HomeMy WebLinkAboutSAM'S FOOD - RETAIL FOOD i
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4738 Fdlmouth Rd ` %'
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�► � Town of Barnstable BOARD OF HEALTH
John T. Norman
Board of Health Donald A.Gaudagnoli,M.D.
DAWNSr.BLE F.P.(Thomas)Lee,.
MAS& 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt.
539•
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstablems
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 319 Issue Date: 01/01/2022
DBA: SAM'S FOOD
OWNER: HALLEMA CORP.
Location of Establishment: 4738 FALMOUTH ROAD COTUIT„ MA 02635
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2022
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: CQ�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
1
v oF1Ne ram, For Office Use OnIv. Initials:
tia Town of Barnstable
Date Paid ,Amt Pd $ ��
BARNSTABLE, Inspectional Services
r� 6 9. ,0� Check# Q��
°1FD11,0,(A Public Health Division _
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A/FOOD ESTABLISHMENT
DATE I A NEW OWNERSHIP RENEWAL
// 1
NAME OF FOOD ESTABLISHMENT: 7 A,
ADDRESS OF FOOD ESTABLISHMENT: �3 �q LM D U`l t-1 "C� . C 06 i y,
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E- -�o��
MAIL ADDRESS: & ►L 4 Y L
4
} V
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: oQ qM- SW-
TOTAL NUMBER OF BATHROOMS: 1
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)
*** SEASONAL, MOBILE & NEW FOOD ONLY***
AEOUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:Wpplication FormsTOODAPP REV3-2019.doc
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OWNER INFORMATION: r /�
FULL NAME OF APPLICANT /�A R >r«T /"` . �-
SOLE OWNER: YE /NO OWNER PHONE #
ADDRESS UP e- �C /'HJT 1 t I I /"t o-S P
CORPORATE OWNER: Hcklwh� C,2
CORPORATE ADDRESS: +D Ct.k e- `3 c 0"-1-
PERSON IN CHARGE OF DAILY OPERATIONS: A I F
List (2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments, including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results'submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FormsTOODAPP REV3-2019.doc
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
nxsrABM Paul J.Canniff,D.M.D.
As 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
4 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, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 319 Issue Date: 01/01/2021
DBA: SAM'S FOOD
OWNER: HALLEMA CORP.
Location of Establishment: 4738 FALMOUTH ROAD COTUIT„ MA 02635
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2021
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q.�
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
•I For Office Use O • Initials:
�`KKEr Town of Barnstable
Date Paid Amt Pd$�
BMWSTABLE, : Inspectional Services
16 9. `0� Public Health Division Check# 3b C
ArEO MAy A
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE >2p NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: � l S FfJ 0 i-
ADDRESS OF FOOD ESTABLISHMENT: >a FA I M 0 () (( kk S�,7 ' ( 04 U 1",4
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: 61 S 1-PC p�J - (yi! �m ^a-I , C o t
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: U q)-a S 36 2 Vr
TOTAL NUMBER OF BATHROOMS: )
WELL WATER: YES NO_Z...(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)? ff A
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED& BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application FormsTOODAPP 2020.doc
'1
OWNER INFORMATION: a
FULL NAME OF APPLICANT /'A 11��A l ! 1 S 1 r
SOLE OWNER: YE /NO OWNER PHONE#
ADDRESS_ APziNIVIS ,, MA-SN SLS 144A — c2264�
CORPORATE OWNER: i AL,—'LSMA
CORPORATE ADDRESS: </�Pr Da i✓LJ , A)1 1'1416 , A-CHER=, MA ^ O2Aq
PERSON IN CHARGE OF DAILY OPERATIONS: rA/?q.A I / ' S')
List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
�I A4919
S GNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION"*
*
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. .
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asy.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually fron-.January 1 st to Dec.3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st.
Q:1Application FonnsTOODAPP REV3-2019.3oc
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
RMA ARM �" F.P.(Thomas)Lee
' 200 Main Street, Hyannis, MA 02601
Daniel Luczkow,Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstablems
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: 319 Issue Date: 1/1/2021
DBA: SAM'S FOOD
OWNER: HALLEMA CORP.
Location of Establishment: 4738 FALMOUTH ROAD COTUIT, MA 02635
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2021
TOBACCO SALES: $85.00
Permit Expires: 12/31/2021
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
For Office Initials:
. Town of Barnstable
1• `. Date Paid An1Lps1$
.CAB ; Inspectional ServicesFRWN �- --
M
i639 � . Public Health Division - ��
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
i
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT :PERMIT APPLICATION.(Non Flavored)
DATE � ® 9�f1 NEW BUSINESS OWNERSHIP RENEWAL
NAME OF TOBACCO ESTABLISHMENT: M, r—O f
ADDRESS OF TOBACCO ESTABLISHMENT: LiAiA620 111 RD,.... UV-j•�1 �I�.' t��G�� x
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
1 1
E-MAIL ADDRESS:
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: ( __45
OWNER'S NAME: 64 NA-r I C' OWNER'S PH#JL01 /
OWNER'SADDRESS:� L.rAPL \ CJe7 AFC zus w
CORPORATE NAME: HA
Sf1�I
CORPORATE ADDRESS:_�D CPLs ���l��� I.�L� /�1IJ�1��P � CORPORATE FID#
ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)..
TOWN OF BARNSTABLE CODE/MA GENERAL.LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/33996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
hqps://malegislature..gov/l,aws/Genera!Laws/Pa,-W/Ti+IPL/Chanter270/Section6
***NEW BUSINESSES AND NEW OWNERS ONLY***
REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED.
PLEASE CALL 508-375-6621
ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS:
1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document N
2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4
4
L
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SIGNATURE: G��r r
PRINTED NAME: f ���
Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx
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ESTABLISHMENT'S NAME
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of
the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the
penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 4
371-9. of the Town of Barnstable Board of Health Regulation:
6
Sales to Minors—4.371-9. Sale and Distribution of Tobacco Products.
1. No person shall sell or provide a tobacco product, as defined herein,to a person under
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
2. Identification: Each person selling or distributing tobacco products,as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The 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:
Ao
Si nature Printed Name Date
S� a Printed Name Date
Si a Printed Name Date
t I
Signature Printed Name Date t
t
Signature Printed Name Date
a
Signature Printed Name Date ;
Signature Printed Name Date
Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx
a
12/24/2020 9:02AM FAX @ 0001/0001
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�4acr�u r MASSACjHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retaile License for Sale of Cigars and Smoking'tobacco
in
r oti.�` This license m stj be posted and visible At all ti ines.The sale of tobacco
produ its to anyone under 21 years of age is prohibited.
I4ALEEMA CORP Account ID: CRL-10240907-0 10
SAMS FOOD.STORE i License Number: 193890304
4738 FALMOUTFI ROAD
MASHPEE MA 02649
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This certifies:that the taxpayer named above is licensed under Chapter 64C of the Massachusetts Gent ral Laws to
sell at retail at,the address shown above.This license is no i-trans ferabic and may be suspended or rev 3ked for
failure to comply with state laws and regulations.
Effective Date:October 1,202i0 i Expiration Date:September 30, 022
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�gsSPc sNi� I MASSACHUSETTS DEPARTMENT OF REVE UE orm
Retailer License fot Sale of Cigarettes
This license must be posted and vi ible at all times,The sale of tobacco
products to onyone juder 11 years of age is prohibited.
I4AJ,EEMA CORD Account TD: CGL-1024 90'7-007
SA'MS FOOD STORE License Number: 15546 73664
4738:FALMOUTII R AD
MASHPEE MA 0264�
This certifies that the taxpayer named abbve is li .ansed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the add�es shown above. This lie nse is on-transferable and maybe suspend d or revoked for
failure to comply with�st to laws and regt lations.
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Effective Date: Octobe 1, 2020 Expiration Date: Septerrber 30, 2022
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12/30/2020 1 :27AM FAX 160001/0001
III�� Comtnonwesltlt of Massachusetts
Department of Revenue Letter ID:L0006097472
Notice Date;May 12,2020
$ 1 Geoffrey E.Snyder,Commissioner
Account ID:PIX-10240907-017
Q1rraR� mass,gov/der 1
LICENSE,FOR SALE OF ELECTROIVT NICOTINE DELIVERY SYSTEMS
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�ntll�ld�ltlltl"ul��'I'I'lll���rltlll'I�i1'I'Ill���hlll���'�I ,
�_a HALEEMA CORP
§ SAMS FOOD STOKE
= 70 CAPE Dlt APT 148
c MASHPEF.MA 02649-3062
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Attached below is your Retailer License for Safe off Electronic Nicotine Delivery Systems. Cut
along the dotted lute and display at your business lac t�ion.A.t an• time,you can log intoIyour
MassTkonnect account at mass.gov/rttasstax :onaect to view and re-print a copy of this
license,,
If you have any questions about your license,call tis at(617) 887-6367 or toll-free in Massachusetts at
(800)392-6089,Monday through Friday,8:30 a.m. to :30 p.m.
