food Protection 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11) Variance Requirements * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rated or of Food Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 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-Immediate is sec Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* PP Y Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* effe cri�rurzoor 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 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 Arens* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. * 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms practices should be debited under#29-Special 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding 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) Commercially Processed RTE Food-140°F* Blue Items 23-30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 8 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 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 Cabello 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. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 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. V a i TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: A1 'I rl Date: _ d- Page: of , 1 OFFICE HOURS P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSrABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified mAss. q MON.-FRI. �A t6 O 00 HYANNIS,MA 02601 - 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'F01AP` FOOD ESTABLISHMENT INSPECTION REPORT L--r, C Name f Date S d Tvoe of Tvoe of InspectionDAIALA l g Routine r C, v 4 r v Address / Risk �1 Re-inspection /_ A. ��� Level Retail Previous InspectionA-(,),), (R Telephone Residential Kitchen Date: O Mobile re-o erati !/ Owner \T A' HACCP Y/N Temporary Iness ` ` Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP 09 ;.r In: Other Inspector uv� J Out: WL( f t �( J t r n/� Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from.Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities t EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives e ❑ 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 '", tl� ` �'� f ❑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 �1 Overall Rating within 90 days as determined by the Board of Health. `Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled f ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal F] 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 9npn-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. within 10 days of receipt of this order. viola' non-critical violations=C. 29.Special Requirements (590.009) Y P 3 .Other DATE OF RE-INSPECTION: Inspe or's Si a r Pymt v 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: (,I�� Outside Dining �� N PIC s Print: Self Service Wait Service Provided Grease Trap Size �U:Variance Letter Posted Y N Dumpster Screen? Y N a-�uj -33S -7- Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to � 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and 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 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 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 1 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 Not Otherwise Processed to Eliminate * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Equipment 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meals&Game Pathogens* Eg crNc mnom 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) 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 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-40 1.11(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 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 foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * ( )13 Handwashing Facilities 3-202.18 Shellstock Identification 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. J YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. 0r DATE: Z Z 1.6 Fill in please: �. 9Bt j APPLICANT'S YOUR NAME/S: - BUSINESS YOUR HOME ADDRESS: �'T�I���f -� / tooTELEPHONE # Home Telephone Number NAME OF CORPORATION: c5v1ji1!,j NAME OF NEW BUSINESS TYPE OF BUSINESS t'5r���h I IS THIS A HOME OCCUPATION? YES NOX ADDRESS OF BUSINESS -'!ll MAP/PARCEL NUMBER (Assessing) .