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ALLTOWN - MOBIL - RETAIL FOOD
ALLTOWN—Mobil 1734 Falmouth Rd. � t , rtx r Town of Barnstable BOARD OF HEALTH — John T. Norman Board of Health Donald A.Gaudagnoli,M.D. DMA RNSTABLL F.P.(Thomas)Lee,. 6MA5`& �` Daniel Luczkow,M.D. Alt. o39 • 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 44 Issue Date: 01/01/2022 DBA: ALLTOWN CENTERVILLE OWNER: GLOBAL MONTELLO CORP Location of Establishment: 1734 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: • 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: For Office Use OnIX.- Town of Barnstable Initials: Date Paid ' (Amt Pd 1 ,A""LE. : Inspectional Services RFD MAC A Public Health Division Check# Thomas McKean, Director (o rc3l 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 V NAME OF FOOD ESTABLISHMENT: Alltown Centerville ADDRESS OF FOOD ESTABLISHMENT: 1734 Falmouth Road, Centerville, MA 02632 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 800 South St., Ste. 500, Waltham, MA 02453 E-MAIL ADDRESS: Permits@globalp.com TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( 08 ) 775 - 2510 TOTAL NUMBER OF BATHROOMS: 2 WELL WATER:YES NO__�/ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:fir/ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: 0 SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? N/A IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:Wpplication FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT Global Montello Group Corp. SOLE OWNER: YES/NO OWNER PHONE # 781-398-4419 ADDRESS 800 South St., Ste. 500, Waltham, MA 02453 CORPORATE OWNER: Global Montello Group Corp. CORPORATE ADDRESS: 800 South St., Ste. 500, Waltham, MA 02453 PERSON IN CHARGE OF DAILY OPERATIONS: William Blackman 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 0 A— 0 �— L Zlillia�k an 11 / 20 / 2025 1. .WJWaa+43t �Cman 11 / 7 /2025 2. SIGNATL7 APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asi). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Apphcation FormsTOODAPP REV3-2019.doc I Town of Barnstable BOARD OF HEALTH John T.Norman ' Board of Health Donald A.Gaudagnoli,M.D. WiRNSe'+,UM 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: 44 Issue Date: 01/01/2021 DBA: ALLTOWN CENTERVILLE OWNER: GLOBAL MONTELLO CORP Location of Establishment: 1734 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: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: ( � FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I For Office Use Only: Initials - ��� Town of Barnstable Date Paidl�_�Ami.Pd$ B,,STABU, : Inspectiional Services ' °' Public Health Division � 7 p�FD Mpt� , Thomas McKean,Director 200 Main Street,Hyannis,NIA 02601.. Office: 508-862-4644 Fax: 508-790-6304 APPLICATION.FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE la'1 ` NEW OWNERSHIP RENEWAL X NAME OF FOOD ESTABLISHMENT: Alltown Centerville ADDRESS OF FOOD ESTABLISHMENT:. 1734 Falmouth Road,Centerville,MA 1 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 800 South Street,Suite 500,Waltham, MA 02453 E-MAIL ADDRESS: permits@globalp.com TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( Q8 ) 775 2510 TOTAL NUMBER OF BATHROOMS: Z WELL WATER:YES_NO X ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: X SEASONAL: DATES OF OPERATION% /_/, TO I / NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: "0" 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 REOUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? ju IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE.CHECK ALL THAT APPLY BELOW) FOOD SERVICE X RETAIL FOOD-ONLY required for TCSfoods(foodsrequ;iring 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 P:\Applicetion'Fo ms\FOODAPP2020:doc OWNER INFORMATION: FULL NAME OF APPLICANT Global Montello Group Corp. SOLE OWNER: YES/NO OWNER PHONE# (781)398-4067 ADDRESS 800 South Street,Suite 500,Waltham, MA 02453 CORPORATE OWNER: Global Montello Group Corp. CORPORATE ADDRESS: 800 South Street,Suite 500,Waltham, MA 02453 PERSON IN CHARGE OF DAILY OPERATIONS: William Blackman List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 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 Exyiration.Date I•:� l f��ct I :.;. l 1 l�12�t 1. ilk I 2. L I SIGNATURE OF AP //�� DATE Ry• , ��:�tcc.�C. �!./ W(40 4,( YYt�,> l o G�Vv� Cwn 1 • ***FOOD POLICY INFORMATION"* SEASONAL FOOD SERVICE!All seasonal food establishments.including mobile trucks must be inspected by the Health Div. prior to oneninaM Please call Health Div.at 508-462-4644 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.towno-Barnstable.us/healthdivision/annlications.asu, i OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by.a food establishment is prohibited♦ NOTICE: Permits run annually from January`I st to Dec.3 0 each calendar year. IT IS YOUR,RESPONSIBILITY TO RETURN' THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC`Ist: O:Wpplication Forms\FOODAPP REV3-2019.doc BOARD OF HEALTH tt+sr Town of Barnstable John T. Norman Board of Health Donald A.Guadagnoli,M.D. BARNSrABM F.P.(Thomas)Lee 9 4&'� , 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,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: 44 Issue Date: 1/1/2021 DBA: ALLTOWN CENTERVILLE OWNER: GLOBAL MONTELLO CORP. Location of Establishment: 1734 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 ��Q n Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY Town of Barnstable Initials: Inspectional SeMces Date P Amt Pd$ Check#Wbll Public Health Division �451a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 i Office: 508-862-4644 Fax: 508-790-6304 OBACCO ESTABLISHMENT PERMIT APPLICATION Non-Flavored DATE NEW BUSINESS OWNERSHIP RENEWAL x NAME OF TOBACCO ESTABLISHMENT: Alltown Centerville ADDRESS OF TOBACCO ESTABLISHMENT: 1734 Falmouth Road,Centerville, MA 02632 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 800 South Street,Suite 500,Waltham, MA 02453 E-MAIL ADDRESS: permits@globalp.com TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 508 775 - 2510 OWNER'S NAME: Global Montello Group Corp. OWNER'S PH#gW 398- 4419 1 OWNER'S ADDRESS: 800 South Street,Suite 500,Waltham, MA 02453 ' CORPORATE NAME: Global Montello Group Corp. 800 South Street,Suite 500,Waltham,MA 02453 I CORPORATE ADDRESS: CORPORATE FID# 04-3443028 ANNUAL: X SEASONAL: DATES OF OPERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) ' k TOWN OF BARNSTABLE COMMA GENERAL LAW INTERNET LINKS: a TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 I MA GENERAL LAW CHAPTER 2701SECTION 6: https://malegislature.gov/Laws/GeneralLaws/PartIV/Titlel/Char)ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DMSION 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 i Global nJello Group Corp. SIGNATUR . � PRINTED N VP DATE: U QMpplication FormsITOBA 0 APP-NonFavor 12-18-19.docx ( i Alltown Centervilre { ESTABLISHMENT'S NAW, { TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)ofthis 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: e t Si ture Printed Name / DtDate 1 in 7 1ti !(7 �i e Printed Name Date M Signature Printed Marne Date �tls'�i,ildr Ad�i�rIQ .12 2t72(� gna a Print a Date Aj In ignature r Printed Name Date a S gnature r" a bate � Signature Printed Name Date 1_ ' e Q:\Application Fom)ATOBACCO APP-NonFavor 12.18-19.docx o.4m Commonwealth of Massachusetts Letter ID:L0021507648 YA X Department of Revenue Notice Date:September 30,2020 e l Geoffrey E.Snyder,Commissioner Account ID:CGL-10105033-180 pE mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES GLOBAL MONTELLO GROUP CORP ALLTOWN MARKET STOUGHTON 800 SOUTH ST PO BOX 9161 WALTHAM MA 02454-9161 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). 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. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ Spc"US�Ta MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 m Retailer License for Sale of Cigarettes o* This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. GLOBAL MONTELLO GROUP CORP Account ID: CGL-10105033-180 ALLTOWN CENTERVILLE Location ID: 10105033-0343 1734 FALMOUTH RD License Number: 432187392 CENTERVILLE MA 02632-3169 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 1,2020 Expiration Date: September 30,2022 i 00 Commonwealth of Massachusetts Letter ID:L0371256896 Department of Revenue Notice Date:September 30,2020 Geoffrey E.Snyder,Commissioner Account ID:CRL-10105033-183 T• pF mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO GLOBAL MONTELLO GROUP CORP ALLTOWN MARKET STOUGHTON 800 SOUTH ST PO BOX 9161 WALTHAM MA 02454-9161 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 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. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------- S& US�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T ti Retailer License for Sale of Cigars and Smoking Tobacco 7, This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. GLOBAL MONTELLO GROUP CORP Account ID: CRL-10105033-183 ALLTOWN CENTERVILLE Location ID: 10105033-0598 1734 FALMOUTH RD RTE 28 License Number: 1170737152 BARNSTABLE MA 02632-3169 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 1,2020 Expiration Date:September 30,2022 SCommonwealth of Massachusetts Letter ID:L0233075264 ' � Department of Revenue Notice Date:May 15,2020 Geoffrey E.Snyder,Commissioner Account ID:EDL-10105033-290 Y pF mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS GLOBAL MONTELLO GROUP CORP ALLTOWN MARKET STOUGHTON 800 SOUTH ST PO BOX 9161 WALTHAM MA 02454-9161 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 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. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------- ss'` SF MASSACHUSETTS DEPARTMENT OF REVENUE Retailer License for Sale of Electronic Nicotine Delivery Systems oF� This license must be posted and visible at all times. The sale of ?tNTtobacco products to anyone under 21 years of age is prohibited. GLOBAL MONTELLO GROUP CORP Account ID: EDL-10105033-290 ALLTOWN CENTERVILLE Location ID: 10105033-0610 1734 FALMOUTH RD RTE 28 License Number: 1667385344 BARNSTABLE MA 02632-3169 This 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:May 15,2020 Expiration Date: September 30, 2022 i Town of Barnstable BOARD OF HEALTH John T.Norman Board Of Health Donald A.Gaudagnoli,M.D. BAJ rstAHM + Paul J.Canniff,D.M.D. MAM 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: 44 Issue Date: 12/10/2019 DBA: ALLTOWN CENTERVILLE OWNER: GLOBAL MONTELLO CORP Location of Establishment: 1734 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: FOOD SERVICE 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: 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: oFt�r Town of Barnstable For Office Use Only: Initials: � �. � Amt�d Inspectional Services Date Paid $ 9QA 1639. 9. ren � Public Health Division Thomas McKean, Director C e 040Z`14b-8� e I kPfb 1� 200 Main Street, Hyannis, MA 02601 -4 A191q Office: 508-862-4644 Fax: 508-790-6304 Du6 IIa / l APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 9 NEW OWNERSHIP RENEWAL ) NAME OF FOOD ESTABLISHMENT: 8mwn Cewrviiit ADDRESS OF FOOD ESTABLISHMENT: MLA 3 u -Fa Im Dinh 120 a d , Ce n-tery 111 G H N (0 .2Y) MAILING ADDRESS(IF DIFFERENT FROM ABOVE): OOl l SOU+h Si,� Ste - 500, qua I+ham MA 09453 E-MAIL ADDRESS: p�rmiffs @ gIbbaIp, can TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (S0�) 115- 25 la TOTAL NUMBER OF BATHROOMS: a WELL WATER: YES NO ... (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 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 MACHINE,... (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 FonnsTO0DAPP REV3-2019.doc I 'OWNER INFORMATION: FULL NAME OF APPLICANT Ciobal MonW d Croup corp . SOLE OWNER: (@E /NO OWNER PHONE # ADDRESS_b D(1 c��U �> C I , ,>1�� , )Alum MA 6053 CORPORATE OWNER: �O Fed OF OfR+if eral ID = CORPORATE ADDRESS: SOD S60 1 Streti , SUIR 590 > Wa(*&M Mh 0 46 5 PERSON IN CHARGE OF DAILY OPERATIONS: 8 r i oLn a bui 9 t r ) so"6 M OA1 Iu- 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. Y'I m a W er o q / o q / a l 1. DGM 01 2. Dora SIGNATUR F APPLICANT DATE 5j: OCV- -WM\)er+5V) ,VIP of Opmhos ***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 508-8624644 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.townolbarnstable.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 1st. Q:1Application FormsTOODAPP REV3-2019.doc i oFTHe r For Office Use Only: Initials: ti Town of Barnstable Date Paid Amt Pd DARNUAgLE, Inspectional. Services MASS. Check# ach Public Health Division ATEp�p'i a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Officer 508-862-4644 Fax: 508-790-6364 p TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE A o ` NEW BUSINESS OWNERSHIP - r- REyAWAL NAME OF TOBACCO ESTABLISHMENTi 1I101�1 �L ► "' v'1I1 V 1 -•� p -k y*A it ... . ADDRESS OF TOBACCO pv�ESTABLISHMENT; 1 1 �Oi' I U� lA� a t,.,L1 11✓ MA A MAILING ADDRESS(IF DIFFERENT FROM:ABOVE): p U� }�U{1) i) S� .5001 a'1 Y t1A1 1 1 q_A E-MAIL ADDRESS: p(TM I�S e Q 1 oCJob- GM Ll TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (54g 11 - OWNER'S NAME: C nj)0 (I -OWNER'S.PH#(1'61)'5�W-L13`A2 OWNER'S ADDRESS:. Vo SwAh Str P , Suifc 500, WdlftM ►A M63 CORPORATEADDRESS: Jame a t� CORPORATE'FID# ANNUAL: _ SEASONAL: DATES OF OPERATION:_/_/ TO T t DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) / TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE T013ACCO CODE LINK FOR CHAPTER 371-9: htt 2s`//www.ecode360.com/33996392 MA GENERAL LAW CHAPTER.270/S) CTION`6: https•//male islg ature gov/Laws/GeneralLaws/PartIV/TitleI/Chal2te:r270/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 ALI,APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State.License to:Sell Cigarettes 3) IR&Federal Tax ID#Document 2) MA Statelicense to Sell Cigars and.Smoking Tobacco 4) Payment of Fee(s) -see Page 4 C11010CLI Mon-kilo circup Carp ..- SIGNATURE: � C PRINTED NAME: X ( CCI �V P DATE: I I / V� / 11 Q:\Aopl ication Forms\TOBACCO APP-NonFavor l i-2 i=19.doc, 1 ESTABLISHMENT'S NAME TOBACCO SALES Employce Signature Forma This form is for official use to indicate that the etnployee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270.:Section f .of tl c Massachusetts General Laws which describes 'thc penalties for selling and/or giving tobacco products to any person under the age of twenty-one(21). Below is Section 37 t-9, of the Town of Barnstable Board of Health Regulation; Sales to Minors—S 371-9.Sale and Distribution of Tobacco Products. 1. No person shall sett 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`biiih that the purchaser is 21.years old or " older, Verification.is required for any person under the age of27. The following ctuployee(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 Massachusetts General Laws: Vt Sin re Print d amc Date /.0 Signature P inted Name _ Date Est. abet _ nature rinted'Name Date I s , Signature Printed,Name Date Signature Printed.Name Date 1 un vacation W,It sub* hers � T')esir�P, SOrok.a i1. zi Signature Printed Name Date, Signature Printed Name Date 4 t C:\Usces\decoIIMAppllaIMI-ocaAMicrosoil\WindowsltYctGnchc\Contcnt.0utIauk\Y.UFABuro6ACCO APP2010 dbb.docx i sshA^n�r�� Commonwealth of 117assachusetts i,ettar ID;L1591960192 p Department of Revenue Notice Date:September 20,2018 Christopher C.Harding,Commissioner Account 1D;CGL-10105033-180 1�51\T pf: mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES GLOBAL MONTELLO GROUP CORP ALLTOWN MARXET STOUGHTON 800 SOUTH ST PO BOX 9161 WALTHAM MA 02454-9161 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, DETACH HERE ----------------------------------------------------------------------------------- --_.......---------------------------------------------------- ���ssncrirs6 MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes y r� y'f�:'nrrov This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. GLOBAL MONTELLO GROUT'CORP Account ID:CGL-10105033-180 ALLTOWN CENTERVILLE Location ID: 10105033-0343 1734 FALMOUTH RD License Number: 1786353664 CENTERVILLE MA 02632-3169 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 COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF REVENUE •: 'i':O BOX 701 Q BOSTON,MA:02204;.