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HomeMy WebLinkAboutMOBIL - RETAIL FOOD Mobil � - , _ 31 - c)og 381 Camp St. Hyannis r FORMERLY SAV-ON GAS Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. DlWNTF ALE. F.P.(Thomas)Lee,. 9 MAS.4 $ Daniel Luczkow,M.D. Alt. 200 Main Street, Hyannis, MA 02601 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, 30513, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 879 Issue Date: 01/01/2022 DBA: MOBIL OWNER: JAY [MAD Location of Establishment: 381 CAMP STREET WEST YARMOUTH„ MA 02673 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - -- MOBILE- FOOD: MOBILE-ICE CREAM: C,�At FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I d ACLko(66, Town of Barnstable For Office Use • Initials: Date Paid Amt Pd$ ! ,ARM STrAB , , Inspectional Services �F 39. Public Health Division Check# 31 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 Io NEW OWNERSHIP RENEWAL V NAME OF FOOD ESTABLISHMENT: , y �� �l{c� .J—nG. U Q. �/1 ect i ADDRESS OF FOOD ESTABLISHMENT: N O&W MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO �...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / 1 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 Fon-nsWOODAPP REV3-2019.doc 1 I OWNER INFORMATION: FULL NAME OF APPLICANT V SOLE OWNE YE /NO OWNER PHONE �-7pZ(Q,2'7t9d — * d blr�& ADDRESS /`v CORPORATE OWNER: 67-{ � CORPORATE ADDRESS: 0 3 PERSON IN CHARGE OF DAILY OPERATIONS: .aL 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 CER T IFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. 2. w SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: 'Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application Forms\FOODAPP REV3-2019.doc i r , Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. Md►U " Paul J.Canniff,D.M.D. MAC F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment lk In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 879 Issue Date: 01/01/2021 DBA: MOBIL OWNER: JAY IMAD Location of Establishment: 381 CAMP STREET WEST YARMOUTH„ MA 02673 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IncloorSeating: 0 OutcloorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: wf/ A SINE fps For Office Use Only: Initials: � � Town of Barnstable Date Paid Amt Pd$ a(7_ ' Inspectional Services �STAB�.� P Health 3'�(�2 `% �� v Mass_ Check# 'b'� Public Division prED MP't� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: Say OtrL SST In G. d%p& tAobi I ADDRESS OF FOOD ESTABLISHMENT: 331 CaM42 St Xd QQ. WmaAK Ws 6AI-3 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: Supncc @ ama -[ray" TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( ) - TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO 1V ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: W Id 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 x!/ A • n OWNER INFORMATION: FULL NAME OF APPLICANT A f I 11rI Ift ri SOLE OWNER: &NO OWNER PHONE#�Sp ADDRESS Cl rde- S. Mrno1)th MA 6ALUy CORPORATE OWNER: SQVr j)m Gas Sir1C. CORPORATE ADDRESS: _93 1 rAr,.0 � . y(,�r I n�L)41n. M A 6;Llea 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 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 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/apl)lications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January I st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsT00DAPP REV3-2019.doc I rr MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include copies of your employees' food protection manager training certificates (at least two) and food allergen awareness training certificate (at least one.) In addition, please include the required fee amount (see fees at bottom of this page). Make check payable to: Town of Barnstable. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax copies of your employees' food protection manager training certificates (at least two) and food allergen awareness training certificate (at least one.) In addition, you must mail the required fee amount (see box below). Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. FEES: Bed &Breakfast Permit=$55; Food Service Permit 0-49 seats = $250; 50 or more seats $300; Continental Breakfast= $30; Retail Food (only TCS Foods) = $20; Retail Food Store—Less than 8,000 S.F. _ $100, more than 8,000 S.F. = $285; less than 1,000 S.F.; Retail Food Combo/Limited Prep. - $200.00; Cottage Food Industry= $75; Mobile Truck=$50; Mobile Ice Cream Truck= $35; Frozen Dessert License = $30; Additional non-refundable Fee for New Establishment or New Ownership= $100-$500(see staff),Late Fee= $10 Q:\Application FormsTOODAPP REV3-2019.doc ` I Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BAWNSTAUM F' F.P.