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Home My WebLink AboutLUKE'S LIQUORS - RETAIL FOOD LUKE'S LIQUORS�'�-C� �+ 395 Barnstable Rd.,HYA I BOARD OF HEALTH �IWtp Town of Barnstable John T.Norman Board of Health Donald A.Guadagnoli,M.D. HA F.P.(Thomas)Lee 200 Main Street, Hyannis, MA 02601 Daniel Luczkow Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: 2021 Issue Date: 1 1 Permit No: 563 / / DBA: LUKE'S SUPER LIQUORS OWNER: AJ LUKES OF HYANNIS INC. Location of Establishment: 395 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, IRS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY rr For Office U Initials: Town of Barnstable Date Paid�� (� Amt Pd$ EAMMAIBM Inspectional Services ' 0, Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,NIA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT...PERMIT.APPLICATION (Non Flavored). DATE I IIII� NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: A -� ! /NG,. ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ST yl v,cP•✓ � 0.G'• Mn i)`- v E-MAIL ADDRESS: h.\J t ri 1 s 10 1 l t. �P�&)A I� inn TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 60-&)-- _ OWNER'S NAME: �4� f2 L. k OWNER'S PH#C72 - D89 OWNER'S ADDRESS: `TU ehS�t ��j S , \1 V-M U U*, , (M A CORPORATE NAME: A.; Ll zf� "ctnr11.� Itjo CORPORATE ADDRESS: 9nn'*f Carl- C Vc .�f;�M &I ACORPORATE FID# ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)., TOWN OF BARNSTABLE.COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httl)s://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https:Hmale�,islature.gov/Laws/GeneralLaws/PartIV/TitleI/Chapter270/Section6 < ***NEW BUSINESSES AND NEW OWNERS ONLY*** I REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 1 FALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document j 2) MA State License to Sell gars and Smoki Ig Tobacco 4) Payment of Fee(s) -see page 4 f SIGNATURE: . PRINTED NAME: i1 ✓PK, DATE: Q:1Apphcation ForrnffOBACCO APP-NonFavor 12-18-19.docx r LuIC.CS Surer- boo/or`• — Ryc vnro ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—4.371-9. Sale and Distribution of Tobacco_Products. __ 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age.of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: 1 � i 112,12,0 U 1 .114 14 c, (� ignature Printed Name Date II Sign a Printed Name Date AiT rnorNy 4 Gt/At.l�t - //_/Zr2� blPature Printed Name Date �l�\t1v 'lr�-_L 1 t i •l 4-2o S PledNam e Date ✓'c g Pri ted Name Date t Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx �k-A(ts Supf, b juo(%s — Nyt�vtnta ESTABLISHMENT'S NAME Fc� 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 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: - Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\YZOF4J38\TOBACCO APP2019 dob.docx 00 Commonwealth of Massachusetts Letter ID:L1068119616 s Department of Revenue Notice Date:September 1,2020 Geoffrey E.Snyder,Commissioner Account ID:CGL-11285212-007 ? QTr$ mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES ��I��Illo��lll�l�l�li��ll'fll�lli�lllloll�ol�e��lll�llaloilllll AJ LUKES OF HYANNIS INC w e LUKES SUPER LIQUORS in= 40 CROSBY STREET EXT BASS RIVER MA 02664-4515 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE NCR MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes q �4, or 4 This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. AJ LUKES OF HYANNIS INC Account ID: CGL-11285212-007 LUKES SUPER LIQUORS License Number: 909240320 395 BARNSTABLE RD HYANNIS MA 02601-2934 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30, 2022 Commonwealth of Massachusetts Letter ID:L0960587328 � y s Department of Revenue Notice Date:September 1,2020 Geoffrey E.Snyder,Commissioner Account ID:CRL-11285212-010 &kwi) mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO als��i�i��l�llli�lllsllln�ls�ils�llis�ieilonl�ii��li�ialeos��o ' AJ LUKES OF HYANNIS INC N= LUKES SUPER LIQUORS N 40 CROSBY STREET EXT BASS RIVER MA 02664-4515 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE •----------------------------------------------------------------------------------------------------------------------------------------------- �P SFe MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T i1PRetailer License for Sale of Cigars and Smoking Tobacco 9 �,�E ro � This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. AJ LUKES OF HYANNIS INC Account ID: CRL-11285212-010 LUKES SUPER LIQUORS License Number: 1571450880 395 BARNSTABLE RD HYANNIS MA 02601-2934 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. �I Effective Date:October 1, 2020 Expiration Date:September 30, 2022 Department of the Treasury