-. 403C ate GLOBAL MONTELLO GROUP CORP. Notice Date: 11/01./13 a 800 SOUTH ST Taxpayer ID Number: 043 443 028 WALTHAM MA 02453-1483 Dear Taxpayer, Below please find your Sales and Use Registration Certificate(Form ST-1). Please cut along the dotted line and display at your place of business. Sincerely, Massachusetts Dept,.of Revenue - - - - - - - - - - - - - - - - - - - - - --- - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - Massachusetts Department of Revenue STA Customer Service Bureau PO Box 7010 Boston, MA 02204 a.v:x/•h:, i ;vCCriiri-::1.Y..v.;r.::Y•'r}.:ii J:iitiJ:•'�C•„I.•.J,na:��.}: - w;w:.... .....s..aJyv'nviiG.'::=l..: .:.:•;.ay-�w•: ... (( ..' .0 r;CinW .L. :::.:.<^.}:..}......v}}r::::::v-:- ".:J.•.<•.... .. •. �... .} ...:..: :i}}:(i:,L'<::.....i•:shy..,.. «9..-.,i.:..:s:}}:.. yid �r�� ryy..�,:�^ ••: .Li...-� :1 t!;tt n>.tS :::Y ..�::::)-::::.....r.. 4.<f.x....•.n:.w.y w}':} }::ti.4;,u..:..o:ii::£:<„.2.:.. ,:.,.;�1:%+..�.yy��}:::!S'-�:1'.�;,•,`,•�:',.Ri�e �...:a.e. .. Y.•v..,y:: :rS:m .:h`9:Y •'.f•:::.::Q '{$%....}.: .nq:}"I n. {{1.v}'.i:n.ha:..:.4 R.>:.7 .1.<0 -.aw:... _ :..i3av$i-r�?j:v�:LJ}?>.•,v.<,i•::ai•:t%:i�:::R•:n•:.Vn:ii}.y:...W:.>.:Lv.C:..::::�•i......4...:.:ti i:.:q•!.{vnvv:::::� .a ..::.nv::.:,..;a....:,..:�..::......:... .. t.-..v.v.... The vendor herein named is registered to sell tangible personal property at retail or for'resale, pursuant to the General Laws, Chapters 62C,64H and 641. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct ST-1 can be issued, IDENTIFICATION GLOBAL MONTELLO GROUP CORP. NUMBER ALLTOWN CENTERVILLE 043443-028 1734 IIALMOUTH RD RTE 28 BARNSTABLE MA 026.32-3169 ISSUBDATE 12/15/98 This registration must be displayed for customers to see and is'not assignable or transferable. CONiNBSSIONER OF RKVENUE or�,o ss^ taF Commonwealth of Massachusetts Letter ID:L180.60.06060 Department of Revenue Notice Date:December 19,2019 L RM 1,4 Christopher C.Harding,Commissioner Account ID:CRL-10105033-183 Of mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO I� nillld�li'll�'��1�Illl�nllll'lll'�III��I�I�II�IIIII � I� GLOBAL MONTELLO GROUP CORP ALLTOWN MARKET STOUGHTON 800 SOUTH ST PO BOX 9161 WALTHAM MA 02454-9161 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 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. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ �,cxvs� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T gyp, Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited, GLOBAL MONTELLO GROUP CORP Account ID: CRL-10105033-183 ALLTOWN CENTERVILLE Location ID: 10105033-0598 1734 FALMOUTH RD RTE 28 License Number: 803932160 BARNSTABLE MA 02632-3169 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:December 19,2019 Expiration Date:September 30,2020 I pk Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNSf'ABLE, Paul J.Canniff,D.M.D. x k 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: 44 Issue Date: 1/1/2020 DBA: ALLTOWN CENTERVILLE OWNER: GLOBAL MONTELLO CORP Location of Establishment: 1734 FALMOUTH ROAD CENTERVILLE, MA 02632 Type of Business Permit: Non-Flavored Annual X Seasonal FEES � YEAR. 2 2 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Q Thomas A. McKean, RS, CHO, Health Agent Restrictions: F PLEASE POST CONSPICUOUSLY ~ rt , Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. BARNS rADM John T. Norman 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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 44 Issue Date: 12/20/18 4 DBA: ALLTOWN CENTERVILLE OWNER: GLOBAL MONTELLO CORP Location of Establishment: 1734 FALMOUTH ROAD CENTERVILLE MA 02632 Type of Business Permit: FOOD SERVICE 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: 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: oFtHE Toys Initials: o� Town of Barnstable p Date Paid �(�.I l Amt Pd $� BARN MASS. Inspectional Services Check leo Public Health Division Thomas McKean,Director �� aq VIC 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_L1__ NAME OF FOOD ESTABLISHMENT: u—rrp w ni (2- -.�..�ir°,�y�u.E ADDRESS OF FOOD ESTABLISHMENT: I -Mq PO 6 ,-414 dde CS2rvLIP.tU�M cj { 2 ���32 MAILING ADDRESS(IF DIFFERENT FROM ABO ): S (7 r("*lV 5S .epla� L9Q..e Aff=00d V(%0. C)04U E-MAIL ADDRESS: P— q16M M , C.tVA. TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 60? -1%T a5t0 TOTAL NUMBER OF BATHROOMS: 9 WELL WATER: YES NO ... (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 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) _KTOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q\Application FormsT00DAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT_T . SOLE OWNER: 09) OWNER PHONE# �t ADDRESS (t 14 , _ r 0C1 H4C"Ui .,U �c1� '5 CORPORATE OWNER: y FEDERAL ID NO. : 1044 - 434 yo ba-1 CORPORATE ADDRESS: NA PERSON IN CHARGE OF DAILY OPERATIONS: r�Z l 1 '13 r List (2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. ,\Al'i P -bL4 EA— 1-4 q /,9b t? 1. !a� 1�0Lo 2.,OCk- QCCd.�M 0 o14ld6,20 0 SIG ATURE 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.townotbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec. 3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION( )AND REQUIRED UIRED FEES BY DEC 1 st. Q:\Application FormsT00DAPPREV2018.doc - -- - -- f�L70l�UI� �IKE Town of Barnstable • Regulatory Services Department KASS. Public Health Division �o i639 �0 200 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 //o LAST NAME OF APPLICANT ..FIRST NAME MIDDLE INITIAL ✓�I�ZJ►� C�ccT�d��ci.P; DB/A STREET ADDRESS TELEPHONE# FID# Do you currently possess a state license to sell tobacco products? Yes _ 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 provided.-on the next page). Each employee who sells tobacco products must t ee m loyee Signature Form (provided herein). S gnature Date Q:\Application Forms\TOBACCO APP2018 dob.docx i 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 retailed. 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 VIIb, and VIIc. of the Barnstable Board of Health to it on of S ok' egulation and Chapter 270 Section 6 of the Massachusetts General Laws: /,/,q7 /'� //,Z —' is rmt d Name tDate nature Printed Name Date St nature d Name e Date 12- ' 0 Signature Printed Name Date Signatur Printed Name Date 0// Signature Printed Name Date Y e'fvt S Spa,u / I r 2 /' 2 C, Signature Printed Name Date O-V tAL Q:1Application forms\TOBACCO APP2018 dob.docx The Commonwealth ofMaswelimetts Ba��rtr�ter�t oa f I�dislr'irxl.�ceitleiits• ', UW I C'ong ess Street,Suite 100 Bosft,HA 02114--2017 www.mass govIdia Workers'Compensation Insurance Affidavit:General Businesses, TO BE.M D WITH TEM PERM t TING AUTHORITY. - An>7ii Please Print Legibiv i . Business/Organization Name: 4/ r LL , i- €,f���!•, ,� d G . e .�,.��..;6 Address: City/State/Zip:A]A-t.nA at,t•.-. &� Phone [no n employer?Cheek the appropriate box: Business Type(required): n�a employer with employees(full.and/ 5, gRetail ert finlo),* 6, QRestanranMBar/LatingEstablishment a sole proprietor or pat•tnersliip and havono 7, Q Oflloo and/or Sales(:iucl,real estate,auto,etc,)loyees worldug for me in any capacity. workers'comp,insurance required] 8. ❑Non-profit are a coxporatien and its oificen have exercised 9. Q Entertainment. x'rightof exemption per:c,152,§1.(4),and we-have 10.Q Manufacturing mployees•[No workers'comp.insurance requiiedr,are a non-profit organization,staffed by volunteers 11`QRealth Cave no employees,[No workers'comp,insurance req.] 12..0 Other '%y appliomt that:checks boxill must also fill out thesaotiou below showing their workers'compeusehonpoliey infomiason. **Iftbe coxporate officers have exempted themselves,but the cotporationhas Aar employees,aworkers'compansa6on policy is requiredand suchan organizatioashould check box A. Xtcm rtn errzpinyer t'/zat rs provir/itz trorlcers'corrrpensattcit iriszzr'rynce fors in erniayees 13eloty is tXte poticy infor3riatiatL Insurance Company Name: Le A�i�ti3_111 �+ )t t'�U a t 1J c k b t r f [t g ,/1 Insurer's Address:_ City/State/Zip: !� 7z.i`: �/1�t4 a II oiicy# Selfivs:Lic,# _1 1 ;b:UL,(sl) ln y Pico, Ex rrafiolDate: Afiach a copy of the woilcers'compensation policy declaration page(shoiv g the pol aynuinher and expiration date). Failure to secure coverage as required under Section 25A of MGL c,152 ean.lead to the.impositiorl of criminal perialties-of it fine up to$1,500.00 and/or one-year hnprisonment,as well.as civil penalties.in the form ofa STOP WORK ORDER and a fine of up to$250.00 a day against the violator: Be advised that a copy of this statement may be forwarded to the Office.of Investigations of the DTA.for insurance coverage yeiificatiori. Xdo hereby cer?t ,urrcler hepains andpena tles of perjury tIzattfze Informattan prokfea'ya�lbove is trice and correct, Si afore W c Date: LeS�jy Phone#: Official use only. Do izat write in t/zis area,to be completed by city or tolvn official• i i City or Town: Permit/Liaense#__ IssuingA-uthority(circle one). 1.Board of Health 2.Building Department 3.City-ff m Clerk 4.Licensing Board 5.Selectmen's Office � 6.Other I Contact Person: Phone M wwnxmass.gov/dia r 6 r�..�• 4MYGER =IFICATE OF LIABILITY INSURANCE 10/1i2019 9/28f2018- Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE.HOLDER, THIS CERTIFICATE.DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed, If SUBROGATION IS WAIVED;subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsements). PRODUCER Lockton Insurance Brokers,TLC NaMKC CALiconse#OF15767 PHONE aC No Three-Embarcadero Center,Suite 600 EMAIL San Francisco CA 9411I ADDRESS: (415)568-4000 INSURERS AFFORDING COVERAGE NAIL II INSURER A.Liberty Insurance Col Tabor 42404 INSURED Global Companies,LLC INSURERS; 1369067 GlobalGP,.LLC INSURERC; A IlinIice Fncrgy,LLC INSURER D; 800 Sowli Street 1NSnRER E; P.O.Box9161 INSURER F: COVERAGES GL.OPAOI CERTIFICATE NUMBER; 15643044 REVISION NUMBER: XXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W)TH RESPECT TO WHICH THIS CERTIFICATE MAY.BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADUL SUHR POLICY EFF POLICY EXP LIMITS YR TYPE OF INSURANCE' POLIGYNUMBER MM ODIYYYY MMIDDIYYYY COMMERCIAL GENERAL LIABILITY NOTAPPLICABLE EACH.00GURRENCE S XXXXXXX O CLAIM DAMAGE RENTEDS•MADE OCCUR PRE ISES'Ea dccurrence S XXXXXXX MED EXP(Any orle person) S XXXXXXX PERSONAL&ADV INJURY .S XXXXXXX GEML AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE s XXXXXXX POLICY El PRO JE O- F LOC PRODUCTS-COMPIOP.AGG S.XXXXXXX OTHER: $ AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT (Ea accidenll _ $ XXXXXXX ANY AUTO BODILY INJURY(Per parson) $ XXXXXXX OWNED SCHEDULED Par BODILY INJURY accidenl) S XXXXXXX AUTOS ONLY AUTOS ( _ _ __ HIRED NON-OWNED PROPERTY DAMAGE g XXXXXXX AUTOS ONLY AUTOS ONLY Paraccidonl s XXXXXXX UMBRELLA LIAOHCLAIM&MADE OCCUR NOT APPLICABLE EACH:O.000RRENCE S XXXXXXX EXCESS LIAe AGGREGATE S XXXXXXX DED I I RETENTION S XXXXXXX WORKERS COMPENSATION N PER (TH. A AND.EMPLOYERS'UABLrry YIN WA5-69D-460066-018 10/1120.18' 10/1/2019 X STATUTE ER' ANY PROPRIETORIPARTNERIEXECUTIVE EL.EACHACGIDE-NT OFFICERIMEMBEREXCLUDED7 a NIA - S 1,000.000 Qhn"Imy In NH) E.L.D1SEME-EA.EMPLOYEE S 1,000,000 IOESGRIPTIONOFOPERATIONSbeIoW E.L.DISEASE-POLICY LIMIT S 1000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ApORD 101,Addlllonal Remarks Schedulo,may 6o ollsohod'[I more space le rogalmd) CERTIFICATE HOLDER CANCELLATION 15643044 Evidence of Insurance SHOULD ANY'OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPS t E ATIVE 1 019138-2015 ACORD CORP:ORATI Ail rights reserved. ACORD 25(2016/03) The ACORD name and logo are redlstered marks of ACORD CI Ssno;!i?car Commonwealth of Massachusetts Letter ID:L13069113b0 ,, 't=� � Department of Revenue Notice Date:September 14,2018 b �I �M' IT. Christopher C.Harding,Commissioner Account ID:CRL-10105033-183 r •rol mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO GLOBAL MONTELLO GROUP CORP CONVENIENCE PLUS#2755 800 SOUTH ST PO BOX 9161 WALTHAM MA 02454-9161 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 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. DETACH HERE --------------------------------------------------------------------------------------------------------------------------------------------- ti�cl�us�. MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco ov, This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. GLOBAL MONTELLO GROUP CORP Account ID: CRL-10105033-183 41t1Uwm C-z_(k.k&V11jte Location ID: 10105033-0590 1134 FALMOUTH RD RTE 28 License Number: 157075456 BARNSTABLE MA 02632-3169 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 I p ¢S` fori• Commonwealth of Massachusetts Letter 1D:L1591960192 �' 7 •- Department of Revenue Notice Date:September 20,2018 �' o +� Christopher C.Harding,Commissioner Account 1D:CGL-10105033-180 9,� Pa3✓ mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES GLOBAL MONTELLO GROUP CORP ALLTOWN MARKET STOUGHTON 800 SOUTH ST PO BOX 9161 WALTHAM MA 02454-9161 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. DETACH HERE -------------------------------------------------------------------------------------------------------------------------------------------------- �PsC�Pc Ji sE� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T ;, Retailer License for Sale of Cigarettes m Ir,�tC� a�aK This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. GLOBAL MONTELLO GROUP CORP Account ID: CGL-10105033-180 ALLTOWN CENTERVILLE Location ID: 10105033-0343 1734 FALMOUTH RD License Number: 1786353664 CENTERVILLE MA 02632-3169 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 I The CommoniveizIth of lFl(zsssttll"etts • bepar'tr�tQ�tofl�rdicsit�al.�tccidefats y 1 Congress Saleet,SUAL'100 Boston,AM 02114 20.17 rvww pass gopldia Workers'Compensation Insurance Affidavit:General Businesses., TO BB MGED WITHTkRPI;ItMtrVMG AUTHORM. . Applicant I ifoz•Inatiau Please Print Legs I Business/Org anizationName: !.d}iJ-�i=b p 611i�.e t Q45 3V •�.=C ..a 4,.�,/'4.�r� Address: (}i`1 �`t t°i�,rz t i t {.t t if Par—, City/State/Zip:b0-(:'r'� y„ •- �a�r - '�l�l Phone r?f�t)o Are you art employer?Check the appropriate box: [7, sinesa Type(required): 1,E; I ant a employer with' employees(full.and/ �Reta or part tinlo),* QRestanrantiBar•ILating Establishment 2,E3 I am a sole proprietor or paine;ship eAd have no .�Office and/or Sales(iuc1.real estate,auto,etc,) employees Working for me in any capacity, [No workers''comp,insurance required] 8• 11 Non-profit 3.Q We are a corporation and its officers have exeroised 9. Q Entertainment. their right of exemptiolt per:e,152,§1.(4),and we-have 10.