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CAPE COD NUTRITION COR. - RETAIL FOOD
i CAPE COD NUTRITION COR. J9 IYANOUGH RD. , HY. R x r } r t IKE, Town of Barnstable BOARD OF HEALTH r John T.Norman Board of Health Donald A.Gaudagnoli,M.D. - DARNSTABLL F.P.(Thomas)Lee,. MAS& 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. 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: 795 Issue Date: 01/01/2022 DBA: CAPE COD NUTRITION CORNER OWNER: JAMES CARRON Location of Establishment: 75 IYANNOUGH ROAD HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2 O2 2 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r • For Office Initials: .�`"�'' ►.� Town of Barnstable fhh71 Date Paid UsLT,, Apt Pd$ I VlJ Inspectional Services &` ��� # I1Rg1 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 NEW OWNERSHIP ( RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: Q e ( �V�l) (AA- V a 6 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Q E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (5 ,()] - SG 5 TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO L/... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: l /—L/-)�TO 1 /-It—/ 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) OD 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 REV3-2019.doc OWAR INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: Y /NO D.O.B OWNER PHONE I ADDRESS CORPORATE OWNER:eoQ�' �d l^Grt<q( �� rEOFBIRTH: C h d CORPORATE ADDRESS: J 1AA 6RO PERSON IN CHARGE OF DAILY OPERATIONS: If 0 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. ° -/ / / 1. 2. SI OATURE 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.asi). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. Q:\Application FonnsTOODAPP REV3-2019.doc I ` IVA Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. ,NSTAsM Paul J.Canniff,D.M.D. S& F.P. Thomas Lee Alternate s � 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: 795 Issue Date: 01/01/2021 DBA: CAPE COD NUTRITION CORNER OWNER: JAMES CARRON Location of Establishment: 75 IYANNOUGH ROAD HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q. FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �tHE rFor Town of Barnstable Initials:Date Paid]C 23 AmtPd$ -- Inspectional Services � MAS S' Check#1639 ,.� Public Health Division ArEp Mp'�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 I NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ��, d.Vkv i 1 11 V\ Co C ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(1F DIFFERENT FROM ABOVE): r,. WA E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: V` WELL WATER:Y NOV (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / � O NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE F OM 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-nsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT V SOLE OWNER: YES/NO D.O.B h OWNER PHONE# ADDRESS , , (� / ADC CORPORATE OWNER: � 5 CORPORATE ADDRESS: U tl��4Ao � n 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. SIG ATURE OF APPLICANT DATE *** *** FOOD POLICY INFORMATION SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/al)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc 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 FormsWOODAPP REV3-2019.doc i Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARNSTAULL = Paul J.Canniff,D.M.D. 3 4 200 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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 979 Issue Date: 01/01/2021 DBA: CAPE COD ORGANIC FARM, INC OWNER: JOSEPH TIMOTHY FRIARY Location of Establishment: 3675 MAIN ST./RT. 6A BARNSTABLE„ MA 02630 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeatin : 0 OutdoorSeatin : 0 Total Seating: g g Seat g 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: 4 A opTNE t For OM se Only.• Initials: Town of Barnstable t 1 Date Paid 1 7iJ Amt Pd$ � ELUMSPABLE, ; Inspectional Services Q C� 1 ``� Public Health Division iOrEa iwor a Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 t Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 1 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: 0A2 NJ f(4A t L- C1t_YI(j IW, ADDRESS OF FOOD ESTABLISHMENT: NoIS Ma SA RulA&±,a,k. N_16 2r b 0 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): PAX � , , �nS- doi� hll/� oz63 6 E-MAIL ADDRESS: A.CARn 0 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER: ES NO I ...