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HomeMy WebLinkAboutSPEEDWAY #2442 - RETAIL FOOD SPEEDWAY#2442 156 Iyannough Rd, H Y A f Yr ` OfiHFT Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARNSTABM. F.P.(Thomas)Lee,. MASS. Daniel Luczkow,M.D. Alt. syq. 200 Main Street, Hyannis, MA 02601 a Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 28 Issue Date: 01/01/2022 DBA: SPEEDWAY #2442 OWNER: SPEEDWAY LLC Location of Establishment: 156 IYANNOUGH ROAD HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IncloorSeating: 0 OutcloorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 202 2 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE- ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: f IMME Town of Barnstable For Office Use Only: Initials: Date Paid i � A Aid$ i O� MUMSTAB Inspectional Services ` 1 iO1E659. 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 FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL ✓ NAME OF FOOD ESTABLISHMENT: npoA Q LI q t l ADDRESS OF FOOD ESTABLISHMENT: _ I J�U 1.�A n('I�t� ICU A o nni S, A �2- �( MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Pb-Ra( o_ ���"�; 1 1�C E-MAIL ADDRESS: C om TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: 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 TAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q'Application FonnsTOODAPP 2020.doc r OWNER INFORMATION: / FULL NAME OF APPLICANT 0-0 ea lnC� SOLE OWNER:.Y�E //NO OWNER PHONE# ^ /3 S a A ADDRESS �'�l X ©�' �CQ.(15.� L . YJt ��g��Ir;� I CIA tysa 1 CORPORATE OWNER: ed�,.�c�U PLC ' CORPORATE ADDRESS:i(",0. 8c� )J�J V�0` I�lI�Q v �I n�-�-el d .0P `/ESb/ PERSON IN CHARGE OF DAILY OPERATIONS: �-wne.141 S 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. ho, 2. W�J Jrp se Coordinator 1 l 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.towtioft)arnstable.us%healthdivision/.Ipplications.as1). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc r Town of Barnstable BOARD OF HEALTH JohnT.Norman Board of Health Donald A.Gaudagnoli,M.D. -' BARNS AH = 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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 28 Issue Date: 01/01/2021 DBA: SPEEDWAY #2442 OWNER: SPEEDWAY LLC Location of Establishment: 156 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: 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: f 1 I For Office Use Only: Initials: 1 �'"E' .� Town of Barnstable Date Paid AmtPd Inspectional Services 4� ;; • 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 FOOD ESTABLISHMENT DATE I I 3 Z NEW OWNERSHIP RENEWAL Z NAME OF FOOD ESTABLISHMENT: St�}P C U w A.\j 2 414 2— ADDRESS OF FOOD ESTABLISHMENT: I CJIo �vTnn�u�InGnniS. MA MAILING ADDRESS(IF DIFFERENT FROM ABOVE) O, �(7X �5 Li C�n�C �� Sir( nPid, pH rjD� E-MAIL ADDRESS: m� �-e�nsi � P �� d�av. C� TELEPHONE NUMBER OF FOOD ESTABLISHMENT: rJ( 0 0)ii5-3 1 $ TOTAL NUMBER OF BATHROOMS: 21 WELL WATER:YES NO ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/ /_ TO NUMBER OF SEATS: INSIDE: _;_I_ OUTSIDE: 0—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. n IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? N V' IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? tA A TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE �ETAIL 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 OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: E /NO OWNER PHONE ADDRESS �. 5� e r 5 l nx I en5e �_.. � lnc�-�tie1�T 4 CORPORATE OWNER• Q CORPORATE ADDRESS PERSON IN CHARGE OF DAILY OPERATIONS: List(2)Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I 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. 4SIGNRE F APPLICANT DATE LICENSE COORDINATOR ***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.towiiotharnstable.us/healthdivisioii/aDRUKafi2nalM. 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.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:1Application Forms\FOODAPP REV3-2019.doc I �KE7 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BAWNSr;ULL F.P.(Thomas)Lee t *SASS: $ Daniel Luczkow,Alternate }� ,m 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: 28 Issue Date: 1/1/2021 DBA: SPEEDWAY #2442 OWNER: SPEEDWAY LLC. Location of Establishment: 156 IYANNOLIGH ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 a n Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY Town of Barnstable For or�ee I�l�s�/7n1v; Initials: # SAAWA Inspectional Services -- =�' -- 1 � Public Health Division �'he�k# �► oag Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMEn-T PERMIT.`APPLICATION GNon-Flavored} DATE �1 170 NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT:S n -e W Qy 7_4 I'?_ - ADDRESS OF TOBACCO ESTABLISHMENT: 15 U J:Ta n Q u__R_d.— M A,.tZ U b I MAILING ADDRESS(IF DIFFERENT FROM ABOVE):�.b, �O1C FJ�' 1 f nfx Dt S'DYI n jqA L I'd 1 T � �5501 E-MAIL ADDRESS: ..r.L h S i n g e Spp[r W iy. C W , TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: SC..a$)775- 3 (_IV OWNER'S NAME:SpC % zz i'f'Z OWNER'S PH## OWNER'S ADDRESS:15LPZUGnnOUAl\ d. nnni5jJ.iA 02_Ubl CORPORATE NAME: 5D,Qt d h1Ay T r,, �t-I5 5N ANNUAL: SEASONAL: DATES OF OPE TION: / / TO / ! DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE CODE/MA GENEML LAW INTEBNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https:/Iwww.ecode360.com/33996392 MA GENERAL LAW CHAPTER 2701SECTION 6: hrtng://maleaiSiat:re.:gov/l aws/0emrgLaws/PartIVITitleUChal)ter270/Section§ �~ *i°*NEW BUSINESSES AND NEW OWNERS ONLY REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. - PLEASE CALL 509-3 7 5-6621 ALL APPLICANTS ARE REQUIRED TO SUS MIT 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 NMA11,Lj LICENSE COORDINATOR SIGNATURE: PRINTED NAME: I-� n� z(Iw(-P I DATE: I I 1 ,3 1 ZD Q:1Applicatidn Form=BACCO APP-NorTwor 12-18-19.doex gg AlY Li '4 £PHISYs' h AT 9"SHARK x � . M011 Amami gt G � � g it j ^ � gm 's.v �� dt ' . �a #ol ,.