(Thomas)Lee Daniel Luczkow,200 Main Street, Hyannis, MA 02601 Alternate o 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: 879 Issue Date: 1/1/2021 DBA: MOBIL OWNER: JAY IMAD Location of Establishment: 381 CAMP STREET WEST YARMOUTH MA 02673 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY For Office Use Only: Initials- j Town of Barnstable Date Paid ?J� Amt Pd$ eAaTA Inspectional Services — - Public Health Division Check# ►67q ` ;2 YI j— s 'Dttyc� Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT .PERMIT APPLICATION[Non-F.lavored). DATE NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: SQL/ on. C-05 l ', d" M b'l I ADDRESS OF TOBACCO ESTABLISHMENT: /)� ra ma s'rtf-k In) `�q �ap� �_M A7 L&3-3 k MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: S m e (a-a mn I ( CL M i TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (910 )-125-5 g OWNER'S NAME:,. ,q, OWNER'S PH# JIM OWNER'S ADDRESS: f0 �Q,!rL�ir�d ('!rr1,, S. rYYI *i v MA 02M CORPORATE NAME: _Su GK- r-r i r 1I'),(. CORPORATE ADDRESS: ��3lCAm,Q1�t. W•YrnQh __ CORPORATE FID# ANNUAL:_� SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS).. I A TOWN OF BARNSTABLE.COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: htf.os:H aletislature gov/Laws/GeneralLaws/PartIV/TitleI/Cha 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 a1lid Smoking Tobacco 4) Payment of Fee(s) -see page 4 t: SIGNATURE: a PRINTED NAME: DATE:. ri Q:1Application FormffOBACCO APP-NonFavor 12-18-19.docx Mow 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 bearers 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: Signature Prm' ted Name Date all U Sign Printed Name Date Signature Printed Name Date ge Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date QAApplieadon FomiATOBACCO APP.NonFavor 12.18.19.doac Commonwealth of Massachusetts Letter ID:L2022305344 Department of Revenue Notice Date:September 22,2020 '4 Geoffrey E.Snyder,Commissioner Account ID:CRL-10666417-010 Etvrue mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO 11111'II'rllsrrlll�illlrlll'1'Itirlt'�rl'll��'�'�I'�I�Irl��rlrld ® BARBARA HANSEN ® SAV ON GAS INC �0 381 CAMPST ® WEST YARMOUTH MA 02673-8578 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 am.to 4:30 p.m. DETACH HERE MASSACHUSE'iT'TS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco 9 01a This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SAV ON GAS INC Account ID:CRL-10666417-010 381 CAMP ST License Number:440883200 WEST YARMOUTH MA 02673-8578 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:L0971986400 Department of Revenue Notice Date:September 24,2020 Geoffrey E.Snyder,Commissioner Account ID:CGL-10666417-M �vrOg massgov/dor RETAILER LICENSE FOR SALE OF CIGARETTES h�d�h�il�"ihdlrlill�lhlllrtlilu�lll�hll�lit�t111111r1 ® BARBARA HANSEN SAV ON GAS INC N 8 SAV ON GAS INC 381 CAMP ST WEST YARMOUTH MA 02673-8578 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 QD MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes of This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SAV ON GAS INC Account ID:CGL-10666417-006 381 CAMP ST License Number: 1935792128 WEST YARMOUTH MA 02673-8578 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 Vk I Letter 1D:L0768043584 jYh ` r � Commonwealth of;Massachusetts Notice Date:May 28,2020 s Department of Revenue Account ID:EDL-10666417-013 Jib Geoffrey E.Snyder,f'ommissioner ofi mass.goildor 0 LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS !#tell,'##,1I if III it lill##1"1'I1'111N1'#1,�1!!!'!!l��I BARBARA HANSEN g® SAV ON GAS INC N CAMP STREET MOBIL 381 CAMP ST WEST YARMOUTH MA 02673-8578 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617)887-6367 or toll-free in Massachusetts at (800)392-6089, Monday through Friday,8:30 a.m. to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ MASSACHUSETTS DEPARTMENT OF REVENUE rt g_g\ul Retailer Licensefor Sale of Electronic Nicotine Delivery Systems �,��� This license must be posted and visible at all times. 'The sale of tobacco products to anyone tinder'21 years of age is prohibited. SAV ON GAS INC Account ID:EDL-10666417-013 CAMP STREET MOBIL License Number: 273635328 381 CAMP ST WEST YARIvIOUTH MA 02673-8578 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:May 28,2020 Expiration Date: September 30,2022 V W. -` Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. s' BARNSTAIDL8, r Paul J.Canniff,D.M.D. 9. , 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790.6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 879 Issue Date: 12/10/2019 DBA: MOBIL OWNER: JAY IMAD Location of Establishment: 381 CAMP STREET WEST YARMOUTH, MA 02673 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: ..e of Teti For Office Initials: Town of Barnstable BARNSfABLE• : Inspectional Services MASS. s639. .� Public Health Division check# AjEO�,t a .,i Thomas McKean, Director c_r, 200 Main Street, Hyannis,MA 02601 , Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE LI 1% NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ( t) 61) gaj, rnC', d ha- � �l iJob ADDRESS OF FOOD ESTABLISHMENT: (// LauV l/-& MAILING ADDRESS(IF DIFFERENT FROM ABOV�Et)):,�/ E-MAIL ADDRESS: �S'�U���'i�iG W, &YX, TELEPHONE NUMBER OF FOOD ESTABLISHMENT: C0 )L✓- '/� TOTAL NUMBER 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) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YE NO OWNER PHONE #`�(��'j 2pZ�pC rIO ADDRESS n ,l/�(l �'�'}'fGfi . �G CORPORATE OWNER: S, t/ 04(d, Ze CORPORATE ADDRESS: (rA4 Tr. (, PERSON IN CHARGE OF DAILY OPERATIONS: �/ 1 List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. ala 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 openine!! 