[]Manufacturing no employees,DNa workers'ciimp.insurance requiied]: 41. We are a non-profit organization,staffed by volunteers, 11 El Cfixe with no employees.,[No workers'comp,insurance req j 12.,0 Other *Any applioant that:etiecks boxitl mist also fill out tbe.sect(ou below showing their workers'comyens'Wonpollay infommatlon. **ftbo coxporate oMeers have exompted themselves,but the coipozationhas oihor employees,aworkers'compensation policy is required and suchan organizationshould bkok.box41. ztrm an errzployer eTiat is providitz�iporlcers'cotnpetrsattoit irrsttr•tcr2ee far.my ern�layees I3eloav is tlrepaficy inforrriatiors. Insurance Company Name: /d i i`ii tom)f t'?1+�d r�l c a a'z rl�t cr (t ci tW) Insurer's Address:_ City/State/Zip: V 11 ,,okGy# r Self ins:Lie# _5 'l e ' at 1) t l `' Expiration ° t c- f V � ± `f In/co, Date: ' Attach a copy, of the woilceis'compensation policy declaration page(showing the policynumber and expiration date). Failure to secure coverage as required tinder Section.25A ofMOL o,152 can.lead to theImllosition of ctiminalpwialties-ofa Inc up to$1,500.00 and/or one-year imprisonment,as well.as civil penalties.in the form ofa•STOP WORD ORDER and'a ffie of up to$250.00 a day against the violator, De advised that a copy of this statement may be,forwarded to the O.ffice.of Investigations of the DIA forinsur--auce coverage vei ftcation. Xdo hereby cer21 ,uyrdw,Irepams andpenaltles ofperlAry tknttlie informatio propidedwhove is tine ails correct. Si attire: . -ei1 c Date: f O f�Q 1 i Phone#: ! �" °'7 / Official use only. -Do riot rerite in this area,to be completed by cloy or town official• i City ar Town: Permit/License# f ; Issuing Authority(circle one): I i 1.Board of Health 2.Building Department 3.City/To�m Clerk 4.Licensing Board 5.Selectmejo-Mce 6 Other ! is Contact Person: Phone#: wvn*i mass.gov/dim I I AC GERTIFICATE OF LIABIL1`l•Y INSU ANCE gAY�(rAMInOnYYY) 10/l/2019 1 9/2812018- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE.HOLDER.THIS CERTIFICATE.DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If The certificate holder Is an ADDITIONAL INSURED,the policy(les)must Have ADDITIONAL INSURED provisions or be endorsed, If SUBROGATION IS WAIVED;subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsements). PRODUCER Lockton7nsurance Brokers,LLC NAME C CA License f14F15767 PHtAlONE Fn C Nn Three Embareadero Center,Suite 600 EMAIL San Francisco CA 94111 ADDRESS: (415)568-4000 INSURERS AFFORAINGCOVERAGE NAIC11 U1suRERA:-U Cr1y1nSUtanC0C=DrafiQR 42404 INSURED Global Companies,LLC INSURER 1369067 Global GP,.LLC INSURERC; Alliance Energy,LLC INSURER D; 800 Soulh Sheet P.O.Box 9161 INSURER E: INSURER F: COVERAGES CrLOPAI)l CERTIFICATE NUMBER; 15643044 REVISION NUMBER? XXXXXXX THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F0R'THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY.BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBS POLICY EFF POLICY EX?YR TYPE OF INSURANCE POLICYNUMBER MMODJYYW MMIDDNYri LIMITS COMMERCIAL GENERAL LIABILITY NOTAhPLICABLE EAcHocGURRENcE S XXXXXXX PRE GE ncutCLAIMS•MADE _ JOCCUR SES Ea d ene $ )bmx ZX MED EXP(Any orle person) S XXXXXXX PERSONAL&ADV INJURY S XXXXXXX GEWL AGGREGATE LIMIT APPLIES PER: GENE.RALAGGREGATE S XXXXXXX POLICY❑PRO• ❑ JECT LOC PRODUCTS-CORiP/OPJ4GG $.XXXXXXX 11 OTHER: S AUTOMOBILE LIABILITY NOT APPLICABLT S (Ea aaiden0 _ XXXXXXX ANY AUTO BODILY INJURY(Per parson) S XXXXXXX OWNED SCHEDULED AUTOS ONLY dUfoS ( ara BODILY INJURY(Par $ XXXXX_XX_ HIRED NON-OWNED PRO ,I)AMAGE AUTOS ONLY AUT08 ONLY Par.accidonl S XXXXXXX $ XXXXXXX UMBRELLA LIAR HOCCUR NOT APPLICABLE EACH OCCURRENCE S XXXXXXX EXCESS LIAR CLARAS.MADE AGGREGATE S XXXXXXX DED RETENTION S XXXXXXX WORKERS COMPENSATION PER OTH• A AND.EMPLOYERS'Li4BILITY YfN N WA5 69D-460066-018 10/112018- 10/1/2019 X' STA.1 ER' ANY PR'OPRIETOR/PARTNEWEXECUTIVE NIA EL EACH ACCIDENT S ]000000 OFFICERIMEMBER EXCLUDED? (IAandatorY In NMI F.,L.DISEASE-EA,EMPLOYEE S 1,000,060 if yus,duscdbe under OESCRIPfiIONOFOPERATIONSbelow E,L.DISEASE-POLICY LIMIT S 1000000 DESCRIPTION OP OPERATIONS I LOW-IONS f VEHICLES(ACORD 101,Additional Remarks SCIIDdulo,may be allachod If more space le roqulrod) CERTIFICATE HOLDER CANCELLATION 15643044 Evidence of Insurance SHOULD ANY OF THE nwe pESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO14 DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPR E ATf d 1 ©1988-2015 ACORD CORPORAT16N. All rights reserved. ACORD 25(2016103) The A-CORD name and logo ere redistered marks of ACORD 4. ALLTOWNT CENT TERVILLId s F.STABLISI£lYIlrIVT'SNAM1 4 1: T09ACCQ9ALES. Dnplayee Signature Form' E This foriit is for official vse to indicate'that the emplc yeie cif this establishment received>,and understood Chapter 371;:of the Town of Barnstable Code and Chapter 27t} Section b of the< Massachusetts General Laws which describes :the penalties for selling and/or gtv ng .tabacctt products to an erson under the:a e of twen -one 21 Below is"Section 371-9. ofthe Town of l p Y p g tY Barnstable Board::of Health Regulation: Sales to.Minors L_ 37.1-9.Sale and Distribution of Tobacco Praduats: :. s 1. No person shad se l or provade a t obacco`product;as'd fl d herein,to,a person;under 1 t The trainimum leg, l sales age. T•h'e mi ii'i�n legal sales dge in the Town of I3ari�stahle 1" is 21 years of age. l 2, Identification: E4ch person selling or distributing fobaocdproduqts,as defined herein,:, 1; shall veiifythe age of the purchaser by means o£'a valid government-issued photo�7aphic l identification containing the bearer's;date o6hth that the purchaser is 21 years old:or older. Verification'is xequ.fired"farany person under tbe:age of 27, The following employee(s)received and undcrstood Section 371-4 of the Town of.Barnatable Board of Health Prohibition of Smoking" Regulation and .Chaplet 27U Section 6 of the: Massachusetts General Laws gnatu�re Printed Naive Date t' Signawre PrintdNaia:: DateLI ' 3 Sign a Printed N"azne Date • I� Signature Printed Name Date. ZIA Signature Printed Na e Date t, Si re PrintedName ate Via. printed Marne Date Q:tlpp}�cat nsi I?.onnstTi3ACC(7 Ai'P24}� }0040ex } } i 4 AI>LT0WN CENTERV'ILLE G:STA DSFi7YIENT'S NAME _. 'r TOBACCO SALES Frnplclyee Signature Toren t = This form is for official use to indicate that the employees) of this establi6ment received,and' understood Chapter° �1; nJ'the'Tn;tn.of Btwnstahle`-Cade and Chapter ,270 Sec"ton G of the; Massachusetts General Lau7s which describes the penalties far seising. and%or giving Cnlacco products to any person uirider the-age.., enty-one(2l): Belo«j;is.Section,37 9. of:tlze Town:al 1 Barnstable Board of IIeal h Rep lation; Sales to ?VZinors - 371,=9.Sale aizd Distribution of Tobacco��B'rn�locts - i 1. Na person shall :sell or provide a tobacco product;as-defined herein,to, person under The mini:mut z leg salee age. The tninimum legal,sales age in ific"l'o of Barnstable x. is 21 years of age.: 2. Identzficatozz EaclZ person selling or distributing tobacco products,as'deftnedherein shall verify'the age of the purchaser by means of'a valid govanUnerrt-issued pltotagnaph c identification containtng=ti e°bearer'a date of birth that thq purchaser is 2 years old or. ' older. Vert catioi .is required for any person under the age of 27'. The follavring employee(s) received,and understood. SecCian 371-9 of the Town of Barnstable:. Board of Health. Prohibition of Smcik ng Regulatios5 and Cl:apto 270 :Section 6 :of the � Massachusetts General I>aws; i Signature :. 1.. Printed Na1?e Data lg nature grin ed Name w Date S ignature Printed•N,atrie i" .. ....... . 'Date Signature Printed-Na e date - l SignaturC P.nnted Dame Date a. Signature :Printed Name D"ate Si gnat i'a Prin ed'Nam.e Date �'. QaAPPH0601)FonnATOi3,M)APP2019 dob,a&x: Op THE Tok, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: - Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY �A n 508-862-4644 'ED MPS FOOD ESTABLISHMENT INSPECTION REPORT Name 1 Dat Type of T Ins ectio / peration(s) Address 2 /� yJ ° Risk01 Fo ervice Re-inspection // i /` j �) �> 4 / 1.'/ J �7 Level et ' Previous Inspection ✓�1 CL Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illnessiew Caterer General Complaint / I -LIF Person in Charge(PIC) W ) I a,La avl Time Bed&Breakfast HACCP I y� In: Inspector gvb Out: Each violation checked recleires 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 EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ✓ d 3 � -�� ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives jG ❑ 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 3 17Lt�/C!�(�� •N Z,/ ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling CJ ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding - . PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control f'Dld ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 1 ! ��� 3IF ', I5ZZ4e / t ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY __ J ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories ^ to �` Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations `v - . 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 Rati ng 9 within 90 days as determined by the Board of Health. � ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Sus p nsion 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 g ❑ 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 g ardless 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 re 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of i ' 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 8non-critical violations. If 1 critical refrigeration. 4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation, � •DATE OF RE-INSPECTION Inspector' ignattire Prin 30.Other , 31.Dumpsterrsscr ed from public view f' y Permit Posted? `"Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N I ature 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* $ Cross-contamination 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* Requirements * 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Re 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 Rated orce,of Food*Contaminated 7-204.12 Chemicals for Washing �Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( P 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eJl cnvc uuzoor 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 155 Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-1 1 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* * Ratites-165°F 15 sec* in mobile food temporaryand residential Sources 10 Proper,Adequate Handwashing g' Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 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) Commercially Processed RTE Food-140°F* (Blue Items 23.30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated �) 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 3-202.18 Shellstock Identification* 3-501.14(A) g Coolin Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within.2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Supplied with Soap and hand Drying Devices Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* 27. Physical Facility FC-6 .00Z 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 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. pF THE fpk, TOWN OF BARNSTABLE - HEALTH INSPECTOR'S Establishment Name: Date: Page:�_of. -OFFICE HOURS - C HEALTH BARNSTABLE°' PUB2 0 MAN STREET 3:30-4:30 P.M. DIVISION � '" - � - 0-9:30 A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:3 639- �0� HYANNIS, MA 02601 soa-s2 as4a No Reference R.-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT S;WIC-- 4f=n42z01. �u� Name (°� jYjE Gl6Ak Date( b .� Type of of Inspection Operation(s) Routine Address t 3l{ Risk Service = ection f 1 ` 1 )✓l � r r Level Re Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness t O Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other C( Qr G'Lt cTvT� K P G Inspector c'�Q`� Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. d 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) ❑ Pee` FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands a� C � ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities !AAr ,/ n EMPLOYEE HEALTH PROTECTION FROM CHEMICALS 1p .� .8 C4 w k ❑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) y ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures 1"�4 ❑ 5.Receiving/Condition ❑ 17.Reheating U ❑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 T�.2- Cam` ❑ 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 Lo Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations r� Critical(C)violations marked must be corrected immediately. (blue&red items) I I-- Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating .�� 2A g ` 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 6=One critical violation and less than 6n violations 9 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i cal violations. If no critical water,sewage back-up,infestation of rodents or insects,or lack of )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-Critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials . (FC-7 590.008 9 violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signa r Print: 31.Dumps r screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination - 14 Food or Color Additives Law Cooled to 41°F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202:12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - 3-302.14 _ Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F)- EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* - 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) q 590.003(G) � Reporting by Person in Charge* - - 7-203.11 Toxic Containers-Prohibitions '- Contamination from the Consumer 3 j 590.003(D) Exclusions and Restrictions* 7-204.11, Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition of Adulterated or Contaminated 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and Food FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and (- ) P - 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations * 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501412 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. L16 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 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* 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 1 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- Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 1 0 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004 C Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec* Other es should violations relating to good retail ( ) practices should be debited under#29-Special 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 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 12 Prevention of Contamination from Hands 3-403.11E Remaining 3-101.11 Food Safe and Unadulterated* ( ) g Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A 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 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 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. con"" `gyp IKEr TOWN OF BARNSTABLE HEALTH.iNSPECTOR,s Establishment Name: �Mff_ Date: Page: of ti 'OFFICE HOURS 11 PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNWABLE. • 200 MAIN STREET 3:30-4:30 F.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified M6 q: `0$ HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY- �ptFO 506-862-4644 F D ESTABLI HMENT INSP CTI N REPORT Name Date a of sec ion O s Routin Address I�Ak ood Servi R = cti (( el Previou pec Telephone Residential Kitchen Date: i Mobile Pre-ope ti 1J Owner HACCP Y/N Temporary Suspect III ess Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP I Othe-/ -rn EM, Inspector Each violation checked requires an explanation on the narrativiisk page(s)and a citation of specific provision(s)violated. d . Violations Related to Foodborne Illness Interventions and 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 EMPLOYEE HEALTH PROTECTION FROM CHEMICALS J ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives (71 ❑ 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 n, ❑ 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 1-n eq D ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories".Violations Related to Good Retail Practices Blue Items Total Number of Critical Violations l a ( 1 Critical(C)violations marked must be corrected immediately. (blue&red items) ' Jag 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 toNitsagent Embargo checked indicate violations of 105 CMR 590.000/Feder ❑ 9 Emergency Closure ❑ Voluntary Disposal Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health memA=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 co 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 be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non- ritical iolations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 11 within 10 da s of recei t of this order. vi lion,4 to 8 non critical v' lion Cp 29.Special Requirements (590.009) y p � 30.Other DATE OF RE-INSPECTION: In ctor' Si tur 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 IN IC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N (A (,�C\ �n l/ Dumpster Screen? Y N Violations related to,Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* * 590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202'.12 " Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* L 19 PHF Hot.and Cold Holding Contamination from Raw Ingredients 15 ot Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101. 