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HomeMy WebLinkAboutFALMOUTH ROAD/RTE 28 RT.28 CONVENIENCE1675 FALMOUTH RD i x Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. DAMNSc 13M F.P.(Thomas)Lee,. MnS& Daniel Luczkow,M.D. Alt. �y ,634 200 Main Street, Hyannis, MA 02601 °"tea 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: 16 Issue Date: 01/01/2022 DBA: RT. 28 CONVENIENCE OWNER: SWICH CORP. Location of Establishment: 1675 FALMOUTH ROAD CENTERVILLE„ MA 02632 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Uu� \ ` For Office Us Initials: Town of Barnstable Z � Date PAid Amt Pd$—&Lf ,IRMAB,E : Inspectional Services 6 9. `� Public Health Division cheek# � - - �FO MAt 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 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: f �. -2 C6�1�F��i 1 C e- ADDRESS OF FOOD ESTABLISHMENT:_I �S- A, yyN O A A--t' 6LO 0—d , C e--n+-eA V1'f 1 IC — o1 A MAILING ADDRESS(IF DIFFERENT FROM ABOVE): S"A bw e— E-MAIL ADDRESS: t�P M A R FA-T X- O6� Y AH 6 6 . Co M . TELEPHONE NUMBER OF FOOD ESTABLISHMENT: S( �Ok 7-7 t -7-7 C�7� 6 yS 2, r 6-7 ��j TOTAL NUMBER OF BATHROOMS: WELL WATER:YYES NO—)�— ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V SEASONAL: DATES OF OPERATION: / / TO 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) V OOD SERVICE ETAIL 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:1Application FormsTOODAPP 2020.doc ' OWNER INFORMATION: FULL NAME OF APPLICANT is-T-L e-S�� ' A (.2 A SOLE OWNER: YES NO OWNER PHONE # r�4S ADDRESS• oY1—� I G Y,e S "` V 1 ck - nn A — d -s-6 CORPORATE OWNER: CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: —C4 T i <i List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. 6 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.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. Q\Application FormsTOODAPP REV3-2019.doc ag Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. ';STABLE, : 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, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 16 Issue Date: 01/01/2021 DBA: RT. 28 CONVENIENCE OWNER: SWICH CORP. Location of Establishment: 1675 FALMOUTH ROAD CENTERVILLE„ MA 02632 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Qh FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �tHE r For Office Use 0 • Initials: -Town of Barnstable d' Amt Pd$ BARNMBLE, : Inspectional Services Date Paidr ' Public Health Division Check# "I p�ED AAp�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 i e.1 14 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: P-T- -2 8 C o r�Yeyi�r�r Ce ADDRESS OF FOOD ESTABLISHMENT: 1Z C-R km 62e-,,J, 'C"+exy 1 II e- m A - 0•2-C3-2, MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Sri1-Y)e-- E-MAIL ADDRESS: t J PM A R FA`f"i-A e yprH Q(--, • Corn . TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (S'��)'7"7 t- -7-7 41 v TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NOV ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: i/ SEASONAL: DATES OF OPERATION: / / TO 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)? 49 , TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) V/FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT 1-3--L 1,,.e-�S kl e. P1 A PC FA TT-T A SOLE OWNER: YES G OWNER PHONE# A�; o - LI S-i — 9-.2 07 V ADDRESS to r� O 2S--�g .1I CORPORATE OWNER: r3 1 L-:Es N ° CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: QJi<<•-,y 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. k!�)( 2. a-oz ® 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/ai)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC l st. Q:\Application FormsTOODAPP REV3-2019.doc oar Town of Barnstable BOARD OF HEALTH 't John T.Norman Board of Health Donald A.Guadagnoli,M.D. IiARN STAB M F.P.(Thomas)Lee s MAM. Daniel Luczkow,Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 16 Issue Date: 1/1/2021 DBA: RT. 28 CONVENIENCE OWNER: SWICH CORP. Location of Establishment: 1675 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY E i t For Office Use Only& Initials: Town of Barnstable °T Date Paid Amt Pd .nnxsrnBr .� Inspectional Services KAW Public Health DivisionCheck# Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 ' Office: 508-862-4644 Fax: 508-790-6304 t TOBACCO ESTABLISHMENT DATE J. ..t© . NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: P T g , Cc�`n Je Wi ir r c E © �c-an rev4i e M A _ va4l'g-v' ADDRESS OF TOBACCO ESTABLISHMENT: �.0�Sl�a�'YYI c' #... '......�� y MAILING ADDRESS(IF DIFFERENT FROM ABOVE): S g w) e- F E-MAIL ADDRESS: _f M A n f�:A-rX-A A-t o a. Ca T1 a TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: )7`7 -17.Li OWNER'S NAME:41 IeJ h �►M �� � OWNER S PH#( OWNER'S ADDRESS: LI S 77r1 �\h o may. I qr, .i -S �� 1r`P` �� Cyl A - ©.1.5ICS r CORPORATE NAME: SW i C 4 C t' r- i CORPORATE ADDRESS: _�qy-n CORPORATE FID# ftAa17 ANNUAL: v SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS).. S TOWN OF BARNSTABLE COMMA GENERAL.LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https:Hmalegislature,.: ov/Laws/GeneraiLaws/Parilll,T,.tleJCha,ter27O/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 n F SIGNATURE: . , 9 PRINTED NAME: jJ I �? m O+'° DATE:. e e Q:Wpplication Forms\TOBACCO APP-NonFavor 12-18-19.docx { �� . 2,5 Ca'4Vea1�e1►� 'L ESTABLISHMENT'S NAME 9 TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors— .371-9. Sale and Distribution of Tobacco Products.. 