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:net. i 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 httt)://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec. 3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Application FormsTOODAPP REV3-20I9.doc r Y" For 0 Initials: `"E'�'r Town of Barnstable Date Paid Amt Pd$�� , MASS. : Inspectional Services vE� 9cb ,�: ,e,Eoy, Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE 1,114 119 NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: � )�'Lt� d1q 6ad-, 2-/X, U& DUI I ADDRESS OF TOBACCO ESTABLISHMENT: JAI MAILING ADDRESS(IF DIFFERENT �yFROM /ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (50ib. —9q-5- OWNER'S NAME: OWNER'S PH# 2,G v?100 OWNER'S ADDRESS: - t l"IJind 1-U u CORPORATE ADDRESS: .awCORPORATE FID# ! az&73 ANNUAL: ✓ SEASONAL: DATES OF OPERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) 1+?I14 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: PRINTED NAME: � C DATE: Ia / y / Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc w (Z�l�f_T4e66A ESTA LISHMENT'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 minimtim 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: Signature Printed Name Date Signature Printed Name Date U ( V) U 12-. !!� ~ t -,:S Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc w ' L`"`� St`�4s,• Commonwealth otMassachusetts Letter ID:L2124518Q16 Department of Revenue Notice Date:September 21,2018 0iA'• Christopher C.Harding,Commissioner Account 11):CRL-10666417-010 4T0F�w mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO Ilrl'lIr�111�1�ril,�ari�rl�l�rrlr'Il�rl���'���r�ri��II„�l'�11��1 OEM BARBARA HANSEN SAV ON GAS INC 381 CAMP ST ® WEST YARMOUTH MA 0 673-8578 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 �actru . NIASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T 'j- Retailer License for Sale of Cigars and Smoking Tobacco 9•t,,` `�' This Iicense must be posted and visible at all times.The sale of tobacco products to anyone under IS years of age isprohibited.. SAV ON GAS INC Account ID:CRL-1066641.7-010 381 CAMPST License Number:27985920 WEST YARMOUTH MA 02673-8578 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address;shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2018 Expiration,Date:September 30,2020 i Commonwealth of MmachuseM Letter ID:LI 139450496 Department of Revenue Notice Date:September 24,2018 5 y :��� Christopher C.Harding,Commissioner Account ID:CGL-10666417-M It Yr co mass.govJdor RETAILER LICENSE FOR SALE OF CIGARETTES Id�'ll�llllt�r�d�dlp�nllllpllglur�l�ll�ll"I'�III�I'�I�I' t� BARBARA HANSEN SAV ON GAS INC ® SAV ON GAS INC 381 CAMP ST WEST YARMOUTH MA 026734578 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)88 7-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday,8:30 am.to 4:30 p.m. DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T W . Retailer License for Sale of Cigarettes � + This license most be posted and visible at all times.The sale of tobacco yvr o products to anyone under 18 years of age is prohibited. SAV ON GAS INC Account ID:CGL-10666417-006 381 CAMP ST License Number:716548096 WEST YARMOUTH MA 02673-8578 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 John T.Norman Board of Health Donald A.Guadagnoli,M.D. ;gym Paul J.Canniff,D.M.D. MA .. F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 lk 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: 879 Issue Date: 1/1/2020 DBA: MOBIL OWNER: JAY IMAD Location of Establishment: 381 CAMP STREET WEST YARMOUTH MA 02673 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY Town of Barnstable BOARD OF HEALTH fl Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. i John T.Norman $ ;b 9. 200 Main Street, Hyannis, MA 02601 F.P.(Thomas)Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 879 Issue Date: 12/20/18 DBA: MOBIL OWNER: JAY IMAD Location of Establishment: 381 CAMP STREET WEST YARMOUTH MA 02673 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES - —-- ---- - --- _ �_ FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: ----- — --- - - - - ----- — MOBILE-FOOD: MOBILE-ICE CREAM: C,�A 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: s c �pIHE row For Office _ Initials: Town of Barnstable Date Paid BARiNATABLE, Inspectional Services MA�A Public Health Division Checic# � l/ 11639. I�' \ X� "t-J` Thomas-McKean,Directot_ 5 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 i; li APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT r C DATE JaI31,1JR, NEW OWNERSHIP RENEWAL ✓ E NAME OF FOOD ESTABLISHMENT: f2U �YZ t~�2� f c 1h( Okit� ADDRESS-OF FOOD ESTABLISHMENT: 31 0-3-nc,kfeQA. SA Ca0LS— MAILING ADDRESS(1F DIFFERENT FROM ABOVE): ( m� z F E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT.- TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: x SEASONAL: DATES OF OPERATION: /_1 ' TO ! / NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST-OBTAIN-A COMMON-VICTUALLER'S LICENSE FROM LICENSINGDIV. .. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING F REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? I IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) k f G 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(SEEPAGE#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 1 Q:Wpplication FornisWOODAPPRGV2018.doc 9 1 PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT tl SOLE OWNER: YE /NO OWNER PHONE# F31 1 a-�pp ADDRESS Ca=f S)Yee} LA) �(�u�nt����rlr� , uW bQ( 113 l CORPORATE OWNER: FEDERAL ID NO. : p-1t-►S-1 L}k,S CORPORATE ADDRESS: lA-� qQ Cn .- d MIA PERSON IN CHARGE OF DAILY OPERATIONS: --2-- it 11 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. S **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. c Certified Food Managers Expiration Date Allergen Awareness Expiration Date ; 1. 