Notice CP279A AI Internal Revenue Service Tax period December 31, 2017 Cincinnati OH 45999 Q038 R Nottce date May 15, 2017 S Employer 1D number 20-5606763 To contact us Phone 1-800-829-0115 Page 1 of 2 008409.756489.197655.11686 1 AV 0.373 540 Fill lll►1-11IIII( I'll III III Jill to III Jill 11,ls,ltsiolllsu11 A 1 LUKES OF HYANNIS INC 395 BARNSTABLE RD 1,96 HYANNIS MA 02601-2934 108409 Important information about your Form 8869 We accepted the election to treat you as a qualified subchapter s subsidiary We accepted the Form 8869,Qualified What you need to do Subchapter S Subsidiary Election,filed byyour parent corporation. As a qualified subchapter S You don't need to do anything at this time. subsidiary,your accounting period is the same as your parent and is effective January 1, 2017. The effective date is subject to verification and approval of the information your parent corporation provided. Continued on back... 3 a BAR or HYABLERPdKiNc Notice CP279A - -- 39s NIS tsMA 6 Notice date May 15, 2017 N�::h"1!S 64A Q26Q?d934 Y Employer ID number 20-5606763 If your address has changed,please call 1-800-829-0115 or visit www.irs.gov. Contact information ❑ Please check here if you've included any correspondence. Write your Employer ID number(20-5606763),the tax period(December 31, 2017), and the form number (1120)on any correspondence. a.m. ❑ a.m. ❑ p.m. ❑ p.m. Primary Phone Best time to call Secondaq Phone Best frme to cal[ INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0038 IFIIIIui�hI�II�I�t�I1f��lllh�llllld�ulll�uil�,�141�1��I�t 205606763 IR - 02 2 -201712 r Bellaire, Dianna From: hyannis@lukescapecod.com Sent: Tuesday, November 24, 2020 7:09 AM To: Bellaire, Dianna Subject: RE: 2021 Tobacco Permit for Lukes' Super Liquors- 395 Barnstable AJ Luke's Super Liquors at 395 Barnstable Road does not sell any of those products. Thank you, Tim Walker From: Bellaire, Dianna <Dianna.Bellaire @town.barnstable.ma.us> Sent: Monday, November 23, 2020 4:22 PM To: hyannis@lukescapecod.com; route132@lukescapecod.com Cc: Bellaire, Dianna <Dianna.Bellaire@town.barnstable.ma.us> Subject: 2021 Tobacco Permit for Lukes' Super Liquors-395 Barnstable Importance: High Hi, This is confirmation that I've received your application. However,this year there is a new MA State License for Electronic Delivery Systems, E-Cigarettes,Vaping and E-Juices. Please let me know if you sell these items, if so, I need a copy of your Electronic Delivery Systems MA License OR I need an email that states you DON'T sell these items and I will place a note on the account. This application will remain in pending until I receive either of those things. Thank you. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us The information contained in this electronic transmission("e-mail"),including any attachment(tile"Information"),may be confidential or otherwise exempt from disclosure.It is for the addressee only.This Information may be privileged and confidential u-ork-product or a Privileged and.confidential cornrnunication.'The..Information nnay also be deliberative and.pre-decisional in nature.-A.s such,it is for internal use only.The Information may not be disclosed without the prior written consent of the Director of public Health and/or the. .1 own Attorneys Office of the`Ibwn of Barnstable. If you have received this e-mail by mistake,please notify the sender and delete it from. your system. Please do not copy or forward it.Thank you for your cooperation. 1 Town of Barnstable BOARD OF HEALTH John T.Norman �i Board of Health Donald A.Guadagnoli,M.D. �• BARNSTABLE : Paul J.Canniff,D.M.D. MAM SS\\ 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 563 Issue Date: 1/1/2020 DBA: LUKE'S SUPER LIQUORS OWNER: AJ LUKES OF HYANNIS INC. Location of Establishment: 395 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 G?r Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY I r For Office Use Only: Initials: �"E' ' Town of Barnstable ��' Date Paid Amt Pd$(� BARNSTABLE, : Inspectional Services r , Mass. Chec caA i6 J9 k# \ Public Health Division lFn��a Thomas McKean, Director �2�3 {200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE �� NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: A , e-- v s4 1AIC, . ADDRESS OF TOBACCO ESTABLISHMENT: 'IaL'5� �&-a- -b I e- o Lx n ri is MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ��r i LN U),y pricat o onj , al,A E-MAIL ADDRESS: huh anylk5(0 1U-�e-3 LIM,,C-Orn TELEPHONE NUMBER OF TOBACCO ESTABLISHMENTT: - OWNER'S NAME: A01-IW (,(j— e, ?Ye}(CleWWNER'S PH# j9q OWNER'S ADDRESS: "7(J C,r ��T l ;�I J ` `I �i�'l0 0-rF1 01 A CORPORATE ADDRESS: Qq SDYZ i N&kZ hV. �`l� M Ou-114L" ORATE � 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://male isg lature_gov/Laws/GeneralLaws/PartIV/TitleI/Chal)ter270/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 q;vIr SIGNATURE: '/ PRINTED NAME: �'�"K fl DATE: / Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc 12/10/2019 16:10 5084185361 AJ LUKES OF HYANNIS PAGE 01/02 A-J LEI Sags Ligvanj ESTAB,LISHNENT'S NAME, TOBACCO SALES µ IA mm5 _ 317 &rns+klQ Rd 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 Massaohusetts 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 Hoalth Regulation; Sales to Minors—6 37i-9.Sale and Dixtribution of Tobacco Products. 