590.004(F) ll Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge 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* 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 Requirements 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q - - Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.1A(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 g ( ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* - Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* _ Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminatc 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective uuzooi 4-602.11 .Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11' Frequency r f Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot.Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Chemical* Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 - Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* - 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercially 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 * 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 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70*F to 41°F/45*F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained 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 590.000. oF, r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Ali Tw- ,r) / ro61 I Date: Page:. of OFFICE HOURS BAR E. PUBLIC 2 0 MAN SH EET 3:30-4:30 P.M. SION - 8: 0- :30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ON 1639. �0� HYANNIS,MA 02601 M 508-8 -FRI.62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT ° NameAl i r6 �10 b t Date/7� / Type of Tou' o Ins ctio � � _ ,,J �f� I Operation(s) fw Address 3 y F'ogmo a C en krvi'd? Risk FnQd ervice Re-inspection �4 J L, I br6utn Level eta' Previous Inspection �6 Telephone Residential Kitchen Date: i�ttcrt4 16a Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP I Other � Co In: _ I � v. Inspector R an Gvr(l Out: % b� 's "n \too 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 tLr J ( ) Anti-Choking 590.009(E) ❑ � Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ wcm SV11t, Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ W'c, FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands �InUC� ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities '-- `vv'14J 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 �� �!Q ❑ 11.Good Hygienic Practices ❑ -22.Posting of Consumer Advisories Lu ` 1 Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ 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 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, 4.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 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 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8 non critical violations C. 29.Special Requirements (590.009) y p Inspector's Signature Print: 30.Other PATE OF RE-INSPECTION: 31.Dumpster screened from public view `1 I Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signaturo,/,. 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.* Protection-from * 19 PHF`Hot and Cold Holding 2-103.11 Person-in-Charge Duties 1y� 3-302.14 Unapproved Additives h1W - Contamination from Raw ingredients 15 Poisonous or ToxicSubstances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 7-202.11 Restriction-Presence and Use* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An . 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 590.00411 uirements 3-304.11 Food Contact with Equipment and Utensils* ) Variance Re q 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* ( Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP Removal f Exclusions and Restrictions ( ) 590.003(E) 0 Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 - Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and * 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of 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* ei/°I've iiuzooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods Sanitization-Hot Water and 3-40L11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meal,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 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 3202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Y 3-101.11 Food Safe and Unadulterated 12 Prevention of Contamination from Hands (E) g Critical and non-critical violations,which do not relate o then the me * 3-403.11 Remaining Unsliced Portions of Beef Roasts* 590.004 Preventing Contamination from Employees*- illness interventions and risk factors listed above,can be found in the 8 Tags/Records:Shellstock (E) g18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70 F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite D Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005 3 402.12 Records,Creation n and Retention* 5-205.1I 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 1 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 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. oF.rw r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of OFFICE HOURS A�E° PU62 0 MAN LIC SH EETSION 3::30-430 P.M.0-9:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified .. ,6;. �0� HYANNIS, MA 02601 eoa-sz aRsaa No Reference R-.Red Item- PLEASE PRINT CLEARLY �'EON1Pya FOOD ESTABLISHMENT INSPECTION REPORT Name - Date Type of s ectio p Routine Address Risk - ection i Level a ail reylo ction Telephone Residential Kitchen Date: L Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violatio'n checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. 59 ✓�/ 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 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 l� 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 �,a 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:Base 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 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 (FC-5)(590.006) establishment permit and cessation of food,establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 violation,4 to 8 non-critical violations=C." 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N (/✓1~r {' #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 IN /(/n �� J Dumpster Screen? Y N / dG oL _ _ .. Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION.FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * - 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 1 g Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41'F/45°F 90004 EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 5 . (F) 590.003(C) Responsibility of the Person-in-Charge to * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* - - Applicants* 3-302.11(P,) Food Protection* 7-201.11 Separation-Storage*g 7-202.11 Restriction-Presence and Use* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) q 590.003(G)-. Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* - REQUIREMENTS FOR- 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 - 11Food and Water From Regulated Sources " 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashing-Hot Water� 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell.Eggst 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* Elf°d9e 1/1/2001 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 REQUIREMENTSr ;2-301.11 703.11 Methods of Sanitization-Hot Water and Stuffin Containin Fish,Meat,Poul or3-201.15 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* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11 C 3 Whole-muscle,Intact Beef Steaks 145°F* kitchen o erations should be debited under Game and Wild Mushrooms Approved By Clean Condition-Hands and Arms* ( )O PRegulatory Authority3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 301.1.2 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 Ammals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. $ Receiving/Condition 2�01-.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23-30) 3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands O Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodbome 3-403.11E g 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°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27, 1 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 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.. `Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. oFINE ro TOWN OF BARNSTABLE , HEALTH INSPECTOR's Establishment Name: Date: Page: of OFFICE HOURS a'BARNSfABLE PUBLIC 2 0 MAN STREET 3:30-4:30 P.M.DIVISION � � � : 0- :30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified mAss. 8 MON.-FRI. a m HYANNIS,MA 02601 508-862-4644 No Reference R Red Item PLEASE PRINT CLEARLY 'fON1P` FOOD ESTABLISHMENT INSPECTION EPORT Name Date/ Tvpe of Inspection Ooeration(s) outi i Address Risk Foo Service pection Level etail Previous Inspection Telephone evidential Kitchen Date: ✓� Mobile Pre-operation Owner CCP Y/N Temporary Suspect Illness Caterer General Complaint Bed&Breakfast HACCP Person in Charge(PIC) ov/�� ime Other In: Mai Out: Each.violation checked requires%an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 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 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 Lo ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items Total Number of Critical Violationsn Critical(C)violations marked.must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No El Yes Non-critical(N)violations must be corrected immediately or Overall Rating `�� 1c� within 90 days as determined by the Board of Health. `�J `p LL��JJ ❑ 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: C 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 o 6 B. non-critical violations von-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 = 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 violations observed,7 to anon-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 8non-critical violations=C. 29.Special,Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dump r 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 s Signature Pr t: 1� �f Self Service Wait Service Provided Grease Trap Size Variance Letter Posted - Y N (� Y• 1 (� 1(1�(/` Dumpster Screen? Y N `! `/ t Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) [Demonstration gnment of Responsibility* 6 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12' Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding_ " - 2=103.11 Person-in=Charge Duties 3-302.14 Protection from Unapproved Additives _ Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F)- - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to - Other* 7-102.11 1 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 Se azation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or Ch .3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _ REQUIREMENTS.FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B)- Compliance with Food Law* 4-501.111 - Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13- Shell Eggs* __ _ - Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(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-]Ol.11_ Drinking Water from an Approved System* _ * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 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 e. 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A Violations of Section 590.009 A in cater- 3-201.15 Molluscan Shellfish from NSSP Listed _ _ Chemical* ( )-�) ( )-�) Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11 C Game and Wild Mushrooms Approved By- ( )(3) 'Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under 11 Cl 301- . ean Condition-Hand d A s and the appropriate Regulatory Authority 2 3-401.12 Raw Animal Foods Cooked in a Microwave PPriate sections above if related to P 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* _ 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity g g 3-403.11(C) Commercially Processed RTE Food-140°F 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 . Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 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: pp THE r TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: Date: Page: of OFFICE HOURS ARN E.O` V- PUBLIC 0 MAN HEALTH DIVISION 3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. u- �, MON.-FRI. A ,639.p.• HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY rEO MAC FOOD ESTABLISHMENT.INSPJECTION REPORT Name y , Dat O&e o Tyne of Insl2ection Reration(s) jwaine. Address Risk Foo ervice spAPWAection / Level ail Previous inspection Telephone tial Kitchen Date: Mobile Pre-operation Owner ACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP XnL In: Other Inspector I/0„ i Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. 1 /J 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 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) '1 ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures +e ❑ 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) f ❑ 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 Itemsi Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: o Y Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-in ction'Scheduled ❑ Emergency Sus n r C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils FC-4 590.005 6=One critical violation and less than 4non-critical violations g ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 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 i cal violations. 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 anon-critical violations. If 1 critical refrigeration. violation,4 to 8non-critical violations C. 29.Special Requirements . (590.009) within 10 days of receipt of this order. = 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view 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 `cam r 01-11 Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions t 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 EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information,_Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to * 7-102.11 Common Name-Working Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 _ Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* 590.003(G) Reporting by Person in Charge* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils*- tensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or 3-306.14(A)(B)Returned Food and Rated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 11 C) Unopened Food Packa a Not Re-Served* 3-201.13 Fluid Milk and Milk Products*' 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801. ( P g 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Eggs-Immediate F'Utensils and Food Contact Surfaces of E Immedi Service 145' 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* ed ame 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 rf ces of Equipment* of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* 10 P ing,mobile food,temporary and residential Proper,Adequate Handwashing 3-401.11(C)(3) . Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF s Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercially Processed RTE Food-140°F* Blue Items 23-30) 3-202.11 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodbome 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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 3-203.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel VFC-5 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection .004 3 402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices27. Physical Facility .