2. / J y SIGNATURE OF APPLICANT DATE a ***FOOD POLICY INFORMATION*** R i SEASONAL FOOD SERVICE: All seasonal foo&establishments,including mobile trucks must be inspected by the Hcalth.Div. prior to opening!1 Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. K 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/liealtlidivision/ai)plications.,isy). i n 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. C NOTICE: Permits run annually from January I st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC l st. x x ( Q\Application FormsTOODAPPREV2018.doc 1 6 5 � E Town of Barnstable For Office Use Only: Initials: ,� G,� Date Paid ®ffit_P.d$ Inspectional Services Check# Cash � 3k t6jq. Public Health Division �0 fpa 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 0/9 am�f' ESTABLISHMENT NAME (DB/A) D�c � �. O 7 ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OWNER'S NAME: LAST FIRS MIDDLE EMAIL PHONE# F ERAL ID# Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products t sign the Employee Signature Form (provided herein). Signature Date lam/°2 ' Q:\Application Forms\TOBACCO APP2019 dob.docx ESTABLISMAENT'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 ern 1 yee(s) received and understood Section 371-9 of the Town of Barnstable Board o Health rohibition of Smoking Regulation and Chapter 270 Section 6 of the Massach s Gen al Laws: d' r� �1113 Signature P ' ted Name Date i ature Printed Name Date ' Signatur . Printed Name Date Signature Printed Name Date 1 i `7p1,�, C ►�rina I Signa Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application FonnATOBACCO APP2019 dob.docx oFtNe, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: �i Date: rJ��I Page: of ti OFFICE HOURS s, eoe PUBLIC 2 0 MAN STREEETSION 3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified BARN3:30-4:30 P.M. �A MASS. es.a�0 HYANNIS,MA 02601 M-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY 508-862-4644 'FDN1P' FOOD ESTABLISHMENT INSPECTION REPORT Name f Date Tvoe of sec io Operation(s) Routine' Address Risk Food Service -inspection Vd Level �alb Previous Inspection Telephone f�sidential 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 i 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 �0� Violations Related to Good Retail Practices(Blue Items] Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No Yes Non-critical(N)violations must be corrected immediately or ❑ �Overall Rating � within 90 days as determined by the Board of Health. Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based,on an inspection today, a 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 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 27.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 (FG-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8 non-criti I violations=C. 29.Special Requirements (590.009) Y p 30.Other DATE OF RE-INSPECTION: Inspe I n re 31.Dumpster screened from public viewQ,� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N Signature Print:'s Si #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC 9 Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N ei- /_c 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 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F g 15 Poisonous or Toxic Substances EMPLOYEE HEALTH -3 2 Raw Animal F Separated from Each 590.004(F) 3 0 .11(A)(2) a Foods S * P7-101.11 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-S[ora e* Applicants* 3-302.11(A) Food Protection* P g 7-202.11 Restriction-Presence and Use* -0 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and RestrictionsA 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 HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F IS sec* Pathogens* Effective 11112001 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 see* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 .. -Eating,Drinking or Using Tobacco* * Requirements. $ Recefving/Condition g� g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PBF'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 3-202.15 Package Integrity* _ 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 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* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A 3-202.18 Shellstock Identification ( ) Cooling Cooked and Fr from 140°F to 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 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�02.12 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 t 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. Fero TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: `( Date: .170194 Page: of OFFICE HOURS p ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M. s BARNSTABLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION /PLAN OF CORRECTION Date Verified MASS.9 N0� HYANNIS,MA 02601 508-808-8MON -FRI.62-0644 5No Reference R-Red Item. PLEASE PRINT CLEARLY prFON1�`' FOOD ESTABLISHMENT INSPECTION REPORT Name Date Qr Tvoe of T sec ion s Routine Address Risk a e-inspection Level Previous Inspection ` 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) ❑ 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) ❑ �C7 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 1718.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ��-� ����1111 ❑ 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) I C) Corrective Action Required: No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating l 1 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 day,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations ' regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 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 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 t 29.Special Requirements (590.009) within 10 days of receipt of this order. i to 8non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Ins Pa-4 at a nr . .