�' '�cn° o,' 3 Hari € � z b#xSox E s°-W ENO 4 >3 3 3 \ y i ' x x R a ..sue R ANY lilt its Aj Ir I � fi 3 a •�Rmrr{ r � �Jib \,`� i^ \ \a \ 1 Commonwealth of Massachusetts Letter ID:L0851357248 0 s Department of Revenue Notice Date:September 11,2020 o� Geoffrey E.Snyder,Commissioner Account ID:CGL-11945027-224 mass.govidor RETAILER LICENSE FOR SALE OF CIGARETTES SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3).Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at _mass.gov/masstaxconnect to view_and re-print a_copy�f ths_l tense. 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 ------------------------------------------------------------------------------------------------------------------------------------------------ S�,cr�rs��� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes of This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CGL-11945027-224 SPEEDWAY 02442 Location ID: 11945027-0198 156 IYANNOUGH RD License Number: 1258956800 HYANNIS MA 02601-2029 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2020 Expiration Date: September 30,2022 Commonwealth of Massachusetts Letter ID: p o L0067046976ARM Department of Revenue Notice Date:September 22,2020 04� Geoffrey E.Snyder,Commissioner Account ID:CRL-11945027-227 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO �I .I I I. I III u I II I III IIII II I II I nlllllllullrlhllhh " SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FWDLAY OH 45840-3229 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/masstaxponnect to view aad_r_e-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 Frid ay, 8:30 a.m.to 4:30 p.m. DETACH HERE -------------------------------------------------------------------------------------------------------------------------- t+ s� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco o �'` This license must be posted and visible at all tunes:The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CRL-11945027-227 SPEEDWAY 02442 Location ID: 11945027-0310 156 IYANNOUGH RD License Number: 1339152384 HYANNIS MA 02601-2029 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2020 Expiration Date:September 30,2022 8 Commonwealth of Massachusetts Letter M:L1943295552 FA 0 I Department of Revenue Notice Date:September 11,2020 Geoffrey E.Snyder,Commissioner Account M:EDL-11945027-239 nvr(0 mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS I�III�IIIII�II��II'�"I'I�III� lilillllnllllllil�ll�l'lll� SPEEDWAY LLC SPEEDWAY LLC 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 Attached below is yo ur ur Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut ong the dotted line and display at your-business location,At_any_time�you_canlog.into.youur_ _. — 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 ----------------------------------------------------------------------------------------------------------------------------------------------- gpCFCVy6 MASSACHUSETTS DEPARTMENT OF REVENUE Retailer License for Sale of Electronic Nicotine Delivery Systems � j This license must be posted and visible at all times.The sale of tobacco products to anyone under 21 years of age is prohibited. SPEEDWAY LLC Account ID:EDL-11945027-239 SPEEDWAY#2442 Location ID: 11945027-0453 156 IYANNOUGH RD License Number: 1938331648 HYANNIS MA 02601-2029 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. i Effective Date:September 11,2020 Expiration Date: September 30,2022 r A Town of Barnstable BOARD OF HEALTH QY John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARNsrABLF. 2 Paul J.Canniff,D.M.D. o , 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate a � Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 28 Issue Date: 12/10/2019 DBA: SPEEDWAY #2442 OWNER: SPEEDWAY LLC Location of Establishment: 156 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: G A FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: i FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: . ' V For Office Qnly— of rqy� Initials:Town of Barnstable WAMtEdsDate Paid y aARNSfABLE, Inspectional Services MA99. { ...-. Public Health Division Check# UU//V4 �FDMA�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 I ��I NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE):p(� . I N&- 16W I,. uk Soso uri y aN 1 E-MAIL ADDRESS: _- f TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: _ SEASONAL: DATES OF OPERATION:_/ / TO NUMBER OF SEATS: INSIDE: ® OUTSIDE: ® TOTAL: 0 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 f OWNER INFORMATION: �V i FULL NAME OF APPLICANT SOLE OWNER: YES/NO OWNER PHONE# J� J— 7 3 _ ADDRESS .V o Lq,,"K MV . SQfhhylVd1l I CORPORATE OWNER: CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. NIA 1. 2. SIGNATURE QF APPLICANT DATE LICENSE OORDINATOR ***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 APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Application FormsTOODAPP REV3-2019.doc �p IKE►o TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: I �� Page: of 'OFFICE HOURS O` PUBLIC HEALTH DIVISION 8:00-9:30 A.M. RARNSTARLE. MAIN STREET .. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �p ,6}q.s�0� HYANNIS,MA 02601 M-8 -FRI.62-4644 No Reference R-Red Item - PLEASE PRINT CLEARLY. - 508-8 'FON1P� FOOD ESTABLISHMENT INSPECTION REPORT Name Date Tvpe 6 f Insli3ection ` Operation(s) e Address , �1 Risk Food Service Re-inspectionDO `� Level a Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector' Out: Each violation checked requires an explanation on the,narrative page(s)and a citation of specific provision(s)violated. \ Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ VJL 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 [A Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations, '/ v 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/Exclusio ❑ Re-inspection.Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations 9 26.Water,Plumbing and waste' (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have 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 )( ) be in writing and submitted to the Board of Health at the above address violations.observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 = 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8rion-critical violations C. 30.Other DATE OF RE-INSPECTION: Inspec s S' \ b 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N l #Seats Observed Frozen Dessert Machines: Outside Dining Y N PICV�L 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.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge[0 Other* 7-102.11 1 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F. Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 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 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and 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* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* y Pe 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 AnimalConsum Foods Tat Posted for Consumption of * 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System * gg Not OtherwiseProcessed to Eliminate Equipment 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective innoot 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* in mobile food,temporaryand residential Sources* 10 Proper,Adequate Handwashing g' 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 929-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g, g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* Blue Items 23-30)' 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated (E) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* F 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-203.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices (J) 9 9 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 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. Town of Barnstable BOARD OF HEALTH w John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNWABLE. Paul J.Canniff,D.M.D. MA 02601 F.P. Thomas Lee Alternate � 200 Main Street, Hyannis, 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: 28 Issue Date: 1/1/2020 DBA: SPEEDWAY #2442 OWNER: SPEEDWAY LLC Location of Establishment: 156 IYANNOUGH ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual x Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Q Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY J l QFI E Eor Office UsInitials: Town of Barnstable Date Paid ' k , Amt Pd$ _ BARNSTABLE Inspectional Services y MASS. '6,9. A Public Health Division AIFD Mf+� Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE ,� NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: p i ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): , . J Uuwst E-MAIL ADDRESS: TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: L & 7 7CD 3� OWNER'S NAME: Q OWNER'S PH#LGQ&3- 1*4 OWNER'S ADDRESS: 1 0 1 6 1- A . A�' CORPORATE ADDRESS: a 1kAjTV%F'0'PE4 \ VI t CORPORATE ANNUAL: SEASONAL: RASTION:_/_/_ 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/TitleI/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY *** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 �/ , } , LICENSE COORDINATOR 'SIGNATURE: `6yo141 �1'��— PRINTED NAME: 4, S / DATE: Q:Application Forms\TOBACCO APP-NonFavo,11-21-19.doc 7AA�DZIU ENT"S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the tmployee(s)of this establishment received,and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General I Laws which.describes the penalties for selling and/or giving tobacco products to any person under the age of twenty=one(21). Below is Section 371-9.of the Town of Barnstable Board of Health Regulation: Sales to Minors §371-9.Sale and Distribntion or Tobacco Products_ I. No person shall sell or provide a tobacco product,as defined herein,to a;perso»under. The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 ycaes of age. 4.� 2. Identification: Each person selling or distributing tobacco products,as defined herein; shall verify the age of the purchaser by means of valid governs ient4ssued photographic identification containing the bearer's date of birth that the purchaser is21'years old or older. Verification is required for any person under the age of 27: The employees)below received and understood Section 371-9 of the Town of Barnstable Hoard of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of th4 Massachusetts General Laws: Stgnattire� Printed Name Date IsignipjZ., Printed Name -Damf 79�- �. Pr ' Signature Printed Name Date Signature Printed Name Aate 5i nature �"— �-�—�- g Printed N e Date Sign re Printed Name f �L raatB r Signature Printed Nartte Date i � I 1 QIApplica+ion FonniATOAACCOAPP-No®Favor 11.21-19dnc i y � 6 a6ed F xed` dH IfLG6l 6°60Z £Z na0 Commonwealth.ofMassaehusetts1. Letter ID L2071990912 r s Dc artmcni of Revenue P NE Date.Scplembcr4,2018 b Christopher C.Harding;Commissioner Account[D CGG-11945027-224 mass.gov/dor RETAILER LICENSE.FOR SALE OF CIGARETTES Ii. L�� III 1 I �;III III hll. I I ,_1,llluhl! II li: hlll.l I ,Ilil I III . . SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FMI AY OH 45840-3229 1 . Y Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T). Cut along the-dotted line and display at your,business location:At any time,you can log into your MassTaxConnect:account at mass.gov/masstaxconnect to view and re-print a copy of this license, If you have any questions about your license,call us at(617)887 6367 or toll-free"in Massachusetts at ' (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 P.M. DETACH HERE sSP'cHUsF�, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes 9 �NTo4� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID. COL-11945027-224 SPEEDWAY 02442 Location ID: 11945027-0198 156 IYANNOUGH RD License Number:1724565504 HYANNIS MA 02601-2029 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1 2018 Expiration on Date: Septem ber 30 2020 s us6 Commonwealth of Massachusetts Lotter[D L1697944192 t ?