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HomeMy WebLinkAboutABSOLUTE WINE & SPIRITS - RETAIL FOOD EAbsolute Wine RdIyannou h Spirits g- u_��Y I i I a y _ =a 411 ..r . 3• :.- ..�i �� �.�. '°'"x��e .;�a. ..��'� � �zz�- spa �.J�w�. 'ti'3^^:0,: .,'^.� p �� �= jr�" w_t 0- err �. P .,,� �r-r ,�;:�^ '_., snx. �': Er si ,�. '� -$°a c 'd°'� �� � ''°:� �m .` -� �' �rq. .». '. _3.-.-,�... ,°.x'�--•�---„==.�-"".'-,�..y>e 41 ORMERLY MOONSHINE LIQUORS rt" ' ►- Town of Barnstable BOARD OF HEALTH 4 John T. Norman Board of Health Donald A.Gaudagnoli,M.D. RAWNSTAOLL F.P.(Thomas)Lee, MAC' ' Daniel Luczkow,M.D. Alt. a}4. 200 Main Street, Hyannis, MA 02601 erg°"" a Phone: (508)862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 850 Issue Date: 01/01/2022 DBA: ABSOLUTE WINE & SPIRITS OWNER: VEDMATA CORPORATION Location of Establishment: 101 IYANNOUGH RD HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 202 2 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Retail with packaged ice cream in freezers. THE Tp� Initials: ti Town of Barnstable For Office Us � � Inspectional Services Date Paid t `3 �Amt Pd$ �ptEo +►'• Public Health Division (acn 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_12-3 -ai NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: "520 1 . IC Lx) )cX112 A ADDRESS OF FOOD ESTABLISHMENT: c5 y a�n�oudh I-P t/p�an�n i S_DIP 0 26- 1 MAILING ADDRESS(IF DIFFEjiRENT FROM ABOVE): ► / O Y V-- E-MAIL ADDRESS: ' j n/Ty� �-`,ZI -G (So�L� 1b!j - C anl— TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (�jb D - 06L TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO_X ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: ✓ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES NO OWNER PHONE # ADDRESS_ pcja-;cf�5 1�7c� 1�bxeSfid�le�� rn 026(4V CORPORATE OWNER V e-d M o+cL Caag2pwc i oq�0 i IDE S k u-#� JeD CORPORATE ADDRESS: e- 14S Pr&oV-�O--- 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. W rii tj y m rf r uy Q 4}fL 4 / IL /2-4 L k'i 5b cal Sk t.t.K 14 1 26 2. ,,� U . 1 2/ Ll o at SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are 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/api)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 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Q:Wpplication FonnsTOODAPP 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. _ $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 FormsVOODAPP REV3-2019.doc 1 Town of Barnstable BOARD OF HEALTH +� John T.Norman Board of Health Donald A.Gaudagnoli,M.D. •' a seaaa a '' Paul J.Canniff,D.M.D. IMa F.P. Thomas Lee Alternate �� ]k 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, 3058, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 850 Issue Date: 01/01/2021 DBA: ABSOLUTE WINE & SPIRITS OWNER: VEDMATA CORPORATION Location of Establishment: 101 IYANNOUGH RD 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: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Retail with packaged ice cream in freezers. For Office Use Only, Initials: Town of Barnstable ~Q` Date Paid Amt I'd MASS.+`WJWgrABLE. : Inspectional Services i6'� Public Health Division Check# prFO MA'S A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 11-1 J(-2b NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: A,bwWle— Udmjl 22S ADDRESS OF FOOD ESTABLISHMENT: J(J 14 facinbU 0 jp�L- "m,gmm 1-s rn A, 0Q-60� MAILING ADDRESS(IIFI DIFFERENT FROM ABOVE): 101 ;;WQ h Rd�'UO nen 6 r'�1WOZIA j E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 50 ---4s - ©66o TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO i. ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIiR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE VRETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT' Z j V�j S�u Kkq SOLE OWNER: ES NO OWNER PHONE# ADDRESS r U30N IZ1��.4� �� MP- 02 CORPORATE OWNER: 1&j mcr- CORPORATE ADDRESS: 101 j44r!MqnpyghPpQd k lr j S MR ®2-6 PERSON IN CHARGE OF DAILY OPERATIONS: GIbr-5 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. qws� 11 / 2D 1. Eamesh IC ,, 1 `:L/ 2 / 21 2. �i1'i 2-0 SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q\Application FormsT00DAPP REV3-2014.doc i Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. > sr�n _`' F.P.(Thomas)Lee i'v 4 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,Alternate �R 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: 850 Issue Date: 1/1/2021 DBA: ABSOLUTE WINE & SPIRITS OWNER: VEDMATA CORPORATION Location of Establishment: 101 IYANNOUGH RD 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: PLEASE POST CONSPICUOUSLY For Office Use Only: Initials: Town of Barnstable Date Paid HARr:BrABLM Inspectional Services --- -- p }679• Public Health Division Check# _ r4b.MA't.1 � Thomas McKean, Director 200 Main Street, Hyannis,M.A 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT._PERMIT.APPLICATION(Non Flavored. DATE JI- p NEW BUSINESS OWNERSHIP RENEWAL-Z NAME OF TOBACCO ESTABLISHMENT: Rb of tkf e Lq j mH e -�.