(AN AL 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? No IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? V40 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 'w OWNER INFORMATION: FULL NAME OF APPLICANT ose Oq My"oDw Ffkyr\ SOLE OWNER: I'E /NO D.O.B Of OWNER PHONE#� ADDRESS_ 36-4S `rnLlwx S 1100 tFOASI&IDIC Lnft 02J.&M CORPORATE OWNER: CORPORATE ADDRESS: Ma1� PERSON IN CHARGE OF DAILY OPERATIONS: Ti' 11► `FIB����' 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. ell NATURE OF PLICANT 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 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.ast). 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.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Application FormsTOODAPP REV3-2019.doc i 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. _ $1.00, 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= $10 Q:\Application FormsTOODAPP REV3-2019.doc a 3 W S' � M TIM FRIARY . ^k for successfully comoleting she standards set forth for the ServSafie N., Pnotectwn Manager Certification Examination, U H}hich is accredited by the:American NotionidI.Standards(nstltute(AN51j-Conference for ood Protection (CFP). x � _ 1747 .067 5419 ;" F EXAMX'AM FORM NUMBER EJi T,i I C i4T E N`U h M6ER 2M 3/2019 2/13/2024 ' DATE OF EX%-'M NATION DATE OF EXPIRATION Local laws apply.Chet3k wi*,.your Zonal mgvlatory:dgency for recetfification requirements. - ,3 7 e Sberma Brown #0655 Executive Vice President,Ndtional Restaurant, ciation Solutions ■ ;L7■ In accordance .Maritprre labour Convention 2006,Res"on ADM N 068-2013 iReg"on 3.2,0tandord A3l• ®2017 NdHonal Restourant Amdation.Educatiarwl Foundation iNRAER AN rights rocerveda ScrvSa a„d tlse ServSaFol logo ara 4rademdrlu of the NR 4Ef.Notional Reataumm h5soc(aRorO and the arc design ars,frademorks of the NalialalRestaurant Assor.Fation. T This doeurnent eonno(6 reproduced or*Mend. O 17110911 v.i7X Conlact us with questions at 238 S.Wacker Drive,,Suh 3600,Chicago,IL.6060$-6383 or SemSaWrest'ourant,org. �r r - 4 � a A' �n �-• ` I M FRIARY for successfully completing Ithe standards'set forth for the ServSaf�®Food Protection Manager Certification Examination, NAich is accredited by the,American Nationdl Standards Institute(ANSIK-",`ferente for Food Protection {CFP). } T4 1747'067 r�419 . Ir€RT`tFICA'7 BER IEXAM FORM 'YNUMBER 2Y13/2019 2/13/2024 p DATE OF EXAMINATION (DATE OF EXPIRATION Lecal laws apply.Ch k with ycmr local repltifdryj c.91,ncy for recertification requiremants. M. "` `-.-.` .r s Sherman Brows+ fi #0665 Executive Vice President,Ndtional Restourant.Ai oc ati,on Solutions O ;M Cow"on 200 Resolution AOMN,M8-201.31 ulalion 3.2 hgndartA3.2t. In accordance with lcbour 4, �g MarNttne �2(T17<Nali ResWuront`Assotiot on�duwtiannt Founddiw INRAE6).M�fghts rmsorvad,$evSa} ,Ond"d.e eS Sefellogo o-tmdem.6 of the NRMF.Notional Restaurant Aa=iallorO and the arc design are trodonorks of the National&astouront Association. . - I This document aowot Ms reproduced or altered. ti 171)081 t v,1.7j_ Contact us with questions at 238 S.WackerDrive„SuRe 3600,Chicago,IL 60606-63113 or Sery st°a Safe®reurord.ag. f I En • �_� iii s i � �•,f • 1 J n f y�T -Yr �: � • • • - •. • - . 1 1 h tom,) u 'a V ` h < La s�:.•�C.,._•:� J '/ I J •:-.aim in ' � C J J J J J n J J I J �, •��c�-���.c.� �a���,�-�:�.e.�: ,?.cam �?,c�;�?,c� �. Town of Barnstable BOARD OF HEALTH o� John T.Norman �y Board of Health Donald A.Gaudagnoli,M.D. HASNWADUL + Paul J.Canniff,D.M.D. �$ 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 795 Issue Date: 12/10/2019 DBA: CAPE COD NUTRITION CORNER OWNER: JAMES CARRON Location of Establishment: 75 IYANNOUGH ROAD HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: o� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: • Initials: Town of Barnstable For Office � Date Paid Amt Pd$�_ BARNSTABLE, : In.spectional Services (� KASS' � Check# Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A F OD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: V iV ut I'�'� �U ADDRESS OF FOOD ESTABLISHMENT: S sj(mm & �_�l�l� �ITh_6 9 MAILING ADDRESS(IF DIFFERENT` FR M ABOVE): E-MAIL ADDRESS: ►�/ BV TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (%)ns -�b TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: ►V 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) F�D SERVICE k/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 �y y t OWNER INFORMATION: FULL NAME OF APPLICANT �y.o Udru SOLE OWNER: YES/NO D.O.B OWNER PHONE# ADDRESS CORPORATE OWNER: UC � Wk � r Z C. CORPORATE ADDRESS: ©�,'l 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. SIG URE 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/a1)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Application FormsTOODAPP REV3-2019.doc i r W� 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 QAApplication FormsTOODAPP REV3-2019.doc p*rrtfc7 Town of Barnstable BOARD OF HEALTH Paul 1 Canniff, D.M.D. Board of Health Donald A.Gaudagnoli,M.D. onWNSUOLL =' John T. Norman p M059.AR& 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: 795 Issue Date: 12 20 18 DBA: CAPE COD NUTRITION CORNER OWNER: JAMES CARRON Location of Establishment: 75 IYANNOUGH ROAD HYANNIS MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE- ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r rr Fz►�roy, Town of Barnstable For Office Use Only: Initials: "o Date Paid l I as A��p�$ * a R • AM. s Inspectional Services Public Health Division Check# b Cash Thomas McKean,Director —1 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fag: 508-790-6304 ` A/PPLICATION FOR PERMIT TO OPERATE A F OD ESTABLISHMENT DATE ���ts�Y NEW OWNERSHIP RE WAL NAME OF FOOD ESTABLISHMENT: UK1141iitikin, d ADDRESS OF FOOD ESTABLISHMENT: �) 0�-6 c;r MAILING ADDRESS(IF DIFFERENT (�FRO ABOVE): E-MAIL ADDRESS: l� C, I1f C v t jut, , TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER: Y S NO V ". (_ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: i SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) _FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FormsT00DAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: C FULL NAME OF APPLICANT SOLE OWNER: 1YES/NO D..O..B OWNER PHONE ADDRESS CORPORATE c �, �vlr,�� wrn�rn O I�'1 L FEDERAL ID NO. CORPORATE ADDRESS: S kAi1Q,_ PERSON IN CHARGE OF DAILY OPERATIONS: l/r7 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. 2. SIG TURE 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. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec. 3 0 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsT00DAPPREV2018.doc AWOO I �p IME r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name, ?� -ate: 1 Page:. ,Of �,R„S,ABoLE. PUBLIC 200 MAIN STREET DIVISION -'00�0:30C4:30 P.MS Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS, o, MON.-FRI. �A 019. HYANNIS,MA 02601 os-862-4saa No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLI HMENT INSPE;CTtOI4 REPORT Name f DO 6A to e o �- inspectionl ^3� .-/ l / Oueration(g) Routines l '-% Address ' Risk c Service -Re=inspecti n y o/r, �,°`` ' LevelsRetai Previou pe _ w Tele hon I J \ -Rest idefitial Kitchen Date: � P Mobile Pre-oper$ or� Owner HACCP YIN Temporary Suspect III ess Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP l Other f bi Inspector A Each violation checked require an explanation on the narrat) ages)and a citation of specific provision(s)violated. g Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ i / y r 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 a / 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 ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories - Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ 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 ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 6=One critical violation and less than 4non-critical violations 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-criti al violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 non-criticalr`violati �s=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: I Cd ct 's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's ure Prin Self Service Wart Service Provided Grease Trap Size Variance Letter Posted Y N , � _ D� �7/d J�/ Dumpster Screen? Y N r v Violations related to Foodborne Illness Violation 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 Cooked and RTE Foods.