1, No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. t The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: tgnature Printed Name Date i Signature Printed Name Date a Signature Printed Name Date Signature Printed Name Date a a Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx IM1119ItcF Commonwealth of Massachusetts Letter ID:L0477255232 Department of Revenue Notice Date:October 14,2020 Geoffrey E.Snyder,Commissioner Account ID:CGL-10519984-007 ,'1 pjre mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES 111�111111 �� 11�11111'I�I1�1i��'ll�l��lllllll�l��llll �ll PATEL/POCASSET CNRTY MKT SWICH CORP ROUTE 28 CONVENIENCE N e 1675 FALMOUTH RD CENTERVILLE MA 02632-2944 Attached below is your Retailer License for Sale of Cigarettes Form CT-3 . Cut along the dotted line g ( ) g ---and-display-at your-business-locations-t any-t-lnie-you-ear-log-intoyour-MassTaxC-onnect accotmt-at- -- mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------- MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 OD Retailer License for Sale of Cigarettes •� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SWICH CORP Account ID: CGL-10519984-007 ROUTE 28 CONVENIENCE License Number: 1258723328 1675 FALMOUTH RD CENTERVILLE MA 02632-2944 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 14, 2020 Expiration Date: September 30,2022 ` tarFj� Commonwealth of Massachusetts s Letter ID:L0525942336 Department of Revenue e Notice Date:October 13,2020 q Geoffrey E.Snyder,Commissioner Account ID:CRL-10519984-010 oF`k mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO r� � i11�IriI �I � � �hmillrn111li� i �i�Iillrhlill o� PATEL/POCASSET CNRTY MKT o= SWICH CORP o� ROUTE 28 CONVENIENCE 1675 FALMOUTH RD CENTERVILLE MA 02632-2944 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut -- along-the dotted line-and-display at-your-bus ries ocsation:At anytime,you can log into your +—` - MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------ S�`"�sF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco a �FNr ok�� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SWICH CORP Account ID: CRL-10519984-010 ROUTE 28 CONVENIENCE License Number: 1538729984 1675 FALMOUTH RD CENTERVILLE MA 02632-2944 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 13, 2020 Expiration Date:September 30, 2022 s Commonwealth of Massachusetts Letter.tD:1.1495601872 Department of Revenue Notice Date:June 2,2020 f§ ' Geoffrey 1,.Snyder,Contmmissioner Account ID:EDI-10519384-013 9, s _OT mass.govldor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS lilt iu PATEUPOCASSET C:NRTY MKT 8 SWICH CORP i ROUTE 28 CONVENIENCE 1675 FALMO(PM RD CENTERVILLE MA 02632-2944. Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along the dotted line and display at your business location. At anytime,you can log into your MassTaxConnect account.at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday,8:30 a.m.to 4.30 p.m. DETACH HE.RX V MA"SSACHUSETTS DEPARTMENT DE REVENUE Retailer License for Sale of Electronic Nicotine Delivery Systems Qs� This license must be posted and visible at all times.The sale of tobacco products to anyone under 21 years of age is prohibited. SWICH CORP AccountID:EDIT-10519984-013 ROUTE 28 CONVENIENCE License Number: 1064617984 1675 FALMOUTH RD CENTERVILLE MA 02632-2944 Ibis certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above.This license is. non-transferable and may be suspended or revoked for failure to comply with state laws and regulations,. Effective Date::June 2,"2020 Expiration Date: September 30,2022 r < 04 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. Paul J.Canniff,D.M.D. 6 !1 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 16 Issue Date: 12/10/2019 DBA: RT. 28 CONVENIENCE OWNER: SWICH CORP. Location of Establishment: 1675 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Ci FROZEN DESSERT: _ Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Ilk 60 s Town of Barnstable Initials: I tI � Iq Amt Pd$— is ,. BARNSPABLE. : Inspectional Services :.4.� E; .a,� Public Health Division Check# Thomas McKean, Director s, 200 Main Street, Hyannis, MA 02601 '` Office: 508-862-4644 Fax: 508-790-6304 ! ' APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 1 I NEW OWNERSHIP RENEWAL ✓ NAME OF FOOD ESTABLISHMENT: (QT• z 2" C6-AVp VN'i em C'f -- L ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): GI-m E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ,(�1--2-5- -72 4 TOTAL NUMBER OF BATHROOMS:_ I WELL WATER: YES NO L"I"... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO 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 V-74RETAIL 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 QA1Application FounsTOODAPP 2020.doc s i OWNER INFORMATION: FULL NAME OF APPLICANT rJ -' 'S� ' Q �1 f�►R �`r=� SOLE OWNER: lam`/NO IOWNER PHONE# ,g '� " 45a—9--2 67 ADDRESS 4 - 5 �"�I (� �1�►1`1 �%r1 �1 `�- S G''1 a� Ws dIN w YYI A CORPORATE OWNER: CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SIGNATURE O APPL ANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/heaIthdivision/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 1st to Dec. 31"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 I c' BOARD OF HEALTH Town of Barnstable John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNSTABLE, Paul J.Canniff,D.M.D. bq 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 16 Issue Date: 1/1/2020 DBA: RT. 28 CONVENIENCE OWNER: SWICH CORP. Location of Establishment: 1675 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 a" Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY • pF'THE Tp� ForInitials: Town of Barnstable p Date Paid Amt Pd$J �J swmvSTABLE Inspectional Services Check# 'b39• �� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE �� 1 `i NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: (-ZT• .2.,R• C 6,sN V e v1 P-v% Ce- ADDRESS OF TOBACCO ESTABLISHMENT: 1 -4 7.S Cl r464tt, C Ile.-"A-6-1493.2— MAILING ADDRESS(IF DIFFERENT FROM ABOVE): S 4YA e-- ' E-MAIL ADDRESS: TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (S4 -7 7 4 OWNER'S NAME: P1 I �'S h gffa i , OWNER'S PH#Q(A O'Z 91a OWNER'S ADDRESS: S`f�''�1 ��h7 S A- A W 1t\f MA - 61•.'Sd 3 CORPORATE ADDRESS: I`7Sl��IrneN� ��. C'e � CORPORATE FID# [ y� �4� ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) iJ 2pr TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: httDS://male2islature.gov/Laws/GeneralLaws/PartIV/TitleI/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: I s� C-A 4s -OL� DATE: 1 / I / 1 �( • Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc I _ ____ Form CT-3T ____ - ----------------------------- Form w�,crtu --- MA DEPARTMENT OF REVENUE. t •y Retailer License for Sale of Cigars and Smoking Tobacco a ��t� This license must be posted and ci18�ears at lof age is pl times. h e sale of tobacco prohibited. ok products to anyone unde Y Account ID: CRL-10519994-010 SWICH CORP License Number: 1825646592 ROUTE 28 CONVENIENCE 1.675 FALMOUT14 RD CENTERV