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 Signature Print: Self Service Wait Service Provided Grease Trap Size ` Variance Letter Posted Y N U 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. 590.004(F) ll Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-]02.11 Common Name-Working Containers Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q , Contamination from the Consumer 3 590.003(D) 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 Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources Fg Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY * Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water 3-401.11A(1)(2) Eggs-155°F 15 sec 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* ep-n-inrzooi - 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* 3-30'2.13 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) 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 2-301.12 Cleaning Procedure* * foodborne illness interventions and risk factors. 3-202.18 Shellstock Identification Present* g 165°F 590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 3-201.17 Game Animals* Requirements. $ 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 O Y Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* i �) g illness interventions and risk factors listed above,can be found in the 6 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 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 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 Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004 Labeling of Ingredients' Supplied with Soap and hand Drying Devices (J) 9 9 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures I 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. I F THE r TOWN OF BARNSTABLE, HEALTH INSPECTOR'S Establishment Name: 11 0b; I Date: Page:�_of -� OFFICE HOURS 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 A. `0$ HYANNIS,MA 02601 soe-s-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY �'FDN1P�6 FOOD ESTABLISHMENT INSPECTION REPORT Name p� Date Ib T e o e o Inspection <rr < I,( My / ) �� �II Operation(s) outine °I�4S Address �$I Gam b�- Q���J/�A Risk F d Service e- ection �q r <O •` Level etai Previous Inspection J Telephone esl ential Kitchen Date: ' b Mobile Pre-operation r tf Owner HACCP YIN Temporary Suspect Illness - D ;s I(( �r r 4 -L-ip o Caterer General Complaint / Person in Charge(PIC) V �� Time Bed&Breakfast HACCP `S lu Vr V In: Other F G� I f i I�JiJ� Cvcf Inspector Gn (f ins 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 t _f'1 i 1_ `�9 ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories 53* / 6 lY f -11 Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items Embargo Other: Emergency Closure 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) 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 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 )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: ^ �� IO v��J 31.Dumpster screened from public view Jj/�► 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 /1 Dumpster Screen Y N /-� Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 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 EMPLOYEE HEALTH � 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* *, Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage Applicants 3-302.11(A) Food Protection* * 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 Rated or 7-204.12 Chemicals for Washing of Food Produce,Criteria* HSP HIGHLY SUSCEPTIBLE POPULATIONS 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 F9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1](B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual 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* 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* 3-801.1](C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. L16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY * Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water 3-401.11A(l)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.1](A)(2) Comminuted Fish,Meats&Game Pathogens* E/!c i-11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* * Shellfish* P 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* L Sources* 10 P ing,mobile food,temporary and residential Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) j 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) Commerciall 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 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006, 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 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 590.060. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. V4q)A' TOWN OF BARNSTABLE HEALTH INSPECTOws Establishment Name: l C/ Date: Page: of OFFICE HOURS LIC HEALTH B AR E O� PU6 200 MAN STREET 3:3030-4:30 P.M.DIVISION :00- :30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified /'v11� ;'ejq >�0� HYANNIS, MA 02601 �i 1� 508-s2-4Rsaa No Reference R-Red Item PLEASE PRINT CLEARLY FDN1�` OOD ESTABLISHMENT INSPgCTJPN.REPORT Name Dat e of Tvoe of Ins ection Ooeration(sl m Address Risk Food Service Re-ins ion Level ous Inspection Telephone Rasialelltial Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness tl Caterer General Complaint ! Person in Charge(PIC) Time Bed&Breakfast HACCP Other Inspector u Each violation checked requir s an explanation on t e narrati a page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions an 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) Q ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY �Q ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) ^rl I Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating dJ 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 o checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑.Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations'.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 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 ' non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 vi lation,4 to 8 on-critical viol Ion - 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Insp , or s I nature int: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y NCsSignature '> Print: #Seats Observed Frozen Dessert Machines: Outside Dining Y N I - Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N T Dumpster Screen? Y N Violations related to Foodborne Illness _ Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives _ ., Law Cooled to 41°F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * _ PHF Hot and Cold Holding 2-103.11 erson-in-Charge Duties - - - 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 7 5 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 O 7-102.11 Common Name- -Other* Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* - - - - - Require Reporting by Food Employees and Contamination from the Environment 3-561.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* _ _ 7-201.11 Separation-Storage*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 a _ 3302.15 _ . 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 * 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)Resumed 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 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 _ _ 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures*- _ TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY * Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 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* - - - Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source - 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan_ Contact Surfaces of Equipment* Shellfish* 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 orViolations_ 590.009 A D of Section 590.009 A Din cater- 3 201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) ( ) ( ) Ratites-165°F 15 sec* Sources* 70 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 2-301.11d- Cleaning 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 Procedure* 165°F* foodbome illness interventions and risk factors. i * 2-301.14When to Wash* 3-0Ol.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms _ ( )( )( )3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11Eating,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* * (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 foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 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 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 () 9 9 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. 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. _.. ..... ._.--•.-...T ._.._... -.,,._ .-.`..q� ..,2:..,.,_.. �,.,_.,-...,:,..^-rr T-.r +.. ._.-..r. . . ,-_,-...... -..'t"... ,. r... ,its,. _r TOWN OF BARNSTABLE 'BAR-W 3433 Ordinance or Regulation . WARNING NOTICE Name of Offender/Managert . aJo _Tend i-.;R+A 2rt4e,,'1 Address of Offender i; 1 ra ,,.,D ,` f'C '� MV/MB Reg.# , , ` Village/State/Zip _A)et /r»�`�t` AMC) h I/ `7 - Business Name 7 csa V -- a -, am/pm; on 20 Business Address A.0 Teel ». A Signature of Enforcing Officer Village/State/Zip ,jQ > fi,y. ,,, Y) Location of Offense .0saV-C7n .. ! r,-4 ..0 SJ . o.o .c, vvte (^a )u� , i Enforcing Dept/Division Offense 0 r [')W i74 itttS -t^ Facts r-1 k'a e r n V)( 014-C wo(4? C1 IFT 1Yt-n© r+ '5 This will serve only as a- warnin4j At this time qo 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. r� I Town of Barnstable MAS& Board of Health Eo rt" 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Paul J.Canniff,D.M.D. FAX: 508-790-6304 Donald A.Guadagnoli,M.D. Junichi Sawayanagi Certified Mail# 7006-0810-000-3525-3763 May 7, 201.8 Jay Imad / Marwan Imad Sav-On Gas 381 Camp St West Yarmouth, MA 02673 Email: savon.jay@gmail.com NOTICE OF HEARING - BOARD OF HEALTH RE: Sav-On 381 Camp Street, Hyannis, MA 1 st Violation On 4/16/18, 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, 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 22, 2018 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, Selectmen's Conference 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 Sav On 381 Camp St Hy Apr 2018.DOC m fn ul m Postage $ C7 ,yc t��N rS C] Certified,Fee O -f POStnmafk C] rsem nt Req t Fee / `�r(y,� ` Here .i (Endorsement Re utred) (f A ResMcted Delivery Fee c (Endorsement Required) ! Total Postage&Fees $ .D ,,�_.___�•� •v Sent To �` 3Yreet,Apt N '-t•--=�L��--��Y: .