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SUSTAINABLE
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Certified Fiber Sourcing
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art , Town of Barnstable BOARDOF HEALTH
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Board of Health Donald A.Gaudagnoli,M.D.
= ■,ARNn, ADLr- F.P.(Thomas)Lee
+Ass. Daniel Luczkow,M.D. Alt.
'b i539. 200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 94 Issue Date: 01/01/2022
DBA: HYANNIS TRAVEL INN
OWNER: HYANNIS TRAVEL INN LP
Location of Establishment: 16 NORTH STREET HYANNIS MA 02601
Type of Business Permit: CONTINENTAL BREAKFAST
Annual: Seasonal: YES
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: $30.00 YEAR. 2022
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM:
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
Continental Breakfast Only!
�tMME rq� For Office Use Only: Initials:
Town of Barnstable Date Paid 3 3a
: .nxrrsr►BM Inspectional Services
' ' `0� Public Health Division f heck# �'►�6�
pTED Mfd 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 �3 )9 f 1 7-- NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: N Y A J /S / 4 4k4l,
ADDRESS OF FOOD ESTABLISHMENT: > G - 1 _8 N OILfk 57- 4 YAWN , o )l (j.L 6 W
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): / U N /-7/A 02,60
E-MAIL ADDRESS: I r 01U A 6 4A P 9_ <C
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YE>S NO__�/.-(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION:L/!/1 t'TO 1 / 30 /
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
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a
OWNER INFORMATION: /
FULL NAME OF APPLICANT A r, n n y wJZ 6j N pp
SOLE OWNER: YES/rQD D.O.B 6 !6 6V OWNER PHONE # S-0 �.[� ` U y�
ADDRESS 9_ L A {:C' V i(C c,/ Adis l Cr N` lt V 1 LC. /�l� O Z 3
CORPORATE OWNER: ®1--1 n A w A 6 f A,T 1 1v G CM 1 ),jA 6l N 6 PT6
CORPORATE ADDRESS: f /M 0 A 01 S j' A/-/A lu 1✓/ 5 t1 A
PERSON IN CHARGE OF DAILY OPERATIONS: d G/rt'r T[I AiNI"6 S
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
1.
2.
�2-jfnv� 3 / 9
SIGNATU 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.asy.
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.315f each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FonnsTOODAPP REV3-2019.doc
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OpiXE r TOWN OF BARNSTABLE _ HEALTH JNSpECTOR's Establishment Name: �+^f�) � 'J"`�Q-\ - �n spate: C� Page: _ of '
BARNSTABLE,O` 200 MAIN STREET 1 3 n30 4:3FRP.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 4 OFFICE HOURS
PUBLIC HEALTH DIVISION, : 800 ,9:30"A.M.
MASS a Verified
,e3v:ae� HYANNIS,MA02601 4 No Reference.. R Red Item PLEASE PRINT CLEARLY-•_
508 862 64
'FDN1P' FOOD ESTABLISHMENT.INSPECTION REPORT
Date o ns ecti nName - T
Address Risk ood Service' Re-inspection
Level - Retail Previous Inspection
Telephone Residential Kitchen Date:
- Mobile Pre-operation
Owner HACCP YIN Temporary Suspect Illness
III
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other . .
Inspector S' Out:
p
Each violation checked requires an explanation on the narrative page(s)and a citationofspecific 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) ❑ r-
Action as determined by the Board of Health: -Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food`Employees and PIG ❑ 14.Approved Food or Color Additives
{❑ 3.Personnel with Infectious Restricted/Excluded ❑ 1.5. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved'Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating -
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling.
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control i
❑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
M 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good'Retail Practices(Blue Itemsl Total Number of Critical Violations -
Critical(C)violations marked must be.corrected immediately. (blue&red items) Corrective Action Required: [] No Yes `
Non-critical(N)violations must be corrected immediately or .. I.
within 90 days as determined by the Board of Health. Overall Rating ❑ Volunta Qom fiance ry• . p ❑_Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction.Based on an inspection' day,the items ❑ Embargo [],Emergency Closure El Voluntary Disposal _ ❑ Qther;
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-.2)(590.003) This report;when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3-non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation' (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
B=One critical violation and less than Orion-critical violations g
25.Equipment and Utensils- (FC-4)(590,005) cited in this report may result in suspension or revocation of the food if no critical violations.observed,4 to 6riori-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-establishrnent operations. If C=2 critical violations and,lesg than 9 non critical: If no critical water,sewage back-up,
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a.hearing. Your request must 9 p,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 8rion-critical violations: If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7 590.008 g violation,4 to n-Critical violations=C.
29.'Special Requirements, (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: Inspecto re Print:
31.Dumpster screened from public view:
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
a�"
#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* 11 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B)_ Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unipproved Additives* 19 PHF Hot and Cold Holding -x
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 590.004(F)
7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other*: 7-102.11 *
Common Name-Working Containers 3-501.16(A) " Hot PHFs Maintained At or Above 140°F*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
Applicants* - 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or M 7-202.11 Restriction-Presence and Use* *
p° ty3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions*
3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
o 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155'F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate
Equipment*
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* ege�rme 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*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs ESPECIAL`REQUIREMENTS r%
3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009 A D Violations of Section 590.009 A
Chemical ( )-O ( )-(D)in cater-
Sources* Ratites-165'F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11 C
Game and Wild Mushrooms Approved By ( )(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
* 2-301.14 When to Wash* * Other 590.009 violations relating to good retail
590.004(C) -Wild Mushrooms 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec
3-201.17 Game Animals* 17 Reheating for Hot Holding 11 Good Hygienic Practices practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3403.11(A)&(D) PHFs 165'F 15 sec*
3-202.11 PW's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* .3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30)
3-202.15 Package Integrity* g g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the odborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3 403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140'17 to 70'17
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F hem Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained*
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2. 003
5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
.
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance
Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices
(J) 9 9 27. Physical Facility FC-6 .007
j Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 009
3-502.11 Specialized Processing Methods*
30. 1 Other
3-502.12 1 Reduced-.Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical Rem in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical Rem in the federal 1999 Food Code or 105 CMR 590.000.