ILLE MA 02632-2944 - his certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts suspended or revoked for to ;ell at retail at the address shown above. This is license is non-transferable and may failure to comply with state laws and regu 1 Expiration Date: September 30, 2020 Effective Date:October 1,2018 t i� i Commonwealth of Massachusetts o Letter ID:L2083676800 a1 Department of Revenue Notice Date:September 4,2018 Christopher C.Harding,Commissioner Account ID:CGL-10519984-007 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES o— PATEL/POCASSET CNRTY MKT SWICH CORP N� c= ROUTE 28 CONVENIENCE 1675 FALMOUTH RD CENTERVILLE MA 02632-2944 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. I DETACH HERE ------------------------------------------------------------------------------------------------------------------------ � SpCHC/g� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes 9 z 01 This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SWICH CORD Account ID: CGL-10519984-007 ROUTE 28 CONVENIENCE License.Number: 2035787776 1675 FALMOUTH RD CENTERVILLE MA 02632-2944 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30,2020 �. �� • Co�fe.�ieYl(� ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—& 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: 1 r O 1 I C,S h . Q' C%'\ Signature Printed Name G` Date Signature Printed Name Date 6k-o" - 1.4 A Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc pF W Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. RARNSUB = John T.Norman Mns5 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems 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: 16 Issue Date: 12/20/18 DBA: RT. 28 CONVENIENCE OWNER: SWICH CORP. Location of Establishment: 1675 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: $100.00 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: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: •pFIKE {yFor OM Initials: ti Town of Barnstable Date Paid OMSAmtPd$ � D� 9BMNST'ABLE,$ Inspectional Services i6 �6 0�_ -b ff 3� �0 Public Health Division Check# U 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 1 9® V NEW OWNERSHIP RENEWAL ✓ NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: -Z- MAILING ADDRESS(IF DIFFERENT FROM ABOVE): :�G E-MAIL ADDRESS: N P rn A e:C—A 1':G A 6 Q Cc M TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS:f WELL WATER:YES NO V ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO 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) VOOD 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) 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:Wpplication FormsT00DAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT jJ -Z L�-S (� dn A(a F A'TT A SOLE OWNER:(�O/NO OWNER PHONE # G 3 o 07 ADDRESS— SY'),vl ov%-r A ® S CORPORATE OWNER: `✓( ® FEDERAL ID NO. : ® �® CORPORATE ADDRESS: I �S , 1 a ne d2® r� �n1�-��i I�t - A - 0 2 PERSON IN CHARGE OF DAILY OPERATIONS: d-3 I l—C�H !�' . C n A-32 F A:T:X�P' 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 L A / / I. 2. SIGNATURE O APP ICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/al)plications.asy. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec. 31'each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:Application FormsTOODAPPREV2018.doc .y�114E}�, Town of Barnstable For Office Use Only: Initials: Date Paid Amt Pd$ Inspectional Services Check# Cash ► sn ?MABLF, 16 a�0� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT �� • sZ � �'m 1'11i�metro�L� ESTABLISHMENT NAME (DB/A) - � 6-7-�;-, (Z-ft i ) C e nvi11 o �-- ADDRESS OF BUSINESS Sege MAILING ADDRESS (IF DIFFERENT FROM ABOVE) ro0:,f t?Fsg-F-Y�A ar-� .iuC--s" , P , � PryA-R �yA+ r*, , 43 u �-►�-�-���� EMAIL PHONE# FEDERAL ID# Do you currently possess a state license to sell tobacco products? Yes � No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form (provided herein). Signature Date Q:\Application Forms\TOBACCO APP2019 dob.docx 5 r ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—4 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the ssachusetts General Laws: Si3iature Printed Name Date ,M lot, a.0r 6142V� a e Printed Name Date ) , Ote2amffie S gnature` P Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP2019 dob.docx y INEo Town of Barnstable Regulatory Services Department MASS.BARNETA Public Health Division i639. ♦0 . A 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL DB/A >S - -�L� m y-�, A-J ce--n +mac If j 11 - CA Oa STREET ADDRESS S`o 1--, -7 7 k- -7 4 TELEPHONE # FID# Do you currently possess a state license to sell tobacco products? Yes V No Each employee who sells tobacco products must receive and understand the Sections VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is rovided_on the next page). Each employee who sells tobacco products must sign th T loyee Signature Form (provided herein). � a I � Signature Date Q:\Application Forms\TOBACCO APP2018 dob.docx TOBACCO SALES TO MINORS PROHIBITED BY MASSACHUSETTS GENERAL LAWS Sales.to Minors — Massachusetts General Laws Chapter 270, Section 6, whoever sells a cigarette, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen (18) or, not being his parent or guardian, gives a cigarettes, chewing tobacco, snuff, or tobacco in any of its forms to any person under the age of(18), shall be punished by a fine of not less than one hundred dollars ($100) for the first offense, not less than two hundred dollars ($200) for the second offense, and not less than three hundred dollars ($300) for any third or subsequent offense. Posting State Law — In conformance with Massachusetts General Laws, Chapter 270, Section 7, a copy of Massachusetts General Laws Chapter 270, Section 6 shall be posted conspicuously by the owner or other person in charge thereof in the shop or other place used to sell cigarettes at retail. The notice to be posted shall be that notice provided by the Massachusetts Department of Public Health. Such notice shall be at least 48 square inches and shall be posted at the cash register which receives the greatest volume of single cigarette package sales in such a manner so this may be readily seen by a person standing at or approaching the cash register. Such notice shall directly face the purchaser and shall not be obstructed from view or place at a height of less than 4 feet or greater than 9 feet from the floor. For all other cash registers that sell cigarettes, a notice shall be attached which is no smaller than 9 square inches, which is the size of the sign provided by the Department of Public Health. Such notice must be posted in a manner so that it may be readily seen by a person standing at or approaching the cash register. Such notice shall directly face the purchaser and shall not be obstructed from view or laced at a height no less than 4 feet or more than 9 feet from the floor. Q:\Application Forms\TOBACCO APP2018 dob.docx w Establishment TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood sections VII b. and VII c. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of eighteen(18). Below are sections VII b. and VII c. of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to. a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file, in the office of the employer and retained. Such signed forms must be made available for inspection, during the license holders normal business hours upon request of an agent of the Board of Health. c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age, the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections V11b. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature Printed Name Date Signature) Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date QAApplication FormATOBACCO APP2018 dob.docx THE Tower TOWN OF BARNSTABLE.. HEALTH INSPECTOR'S Establishment Name: Date: Page:_ ( of ' OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. ]BARNS ABLE, 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 - MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY n rEO MPS FOOD ESTABLISHMENT INSPECTION REPORT 508-862-4644 Name � leC�e Date (( I -Tyne o f Inspection 3 �� t Oneration(s) Routin AddressRisk Foo Service n Level tai Previous Inspection Telephone i ential Kitchen Date: Mobile Pre-operation Owner J HACCP Y/N Temporary Suspect Illness v��IIL Caterer General Complaint Person in Charge(PIC)L J ( ;, Time Bed&Breakfast HACCP Tt � ( 1 `'� In: Other Inspector � Out: !%okj Each violation checked rediuires 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 cL-_ 6 _ EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) 1 ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories \\ Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating Voluntary Com❑ ry Compliance p ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 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 g 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 Signatur , Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatur Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N .. _. ...-`^s..-s�-v`-....��1-+�r.r-..r. •.r-�----. .'--���s...-..._..A-'+�+----'-+-^-"`--t--•.--.-r..-,--..+�-.. .._,i`�..-_..,..._< _ .�..-y.-� .,,r.5.w,..�,�,.s-.+- .. �_-..... �z - - � _.. -..s--•� - - _,r�,� ,:y__�-.. -..�.,� �.. ^-ter-'-'.',-�,...._ i ..__-°----.-,..�----�"•.,+.�.,,•�^""; Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 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 15 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 7-]02.11 Common Name-Working Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.1 l(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 Require Reporting by Food Employees and Contamination from the Environment g Containers* 3-501.16(A) Roasts Held At or Above 130°F* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation 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* i 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 Reared or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE q4-501.111 -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 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 Manual Warewashing-Hot Water 7.206.12 Rodent Bai[Stations * 3-201.12 Food in a Hermetical] Sealed Container* Sanifization Tem eratures* Raw Seed Sprouts Not ServedY P 7-206.13 Tracking Powders,Pest Control and * 3-201.13 Fluid Milk and Milk Products* I -501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* I Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg c""e uuZoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- * Ratites-165°F 15 sec* in mobile food,rem or and residential Sources 10 Proper,Adequate Handwashing g' P Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 11 Good Hygienic Practices practices should be debited under#29-Special 3-201.17 Game Animals* 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) 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 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 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 Roan and hand Drying Devices 27. Physical Facility Fr-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. 1 special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Op THE ro TOWN OF BARNSTABLE p/ HEALTH INSPECTOR,s Establishment Name: `. %7 P Date: , Page: Of �40 , C OFFICE HOURS T PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. ` 200 MAIN STREET ,/��/f�� 330-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. (/"/�V�J MON.-FRI. 'gp .a�9•e.� HYANNIS,MA 02601 508-862-464a No Reference R Red Item PLEASE PRINT CLEARLY 'EDAM FOO ESTABLISHMENT INSP C ION REPORT , Name to Type of Ins ec ion J Operation(s) outine k 11 V I t Address Risk Food Service e-inspection Level e a Previous I Telephone ential Kitchen Date: , Mobile Pre-operati ` Owner HACCP Y/N Temporary Suspect Illness A C�­U y //Q� Caterer General Complaint Person in Charge(PIC) Time Bed 8 Breakfast HACCP Other � t Inspector Each violation checked requir "s an explanation on the narra i e 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 0(6 EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling - ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for H�SP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo Emergency Closure Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when,signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations 9 if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (F6-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a,right to a hearing. Your request must C=2 critical violations and less than 9 non critical. If no critical water,sewage back-up,infestation of rodents or insects;or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-Cr'tical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical viol ons 30.Other PATE OF RE-INSPECTION: Insp is i a re � d t: 2� � 31.Dumpster screened from public view J n Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N (/ #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size - Variance.Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.1-2-.� Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-]03.11 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 Identi in Information-Ori mat Containers* Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C)-. Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge - * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) I 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 g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1](B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.]12 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* - Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effects a 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* quiPment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf of Equipment* Shellfish* - 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(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 Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. * 2-301.14 When to Wash* 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 3-202.15 Package Integrity* ( ) Y Critical and non-critical violations,which do not relate to the foodbome 12 Prevention of Contamination from Hands 3-403.11 Remaining 3-101.11 Food Safe and Unadulterated* (E) g Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 13 590.004(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* Handwashing Facilities 3-501.14(A). Cooling Cooked PHFs from 140°F to 70°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' __ Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28- Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 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 590.00D. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. HEALTH INSPECTOR'S Establishment Name: � r 11 �L Date: , -+ �': t OF TMEi TOWN OF BARNSTABLE .. � � -Page:_of Y OFFICE HOURS : PUBLIC HEALTH BAR E.O' 2 0 MAIN STREET DIVISION :3 - :30A.M. -_ - 304 MON.-FRI Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. g' . HYANNIS, MA 02601 - 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'FDN1P� FOOD ESTABLISHMENT INSPECTION REPORT Name P1+ C onv*9 ;6176( Date /q i e o I lyge of Inspection Operation(s) ou I Address rp �.+j Risk Food Service �675 ����O Abu Level �al PreviousInspection r G� "' V qv Telephone `Residential Kitchen Date: ©��,�/ Qt Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP 11 I(' In: Other r� Inspector Rl' o Out: t, i 1006 am 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) ❑ t Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. . Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or ColorAdditives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and.Food Preparation for HSP n ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories ± IVY Violations Related to.Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) © Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,- 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in.an F. 25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4non-critical violations 9 )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and.Waste. (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) Y p 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view � Permit Posted? � Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap.Size Variance Letter Posted Y. N t Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 15 Poisonous or Toxic Substances 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* 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 * 590.004 11 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 ) Variance Requirements 590.003(G) Reporting by Person in Charge* _ 7-203.11 Toxic Containers-Prohibitions* ( Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR - 3-306.14(A)(B)Returned Food and Rrated or of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * o Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* Equipment 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg cri-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 c 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- , Sources* ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* 10 Proper,Adequate Handwashing Ratites-165°F 15 sec*3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under 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* * (Blue Items 23-30) 3-202.15 Package Integrity g g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* �) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-202.12 Shellstock Identification g Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 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. 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 590.600. of,HE►o,, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: D C l Page: . of . 10 OFFICE HOURS + BARNSTABLE. • PUBLIC HEALTH DIVISION 3:30-4:30A.M. 200 MAIN STREET 3:3o-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. g MON.