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DETAi.'H EL2E
------------------------=-----------------------
--------------------------------------------------------------
MASSACHUSE'rTS I)EP�R lVi ENT OF REVENUE
R 1 y
�9 Retailer License for Sale of Elcctro I iq Nicotine Delivery Systems
rot�� This license must be posted and visi Ible at all times. The sale of
itobacco products to anyone W del 21 years of age is prohibited.
IIAI.F iMA CORD Account ID: EDL-10240907.017
SAMS FOOT) STORE License Number: 867506176
4738 FALMOUTH ROAD
MASH�EU MA 02649
This certifies that the taxpayer named above is licensed ttndcr Chapter 64C of the Massachusetts
General 'IAws to sell electronic nicotine delivery systems at the address shown above.'l'his license is
non-transferable and may be suspended or revoked ft�>r fa lure to comply with state laws and regulations.
I
Effective Date:May 12 2020
y , Expiration DAte: September 30, 2022
• i
I
' Town of Barnstable BOARD OF HEALTH
ay John T.Norman
�Y Board of Health Donald A.Gaudagnoli,M.D.
BAPMADUL Paul J.Canniff,D.M.D.
MAM r, 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (S08)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: 319 Issue Date: 12/10/2019
DBA: SAM'S FOOD
OWNER: HALLEMA CORP.
Location of Establishment: 4738 FALMOUTH ROAD COTUIT, MA 02635
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
I
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2020
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
FROZEN DESSERT: _ _ Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
w
�e
OFF►off Town of Barnstable For Office Use Only: Initials.
Date Paid' Amt Pd$ ".
BAMSPABLE. Inspectional Services :?
Public Health Division t
Thomas McKean, Director VZ t
200 Main Street, Hyannis,MA 02601 `
Office: 508-862-4644 Fax: 508-790-6304
�nA PLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT R DATE I . NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: Ur✓fovvvt�. G,�h �'�' u�w;`� �=c��I
ADDRESS OF FOOD ESTABLISHMENT: t-(��Q C, c�-wV y— 7 Ca W O 2- 3 "jam
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: Dt Si /a OI,r/ 401 "7"o;/ f
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (PL AU �-
TOTAL NUMBER OF BATHROOMS: I
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)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q\Application FormsTOODAPP 2020.doc
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OWNER INFORMATIONV: 1� n
FULL NAME OF APPLICANT
SOLE OWNER: YE /NO � OWNER PHONE 47-
ADDRESS � ��
CORPORATE OWNER:
, L �, /
CORPORATE ADDRESS: 4111 f�a1 cnl ti{ �l7 , t�Z�3�
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
I.
2. 6E)
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All,seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health.Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who:caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor coking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec. 3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
I
Q:Wpplication FormsTOODAPP REV3-2019.doc
.ptiZ Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
PaulJ.Canniff,D.M.D.
bq H MA 02601 F.P. Thomas Lee Alternate
200 Main Street, Hyannis,
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: 319 Issue Date: 1/1/2020
DBA: SAM'S FOOD
OWNER: HALLEMA CORP.
Location of Establishment: 4738 FALMOUTH ROAD COTUIT, MA 02635
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2020
TOBACCO SALES: $85.00
Permit Expires: 12/31/2020
I
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
I
' For Office-Usc Oply Initials.
Ft"E'°'�� Town of Barnstable -
' v
Date PaidW JAmt Pd$
BARNSTABLE. ; Inspectional Services
1639. Public Health Division Check# 7°0
ArEO MA'1 a
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601 't3
Office: 508-862-4644 Fax: 508-790-6304 '
TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) 1 N
;tea
DATE 'Z j NEW BUSINESS OWNERSHIP RENEWAL ►�
NAME OF TOBACCO ESTABLISHMENT: D Ik-J A Sn Yv�s q mA
ADDRESS OF TOBACCO ESTABLISHMENT: ��--
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ,_
E-MAIL ADDRESS: etsi a.c�li 1 (0,
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT:
OWNER'S NAME: OWNER'S PHt#LQO- jftcl,
OWNER'S ADDRESS: `ID - 1.Lf 01 a i O L tr-f
CORPORATE ADDRESS: S -c_ CORPORATE FID#
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)
TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/33996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
https://malegislature.gov/Laws/GeneralLaws/PartIV/TitleI/Chapter270/Section6
***NEW BUSINESSES AND NEW OWNERS ONLY ***
REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED.
PLEASE CALL 508-375-6621
ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED-DOCUMENTS:
1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document\
2) MA State License to Sell-Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4
SIGNATURE: -Y
PRINTED NAME:��� :A�5,�
DATE: / 1/
Q:\Application Forms\TOBACCO APP-NonFavor I 1-21-19.doc
f
mS F-00
ESTABLISHMENT'S NAME
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371
of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the
penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section
371-9. of the Town of Barnstable Board of Health Regulation:
Sales to Minors—&371-9. Sale and Distribution of Tobacco Products.
1. No person shall sell or provide a tobacco product, as defined herein,to a person under
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
2. Identification: Each person selling or distributing tobacco products, as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of
Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws:
of yaA I/— 20— f
Signature Printed Name Date
29 -22
� .
Signature Printed Name ate
%%a a Printed Name ^� Date / f
ign ture Printed Name Date
Signature Printed Name Date
Signature Printed Name Date
Signature Printed Name Date
Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc
12/02/2019 12:51 5087474383 COLONNA FINANCIAL
�S PAGE 01/01
commonwealth of hTessachusetts Letter ID:L1649845440
' Depamnent of Revenue p
Christopher C.Harding,Commii ssoner Notice Date:September 4,201$
Account ID:CRL-10240907-010
CA znass.govldor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
��IdlttPtph�h�Il�il�lh��hlllt"llPrllllll�a�l�lllrbll
o HA,LEEMA,CoRp
$ SAMS FOOD SWORE
m 70 CAPE DR AFT 14B
MASHPEE MA, 02649-3062
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/masstaxeonnect 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"t' MASSACHUSETTS DEPARTMENT OF REVENUE
Form CT-3T
Retailer License for Sale of Cigars and Smoldug Tobacco
o� Tbts license must be posted and visible at all times.The sale o>Ftobacco
products to anyone under IS years of age is prohibited.
HALEEMA CORP Account ID: CRL-10240907-010
SAMS FOOD STORE License Number: 85616640
4738 FAL.MOUTH ROAD
MASIVEE MA 02649
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
Town of Barnstable BOARD OF HEALTH
Paul J Canniff, D.M.D.
A.Ga
Board of Health Donald A.Gaudagnoli,M.D.
= nstas John T.Norman
° A zQ.
200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
6
� 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, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 319 Issue Date: 12/20/18
DBA: SAM'S FOOD
OWNER: HALLEMA CORP..
Location of Establishment: 4738 FALMOUTH ROAD COTUIT MA 02635
Type of Business Permit: RETAIL FOOD y
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR: 2019
RETAIL FOOD: $100.00
COTTAGE FOOD,OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: - ------- --
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
TOBACCO SALES: $85.00
FOR ESTABLISHMENTS WITH SEATING:
I
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
0
oFs"E Initials:NU
Town of Barnstable I '
Date Paid ( �l I BARNAffirm$
AM M • Inspectional Services
y MARS' g'
Public Health Division
Thomas McKean, Director ;.
200 Main Street,Hyannis,N A 02601 p
Office: 508-862-4644 Fax: 508-790-6304 PS?
-IDS
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE 11--27—► NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT: l Z /EG 90 ( 1 T oZ(o �
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: i K11q,UI! Z.
