HomeMy WebLinkAboutKAPPY'S FINE WINE & SPIRITS - RETAIL FOOD KAPPY'S FINE WINE&SPIRITS-
333 Iyannough Rd
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
B,►u.NWanLE, s F.P.(Thomas)Lee
200 Main Street, Hyannis, MA 02601 Daniel Luczkow Alternate
+k 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: 1076 Issue Date: 1/1/2021
DBA: KAPPY'S FINE WINE & SPIRITS
OWNER: HYANNIS WINE AND SPIRITS INC.
Location of Establishment: 333 IYANNOUGH RD HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES
TOBACCO SALES: $85.00 YEAR. 2 21
Permit Expires: 12/31/2021
Thomas A. McKean, IRS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
i
1
• Initials: i
Town of Barnstable
-
Date Paid 1 Amt.l'd$ 1
Inspectional Services
• 8ARNSTABLE,.�
� 'AN
Public Health Division U b
710
039. Check
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT PERMIT APPLICATION Non-Flavored
DATE �L NEW BUSINESS OWNERSHIP RENEWAL
NAME OF TOBACCO ESTABLISHMENT: OF
�PGµh�s
ADDRESS OF TOBACCO ESTABLISHMENT: 333 -�It�nf2QY� /2d 14 y Gkiti g
MAILING ADDRESS(IF DIFFERENT FROM ABOVE.):
E-MAIL ADDRESS: 1,S�C�'K �17��S CD
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 77 V��, /
OWNER'S NAME: ✓t *W'51!!� y OWNERS PH#&JIft 1&3
OWNER'S ADDRESS: 16-8 D� � rJ� At4t l /" v l� _
< I
Gin
CORPORATE NAME: kiy(lo .5 W 1 ± /11 M `'/
/V-C
�33 zyC�yhQyf 4 4/7- 33zz8/�
CORPORATE ADDRESS: CORPORATE FID#
ANNUAL:— SEASONAL: DATES OF OPERATION:_/ / TO
i
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)., 3
TOWN OF BARNSTABLE.COMMA GENERAL LAW INTERNET LINKS:
k
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/33996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
httgs://maleg,islatwe gov/Laws/GeneralLaws/Pat*,A'V,'Titlel/ChaE,,ter270/S-.etion6
***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:
E 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document
2) MA State License to S(4 Cigars and Smoki g o 4) Payment of Fee(s) -see page 4
SIGNATURE: �II 1 •� Y
�� s PRINTED NAME: DATE:
Q:1Application FormsJOBACCO APP-NonFavor 12-18-19.docx
c
g
o
Commonwealth of Massachusetts Letter ID:L01 I7159488
.r�
� Department of Revenue Notice Date:September 11,2020
Geoffrey E.Snyder,Commissioner Account lD:CGL-18026594-01 I
rSI
mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
ICI'I�'�II��I"�'�'III'I'110�lllllsllll�llo�ll�l��lll��l1� 1111
HYANNIS WINE&SPIRITS,INC.
o= KAPPY'S FINE WINE&SPIRITS HYANN
N® 333 IYANNOUGH RD BLDG
HYANNIS MA 02601-2035
Attached below is your Retailer License for Sale of Cigarettes (Form CT-3). Cut along the dotted line
I and display at our business location. At an time you can to into our MassTaxConnect- at
P Y" Y Y � Y g Y -
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
-------------------------------------------------------------------------------------------------------------------------------------------------
sNC sF�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
o �-- r
Aa ,; Retailer License for Sale of Cigarettes
yFro�� This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
HYANNIS WINE& SPIRITS, INC. Account ID: CGL-1 8026594-0 1 1
KAPPY'S FINE WINE& SPIRITS HYANNIS License Number: 1409746944
333 IYANNOUGH RD
HYANNIS MA 02601-2035
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts Geneial 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
LHi1,
Commonwealth of Massachusetts Letter ID:.L0701638208 t-
�� Department of Revenue Notice Date:September 9,2020
`i '. Geoffrey E.Snyder,Commissioner Account ID:CRL-18026594-014
F\TOF`M1� mass.8ov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
o=
HYANNIS WINE&SPIRITS,INC.