-FRI. HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTIO REPORT _ Name DateIffType of T sec ion -� outinAddress Risk -inspection Level Previous Inspection Telephone itchen Date: Mobile Pre-operation Owner HACCP Temporary Suspect Illness t Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP 14 In: Other , Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. x Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ / - Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ / ' `; Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ s FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands I ❑ 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 f ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous oods) ❑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 c PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. '� © ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health.. Failure to correct violations regardless of the number of critical, results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than 4 non-critical violations if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. i 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: I 31.Dster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y IN Y y #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI Sin 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* F 8 Cross-contamination 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12' Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* *- PHF Hot and Cold-Holding. 2-103.11 Person-in-Charge Duties 3-302.14. _ Protection-fibru Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Sutistarices 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F)- EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information--;Original Containers* - 2 590.003(C) Responsibility of the Person--in-Charge to - Other* _ 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * - 7-201.11 Separation-Storage* Applicants 3-302.i1(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 _ .Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use*� * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance-Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water-From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(1--)) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-262.16 "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* Eff cti° 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15- Molluscan Shellfish from NSSP Listed Chemical* g g �' 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- ! Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved B 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority y 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 * (Blue Items 23-30) 3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 TagsiRecords: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°17 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 an Placement*d 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3�02.11 Parasite Destruction* oc 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 1 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. �p THE Tpk, TOWN OF BARNS_ TABLE... .. .HEALTH.INSPECTOR•s Establishment Name: Date: Page: of P� ~o. OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30;4.M. BARNSTABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/ N O CORRECTI P ON Date Verified 26s9: �0� HYANNIS,MA 02601 8-8MON -FRi. No Reference R-Red Item, PLEASE PRINT CLEARLY 508-862-4644 A,FOMP,a FOOD ESTABLISHMENT INSPECTIOJ4 R PORT J Name Dat , Pential inspection rz' e One Address Risk ion Level a Previous Inspection Telephone tchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: 71 CA LC"- 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 F­] 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than Orion-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 infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up, 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8rion-critical violations=C. 29.S pecial R quirements (590.009) Y p 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dump er screened from public view 2�6 - Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N I #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: _ Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y - N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Chazge 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 Responsibility P Y 3-302.15 Washing Fruits and Vegetables 7 202•I1 Restriction-Presence and Use* 590.003(F) Res onsibili of A Food Employee ee or An 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*- tensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Pe 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs 155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* gg* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* effec"°°urnoar 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009 A (D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and AutMid Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* RegulatoryAuthorlty 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* 3-401.11 2-301.14 When to Wash* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )ro) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practicRequirements.esrho ld be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 * (Blue Items 23-30) 3-202.15 Package Integrity C( ) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the g Tags/Records:Shellstock 13 Handwashing Facilities 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* 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F K25. Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and MaintenanceSupplied with Soap and hand Drying Devices Within 4 Hours* Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients• 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 m Provision Drying 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. NAME OF OFFENDER r\I i [:.r sh- R rl Pah ca LA- R TOWN OF ADDR, ESSOFO�FF�NDEfl _�n��� BARNSTABLE DI�Y,j Z� +l1 ter pfi rOk, MV/MB REGISTRATION NUMBER � o •9 VAOFFENSe w1ANATANIF. 