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: l 4 J -1120-
TOTAL NUMB I
ER OF BATHROOMS:
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)
_TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
Q:\Application FormsT00DAPPREV2018.doc
- - - ---- - -
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNER: O/NO OWNER PHONE # 509- ` 1l-7
ADDRESS_ l 6) 1 rl�✓e- i ``7l e s e Me , U _l..,
CORPORATE OWNER: Y�� f 6 f C ' FEDERAL ID NO. :
CORPORATE ADDRESS: 7 Ll i,,c .( lC!' m115 P1 1/,:5 �..-ez-, 1 (2 2-6 q!2
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
�I
2.
z Izz.1g
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to openinz!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
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(S)AND REQUIRED FEES BY DEC 1st.
Q Upplication FormsTOODAPPREV2018.doc
�TNEta, Town of Barnstable Initials:
ti �o Date Paid Amt Pd$
Inspectional Services Check# CAA
r ' 39- Public Health Division
200 Main Street, Hyannis MA 02601L
Office: 508-790-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
Fee: $85.00
,c.:.
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
1A'-Je-q-Vq\ 4:24 a)([? A 5:c�Yn C3 A
ESTABLISHMENT NAME (DB/A)
ADDRESS OF BUSINESS
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
Asi � �E I
GYSJ et" o c i , Caw" O& 42-0 -sib 2
EMAM PHONE# FEDERAL ID#
Do you currently possess a state license to sell tobacco products?
Yes I No
Each employee who sells tobacco products must receive and understand Chapter 371 of
the Town of Barnstable Code (copy provided herein) and the Massachusetts General
Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee
who sells tobacco products must sign the Employee Signature Form (provided
herein).
z
Signature Date
Q:Wpplication Forms\TOBACCO APP2019 dob.docx
ES ISHMENT S NAME
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s) of this establishment received and
understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the
Massachusetts General Laws which describes the penalties for selling and/or giving tobacco
products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of
Barnstable Board of Health Regulation:
Sales to Minors—4 371-9. Sale and Distribution of Tobacco Products.
1. No person shall sell or provide a tobacco product, as defined herein,to a person under
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
2. Identification: Each person selling or distributing tobacco products, as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The following employee(s) received and understood Section 371-9 of the Town of Barnstable
Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the
Massachusetts General Laws:
ignature Printed Name Date
gna a Printed Name Date
z-2-7—fg-
i e Printed Name Date
S ature Printed Name Date
Signature Printed Name Date
Signature Printed Name Date
Signature Printed Name Date
Q:\Application Forms\TOBACCO APP2019 dob.docx
NUMBER FEE
162 THE COMMONWEALTH OF MASSACHUSETTS $100.00
TOWN OF BARNSTABLE
Sea Street Cafe Inc d/b/a, Sea Street Cafe Inc
Thisis to Certify that...................... ....................................................................................................................
50 Sea Street, Hyannis , MA
........................................................................................................................................................................................................................
IS HEREBY GRANTED A
COMMON VICTUALLER'S LICENSE
H
insaid.....................................................................yannis..,...MA..................................................................and at that place only and expires
December 31, 2022 unless sooner suspended or revoked for violation of the laws of the Commonwealth respecting
the licensing of common victuallers. This license is issued in conformity with the authority granted to the licensing
authorities by General Laws,Chapter 140,and amendments thereto.
HOURS: 48 interior seats.Daily hours of operation will be 7:OOAM to 10:00PM.
RESTRICTIONS:
In Testimony Whereof,the undersigned have hereunto affixed their official signatures.
NOT VALID . " a//00.0-
unlessissued in ......................... .......................
conjunction with a Licensing
.......
Food Service Permit w �. ...' Authorities
Issue Date• December 13, 2021 THIS LICENSE MUST BE POSTED IN A CONSPICUOUS PLACE UPON THE
PREMISES.
`°p INE row TOWN OF BARNSTABLE _ - - H OFFICE HouRS P R's Establishment Name: -S Date: _age: ( of
PUBLIC HEALTH DIVISION 8:00-9130A.M.
BARE. 200 MAIN STREET 3:30-4�30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MA.- �.. MON.-FRI.
'qp ,659•a e HYANNIS,MA 02601 soa-ssz asaa No Reference_ R-Red Item PLEASE PRINT CLEARLY
'FON1P� FOOD ESTABLISHMENT INSPECTION REPORT
Name S? is Vt' Datel 13 2 Type ci f InspectionI /
Operation/s) Routin / I✓1 / O(
Address �3�' �� �,'- Risk �Oetail
rvice Re-inspection
Level Previous Inspection
Telephone tial Kitchen Date: � _ /�U j-
Mobile Pre-operation .
Owner HACCP Y/N Temporary Suspect Illness I '>GY►d a+-
Caterer General Complaint
Person in Charge(PIC) OdA^_S a. Time Bed&Breakfast O HACherCP /
In:Z`.Z('b I
Inspector hjb Out: 'y; u
C 3 j ?
Each violation checked req res an explanation on the narrative page(s)and a citation of specific provision(s)violated. 11,
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ D 11-e�
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ � ��-�( i r L
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands JJ_
❑ 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 h2e�
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals /
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding / L
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) r
�r
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) 1 2A Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating L
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 Embar o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 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 regardless of the number of critical, results in an F.
26.Water,Plumbing and Waste, (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
25.Equipment and Utensils B=One critical violation and less than 4 non-critical violations 9
(FC-4)(590.005) cited in this report may result in suspension or revocation 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
back-up,sewage water,critical
If l no crca ,iti 9 than non-critical. a
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 g p,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
violation,4 to 8 non-critical violations=C.
30.Other 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
Dumpster Screen 7 Y N
.. __.,..... �...�. 'ram _.,- t. -'�..._ .- ..• .�..t ,. .� -T ,.. �. . � - .. ... _ � ,_ �-. .� _ _,. ----- -= �--- v_-_. .. .° _. _-�.-.• -�-,-. .. - -• ..-�
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41'F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202-12, Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and-cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additive*s
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41
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
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 * ( ) 9
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g ( )
_ - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B)_Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* - 4-501.112 Mechanical Warewashing-Hot Water 1 Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 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
5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
_
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* - 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg en a/O/2001
_ 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(13) Water Meets Standards in_310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3 401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009 A Din cater-
3-201.15 Molluscan Shellfish from NSSP Listed_ Chemical* ( )-( )
Ratites-165°F 15 sec*
Sources* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and AuWilthority
y ooms 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 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements.
radicsshould be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Y
12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* L18 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* 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.
°F tMF T � TOWN OF BARNSTABLE_ �/'{r�` HEALTH INSPECTOR'S Establishment Name: l Date: T Page: of
_ '1 I OFFICE HOURS
PUBLIC HEALTH DIVISION 0V 8:00-9:30A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-a:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
mass g p.+pS9,p`m HYANNIS, MA 02601 MON.-FRI.
508-862-4644 No Reference R-Red Item - PLEASE PRINT CLEARLY
rFO MPS FOOD ESTABLISHMENT INSP TON REPORT -
Name Date Type of Inspection
^ Operation(s) outin
Address isk Food Service -nspectio
evel a al Previous I ti
Telephone Idential Kitchen Date:
Mobile Pre-ope
Owner HACCP YIN Temporary Suspect II ess
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In Other
Inspector,-,' 4alffi Ze 10-1
Each violation checked requires an explanation on the narrative age 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
/N VIM
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities O
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 1/1 IN17
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 A le-
f n
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 HSPp
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY 1 d
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories L
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations _
Critical(C)violations marked must be corrected immediately. (blue 8T red items) 1 a Mn Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance
Com ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items ❑ go F] Emergency Closure Other:
Embargo
checked indicate violations of 105 CMR 590.000/Federal Food Code. Voluntary Disposal ❑
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4nori-critical violations 9
)( ) cited in this report may result in suspension or revocation er the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 non-critical vi atio =C. .
29.Special Requirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: In borSiature
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) I Assignment of Responsibility* F a 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 F 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* g7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Se 3-501.16(A) Roasts Held At or Above 130°F*
Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P 8 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated 3-306.14(A)(B)Returned Food and Re or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
ed 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 Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
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* sg cnvc mrzoot
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
aces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Ho[Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* 1 p Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Y d Mushrooms Approved B 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* * (Blue Items 23-30)
3-202.15 Package Integrity g g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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 V6-301.12
Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans Hand Drying Provision 29. 1 Special Requirements 1.009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103. 22 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
°p 114Er TOWN OF BARNSTAB.LE: HEALTH.wSPECTOR's Establishment Name: sq`rn6 Food Date: V _Page: of
'4 OFFICE HOURS
PUBLIC HEALTH DIVISION 6:00-9:30A.M.