1. No person shall sell or provide a tobacco product;as defined heroin,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 heroin, 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)belov/reeeived and understood Section 371.9 of the Town of Barnstable Board of Health Prohibition,Qf Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: igix Printed Name Date IIM signature Printed Name Date ✓fZ �--� �72RlCK E2e�___,_ if-Z T Ir/ - apatal Pd tted Name Date ��Lt S16� 11 2(0• C� Sign Printed Name Date `51 a Printed Name Data 1.4cn l)I 1112� re Printed Name Date S Priuted Name Date Q:1Applieatdon PoQm%1013ACM APR N=Favor t i-21-19.doc 12/10/2019 16:10 5084185361 AJ LUKES OF HYANNIS PAGE 02/02 ESTABLISHMENT'S NAM TOBACCO SALES Employee Signature Form 1'his 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 ofBamstable Board of Health Regulation: Sales to Minors—S 371 9,Salo 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: paeh person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by moans 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 U. The employees)below received and understood Section 371-9 of the Town of,Barnstable Board of 'Reatth prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: .,Sign -Prlaw Name Dat fldl A r Da Si Printed Nw))c p ✓ _ Printed Name Date Signatvra c , 2 r Si r Printed Name Date cc-�- prButed Name Date Printed Name signature rr�.►eAa rraR.a sip pure 4:VN.PIIrt--r0.�4C1I,.11-A�JCC AT'f�NP..wwN�.-0 _.OAPO Commonwealth of Massachusetts Letter ID: L04627790080 �' ^s Department of Revenue Notice Date:September 26,2018 Christopher C.Harding,Commissigncr Account ID:CGL-1 1 2852 1 2-007 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES °III�I�IiI�'llllllll�ll°"°III°°III1��11�1'lo'ii�lllaB"II'ilil°°° — AJ LUKES OF HYANNIS INC _ LUKES SUPER LIQUORS o- 6 NARROWS LN SOUTH YARMOUTH MA 02664-2213 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. . DETACH HERE ----------------------------------------------------------------------------------------------------------------------------------------------- sF�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T g; Retailer License for Sale of Cigarettes W�J� . r' �r& This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. AJ LUKES OF HYANNIS INC Account ID: CGL-11285212-007 LUKES SUPER LIQUORS License Number: 464177152 395 BARNSTABLE RD HYANNIS MA 02601-2934 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 7 Lrrt, :U s5�u s Commonwealth of Massachusetts Later ID:LI 110479488 ID , == s Department of RcvcnuE Noticc Datc:September 25,2018 _h Christopher C.Harding,C.ommissioher Account ID:CRL-11285212-0 10 mass.gov/dor RETAILER LICENSE FOR SALE'OF CIGARS AND SMOKING TOBACCO �I lullllnlllrinrlllllllllllllll°IIIIIIIr�lllllnroll'ILII°II'I� AJ LUKES OF HYANNIS INC LUKES SUPER LIQUORS o� 6 NARROWS LN SOUTH YARMOUTH MA 02664-2213 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted lime and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ---------------------------------------------------------------------=------------------------------------------------------------------------- I $?.clrts�T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T ' '1� Retailer License for Sale of Cigars and Smoking Tobacco F�I �.