¢ 566 /"-"A >t When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. _ 1. BUILDING COMMISSION 'S OFFICE This individual has bee in r ed of a er t re uirements that pertain to this type of business. horiz i n ture* COMMENTS- v I 2. BOARD OF HEALTH This individual has bee infor d of the ermrj�quire jen that pertain to this type of business. I G A th ri ed Signature 'J COMMENTS: v. vi V -t- r me� (,or ✓yin 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: No. ® Fee r �•a"yZ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: e� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01ppfication for Dizpogar 6potem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 37Z el-M tS Owner's Name,Address and Tel.No. Assessor's Map/Parcel qt Innsstallller's Name, Address,and Tel.No. Designer's Name,Address and Tel.No. J '3 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title — Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) .�i�4Z— GY 6K Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 f the Enviro ato!�d not to place the system in operation until a Certifi- cate of Compliance has been issued by t oard�f a Signed Date 2 - Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued -- — -------------------- -- 'I Feie 4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppficartion for �Di000ar *pgtem Con.5truction Permit 1 Application for a Pemut to Construct( )Repair( )Upgrade(V)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 37z g11A Owner's Name,Address and Tel.No. Assseessor's Map/Parcel n JCA 37_ S rJ CJ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. IZ �G 7RE�T� G/� M/lRsrG�S /�zCL S Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of<Building Rfif AMA.#- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets - Revision Date Title — 0 Size of Septic Tank 5W,96Z T&10 Type of S.A.S. Description of Soil # L'Nature of Repairs or Alterations(Answei;when applicable) J16�Az1_ Qmg Q1' /g u { 12L 7 Date last inspected: Agreement: , 4 The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5A the Environs a o d not to place the system in operation until a Certifi- cate of Compliance has been issued by t s' oard of dal Signed ` Date S 9!1,/ Application Approved by Date 01 Application Disapproved for the following reasons, i.— r`„ Permit No. Date Issued ————— ——————— ———————————— —————— C' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned )by a 9y6*_ at 7.2 Z?2 /& has been constructed in ac ordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�©1— 7 dated r 7� �f` Installer Designer 1� The issuance of this veimit shall not be construed as a guarantee that the syst ,ll fun�c+tio design Date S a .� Ins ector / 9 No. IJcJ(l 3�0 , �F _ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lizpozar 6p.5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(4/f Abandon( ) System located at 7•2 A-7/9//V G'n it 1 S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of tlrigp—ee i Date: +oZl-�f' Approved by I " 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR DISPOSAL y WORKS CONSTRUCTION PERMIT.(WITHOUT DESIGNED PLANS) hereby.certifY that the application for dispo sal works construction permit signed by me dated -Q t , concerning the property located at ij7� / l�Y meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system Y There are no private wells withiri 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation..[Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S.will be Iocated with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not.be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the followinb: A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation +the MAX. High G.W. Adjustment . _ DIFFERENCE BETWEEN A and B k SIGNED : DATE: �� [Please Sketch propose plan of sys n ack]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cent 1 .� . .-�� :�- .. Y O O 1�LL �Q. G/�uo� G�'.�C �I ,. fk mks aft L3�1 TOWN OF BARNSTABLE x QC LOCATION t 7� ! '. �flG SEWAGE # 41— VILLAGE ASSESSOR'S MAP & LOT I Z�� I — � INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE''DATE Separation Distance Between the: J Maximum Adjust Feet ed Groundwater Table to the Bottom of Leaching Facility Private Water Supply.Well and Leaching Facility (if.any wells exist Feet on site or within 200.feet.of leaching facility) Edge of Wetland and Leaching Facility(If any we exist; Feet within 300 feet of leaching facility) Furnished-by .. ` to L � _ 0 JAN-7-2015 14:55 FROM: TO:15087906304 P.2 AG 04-Aebeatoc Romw 4 Notific:Won Form ANF-001-Trandattion#71249D Commonwealth of Massachusetts 1=21274RI Asbestos Notification Form ANF-001 Asbestos Project Number Project Revision Notification Project RovlOm 1(� Project Concellation IPrO)8Ct atl�ttdd A. Asbestos Abatement Description 1. Facility Location, IZOU,LLC Name of Faulty Street Address `HYANNIS __- •j MA - 2601 Wit-341-7408_ ----� Cltylrown State Zip Code Telephone Instructiaru 1.All Facility Contact Person Name FacIty Contact Person Title mriarns of this loan WOrksite Location: ASEM�NT must be completed In auiltift Name,Wing,Floor,Room.etc. ardor 16 comply with Mam=-P notlficallon 2. Blanket Permit Projoot Approval,if opplicobic: � 1-0quirertimrga of 310 Approval ID k CMR 7.15 and 3, Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Oepaftment of Labor ltrmnrrMtal,IfJ,il v Standards(OILS) 01/12/2015 r�p 1/1212015 _ notification requirements Project Start Data(MMIODIYYYY) End Date(MM1DD/YYYY) of 453 QIVIR 6.12 Work Hours-Monday Through Friday Work Hours.Saturday 8 Sunday MassDEP Use Oniy =T ; B. Other Project Revisions: Date Receivod ..............:.. ..