BARNSTABLE. 200 MAIN STREET 3:30-4:30 P.M. - Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS,MA 02601 sos 862-asna No Reference R-Red Item PLEASE PRINT CLEARLY. _
FOOD ESTABLISHMENT INSPECTION REPORT yoje3
Name Sav►) F00� Date��'���(� Tvue 0 Ivat of inspection r
Operation(s) Routine < Uw
Address L{7`�� I-a l Risk Service - = scoop -D 1b L-V0-0
Level a Previous Inspection
Telephone Residential Kitchen. Date:
Mobile Pre-operation
Owner HACCP YIN Temporary Suspect Illness } -r 41 lei
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP 5ctihc LV(A In
In: Other
i
Inspector an rnS Out: - ('t �Bu✓ f
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 TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
1718.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY,SUSCEPTIBLE POPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HS-
❑ 10.P.roperAdequate Handwashing CONSUMER ADVISORY � ••- _3_9
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) , FI Corrective Action Required: I j No ❑ Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating ry p ❑ ❑ p ❑
Y y ❑ 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.
(FC-4(590.005 B=One critical violation and less than 4non-critical violations 9
25.Equipment and Utensils ) ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6von-critical violations=B.
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials. (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
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 DATE OF RE-INSPECTION: /t J n �- ✓�n�
31.Dumpster screened from public view �`v` I f I 'f
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
A-.1 Af
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 ._ Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* *
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical 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.I IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System*
4-601.11(A) Clean Utensils an Eggs d Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg ca-/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 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
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms*
2-301.14 When to Wash* 3-401.11(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*
* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11 Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.11 PHF's Received at Proper Temperatures* (B) g
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
590.004(E) Preventing Contamination from Employees* Proper Cooling of PHFs
6 Tags/Records:Shellstock 18 p g 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. Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6.2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
47
7q
`oa7NE Tok TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Qage: of
ti OFFICE HOURS
p ° PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
mAss. g. MON.-FRI.
FC639- HYANNIS, MA 02601 soa-as2�saa No Reference R-Red Item PLEASE PRINT CLEARLY..
FOOD ESTABLISHMENT INSP CT O REPORT
Name Date , ine o g5RXf Ins ection
OOperation(s) Routine i
Address Risk &ential
ervice e-Inspection
Level us Inspection
Telephone Kitchen Date: j
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP G
In: Other
Inspector Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. tr
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 Asa 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❑ l-,O ^ (�
10.Proper Adequate Handwashing CONSUMER ADVISORY -�/ll' 1�y1 /✓�
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) (� IG Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately.or Overall Rating v I
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 4 non-critical violations
if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if:-no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
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 9non-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: InspectoMSignare Print:
31.Dumps r screened from public viewYV
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y IN
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PI s Si a 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* S 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* 1 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
3-302.14 Protection from Unapprbved 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 3-30211(A)(2) Raw Animal Foods Separated from Each 590.004(F)
. * .
7-101.11 Identifying Information, Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers*
3-501.16(A) Hot PHFs Maintained At or Above 140°F*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
PP *
A licants 7-201.11 Separation-Storage*3-302.11(A) Food Protection* • 20 Time as a Public Health Control
' 590.003(F) Responsibility of A Food Employee or An 3-302.15 7-202.11 Restriction-Presence and Use*Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions*
3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
590.003(E) I Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.13 Tracking Powders,P
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Pe 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* 3-401.1IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* sg c"°e urrzoor
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 u Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11 C 3 Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* ( )( ) p
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 * (Blue Items 23.30)
3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome
12 Prevention of Contamination from Hands
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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45'F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained*
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
3 402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501..14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
°F/45°F
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41 25. Equipment and Utensils FC-4 .005
Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices
27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures 1 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision
29. Special Requirements .009
3-502.11 Specialized Processing Methods*
30. Other
3-502.12 Reduced-.Oxygen Packaging Criteria*
8-103.12 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 IMF row TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: ` Date: Page: of
ti OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
.65 s•� HYANNIS,MA 02601 sos-862-464a No Reference R-Red Item PLEASE PRINT CLEARLY
'FDN1P' FOOD ESTABLISHMENT INSPECTION REPORT
nwfkA
Name Dat Tyne of of Insl2ection
Operation(s) out
i
Address Risk Food Service --Inspection
Level et Previous Inspection r-- l
Telephone residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness _
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector Out:
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) ❑ od
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
5i
VCritical(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
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 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
C=2 critical violations and less than non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations 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
29.Special R uirements � (590.009)
within 10 days of receipt of this order. violation,4 to a non critical violations=C.
30.OtjMp-V
DATE OF RE-INSPECTION: Inspector's Signature Piin_t:
31.Dusc7ened from public viewPermit Posted? - 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-I03.11 [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 7-201.11 Separation
Common Name-Working Containers*aration-Storage* *
3-501.16(A) Hot PHFs Maintained At or Above 140'F
Require Reporting by Food.Employees and ' Contamination from the Environment 3-501:16(A) Roasts Held At or Above 130°F
Applicants*- -- - --- - '- '-" 3-302.11(A)- Food Protection* P g 20 Time as a Public Health Control
i 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables i 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
3-304.11 Food Contact with Equipment and Utensils
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* " _ 590.004 11 _ Requirements
590.003(G) Reporting by Person in-Charge* - --_ _ 7-203.11 Toxic Containers-Prohibitions*
( ) _ Variance
- Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Resumed Food and Rrated or of Food 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions g ( )
• Disposition of Adulterated or Contaminated
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 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
Raw Se
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Seed Sprouts Not Served* *
3-201.13 Fluid Milk and Milk Products* 4-501112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* - - - Concentration and Hardness* 3-401.11A(1)(2) Eggs-155`F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* ex crfve inrzooi
4-602.11 Cleaning Frequency of Utensils and Food Animals-155`F 15 see*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Fggs Substitute for Raw Shell
4-702.11 Frequency of Sanitizatiop of Utensils and Food
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec*
Sources*. ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
2-301.14 When to Wash* . Other 590.hou violations relating to good retail
590.004(C) Wild Mushrooms* 3-40111(A)(1)(b) All Other PHFs-145'F 15 sec* practices should
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding ld be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165`F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3'-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodborne
* 12 Prevention of Contamination from Hands - 3403.11E 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
3-202.18 Shellstock Identification* 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
3AO2.12 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.
°FINE Toy," TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of
l OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNS7'ABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
6 q: �0�' - HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY .
�Dren MPS° 508-862-4644
FOOD EST BLISH ENT INSPECTION EPORT
Name Dat �t a of e o sec ion
p Routin
Address Risk I e-inspection
Level R_a al Previous Inspection
Telephone ential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector Out:
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) ❑ L VIA
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
F] 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous F ods)
❑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 Asa Public Health Control
1718.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 kx vff
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violationsa
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 18 I ❑ ❑within 90 days as determined by the Board of Health. 6 v Voluntary Compliance ❑ Employee Restriction/Exclusion Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspecti n 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 o 6 n-critical violations 9
26.Water,Plumbingand Waste if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
(FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 -critical. If no critical ' water,sewage
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you'have a right to a hearing. Your request must non 9a 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 8nnn-critical violations C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
=
30.Other
DATE OF RE-INSPECTION: Inspector's Signat re Print:
31.Dump er screened from public view Y)A4�
Permit Posted? Y
N Grease Trap Previous Pumping Date Grease Rendered Y N - VIA
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's ignature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
r
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1q Food or ColorAdditives. 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 Un_approv_ed Additives* 79 PHF Hot and Cold Holding
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* g * 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
7-102.11 Common Name-Working Containers *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
* 7-201.11 Separation-Storage*
Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements
ontamination from the Consumer
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
C
3 1590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals*
3-306.14(A)(B)Returhed Food and Reservice of Food* REQUIREMENTS FOR
1590.003(E) Removal of Exclusions and Restrictions 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Disposition of Adulterated or Contaminated
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
q - Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual 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 Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-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. 1 g Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate
Equipment*
590.006(A) Bottled Drinking Water* -- 3-401,I l(A)(2) Comminuted Fish,Meats&Game Pathogens* effe eve uuzoot
4-602.11 Cleaning Frequency of Utensils and Food t Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
faces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
2-301.14 When to Wash* * Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
$ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 * (Blue Items 23-30)
3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne
* 12 Prevention of Contamination from Hands 3-403.11E Remainin 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,Crcation 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 2g. 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:590Forrnback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
• NAME OF OF310
FENDERr p DAD Yy
TOWN OF ADDRE S OF OFFENDER T(�I D„n ■I
',a art., � d TI 3A ��l>rntDw411
BARNSTABLE CITY,STATE ZIP CODE
111E tp�
OFFENS
NAN\�I ABLE. ,ram�*y {f Q -•t�')�,, ^� +,+� /A{ W
MASS, �"`��� ^a'/� i 1 4J �'� 3 e i U4�''a V�. V�I{j��C.+t,:.iEt ��� CL
1639-
ED MAY y. //"^a Air y LU
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5.