�-^��'0-•-------• or PO Box No. City,State,ZIP+4 :ri r� Certified Mail Provides: w ® A mailing receipt (eWMH)90OZ eunr 009E-CU Sd IN A unique identifier for your mailplece to A record of delivery kept by the Postal Service for two years Important Reminders: n Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. m Certified Mail Is not available for any class of international mail. p NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail ra For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mall receipt.is required. ® For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mallpiece with the endorsement"Restricted Delivery° a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. MTCP ID: Tobacco Compliance Check Form 2014-2015 Section 1: EstablisPnent Survey Participants Name: 0 �-- Yl #-S ID of Purchaser: CM Age: ❑ 16 gFemate 7 Sex:P-Malc Name of dult Supervisor: City; r S Zip Code: d C Time of Check: S am❑ prnad— Type of Establishment: i1chain ❑ Independent O Not Known Date of Check! Day of the Week.—)?'Non ❑Tues❑Wed ❑Thurs ❑Fri ❑ Sat ❑Sun Style of Establishment(Check Only One): 1 ❑ Convenience Store ❑Grocery Store ❑Bar ❑ Department Store ❑Liquor Store ❑Private Club VFW,Legion,etc.) f}as Station Only ❑Pharmacy/Drug Pharmacy/Drug Store El Restaurant ❑ Gas Mini-Mart ❑Other(bowling alley,golf club etc. O Tobacconist Section 2: t Was Compliance Check completed? Yes -No 0 1f'Fes please continue on to the new question,if No please slip this section and go to section 3. H w was tobacco marketed? Over-the-counter:youth asks the clerk for the product. O From a vending machine with a lockout device. ❑ Other Describe: Was the Purchaser asked for ID? Yes❑ Nok Was this an.ID-based check? Yes C7 No 4- 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 Branca of cigarettes asked for -Marlboro ❑Newport ❑Other: ❑ Chew/Dip ❑ Cigars ❑ E-Cigarettes O Other Brand: Was the product requested flavored (NOT Tobacco or menthol)? Yes ❑ No; Was the sale made? Yes�io El If"Yes"how much did the product cost: $ a 50 G p ^Was a receipt given?Yes❑ No�- Purchaser made payment using- O 1 bills ❑ $5 bill(s) 0 $5 bill and$1 bills/or change 0 $10 bill(s) change Section 3: If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why: ❑ Out of Business ❑ Temp.lopy,term closure ❑ In o eration,closed at time of visit ❑ Drive tlru only ❑ Does not sell tobacco ❑ Unlocatable ❑. Unsafe to access ❑ Tobacco out of stock O Inaccessible by youth ❑ Wholesale only/cartons ❑ Presence of police ❑ Permit Suspended ❑ Private club/personal ❑ Machine broken ❑ Other residence ❑ "Don't sell"but tobacco seen in. storellFas permil s .4114115 i r- rT SOV'EREIGN CONSULTING INC . January 31,2018 Thomas A.McKean Town of Barnstable p Public Health Division 200 Main Street Hyannis,Massachusetts 02601 John C. Klimm Barnstable Town Manager - 387 Main Street Hyannis,Massachusetts 02601 Re: Notice of Availability of Phase V Remedy Operation Status and Remedial Monitoring Report Former Shell-Branded Gasoline Station 381 Camp Street West Yarmouth,Massachusetts MassDEP RTN 4-1179 To Whom It May Concern: In accordance with the Massachusetts Contingency Plan (MCP) 310 CMR 40.1403 (3)(e), this correspondence serves as notification that a Phase V Remedy Operation Status and Remedial Monitoring Report (ROS-RMR) was submitted to the Massachusetts Department of Environmental Protection (MassDEP) for the above referenced location (the disposal site). The report summarizes activities conducted between July 2017 and January 2018. Continued activities on site Will include quarterly groundwater gauging and sampling scheduled for January"and April 201;and submittal of a ROS-RMR Status Report in July 2018. Copies of the report can be obtained at the Massachusetts Department of Environmental Protection Southeast Regional Office in Lakeville, Massachusetts. If you have any questions please call the undersigned at(508)339-3200. Sincerely, SOVEREIGN CONSULTING INC. Diann Ewanchuk Rachel B.Leary,PE,LSP Project Manager Senior Project Engineer cc: MassDEP SERO Marc Oler,Equilon Enterprises LLC DBA Shell Oil Products US(Equilon) Sovereign File-2S774 16 Chestnut Street,Suite 520 9 Foxborough,MA 02035 9 Tel:508-339-3200 • Fax:508-339-3248 • ' -CONSULTING July 31,2018 Thomas A. McKean Town of Barnstable Public Health Division 200 Main Street Hyannis,Massachusetts 02601 John C. Klimm Barnstable Town Manager 387 Main Street Hyannis,Massachusetts 02601 Re: Notice of Availability of Phase V Remedy Operation Status and Remedial Monitoring Report Former Shell-Branded Gasoline Station 381 Camp Street West Yarmouth,Massachusetts MassDEP RTN 4-1179 To Whom It May Concern: In accordance with the Massachusetts Contingency Plan (MCP) 310 CMR 40.1403 (3)(e), this correspondence serves as notification that a Phase V Remedy Operation Status and Remedial Monitoring Report(ROS-RMR) was submitted to the Massachusetts Department of Environmental Protection (MassDEP) for the above referenced location (the disposal site). The report summarizes activities conducted between January and July 2018. Continued activities on site will include quarterly groundwater gauging and sampling scheduled for July and October 2018 and submittal of a ROS-RMR Status Report in January 2019. Copies of the report can be obtained at the Massachusetts Department of Environmental Protection Southeast Regional Office in Lakeville, Massachusetts. If you have any questions please call the undersigned at(508) 339-3200. . Sincerely, SOVEREIGN CONSULTING INC. ? Diann Ewanchuk Rachel B. Leary,PE,LSP Project Manager Senior Project Engineer cc: MassDEP SERO Rob Rule,Equilon Enterprises LLC DBA Shell Oil Products US(Equilon) Sovereign File-2S774 16 Chestnut Street,Suite 520 • Foxborough,MA 02035 • Tel:50$-339-3200 • Fax:508-339-3248 i President