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HomeMy WebLinkAboutWILLOW TREE MARKET - FOOD - CLOSED J 5 Char Ies 3tre-et y a r)h 7 I� Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BA rrsexaxm Paul J.Canniff,D.M.D. .. A 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 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: 752 Issue Date: 01/01/2021 DBA: WILLOW TREE MARKET OWNER: WILLOW TREE MARKET INC. Location of Establishment: 15 CHARLES ST HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $200.00 YEAR. 2®21 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Will provide Servsafe/Allergen if commercial kitchen is re-instated. er T' �I WE rpm For Office Use Only: Initials: �.� Town of Barnstable Date Pawl , D 2b Amt Pd$ 2CO W N5PABLE. : Inspectional Services ' ' `�� Public Health Division Check ArFO MAy a Q's 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: ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ,�/ E-MAIL ADDRESS: , 3 '!� DD ( ©(' TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ,(kLL - Z 7 TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO V/...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO NUMBER OF SEATS: INSIDE: 4 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 DO0R(S)9 TYPF OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) TA SERVICE TAIL 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 Q1Application FonnsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/( OWNER PHONE# ADDRESS_ '1' <:;;A9 "lzrG1) W CORPORATE OWNER: l � CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1.�`�.� S�/l.�lG�t�7.�1�✓l l� ���� �l l�� lf/Y�L�-J�f1/N/��/O 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/apt)lications.asi). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January I st to Dec. 3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. Q1Application FonnsTOODAPP REV3-2019.doc I �ptMg Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BAR lSt.B. : F.P.(Thomas)Lee WIAS& Daniel Luczkow,Alternate {, ,6 200 Main Street, Hyannis, MA 02601 a 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: 752 Issue Date: 1/1/2021 DBA: WILLOW TREE MARKET OWNER: WILLOW TREE MARKET INC. Location of Establishment: 15 CHARLES ST HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: Will provide Servsafe/Allergen if commercial kitchen is re-instated. PLEASE POST CONSPICUOUSLY it For Office Use Only: Initials: Town of Barnstable Date Paid 11 3 AmtPd$ 0 Inspectional Services (�n A 6 � . Public Health Division s'1eC'`#— rFb.r�tpY" .007j Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT.APPLICATION-Non-Flavored`. DATE,' NEW BUSYNESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: ADDRESS OF TOBACCO ESTABLISHMENT: � C %i�L -5 ✓�. 1. �Gf� S � �D MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: (fy// i�1 TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: &!L 72e-/ 7 ac _ OWNER'S NAME: WNER'SPH#�k ��� OWNER'S ADDRESS: CORPORATE NAME: CORPORATE ADDRESS:/ firs e� �np CORPORATE �"' �✓ ANNUAL:V SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) ; TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: I https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https:Hmalegislature. ov/Laws/GeneralLaws/PartlV/Titlel/Chap,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 FALL APPLICANTS ARE REQUIRED TO SUBMIT,THE FOLLOWING REQUIRED DOCUMENTS: i 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document a 2 MA State License to Sell Cigars and Smoking Tobacco 4 Payment of Fees see page 4 g g ) Y () - P g a SIGNATURE: PRINTED NAME: C% � DATE: / Q:Wpplication Forms\TOBACCO APP-NonFavor 12-18-19.docx 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 3710 f the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—4.371-9.Sale and Distribution of Tobacco.Products. 1, No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification:is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature Printed Name Date Si a Printed Name Date e'L9i2 ��—Z3'-.2029 �gna a Printe ame Date s. Signature a 'Hied .ame Date Z Zo 2 a _ :Signature Printed Name -T Date Signature Printed Nanie Date (Signature Printed Name 'Date.. Q:\Application Forms\TOBACCQ APP-NonFavor 12-18-19.docx a''SsIsF�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes or�� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. WILLOW TREE MARKET INC Account ID: CGL-10919185-007 WILLOW TREE MARKET License Number: 449783808 15 CHARLES ST HYANNIS MA 02601-5596 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 ------------------------------------- MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco T�F �� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. WILLOW TREE MARKET INC Account ID:.CRL-10919185-010 WILLOW TREE MARKET License Number: 1454622720 15 CHARLES ST HYANNIS MA 02601-5596 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 f Commonwealth of Massachusetts Letter ID: L1618506304 �s Department of Revenue Notice Date:May 8,2020 Geoffrey E.Snyder,Commissioner Account ID:EDL-10919185-017 ��4TOFf`ry mass.govldor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS WILLOW TREE MARKET INC o= WILLOW