TIME AND DATE 0WOOLATION [+r;! LOCATION OF VIOLATION `v'I .�" w
NOTICE OF nr64 2A ;('A M1 P.M.)ON �(I 2A 1201 7 '7 off #"Yap+ a Ut} q a
SIGNATUR�E�O�,;,;fIFO,RGI�:PkERSON ENFORCING DEPT. BADGE N0. � rw
VIOLATION 1Al"at fl-
0
OF TOWN I HE B`1' ACKNOWLEDGE RECEIPT OF CITATION X Q
ORDINANCE Unable to obtai sI nature of offender. THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ ��. F—
�20 1'7 w
Date mailed �r W
OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL
DISPOSITION WITH NO RESULTING CRIMINAL RECORD: W
REGULATION Uj
(1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, J
before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a,check,money order or postal note to Barnstable Clerk,P.O.Box 2430, a
Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE.
is (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST
BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this
citation for a hearing.
. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing
to be due,criminal complaint may be issued against you.
❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$
Signature
P�OFZHE T�� Town of Barnstable
Regulatory Services Barn
BARNSTABLE, # Richard Scali,Director MAmerica MItY
9� 639. Public Health Division ■\ !
pTFD N10�a Thomas McKean, Director 2007
200 Main Street
Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Certified Mai14 7015 1730 0001 4990 1505
April 28, 2017
Sam's Food
Farhat Asif, Owner
4738 Falmouth Road
Cotuit, MA 02635
NOTICE OF SHOW CAUSE HEARING
On 03/28/17, cigarettes were sold to a minor (a person who was under the age of 18 years)by a
person employed at your store.
According to Section 371-7($) of the Town of Barnstable Code,revised on August 23, 2016,
no person, firm, corporation, establishment, or agency shall see tobacco products to a minor.
According to Section 371-8 of the Town of Barnstable Code, "any proprietor(s) or other
person(s) ... who fail(s)to comply with these regulations shall be subject to the following
actions for each offense: A fine of$100 may be issued for the first offense. A fine of$200 .
along with a 7-day suspension of their tobacco permit may be issued for the second offense, a
$300 fine along with a 30-day suspension of their tobacco permit within a three year period may
be issued for the third offense, and if a fourth violation occurs during a three year period,they
will lose their tobacco license altogether.
You are hereby notified to appear before the Board of Health on Tuesday,May 23,2017, at
3.00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss
any future plans you may have to comply with this regulation. The hearing will be held in the
Town Hall, Hearing Room, 367 Main Street, Second Floor, Hyannis, Massachusetts.
PER ORDER OF THE OARD OF HEALTH
Th cKean,RS, CHO
Director of Public Health
Q:\TOBA000MP Files\tobacco hearing letter Sams Food Viol Mar28-17 BOH May2017.DOC
1
MTCP ID: Tobacco Compliance Check Form 2014-2015
Section 1:
Establishment Survey]Participants
Name: MA _S A4Wt'_S
1D of Purchaser: /✓ i
Address: 12-y,-e Age: ❑ 16 17
Sex.pMale ❑Female
//ttM �j Name Adult Supervisor:
l:t
City: (7' Zip Code: L _ l.�L
Time of Check: .��1 am<pm❑
Type of Establishment: �4 Date of Check:.❑ Independent .❑ Not Known -317
Day of the Week:❑ Mon Alues ❑Wed
❑Thurs ❑Fri ❑ Sat ❑Sun
r
Style of Establishment(Check Only One);
❑ Convenience Store ❑Grocery Store ❑Bar
❑ Department Store ❑Liquor Store ❑Private Club MW,Legion,eta
❑ Gas Station Only ❑Pharmacy/Drug Pharmacy/Drug Store ❑Restaurant
:Vigas Mini-Mart ❑Other(bowling alley,golf club etc. ❑Tobacconist
Section 2:
Was Compliance Check completed? Yes tL No 0
If Yes please continue on to the next question,if No please skip this section and go to section 3, j
ow was tobacco marketed?
Over-the-counter:youth asks the clerk for the product.
❑ From a vending machine with a lockout device. I
❑ Other Describe:
Was the Purchaser asked for ID? Yes❑ No Was this an TD-based check? Yes❑ N04
Was the Purchaser asked his/her age? /Yes❑ No
Sex of Clerk: Male Female❑ Approximate age of clerk:❑Teen ❑Young Adult 64Adult ❑Older Adult I�
Type of tobacco asked for: Cigarettes Brand of cigarettes asked for:❑ N arlboroANewport ❑Other:
❑ Cbew/Dip ❑ Cigars ❑ E-Cigarettes ❑ Other Brand:
Was the product regnested flavored.(NOS'Tobacco or menthol)? Yes Q Nox
Was the sale made? Yes A-No 11
If"Yes"how much did the product cost: SO i 6 Was a receipt given?'Yes❑ NOA
Purchaser made payment using:❑ 1 bills ❑ 5 bills ❑ bill and 1 bills/or change❑ 10 it .s 20 bill ❑ change
Section 3:
!
If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why: i
❑ Out of Business ❑ Temp.long term closure ❑ In o eration,closed at time of visit ❑ Drive thru.only
❑ Does not sell tobacco ❑ Unlocatable ❑ Unsafe to access ❑ Tobacco out of
stock
❑ Inaccessible by youth ❑ Wholesale only/cartons ❑ Presence of police ❑ Permit Suspended
❑ Private club/personal ❑ Machine broken 11 Youth inspector knows si ❑ Other i
residence ❑ `Don't sell"but tobacco seen:in
s are as permit '
i
i
4/14115
' I
i
uiLn
Ir
p" Certified Mail Fee' V
:I" ExtWServices&FeFs(checkbox,add fee as appropriate 4 +f
VRetu� Receipt(hardcopy) $
C3Receipt(electronic) $ �1 Postmark
d Mail Restricted Delivery $ + +1n7 r Here
C3 ❑Adult Signature Required $ 6tW L—jl1rr
[]Adult Signature Restricted Delivery$ t�.
IO Postage
m
Total Postage and Fees �.rq
,-
a se' Sam's Food
""."""-"""-."."""""""""."""
rr, Farhat Asif, Owner
uk 4738 Falmouth Road "' """"""""""
Cotuit,MA 02635 `S�
Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
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■Electronic verification of delivery or attempted return receipt for no additional fee,present this,
delivery. USPS®-postmarked Certified Mail receipt to the.'
retail associate. G'
a A record of delivery(including the recipient's .7,
signature)that is retained by the Postal Service- Restricted delivery service,which provides
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent
Important Reminders. Adult signature service,which requires the
■You may purchase Certified Mail service with L
Y P signee to be at least 21 years of age(not r t
First-Class Mail®,First-Class Package Service®, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which
i Certified Mail service is notavailable for requires the signee to be at least 21 years of age
International mail. and provides delivery to the addressee specified
a Insurance coverage is not available for purchase by name,or to the addressee's authorized agent,
with Certified Mail service.However,the purchase (not available at retail). r—
of Certified Mail service does not change the a To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark If you would like a postmark on j j
•For an additional fee,and with a proper this Certified Mail receipt,please present your r
endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for _
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a.record Certified Mail receipt,detach the barcoded portion
of delivery(including the recipient's signature), of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an :appropriate postage,and deposit the mailpiece..
electronic version.For a hardcopy return receipt 7
complete PS Form 3811,Domestic Return 11
Receipt attach PS Form 3811 to your mailpiece; IMPORTAR7:Save this receipt for your records.
Ps Form 3800,April 2o75(Reveme)PSN 7530.02.000.9047
1 • • • I DELIVERY
a Complete items 1,2,and 3.