�roY�� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. AJ LUKES OF HYANNIS INC Account ID: CRL-11285212-010 LUKES SUPER LIQUORS License Number: 448485376 395 BARNSTABLE RD HYANNIS MA 02601-2934 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 f Department of the Treasury Notice . CP279A Internal Revenue Service Tax period December 31,2017 Cincinnati OH 45999-0038 Notice date May 15,2017 Employer ID number 20-5606763 _ To contact us Phone 1-800-829-01 I5 Page 1 of 2 008409.756489.197655.11686 1 AV 0.373 540 1,1,1111,I,1111111,111111111r1rl1r11rr1��l1�1„11,1111h1111 A J f_UICES OF HYANNIS INC 395 BARNSTABLE RD f` HYANNIS MA 02601-2934 )8409 Important information about your Form 8869 We accepted the election to treat you as a qualified subchapter s subsidiary We accepted the Form 8869,Qualified What you need to do Subchapter S Subsidiary Election,filed by your parent corporation. As a qualified subchapter S You don't need to do anything at this time. subsidiary,your accounting period is the same as your parent and is effective January 1, 2017. The effective date is subject to verification and approval of the information your parent corporation provided. Continued on back._. A J LUKES OF HYANNIS INC Notice CP279A 395N ABLE 6 Notice date Pita .I5, 2017 HYAP:NG NL &�1 024'-293=I y ----------- Employer ID number 20-5606763 JDQ If your address has changed,please call 1-800-829-0115 or visit www.iFs.gov. Contact information ❑ Please check here if you've included any correspondence. Write your Employer ID number(20-5606763),the tax period(December 31, 2017),and the form number (1120)on any correspondence. a.m. Primary Phone Best time to call secondary Phone Best Ei'rne to call INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0038 iFlfllff�fhhll1f=FtIIF,1I111is llldvflllrurff1 till fff""f`I 2056OL763 IR 02 2 2.01712 1 Town of Barnstable BOARD OF HEALTH cY 1+ s Paul J Canniff,D.M.D. Board o1 Health Donald A.Gaudagnoli,M.D. •' aAI NSTAISM John T.Norman � aA55 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate i63 s f0a Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 563 Issue Date: 12/20/18 DBA: LUKE'S SUPER LIQUORS OWNER: LUKE'S SUPER LIQUORS/ARTHUR J. LUKE Location of Establishment: 395 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES (� FOOD SERVICE ESTABLISHMENT: YEAR. 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - --- -- -- - - - -- MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: i 1 '{ �114E Town of Barnstable For Office U Initials 41-5 . �. Date Paid Amt Pd S g Inspectional Services Check# " BARNBTABLE, b �m� Public Health Division { 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT ESTABLISHMENT NAME (D A) 3R 11�el kble a ADDRESS OF BUSINESS MAILING A RESS IF DIFFERENT FROM A OVE) OWNER'S NAME: LAST FIRST MIDDLE EA WAIL PHONE# FEDERAL Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco pro cts must s' n the Employee Signature Form (provided herein). Signature Date Q:\Application Forms\TOBACCO APP2019 dob.docx 12/21/2018 08:39 5084185361 AJ LUKES OF HYANNIS PAGE 01/01 ESTABL],SOP JENT B .TOI§ACCO SALES Employee Signature Form This fon-n is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of tlle Town of Barnstable Code and. Chapter 270 Section 6 of the Massacb.usetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenly-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sa)Aeg to Minors—&371 9. Sale and Distribution of obacco Prodnctg. I.. No pe.rsoil shall sell or provide a tobacco product,as defitled to the Towl of Barnstable rson under The minimum legal sales age. The minimum legal sales age 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. arnstable 1,11c following employees) received and understood Sectlota 3CI�a ter 270 1-9 of the T own of Section a6 of the Beard of Health Prohibition of Smoking Regulation p Maisachy�6 General Laws: Printed Namc Rate Si nature �- y_/f _ printed Name w. .. ., . Sl. turc f. �... �',/(,/•,/ pat. Printed Name Atgnature t Date Printed Name t S Dare Printed Name (,2 Date Printed Name Sign ure Date A Printed me ignature b.doax G JCI'/ l 5\T01 jhcco A1� 2 l9 do JV�/ Received Time Dec, 2�1N,1 2018 8.40AM No, 0955 �e�P h 4 ( .��`1'id, i oFt H�E rok TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: L,k01 L vv r 3 Date: Page:_�of ' ti OFFICE HOURS i ARNsrAB,Eo PUBLIC 2 0 MAW STREET 3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. M47q: �0� HYANNIS, MA 02601 M-8 -FRI. No Reference R-Red Item. PLEASE PRINT CLEARLY 508-862-4644 - - FOOD ESTABLISHMENT INSPECTION REPORT G ge NameLuof I) S Date T e o 9 f inspection Ooeration(s) outi Address �� G Risk F Service Re-inspection Level a ai Previous}asp ction r Telephone esidential Kitchen Date:3/� (O Mobile Pre-ope atio 0 Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Ve S Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding 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 ^74' Violations Related to Good Retail Practices(Blue Items) Total Number of Critical ViolationsCritical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ElYes 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 6=One critical violation and less than 4von-critical violations 9 . )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violatio �7 -critical n 