� m Department ofRcygnuc NodccDatc Scptcmbcr4 2018 e� Christopher C Harding,Commissioner Account ID CRL 11945027-227 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO SPEEDWAY.LLC SPEEDWAY LLC 2468. 539'S MAW.ST RM 3212 FrNDLAY OH 45840-3229 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. a - DETACH HERE 5°` UsP MASSACIiUSETTS DEPARTMENT OF REVENUE Form CT 3T Retailer License for Sale of Cigars and Smoking Tobacco F p4 This license must be posted and visible.at all times.The sale of tobacco Nr products to anyone under 18 years of age is prohibited SPEEDWAY LLC Account ID: CRL-11945027 227, SPEEDWAY 02442 Location ID: 11945027-0310 156 IYANNOUGH RD License"Number:`1526884352 HYANNIS MA 02601-2029 t 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 maybe suspended or revoked for failure to comply with state laws and.regulations. Effective Date:October 1,2018 Expiration Date:September 30,2020 i r ' DEPARTMENT OF THE TREASURY r ° INTERNAL REVENUE SERVICE �y9 WASHINGTON, DC 20224 LAROB BUSINESS AND INTERNATIONAL DIVISION January 11, 2013 Charles VanBelle Team Manager Large Business & International Nicole Busey Internal Revenue Service Income Tax Audit& Legal Manager 433 N. Summit Street, Marathon Petroleum Corporation Toledo, Ohio 43604 419-213-5166 IRS Badge#1000220353 Dear Ms. Busey, Per our discussion I have researched the Federal Employer Identification Number (FEIN)for Speedway LLC. The FEIN for this entity is 31-1551430. Sincerely, K6 7 C B V"&K06iry 9 emal6dharlef T. Date:2013.01.11 11360-05W Charles VanBelle, Team Manager, LB&I �Hk Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. q Board of Health Donald A.Gaudagnoli,M.D. e,nsxAaM _" John T. Norman MASa F.P. Thomas Lee Alternate $0 � 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 28 Issue Date: 12/20/18 DBA: SPEEDWAY #2442 OWNER: SPEEDWAY LLC, Licensing Dept.; Attn: Sherry Sowry, Licensing Coordinator Location of Establishment: 156 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: �� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: ' PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: FIKE • Initials: "o Town of Barnstable � Date Paid Amt Pd$ „ $ Inspectional Services y-7 4 S8 t63q. 10 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 DATES lJ3/1 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: . ADDRESS OF FOOD ESTABLISHMENT: Ad. klnh`b,�1 OJ601 12 MAILING ADDRESS(IF DIFFERENT FROM ABOVE)TO 6d )�N ')j C D '��q I J kit Id E-MAIL ADDRESS: (%l 1' 9 1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 6 , 01 �I C TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: Nlh 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:Wpplication FormsT00DAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: /NO OWNER PHONE#_. ,�� ADDRESS V O -� )5K6- L'icmee D-erd, Si?nWR ,1d, OIJ CORPORATE OWNER' LCFEDERAL ID NO. :' CORPORATE ADDRESS: 6 D 7 PERSON IN CHARGE OF DAILY OPERATIONS: _D-L P ra 7 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 Da Allergen Awareness Expiration Date 2. NlA SIGNATURrOF APPLICANT DATE JO'Fy K ALLEN, TREASURER FOR SPEEDWAY LLC ***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 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q:Application FormsT00DAPPREV2018.doc Town of Barnstable • Regulatory Services Department 9' MASS. Public Health Division 9 s63 . �D M 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 z 5 LA T NAME OF APPLICANT FIRST NAME MIDDLE INITIAL eoeedootv 4faqqj. D /A Plo Vannounh Rd. a STREET ADRESS TELEPHONE # Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand the Sections VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (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). IRY f 4- Sign a Date/ JOEY K ALLEN, TREASURER FOR SPEEDWAY LLC Q:\Application Forms\TOBACCO APP2018 dob.docx • Establishment TOBACCO SALES -�—YakQ0 1 Employee Sipntare Form This form is for ofcial use to indicate that the omployee(s)of this establishment reeelved and understood sections VIi b, and VU c. of the B;Uunstable Board of Health Prohibition of Smoking�guladon and the enclosed copy of Chapter 270 Sectiv7�6 of the Massachusetts General Laws whiab describes the pmaities for gelling and/or giving tobacco products to any person under the age of eighteen,(19), Below an secdoas VU b,and VU G.of the Barnstable Board of Health Regulatit : s C TOW VIt—SALE AND DISTRIM TiON OF TOBACCO PRODUCTS b. Sales To Minors—In eonform=re'wlth the Missaehusem General Laws Chapter 270,Section 6, IM person, firm, eorgoratiop, establi omen% or agency shad sell tobacco products to a minor, Each employee wvrldng in an eatablisbsnant lacensed to sell tobacco product sball bo required to receive a copy of the Board of Health reguladom and State Law regarding the sale of tobacco and sign a form indicating that surb reguladons/laws have been received and understood, a copy of which must be placed on 51e,in the office of the employer and retained. Such signed forms must be trade available for iosspection,dusiug the 1/cease holders normal businass hours upon request of an agent of the Board of Health,. , c. AU distributorslretailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 yearns of age, the customer present a valid State issued picture identification card or drivers kense with appropriate photograph to cones that the customer is of le al qeto purchase Lbe tobacco produa The following employees)received and understood SeGYiM VIM sad M. of.tbc.Barnstable Board of Health Prol ibidon of Smoking Regulation and Chapter 770 Section 6 of the Massachusetts General saws, �rw�& djs- I I E is Printed lame • Data signatureV V _ a � 0s c Printed Nye Date Signature � � 62 Slgna Printed Name Data Signature Mulo I Nance Date Signature Printed Name Date Signature Printed Name Date Signattu a PrintedN=e Data QAApp6m ion FmmsITOBACCO APP201S deb.docx a-a Commonwealth of Massachusetts Lotter ID:L1697944192 is Department of Revenue Notice Date:September 4,2018 Christopher C.Harding,Commissioner Account ID:CRL-I 1945027-227 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO ;I I � InIIII� I I i � �11IJ � III � � �li � ' � I hll II I I I u II I II I I I Inl I I i Illhnl SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840-3229 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. ,d i N I DETACH HERE CH MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Cr Retailer License for Sale of Cigars and Smoking Tobacco �nrrog"� This license must be posted and visible at all times.The sale of tobacco _ products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CRL-11945027-227 SPEEDWAY 02442 Location ID: 11945027-0310 156 IYANNOUGH RD License Number: 1526884352 HYANNIS MA 02601-2029 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2018 Expiration Date:September 30,2020 I � . Commonwealth of Massachusetts 0"O Lettcr'ID:L2071990912 Department of Revenue 0� b c Nonce Date.September 4,2018 Christopher C.Hardin Commissioner P g+ Account � ount ID:CGL-11945027-224 aft` mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES ,. �;. II �I�IIIII � II'�I�il�l��llll'll�lll�li�ll�l�ll'I��II'I"11'I .. SPEEDWAY LLC SPEEDWAY LLC 2468 539 S MAIN ST RM 3212 FINDLAY OH 45840.3229 Attached below is.your Retailer License for Sale of Cigarettes(Form CT-3T).Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617)887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m DETACH HERE HUg MASSACHUSETTS DEPARTMENT OF REVENUE --Form CT-3T o Retailer License for Sale of Cigarettes Nrof This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SPEEDWAY LLC Account ID: CGL-11945027-224 SPEEDWAY 02442 Location ID: 11945027-0198 156 IYANNOUGH RD License Number: 1724565504 HYANNIS MA 02601-2029 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2018 Expiration Date: September 30 2020 �114E, Town of Barnstable For Office Use Only: Initials: Date Paid Amt Pd$ Inspectional Services Check# Cash w BARNSfABM 'M^ Public Health Division s639. ♦0 i 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 LC EST BLISHMENT AME (D/B/A) 0 n °1 ADDRESS Ot BUSINES MAILING ADDRESS (IF DIFFERENT FR M ABOV ) at L a .can -730a EMA PHONE # FEDERAL ID# Do you currently possess a state license to sell tobacco products? Yes ) No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form (provided herein). Signature Date JOEY 6ALLEN, TREASURER FOR SPEEDWAY LLC C:\Users\CZ.54\AppData\L,ocal\Microsoft\Windows\LNetCache\Content.Outlook\86NF5QTD\TOBACCO APP2019 dob.docx r ..�. ay q . rs UISiiM EtNT'S NAME TOBACCOSALES Employee Signature Form This form is for official u5c to indicate that the employee(s) of this estttblisitment received and understood Cbapter 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 -one t21). Below is Section 371.9.of the Town of products to any person under the etc of twenty Barnstable Board of Health Regulation: Sales to Minors 371-9,Sale and Di Hbution of Tab-,jeco Pro 1. No person shall sell or provide a tobacco product,as defined herein,to a perswit under The mininturn legal sales age. The minimum legal soles age ill the Town of Barnstable -.,is 21 yeah of stge. 2. Identification: Each person selling or distri but vrrg tobacco products,as defined herein, sliall verify the age of the purchaser by means of a valid governrr2ent-issued photographic. identification containing the bearer's date of birth that the purchaser is 211 years old or older. Verification is rquired for any person under the age of ro7. I'he following employee(s) rcce'sved 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-- Sig ture Printed Name pate Sign t re. Printed Name Datc m Signature printed Name Mite y � nature Printed Name Date Signature PriMcd Name Uote Signatuc Printed Name Signature M Printed Narne mate pw. �� <:•1J5::s't,'f •#�.�piit),°t;i(,o�td.hfrdrr»nt"t41if1�lcsirti'•.INc!tt;ncl;r:lf.'urtr�,:i(1,rttaco},.SGitlf 5Q•!!)'.'fr�13AL"C:C)AN►°?019 dt�h t1u�4 � °p ME r TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: � •eQ�1Nj�N Date r I , _ Page; _of PUBLIC HEALTH DIVISION OFFICE HOURS 8:00-9:30A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified Me3. `0� HYANNIS,MA 02601 M-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY gb,,rEOMp+° 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORTvokli Name Date /(4/11 Dpe of e of Inspection y 1 Operation(s) outine at ,vi uo our O Address b 4 Risk Food Service ection f 7 �d� Level etai Previous Inspection v f3c4hrears CvG �t Telephone - I���� 9L Telep sidential Kitchen Date: I ps _v/ Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness "- ®o Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other r^ S< / Q �n� �O Inspector �V (Y Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic.Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items l Total Number of Critical Violations + In 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ 9 Y ❑ 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. if no critical violations 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 6 non-critical violations von-critical violations 26.Water,Plumbing and Waste (FC=5)(590.006) establishment permit and cessation of food establishment operations. If observed,4 too =B. Seriously Critical Violation=F is scored automatically if: no hot 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 8 non-critical violations=C; 29.Special Requirements (690.009) y p 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view j4r 8" " Os Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N J #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 M19TA� 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 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each * 590.004(F) * P 7-101.11 Identi in Information-Original oral Containers Other* Identifying 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* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(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 Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y 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* TIMErTEMPERATURE 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 Eggs 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff c ire 71112001 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 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 Surf aces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* 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. $ Receiving/Condition g� g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2A01.