4`{�o� � I �✓) A V MAS5. �A 1639. �0CD rED MAY�. S-a le OF !V `.1-0 D �l.l�C 1"w-+'� 4o w 7 TIMIJAND,DATE ,'/►OF VIOLLL'ATI �} LOCATION OF VIOLATION �'j�'''�' .A LU Z NOTICE OF SIG TUREOF ENFORCIN6A N P.M.)ON 1 �G 2 ENF16-is wm c-A PA,B AD e-ik-W A-to W VIOLATION „� y o OF TOWN 1 HtEREBY ACKNOWLEDGE RECEIPT OF CITATION X a ORDINANCE 11 Unable to obtain sjgnat a of�f�der. THE NONCRIMINAL FINE FOR THIS OFFENSE IS $100pa Date mailed �1 �� w w OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL LU DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w co REGULATION , You may elect to a the above fine,either b appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, Q O Y pay Y PP 9 P Y 9 Y 9 Yw before:The Barnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, w Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. • (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature I 'awn of Barnstable pFTHE tom,o Regulatory Services Thomas F. Geiler, Director • BARNSfABLE, • MASS.: ��� Public Health Division ArEO�AO�A Thomas McKean, Director 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 7,2006 N. P. Marfatia Route 28 Convenience Store 1675 Falmouth Road Centerville, MA 02632 NOTICE OF SHOW CAUSE HEARING On November 17,2004, and on March 28, 2006, cigarettes were sold to a minor(a person who was under the age of 18 years)by a person employed at your store. According to Section 371-7(B)of the Town of Barnstable Code,no person, firm, corporation, establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s)to comply with these regulations shall be subject to the following actions for each offense: A warning shall be issued for the first offense. A fine of$100 may be issued for the second offense; $200 for the third offense, $300 for the fourth offense,and$300 for any subsequent offense. You are hereby notified to appear before the Board of Health on Tuesday,April 18,2006 at 3:00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss any future plans you may have to comply with this regulation. The hearing will be held in the Town Hall, Hearing Room, 367 Main Street, Hyannis,Massachusetts. PER ORDER OF TH B OF HEALTH Thomas A. McKean,RS, CHO Director of Public Health gAtobacco\wp files\tobacco hearing letter.doc I MAR-28-2006 15:18 BARNS TOBACCO CONTROL 15083622602 P.08i10 Section ><: 19stablishment . -Survey Participants Rout IU�,��WJ Name: a 28 Convenience , 1675 Falmouth Road ID of Porchasm Adds: Centerville.� 02032 Age: ❑ 15 ❑ 16 17 Sex: ❑Male OFemale Name of,.4dult Stg grvisor. TMM of Crack am d pm.Q Type dMstablisltmeat: ❑ Chain'*19Ittdepea Icat O Not Kama Date of Checc Day of the Week: ❑ Mon ATues❑Wed ❑Thms ❑Fri l7 Sat ❑Sun Style of Establishment(Check Only One): Store 04racery Store D Bar Stare ❑ Store ❑Pri =Club .Ix 'am•etc. ❑ Gas station only ❑P Store ❑Restaurant ❑ Gas Muri Mart ❑Other(bowling alley,golf club etc.) ❑Tobacwuisst Section 2: Was Complh mce Check completed?Yes1�—No 0 if Yespleaw candnue on to the nest question,if No please skip dais section and go to section 3. Hbw Was tobacco marketed? $ Over-the-oaanrer_youth asks the deck for the pmdi= 17 From a vending machine with a lockout device. ❑ Other Describe: Was the Purchaser asked for ID? Yes❑ N09' Was this an ID-based check? Yes❑ No it Was the Purchaser asked biiwlw age?' Yes❑ No id— 1`k i&,- eazi-U n Sex of Cleric Male#—Female❑ Agpr =ate age of deck: ❑Teen ❑Young Adult $L Adult ❑Older Adult. - Type of tobacco asked for. i.Cigarettes -Brand of cigarettes asked for. ❑ Marlbom ANewpon p Other. ❑ ChewMip ❑ Cigars ❑ Other Brand: - Was the sale made? Yes$—No 0 If"Yes"how much did the product caste Purchaser made payment using:.e$1 bills C(J$5 bill(s) ❑ $5 bill and$1 bills/or change❑ $10 bill(s) ❑ $20 bM ❑ Change Section 3: If the youth did not earner the premises or did not attempt to purchase tobacco produds please indicate wW— D Out of Business 17 T !M term dosme ❑ In opeMa&closed at tune of visit ❑ Drive thru only ❑ Dods nat sell tobacco ❑ Unlocaw>e ❑ onsat to access O Tobacco out of stOCk ❑ Iuaccdssble tUoulh ❑ Wholesale a /Canons D Presence Of lick ❑ Permit Suspended ❑ Ptnrate cinb/persond ❑ Machine br&M ❑ Youth inspector knows salesperson ❑ Other reside ocs ❑ "Don't sell"but toba=seen in 6/26/06 Q%D0CUME-I=TL%L0CAL5-11Temo1FY 08 MTCP cardprww d iw*fwm•doc i ®way of Barnstable y FSFaE T Regulatory Services /r� of Thomas F.Geiler,Director r Mass �� *4,�39 L.F. Public Health Division FD MAC Thomas McKean,Director 367 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO COMPLIANCE CHECK FORM Es`tablishi Survey Participants Name: Rte. 28 Convenience Name of Purchaser: ,+-.;1 y or ID# Address: Age: l(o Sex: 0 Male K emale 1675 Falmouth Rd. Did a second.person go into the establishment? Yes ❑ No (� Centerville, NIA 02632 If Yes,what was the second persons: City: Age: Sex: ❑ Male ❑Female Time of Check: .> O - am❑ pmV. Date of Check: 12-2'?-0 1 Name of Adult Driver/Escort: Type of Establishment Check Only One IZ Copvenience Store 0 Pharmacy/Drug Phan-nacy/Drug Store 0 Gas Mini-Mart ❑ Gas Station Only ❑ Grocery Store ❑ Liquor Store ❑ Department Store ❑ Bar ❑ .Private.Club VFW,Legion etc. ❑ Restaurant Bar Area ❑ Restaurant Other Area ❑ Other(bowling alley,golf club,etc.): Is this establishment within''/2 mile of a school? Yes ❑ No ❑ Don't Know t& Is this establishment between''/2 mile and 1 mile of a school? Yes 0 No ❑ Don't Know 19'— Is this establishment between'/2 mile of a youth center(Boy's/Girl's Club)? Yes ❑ No ❑ Don't Know Is this establishment between'/2 mile and 1 mile of a youth center(Boy's/Girl's Club)? Yes 0 No ❑ Don't Know Is this establishment within'/2 mile of an outdoor recreational site(park,ball field;etc.)? Yes 0. No ❑ Don't Know 19, Is this establishment between'/2 mile and 1 mile of an outdoor rec.site(park,ball field)? Yes ❑ No ❑ Don't Know AL Tobacco Purchase Attempt: Was the purchase of tobacco attempted: YeskNo ❑ If No,please explain why not: 93 Was the sale made?.Yes YNo ❑ Brand Purchased: m'Ui1 h6vl Price: $ 3. a Type of Tobacco purchased attempted. Cigarettes'Chew/Dip ❑ How was tobacco sold? D�,Clerk was requited to select tobacco-Purchaser req u*ested. ❑ Purchaser was able to place tobacco on the counter. Was the Purchaser asked for ID? Yes 0 No X- Was the Purchaser asked his/her age? Yes 0 No Was there any tobacco advertising(logos,posters or other promotional displays?) Yes ❑ Nok- Were any loose(single)cigarettes for sale? Yes 0 Nok-Don't Know❑ Sex of Clerk:. MaleKFemale ❑ Approximate Age of Clerk: Did the Clerk say anything to ou when the purchase attempt was made? Other Comments: How was the merchant informed of the results of the compliance check? KBy an adult supervisor immediately after youth has/have left the premises. ❑ Notified after all compliance checks were.complete. 0 Merchant was not notified 0 Other-please specify _. . . ,,` -• ,r - .r,` .� .r+_• ti�^. rti...�:r.�»"r'+�,T <'ac- r..H` .,. a w ar.r.'