- j}5- Sn l �- ADDRESS OF TOBACCO ESTABLISHMENT: OUq thiagam 5.,,,,,0c1.B.. J_- MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Ia. ���p tij,d.-14 �an�►) rY1 a 0260 �� .. E E-MAIL ADDRESS: h 56 L —i-zl-+6 16 11aA®B,4,O/1'L• d TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: C5i SU-+75 06E6. OWNER'S NAME: Qi p6 dJ 1. h14 OWNER'S PH# 9 -� D.O.B �.act-19 (y OWNER'S ADDRESS:_.:L.._ (:It w aty Gbre-5ldaZe I'a'& =60q CORPORATE NAME: i,Lri YY a a NX i CORPORATE ADDRESS: !�pjQ j2j CORPORATE FID# � -2,4�2-5 25 ANNUAL:_ SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS). TOWN OF BARNSTABLE.COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https://male islature.:gov/I,aws/GcneralLaws/Par.tIV/Titlel/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 3 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:1Apphcation Forms\TOBACCO APP-NonFavor 12-18-19.docx j ESTABLISHMENTS NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—4 371-9. Sale and Distribution of Tobacco Products. 1, No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. s 1 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: i t Signature Printed Name Date Signature Printed Name Date X�r rmuk8c�ikUi,CM tI—Lk-2W2-6 Signa Printed Name Date Signature Printed Name Date Signature Printed Name Date I Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx x -I' Commonwealth of Massachusefts € 0 � Dc artmcnt of Revenue j Letter ID:L0856977728 rn t`{ Il Geoffrey E.Snyder,Commissioner Notice Data November30,2020 Clrz� _A+y+ Account ID:CGL 1899,1808-010 mass.gov/dor j. i RETAILER LICENSE FOR SALE OF CIGARETTES '(�(Illlltll((Iltll(f�llltilt( tttl(tl(tt �ltl(II'II'!'(tllll�!! j VEn MATA CORPORATION l o ABSOLUTE WINE&SPIRITS o'er l PATRTCKS WAY i o FORESTDALE MA 02644-1030 I Attached below is your Retailer License for Sale of.Cigarettes.(Form CT`3.).Cut along the dotted line and display at,your,.b...usiness..:lncation. At any time,,,you can,log;into your` assTax.Connect 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•inrMassachusetts at (800) 392-6089,Monday through.Friday,8:30 a.m. to 4:30 p.m. I i j I i 1 DETACH-HERE -------------------------------------------------- SauiUs� MASSA,CHUSETTS DEPARTMENT OF REVENUE. Form CT-3' m Wi Retailer License for Sale of Cigarettes �%g This license must be posted and visible at all times.The sale.of,tobacco products to anyone under 21 years of age is iprohibited: I VED MATA CORPORATION .Account ID:CGL-18991808-0.10, ABSOLUTE WINE& SPIRITS Licen4 Number:.1838573568 I01 IYANNOUGH RD HYANNIS MA 02601-2028 i This certifies that the.taxpaYer named above is.licensed under Chapter 64Cjof 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. 1 Effective Date: October 1,2020 Expiration Date: September30, 2022 _._ ......................... y.�ttrsT Commonwealth of Massachusetts r Department of Revenue Letter ID:L054WM92 O y j, y Geoffrey E.Snyder,Commissioner Notice Datc:Novcmber30,2020 � �sj Account ID:CRL-18991808-013 a 'CvrOV mass:gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO I In,l1,llltlltitll�lll i1111'l1III'hllllhlilltlllllllllyillt 'I VED MATA CORPORATION N ABSOLUTE WINE&SPIRITS ! w= I PATRICK S WAY FORESTDALE MA 02644-1030 Attached below is your Retailer,License for Sale of Cigars and Smoking Tobacco(Form.CT-3T). Cut along__the dotted line and,display at your business location.At any time,you can. og into your IYfassTaxCon.nectaccount at mass..gov/masstaxconnect to view and re-pri tt a,copy of this license. If you have any questions about your license,callus at(61:7) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:3.0 p.m., DETACH HERE I -------------------------------------------- ------------------------ -- ----------------------;---------- ------------------- - S�cxc1 SE��r MASSACHUSETTS DEPARTMENT.OF REVENUE: Form CT-3.T Retailer License-for Sale of Cigars and Smokin �Tobacco Tt'F. raF�� This license must be posted and visible at all times.Th sale of tobacco products to anyone under 21 years of age.is pr htbited. VED MATA_CORPORATION Accourit ID: CRL-1999180&013 ABSOLUTE WINE& SPIRITS Licens Number: 1945061376' 101 IYANNOUGH RD H.YANNIS MA 02601-2028 This certifies that the taxpayer named above is licensed under Chapter 64CIof the Massachusetts General Laws to sell at.retail at theaddress shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state.laws.and regulations. j I Effective Date:October 1 2020 Expiration Dater September 30,2022. Commonwealth of Massachusetts r¢3 Department of Revenue Letter ID:L0159459904 0 Fr, ,',� Geoffrey E Snyder.Commissioner Notice Date:May 15,2020' '1 f; Account ID:EDL.18991808-016 mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS nl�►iII��Iliiil �liIIII �I�li�h��rli�Nitl�ii�l��,ny�,� � VED MATA CORPORATION I ABSOLUTE WANE&SPIRITS 1 PATRICKS WAY FORESTDALE MA 02644-1030 I I Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along he 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. 