A. Signature
■ Print your name and address on the reverse X . ` gent
so that we can return the card to you. `w ' ❑Addressee
■ Attach this card to the back of the mailpiece, B. Received by!(`Pririinntteed/Name) C..D to of Delivery
or on the front if space permits. t--A
1. Article Addressed to:_ D. Is delivery address different from item 1? ❑Yes
Sam's Food If YES,enter delivery address below: 'Emo
Farhat Asif, Owner
4738 Falmouth Road I
Cotuit, MA 02635
I
II I IIIIII IIII I!I I III I II II I I I I IIIII I Il II Il I III ` ` e ty Mail �®IAdult Signature Cegstered MailT^^
� i,Sitrre Restricted Delivery R stered Mail Restrict
ed��ert M 9590 9402 2480 6306 7770 46 ❑certified Mail Restricted Delivery nyReceipt for
❑Collect on Delivery Merchandise
_9_Articles Ni j'her!Transfer fromseiV/cg/ab2/) :T, ❑Collect on Delivery Restricted 6ellvery Signature ConfirmatidnTm
❑Insured Mail ❑Signature Confirmation
7 015 173 0 0 0 01 4 9 9 0 15 0 5 o Insured Mail Restricted Delivery Restricted Delivery
(over$500) .!�C/
PS Form 3811,July 2015 PSN 753Q 02-000-9053 Domestic Return Receipt;
LISPS TRACK[NG#
First-Class Mail
.Postage&:Fees Paid
LISPS --
Permit No.G-10
9590 d2 2480 6306 7770 46
United States •Sender:Please print your name,address,and ZIP+4®in this box•
Postal Service
PUBLIC HEALTH DIVISION
TOWN OF BARNSTABLE f
200 MAIN STREET `
HYANNIS, MA 02601
Jill iiiF Ill I ill Jill Ill i'illj i111.1-1111 ill i1,11 hill i1hIII illt1111
17
a Complete items 1,2,and 3.Also complete 7A. atureiitem 4 if Restricted Delivery is desired. Agent
a Print your name and address on the reverse Addressee
so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery
■.Attain this card to the back of the mail piece,
p 1PROor on the.front if space permits. •/3 �
D. Is a iver address different from item 1? ❑Yes
1 Article Addressed to: If YES,enter delivery address below: ❑No
15AVO sTb04/�VRu 14 urn G6
,��ovi: VV1U�anniv�aA �-d�I
3. Service Type
PQ Certified Mail ❑Express Mail
❑ Registered ❑Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 11 7H2 1012 '0000-2851 0466,
(Transfer from service label) i
LIPS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
'�C�:
UNITED.STATES POSTAL,SERVICE First-Gas s�Nlait, 9
<Rostage&-ees=PI�d
USPs,
t r+ermit N G-Ib
res a
I •Sender: Please print your name, address, and ZIP+4 i thlst ox • �
—Towvj
kA IV6IM
-{— yowvit5, 0 D2(oD I
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TOWN OF BARNSTABLE BAR-w I, 528
Ordinance or Regulatiot
Sf4x1 S �{� WARNING NOTICE
Name of Offender/Manager A4tJ k'aMM ?0 AJ- 1 „ (05+ArN4ke.t'
Address of Offender MV/MB Reg.#
Village/State/Zip 1j
Business Name Nye �D d lsar«hi � � oc a -AJ : 2,2am/pm� on ln' J s 20
""4► 3 p x
Business Address '"� t��rn��`� ��e��
Signatu=e .of Enforcing Officer
Village/State/Zip
> /y eY' . ►
Location of Offense Rd . (-JUJ AAA
Enforcing Dept/Division
Offense '4SeC-tt _'O() -1 1 - 1 t/":5 1! Q{1, ��'t,,,' fir+ Or
Facts her x e) JorocuGt Were_ 1:s018 '�►nyr"
1
This will serve only as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
TOWN OF BARNSTABLE
• y�B _ 1.
y Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager mukz AAIAao A ex rAe.r
r � y
Address of Offender MV/MB Reg.#
Village/State/Zip
Business Name �r�3t�n<: t ra r �=,�tr,} �. ''�Df it 41 22am/p on �� 20 i
Business Address ;' WtAi 1A �'v .Q
Signature .of Enforcing Officer
Village/State/Zip
C} , i7 .�
t
Location of Offense 4V-16f'i ,f�..a ' ( ol- ,� ' Al
Enforcing Dept/Division
Offense
Facts r r , 0 CI V C tom'{C' .:1 I a .3 t%f 'Nor
This will serve only as a warning. At this time no legal action has been taken. o
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
2 �l
AiycP *acco Compliance Check Forn* 2011-2012
Section 1: -
Establishment SAYAs Survey Participants
e: �t?nn�. � 5�o GO f'
p r q ID of Purchaser: y
Address: Age: ❑ 15 1116 tp 17
Sex: ❑Male OFemale
Name of Adult Supervisor:
City: QQ& Zip Code: b
Time of Check: 2 2 am❑pm ,
Type of Establishment: Chain ❑ Independent ❑ Not Known Date of Check: 12 13
Day of the Week: ❑Mon ❑Tues❑Wed
❑ Thurs Fri ❑ Sat ❑ Sun
Style of Establishment(Check Only One):
❑ Convenience Store ❑ Grocery Store ❑ Bar
❑ Department Store ❑ . Liquor Store ❑ Private Club VFW,Legion,etc.
❑ Gas Station Only ❑ Pharmacy/Drug Store ❑ Restaurant
Gas Mini-Mart ❑ Other(bowling alley,golf club etc.) ❑ Tobacconist
Section 2:
Was Compliance Check completed?Yes d No ❑
If Yes please continue on to the next question,if No please skip this section and go to section 3. L6
How was tobacco marketed?
I
* Over-the-counter:youth asks the clerk for the product. ii 11
❑ From
m a vending machine with a lockout device.
❑ Other
M
Describe:
Was the Purchaser asked for ID? Yes ❑No� Was this an ID-based check? Yes ❑No
Was the Purchaser asked his/her age? Yes ❑No'�
Sex of Clerk: Male Female❑ Approximate age of clerk: Teen ❑Young Adult ❑ Adult ❑ Older Adult
Type of tobacco asked for: ❑ Cigarettes Brand of cigarettes asked for: ❑Marlboro ❑Ne rta ❑ Other C_
�o f-
z
❑ Chew/Dip ❑ Cigars � Other Brand:
Was the sale made? Yes No ❑
ii G,
If"Yes"how much did the product cost: $ 1 e.
p Uy Was a receipt given?Yes❑No�A
Purchaser made payment using:�k$l bills ❑ $5 bill(s) ❑ $5 bill and$1 bills/or change ❑ $10 bill(s) ❑ $20 bill ❑ hange
Section 3:
y- F-
If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why:
❑ Out of Business ❑ Temp.long term closure ❑ In o eration,closed at time of visit ❑FDriveru onl❑ Does not sell tobacco ❑ Unlocatable ❑ Unsafe to access ❑ out of stock❑ Inaccessible b outh ❑ Wholesale onl /cartons ❑ Presence of olice ❑ us endedPrivate club/personal Machine broken Youth ins ector knows sales erson
residence ❑ "Don't sell"but tobacco seen in
store/has permit
� ��� ��,��- �s��
r
�FtHE
,,,RNSMBLE, : Town of Barnstable
16 9. ,.� Regulatory Services Barnstable
Thomas F. Geiler, Director AM-America City
Public Health Division 1 I 1 S.
Thomas McKean,Director 2007
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 2, 2013
Sam's Food
Farhat Asif, Owner
4738 Falmouth Road
Cotuit, MA 02635
NOTICE OF SHOW CAUSE HEARING
On 06/21/13, cigarettes were sold to a minor(a person who was under the age of 18 years)by a
person employed at your store.
According to Section 371-7(B) of the Town of Barnstable Code, no person, firm, corporation,
establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of
the.Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s) to comply
with these regulations shall be subject to the following actions for each offense: A warning
shall be issued for the first offense. A fine of$100 may be issued for the second offense, $200
for the third offense, $300 for the fourth offense, and$300 for any subsequent offense.