TREE MARKET N= 15 CHARLES ST HYANNIS MA 02601-5596 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 ------------------------------------------------------------------------------------------------------------------------------------------------ �TSSSFT� MASSACHUSETTS DEPARTMENT OF REVENUE Retailer License for Sale of Electronic Nicotine Delivery Systems .y 1Jl `k N � This license must be posted and visible at all times. The sale of tiF.N.r 0ti tobacco products to anyone under 21 years of age is prohibited. WILLOW TREE MARKET INC Account ID: EDL-10919185-017 WILLOW TREE MARKET License Number: 530098176 15 CHARLES ST HYANNIS MA 02601-5596 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 8, 2020 Expiration Date: September 30, 2022 ' dot Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BAWM&BM Paul J.Canniff,D.M.D. +��� &,+� 200 Main Street, Hyannis, MA 02601 IF.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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 752 Issue Date: 12/10/2019 DBA: WILLOW TREE MARKET OWNER: WILLOW TREE MARKET INC. Location of Establishment: 15 CHARLES ST HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $200.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Will provide Servsafe/Allergen if commercial kitchen is re-instated. 44 MCI � rq� For Office Use 0 Initials: Town of Barnstable Date Paid $ , STAB . : Inspectional Services K,SS. 1679.p�� Public Health Division check# J Eo�r Thomas McKean, Director �k 200 Main Street, Hyannis, MA 02601 ' Office: 508-862-4644 Fax: 508-790-6304 -i APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATEIL � NEW OWNERSHIP RENEWAL NAME OF FOOww"D"'' ESTABLISHMENT: A'/Jae ADDRESS OF FOOD ESTABLISHMENT:_/.5 Ceel4SS J� MAILING ADDRESS(IF DIFFERENT ,FROM �AABgOVE): 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:_/_/_ TO NUMBER OF SEATS: INSIDE: o OUTSIDE: 0 TOTAL: a 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) EtODSERVICE DETAIL 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: C ,1 FULL NAME OF APPLICANT SOLE OWNER: YES& OWNER PHONE #� ADDRESS CORPORATE OWNER: ��/Lf�J+ 6✓ %/C!' �-6 / f/Y CORPORATE ADDRESS:/ PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SIGNATURE 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!I 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 htti)://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. QAApplication FormsTOODAPP REV3-2019.doc r� oFtM¢r For Office Use Only: Initials: \ Town of Barnstable Date Paid �, �AB�, ; Inspectional Services y MAW. Check# n�y—SJ -�— 1h 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 r NEW BUSINESS OWNERSHIP RENEWAL {� NAME OF TOBACCO ESTABLISHMENT: 1A11&-AV 1-1 1 /'ll�A- ?Q- T ADDRESS OF TOBACCO ESTABLISHMENT: /5 C //`L � ✓��i/��Y�V l� �� 8�0�� MAILING ADDRESS(IF DIFFERRENT FROM ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: - n OWNER'S NAME: l/ /� L /lil�� OWNER'S "PH#5 OWNER'S ADDRESS: CORPORATE ADDRESS:, A /y 1''" CORPORATE o� I ANNUAL: SEASONAL: DATES OF OPERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) � � TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https•//male,gislature gov/Laws/GeneralLaws/PartIV/TitleI/Chal)ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY *** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: DATE: Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc I ON Ail ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—$371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature Printed Name Date de a 11-Z 6 009' gnature q Printed Name Date S(A:::: N Ix 0 f 4" 1/,- Si nature Printed Nwbe 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 � �cHUsF�� MASSACHUSETTS DEPARTMENT OF REVENUE ' r Retailer License for Sale of Cigarettes Form CT-3T ��F�7Ok�c This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. WILLOW TREE MARKET INC Account ID: CGL-10919185-007 WILLOW TREE MARKET 15 CHARLES ST License Number: 1796859904 HYANNIS MA 02601-5596 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 Retailer License for Sale of Cigars and Smoking Tobacco ��.r � This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. WILLOW TREE MARKET INC Account ID: CRL-10919185-010 WILLOW TREE MARKET License Number: 1401100288 ? 15 CHARLES ST HYANNIS MA 02601-5596 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 _ R Town of Barnstable BOARD OF HEALTH � John T.Norman ` Board of Health Donald A.Guadagnoli,M.D. t• s��asc+Qes Paul J.Canniff,D.M.D. �tas� a F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 752 Issue Date: 1/1/2020 DBA: WILLOW TREE MARKET OWNER: SAEED A. CHAUDHRY Location of Establishment: 15 CHARLES ST HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual X Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: Will provide Servsafe/Allergen if commercial kitchen is re-instated. PLEASE POST CONSPICUOUSLY Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. T,.k L 8T.ABM John T.Norman F.P.$,� •��� � 200 Main Street, Hyannis, MA 02601 Thomas Lee Alternate a ° 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: 752 Issue Date: 12/20/18 DBA: WILLOW TREE MARKET OWNER: SAEED A. CHAUDHRY Location of Establishment: 15 CHARLES ST HYANNIS MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $200.00 YEAR. 