9non-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 o ry violations. If 1 critical refrigeration. within 10 da s of recei t of this order. violation, to B nations=C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: Inspector' Signature Prin 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V Y - #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's ign ture 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 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 EMPLOYEE HEALTH - � 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits Restriction-Presence and Use*its and Vegetables * 590.00411 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 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Foam* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitofing* 3-801.11(C) iUnopened 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 E Equipment s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Eggs Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* ep cti,e 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F IS sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS n 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 y Game and Wild Mushrooms Approved B 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 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 2-401.11 Eating,Drinkin 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-Roast Critical and non-critical violations,.which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3 403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* Lu 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 1590.000 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 1 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 1 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. � i 1 °FINEr° TOWN OF BARNSTABLE HEAL OTH I PECTOR's Establishment Name: `-y �i f Date: Page: . of _ OURS V PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �p aSSq;a m� - HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY - - 'EON1P� FOOD ESTABLISHMENT INSPECTION REPORT soa-aszas44 P L C 7O Name �V Date L Type of Ins c io Ooeration(s) I Routine Address Risk Food Service spection f^ Level etail Previou Ins ction Telephone ential Kitchen Date:9 )Lii Mobile Pre-op ratibf� Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint �p Person in Charge(PIC) Time Bed&Breakfast HACCP S � (;a In: Other V I , 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) ❑ 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 ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: 15KNO ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined b the Board of Health. Overall Rating Ith Y y ❑ Voluntary Compliance. ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspectio ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) checked indicate violations of 105 CMR 590.000/Federal Food Code. 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 4 non-critical violations 9 )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations a less than 9non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address vi lions o ed, o 8 non-critical violations. If 1 critical refrigeration. t of this order. v within 10 days of receipt olat n,4 to 8 n cn ical violati s=C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: Inspecto 's Signatu t: 31.Dumpster screened from public viewA, Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V V #Seats Observed Frozen Dessert Machines: Outside Dining Y N AQ&gnatur Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N I Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment * g 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* p g * 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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 Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* I Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* E//°"°e innooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whale-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* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140°F to 70°F 3-202.12 Shellstock Identification ( ) g Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Coaling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. _ I 1 INCI - -- -- -- - -- - - - I � Nil --— —— -- —--—--- —— •� - , , i tr � ,-- _—.: _— _ ew :n+a�.MvwrrF,w�✓mrr.+•:r,q..nf.nl�/a'!�e:,f, v..cue.nr,•.vro••^.^�wr.�.^^'�e,•.cf^.:�,•�-^.-avn••tr�•xwp,yl,?r,afittP.nt _ --— I :'.. ''� I � _ !.�. _ —__ — _ ___.. _. __ —_--____._—._ _ .____, �w:n.�.>T_wwF. --a':t,,.+xrr.,:.s:... r 1,.... ._ ..M..e Jrsv:.. 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