3 If you have any questions about your license,call us at(617)887-6367 or oll-free in Massachusetts at (800)392-6089,Monday through Friday,8:30 a.m.to 4:30 p.m. I I I I I 3 i DETACH HERE ------------------------------------------ MASSACHUSETTS'DEPARTMENT OF REV] UE s i ' P Retailer License.for Sale of Electronic Nicotine Delivery Systems This license m •t;�r,.�,�. ust be posted.and visible.at all times, The sale of tobacco products to anyone under 21,years-of age`;is prohibited. VED MA TA CORPORATION Account ID:EDL-18991808-016 ABSOLUTE WINE& SPIRITS License Number: 2116724736 101 IYANNOUGH RD Age-Restricted Store HYANNIS MA 02601-2028 i This certifies that the taxpayer named above is licensed under Chapter 64C if the Massachusetts General.Laws to sell electronic nicotine delivery systems at the address shown above.This license is non-transferable and may suspended or revoked for failure to comply with state laws and regulations. Effective Date:May 15,2020 Expiration Date: September 30,2022 mom= EIN Assista it You,progroon: i.Idomity 2.Aumentfcato .3.Addressor. A,Demkt 5.EIN Confirmation - Congratulationsi The EIN has been successfully assigned: �eip Topics EIN Assigned: 83.2625257 Can I�ha EIN pe use, r1_ before fhgctvtfrmat'r••ra ram.. L:galName: VEDMATACORt?ORATION � receiv d? The confirmatia;letter will t.e Mailed to the applicant,This letter Will be the applicants official IRS notice and will contain important infomtalicn regarding the 81 N.Allow Up to 4 weeks for the letter to arrive by mail i We.strongly rocommend you printthis page foryourrecords, !- I I Gick-Confiru da 0 get additanai information about using the new EIN. I Continua» { l i f� i I I i I 1 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. 13ARNSTAB e. Paul J.Canniff,D.M.D. HAS& F.P. Thomas Lee Alternate $egg. , 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, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 850 Issue Date: 12/31/2019 DBA: ABSOLUTE WINE & SPIRITS OWNER: VEDMATA CORPORATION Location of Establishment: 101 IYANNOUGH RD 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: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: �YGi FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Retail with packaged ice cream in freezers. Use Town of BarnstableL��O?Oi 'Initials: Amt Pd$ BAMMBLE. : Inspectional Services �f 39. Public Health Division Check# 1330 Cash Thomas McKean, Director W Ovonit( 200 Main Street, Hyannis,MA 02601 bo-(A) Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE j ()ate NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: �S��u Gil//✓I l✓ �►� 1 ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 5 ' E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (g TOTAL NUMBER OF BATHROOMS: WELL WATER:/YES NO '�... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: // SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: `z)­ 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? '"/4— IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE 1/ RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeratio reeze� 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 QAApplication FormsWOODAPP 2020.doc re OWNER INFORMATION: FULL NAME OF WNER PHONE ADDRESS CORPORATE OWNER:�V.��h��t � JJ `� CORPORATE ADDRESS: ( D l�y�• //c �'! k' �'J/�I S �/� ��. �/ PERSON IN CHARGE OF DAILY OPERATIONS: ��sh 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 AOT 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.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.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. Q:\Apphcation FormsTOODAPP REV3-2019.doc Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 Regulatory Services Department „M Public Health Division BAROm- Thomas A.McKean,CHO 634. E 200 Main Street, Hyannis, MA 02601 �b MA'S Payment Receipt Food Service Permits Payment received: $30.00 (Cash) on 1/9/2020 Permit number: 850 rv� � Business: ABSOLUTE WINE &SPIRITS Owner: VEDMATA CORPORATION Address: 101 IYANNOUGH ROAD/RTE 28, Hyannis Note: Retail Food Permit Yr 2020 $ 20, and Late Fee Tobacco $ 10, Balance Due $ 100 for new establishment for 'Mood permit. L I tk1 � Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNSMAULE, Paul J.Canniff,D.M.D. MASS. 