You are hereby notified to appear before the Board of Health on Tuesday, July 9, 2013, at
3:00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss
any future plans you may have to comply with this regulation. The hearing will be held in the
Town Hall, Hearinil Room, 367 Main Street, Hyannis, Massachusetts.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, RS, CHO
Director of Public Health
Q:\TOBACCO\WP Files\tobacco hearing letter Sams Food Ju12013.DOC
OF THE Tp�
BAINST
ABLE. Town ®f Barnstable
QQ Regulatory Services Barnstable
OD i6;g, ♦�
'Thomas F. Geiler, Director merica rity
Public Health Division
Thomas McKean,Director 2007
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 2, 2013
Sam's Food
Farhat Asif, Owner
4738 Falmouth Road
Cotuit, MA 02635
NOTICE OF SHOW CAUSE HEARING
On 06/21/13, cigarettes were sold to a minor (a person who was under the age of 18 years)by a
person employed at your store.
According to Section 371-7(B) of the Town of Barnstable Code, no person, firm, corporation,
establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of
the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fails) to comply
with these regulations shall be subject to the following actions for each offense: A warning
shall be issued for the first offense. A fine of$100 may be issued for the second offense, $200
for the third offense, $3001or the fourth offense, and $300 for any subsequent offense.
You are hereby notified to appear before the Board of Health on Tuesday, July 9, 2013, at
3:00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss
any future plans you may have to comply with this regulation. The hearing will be held in the
Town Hall, Hearing Room, 367 Main Street, Hyannis,Massachusetts.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, RS, CHO
Director of Public Health
Q:\T0BA000\WP Files\tobacco hearing letter Sams Food Ju1201330C
y�
I
i
MTCP ID: I obacco Compliance Check Form 2011-2012
Section l:
Establishment S Survey Participants
e:
(� "� pp 1 p ID of Purchaser: G
Address: 3 F'c�lvv�o ,� !�1 Age: ❑ 15 ❑ 16 f 17
Sex: ❑Male [!Female
t Name of Adult Supervisor:
City: Zip Code: ��
Time of Check: t-/j�: 2 2 am❑pm
Type of Establishment: N Chain ❑ Independent ❑ Not Known Date of Check: b I ( J
Day of the Week: ❑Mon ❑Tues ❑Wed
❑ Thurs Fri ❑ Sat ❑ Sun
Style of Establishment(Check Only One):
❑ Convenience Store ❑ Grocery Store ❑ Bar
❑ Department Store ❑ . Liquor Store ❑ Private Club W,Legion,etc.)
D Gas Station Only ❑ Pharmacy/Drug Store ❑ Restaurant
Gas Mini-Mart ❑ Other(bowling alley,golf club etc.) ❑ Tobacconist
Section 2:
Was Compliance Check completed?Yes t�No ❑
f Yes please continue on to the next question, if No please skip this section and go to section 3. , r Q .
low was tobacco marketed?
Over-the-counter: youth asks the clerk for the product.
From a vending machine with a lockout device.
7 Other
Q_
)escribe: �iJ 1 S '
Was the Purchaser asked for ID? Yes ❑No Was this an ID-based check? Yes ❑No
Was the Purchaser asked his/her age? Yes ❑No
.ex of Clerk; Male Female❑ Approximate age of clerk: Teen ❑Young Adult ❑ Adult ❑ Older Adult
.ype of tobacco asked for: 0 Cigarettes Brand of cigarettes asked for: ❑Marlboro ❑Newport; ❑ Other:,
❑ Chew/Dip ❑ Cigars Other Brand v.�
Vas the sale made? YA No ❑
If"Yes"how much did the product cost: $ U lV Was a receipt given? Yes ❑No
'urchaser made payment using: $1 bills ❑ $5 bill(s) ❑ $5 bill and$1 bills/or change ❑ $10 bill(s) ❑ $20 bitl" ❑:`change
section 3: _.... .
f the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why:
] Out of Business ❑ Temp. longterm closure ❑ In operation, closed at time of visit ❑ Drive thru or-t
I Does not sell tobacco ❑ Unlocatable 0 Unsafe to access ❑ Tobacco out of stock
7 Inaccessible by youth ❑ Wholesale only/cartons ❑ Presence of olice ❑ Permit Suspended
Private club/personal 0 Machine broken 0 Youth inspector knows salesperson Other
esidence ❑ "Don't sell"but tobacco seen in
store/has permit I
i1
I J
i
growing No. Revisions '
o 9-7-02007 , Existing
Drafting 8c Design +
by 2 t1 - 3 �
o -- - _ -_-- LpCvti 4 Floor Plan
C CrN V E N I E N C E s T O R E s Santuit.t
-- C"cola• 1/4" = 1• �
i
---- - 25' Of " �
T-=
Electric
Desk
2 doc�-r 2 door N
cooler cooler O
\/ 4
00.
4.
O
O \ ON
0 p
�0
U.
3' E'
o f -7
Orowing No. Revisions IA.A� k'4 �)1 c
0 97-OZ008 1 3-18-97 Proposed
Drafting & Design. ootF, 2
by JC r !-art
a ra 2-1 9-97 3
=�tj it 4 Floor Plan
O N V E N I E N C E S -r O R E S Sontult
ScolO 1/4" = 1
1
#1 Remove existing 2 door cooler.
#2 Install a used 6' coffee counter.
#3 Water and electric from ove-ncead.
/ - #4 Install new 3 bay sink
rr
2 ' 0 #5 Tum existing mop sink
- #6 Build plumbing wall and
Z TEjecl
- cower with.FRP.
ric o � Estimated cost for\\ Nevv 3 bay sink above1,500.
-- T-1� C -
---- �, � � Desk
Q,::all 2 doer
COOIe"
r� New 6' cc.3ffee
0 Q
I °
Rernove 2 door cooler
J
J
We do not have a one
1 door doom cooler. if we have to
• I buy it will cost $4,000.
0
J
_ pN
Oa
-0
13' 10-23/64"
3' 8. ---
I
r,
KENYON OIL COMPANY, INC.
221 Quinebaug Road
North Grosvenordale, CT 06255
Ph: 860-935-5200 Fax: 860-923-2172
P0767V3-(o3j �
November 19, 2001
Town of Barnstable
Public Health Division
P.O. Box 534
Hyannis, MA 02601
508-862-4644
Dear Sir or Madam:
Enclosed please find a Retail Food, Milk, and Tobacco License renewal for Santuit Xtra Mart
located at 4738 Falmouth Road, Santuit, MA 02635. License renewals are sent to this location,
which delays process and prompt payment. Kenyon Oil Company, would like to request a
change of mailing address.
Please send License renewals and licenses to Kenyon Oil Company, Inc., 221 Quinebaug Road,
North Grosvenordale, CT 06255. This will insure that renewals get processed promptly. New
licenses sent to this office, Kenyon Oil Company makes a copy,which is left here on file and the
original is sent to the store for posting.
Your prompt attention to this matter will be greatly appreciated. If you have questions please call
Deborah Raymond at 860-935-5200 ext. 2298.
Sincerely, nn
01' �d
G�
Deborah A. Raymond
Assistant Accountant
DRAKE PETROLEUM COMPANY. INC.
221 QUINEBAUG ROAD
NORTH. GROSVENORDALE, CT 0625.5
Ph: 860-935-5200
Fax: 860-935-9396
January 13,2004
To Whom It May Concern:
Please be advised that effective January 1,2004 Kenyon Oil Company,Inc.,Fed ID #06-0646273,has
been merged into its sister company,Drake Petroleum Company,Inc.,Fed ID#04-2236089,with Drake
Petroleum Company,inc.,Fed ID#04-2236089 becoming the surviving entity.
You should continue to direct any questions as before,except that correspondence,checks and telephone
greetings will be in the name of Drake Petroleum Company,Inc.The telephone numbers and address
shown on this letterhead should continue to be used.
We kindly ask that you forward any paperwork necessary to facilitate a smooth transition to the attention of
Amato DiBiasio,Assistant Treasurer, at the above address.
Sincerely,
Kenyon Oil Company,Inc.
Ernest J. Wilk
Treasurer
. > Massachusetts Department of Conservation.and Recreation
Office of Water Resources ,. . 161890 I
TYPE OR PRINT ONLY. Well Completion Report - �
.WELL LOCATION GPS (Required) North ° Z .•' West D '�
Address at Well-Location Property Owner/Client: 0 -
Subdivision WA Name:p4p73��d11_ .. /J JmU� �O Mailing Address: . 6 .