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. MAR/22/2012/THU :0:09 Ali 0.0.M.M. Fire Dept FAX No. 508-"60-2385 P. 005 0664CU4 ss c►-e ww d O�W 14JUITChtll Oct LV 6a--*W-qLAW" or t o-LT4-( J � T(A s� ( n UXAS te.45�V U 14, S w c -- �-�, Oct. 15. z012,1-1 42�P� No. 6029 P. 1 A\ffiance Alliance Energy TIC 404 Wyman Street,Suite 425,Waltham,MA 02451 800-225-1927 781-674-7780 Fax:781-674-7799 October 15,2012 VIA 1~ACSMLE(508-790-6204) Ms. Ellen Wallington Town of Barnstable Health Division 200 Main Street Hyannis. MA 02601 RE: Site 2729 - 1734 Falmouth Road,Centerville,MA 02632 Dear Ms. Wadlington, Pursuant to your conversation with Marla Belostock,we recently changed the name of our store located at 1734 Falmouth Road,Centerville,Massachusetts 02632 (the"Location"). please amend our license for the Location to reflect the new name as "Alltown Centerville". Please contact me if you need any additional information or have any questions. Thawk you, , Srtacey A.lkey Associate General Counsel I { TM GLOBAL MONTELLO GROUP CORP. 800 South Street P.O.Box 9161 Waltham,MA 02454-9161 ph:781-894-8800 fx:781-398-9000 August 27, 2010 VIA FEDERAL EXPRESS Health Division 200 Main Street Hyannis, MA 02601 Re: 656 Boston Post Road East, Marlborough, MA Dear Sir/Madam: Enclosed please find the following: 1. Application for Permit to Operate Food Establishment; 2. Application for Tobacco Sales Permit; and 3. a check in the amount of$250.00 to cover the cost of obtaining the abgve-.referenced permits Should you have any questions or require additional documentation, please do not hesitate to contact either Marla Belostock at (781) 398-4133 or me at (781) 398-4254. Thank you for your assistance. S n erely, lisha ankins Junior Paralegal Enclosures ----- cc: Marla Belostock(via email only) O.REC'D i L!LAUG 3 J:\Legal\GLOBAL M&A\ExMo MA,NH,RI\Permits-Licensing\MA\Centerville-Bamstable\Ltr Filing Permit Applications 8.27.10.doc www.globalp.com YOU WISH TO OPEN A BUSINESS? ?� For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1" FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and 200 Main Street Offices at the Licensing counter. DATE: $ 'rryx Fill in please: / APPLICANT'S YOUR NAME: GLf7(Oca 4 � F BUSINESS YOUR HOMF ADDRESS: 775 ago U 90 1_� TELEPHONE # kl•s4:p&Telephone Number: r. -79 1 . 9 b `'1211 NAME OF NEW BUSINESS 02. TYPE OF BUSINESS d IS THIS A HOME OCCUPATION? YES NO Have you been given approval fro the building vision? YES NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER 3�- When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature" COMMENTS: 2. BOARD OF HEALTH This individual h-s n in4 ir f he t r irements that pertain to this type of business. Aulfiorized gnature" - COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature" COMMENTS: r r TM oGAMBAL GLOBAL MONTELLO GROUP CORR 800 South Street P.O.Box 9161 Waltham,MA 02454-9161 ph:781-894-8800 fx:781-398-9000 August 31, 2010 VIA FEDERAL EXPRESS Health Division Attn: Ellen 200 Main Street Hyannis, MA 02601 Re: 656 Boston Post Road East, Marlborough,MA Dear Ellen: Pursuant to,your recent discussion with Marla Belostock, enclosed please find a check in the amount of$100.00 to be applied toward the permit applications previously submitted for the above-referenced property. Should you have any questions or require additional documentation, please do not hesitate to contact either Marla Belostock at (781) 398-4133 or me at (781) 3984254. Thank you for your assistance. LSEP '� 1 RE DD `� Si erely, i li a ankins Junior Paralegal Enclosures cc: Marla Belostock(via email only) J:\Legal\GLOBAL M&A\ExMo MA.,NH,RI\Permits-Licensing\MA\Centerville-Bamstable\Ltr Filing Additional Permit Fee 8.31.10.doc www.globalp.com AYOUB ENGINEERING, INC. Page No.1 of 1 Pages 414 Benefit Street Pawtucket, Rhode Island �02861 LETTER OF �o 41) 24>01)724-1110-- 3 ax TRANSMITTAL ( e ,f1^ JOB NUMBER: 3825.106 DATE: 3/21/07 TO: � +(_J1 Ms. Donna Miorandi `l \ � ATTENTION:RE: ExxonMobil Health Inspector Centerville, MA 200 Main Street 1734 Falmouth Road Hyannis,MA 02601 WE ARE-SENDING YOU ®Attached ❑Under separate cover via the following items. ❑ Copy of letter ❑Prints E Plans ❑ Specifications ® Other: COPIES DATE NUMBER DESCRIPTION 3 3/16/07 Al PROPOSED INTERIOR MODIFICATIONS (Rev.#l, 3/20/07) I 1 SPECS Star Roller Grills - Hot Dog Grill and Taquito Grill Heated Peristaltic Dispenser Barker Cases - Deli Case Eagle Worktable True Solid Door Freezer Units THESE ARE TRANSMITTED as checked below: E For approval ❑As requested ❑Approved as submitted ❑Resubmit ❑Return ❑For your use ❑For review and comment ❑Approved as noted ❑ Submit ❑ Other ❑FOR BIDS DUE/DATE: ❑PRINTS RETURNED AFTER LOAN TO US REMARKS: Per our conversation regarding the mop sink,we are enclosing a revised set of interior plans showing the Corian partitions isolating the mop sink from the 3-compartment sink and hand sink. We also have enclosed equipment specifications for the proposed new equipment. If you have any questions,please do not hesitate to call. COPY TO: SIGNED If enclosures are not as noted,please notify us at once. Alan J. Micale,P.E.,Vice President ROLLER GRILLS Model No. i Capacity Dimensions Overall Height 1 at j Electrical I Shipping � I Width(A) Depth(8)I Heiaht(C)I (D) (E) I (F) i Rollers Volts I 'Wattage Amos j 'Weight(lb.l 20&20S` 20 I 171la" .I 20'/a" 121/z" i :" 130'/+" I i1 I 120 i 930 i $ i ^^-.3 30&30S' 30 23'/`" 20'/a" I 12'/z" 21'Iz" 211/ 30'/," 1 411 120 2301 1150 { 10 5 I 50 45A&45SA' 45 23'/<" I 281/z" 1211z" 211/z"1 21'!+"1301/," i6 120 2301 1650 114 I 65 50&SOS' S0 I 35'/," 201/a" I i2'/z" 21'/z" 21"b" S0'/a" 11 1120 2301 1535 �I i3 7 I 64 75A&75SA' 75 I 35'/" I 28'/z" I 12'!z" 121'/z"1211/a"j 30'/" I 16 1 240 I 2400 10 9 ,I i i0 Mociels available with rollers in reverse position. COMBINATION ROLLER GRILUBUN DRAWER Model No. Capacity Sun Dimensions j Overall Heiaht W of Electrical Shipping Capacity I 'Width(A) Depth(B) Height(C) (D) (E) (F) I Rollers I Voits { Wattage j imps 1 'Weight(lb.) SOBS&30So8" 30 32 231/+" 201/a" I 12'iz" i 21'!z" N/A N/A I 11 120 230 115U lU 5 I 55 ?SASS&?SSABB� ?5 I 32 23'/<" I 28'/z" 12 21'/z" N/A NIA 16 I i 20 230 165U i 14 i i3 5088&50S88'.. 50 I 48 35"Aa" i 2TA 12'/z" l 2i'(z" N/A N/A I 11 120 230 1535 13 7 i5 75AB8&755A88 i 75 48 35'/" 28'/r" i 2'!z" i 211h" N/A N/A 6 1 240 t 2400 10 9 I BON WARMERS MOWS available with rollers in reverse position. Model No, Capacity I Dimensions i Overall Height ! Electrical 1 Shipping I Width(A) Oepth(B)I Height(C)I (D) I (E) I (F) I Volts Wattage amps Weight flb.) SST-20 32 1 T/a" 20'/a" 9'/ N/A I NIA I N/A 120 230 I 300 j 2.5 1.3 43 SST-30 48 23'/ 20'/a" I 9'/," N/A i NIA N/A 1120 230 I 45U ?.0 2.0 1 52 SST-50 64 35'1�" 20'/a" 9'/ N/A N/A I N/A120 230 600 -10 2.6 ! 70 RUN BOXES Model No. I Capacity Dimensions Overall Height 1 I. Shipping Width(A) Depth(B) Height(C)I (0) (El j (F) ! ; ''Weight(lb.) 3 3 3 0 3 IS 48 231/a" 20'!a" 6'/a" I N/A i NIA i N/A 37 SS50BB 64 35'/a" 206/a" b'/s" N/A N/A I N/A I 53 SNEEZE GUARDS Model No. Dimensions Shipping Width(Al I Oepth(B)I Height(C)I I Weight(lb.) 20SG-1 D,20SG-20 1 T/a" 21'/a" I 9" I 12 30SG-10,30SG-20 24'/z" 21'/8" 9" 15 45SG-1 D,45SG-20 24'/2" 29'/+" 9" I 17 SOSG-1 D,5OSG-20 351/z" 29'/," 9" I 20 755E-10,75SG-20 1 361/2" 291/4" °" 27 \< Eisaws ms; i SUN 'WAatitEF� G � SHE_r � :� �% \' A. / / A. •J �' 8 STANDARD STAR GRILL-MAX" REVERSE ROLLERS STAR GRILL-MA)(" 3OBB WITH 3OSG-1 D ROLLER GRILL 45RA, SST30,3OSG-10 'C,5TAR MANUFACTURING LN7MRNATIONA1,INC. Phone:300.264-7327 ^ 314-781.3353 `f m 10.Sunnen Dave/St.Louis,:Ytissouri 63143 caY: d00.264-6666 314.7:91.4344�In�'1? /1 Web:hap::/—'w•srar-mfg,com ` a` �� an �� iaciu �tng lnt � rn. a � inal , 3 0 ELECTRONIC POLLEM GRILLS Model30E, 3o5E, 3osBE, 305BBE, 45SAE, 45SAR , 53E. 505E, 5OBBE, SOSSBE, 75Ai, 75SAE, 7155AR , 75ASSE & 75SA4BB * Star's parent pending eiectronically controlled Grill-Maxi roller grills provide the latest technology for heating and 'holding hot does, 'bakery sticks and other specialty products designed for roller oriils. ?r Our unique electronic controls significantly improve multi-zone temperature control throughout the entire grill surface. This technology breakthrough significantly improves food safety and minimizes product waste as a result of accurate temoerature control. * industry first LED, displav orovides temperature reading of grilled product for both the cook and hold cycles improving food safety and grill management. R. _...... �• •}y •t r �I �N, t �1Y 1 �. X Unique heating cycle allows the operator to load the grill and the electronicR. wrY- t control will COOK Product for a preset time and return io hold setting automatically taking the guesswork out of preparing a variety of menu items. An audible alarm will alert the operator from across the room that the product `ias reached its seriina temoerature and is readv to be served. Plus -his ='? feature allows the product to be brought up to temperature without overheating • and shortening the shelf life of the product. - Stadium seating slanted roller design provide a 3' to 6' slope for the best presentation of your products increasing saies and impulse purchases. I * Slim-line desion provide more drill surface in the same space. Increased capacity means additional sales and greater prerits. Model 50Sc * Nlodeis with BBE suffix have built-in bun drawer design that saves space, r reduces costs and provides sanitary storage of buns. * Our exclusive Ouratec"coated non-stick rollers are the best non-stick high performance coating for today's high volume operations. Duratec4 rollers meet the demands for improved durability, ceanability and feature superior trip ror improved roilability of today's new roller grill snack foods. , chrome roller surface is available to provide a stable cocking surface for traditional cooking operations. s� * All Star roller drills contain Seal-Vax°, Star's exclusive superior heavy-duty roller bearing and seal combination. Seal-Max° provides smoother operation, ionger life, low maintenance and grease-free internai compartments. Star's Grill-Max,'electronic roller grill combines the highest quality and performance with the latest technology providing the most advanced roller grill in the industry., . Combine Star's Electronic Roller Grills with our Sun Warmers, Sneeze Guards and +a� Condiment Dispensers, Star is your One-Stop-Shop for all of your roller grill and ti • accessory needs. Electronic roller grills are available in a variety of styles and sizes siw� and are perfect for snack bars, convenience stores, recreational facilities, stadiums,and virtually any venue where fast food is sold. v t;a iit?y C.�::ins UC`r9i3li: 'I Individual front and rear electronic controls for cooking and holding from low to high temperatures holding from 140' to 190'. Heavy-duty motor orovides 3600 rotation wsaossoao of rollers. Star exclusive Seal-Maxi seal and bearing combination and pilot light C `us are standard. Units are 120V, 230V and 240V and come with e'cord. LISTED OWN W Grill-Max" Pro Electronic Roller Grills are covered by Star's one-year parts and labor warranty. Star Manufacturing International Inc. • 10 Sunnen Drive - R.O. Sox 130129 - St. Louis, iVIC 63143-3800 ?hone: (800) 264-7827 - PAX: (800) ^64-6686 -'www.star-mrg.com S1T1/0102 yr - I ELECTPONIC POLLER GRILLS -..._... ....-._.....----...._...__........_.................... - .._....._._._.- i 9 ::. --.._.. - _.._.....-.._........... .......----- ........................................................................ _... A, _........ ....._...._..._...� __...._....__ -O _...................... -- �. ......._._..... _ . ....-- ... ..: --------. _...--- - C _..._........ _-......... -..-.. :.._.........._......................_....... ® _ . . • 7 :. Wit . 1 i imensions li (A) (g} (C) Approximate Weight Model I Capacity j Width Depth Height I Voltage 1 Wattage Amps ! Shipping Installed No. Surface i Inches Inches Inches lbs. lbs. (cm) --(cm)._-.._._�_cm)----._...._..-_ (kg) (kg) 0 30E Chrome 30 Hot Dogs 23-3/4 20-5i8 12-1/2 120V 1150 10 53 ^0 (60.3) (52.4) (31.3) 23OV - (22.7) (13.':) 5OE Chrome i 5O Hot Cogs I 35-3/4 20-518 12-1i2 120V 1535 13 69 53 ' (90.8) (52.4) (31.8) i (29) ( 4) 75AE Chrome 75 Hot Doc_s 1 35-3/4 28-1/2 15-1/2 120V 1730 14 108 78 -- --- (90.8) (/G ^) ( 9.3). 240V 2210 9 30SE Ouratec l 3 Hot Doss 2a- 20 .._.. ur4 �0 �Fc. iG-1ici 115U 10 3 0 4.41 ,31 31 .._.. Gov .--= 45SAE CurateG i 15 Hot Doo= 3-324 8.162. 12'1r2- 230V 1 165C: i 7.5 31 34 60 3 2 4', 31 81 Only 3d OY c°.0'r yam.....«.. __ 50Sc Curates 50 Hot Doc= 35'3r:4; 20 crir 12-1ic 120V. 153E 13 9 �a (52.41 (31.8) 2°) ---,2d}- 7°SAE Ouratec 1 7o riot Coos 35 3r�#; 28 1r1• c-x1/ 1^T) 173C i08 78 i �. i =-2apV 221 C ---a '49 Oh 3� 4) I Roller Grills with Built-in Bun Drawer i 30SEE Chrome 30 Hot Cogs i 23-3/4 20-5i8 12-1/2 120V I 1150 10 63 'S 32 Buns !_(60.3) (52.4) 31.8) (20.1) SOBBE Chrome 50 Hct Dogs 35-3/4 --20 51 18 12-1/2 1 120V j 1535 13 32 64 i 48 Buns (90.8) (52.4) (31.3) 1 I (36.9) 75ASSE Chrome 175 Hot Dogs 35-3/4 28-1/2 15-1/2 120V 1730 15 120 37 18 Buns (90,8) (72.4) (39.3) 240V 2400 10 (53.9) (39.4) 30S88E Duratec 30 Hot Dogs 23-3/4 20-5i8 12-1/2 120V 115G 10 63 45 32 Buns (60.3) (52.4) (31.8) (28.?) (20.4) 5OSBBE Ouratecl� 50 Hot Dogs 35-3/4 20- Sib 12 1/2 120V i 1535 13 81 64 j 148 Buns (90.8) (52.4) (31.3). (34.0) (29.0) 75SASSE Duratec'i 75 Hot Dogs 35-3/4 28-1/2 15-1/2 120V i 1730 15 120 87 48 Burs l °0 81 (72 } (39.31 240V 2400 10 (53.9) (39.4) j Roller Grills-with Reverse giant.--._....__.___._..--_---......_.____.___....._.._.-_.._-__.._. 4 DARE Ouratec 1 45 Hot Dos 23-3/4 28-1/2 12-1/2 120V 1 1650 1 13 81 64 (60,3) (72.4) (31.8) (34.0) (29.0) j 75SARE Duratec" 75 Hot Dogs 35-3/4 28-1/2 15-1/2 120V 1730 15 120 37 . I (90.8) (72.").__..__.....3°-3.� _.._240\/._. 2400_._..___. 11._0..._.'.___G3.9) Electronic Roller Grills are constructed of all stainless steel and use Ouratec'non-stick coated rollers or chrome rollers and tubular stainless steel sheath elements. Elements are mounted in a fixed and floating system allowing for lateral exbansion to minimize warping. Electronic temperature controls provide accurate cooking ano holding from 140T to 190°F- Unit has a heavy-duty motor and provides 3600 rotation of rollers. 7 he Roller Grill incorporates Seal-Max", Star's exclusive seal and bearing combination. The unit has a pilot light, he 120V units (nave a 6'lead in cord with NEMA 5-15P. CE models have CEE7.7 plug. UL•Sanitation to it ISF Etd•14 approved and UL listed. Units with 230 volts are Cc'approved, Printed I n the U.S.A. Star Grill-Max is patent number 6.393,971. Star Manufacturing International Inc, - 10 Sunnen Drive - P.C. _ox 430129 - 3t. Louis, 1V10 63143-3800 Phone: i800) 264-7827 - FAX: (800) 264-6666 - ',vww.star-mrg.corn St:Gr ManuTa0'L[m' g Internat � o,ri'atl,3tw� ` ; u�. o� a STAR GRILL-ill ACCESSORIES SNEEZE GUARDS reatures"Beneflts: • Star's Sneeze Guards have Ultra clear plastic to provide a clear and appetizing view of products. x Easy installation - fits tightly on sides of Roller Grills -no toois required. x Maintain cooking and warmir;g temperatures more evenly. x One and two door styles available for use as operator only or self-serve applications. (Models are.avaiiable to tit all new and old style roller grills Grilktvlax roller grills (Models 40 and 12 excluded). -- UL sanitation and safety Go oved - Meets Health Department - requirements. ,;.... x Heavy-duty poiycarbonate material for ye=rs of maintenance free — -. service. • Pass thru styles available. * Door access accommodates both operator and self-serve needs. Sneeze ouards have nesting framework.to provide a secure fit for all Star roller grills. Application: i Model3OSG-10 i These sneeze guards are designed to fit Grill-Max roller grills. Com- plete your needs by adding a sneeze guard to protect your proaucts. Quality Construction: i! Star's line of sneeze guards are constructed of 3/16" thick formed polycarbonate for easy maintenance free service. 