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: 850 Issue Date: 1/1/2020 DBA: ABSOLUTE WINE & SPIRITS OWNER: VEDMATA CORPORATION Location of Establishment: 101 IYANNOUGH RD HYANNIS MA 02601 Type of Business Permit: Non-Flavored Annual X Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY tLlp HE Town of Barnstable For Office Use Only: Initials: 'Tp T •�` Date Paid q dOApt$ �� MUMSTABIZ, : Inspectional Services //��- y� ,"AM. AtEo Public Health Division Thomas McKean, Director S'�t 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE ZO NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: C�°t of c- a'LJ S p! 9,(,f-S ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): SG.,Mf_ cif a 4U(-,C— Zkf E-MAIL ADDRESS: Z. k S (112 i 7 �© �CO� TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (Lob q;ls- OWNER'S NAME juk14 �`P� 1/lS� k t OWNER'S PH#(9 d'). ZA- S3 OWNER'S ADDRESS: �- 6DG,¢�cG�S 6✓ fan 0_5Ma I 0 pi & C)6Ak CORPORATE ADDRESS: J."Aer�k �exl ����NmlS n� CORPORATE FID# �3 ZszS�ZS'' ANNUAL:- -� SEASONAL: DATES OF OPERATION: '% / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) --- TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https•//malegislature.gov/Laws/GeneralLaws/PartIV/Titlel/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: (L State License to Sell Cigarettes 0 IRS Federal Tax ID#Document MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE:',% PRINTED NAME 1! I �1/ I�Y1r1a 5h Y 62 DATE: Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc 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—k 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: 202-6 \. Signature Printed Name Date - 2026 Signature Printed Name Date MC1C-11 S how �Q -- 1 - 9 - 20 20 Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date QA\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc :,nt^Rtc 0$0 F Commonwealth of Massachusetts Letter ID:L1959290240 Department of Revenue Notice Date:February 27,2019 !j Christopher C.Harding,Commissioner Account TD:CGL-19991808-010 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES 11111'1"Jill'I111111 VED MATA CORPORATION ABSOLUTE WINE&SPIRITS 1 PATRICKS WAY FORESTDALE MA 02644-1030 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. s If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m, to 4:30 p.m. • DETACH HERE ----------------------------------------------------------------------------------------------------------------------------------------------__ MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes �:�.���.�t' This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. VED MATA CORPORATION Account ID: CGL-18991808-010 ABSOLUTE WINE& SPIRITS License Number: 1574422528 III IYANNOUGH RD HYANNIS MA 02601-2028 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: February 27,2019 Expiration Date: September 30, 2020 Bpi ,Pc:rir,;c , Commonwealth of Massachusetts Letter ID:L0688342400 Department of Revenue Notice Date:February 26,2019 Christopher C.Harding,Commissioner Account ID:CRL-18991808-013 P g mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO III IIIIIIII Jill 111 1111113111111111111111111111 VED MATA CORPORATION ABSOLUTE WINE&SPIRITS W l PAIRICKS WAY FORESTDALE MA 02644-1030 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut along the dotted line and display at your business location.At any time,you can log into your . MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE •---------------------------------------------------------------------------------------------------------------------------------------------- MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking g g Tobacco This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. VED MATA CORPORATION Account ID: CRL-18991808-013 ABSOLUTE WINE& SPIRITS License Number: 692348928 101 IYANNOUGH RD HYANNIS MA 02601-2028 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:February 26,2014 Expiration Date:September 30, 2020 4Y, .• EIN Assistant Yow Progress: t.Identity 2.Authenticate 3.Addresses 4.Details 5.EIN Confirmation Congratulations!The EIN has been successfully assigned. Help Topics Can the EIN be used before EIN Assigned: 83-2525257 the confirmation letter is Legal Name: VED MATA CORPORATION received? The confirmation letter will be mailed to the applicant.This letter will be the applicant's official IRS notice and will contain important information regarding the EIN.Allow up to 4 weeks for the letter to arrive by mail. We strongly recommend you print this page for your records. Click"Continue"to get additional information about using the new EIN. Continue» r t 1 f Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. + ' Board of Health Donald A.Gaudagnoli,M.D. BAR xAUce = John T.Norman 'SSA 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: 850 Issue Date: 02/21/2019 DBA: ABSOLUTE WINE & SPIRITS OWNER: VEDMATA CORPORATION Location of Establishment: 101 IYANNOUGH RD HYANNIS MA 02601 Type of Business Permit: TOBACCO Annual: YES Seasonal: IncloorSeating: 0 OutcloorSeating: 0 Total Seating: 0 FEES (� FOOD SERVICE ESTABLISHMENT: YEAR. 