CttylTown: �IILTi= • �'` Ciiy/Town." d 3
Assessors-.MapAssessors Lot# # '~ y NOTE Assessors'M -"
^* Map- Lot# mandatory rf no available
Board of Heatthpermit obtained: Yes' Not-Required ® Permit Number Dafe Issued
2.WORK PERFORMED 3.WELL'TYPE; ?' -: 4. DRILLING METHOD 6:CASING'
Overburden Bedrock From(ft) To (ft) Type°..! Thickness Diameter
Mg 109
np- , PT 911�11�lt 161 E F _E1 4 7
5.WELL LOG OVERBURDEN Extra �" � �'❑
Water Loss or Drop in
LITHOLOGY Bearing Addition Drill Fast or ❑®❑
Slow � •-.
From(ft) TOO) Code Color Comment Zone of Fluid Stem Drill Rate 7.SCREEN
Q W S; ;' Y / N Y / N F / S From(ft To`(ftj o Type Slot Size Diameter
Y / N Y / N F / SZ1
" y Y / N Y / N F / S El❑❑
❑❑❑ 1. - -
Y / N Y / N: F / S ; 8.ANNULAR SEAL/FILTER PACK/ABANDONMENT MTL'
Y / N Y / N F./4S From'(ft) To (ft) Material Description Purpose
Y / N Y / N F / S__ tKI
Y / N Y / N F,'/;'S• �
Y / N Y / N•e' R/'S El El ❑❑
Y / N Y //Nl Z F / S ❑❑ ❑
WELL LOG BEDROCK Exl�a -.�. 9. SITE SKETCH
_ Water .Drop in Extra ' Visible Loss or : #of rt
LITHOLOGY Bearing Drill Large Slowr Rust Addition Fracture
From(f t) To(ft) Code Comment Zone Stem AChi- PI'Drill Rate Staining of Fluid per foot -
Y / N Y-h�N`Fy/ S Y / N Y / N Q
Y / NYC/-N 10 / S Y / N Y / N -
i
NY``hNF / SY / NY / N
X�I.8,NY / N F / S Y / N Y / N
2 7 REC' i 'Y,i�' N F / S Y / N YVN
1 Y / NF / .SY / NY /.N
Y-% NY / N FlSYlN Y / N I ,'
Y / NY / NF / SY / NY / N
Y / NY / NF / SY / NYlN
• i i
m Y / N Y ! NJ F / S Y / N Y / N
10.WELL TEST DATA(ALL SECTIONS MANDATORY FOR-PRODUCTION WELLS) 11.STATIC WATER LEVEL(ALL WELLS)
Yield Time Pumped Pumping Level Time to Recover Recovery Depth Below <:
Date Method (GPM) (fais&min (Ft BGS) (hrs&min) (Ft. BGS) Date Measured Ground Surface (ft) I
12.PERMANENT PUMP(IF AVAI ILABLE) ITotal
13.ADDITIONAL WELL INFORMATION,,Pump Description -. " Horsepower Developed Y N racture Enhancement YPump Intake Depth - �` `� (#-)•Nominal Pump Capacity (gpmDisinfected Y Surface Seal Type
14.COMMENTS ` � Well Depth Depth to Bedrock
15.WELL DRILLER'S'STATEMENT This well was drilled;altered, and/or abandoned u der my supervision,according to.applicable
ules and re lations, and this report i o plete A correct to the best of my knowledge.
Driller: _ Supe�ising"Dn•IlSignature: Registration #:L514 10
�`� ,' Complete: G 15
Firm- = — C Date .� Rig Permit#:
•_ * IYOT :,wgl�,CoWpje(ion;$epgr(s mustbe;fledrby the.reg ter-ed.well driller,withirf 30 days of well campletion., ,, a.,•,=
BOAAD OF=MEALTli:
•EOPY{' ' ' _
Well Completion Report Codes y
[t 0 t V
i Section 2 - t7 Section 3"' t Section 4
Work 1ti .tNy Well Drilling
Work Performed a Type Method
Performed ;Code Well Type Code u';, Drilling Method'. Code
Decommission ",DC "Cathodic Protection CTPR :Air,Hammer AH
Deepen DP 4 Domestic DMST 'Air Rotary. AR '
Hydrofracture HF Geoconstruction GC.ON Auger AG
New Well NW Geothermal Closed Loop GTCL Cable Tool CT
Repair RP Geothermal Open Loop GTOL Casing Advancement CA
Replacement RE Industrial INDS Core CR
Injection INJC Direct Push DP
Irrigation' IRRG Drive and'Wash DW
Monitoring MONT Dug DG
Public Water Supply ! PBWS . 'Mud Rotary, MR.
Recovery ` RCVR Reverse Rotary RR
Test Wells TSTW Sonic SN
Section 5 Sectiom_ 6
Overburden ' Casing
Lithology Overburden Overburden Overburden Bedrock Type Thickness
Name (OB)Code Color Color Code Bedrock Name (BR Code) Casing-Type Code Thickness (NO CODE)
Artificial Fill AF Black BL Amphibolite AM Certa-Lok CTL . Schedule 5
Boulders B Bluish Gray - BG Basalt. BS Fiberglass FBG Schedule 10 ( '
Clay CL Brown BR Conglomerate/Breccia CG/BR Galvanized Pipe GLP Schedule 40
Coarse Sand CS Dark Gray DG Diorite DI, HDPE HDP Schedule 80
Cobbles' C Greenish Gray GG ' Gabbro GB NSF Coated Steel NCS Schedule 160 _ I
Fine Sand FS Light Gray. <LG Gneiss GN PVC PVC SDR 13.5 „vt
Fine to Coarse Sand FCS:• Reddish Brown RB Granite GR Stainless Steel SST SDR 17 I
Gravel G Yellowish Brown YB Limestone LS Steel, STL SDR 21
Medium Sand MS Marble MA SDR 26
,
Organics 0 Quartzite QZ . SDR 32.5
Sand&Gravel SG Rhyolite RH SDR 40
Silt Si- Sandstone SS 17#
Silty Clay " SICL Schist SC 19#
Silly Sand SIS Shale SH
Silty Sand&Gravel SISG SlatelPhyllite SUPH
Till T Pegmatite PM
4
-Section 7 Section 8 Section 10
` 1 Annular Seal/Filter
Screen Annular Seal/Filter Pack/Abandonment Purpose Method
Screen Type Code Pack/Abandonment Material Code Pur Code Method Code
,Posed
Carbon Steel CST Bentonite Chips/Pellets BC Fill FL Air Blow with Drill Stem AB
Continuous Wire PVC CWP Bentonite Grout BG Filter FT Air Lift AL
Galvanized Wire Wrapped GWW Cement/Bentonite Grout CB Seal AS Bailing BL
Perforated Pipe PFP Concrete CT Constant Rate Pump CR
Pre-pack'PVC'. PPP Sand SD Variable Rate Pump VR
Pre-pack Stainless PPS Native Material NM Slug SG
Slotted PVC SLP
Stainless Steel Vee Wire SSV
Stainless Steel Well Point SSP
Section-12 Section`13 _
z- Pump
Description , Well Seal
" Pump Description- Code Horsepower Surface Seal Type Type Code
3 Wire Variable Speed,Submersible 3WVS 1/2 20 Cement r,. CM
2 Wire Variable Speed Submersible 2WVS 3/4 25 .Gem6nt/Bentonite CB
2 Wire Constant Speed Submersible 2WSS 1 30 Concrete CT
3 Wire Constant Speed Submersible 3WSS 1 1l2 40 None NO
Constant Speed Submersible Turbines CSST , 2 50
Variable Speed Submersible Turbine VSST 3 60
Jet JET 5 75
.-Line Shaft Turbine LST. 7 1!2 100
Centrifical CENT 10 -125
15 150 ,
DRAEE PETROLEUM COMPANT, INC.
.............................
TITLE RAKE ADDRESS
President Francis 1. Worge 152 Walker Pond Road, Sturbridge, MA 01566
Vice President Edward M. Cosgrove 389 Wauregan Road, Danielson, CT 06239
Vice President Janes F. Ahern 15 Wacbusett Dr., P.O. Box 18, Sutton, MA 01590
Vice President David H. Preble 42 Lisbon Heights, Lisbon, CT 06351
Treasurer Aeato DiBiasio 218 Wellspring Drive, Warwick, RI 02886
Assistant Treasurer John T. Dziedzic 2 Gail Drive, Bristol, RI 02809
Clerk Benjamin Alpert 19 Westgate Road, Newton, KA 02159
Assistant Secretary Ann Marie Cappello 42 Winsor Avenue, Johnston, RI 02919