'Na rranty: Sneeze Guards are covered by Star's one year parts and labor _ 9' warranty. a. Patent'16,659,574 3' :1 Model 45SG-FCA with optional SGS Sneeze Guard Shields y i CSATIRICATION 150 9001:1c00 Star Manufacturing International Inc. - 0 Sunnen Orive-P.0. Box 430129 -St. Louis, MO 63143-3800 Phone: (800)264-7827 - FAX: (800) 264-6666-'www.star-mfg.corn �;33/0105 O • SCAR GRILL-MAC ACCESSORIES SNEEZE GUARDS / i Dimensions Model Description (A) (8) (Cj Shipping No. Width Depth Height `Height Inches Inches I Inches lbs. (cm) (cm) (cm) (kg) STAR GRILL-MAX. SNEEZE GUARDS 1 20SG-10 Singie Door Sneeze Guard-Models 20C&20SC ?7-1/2" 21-3/8" '" � 12 20SG 20 Two Door Sneeze Guard-Models 20C&20SC (44.51 (54.3-) I (22.9) (5.4) 30SG-1D Single Door Sneeze Guard-Models 30C,30SC, 30058, 30SCSS 24-1/2" 21 3I8" 9" i5 30SG-20 Two Door Sneeze Guard-Models 30C, 30SC, 30C38, 30SC38 (62.2) (54.3) (22.9) `5SG-10 Single Door Sneeze Guard-Models 45C, 45SC, 45C38, 45SC88 24-t/2" 29-1/4" 9" 17 !SSG-2D Two Door Sneeze Guard-Models 45C, 45SC, 45CSB, 45SCSB (62.2) (74.3) (22.9) I (7.7) 50SG-10 Single Door Sneeze Guard-Models 50C, 50SC, 50C33, 50SC88 36-1/2" 21-318" 9" 20 50SG-20 Two Door Sneeze Guard-Models 50C, 50SC, 50C38,50SCSS I (92.7) (54.3) (22.9) 755E-10 Single Door Sneeze Guard-Models 75C, 7SSC, 75CSS, 75SC88 36-1/2" 29-1/4" 9" 27 75SG-20 Two Door Sneeze Guard-Models 75C, 75SC, 75C38, 75SCB8 (92.7) (74,3) (22.9) OLD STYLE SINE=ZE GUARDS 253G-FCA Two Door Sneeze Guard for Models 25 and 25S 23-5i8" 18" 9" I 15 (60.0) (45.7) (22.9) ( (6.8) 45SG-FCA Two Door Sneeze Guard for Models 45 and 45S 35-3/8" 181, 9" 21 (90.5) (45.7) (22.9) 75SG-FCA Two Door Sneeze Guard for Models 75A and 75SA 35-3/8" 27-1/2" 9" 21 (90.5) (12.5) (22.9) (9.5) 40SGA-PT Pass-thru Sneeze Guard for Models 40 and 40S SNEEZE GUARD SHIELDS 20SGS Sneeze Guard Shield to replace one door for(Model 20 Sneeze Guards . . . . . . . . . . . . . . ..... .. .. . ... . .2 30SGS Sneeze Guard Shield to replace one door for Model 30 &45 Sneeze Guards . . . . . . . . . . .. ... .... . . .. . .. 50SGS Sneeze Guard Shield to replace one door for Models 50& 75 Sneeze Guards . . . . . . . . . ........ . . . . . . .4 Note: Sneeze Guard Shields can be added to two door models to create a pass through model. Dimensions will increase slightly in the depth of the unit. Sneeze Guard is constructed with 3/16" formed polycarbonate. Units are UL-Sanitation Classified to NSF Std.„4 approved. Printed in the U.S.A. Oue to periodic changes in designs,methods,procedures,podciee and regulations,the specifications contained in thls sheet are sudiec:to change without notice.while star Hanufactunng exercises good faith shorts cc provide information(hat is accurate,we are not responsible for errors or omissions in information droviosa ar conclusions rearmed as a result of using the specifications.By using the information provided,the user assumes ail risKs in connection with such use. Star Manufacturing International Inc. - 10 Sunnen Drive - P.O. Box 430129 -St. Louis, MO 63143-3800 Phone: (800)2664-7827-FAX: 1800) 264-6666-irow v,star-mfg.com Star Manufacturing International Inc. Installation and 10 Sunnen Drive Operating U St. Louis, MO 63143 Instructions Phone: (314) 781-2777 Fax: (314) 781-3636 2M-Z4671 Rev. E 2/12/03 r E " i T 'm L T I mu` I S 'Fr% E S) E 0 8EATEU LISTED 1 rPil ?I SPECIFICATIONS 8M-HPD1, 8M-HPD1H, 8M-HPD1P, 8M-HP0IHP Capacity: Two 6 pound bags (Two 2.7 KG Bags) Electrical: 120V, 60 hertz, single phase, 800 Watts; 7.10 amps 230V, 50/60 hertz, single phase, 800 Watts; 3,75 amps Cord: 6 f , length Plug: 120V - NEMA 5-15P 230V - CEE7-7 Dimensions: 9 7/16" W x 20 7/16" D x 26 13/16" H (23.97 W x 51.91 D x 68.10 H cm) Net Weight: 36 lbs. (16.34 KG) I � 8M-HPD2, 8M-HPD2H, 8M-HPD2P, 8M-HPD2HP ! Capacity: Four 6 pound bags (Four 2.7 KG Bags) Electrical: 120V, 60 hertz, single phase, 950 Watts; 9 amps 230V, 50/60 hertz, single phase, 950 Watts; 4.75 amps Cord: 6 ft. length Plug: 120V - NEMA 5-15P 230V - CEE7-7 Dimensions: 14 5/16" W x 20 7/16" D x 26 13/16" H (36.35 W x 51,91 D x 68.10 H cm) Net Weight: 50 lbs. (22.7 KG) II i i I SAFETY SYMBOL This symbol is intended to alert the user to the presence of important operating and maintenance instructions in the manual accompanying the appliance. RETAIN THIS MANUAL FOR FUTURE REFERENCE NOTICE Using-any part other than genuine Star factory supplied parts relieves the manufacturer of all liability, NOTICE Star reserves the right to change specifications and product design without notice. Such revisions do not entitle the buyer to corre- spondi�ng changes, improvements, additions or replacements for previously purchased equipment. MAINTENANCE AND REPAIRS Contact your local authorized service agent for service or required maintenance. Refer to the authorized service center listing provided with the unit. The Star Service Help Desk (1-800-807-9054) is available during normal business hours to answer any questions that may arise. Please have your model number and serial number for faster service. 3 CAUTION 4. Insert the new bag into tray making sure the fitment rests on the block track and route the tube around This equipment is designed and sold for commercial the rollers, use only by personnel trained and experienced in its (Note: Make sure tube is not twisted) operation and is not sold for consumer use in and 5. Place the end of the tube in the slot of the bottom around the home nor for use directly by the general bracket. public in food service locations. 6. Slide the pump block towards the pump head. 7. Hook the tension spring onto the catch. -IMPORTANT- 8. Route the tube through the hole in the tube cover Read this manual completely before attempting leaving 1/2" of the tube below the cover. installation. 9. Dispense a small amount of product to insure the tube is seated correctly,and the product is flowing. INSTALLATION This peristaltic dispenser is equipped for the voltage and wattage indicated on the nameplate mounted on BAG the back of the unit, and is designed for use on ii alternating current (AC) only. PUMP HOCK, i r MEA17 SPRING RELEASED �! NOTE: The peristaltic dispenser .should not be PUMP .HEAD installed without the four-inch (10cm) legs provided sP4wc NcacED with the machine. The legs screw into the nuts on the bottom of the dispenser. w '~ CAUTION DO NOT CON NECTTO DIRECT CURRENT PORTION CONTROL (DC). This dispenser is supplied with a portion control timer. This portion control is based on a time setting. GENERAL OPERATING INSTRUCTIONS Variations in product temperature and consistency This heated dispenser is designed to be used with a 9" will affect the dispensed amount. To insure a consistent x 18" (22.8 x 45.7cm) poly bag with a 1 inch (2.5cm) portion,use product that is at the correct temperature outlet fitment. The peristaltic dispenser is designed to (145'F to 160°), be used with 1/4 inch ID (.6cm) to 1/2 inch id. (1.3cm)tubing with 1/16 inch (.16cm)wall To set portion: thickness. 1. Load preheated product bag into dispenser. 2. Dispense product until there is a steady flow. The dispenser is designed with a preset non-adjustable 3. Dispense the product into a clean container, and thermostat. It is designed to maintain a product measure the product to verify the dispensed temperature of 155°F +/- 10°F, This is not to be amount. confused with the thermometer temperature which 4. Using a small screwdriver, turn the control dial will be different. located on the back panel clockwise for more product and counter-clockwise for less product. Loading Product: 5. Repeat steps 3 and 4 until the desired amount is reached. 1. Turn the dispenser OFF. 2. Unhook the tension spring from the catch. 3. Slide the pump block away from the pump head. 4 Operation Notes: The product should be preheated according to the manufacturer's instructions. The product should be a minimum of 140°F before dispensing. The dispenser will not function correctly if the product is not at the correct temperature. i CHECKING PRODUCT TEMPERATURE The dispenser should be plugged in and turned on with product in the dispenser for a least 5 hours. 1. Dispense at least 3 inches of product into an o insulated cup. 2. Without hesitation,insert the thermometer to the �- bottom of the cup and stir the product gently with the stem of the thermometer. 3. Position the tip of the thermometer in the center of the product mass. P - CLEANING INSTRUCTIONS i 4. The temperature should read between 140°F and 165°F. To clean the peristaltic dispenser: The dispenser is designed to operate 24 hours a day. The stainless steel body is corrosion resistant,but may Once the product is placed in the dispenser it should corrode if not cleaned properly. The dispenser should not be removed until the bag is empty, or the holding be cleaned with a soft cloth with mild soap and water and wiped dry. Do not use detergents, strong period of the product has expired. . i P P P abrasives,or metal scouring pads on the stainless steel Note: To increase the evacuation, open the dispenser panels. and pull the product towards the outlet fitment once or twice during operation. The pump mechanism should not need cleaning during normal use. If product should spill onto the pump If the pump drips, or does not dispense product, head, it can be removed for easy cleaning. Clean the check to make sure the tube is routed correctly, the parts in a solution of mild soap and water using a soft spring is latched onto the catch. cloth. Dry parts before reassembling. NOTE: The tube cover must be in place for The spring can also be removed for cleaning by proper operation. removing the knob and retaining washer. r 7 I To remove and clean the pump head: Note: When installing the pump head onto the drive 1. Open the door. shaft, make sure the pump head is fully seated onto 2. Remove the bag according to the instructions, the square end of the drive shaft before installing the 3. Unscrew the knob from the pump head. knob. 4. Remove the pump head. 5. Slide the pump block out of the track. 6. If needed the rollers can also be disassembled for cleaning. rI o � F "6x ILR i I w 'V ALIGN SQUARE SHAFT WITH - F UMP H�,�D SQUARE C : The drive shaft and um head WARNING pump could be damaged if the pump head is installed incorrectly. RETAIN THIS MANUAL FOR FUTURE REFERENCE _ PART NO. 2M-Z4671 Rev. E 2/12103 6 Visit our Website at: www.star•mfg.com Email: service(i s'tctr-mfg.corn For Fax-On-Demand Literature: (800)-307.9814 THOROUGHLY INSPECT YOUR UNIT ON ARRIVAL This unit has been tested for proper operation before leaving our plant to insure delivery of your unit in perfect condition. However,there are instances in which the unit maybe damaged in transit.In the event you discover any type of damage to your productuponaeceipt,you must immediately contact the transportation company who de livered the item to you and initiate your claim with same. If this procedure is not followed,it may affect the warranty status of the unit. I LIMITED EQUIPMENT WARRANTY I Ail workmanshio and material in Star products have a one(1)year limited warranty on parts&labor in,the United States and Canada.Such warranty is limited to the original purchaser,only and shall be effective from the date the equipment:is placed in service..Star's obligation under this warranty is limited to the repair of defects without charge, by the factory authorized service agency or one of its sub-agencies.Models that are considered ponabie(see below)should be taken to the closest Star service agency, transportation prepaid. > Star will not assume any responsibility for loss of revenue. > On ail shipments outside the United States and Canada,see International Warrantor. i j * The warranty period for the-JetStar series Six(6)ounce popcorn machines is two(2)years.. * The warranty period-for the Chrome-Max Griddles is five(5);yenrs on the griddle s ritace.See detailed wan-anty provided with unit. * The warranty period for TefltiniDu a-Tec coatings is oueyear undernorrnai use and reasonable care-This warranty does not apply if damage occurs to TefloniDura-Tec coatings from improper cleaning,maintenance,use ofinetall is utensils,or abrasive cleaners. This wanranrydoes not apply to the"non-stick"properties of such materials. > This warranty does not apply to:"Special Products'but to regular catalog items only.Star's warranty on"Special Products"is six(6)months on parts and ninety(90)days on labor. >This warranty does not applyto any item dtatis disassembled or tamperedwith for any purpose other than repair by a Star Authorized Service Centerorthe Service Center's sub-agency. Misuse;wrong voltage,wrong gus or operated contrary to the Installation and Operating > is warranty does not apply if damage occurs o er installation,mrs g 11Y This y ,p.y g s from>iinpr p � _ _ _ insauctions.. >This warranty is not valid on Conveyor Ovens unless a"start-up/check-out"has been perforated by a Factory Authorized Technician. PARTS WARRANTY I Parts chat are soldto repair out of warranty equipmenrare warranted for ninety(90)days.The part only is warranted.Labor to replace the part is chargeable to the customer. SERVICES NOT COVERED BY WARRANTY i 1. Travel time and mileage rendered bevondithe 50 mile radius limit 10. Voltage conversions 2. Mileag 11 ,Pilot light adjustment and travel time on portable'equipment(see below) 11. Gas conversions 3. Labor to replace such items that can be replaced easily during a daily cleaning g routine,ie:removable.kettles on fryers,.knobs,grease drawers on griddles,etc. 13. Miscellaneous adjustments 4. Installation of equipment 14. Thermostat calibration and by-pass adCjusunenc 5. Damages due to improper installation 15. Resetting of circuit breakers or safety controls 6. Damages from abuse or misuse 16, Replacement of bulbs Operated contrary to the.Operating and Installation Instructions 17. Replacement of fuses 8. Cieaning of equipment. 13. Repair of damage created during transit,delivery,& 9. Seasoning of griddle plates installation OR created by acts of God PORTABLE EQUIPMENT Star will not honor service bills that include travel time and mileage charges for servicing any products considered"Portable"including items listed below. These;products should'oe taken to the Service Agenev for re-jair: *The Model 51 OF Fryer. ALL: *The Model 526TO Toaster Oven. * Pop-Up Toasters *The N(odei J4R,4 oz.Popcorn Machine, * Butter Dispensers i The;Model CPS Series Food Stearner. *Pretzel Merchandisers The Model 526WO Warming Oven. *Pastry Display Cabinets *The Model 518CM&526CM Cheese Meirer. *Nacho Chin b(erchandisers The Model I21MC& 15:MC& 18MCP Hot Food Merchandisers. *Accessories of any kind *The Model 12NCPW& 15NCPW Macho Chip/Popcorn Warmer. *Sneeze Guards *All Hot Dog Equipment except Roller Grllis&Drawer Bun Warmers. `Pizza Ovens All Macho Cheese Warmers except Model 11WLA Series Nacho Cheese Warmer. *Heat Lamps *All Condiment Dispensers except the Model CSD&H.PD Series Dispenser. *Hot Cups { *A.11 Specialty Food Warmers except Model 130P,300,.1.1 RW Series,and I WSA Series. * Pumps The foregoing warranty is in lieu or any and all other warranties expressed or implied and constitutes the entire warranty. FOR ASSISTANCE Should you need any assistance regarding the Operation or Maintenance of any Star equipment:write,phone.fax or email our Service Departmene. _ In all correspondence mention the Model number and the Serial number of your unit,and the voltage or type or'gas you are using. Part#2M•4497.2 10102 R8 7 MATERIAL MODEL NO. PART NO. STAR MANUFACTURING INTERNATIONAL INC. — H P D 2 S K 18 6 7 ® 110 SUNNEN DRIVE, ST. L0111S, u0. 63143, USA FINISH TITLE WIRING DIAGRAM H P D 2 DR. MH, C1<. DATE �10-2�5-01� — _ REVISIONS LTR DATE DESCRIPTION OF CHANGE DR TOLERANCES UNLESS OTHERWISE NOTED THIS DRAWING CONTAINS INFORMATION CONFIDENTIAL_ TO STAR MFG. INT'L. INC. — FRACTIONS t 1/64- DECIMALS _L- .005 NO REPRODUCTION OR DISCLOSURE OF ITS CONTENTS IS PERMITTED. — BLACK I�-WHITE 14 15 FOR 230V C:F _F qW�: /GREEN A POWER SWITCH E B TERMINAL BLOCK C LEFT PUMP MOTOR FOR 120V -GREEN = D RIIIIN ET (2 O�TOR ONLY) II III ° �wr1nE C F THERMOSTAT 147"F III G THERMOSTAT 165'F H FAN BLACK I PUMP SWITCH 4 ° J SAFETY SWITCH ° A BO 6 z RED o 0 III- DOOR o ° a ° I_I 0 0 ——---———— I C D G Fo I I I ------------ 0 o I I � I RED I o 1 WhIITE J , W1411-E --1 BLACK 10 II I I BLACK I I -------------------J if I J�j U S R S R � FRIGl_DA P D AND DR" SERIES � Standard r r-eatures ! ! • Standard grade exterior 'I laminate • Chrome interior and exterior trim ill • Ceiling light and undershelf I - .......... u lights Mirrored inside back • Square cornice ....:...:...:.... _.... Non-Refrigerated Cases • ? rows or 26" adjustable chrome, white, or black wire shelves - • Frameless self-closing doors_:of 1/4" tempered glass Refrigerated BWU Non-Refrigerated BWU Refrigerated Cases I with BLF Profile With radius cornice and BLF Profile • , rows of 20" adjustable white or black metal shelves Dimensions (without ends) Refrigerated or Non-Refrigerated • Solar digital thermometer BWU-10 37x32x81 SWU-96 921/2x32x81 BWU-48 451/4x32x81 BWU-120 111x32x81 BWU-59 -,5ii2x32x81 B\NU-144 148x32x81 Options BWU-77 7Ax32x81 • Rear L cad Doors Add 1 7n6" each for mirrored ends • rCertt Rail Add 314" each for thermal glass divider • ,,h0ice of Ends Add 1 3/8,, each for glass or laminated ends • Bag Storage Oak accent rail Mechanical Data • Oak or corian bag storage ledge ........... • Recessed bag and tissue storage • 'Brass Trim ::cnillrtad Forall remote cases ..................................................._....._.