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �FTME 1p� Town of Barnstable For Office Use Only: Initials: Date Paid GyT"r^ AmtP�$�� 9 MASS. s Inspectional Service � 019. Public Health Division Cash 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 9-1 A -IQ NEW OWNERSHIP_ RENEWAL NAME OF FOOD ESTABLISHMENT: /Tasa lufc W�mp'e-� ADDRESS OF FOOD ESTABLISHMENT: JOA �LMCM-noL4all Qd ,"ACt-n-rN 1 S .M R 0 2.66) MAILING ADDRESS(IF DIF1FERENT FROM ABOVE): S ekm-e— CtA A-bey�e, E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (Sod)_2'S:- TOTAL NUMBER OF BATHROOMS: I WELL WATER: YES NO ✓ ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V/ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE:TOTAL: SEATING: MUST OBTAIN Ar COMMON VICTU- LLER'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? l 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 Forms\FOODAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT D j D-;-j SOLE OWNER: YES/NO OWNER PHONE # f2ty a .S 2L( --3?,4 Y ADDRESS_ �. Pa i�KS W0 / p2W LJ CORPORATE OWNER V?A q (DW074hu�FEDERAL ID NO. : CORPORATE ADDRESS: 1 t3l �W p-1`n DU G ii lLd J:W e,Cq rn i_q i'Y A 02601 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 Foodyr6tection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The He Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFI-ATES at your food establishment. Certified Food Managers Expiration-Mate 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 Dv. 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 the Town 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 1st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q\Application FormsTOODAPPREV2018.doc AA oF1wEr Town of Barnstable For Office U e Only Initials: f " --� Inspectional Services Date Paid ID BARNSTABLE, MASS.: � Public Health Division — 40 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT y ESTABL SHMENT NAME (D/B/A) ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERENT FROM ABOVE) `J-)�104; U;6W OWNER'S NAME: - LAST FIRST MIDDLE - 50s- 32U -9-2-Wil 8 3-2!5'25 25 � EMAIL PHONE# FEDERAL ID# Do you currently possess a state license to sell tobacco products? Yes V00" No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form ..(provided herein). - Signature Date 2-f9 -2®SDI Q:\Application Forms\TOBACCO APP2019 dob.docx 1 y 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—b 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: (`(lay -�►4 Pof q'is-26Q - -- - - Signature Printed Name Date Signature Printed Name Date —�9 -2oM 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 Town of Barnstable Office:508-862-4644 Fax:508-790-6304 Regulatory Services Department w saAss. Public Health Division MASS,, Thomas A.McKean,CHO 6 �` 200 Main Street,Hyannis, MA 02601 Payment Receipt Food Service Permits Payment received: $85.00 (Cash) on 2/19/2019 Business: Absolute Wine&Spirits Address: 101 IYANNOUGH ROAD/RTE 28, Hyannis Note: Tobacco for 2019 (new owner) formerly Moonshine OF IRE To TOWN OF BARNSTABLE.. HEALTH INSPECTOR'S Establishment Name: Gsc�! C) �� \ Dater / - Page: _ of- OFFICE HOURS BARN57'ABLE. PUBLIC 6200 MAN STREET EETSION 3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. A 639.'p`0� HYANNIS,MA 02601 sos-s-FRI No Reference R-Red Item PLEASE PRINT CLEARLY . FOOD ESTABLISHMENT INSPECTION REPORT Name / 1�; 'Date ,.6 1� T e Inspection Ooeration(s) outin 6 Address l7 Risk Food Service Re-inspection Level a Previous Inspection Telephone Residential Kitchen Date: Q(�1 Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP `� •K� 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 TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) (� Corrective Action Required: o ❑ 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. F] ❑ Emergency Closure Voluntary Disposal Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than 400n-critical violations if no critical violations observed,4.to boon-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 8 non-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to on-critical violations=C. 29.Special Requirements (590.009) y _ 30.Other DATE OF RE-INSPECTION: Inspe or igna re Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N a ry-\ C-k7�\ J 1 ck 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* $ 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 3-262.1.2- - Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding - _ oo 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 7-102.11 Common Name-Working Containers* 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR - _ 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations * 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13_ Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective tizrzoot 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) I Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- * Ratites-165°F 15 sec* in mobile food,tern or and residential Sources 10 Proper,Adequate Handwashing g' P Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHFs Received a[Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercial) Processed RTE Food-140°F* Blue Items 23-30) 3-202.15 Package Integrity Y non-critical Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification g 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 ]Accessibility, Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-02.12 Records,Creation and Retention* 5-205.11 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 Conformance with Approved Procedures I 6-301.11Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision ' 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Forrnback&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. 2t'�THE ro TOWN OF BARNSTABLEHEOFFICE ouRORs Establishment Name: age: of P. PUBLIC HEALTH DIVISION 8:00-9:30 A.M. '. UBC 0 ` BARNSTABLE. ` 200 MAIN STREET n / \ 3:30-430 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 /vlyv) MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY p �rFD MP�p FOOD UTABLISHMENT INSPE TI N REPORT 508-862-4644 Name ate of f Inspection ration(s) Routine Address Risk d Service spection Level Retai Previous Inspection J Telephone esidential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness / Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP n, Other Inspector O Each violation checked requires an explanation on the narrative age(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Related Foodborne Illness Interventions and Risk Factors Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations ViolationsRelatedto Good Retail Practices(Blue IternslGood Retail Practices(Blue Iternsl 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 g re ardless 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 if no critical violations observed,4 too 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, 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must g p,infestation of rodents or insects,or lack of be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non- itical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to Snon-critical vio lions- 30.Other DATE OF RE-INSPECTION:RE-INSPECTION: In p or's ignature 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* h 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 7-201.11 Separation-Storage** 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 590.004 11 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 ) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* ( Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources F 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 ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 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* 3-801.1](C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 1112001 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 rf ces o f qui of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* * Ratites-165°F 15 sec* in mobile food,tempor and residential Sources 70 Proper,Adequate Handwashing g' Game and Wild Mushrooms Approved B 3 401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority y 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3401.11(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 practiceRequues should be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C CommerciallyProcessed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) 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 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13 Handwashing Facilities 3-202.18 Shellstock Identification* 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70*F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Tags/Records:Fish Products V6-301.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes.critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.