o= KAPPYS FINE WINE&SPIRITS HYANNI
o—
0= 333 IYANNOUGH RD BLDG
HYANNIS MA 02601-2035
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/r-rasstaxconnect 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
------------------------------------------------------------------------------------------------------------------------------------------------
A7Sp,CH[-,-S, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
T
Retailer License for Sale of Cigars and Smoking Tobacco
t
c��` This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
HYANNIS WINE& SPIRITS, INC. Account ID: CRL-18026594-014
KAPPYS FINE WINE& SPIRITS HYANNIS License Number: 132782080
333 IYANNOUGH RD
HYANNIS MA 02601-2035
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
1je-5 /:i�D 74 e-.z 1.40
1�O c -Altr
.P
Corporation Income Tax Retvf n OMB No.1545-01232020
Form11201
For calendar year2019of tax year beginning r-EBRUARY 1 2019 endingJANUAF�Y 31 ' 2019
Department of the Treasury
internal Revenue Service Go to www.irs. ov/Form1120 for instructions and the latest information.
B Employer identification number
A Check if Name 4 7—3 3 2 2 810
1aConsolidatedreturn o $yANNIS WINE & SPIRITS INC.
(attach Form 851).... TYPE (, Date incorporated
b Lite/nonlife consoti- Number,street,and room or suite no.If a P.0-box,see instructions.
dated return............. 0 OR 0 3 0 5 2 015
2 Personal holding co. 333 IY,ANNOUGH ROAD
(attach Sch.PH)........El PRINT D Total assets(see instructions)
3 Personal service core. City or town,state or province,country,and ZIP or foreign postal code -
(see instructions)......
4 Schedule M-3
attached...................
E Check it 1 D Initial return 2 0 Final return 3 L Name change 4 Address chan e
Bellaire, Dianna
From: Larry Burak <Iburak@kappys.com>
Sent: Wednesday, November 18, 2020 4:24 PM
To: Bellaire, Dianna
Subject: Re: Kappy's Tobacco License
Hello Ms. Bellaire,
We do not sell any of the e products you mention below...
Thank you, Larry
On 11/18/2020 3:46 PM, Bellaire, Dianna wrote:
Hi,
I need confirmation if you sell e-cigarettes, a supplies or e-juices. If not, please respond to this email. If
you do,there is a new electronic delivery systems license,that I need a copy of from the MA State
office. Your permit will remain in pending until I receive that document.
Thank you.
Dianna Bellaire
Permit Technician
Town of Barnstable
Health Division
200 Main Street
Hyannis, MA 02601
P:508-862-4643
Fax:508-790-6304
Email:Dianna.Bellaire@town.barnstable.ma.us
The information contained in this electronic transmission("e-mail"),including any attachment(the"Information"),may
be confidential or otherwise exempt from disclosure.It is for the addressee only.This Information may he privileged
and confidential work-product or a privileged and confidential communication.The Information may also be
deliberative and pre-decisional in nature.As such,it is for internal use only.The Information may not be disclosed
without the prior written consent of the Director of Public I Iealth aril/or the Town Attorney's Office of the Town of
Barnstable.If you have received this e-mail by mistake,please notify the sender and delete it from your system.Please do
not copy or fomvard.it.Thank you for your cooperation.
Larry S. Burak
President
Everett Management Corporation
ph: 617.389.7600 x213
fx: 617.389.0296
www.kappys.com
1
4
tF Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
WiRNSTABM : Paul J,Canniff,D.M.D.
M.A 5 L F.P. Thomas Lee Alternate
'1ulk 200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Sell Tobacco
In accordance with reguPations 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: 1076 Issue Date: 1/1/2020
DBA: KAPPY'S FINE WINE & SPIRITS
OWNER: STEVEN SHELBY- HYANNIS WINE & SPIRITS
Location of Establishment: 333 IYANNOUGH RD HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2020
TOBACCO SALES: $85.00
Permit Expires: 12/31/2020
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
f
For Office Use Only: Initials:
Town of Barnstable ti C/
BA w&rABLE. . Inspectlonal Services ,
9q, MA-ft. Check
Ar16 9. . Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored)
DATE /Z/ 7`/ NEW BUSINESS OWNERSHIP RENEWAL
n
NAME OF TOBACCO ESTABLISHMENT: f immw GJ i w +S pl V 7S /N C d�4 • bW
w►NE- -I-sp) zs
ADDRESS OF TOBACCO ESTABLISHMENT: 333.rYtrN00V&H &A-D /ty-"Pi S od '62 601
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS:
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (/ ' / ) ` 7D-
OWNER'S NAME: 7�t L OWNER'S PH# `( /�)Lg10- �` ?�
OWNER'S ADDRESS: Sg ��iKA J/ �y` � � y!�!� a J
CORPORATE ADDRESS:�?33 z yhuN o JE H /b NY N'Vs CORPORATE FID#
ANNUAL: V SEASONAL: DATES OF OPERATION:_/ / TO
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)
TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/33996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
httts://nialegislature.gov/LaNx�s/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 Smoki g Tobacco 4) Payment of Fee(s) -see page 4
4
SIGNATURE:
PRINTED NAME: 5t Gv� set
DATE: /Z/ I / \
Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc
Commonwealth of Massachusetts Letter ID:L0336884352 o.o
Department of Revenue Notice Date:October 2,2018
Christopher C.Harding,Commissioner Account ID:CGL-18026594-011
�-
mass.gov/dor
g
RETAILER LICENSE FOR SALE OF CIGARETTES
HYANNIS WINE&SPIRITS,INC.