* * 3-501.15 Cooling Methods for PHFs 19, 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage*Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 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 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)Resumed Food and Rated or of Food*Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* I 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. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Equipment Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from 2n Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* - 3-401.11(A)(2) Comminuted Fish,Meats&Gam_ a Pathogens* eg"°e ulnoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B). Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g �' S90.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 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* I 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * EO2 Preventing Contamination When Tasting* 3-403.11 * (Blue Items 23-30) 3-202.11 Package Integrity (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* 12Prevention 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 ) Preventing Contamination from Employees* 18Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* * 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 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Message 00 00 Page 1 of 1 Crocker, Sharon To: File Subject: RE: cape cod nutrition center They are unhappy with the high cost for permit and for servsafe classes. They only serve milkshakes. -----Original Message----- From: Wadlington, Ellen Sent: Tuesday, January 30, 2007 11:11 AM To: McKean, Thomas Cc: Stanton, David; Crocker, Sharon Subject: cape cod nutrition center I called Cape Cod Nutrition Center to inform them their establishment owes$100 for movement to new facility and also $200 for this year's permit. I was informed that they will discuss this matter with Tom because they see Tom every day. Ellelr w �Bfaa mov--e-1 1/30/2007 S f Town of Barnstable p� MA&& Board of Health. fir° ' fna 2002 Main Street, Hyannis.MA 02601 �w ' 'c'. Office: 508-8624644 Wayne Miller M.D. FAX: 508-790-6304m Paul J.Canniff,D. 7 l/.J'11 , September 29, 2006 Alexandro Moriera. 89 lyannough. Road Hyannis, MA 02601 RE: Proposed. Deli,.89. lyannough. Rd,. Hyannis, MA 02601, Grease.Trap Variance.and Toilet Facilities.Variance Dear Mr. Moriera:.. You are granted.a conditional variance from.Section 322-3 of the Town of Barnstable Code,.to serve only those.foods. listed on.your submitted. menu dated July 14, 2006.. This. section of the code. requires minimum. 1,000.gallon. capacity grease traps at all.food establishments. You are also.granted a variance from Section.322-4.to.operate a.food establishment with only one.toilet facility.. These variances.will. allow you to operate.a food establishment at the. proposed. Deli located.at 89. lyannough Road,. Hyannis with.the following. conditions: (1) Cooking.of food(s). is not authorized.at this site. . (2)The menu. is restricted to. cheese, sliced ham,turkey breast,. ham,. salami,and.other sliced meats. in. accordance with the. menu.submitted July 14, 2006.. No other food items.are authorized to be prepared.or served. (3) Seating.for patrons. is not allowed.due to the lack of restroom.facilities onsite. (4)An in-line grease interceptor shall be installed in accordance with the State Plumbing. Code.. (5) A person in.charge shall be onsite all times the store is.open for business. This person shall be. properly trained and certified in food sanitation and safety (e.g. ServSafe certified). Moreira Deli 2006 1 of 2 a� a • F (6) Furthermore, an.alternate shall be available. and onsite anytime the. prima ry,person-in-charge is not available. The.alternate person shall be. properly trained and certified in.food. sanitation. (e.g. ServSafe certified). (7).These variances are not transferable to.another owner or lessee of this establishment.. (8)These variance may be