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: I PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Will provide Servsafe/Allergen if commercial kitchen is re-instated. FT HE rO�ti • Initials: o� Town of Barnstable a ( ZS 1 Date Paid Amt Pd$ t MAN. Inspectional Services t639. 10`� q'FDr1►A'�A Public Health Division Check# 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 �/ g` r�%p NEW OWNERSHIP RENEWAL L NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: ,��� � �S /1&10a MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �1 E-MAIL ADDRESS: �i��G� /! 1 7/!' TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: - _ WELL WATER:: YES NO V ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: 1/ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: -A�L OUTSIDE: TOTAL: O 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) AFOOD 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) _eTOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL, MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FormsTOODAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: �f FULL NAME OF APPLICANT SOLE OWNER: YES/� OWNER PHONE# ADDRESS CORPORATE OWNER: ,qM- OIV �- `rEDERAL ID NO. : CORPORATE ADDRESS: G I &X2-1V1VY 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 r 2. 51*V1 ,19` 70 a1-7-1U2-,F5 GPI -t �� 14D11W W&e;V (✓,E &f��� 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 htti)://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec.315`each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1 st. Q:\Application FormsT00DAPPREV2018.doc I 0 IKE Town of Barnstable Regulatory Services Department * BARNRrABI.F. *9� M Public Health Division �f°r A 200 Main Street, Hyannis MA 02601 Office: 508-7904644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health 3; Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL I yam._ D/B/A STREET ADDRESS 50y, -1l;77 TELEPHONE# FID . _ Do you currently possess a state license to sell tobacco products? Yes y 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 toblZ ucts must sign the Employee Signature Form (provided herein). Signature Date Q:\Application Forms\TOBACCO APP2019 dob.docx Establishment 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 the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below are sections VII b. and VII c. of the Barnstable Board of Health Regulation: SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the 1vlassachusctts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file, in the office of the employer and retained. Such signed forms must be made available for inspection, during the license holder's normal business hours upon request of an agent of the Board of Health. C. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a rs of age,the customer present a valid State issued customer appears to possibly be under 27 yea picture identification card or driver's license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIlb. and VIIc. Of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: ~' Si Printed Name Date gnature- _.-�_ i Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP2019 dob.docx %cli SF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T a Retailer License for Sale of Cigarettes T 7 bFti r 0* This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. ,o WILLOW TREE MARKET INC Account ID: CGL-10919185-007 CTJ WILLOW TREE MARKET License Number: 1796859904 ? 15 CHARLES ST HYANNIS MA 02601-5596 ; i-A 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 c- MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T �' Retailer License for Sale of Cigars and Smoking Tobacco -b o* This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. WILLOW TREE MARKET INC Account ID: CRL-10919185-010 WILLOW TREE MARKET License Number: 1401100288 15 CHARLES ST HYANNIS MA 02601-5596 I 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 own of Barnstable OF THE o Regulatory Services Thomas F. Geiler,Director * STABLE, » 0.19. 16 Public Health Division rED MA'S Thomas McKean, Director .367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 4, 2001 Richard Roberts, Owner/Manager Willow Tree Market 15 Charles Street Hyannis, MA 02601 Order To Appear At The Board Of Health Meeting on May 15, 2001, 8.:00 pm On May 1, 2001, cigarettes were sold to a minor (a person under the; of 18 years) by Sarah Stevens, who is employed at the Willow Tree Market, Hyannis, Massachusetts. Ms. Stevens received a Warning Notice at the time of the violation. According to Chapter 270, Section 6 of the Massachusetts General Laws "whoever sells a cigarette, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen (18) or, not being his parent or guardian, gives cigarettes, chewing tobacco, snuff, or tobacco in any of its forms to any person under the age of _ eighteen (18), shall be punished by a fine of not less than one hundred dollars ($100) for the first offense, not less than two hundred dollars ($200) for the second offense, and not less than three hundred dollars ($300) for any third or subsequent offense. Also, Board of Health Regulation Part IX, Section VII specifically states "Persons, firms, corporations, or agencies selling tobacco products to minors (or selling tobacco products without a Tobacco Sales Permit) shall be punished by a fine of not mgre than $300 per day for each day of such violation and/or suspension of the tobacco sales permit. This letter shall serve as a Warning Notice to you, as you are the manager-of this establishment. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules, and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance.. _ Subsequent violations will result in appropriate legal action by.the Town. You are directed to appear before the Board of Health at the Tuesday, May 15, 2001 meeting at 8:00pm. The meeting will be held at the Barnstable Town Hall, 367 Main Street, Hyannis, MA, in the 2nd Floor Conference Room. The reason for the meeting is to provide you an opportunity to present your action plan to prevent sales to minors in the future:--': PER ORDER OF ME BOARD OF HEALTH mas A. McKe en. RLS, C HH( Agent of the Board of Health LLLL;7.15 ru Er Postage $ / CO Ln Certified Fee 1 c —0 1 /O Postmark, Return Receipt Fee c Here M (Endorsement Required) I O rl � p Restricted Delivery Fee 0 (Endorsement Required) � tl � "'J Total Postage&Fees $ [ � LS% �� -.•n r o r ---�_ a \ :G�/larcJ Rb�c-IS! �t,�le� �GG ............. ---------- J`------- C3 Street,Apt.No.;or PO Box No. � -f LS 6�,r r�s S{ _�:i�_t_G_w?._..'C_e --p_1 k� O Cjry,State,ZIP+4 �n �`01�-I------ � CertWail Provides: o A receipt " o A unique identifier for your mailpiece o A signature upon delivery 4 e A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. n 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 Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o 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.` PS Form 3800,May 2000(Reverse) 102595-99-M-2087 • • ■ Complete items 1,2,and 3.Also Complete A. Received by(Please Print Clearly) B. of Delivery item 4 if Restricted Delivery is desired. Pate,of ■ Paint your name and address on the reverse C. Sign Jurd so that we can return the card to you. j ■ Attach this card to the back of the mailpiece, X // ❑Agent or on the front if space permits. ddressee D. Is de' r address different from item 1? ❑Yes 1. Article Addressed to: ES,enter delivery address below: ❑No L, A: o� i�--`2- Nar kit �� Cr►)Ok(' `e5 '[-, 3. Service Type k Certified Mail ❑Express Mail Ck on ;�J �a b�' ❑ Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Artic a ber(Copy from service label) I&761 ; on-13 65 9 C�: �a ; PS Form 3811,;July 1999 Domestic Return Receipt 102595.00-M-0952 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit NGraG-10 *.Sender: Please print your name, address, and ZIP+4 in this box • r Town of 8a rd" P.O.Boot 534 Hyannis,Maseadnmetb 02601 I P �"(LCarvn�cic � �. ...., .. .._ r_ ..tia..--.,:....y,t.:a--.y:r.-.._« ..�.y.r,.'f"1 ..r'S..r..��:....•.....:....:,,+ _. .. �� y, .. ,.. n.. '•'*, .-, ,r..'..-r '•.}.., r + R„ OWN OF BARNSTABLE B' -W Ordinance or Regulation WARNING NOTICE Name of Offender/Manager r ► 3r"�S Af !Address of Offender .� S 1 `�► { �5 MV/MB Reg.# Village/State/Zip A'4'vr4l�' azeo�l Business Name t row e. ' � 'J /pm, on 2001 Business Address I /} Signitu e .of Enforcing Officer Village/State/Zip ��', f"� ►G Location of Offense { Enforcing Dept/Division Offense `�A (e- OF 6- hA 64 d. a duC f C /41IIV a Facts l —57e wNs j This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary , compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. py�p IKE r, TOWN OF BARNSTABLE - _ HEALTH INSPECTORS Establishment Name: Date:l Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified � 639• `mg HYANNIS,MA 02601 MON.-FRI.508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY Aleu MPS a FOOD ESTABLISHMENT INSPECTION REPORT d Name Date (� ype of �Inspection v r , Operation(s) utin Address Risk Foo Service inspection Level eta Previous Inspection Telephone 4 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) ® / 1 �- FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities /a EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ` U ❑ 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 U Violations Related to Good Retail Practices(Blue Items). Total Number of Critical Violations . Critical(C)violations marked must be corrected immediately. (blue&red items) ��, o Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or _ within 90 days as determined b the Board of Health. Overall Rating y y ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 6 re 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. =One critical violation and less than 4non-critical violations 9 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food p y resu sus fd p 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 9 non critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to a non critical violations=C. n 29.Special Requirements (590.009) Y P 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dum ter 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 Ple's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N r Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH_ 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to. 