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity* g g 3 403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,,which do not relate to the 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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 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 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction. Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC,-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. ME Tp� TOWN OF BARNSTABLE. .HEALTH iNSPECTOR,s Establishment Name: Date: Page: . of ti OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ` V/ 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS v `0$ HYANNIS,MA 02601 MON.-FRi. No Reference R-Red Item. PLEASE PRINT CLEARLY �DrFo MAC° OD ESTABLISHMENT INSPETI 508-862-4644 N REPORT Nam Date . e of s io Oaeration(sl RoutI ' Address Risk % ice e-ins n Level Retai Previo e Telephone esidential Kitchen Date: IF Mobile Pre-oper i6n , Owner HACCP Y/N Temporary Suspect Ilness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP Other Inspector . Each violatiod checked requires an explanation on the narrativ pages)and a citation of specific provision(s)violated. d 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 C ❑ 9 9 ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS. ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures �- ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling en AA I ❑ 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 LProtection 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 J 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 Re No Yes i D ❑ Non-critical(N)violations must be corrected immediately or C� J Overall Rating J Required: ❑ 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 er 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 9 than and less n ti l l vio lations oaos a s an 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 C=2 c g p,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-_ ical viol tions. If 1 critical refrigeration. vjoli29.Special Requirements (590.009) within 10 days of receipt of this order. on,4 to Snon-critical viol ions 30 Other PATE OF RE-INSPECTION: In or's i to Print: 31.Dumpster screened from public view J/ Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N v #Seats Observed 9 PI 's S' ature Print: Frozen Dessert Machines: Outside Dinin Y N Self Service Waft Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N .. � ,Y _ , ; °t.1'.. . '�✓"���"-.-,r�-fir -� � -� , 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 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 590.004(F) * 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment ( ) Roasts Held At or Above 130°F 7-201.11 Se azation-Storage* 3-501.16A Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _ REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 8 Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 - Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1 g Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(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* Eg a"°°11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(R)(1)(2) Pork and Reef 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* 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* 8 590.009(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 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) 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 practices Requirem no[s ld 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 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°17 Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * r6-301.12 4.11 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* 5.11 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/ 1.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S.590Fonnback6-2doc *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. w �--•.� .J _...,�: +'1`}:,."+w.f's..-.� � ._ _- �..t .. �"r+ -y-.y, •--z.,- :i✓-"- a._FY.� _ d. s,.--S.Y- v'-G..s.aA'e' .r ...�'.',�" •s-.t++•'.,y - - i+... �.,, ,�,F.iw,.i '.-.t.•�..n.t..,..-.. -c` ' ,y .,r...�..�:..r:.r"'-arw'�� � "�.,'.-*.•.c-�.' r" "'?`� ..�. .wr" v ... .'-..,.--^.�'�-,k--t ��"'•' "`P:,*t'7Ca'ab+F'` .i`:..,.yi.TN�.+s..:;•?w_-�'..��..:2 °F� r TOWN OF BARNSTA OFFICE HOURS HEALTH INSPECTOR'S Establishment Name:, Date: Page:_ ¢f ti PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSfABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �A ;'a spa-8sz-asaa 39;a 0� - HYANNIS,MA 02601 - _ - - MO - 64 No Reference R-Red Item - PLEASE PRINT CLEARLY . 'FD1AP' FOOD ESTABLISHMENT INSPECTION REPORT I ci k F � Date p T o Tvoe of Inspection Name S C {' )a 4�5./a O Operation(s) 12out it' �'! / l ! V, I t Address f ( `f Risk Food Service "^Re<ufspection - (a 1 0 ' :�� ) Level ( etallo Previous Inspection Telephone J. �� �12e is dential Kitchen Date: �_� �, r ^� Ir j Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness n) e � l e - c L 'I Caterer General Complaint - - Person in Charge(PIC) Time Bed&Breakfast HACCP Other i Inspector { r7 Out: n T� ri'1 f Each violation checked requires an explanationdnAl4e narrative page(s)and a citation of specific provisions)violated. °--' Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ >r rt Violations marked may pose an imminent health hazard and require immediate corrective Tobacco' 590.009(F) ❑ ( } y (^ f �^,{ , ( e r!' " 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 per` ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17,Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE,POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP '; -A.. _ 1 ❑ per Adequate Handwashing CONSUMER ADVISORY .Pro 0 # r}Y t ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories r f f ),1 Y, f Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations _ Critical C immediately. blue&red items . .