-- - .._. — i 2.Submit Original Form To.Commonwealth 01 Massachusetts ------•�.....,...,w._.,,.®_r.,....M._�.- W...�. , Asbestos Program P.o,Box 92W87 C. Certification Boston,MA 02112• "I cent that l have ----- - --- -- -- -- -- tfy personally examalad 0087 bra foragoa,y and am familiar with the Name Authorized Signature information contained in this document: LVP_.-,_.._— and ptl al�chmQnt6 and thdt,based on ._..................-.-- _..,._.............P•,,.....,,.....—..--- Note:'temporary my inquiry of thwo individuelt3 Posltlon/Tlde Date(MMJpp/YYYY)_--- storage,ofAsbestos immeftely responsible for obtaining the containing waste Information,I believe that the Information Telephone Representing material i;only allowed p �SJVy1E - ------- --- - E �true,accurate,and complete-t am --� �,.......,J at the pace of business aware that thorn are significant penalties Address Gity/Town of*a QLS licensed for eubmitli ft false information,inotu&Q — Asbastos currtfacicu or possitAe fines and imprisonment.The !MA �2062 --- a transfer Station that is undersigned haroby status ulat I hoQG State Zip Code parmbted by Wai;DFp read the Commonwealth of and operal)l in Ma9SaChugattS regulatkm governing compliance wah Sobd esbeatoa abatement(453 CMR 6,00 Wavle Reguletion5310 promulgated by tho 0opartment of Labor CMR 19,000 Standards and 310 CMR 7.15 promulgated by the Clepartment of Cnvironmental Protection),and that I am Ilt4zJ/wisp,depanass,goyANebForms/AsboatosMW PAN F001 daspz 112 I JAN-7-2015 14:55 FROM: TO:15087906304 P.3 Commonwealth of Massachusetts 100212746 Asbestos Notification Form ANF-001 Asbestos Project# d i ' Ir Project Revision r Project Cancellation A. Asbestos Abatement Description I,Facility location: 2©U,LLC 370-386 I"N STREET Name of Facfllly Street Adrimvp InstrUCtlot�9 1-All HYANNLS MA 02601 6083417408 sections of this form Cilylt'own $te14 zip coda Telephoria must ba completed in 9N�tiE SAME order to comply with INMMP notification Fatality ConW Pow Norris Faciln Contact Person Title requira9menle of 310 Worksite Location: BASEMENT Department of Labor 6utding Name,VVinp,Fi wr,Room,eta standards(DI;s) 2,Is the facility occupied? r Yee r..No notlffcadan requirements of 433 I CMas:12 3.fs this a fee exempt notification (City, town,district,muniel al housing authority,State facility,or p a � ry, ty, f owner-occupied residential property of four units or less)? .r Yes r Nu MaaeDEP Use Only 4,Blanket Permit Project Approval,if applicable: Date Recalvoe Approval ID# 5.Nan-Traditional Asbestos Abatement Work Practice Approval, SubmiJ'OriDltte! if applicable, Approval Ip# Form Ter Commonwealth or 6.AllbCMas Contractor: j Massichusetts AIR WE:INC BIEN=T75TRE`tr Asbsstes Program P.O.Box 12DO87 Nt% Address Soaton,MA 02112• NOROA= MA 02062 7817623390 =7 --- Cityrrown State Zip CAde Teleptimm AC000484 ContTaot Typc; r,77 Written r verbal DLS Licende# i 7. JAIME E AMAYA AS060847 Name of Coruractoee On-Site Supervlsor/Foreman OLS Certiflcation It 8. SAMUEL N COHEN AM060787 j Noma of Project Monitor Ql S Corti iicolion# 9, ENAROTEST LABORATORY INC AA000128 Name of 4bestos Analytical Lob DLS Certification# I 10. 1I712015 1/7/2015 Rroac4 Start Date(MM/DDlYYYY) End DoW(MMIDWYYY) 7AM-6PA+1 NA work Hwrc-Monpay Through Friday work Flours•Saturday 8 Sunday 11,what type of proitet is this? r'` Demolition r Renovation ry Repair I` Other-Please Specify: Revised: I I 113/2013 Page I of 4 JAN-7-2015 14:59 FROM: TO:150e7906304 P.1 Ctimmonwealdi of Massachusetts 100212746 Asbestos Notification Form ANF-001 .- Asbestos�. s Project# 1W Project Revision — Project Cancellation A.Asbestos Abatement Description:(cant,) 12,Abatcntont pruoudures(check all that apply), Fe- Glove Bag r- Encapsulation l'i Enclosure r Disposal Only r Cleanup r7I Full Containment r'-I Othcr-Please Specify: 13,Job is being cnnducled: ry Indoors r- Outdoors 14,Total amount of cacti type of asbestos Containing motcrials(ACM)to be removed,enclosed,Dr a,wupsulawd; so 35 Weer Foot(Un,Ft.) Squaro Feet(Sq.FL) Boiler,Breaching,Duct, 35 Transite Pipe Tank Surface Coatings Lin,Ft. Sq,FL —--^"' Lin,Ft. Pipe Insulation 60 Transite Shingles Lin.Ft. Sq.FL Lin,FL Sq.R. Sptuy-On Fireproofing Tra nsito Ptutels Lin.R. Sq,Ft. Un.FL Sq.Ft. Cloths,Woven Fahtics Other-Plcase'Specify: Lin.FL Sy.Ft lnsulaling Cement Un.FL Sq.Ft. — .. 