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* * 7-102.11 Common Name-Working Containers*2 Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* P g 20 me as a Public Health Control 7-201.11 Separation-Storage** Time 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* * Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(1) 3-306.14(A)(B)Returned Food and Reservice of Food* ) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed Sprouts Not Served* 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and * 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1 g Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145° Not Otherwise Processed to Eliminate F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Equipment 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg cme wnooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources g. P razY 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and AutMidhority Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* RegulatoryAuthorlry 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under/Y29-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 3-202.15 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 8 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 590.000 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products P 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 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients[0 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention 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. 1 Poisonous or Toxic Materials I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 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. oFt ►o TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: �'� �(ON '(�- /�IG/YCet. Date: . /9 Page:_�of OFFICE HOURS PUBLIC HEALTH DIVISION 8.00-9:30A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MAss. HYANNIS, MA 02601 MON.-FRi. a639• 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY �'FDN1P�� FOOD ESTABLISHMENT INSPECTION REPORT / Name Date, TvDe of section C� a °2 Operation(s) Routine Address . 1 Risk Food Service Re-inspection ('1 f Level a ail Previous ps� ion <' Telephone esi ential Kitchen Date Mobile Pre-o era on r^B 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) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) El 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 L� �„(1 ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories l CVill�l Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Q Critical(C)violations marked must be corrected immediately. (blue&red items) I 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. 1 /I ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ RE-inspection Scheduled ❑ Emergency.Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure Voluntary Disposal ❑ Other. checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590:005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. if if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have aright to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation to 8 An-critical violations=C. 30.Other DATE OF RE-INSPECTION: InspecVy, P t:31.Dumpster screened from public view � , Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' nature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N f' 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* ti Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F 7-102.11 Common Name-Working Containers Require Reporting by Food Employees and Contamination from the Environment 3-501.16 A( ) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* pStorage* 20 Time as a Public Health Control 7-201.11 Separation-590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* * Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(I1) Variance Requirements Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR- - 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and * 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations 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 I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.1](A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef i-I112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Chemical Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other es sho9 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices -17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-102.11 Package Integrity* g S 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 g 3-202.18 Shellstock Identification (A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 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 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures 1 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials I FC-7 1.008 HACCP Plans 6-301. 22 Hand Drying Provision 29. 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:59OFormback6-2doc *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.