� • Cart Bumper • Painted Metal Exterior • BLF Profile • Trash/Waste Bin • Radius Top Technical Data • Non-glare glass Hot Gas Defrost Evap Temp: emp: 200 BTU/Lin Ft: 1400 Unit has no outside plug. 120-1.80 required for EMU—* BWU-48, BWU-59. 120.208.1.60 required for SWU-77, SWU-96, BWU-116, SWU-120. Darker Company Conforms to UL Standards 65 and 471 and iINSF Standards 2 and 7. 703 Franklin Street Self Contained Amperage ;i 6 ??0 48 59 ;7 6 Post office Box 478 I 23A 23A 28A 8A 20A 23A 25A Keosauqua, Iowa 52565 Remote and ilNon-Refrigerated Amperage 9.2g i0 �8 ,a ,7 96 1 1 6 20 1 3-`77 — 2A 2A 3A 3A =!A :"A -ATel; Fax: 3 19-293-3776 �W,,, �+� e•xl••Ina i• sa•rarw io FRISIZ•ut E1V w1XE0 /E�,', Im.■.sotir (�T� ;ro.,v+r.l avewm•e• CAOIXETS \ r/ W \„�/ , `Nww,bai`kerCOmQanV,com � � ul•leraus c••nunrarlw••• "�"'u'II P :cu•1e1CAT c:m.rvs a Yl f10�71 BWU732D VOLT. f 12-0-1-�60 [32" W/ ENDS-- Br Allr s NiA i LVAP. TEMP. 29 1 /4"— is C(lICUICIted rel-110te coses Expansion valve sizing 1 JLI based or, 90 degree liquid refrigerant tell-1-�e(C I-e* If 10" the refrigerant. is si-ibcooled, specify Iiq')id ter"Perat"re wl-lar, c)f(le,ing. 2—3 1 -IT TOE KICK �F�R -NL REAR LOAD DOORS \ � 8" LIGHTED WIRE \� 46 1/4" L\�� SHELVES 81 34" 25 13/16" 5 1/2" 1126 w., c) ........... -Cibe... ----------—- 478 u HAD C. iAR mo6iL OIL 11 PR I E CT 4 16 NDrr ko, F..; (319) 293-3776 I A .......------ ---------------- .......... .................. BWU-40D VOLT. 120-1-60 AMPS. 1 1.26 39 3 ./4„ � I 37 II 27" 32" yl 6„ POWER SUPPLY KRISPY K -LIGHTED CORNICE LIGHTED WIRE _ ZYP)�- SHELVES 69" 7 1/4" H32" 24" 30 32" ORA�fER APPROVED DY REVISION P.O. BOX 478 CUSTOMER: MOBIL TODD DEVORE DATE: 12/21/00 PROJECT # �Q KEOSAUQUA, IA 52565 O PHONE: (319)293-3177 BW(J—Q.D D scuE (3 0 DRAWING # 9528 ORDER # _- NONE Q FAX: (319)293-3776 catalog sheet ANEACLE EIO, 4 Profit from the Eagle Advanta e Pr 9 i ► ► ► ► ► ► ► ► ► ► ► 1 ► Item Model tt: Project r: 7iin t 1 tDrawer W orktabIes with Backsplash and Galvanized Base tfeeiveswith Undershelf eceotacle - v 1 (ti114 yit«�� r. te�'2- n- � •'�. 77NSF e sR�: _t I N II a IC ♦ Budget, Deluxe, and Spec Master Series feature front with rolled down worktable with backsplash edge and sides turned down 90 , and Undershelf ♦ Spec-Master' Marine Series feature a marine counter edge on front and ends. patented ♦ Three grades of steel to choose from. uni-lok - ♦ Wide selection of sizes and styles. system ♦ Full range of options and accessories. wprk,able 1pa ♦ Easy assembly. hat channel sound•deadening and tacle too tape between - are weldetl o Unsurpassed strength and performance. channel and tdtp 12-gauge oackup together plate adds stability - gussetre�ess eedln[o channel pravms lateral movement "hat"channel Irame ..indicates 12-gauge gusset for 1W lag weld pwl is douole-welded on backup plate and channel frame for added staoility - \I 1 f I / E Foodservice Division: (800) 441-8440 For custom configuration or fabrication needs, MEAC/L MHC/Retail Display Divisions; (800) 637-5100 contact our SpecFAB Division, WlituOlaw Profit from the Eagle Advantage- FAX: (302) 653-2065 or 653-3036 Phone: (302) 653-3000. FAX: (302) 653 3091, F-mail specfab@eaglegrp.com 100Industriai Bouievard • Clayton, DE 19938 USA - (302)653-3000 • www,eaglegrp,com EG10.44 Rev. 11/00 Eagle Foodseniice Equiomenr,Eagle MHC,SpecFab,and Retail Display are aivislons of eagle Grotto. y2000 by the Eagle Grotto AA • 900,1111111liv - i 1 Profit from the Eagle Advantage- Worktables with Backsplash and Galvanized Base with Undershelf ENGTH WIDTH On Budget, Deluxe and 114mm1 I Spec-Master"' Series roiled edge con" 38mm strucfion 341/i J41/'- 876mm 876mm L On Spec-Master' Marine Phis t" Series 25mm 25mm adi.loot 1. adi,foot 38m2m I 2'116 marine counter edge (25mm)leg adjustment 52mm construction . For custom sizes - fill in required dimensions in layout provided Materials BUDGET DELUXE SPEC-MASTER® MARINE tabletop 16 gauge type 430 SiS 16 gauge type 304 S/S 14 qauqe type 304 S/S 14 gauge type 304 SiS undershelf heavy gauge e alv.steel heavy gauge a galy.steel heavy gauge aaly.steel heavy gauge qalv.steel 15/8"(41mm)O.D.tubular 1518"(41mm)0.0.tubular 151s"(41mm)O.D.tubular 15/8"(41mm)0.0,tubular legs 16 gauge galv.steel, 16 gauge galy.steel, 16 gauge galy.steel, 16 gauge gals.steel, n Features galy.gussets,1"(25mm) galy.gussets, 1"(25mm) gaiv.gussets, 1"(25mm) galy.gussets,1"(25mm) Design adj.hi-impact plastic feet adj.hi-impact plastic feet adj,hi-impact plastic feet adj.hi-impact plastic feet ♦Heavy gauge polished stainless steel top. Dimensions and Weights ♦Top reinforced with welded-on hat channel. `SPEC MASTER®. ♦Sound-deadened between top width x length of weigti.t BUDGET DELUXE. *SP.EC-MASTER® MARINE and Channels, in. mm legs lbs, kg, model# model# model A model#. ♦4Vz (114m)•high 90-backspiash with 24"x 24" 610 X 610 4 43 19.5 T24248-BS T24 T2424E-8S T24M-BS (25mm)turn at 90. 24"x 30" 610 x 762 4 48 21.8 T24308-B5 1 T2430EES-8 B3 72430E BS T2430 EEM•BS 24-x 36" 510 x 914 4 53 24.0 T24366-BS T2436EB-BS T2436E-BS T2436EM-BS ♦Budget, Deluxe,and Spec-Master4 24"x 48" 610 x 1219 4 63 28.6 T2448B-BS T2448EB-BS T2448E-69 T2448EM-8S worktables feature 11h-(38mm)- 24"x 60" 610 x 1524 4 73 33.1 T24608-BS T2460EB-8S T2460E-BS T2460EM-8S diameter 180'rolled edge on front. 24"x 72" 610 x 1829 4 85 38.6 T2472B-BS T2472EB-BS T2472E-BS T2472EM-83 Ends are turned down 90-providing 24"x 84" 610 x 2134 4 97 44.0 T24846-BS T2484EB-BS T2484&BS T2484EM-BS 24"x 96" 610 x 2438 6 114 51.7 T24966-BS T2496EB-BS T2496E-83 T2496EM-BS for flush installations when required. worktables 24"x 108" 610 x 2743 6 142 84.4 T24108B•BS.T24108EB-63 T24108E-ES T24108EM-BS ♦Spec Master'Marine feature a marine counter ae on 24"x 120" 610 x 3048 6 154 69.9 T2412OB-BS T24120EB-BS T24120E-BS T24120EM-BS 24"x 132" 610 x 3353 8 166 75.3 T241328-BS T24132ES-BS T24132E-BS -T24132EM-BS front and ends. 24"x 144 610 x 3658 8 178 80.7 T241448-BS T24144EB-BS T24144E-BS T24144EM-BS ♦Units 96"(2438mm)and 120" 30"x 30- 762 x 762 4 50 22.7 T30306-BS T3030EB-BS T3030E-BS T3030EM-BS (3048mm)come with six legs. 30"x 36" 762 x 914 4 53 24.0 T3036B-BS T3036EB-BS T3036E-BS T3036EM-BS 132"(3353mm)and 144"(3658mm) 30"x 4II" 762 x 1219 4 70 31.8 T3048B-BS T3048EB-8S T3048E-BS T3048EM-BS come with eight legs, 30"x 60" 762 x 1524 4 81 36.7 T30606-BS T3060EB-BS 73060E-8S T3072EM-SS ♦"Strength by design"patented uni-tok� 30"x 72" 7E2 x 1829 4 94 42.6 T3072B-8S T3072EB-BS T3072E BS T3072EM BS gusset system is recessed into channel, 0 x 84" 762 x 2134 4 . 108 49.0 T30846-BS T3084EB-BS T3084E-BS T3084EM-BS 9 Y 30"x 96" 762 x 2438 6 130 59.0 T30968-8S T3096EB-BS T3096E-BS T3096EM-BS reducing lateral movement. 30"x 108" 762 x 2743 6 150 68,0 T30108B-85 T30108EB-BS 730108E-8S T301EM-BS ♦Heavy gauge undershelf. 30"x'120" 752 x 3048 6 170 77.1 T3012OB-BS T30120EB-BS T30120E BS T30120EM 8S 30"x 132" 762 x 3353 8 188 85.3 T30132B-BS T30132EB-83 T30132E•BS T30132EM-BS Optional Accessories 30"x 144" 762 x 3658 S 207 93.9 T30144B-BSI T30144E8-BS 730144E 8S T30144EM-BS ♦ Stainless steel coved drawer on 36"x 48" 914 x 1219 4 77 34.9 T36488 BS T3648EB-BS T3648E-BS T3648EM-BS roller slides. 36"x fi0" 914 x 1524 4 90 40.8 T366OB-BS T3660EB-63 T3660E•BS T3660EM-BS 36"x 72" 914 x 1829 4 106 48.1 T3672B-BS T3672EB-BS 73672E BS T3672EM BS ♦ 4"or 5"(102 or 127mm)-diameter 36"x 84" 914 x 2134 4 123 55.8 T3684B-BS T3684EB-BS T3684E-83 T3684EM-BS casters with or without brakes. 36"x 96" 914 x 2438 6 132 59.9 T36968-BS T3696EB-BS T3696E-8S T3696EM-BS ♦Stainless Steel bullet feet. 36"x 108" 914 x 2743 6 169 76.7 T361088-BS T36108EB-SS T36108E•BS T36108EM-63 ♦ Stainless steel gussets. 36"x 120" 914 x.3048 6 192 87.1 T361208-13S T36120EB-BS T36120E-SS T36120EM-BS Adjustable undershelf, 36"x 132" 914 x 3353 8 216 98.0 T361326-BS T36132EB-BS T36132E-BS T36132ENI-BS ♦ ♦AdjOverustable es,pot racks,sinks, 36"x 144" 914 x 3658 8 239108.4 T361448•BS T36144EB-BS T36144E-BS T36144EM-BS • *On Spec-Masters and Spec-Master Marine-Series tables, increase stated weight by 10%. duplex receptacle. 1 1ITt l l „1172, 11711 Although every attempt has been made to ensure the accuracy of the information provided,we cannot be held responsible for typographical or printing errors.Information and specifications are subject to change without notice. Please confirm at time of order. c Project Name: TM Location: TRUE FOOD SERVICE EQUIPMENT, INC. Item No: Qty: St. Charles Industrial Center • P.O. Box 970 • O'Fallon, Missouri 63366 (636)240-2400 • FAX (636)272-2408 • (800)325-6152 • www.truenifg.com Model No: T-Series Reach-In Freezers Solid Door Reach-In Freezers T-12F, T-19F, T-19FZ, T-23F IN (single door models) SPECIFICATIONS/FEATURES DOORS: 300 series stainless steel exterior with white aluminum interior to match cabinet liner. Doors extend full width of cabinet shell. Door gaskets of one piece construction. • Lifetime guaranteed adjustable torsion spring mechanism with nylon block supports. The face of each door fitted with a 12"long recessed handle with sheetrnetal interlock. Handles are foamed-in-place to s "d insure permanent attachment. INSULATION ® Entire cabinet structure and doors insulated using foamed-in-place z �� _ CFC free polyurethane foam. t ��d SHELVING: � �b N � ysx • Adjustable vinyl coated wire shelves(3 per door). Shelves capable of ' l ,�i,�r supporting up to 250 lbs. ............ � Full height shelf support pilasters,with double oblong holes on 1/2" `� � centers. Pilasters made of the same material as cabinet interior. Four Irr ` - �� (4)chrome plated,stainless steel shelf clips to be included for each shelf. s LIGHTING: y "` Incandescent interior lighting. Light(s)activated by rocker switch mounted above door(s). ..v REFRIGERATION SYSTEM. T23F Refrigeration system factory balanced using CFC free R404A refrigerant (T-19FZ uses 134A refrigerant). TRUE, rated the #1 brand in America. Bottom mounted condensing unit-easy access for maintenance. SPECIFICATIONS/FEATURES • Factory pre-engineered capillary tube system with oversized condenser (excluding T-19FZ)and evaporator to reduce product pull down time and to consistently maintain-10 F(T-19FZ holds 0 F)interior cabinet CABINET CONSTRUCTION: temperature. (non-adjustable capillary tube system superior to • 300 series stainless steel front grill,shroud and doors. Anodized problematic expansion valve) aluminum exterior ends and back. • White anodized aluminum interior cabinet liner with 300 series • Defrost system time initiated,temperature terminated. stainless steel floor. Construction of liner in accordance with NSF • Automatic evaporator fan motor delay during defrost cycle. standards. • Barrel lock standard for each door(excluding T-1217). Dial exterior • Large evaporator and coil heater permit short defrost cycle. mounted temperature monitor. • Evaporator-epoxy coated at the time of manufacture to eliminate the potential of corrosion. • Cabinet mounted on a welded,galvanized frame rail,painted for additional corrosion protection. Frame rail fitted with 4"diameter ELECTRICAL CHARACTERISTICS: castors,front castors include brakes(not available for the T-1217; Unit completely pre-wired at factory,and ready for final connection 2 1/2"castors standard for T-19F&-FZ). to appropriate outlet(see diagram below and NEMA listing next page. A cord and plug set to be included. Also available: A sole use circuit is required. Two and Three Door Models • Top Mounts • Glass Door Models • Half Door Models • Refrigerators T-12F T-19F • All Stainless Steel In/Out T-23F T-19FZ • Dual Temperature Models Specifications subject.to change without notice. Printed in APPROVALS: U.S.A. A*61se 5/10/00 Exceptions: 25" I (+—27"' �I ��z7 —►I ,6$cm D 62 t 6 D 58 cm ',,Q,Srn � - 'cm H'"-163 cm H 493 cmMY," 23" Doo M1 H 199 cm ' 29'/2" Door, .1 Donc Swink;59 cm -swing-64cm .�$p4n64 cm� 46Y," �:i r � i 49'/n" ' e e �. � 59'/4" :23'/a' � "'/A 77 �� o. 1 78 y 54'/a" 78'/4 � 54'h" 63 8-'/.,„ .a.n 83'/4' a. . 81 5° ;h T-12F T-19FZ & T-19F T-23F Rough In Data Dimensions Cord Capacity #of (inches) NEMA Length Crated Model Doors (Cu.Ft) Shelves L I D H HP Volts PH Amps Confi (feet) Weight T-12F(1) 1 12 3 25 23 64 1/3 115 1 6.0 5-15 6 195 T-19F 1 19 3 27 241/2 78 1/2 115 1 7.0 5-15 9 268 T-19FZ 0 1 19 3 27 24 1/2 78 1/3 115 1 6.0 5-15 9 268 T-23F(1,2) 1 23 3 27 29 1/2 78 1/4 1/2 115 1 9.0 5-15 9 290 (1) Available with full glass doors Specifications subject to change without notice. (2) Available with solid half doors Standard Features • 300 series stainless steel doors&front. • T-2317: 4" swivel castors standard Optional Accessories • White anodized aluminum interior and equipment-locking castors provided for -�Available with 6" stainless steel legs stainless steel bottom. front set. (not available for the T-12F) • Anodized aluminum top,sides and back. • T-19F&T-19FZ: 2 1/2" castors standard p Additional shelves available. • Oversized and balanced,environmentally equipment. O Remote available for available. F. friendly refrigeration system holds-10 F • T-12F: leg levelers standard. (T-19FZ holds 0 F). • Slide out compressor can be serviced easily • Recessed handles. and accessed by a single repairman. • Exterior mounted thermometer(not • Environmentally friendly R404A available for T-12F). refrigerant(T-19FZ uses 134A refrigerant). • Door locks (not available for T-12F). • Large evaporator and coil heater permit • Magnetic door gaskets. short defrost cycle. • Adjustable vinyl coated wire shelves. • Defrost system time initiated,temperature • Epoxy coated evaporator. t-rrninated. • Incandescent interior lighting • Automatic evaporator fan motor delay (fluorescent interior lighting for glass during defrost cycle. Clearance Required For Coolers(USA) door models). • 1 year parts&labor warranty(USA). Sides Top Rear • 5 year compressor warranty. Inches/min Inches/rnm Inches(rnm 2/50 6/152 1 2/50 TRUE FOOD SERVICE EQUIPMENT St.Charles Industrial Center•P.O.Box 970•O'Fallon,Missouri 63366• (636)240-2400•FAX(636)272-2408• (800)325-6152 •www.truemfg.com Printed in U.S.A. Town of Barnstable P# o4I"E r Department of Regulatory Services : ELUMS A]" : Public Health Division Date M � 039. �� 200 Main Street,Hyannis MA 02601 '�en trxt" Date Scheduled ` Time Fee Pd. 7 Soil Suitability AssessnIentfor Sewa a Disposal /�A a Performed By:2✓IdN / taV7_ � G l Witnessed By: - - LOCATION& GENERAL INFORMATION Location Address /7 /rn�u Q_/ Owner's Name �xx oT, Address Assessor's Map/Parcel: D r /�/�,{ �'�✓Z Engineer's Name 441di /" e;V7 NEW CONSTRUCTION I REPAIR Telephone# S7Z>e'7?e Land Use 6C 0-41 Slopes(%) Surface Stones Distances from: Open Water Body �aL� ft Possible Wet Area /�y ft Drinking Water Well rG✓J It Drainage Way Ta/) ft Property Line _r,40 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 4r rpc*eA -.654LV Parent material(geologic) G/aGlm Dt vaaL- Depth to Bedrock > /,Za u t � / Depth to Groundwater: Standing Water in Hole: NdN12_ Weeping from Pit Face Estimated Seasonal High Groundwater } 120� tJ G✓CeG� ' n I DETERMINATIM FOR SEASONAL HIGH WATER TABLE Method Used: _� Depth Observed standing in ohs.hole: in. Depth to soil mottles: yYLL in. Depth to weeping from side of ohs hole: in. Groundwater Adjustment ,a/�A ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST _�14 Observation Hole# 96V Time at 9" n Depth of Perc /y/g—�,6� f Time at 6" Start Pre-soak Time @ ^ 1 CrA6l(J Time(9"-6") End Pre-soak Rate Min./Inch Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# gf"1d I Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) Ifs-3zu Qb .._ loVP 39A A/".Q- M-F y�/Lo" G S4 !o ye 6/tr DEEP OBSERVATION HOLE LOG Hole#i7iZ4 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Lose- or, 3/z �✓o,tt_ rf F Ali , �° ►' /�y�S-A we"e M--r a ` �/t-120 G oan� AM i# A ohc a Qr DEEP OBSERVATION HOLE LOG_ Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) - _- Flood Insurance-Rate Map: / Above 500 year flood boundary No Yes v Within 500 year boundary No V// Yes Within 100 year flood boundary No Y Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? !k5 If not,what is the depth of naturally occurring pervious material? Certification I certify that on uA oW (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required tramin ex ertise and experience described in 310 CMR 15.017. Signature Date I� DIE? A�?