revoked.anytime the operator fails to comply with a. condition.of these.variances.or anytime. unsanitary conditions.are. observed. (9) This variance decision letter shall. be posted on a wall.adjacent to.your food. service. permit in an. easily accessible location for viewing. by a health inspector during. inspections. These.variances.are granted. because the.applicant stated.that this.will. be. a.deli, only, and will not sell.sandwiches or cook food.. The menu consists of cheese and deli meat.. The application appeared to comply with the Board's grease.trap. variance guide. In regards to the restroom, the applicant stated.that there.will. be no more than two employees onsite and there won't be.any seating. provided.for patrons.. Since ly yours,. W ne. filler,. M.D. Chairm n. Moreira Deli 2006 2 of 2 �ptHE t • DATE: 7y „ FEE: « SARMABLE, w 9 MASS. g QjA 1639• REC. BY Town of Barnstable sac SCHED. DATE: i .Board of Health 200 Main Street,Hyannis MA 02601 ' Office: 508-8624644 Susan G.Rask,R.S. FAX: 509-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION n® 1 Property Address: t' Ci f -e:,'r' 29 coo NJ Assessor's Map and Parcel Number: Size of Lot: Wetlands Within 300 Ft. Yes Business Name: n No Subdivisio `Name: t( s � APPLICANT'S NAME: Phone Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON Name: � hems? Name: Nt-rcet' CQ rt? I' i lor.6 rzj Address: �` R 0 , d4, ,gin A Address: Z,&°s \ Phone: • 4 ';�,O -2.2 Z i Phone: �, 1 �/i�-{ C�D 2 f VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) � unls�� Fa�rorM �� a.-Fc,( c�iF e�-�lo,,,e,� o,.[�► - t- w d Li --1 C A NATURE OF WORK: House Addition ❑00000 House Renovation ❑ Repair of Failed Septic System ❑ Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets. _ Four(4)copies of the completed variance request form _ Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) , _ Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only], outside dining variance renewals [same owtier/leasee only], and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) G Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne A.Miller,M.D.Chairman NOT`APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Susan G.Rask,R.S. Q:\HEALTH\Application Forms\VARIZEQ.DOC `� � �fy) 9021 vto ��vu� 5.i,ur ---------------- s�I P. DIP r � r-7 aS�Icift,� J e J t ti t i i �4 l I �pIKE, qkTE- FEE: « BARNSrABLE, NAM 039• ��� REC. BY Town of Barnstable SCHED. DATE: .Board of Health 200 Main Street,Hyannis MA 02601 Offide: 508-862-4644 Susan G.Rask,R.S. FAX 508-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION % Property Address: M cmo NJ Assessor's Map and Parcel Number: Size of Lot: Wetlands Within 300 Ft. Yes Business Name: i t No Subdivisimi`Name: APPLICANT'S NAME: Phone Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON Name: '� C+n -j�p� Name: {�1t'k�1lQ ro 0r�1 r� Address: R 0 FOk 1 to Ca rM• cD. ,An A Address: R — a, (ZA Phone: 4 30 -2 22 Phone: c 90 2`i _ VARIANCE FROM REGULATION(List Rog.) REASON FOR VARIANCE(May attach if more space needed) U.nlse lc 04' 3 0,%N LZ wdL wvfc al— — AAA �frzaQ E4&12 R — J-h P+u4N� 4 ole � NATURE OF WORK: House Addition ❑=00 House Renovation ❑ Repair pf Failed Septic System ❑ Checklist (to be completed by office staff-person receiving variance request application) Pleasesubmit copies in 4 separate completed sets _ Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) _ Four(4)copies of labeled dimensional floor plans fibmitted(a.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent him/her for this request _ Applicant understands that the abutters must be notified by certified mail at least tea days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) _ Variance request application fee collected {ao fee for lifeguard modification renewals, grease trap variance renewals [same owaer/leasee only], outside dining variance renewals [same owner/leasee only], and variances to repair failed sewage disposal systems [only if no expansion to the building proposedD E Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Wayne A.Miller,MD.Chairman NOT APPROVED Sumner Kaufman,M.S.PIL REASON FOR DISAPPROVAL Susan Q.Rask,R.S. 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