( )violations marked must be corrected y ( ) t Corrective Action Required. No ❑.Yes Non-critical(N)violations must be corrected immediately or Overall Ratin al,t 9 f within 90 daysBoard of Health. Voluntary Compliance Em to ee Restriction/Exclusion R -Ins a tl n heduled Emer enc Sus ension as determined by the B , � ❑ ry p ❑ p y ❑ e. p c o Sc ❑ g y p , " C N Official Order for Correction:Based on,an.insp e do 'oday,the items checked indicate violations of 105 CMR 590'.000/Federal Food'Code. ❑ Embargo Emergency Closure Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590:004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005 B=One critical violation and less than 4 non-critical violations g ) 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. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot 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 d 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, to 8npn-critical violations. If 1 critical refrigeration._ within 10 days of recei tof this order. violation,4 to 8 non- ritical violations=C. w 29.Special.Requirements (590.009) Y p 30.Other RATE OF RE-INSPECTION: Inspector'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 Signature - Print: Self Service Wait Service Provided Grease Trap Size Variance Letter.Posted Y . - N ' Dumpster Screen.. Y IN y Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives-. Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*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* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-501.19 Time as a Public Health Control* 3-302.15 Washing Fruits and Vegetables Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-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 liuzoot 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 P 3-401.11(B)(1)(2) Pork and Beef Roast 130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Cough[Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces 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 3-201.15 Molluscan Shellfish from NSSP Listed_ Chemical* ( ) ( ) ( )-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* 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 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000, 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70'F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1 009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. SUITE 2700 G R A Y R O B I N S O N 401 E.JACKSON STREET(33602) BOCA RATON P.O.BOX 3324 FORT LAUDERDALE ATTORNEYS AT LAW TAMPA, FLORIDA 33601-3324 JACKSONVILLE TEL813-273-5000 KEY WEST FAx 813-273-5145 LAKELAND MELBOURNE MIAMI 813-273=5161" NAPLES ORLANDO ANGELA.ROTELLA-GARZON@GRAY-ROBINSON.COM TALLAHASSEE June 24, 2014 TAMPA Town of Barnstable Attn: Health Department 200 Main Street Hyannis, MA 02601 Re: Hess 21248— 156 Iyanough Rd.,Hyannis,MA 02601 Food Service Establisbment/Tobacco Sales Permit Notice of Change of Licensee to New Hess Entity Dear Sir/Madam, GrayRobinson,P.A. serves as national regulatory counsel for Hess Corporation (NYSE:.HES), a publlcally-traded corporation: The"curreni.-Hoensee,' Hess Corp d/b/a Hess21248;will be changing to a new entity,'Hess Retail`Operatiorfs,LLC (".HRO") d/b/a Hess 21248,AIN 22-2462225. . - c In accordance with our recent telephone conference, our office was advised that a letter of notification of this change to your office would be sufficient. The business will remain the same and there will not be any structural or employee changes. The officers for.HRO are: Name Title Patrick McAndrew Vice President Kristy Cunningham Vice President David Goodes Vice President Steven Kemps Vice President& Secretary Andrew Bernstein Vice President&Assistant Secretary Stuart Steigerwald Treasurer The mailing address for the`license'will remain the same,which is: Hess-Retail Operations LLC, 11 Hess'Plaza,Attn Janice Flaherty,-Woodbridge,NJ 07095: www.gray-robinson.com GRAYROBINSON PROFESSIONAL ASSOCIATION June 24,2014 Page 2 If you have any additional questions, please do not hesitate to contact our office. Thank you. e truly our , Angela T. .: =Garzon; Licensing Specialist \10\2192-#5162759 V1 Massachusetts Department of Conservation and Recreation j \. Office of Water Resources d 157802 TYPE OR PRINT ONLY Well Completion Report 1.WELL LOCATION GPS (Required) North West .S� Address at Well'Location: Property Owner/Client: I Subdivision Name: 1 Mailing Address: 1' Ak'A City/Town: Cityfrown: Assessors Map Assessors Lot#: NOTE:Assessors Map and Lot#mandatory if no 5treet,address available Board of Health permit obtained: Yes ❑ Not Required Permit Number Datb,lss ed 2.WORK PERFORMED 3.WELL TYPE 4.'DRILLING METHOD 6. CASING Overburden I Bedrock From (ft) To (ft) Type °r Thickness Diameter l 000� f�] Q I ❑ ❑ ; _ o 5.WELL LOG OVERBURDEN Extra AN ❑ Water Loss or Drop in Fast or d``�\Q❑1-1LITHOLOGY Bearing Addition Drill Slow From(ft) To (ft)' Code Color Comment Zone of Fluid Stem Drill Rate �'SCREEN Fr (ft)" To"�(ft)�, Type Slot Size Diameter Y / N Y / N F / S Y / N Y / N F / S �+ ii C. R. Y / N Y / N F / S . m�> Y / N Y L N F / S g ANNULAR SEALIFIL'TER PACK/ABANDONMENT MTL. Y / N Y=/ N. F /,S Frorti'(ft) To (ft) Material Description Purpose Y / N Y / N F / S � 0 - Y / N Y / N F,1�5-m115 Y / N Y I/N SF /;S ❑❑ ❑❑ WELL LOG BEDROCK Ext6Z 9 SITI:.SKETCH Water Drop in Extra Visible Loss or' #wof. Fast Ore LIT LOGY Bearing `Drill Large Rust Addition Fracture ow From (ft) To (tM C e Comment Zone Stem Ohips{Dnill Rate Staining of Fluid per foot Y / NY`%�N,_F,/ S Y / N Y / N pl [�+ Y / N Y IV F / S Y / N Y / N errz l�/ NY'1 F / S Y / N YJN `4 v: p YN,Y / N F / S Y / N Y / N pJa�lS Y,/,., Y;/ N F / S Y / N Y / N CD YPNY / N F / S Y / N Y / N 7) � Y/ NYr/ N F / S Y / N Y / N _. M �'`- Y / NY / N F / S Y / N Y / N " r YlNY / N F / S Y / N Y / N _ Y / NY / N F / S Y / N Y / N ' .10.WELL TEST DATA(ALL SECTIONS-MANDATORY.