/ove� �� +1 -#&Z-772 Q:\SEPTIC\PERCFORM.DOC f - TOWN OF BARNS TAELE LOCATION SEWAGE # I J VILLAGE_ ASSESSOR'S MAP Cr LOT INSTALLER'S NAME a P14ONE NO./5'/7/1lhe S ISEPTIC TANK CAPACITY ��� 1��►� LEACHING FACILITY-(type) /%S' (size) DODO ° ti NO. OF BEDROOMS. PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER /� a DATE PERMIT ISSUED: DATE , COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No IF 1� C v s � � t� u �P��FTBEtO��o TOWN OF BARNSTABLE OFFICE OF STAs�aM"t BOARD OF HEALTH iva . i639 367 MAIN STREET HYANNIS, MASS. 02601 August 14, 1987 Frank Masan Mobil Oil Corp. Route 28 Centerville, MA 02632 Dear Mr. Mason: You are reminded that State regulations require periodic pumping and or cleaning of all MDC traps (Metropolitan District Commission;''gas and oil separator tanks) . You are directed to contract with a licensed hazardous waste transporter\contractor to perform the required pumping and Z'r cleaning of your MDC trap by September 11 , 1987 , or provide proof of such maintenance performed within the past three months . You are further directed to have your MDC trap inspected and cleaned if necessary, by a licensed hazardous waste contractor every three months . Written proof from a licensed contractor will be required. Inspections will follow by the Health Department to verify compliance . You are reminded that failure to comply' could result in a. fine of $200 . 00 daily under the Town of Barnstable Toxic and Hazardous Waste By-law. Very Truly Yours , 1v\` ohn M. Kelly Director Barnstable Health Department w r THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) A I / L DATA - 4 '-�-�-�.w.rw�v ..�,,•Ar.-i. -'br'swclr1. .M'.A1n-v—:tr.nnT�.�.... .,.. yyK j MEMBER ` ,< $: 345 WEST MAIN STREET ��r1 INS NORTHBORO, MASSACHUSETTS 01532 INVOICE • `aLY TEL: 1617► 393 2537 PEI,gtva fflurew WSN A SERVICE CHARGE OF 1'/s% INTEREST PER MONTH (18% PER YEAR WILL BE CHARGED ON OVERDUE BALANCES. S MOBIL STATION H RT. 2.9 1 SAME CENTERVILLE, P MA 02632 Tp 00000 t'E YOUR ORDER NO. SHIP VIA SHIPPED/COMPLETED TERMS INVOICE Na I y/`q7 -UST#0'37494 5/21/C-c7 _ ET 24307 , TfTY DESCRIPTION UNIT' RICE AMOUNT PUMP AND CLEAN MDC TRAP AND CLEAN FLOOR DRAINS INSIDE GARAGE AS DIRECTED BY FRANK MASON. r ,00 DOT 17H DRUM 24.000 .00 BUNDLE ABSORBENT PADS5 r 10.000 20.00 t 40.000 40.00 .00 DOT 17H DRUM DISPOSAL 34.00 .000 MASS TRANSPORTER FEE 200 . 134.000 134.00 , LBS.' @.0092 1.840 1.S4 '• ).00 GALLONS DISPOSAL .000 GALLONS MASS TRANSPORTER FEE . 092 390. 00 0�'2 .00 HRS. VACUUM TRAILER ' 69.00 . 000 HRS. LABOR 45.000 150.00 24.01:►0 334.00 ( 242.84 i.. _,t t.. .._ . S.007 SALEQ TA 4. 20 Ci I' AMOUNT D�tE't _-. 247.C►4# , 14, '[}. 3 SERVING THE PETROLEUM- INDUSTRY .® EQUIPMENT SALES, SERVICE, ]NSTALLATICiN5 , , rinted/Typed Name ORIGINAL insporter 2 Acknowledgement of Receipt of Materials Date Tinted/Typed Name Signature Month Day Year screpancy Indication Space rcility Owner or Operator:Certification of.receipt of hazardous materials covered by this manifest except as noted in Item 19. Date Pri ed/Typed Nam Signature's Month Day Year ,d OMB No.2 50-0 39,Expires 9-3 -88 9700-22(Rev.9-86)Previous editions are obsolete. COPY>3a GENERATOR—MAILED BYTSDF I.I, ° COMMONWEALTH OF,MASSACHUSETTS DEPARTMENT OF ENVIR PH-Ate TAL QUALITY ENGINEERING DIVISION OF SOLID AND HAZARDOUS WASTE One Winter Street 4 Boston, Massachusetts 02108 Please print or type.(Form designed for use on elite(1 2-pitch)typewriter.) UNIFORM HAZARDOUS 1.Generator US EPA ID No. Manifest 2.Page 1 Information in the shaded areas WASTE MANIFEST Document No. 0 of snot required by Federal law. 3.Generator's Name and Mailing Address � A.State AM Cfest�o�rr�r�y�ib 3 �O�// 0/ / Cc�, wti BdJr�a A S8� 'CA IS�A S W 11-7 B.State Gen.ID leT, .1 g 4 �/p S at►6c n 4.Generator's Phone 1 1 t j /L/ w n1 5.Tran t 1 any Name 6. US EPA ID Number C.State Trans.ID LU ��op ��v r'1I) D05292449 (n 7.Transporter 2 Company Name 8. US EPA ID Number D.Transporter's Phone 1 1 E.State Trans.ID 9.Desirert�c�ility Name and Site Address 10. US EPA ID Number I I I I I I I I I n LL ll ''�l?t F.Transporter's Phone( 1 345 WEST MAIN ST. O G.State Facility's ID Not Required 0 i NORT14BORO MA 01532 Ni I A 1 0 1 0 1 51 2 '?1 2 1 4 4 1 9 H.Facility's Phone( 617) 393-2537 v i 12.Containers 13. 14. I. W 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total Unit Waste No. ,,�/ No. Type Quantity WtNol a. G(/jQSff CO/>'1�US �! /h �16c// /(/. � s. I G b. 1711 E i*1 N E A R c. C A T 0 R d. - F-i r r'7 J.Additional Descriptions for Materials Listed Above(include physical state and hazard code.) K. Handling Codes for Wastes Listed Above a) a _ # t a c. b. b. d. 15.Special Handling Instructions and Additional Information 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method o'treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health and the environ- ment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is available to me and that 1 can afford. Date Printed/Typed Name a Month Day Year ZT r 17.Transporter 1 Acknowledgement of Receipt of Materials Date R A Printed/Typed Name Signature Month Day Year N 0 18. Transporter 2 Acknowledgement of Receipt of Materials Date R T Printed/Typed Name Signature Month Day Year E N 19.Discrepancy Indication Space F A C I iL 20. Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.., TDate Y Pri ed/Typed Nam Signature Month Day Year 'Form Approved OMB No.2 50-0 9,Expires 9-3 -88 :PA Form 8700-22(Rev.9-86)Previous editions are obsolete. COPY>3 : GENERATOR—MAILEDBY'TSDF Fuels Marketing U.ao lJ U goo U 61 '--4" EC11gh&& Ong COPYRIGHT©2= EXXON MOBIL CORP. ALL RIGHTS RESERVED OD Z � I Z H J Q � p p W ' L (D ZLu0Z 0 v W " � Z lL EXISTING EXISTING W Q � x z RETAINING RETAINING ? Y L W WALL WALL Z � M 0 = 3Lr) r 0. W U < Lr) /� INSTALL 3/4"x24"x6'-0" SOLID SURFACE NEW Q I cc) O MATERIAL "CORIAN" TO PROVIDE ORANGE SEPARATION BETWEEN THE MOP SINK MARLITE W N Z AND HANDSINK/3 COMPARTMENT SINK, p W USE WALL. & FLOOR CL..IPS TO SECURE, EXISTING 3 z F- O -J j SEAL WITH SILICONE SEALANT O W (n v EXISTING COMPARTMENT g DOOR I Z E W W EXIST. .SINK SINK _ _ W Z 0 _C - -_ -- , I COOLER m BOX X151 ► MOP I{ r. AT LJJ R iIf O I II �� >�NII a�_� all W SINK I � CO2� _ _ NEW EXISTING ONDIMEN NEW TRUE _ STAR NEW REPRAC TAC 30 CHILI- CHIP EXISTING EXISITNG WILBUR DELI COOLER REMOVE DAIRY DEC K cn CHEESE RACK GLO-RAY 0 STAR 75SAE CURTIS SELF CONTAINE M-HPD WARMER AP MACHINE ( CONDENSER) ELECTRICAL "Moz 2a MODEL ADD TWO NEW L''L1 0 z$ OR250S-24D EW PANELS '�� _ T OGLER DOORS TRASH 4 CUPS DI LAY OD J U I C V / ATE :E UJI O > UNDER � 3 a 3 0 DZ ' Z� 13'— NEW BLUE ICE OM m � I „� LANCE �, x III oil 11111111 X0_>� _ o o =TOE _ N N - 4'-6" NEW 4'_0" NEW 1 �_ " NEW 1 � W3 TA LE NDCAP 1 4 0 0 ;U rr X Z _J Z 1:0 01 c� 1 � Z �_� _ z z z 4 -14 - > M 3� O O o O O 3 DOOR Y Zc) � N W�m OC11o.: w `� WALK — IN G% rn x w w NEW x N C EAMISER DEA z z z RANGE o=i M DEL 220 0 FREEZER 0 Z o _ ARLITEN EW BT - I k -- GRID ABOVE zo z z o 0 O O I ': ELECTRICALLi LLJ CD C PANELSED (a] z z 0 NEW ED 01 C21a I ' STOR . U TI YELLOW ONOO ,Z o z z 5 E VALANCE ED a O O W z' 9- - M3N z O EXSTENID 3 0 NEXISITNG z p WALL j N M w w W ; f 5 �O NEW BENGAL If 4�—Q" TRADERS z . _. BAKERY RACK !I 0Z 3 WOMEN ZW ; -J 03 w o __.._ EXISTING RELOCATED E NEW NEW 9' x 5' COFFEE EM CHI BULK BULK _ REMOVE D " PLATFORM Z PREP CTR AND r , -- �-- n AND NEW w p TILE TO Z. CASEWORK f� . --- MATCH N SALES AREA L r _OFFICE x o EXISTING n UJINEW BLUE IICE M VALANCE Z m S r I L w+1 S Z I 0- 30 �� L� SJ EXISTING (/� EXIST EXIST MEN �.. Q z" I 1S ��� a�S To�oY ICE CREAM MAPS 0% RAC = W N S TRADER RAC J W C/� > f nn Ld z0 r� z n-,mow " 0 n RAS Number 11826 Design Type Building Type Size: Building Style: D 5 10 Bldg. Code: Scale:20 1/4»= 1 Drown, By ,t 4pproy'o By; File Name: fC M Date: 1 1826a 1 . 1 Issued For: 3/16/0 7 Concept Project No. 90200 Drawing No. Al % ........... ------ SCOPE OF WORK: BUILDING EXTERIOR: REFER TO STRUCTURAL PLANS PRIOR TO DEMOLITION - DEMO BUILDING SURROUND - DEMO. (2) EXTERIOR RESTROOM DOORS - DEMO OVERHEAD BAY DOORS AND TRACKING (2 TYP) - BLOCK UP RESTROOM DOORS 61'-5 114� DEMO BRICK ON RIGHT SIDE OF BLDG. AT STOREFRONT AND REPLACE 4'! 3/4 4 3�4" MATCH EXISTING BRICK ON- SIDES OF BUILDING 81-0" 5'-0 9/16- 41 11,-1 1/87 #1 4'-8" 30'-6 9/115' 1 A INSTALL FROST WALL BELOW BAY DOORS INSTALL NEW STOREFRONT INSTALL NEW SPIGGOT ON RIGHT SIDE OF BUILDING FOR IRRIGATION FORM & POUR NEW BUILDING SURROUND (ENSURE SLOPE AWAY FROM BLDG) 24"X36' 24706" ICE 14'x4T 14-,�F 14'x 17x r C PAD IN REAR OF BUILDING. lTxw lrx6lt 1Tx60' INSTALL FENCE TO ENCLOSE HVAC PAD W/ SINGLE GATE SHELVING SHELVING SHELVING SHELVING SHELVING SHELVING SHELVING SHELVING ,/ I 'F 18--6c —1 MACHINE SHELVIN _�o C14 x86" x86* G ABOVE kEIVIILG ABOai�StIVING SHELVING ABOVE TX607 INSTALL REAR EXIT DOOR IN UTILITY/STORAGE ROOM - SEE STRUCTURAL PLAN HAND SINK 3 COMP SINK W/ 147 X 4T W/CRID ABOVE 9 DOOR ��VING ABOVE Sw BUILDING INTERIOR: to WALK-IN I I tK x 00 I=A4 CIj COOLER REMOVE LIFT HEADS (2) (LIFT OIL IS TO BE SAMPLED AND DUMPED INTO If I (124� DOORS) WASTE OIL TANK IF CLEAN) N SERVICE Z9 CLOSE EXISTING BAY DRAINS N if AREA 1*2 HEAD WCA FWWMI ----------- g, ,c SANDWICH COOLER Li CO REMOVE ALL INTERIOR EQUIPMENT AND DISPOSE N I/ICE MACHINE & fit N 48*wv2_Tdx31 11:2r' 04 -,Er- 3 ; 1 _zS N r6/8.25w�x_1V0.5dfx54 2�7h)l DEMO ENTIRE CONCRETE FLOOR N N D u_ 0 V) x co N + zu 1* 04 REPOUR AND LEVEL FLOOR Zn -:V�i- v V�x if INSTALL STRUCTURAL STEEL AT BUILDING EXPANSION AS SHOWN ON STRUCTURAL PLANS. uj FRAME AND SHEETROCK INTERIOR WALLS AS PER PLAN INSTALL NEW 8" X 8" CERAMIC FLOOR TILE PER PLAN (SUPPLIED BY OTHERS) x _j 5'-Cr x 4'-Cr .3'-6 1/4� x uj Ix COFFEE/CONDIMENT If INSTALL NEW HVAC SYSTEM (REMOTE CONDENSER) z 9 x fill ------ _j Q 1 6'-8 7/8- CENTER WALK--IN BUILDING INTERIOR: -0 Jill FREEZER ----- -- ---- ---- -- - RESTROOMS: xoo�-4- x 8'-0" 1. REMOV lTx3Cr to INSTALL NEW ENGLAND RESTROOM PACKAGE SHELVING 3 TIER --n 04 RAND 4,-10. E/REPLACE EXISTING FIXTURES WITH NEW ADA FIXTURES I I - WRAP OR SHIELD EXPOSED PIPE UNDER SINK It < SINK <\ %K It RELOCATE REQUIRED PLUMBING 'Cli 7_ INSTALL FLOOR DRAINS FOR EACH RESTROOM DWEP-1, DECK INSTALL (2) NEW INTERIOR DOORS U-) K) FURNISH & INSTALL MARLITE IN RESTROOMS C) INSTALL NEW CEILING LIGHT FIXTURE & EXHAUST FAN PER PLAN U2 FURNISH & INSTALL NEW 2' X 4' CEILING TILE GRID PER PLAN INSTALL NEW 8" X 5' CERAMIC FLOOR TILE PER PLAN wom 14' UTILITY' if 0 L --------j� INSTALL 3 COMPARTMENT SINK L we" PROVIDE ICE MACHINE AND CONDENSATION DRAIN gc J OFFICE FURNISH AND INSTALL WATER HEATER J;K I TRANSACTION v)::t -_-_ 0 1 < AREA 10 INSTALL AIR COOLED ICE MAKER FURNISH AND INSTALL MOP SINK S2 z u co D2 to z lu__ FURNISH AND INSTALL HAND SINK D x v4T MANAGERS INSTALL SHELVING IN BACKROOM (AS PER PLAN) uj ------ *4- STATION z MEN 04 A14 1 0 it.. ..4 1 STAR 455 ---- ----- DIAPEY 400 AMP UPGRADE WITH NEW ELECTRICAL PANELS r "Bcm 3: 8' SE ATM 09.tRE AWVE HOT DOG I .I THRU FILE MER 00 FIRE PROTECTION CONTRACTOR TO INSTALL FIRE DETECTION PANEL. Q'7 17-r)* I DEALER OFFICE: 7 INSTALL SHELVING IN DEALER OFFICE (SHELVING TO BE FINISHED) NOTE: MCLANE COMPUTER TO BE INSTALLED IN OFFSITE OFFICE (BY OTHERS) 4 5/8% 4 3/4�' 7'-7 1/4- INSTALL CORNER DESK FOR MANAGER pIj 5'-9" 5'-9" 5 -5 1/8- 2'-5" 5'-5 1/8" 51-9" 4'-0" L III" Ile 8'-3 112- NEW 20--1 5/8- STOREFRONT 6'-0" DOORS NEW 18'-4 5/8- STOREFRONT 8'-7 1/2" TRANSACTION AREA: 6 1'-5 114- - PROVIDE ALL NECESSARY ELECTRICAL FOR WAYNE, McLANE, DATA ETC. - INSTALL O.H. CIGARETTE RACK MTG, BRACKETS ONLY (FOR FUTURE USE) - INSTALL ADDITIONAL OUTLETS - INSTALL AUTOBANK - PROVIDE H20 FOR COFFEE MACHINE (220V ELECTRIC REQ'D) REO'D PHONE LINES - TELEPHONE, FAX, DATA-McLANE, POS, DATA DIR GENERAL NOTES PROPOSED FLOOR PLAN (JACKS REQ'D IN TRANSACTION AREA DEALER OFFICE) SCALE: 1/4" V-0" 1. EXISTING DIMENSIONS SHOWN ARE INTENDED FOR GENERAL INFORMATION ONLY. PROVIDE CONDUIT FROM BACK ROOM TO TRANSACTION AREA TO DEALER OFFICE CONTRACTOR SHALL FIELD MEASURE AND VERIFY ALL DIMENSIONS BEFORE FOR MCLANE LINES (4) 1". FABRICATION OF MATERIALS. NOTIFY THE ENGINEER OF ANY FIELD CONDITIONS FOUND TO BE DIFFERENT THAN INDICATED ON THE PLANS. SALES AREA: 2. IN CASE OF DISCREPANCIES BETWEEN PLANS, THE SITE PLAN WILL SUPERCEDE PROVIDE 6" CHASE FOR POST-MIX IN ALL CASES, NOTIFY ENGiNEER OF CONFLICTS. PROVIDE 6" CHASE FROM STORAGE/UTILITY ROOM TO CONDIMENT CENTER 3. CONTRACTOR SHALL REFER TO STRUCTURAL DRAWINGS BY OTHERS FOR ACCURATE PROVIDE H20 AND ELECTRICAL TO CONDIMENT CENTER (CAP FOR FUTURE) INFORMATION REGARDING THE REMOVAL AND CONSTRUCTION OF ALL MATERIALS. ALL SHELVING TO BE INSTALLED BY MILLER/ZELL 4. ALL BUILDING CONSTRUCTION AND COMPONENTS SHALL CONFORM TO THE' WIRE AND INSTALL WALK-IN-COOLER & 3-DOOR FREEZER INCLUDING REAR TOWN OF CENTERVILLE REGULATIONS AND THE APPLICABLE BUILDING SHELVING (REMOTE CONDENSER). CODE FOR THE STATE OFMASSASSACHUSETTS. WIRE AND PIPE REMOTE CONDENSER FOR 6' OPEN AIR COOLER 5. THE INSTALLER SHALL BE RESPONSIBLE FOR COMPLIANCE WITH APPLICABLE CODES INSTALL COUNTER TOP EQUIPMENT AND ENSURE OPERATIONAL AND REGULATIONS REGARDING DESIGN AND CONSTRUCTION FEATURES OF THIS INSTALL ADDITIONAL OUTLETS SYSTEM. HANG MARLITE IN SNACKBAR AREA 6. SOLID WASTE TO BE DISPOSED OF BY CONTRACTOR IN ACCORDANCE WITHALL LOCAL, STATE AND FEDERAL REGULATIONS. 7. IT IS THE RESPONSIBILITY OF THE CONTRACTOR TO NOTIFY THE BUILDING AND FIRE DEPARTMENTS 148 HOURS PRIOR TO COMMENCEMENT OF CONSTRUCTION. WARNING: GRAPHIC SCALE 8. ALL MATERIALS AND EQUIPMENT. SHALL CONFORM TO MOBIL OIL CORPORATION SPECIFICATIONS. THIS WORK CONTAJNS AND CONSTITUTES CONFIDENTIAL BUSINESS INFORMATION 4 0 2 4 16 AND TRADE SECRETS OF MOBIL ANY UNAUTHORIZED DISCLOSURE OF THE WORK, 9. REFER TO SCHEDULE SHEET FOR ALL SCHEDULES AND GENERAL CONSTRUCTION NOTES. ' in Its r� 6!� . 1, 1 _I OR ANY PORTION 'THEREOF. IS STRICTLY PROHIBITED. COPYRIGHT IN THIS WORK IS THE SOLE AND EXCLUSIVE PROPERTY OF MOBIL ALL RIGHTS RESERVED. 10. ANY REPRODUCTION OF THIS ENGINEERED DOCUMENT WITHOUT THE PRIOR CONSENT IN IFEET SHOULD PUBILICATION OF THIS WORK OCCUR, THE FOLLOWING NOTICE SHALL APPLY: OF THE "ENGINEER OF RECORY' IS STRICTLY PROHIBITED. 1 Inch 4 ft. @ 1995, MOBIt: 5 REV. RR TO MASS CODE, REV. WINDOW SIZES, MOVE COOLER/INT. WALLS 3/19/97 _�A�P MAN USM&R Asset ServWes THIS DRAWING AND ALL INFOkkooN HEREON IS - Lq rjwTQ_)TwTm /m I I , I . " el�p DESICN ENGINEERING. 'FAIRFAX, VIRGINIA PROPOSED FLOOR PLAN THt'PROPERTY OF MOBIL USM&R ASSET SERVICES 4 REVISED TO NEW STORE LAYOUT FOR OTR --� BY MOBIL'FAIRFAX 3/10/97 f�M �R TPR EXCEPT. CA�P CIVIL & CONSULTING 7 EN I GNEERS ENVRONMENTAL & SITE PLANNERS* DESIGN AST �1/211/96 APPROVED SS # O1—QJK ENGINEER AND SKALL NOT BE COPIED OR USED, 3 ADDED 'RECESSED DOORS PUZ SITE PLAWAND REVISED STOREFRONT TRAFnC ENMNEERS ARCHITECMR& DES11GI&TS* FOR THE PURPOSE FOR WHICH rr.'lS EXPRESSLY CAP o SURVEYORS PROJECT MANAGERS* DESIGN RT.. 28 1734 OLD STAGE 'ROAD 2 INSERTED NEW 11ITLE BLOCK INTO DRAWlNG,L REVISED SALES AREA WITH NEW 1/28/96 CHECK CENTERVILLE, MX FURNISHED. THE DRAWING AND AWYCOPIIES DRAWN PM CAP �TEL.'(508) 871-8400 9 OTIS STRM FAX., (508) 871-8401 PML 7/6/95 THEREOF (PARTIAL OR'COMPLETE) SHALL BE TRANSACTION' AREA AND CONDIMENT CENTER, REOSED DI TO STRUCTURAL �6 ADD HAND SIN1< IN U11L RM. RELOCATE RANS AREATER BY, M DUE 10/9/�5, PM HOT DOG MACHINE TO T SH 4/11/97 SCALE DRAWING No. REV- No. SHEET UPON DEMAND" DRN-,-- AM , FARM1N(;UQ4 NY mWil 1/4-7 1 PETURNED TO THE OWNER �N REVISION DATE HK, APR, No. REVISION DATE BURUNGTON. NJ BROWJW, CT, STERUW. VA DATE 0 --CH CHECK wo5bolFP 6 LWIN (CAHIR COCILEE -.1 1� R DWEP-"' DEC :C P;\CU Rk ENT\MOBIL\CE NTVtLL\q5001 FP.DWG,' 5,