!, sn.. w`.`:ly r°'�'i.w + .�r!'-.. y .- .. ..-f ,.,..r+•. ' TOWN OF BARNSTABLE g =W ' Ordinance or Regulation WARNING NOTICE Name of Offender/Manager-7W ct, 06(p. -DeA 94e 11 Ctpvgr0.C1Pce � r Address of Offender IG e =(tkii L MV/MB Reg.# Village/State/Zip btlqeevdil% ( Business Name roe, 0 W tt r�c..f1 am/ on I '? 20 't' Business Address '! r+ �-'� . , ; Signature of Enforcing Officer Village/State/Zip pk4l r y,11a A MA L. 3 2— Location of Offense i L.:15 13a t Ael EnforcingU Dept/Divis ion 4, Offense g'C k •e In r,V1 j w Facts r(c ;, e.5 1 ! t o t7w, This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. !TOWN OF BARNSTABLE Ordinance or Regulation WARNING NOTICE Name of Offender/Manager5wirl, Nip. L MV/MB Reg.Address of Offender Village/State/Zip C. t, 4t , -- Business Name. K4". 2? 011Vfe i -f i"C'L. l am/,i5m, on llb'7 20C/ Business Address IQ� Signature of Enforcing Officer Village/State/zip 4f r v /4, A 11 ' Location of Offense it Enforcing.' Dept/Division Offense .01 Facts T(A.'( ('(( ry This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to a'chieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance Subsequent violations will result in appropriate legal action by the Town. • OK FOOI Permit? Tobacco Sales Permit Inspection Report Form TOWN OF BARNSTABLE BOARD OF HEALTH Business Name DI I Date OO&VU'eA1CQ fo(rAeC)14 ChrZ shy s Business Telephone I ©� 61 Location I�r�� ( � � 'I� ✓, 1�e Time: In Out Person in Charge �"( Purpose Routine Follow-up Inspector's Name Complaint Initial RBGIIIATION COMPLIANCE Remarl�s or Xes No Recomgmendata ans Signs Posted [MGL 270/61 Permit Posted [VIIa] I -B4Gvl;6 License T�buccu Employee Signed Forma Kept On File [VIIb] J 41.A 011f Self-service Displays On Counter and within / 5 Ft. of a Clerk [VIId] J No. Floor Displays [VIId] No Tobacco Products / Free of Charge [VIIc] Inspector: Person Interviewed: q:health:tobinsp T EQUIPMENT SCHEDULE RTE #28 FALMOUTH RD . CENTERVILLE , MASS . SCHEDULE DESCRIPTION 1 . Two bay stainless steel sink/hot and cold water. 2 . A 16 ' long snack food counter with a non-porous formica and stainless steel counter top. The following equipment will be i located on the counter : A. Microwave B. 5 Burner Bunnomatic Coffee C. A stainless steel sink w/hot and cold water D. Coke Post Mix Machine 3. Multi-deck refrigeration equipment by Tyler Refrigeration for Dairy Products , Produce , frozen foods , ice cream and walk-in cooler. A floor drain will be located outside the walk-in cooler . 4 . Gondola shelving by Kent Fixtures . All shelving is steel with a factory enamel finish. 5. The wall behind the snack counter has ceramic tile ( blueberry) by Mid-State Tile Co. of Lexington, North Carolina . 6. The walls behind the gondola shelving and check-out counter will be painted with "Nubrite" paint , latex interior vinyl-acrylic semi-gloss , off white #30-oo727 . 7 . The floor covering consists of two materials : A. Quarry Tile : Stone Grey by American Olean. B . Vinyl composition the by Azrock to be V-824 Sesame and VS-294 Blue . 8. Existing Mens and ladies rooms in the storage room to have sinks (hot and cold water) toilets , ventilating fans and the necessary dispensers ; soap , towels , mirrors , etc . 9 . A Utility Sink w/hot and cold water . 10. The ceiling consists of mineral-fiber panels by Armstrong. CleJ. (� CENTERVILLE PLAZA -Wastewater Design Flow Comparison tic WASTEWATER DESIGN FLOW CALCULATIONS- MAY 2006 Cr Unit Address i Use/Area Title 5 Design Flow d 1661 Pinocchio Pizza fast food 42 seats X 20 d/seat 840 1663 PhysioTherapy Associates 2,400 SF office X 75 d/1000 sf 180 1667 Ba side Design & Remodeling Office 1,200 sf office X 75 pd/1000 sf 90 1669 Light Speed Mortgage 2,400 sf office X 75 pd/1000 sf 180 1671 Cape Cod Chicken fast food 16 seats X 20 d/seat 320 1673 Kelle 's Music 1,500 sf retail X 50 d1000 sf 75 1675 Rt. 28 Convenience Store 2,600 sf retail X 50 d/1000 sf 130 TOTAL 1,815 GPD WASTEWATER DESIGN FLOW CALCULATIONS-JANUARY 2015 Unit Address Use/Area Title 5 Design Flow d 1661 Pinocchio Pizza fast food 42 seats X 20 d/seat 840 1663 PhysioTherapy Associates 2,400 SF office X 75 d/1000 sf 180 1665 New Thai Restaurant fast food 10 seats X 20 d/seat 200 1667 Vacant Office 1,200 sf office X 75 d/1000 sf 90 1669-1671 Cape Cod Pie fast food 16 seats X 20 d/seat 320 1673 Centerville Cleaners 1,500 sf total 80% Storage &20% Retail = 300 sf x 15 50gpd/1000sf + 2 employees x 15 gpd 30 1675 Rt. 28 Convenience Store 2,600 sf retail X 50 d/1000 sf 130 TOTAL 1,805 GPD EXISTING APPROVED TITLE 5 DESIGN FLOW(May 2006): 1,815 GPD EXISTING TITLE 5 LEACHING CAPACITY INSTALLED (May 2006): 1,869.2 GPD PESCE ENGINEERING &ASSOCIATES, INC. Phone 508-743-9206 451 Raymond Rd., Plymouth, MA 02360 Fax 508-743-0211 -�` CENTERVILLE PLAZA -Wastewater Design Flow Co �ison ��� / Y-1 e WASTEWATER DESIGN FLOW CALCULATIONS- MAY 2006 Unit Address Use/Area Title 5 Design Flow d 1661 Pinocchio Pizza fast food 42 seats X 20 d/seat 840 1663 PhysioTherapy Associates 2,400 SF office X 75 d/1000 sf 180 1667 Ba side Design & Remodeling Office 1,200 sf office X 75 d/1000 sf 90 1669 Light Speed Mortgage 2,400 sf office X 75 d/1000 sf 180 1671 Cape Cod Chicken fast food 16 seats X 20 d/seat 320 1673 Kelle 's Music 1,500 sf retail X 50 gpd1000 sf 75 1675 Rt. 28 Convenience Store 2,600 sf retail X 50 d/1000 sf 130 TOTAL 1,815 GPD WASTEWATER DESIGN FLOW CALCULATIONS-JANUARY 2015 ./ Unit Address Use/Area Title 5 Design Flow d l� 1661 Pinocchio Pizza fast food 42 seats X 20 d/seat 840 1663 PhysioTherapy Associates 2,400 SF office X 75 d/1000 sf 180 1665 New Thai Restaurant fast food 10 seats 20 g pd/seat 200 1667 Vacant Office 1,200 sf office X 75 d/1000 sf 90 1669-1671 Cape Cod Pie fast food 16 seats X 20 d/seat 320 cvm." at a s o Se = o f cvEA V410 1673 Centerville Cleaners 1,500 sf total 80% Storage &20% Retail = 300 sf x 15 50 d/1000sf + 2 employees x 15 gpd 30 1675 Rt. 28 Convenience Store 2,600 sf retail X 50 d/1000 sf 130 TOTAL 1,805 GPD EXISTING APPROVED TITLE 5 DESIGN FLOW(May 2006): 1,815 GPD EXISTING TITLE 5 LEACHING CAPACITY INSTALLED (May 2006): 1,869.2 GPD PESCE ENGINEERING & ASSOCIATES, INC. 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