'Lin,Ft Sq.Ft 15.Describe the decontamination system(s)10 be used: 3 Gh AM3ER QEOON 16. Drsuribe the conwineri22tion/disposol methods to comply with 310 CMR 7.15 and 453 CMR 6,14(2)(g); 6 MIL POLY BAGS 17,For Etrtergency Asbestos Operations,the MassUP and DLS officials who ovaluated the emergency; Name of MaU09P Mal Tide of MawDEP 011ciat Date of Authorization(MMIDO/YYYY) Waiver* Namo of DL$Offi*l Tide of 00 Official Date of Authorization(MM1DblYYYY) Waiver p 18.Do prevailing wage rates as per M.G.L.c. 149,§26,27 or 2,7A- F apply to this r, yw (✓• No projeot'i Revised: 11/13/2013 page 2 of 4 JAN-7-2121115 14:58 FROM: TO:15oe7906304 P.2 Commonwealth of Massachusetts 0021274s Asbestos Notification Form ANF-001 Asbestos Project 0 ' r PreJCCt Revision ff (". Project Cancellation B.Facility Description ..�.. 1.Current or prior use of ruoility: PESMENIMIL 2.is the rucility owner-occupied residential with 4 units or less? � Yes l- No 3,2011.11 LLC 370-3W MAIN 5T PWUty Owner Name —+ R' Addrase IIYANNS MA 02801 5083417406 Glty/Totwn State Zlp Gala Tel� — -- 4.HYANNIS 370-388 MAW ST. Nartt9 of Fatlllty Owner's On-Site Manager Address SAME MA 02601 5083417408 CityfTown tat7(6 Zip Code Telephone ••�«��..T 5.NA NA Name of General Cenlraclor Address NA MA 02062 76176233W CpyrTown •�,�SUOW Mp Cods Tale oie Note:Temporary NA storage ofas Concor•s Warkee C s art lon Insurw Containing waste tml �sa materiel Is only NA 12/31mo14 allowed at the place FVicy# Expiration OaG(MMIDD/YYYY) of bu$inepg of a OLS Iicanssld As4eeW 6.Whnt is the size of this facility? 1000 1 contmetot or a transfer ^ station that to permitted by Square Feet #of Floors op ssDEP a d C.Asbestos Transportation &Disposal wd in vimpliance with Solid Writs Regulations 1.Transporter of asbestos-Containing waste materiel from site of generation: 310 CMR 19.000 r Directly to Landfill or r To Temporary Storage Location/Transfer Station AIR SAFE INC SAME Name of Transporter Address SAME MA 02%2 7817823390 41ty1Tmun Stets Zip Code Telephone 2.if a temporary stnrage Ineatinn/trnnarcr sialinn is used,list name of transporter of asbestos containing waste material from temporary storage locatinn/transfer station to,final dispoca!site: SUNICETRANS se PYLE$ Name of Transporter Address NEW GASIU CE '19720 877999M9 Glryrrown ��� State Zip Code Telephone Rcvised: 11/13/2A13 Page 3 of 4 f JAN-7-2015 14:58 FROM: TO:15087906M4 P.3 Cotmllonwealtly Gf Massachusens 10021274fi IL7 . . Asbestos Notification Form ANF-001 Asbestos Project# I" Project Revision (" Prvjum Canccliation NOW Lwroxi for mugs C.Asbestos Trans ortatiotr&Dis oli4l: cant. Sign tMp'Ionn for pt.9 P p (cant.) nptilihhation purppaoa 3,Natno and address of temporary storage location/transfer station for the asbestos containing waste material: AS SAME Temp*ta;Storage LaGatlon Nam Address $A E MA 02062 7817523300 CityrTown SIatO Zip Code TaIOp a 4.Name and location of final disposal site(asbestos landfill): MINERVA MINERVA Final DISpOetll Site Name Final Uispnnw Site owner Name 9g0Q'MINERVA AOtlrysa WAYN14SBURG U1 46M 1111111111 Cltyrrown State Zip coda 1'dwiKM D. Certification "I certify that I have personally exeminod the foregoing and am OFW familiar with the information Name Authorized Signature Contained in'this dorumant and VP Fill attachments and that,based on my Inquiry of those Poaltlotl/rUe Date(MM/DDryyyy) individuain immediately 7817023300 AS responsible for obtaining the Telephone Flopresenting information,I tiolieve that the SAME SAME information is true,accurate,and Address city/Town complete.I am Bwere that there M4 02062 -are significant ponalli4s fnr ,.r_ submitting false information, State zip Code including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts rogulotiona phverning asbestos abatement (453 CMR 6.00 Promulgated by the Department of labor Standards and 310 CMR 7,15 Promulgated by the Department of Environmental Protection), and that I am aware that this permit.application or notification shall not be dAamed valid unless payment of the applicable fee is made." Revised: 1 111 3/20.1 3 Pagc 4 of 4 't TOWN OF BARNSTABI:; LOCATION a � �'01G , SEWAGE # 1 �3 VILLAGE � �/ S ASSESSOR'S MAP &'LOTI'-1 -on Z- INSTALLER'S NAME&PHONE N0. _8a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �1.VgaG- ,, S .. � t'�,�'' `� E ., �r c t .. l t� � y ��� �� � (�,1 M as ND 4h. An k 0)7-T-71-1 k4,�i4 41, I Fri j `W l �61- 114 i -s �_I GPI Awl { �C�O`ot�rw•; rc I I t r 61lvl� -IA