Comptroller Derek P. Fullerton, RS, CHO Steven Baccari, RS, CHO Middleton � Westborough Vice President MHOA Secretary Samuel S. Wong, PhD, REHS Sigalle Reiss, MPH, RS Hudson Norwood September 27, 2017 Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Dear Barnstable Board of Health, The Massachusetts Tobacco Cessation and Prevention Program (MTCP) recently conducted a tobacco retail inspection/compliance check in Barnstable as part of the Food &Drug Administration (FDA) contract with Massachusetts. After the retail inspection/compliance check was completed in your community, MTCP submitted the results to the FDA. The FDA has determined that the following vendors have had violations of the Family Smoking Prevention and Tobacco Control Act: SAV-ON GAS 381 CAMP STREET These vendors have received warning letters from the FDA for these violations. The inspection results are posted on the FDA website: http://www.fda.gov/ICECl/EnforcementActionsMarningLetters/Tobacco/default.htm This letter is simply to inform you of the violation. No action on your part is necessary. If you have questions, please contact me at 413-636-6418 or at smccolgan@mhoa.com. Yours Truly, Sarah McColgan Tobacco Control Director Cc: Bob Collett, Barnstable County Tobacco Collaborative F Im www.mhc)a.com .a Crocker, Sharon From: Sarah McColgan <smccolgan@mhoa.com> Sent: Wednesday, September 27, 2017 8:26 PM To: Health Cc: Bob Collett Subject: Fwd: FDA Tobacco Violation Attachments: FDA Letter to Funded 2017.doc Tom, Due to a error on the FDA website, a FDA tobacco violation notification for Sav On Gas, 381 Camp Street was mistakenly sent to the Yarmouth Board of Health. We were informed by their health inspector that Sav On Gas was licensed in Barnstable. I have attached a corrected notification. Thank you for your understanding. Sarah McColgan Mass. Health Officers Association Tobacco Control Program Director (413) 636-6418 ---------- Forwarded message ---------- From: Renaud, Philip <PRenaud@yarmouth.ma.us> Date: Wed, Sep 27, 2017 at 11:59 AM Subject: RE: FDA Tobacco Violation To: "smccolgan2mhoa.com" <smccolgan cr,mhoa.com> Hi Sarah, Sav on Gas is licensed by Barnstable Health Department for tobacco. Do you know if all others in Yarmouth had passed this recent FDA tobacco compliance check. Thanks, Philip J. Renaud Health Inspector Town of Yarmouth 1 Tel: 508-398-2231 ext. 1241 From: Murphy, Bruce Sent: Tuesday, September 26, 2017 10:46 PM To: Renaud, Philip Subject: Fwd: FDA Tobacco Violation Sent from my iPhone Begin forwarded message: From: "Sarah McColgan" <smccolgankmhoa.com> To: "Murphy, Bruce" <BMpMhykyarmouth.ma.us> Cc: 'Bob Collett" <bcollett(2obarn stab]ecounty.org> Subject: FDA Tobacco Violation Please see attached notification. Sarah McColgan Mass. Health Officers Association Tobacco Control Program Director (413) 636-6418 2 Ni SOVEREIGN CONSULTING INC . January 29,2015 Thomas A. McKean Town of Barnstable Public Health Division 200 Main Street Hyannis,Massachusetts 02601 John C. Klimm Barnstable Town Manager 387 Main Street Hyannis,Massachusetts 02601 Re: Notice of Availability of Phase V Remedy Operation Status and Remedial Monitoring Report Former Shell-Branded Gasoline Station 381 Camp Street West Yarmouth, Massachusetts MassDEP RTN 4-1179 To Whom It May Concern: In accordance with the Massachusetts Contingency Plan (MCP) 310 CMR 40.1403 (3)(e), this correspondence serves as notification that a Phase V Remedy Operation Status and Remedial Monitoring Report (ROS-RMR) was submitted to the Massachusetts Department of Environmental Protection (MassDEP) for the above referenced location (the disposal site). The report summarizes activities conducted between July 2014 and January 2015. Continued activities on site will include: • Quarterly groundwater gauging and sampling scheduled for February and May 2015; and, • Submittal of a ROS-RMR Status Report in July 2015. Copies of the report can be obtained at the Massachusetts Department of Environmental Protection Southeast Regional Office in Lakeville, Massachusetts. If you have any questions please call the undersigned at(508) 339-3200. Sincerely, SOVEREIGN CONSULTING INC. f Lisa M. Stone Eric D.Simpson,PG,LSP Senior Project Manager Program Manager cc: MassDEP SERO Annette Dokken,SOPUS Sovereign File-2R774 16 Chestnut Street, Suite 520 • Foxborough, MA 02035 •Tel: 508-339-3200 • Fax: 508-339-3248 r January 31,2014 Thomas A. McKeanf Town of Barnstable Public Health Division � 200 Main Street Hyannis, Massachusetts 02601 John C. Khmm (/ Barnstable Town Manager 387 Main Street Hyannis,Massachusetts 02601, - - - - - - ,- Re: Notice of Availability of Phase V Remedy Operation Status and Remedial Monitoring Report Branded-Csel' tation 1 Camp Street; ��om""�� West Yarmouth,Massachusetts 4-1179 To Whom It May Concern: In accordance with the Massachusetts Contingency Plan (MCP) 310 CMR 40.1403 (3)(e), this correspondence serves as notification that a Phase V Remedy Operation Status and Remedial Monitoring Report (ROS-RMR) was submitted to the Massachusetts Department of Environmental Protection (MassDEP) for the above referenced location (the disposal site). The report summarizes activities conducted between July 2013 and January 2014. Continued activities on site will include: • Quarterly groundwater gauging and sampling scheduled for February and May 2014; and, • Submittal of a ROS-RMR Status Report in July 2014. 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