-FOR PRODUCTION.WELLS) 11.STATIC WATER LEVEL(ALL WELLS) _ Yield Time-Pumped Pumping Level Time to Recover Recovery Depth Below Date Method (GPM). (hrs min) (Ft. BGS) (hrs&min) (R.BGS) Date Measured Ground Surface (ft) 12.PERMANENT PUMP(IF AVAILABLE) 13.ADDITIONAL WELL-INFORMATION Pump Description A'[]'EY❑ ❑ Horsepower Developed Y / racture Enhancement Y / N Pump Intake Depth -. ft No inal Pump Ca aci m Disinfected Y / N Surfa Seal T e ❑ RL 'P P O P P tY (gP ) 7 yP 14. COMMENTS " ``� ' - .�. S� Total Well Depth - Depth to Bedrock 15.WELL DRILLER'S STATEMENT This well was drilled, altered, and/or abandoned under my supervision, according to applicable y rules and regul ions, and his repo isrcom ete and correct to the best of my knowledge. Driller: � ���' SupervisingDrillef Si nature: Registration #: g 9 Firm: %� Date-Com lete: Vrj -�) i- , Rig Permit#: �` • . ., ,NOTE well.,Completton Reports must bef ded by.the registered well duller within 30 days of well-completion. �•• .`'_ . . _. . _. .°.'.'.` � �.,:• ,r,'�.::.'.l � . .' E . . ' .`.BOARD•bK'HEAL'THGOPY= .. . , . '. . . . .. .'. .`. . • Well Completion Report Codes - . P ' 2. Section 2 - `" Section:3 Section 4 Work Well Drilling Work Performed Type Method Performed 'r: Code + Well Type Code Drilling Method Code Decommission.DC Cathodic Protection CTPR Air Hammer AH Deepen DP Domestic DMST Air Rotary AR Hydrofracture HF Geoconstruction GCON Auger AG New Well NW Geothermal Closed.Loop GTCL Cable Tool CT Repair RP Geothermal Open Loop. .GTOL Casing Advancement CA Replacement RE Industrial 1NDS Core CR Injection INJC Direct Push DP Irrigation IRRG Drive and Wash DW +Monitoring MONT Dug DG ' 'Public-Water Supply PBWS Mud Rotary MR Recovery RCVR Reverse Rotary RR 'Test Wells TSTW Sonic -SN Section 5 Section 6 Overburden Casing Lithology Overburden Overburden Overburden Bedrock Type Thickness Name- (OB)Code Color Color Code Bedrock Name (BR Code)' :Casing 1ype Code Thickness (NO CODE) Artificial Fill AF Black BL Amphibolite AM Certa-Lok CTL, Schedule 5 Boulders B1 Bluish Gray BG Basalt ' BS Fiberglass FBG Schedule 10 Clay CL Brown BR Conglomerate[Breccia CG/BR Galvanized Pipe GLP Schedule 40 Coarse Sand CS Dark Gray ,.DG Diorite DI HDPE HDP Schedule 80 Cobbles C Greenish Gray GG Gabbro GB NSF Coated Steel NCS Schedule 160 Fine Sand FS• Light Gray LG o Gneiss GN PVC PVC SDR 13.5 Fine to Coarse Sand FCS. Reddish Brown RB Granite GR Stainless Steel SST SDR 17 ' Gravel i G Yellowish Brown YB. Limestone .<LS Steel STL SDR 21 Medium Sand MS Marble MA SDR 26 Organics 0 Quartzite QZ SDR 32.5 Sand&Gravel SG _ Rhyolite _ RH SDR 40. Silt SI Sandstone SS 17# Silty Clay SICL Schist Sc 19# Silty Sand SIS Shale __ SH Silty Sand&Gravel SISG _ Slate/Phyllite SL/PH Till T Pegmatite PM Section 7 _ Section 8 Section 10 Annular Seal/Filter _ Screen -Annular Seal/Filter Pack/Abandonment -Purpose Method Screen Type - Code Pack/Abandonment Material Code Purpose Code Method Code Carbon Steel CST Bentonite.Chips/Pellets BC Fill FL Air Blow with Drill Stem AB Continuous Wire PVC CWP Bentonite Grout BG Filter FT Air Lift AL _Galvanized Wire Wrapped -GWW Cement/Bentonite Grout CB Seal AS Bailing BL Perforated Pipe PFP . Concrete CT Constant Rate Pump CR Pre-pack PVC' PPP Sand SD Variable Rate Pump VR Pre-pack Stainless PPS Native Material NM Slug SG Slotted,PVC SLP Stainless Steel Vee Wire SSV Stainless-Steel Well Point SSP• Section 12 - Section 13 Pump Description Well Seal Pump Description Code Horsepower Surface Seal Type Type Code 3 Wire Variable Speed Submersible 3WVS 1/2 20 Cement CM 2 Wire Variable Speed Submersible 2WVS' - 3l4 25 - Cement/Bentonite CB 2 Wire Constant Speed Submersible 2WSS 1 30 Concrete CT 3 Wire Constant Speed Submersible 3WSS 1 1/2 40 None NO Constant Speed Submersible Turbine CSST 2. 50F + �, Variable Speed Submersible Turbine VSST 3.'. 60 Jet JET 5 75 _ Line Shaft Turbine LST. 7 1l2 100 Centrifical CENT - 10 125 - 15_ 150. 200, h application to local Fire D partment. / Fire Department rgis original application and'i sues dupes as Permit. V W I PPLICATI.O->u_and PERMIT Fee: .oa for storage tank removal - tCarisportation to approved tank dim o al'. . rd in acc� p �� ordance with the provisions of M.G.L. Chapter 148 'ion 38A, 527 CMR 9.00, application is hereby de by: J Tank Owner Name (please print) _� I1 f 5'�Y 0 F G�Pr6 G®p X ? nature i ap g orpermrt Address1C�Jr G-�--1= 517�— 7�_.....___ / i�f'11l 111 f•$' 1�- C�' 02.!vy Street . City State zip Company Name y5 C rvyY5T- Co. or Individual_Coq ALti1"--c Az Print /� Pnnt Address 31 &T©�P,�ei. , �'F' ���1� �pFb�D Address(p T®11C �� '1 (� Prat — S Tip'© l2 L7 Print —�"��� Signature 'rf ying for pe ) Signature(if applying for permit) O IFCI Certified Other ❑ IFCI CertifiedLSP# Other Tank Location �t; fG -�,`�J�f/ljQV�(rl-� .n �f D '�S N/(G t'., Steel Address GUY /' - Tank Capacity(gallons) 4 ® V S Substance Last Stored ��S T� d/Z Tank Dimensions(diameter x length) 8 Remarks: Firm transporting waste State Lic. # � `14Q® Hazardous waste manifest# "���� � E.P.A.# Approved tank disposal yard MID C iTY BRA-P Tank yard# /�9$ Type of inert gas At R R/R C Tank yard address ZT,4-C Rav%P (JE S i PGA j�,-7" hi/i City or Town iVi�ls 05811 FDID# i 9 a a Permit# Date of iss ROgSA ;'of expiration ' V Dig safe approval number: [Dig Safe Toll Free Tel. Number-800-322 4844 Signature/Title of Officer grA4 N 'err .� , �=� � ajAOC31 1 After removal(s)send Form FP-29OR signed[J� -ocal Fi ept. to UST Regulatory Compliance Unit, One Ashburton Place, Room 1310, Boston, MA•02108-1618. FP-292 havicarf Q/QA) g} a.Tr. r( � t�'R{•'� t{1P' 11�r��\F�{a�11'� �� ^ . ; FEB. 21 pM 3' 03 r °i