KAPPY'S FINE WINE&SPIRITS HYANN
333 IYANNOUGH RD BLDG
HYANNIS MA 02601-2035
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
------------------------------------------------------------------------------------------------------------------------------------------------
'K se�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigarettes
�i Olt This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
HYANNIS WINE&SPIRITS,INC. Account ID: CGL-18026594-011
KAPPY'S FINE WINE&SPIRITS HYANNIS License Number: 982255616
333 IYANNOUGH RD
HYANNIS MA 02601-2035
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 2, 2018 Expiration Date: September 30,2020
Commonwealth of Massachusetts Letter ID:L0455946880
Department of Revenue Notice Date:September 30,2018
Christopher C.Harding,Commissioner Account ID:CRL-18026594-014
mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
HYANNIS WINE&SPIRITS,INC.
o—
KAPPYS FINE WINE&SPIRITS HYANNI
o
333 IYANNOUGH RD BLDG i
HYANNIS MA 02601-2035
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.
I
DETACH HERE
-----------------------------------------------------------------------------------------------------------------------------------------------
WHO,, MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigars and Smoking Tobacco
7�
Ole4 This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
HYANNIS WINE& SPIRITS,INC. Account ID: CRL-18026594-014
KAPPYS FINE WINE&SPIRITS HYANNIS License Number: 451192832
333 IYANNOUGH RD
HYANNIS MA 02601-2035
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
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
m A
7
DATA ,
` 0
l •t1, N
CSTABLNRMENT'S NAME
;`CO SALES-
- Employee Signature Form
This form is for official use to indicate that the, employee(s)of this establishment received and.understood Clhapter 371
of the Town of Barnstable Code:and Chapter 270 Section 6 of the Massachusetts General Laws whieh describes the
penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below-is Section
371-9. of the Town of Barnstable.Board of Health Regulation:
Sales to Minors--$371-9.Sale and Distribution of Tobacco Products
I. No person�shall'sel'Vor provide°ahtobacco productx as.definodJae►_ein,to a'person underu
-. .
The minimum legal sales age. The minimum legal sales age in the Town of Barnstable
is 21 years of age.
2, Identification: Each person selling or distributing tobacco products, as defined herein,
shall verify the age of the purchaser by means of a valid government-issued photographic
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27..
The employees)below received and understood Section 371.-9 of the Town of Barnstable Board of
Health.Prohibition of Smoking:Regulation and Chapter 270 Section 6 of the Massachusetts General Laws:
_ — 1
14 gnature .Printed Name L Date
S Printed Name Date
ur Printed Name Date
Si a Printed Name Date
r a d J " 2 9
S gnature Printed.Name Date
Signature Pr' ted Naive ee Date
&. -'
Signature
Printed Name J Date
Q:\Applicpuon Forms\ 0 APP•NonFav 11- 19.d //
Town of Barnstable BOuAD IRCann
OF HEALTH
Board of Health Donald A.Gaudagnoli,M.D.
.' BAMNSTABL , John T. Norman
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 10S CMR 590.000 M.G.L. Chapter 94 Sections
30SA, 30SB, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 1076 Issue Date: 12/20/18
DBA: KAPPY'S FINE WINE & SPIRITS
OWNER: STEVEN SHELBY- HYANNIS WINE &SPIRITS
Location of Establishment: 333 IYANNOUGH RD HYANNIS MA 02601
Type of Business Permit: TOBACCO
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES (�
FOOD SERVICE ESTABLISHMENT: YEAR. 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B- FULL BREAKFAST:
CONTINENTAL BREAKFAST: -- - - - -
MOBILE-FOOD:
MOBILE- ICE CREAM: a�
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES: $85.00
FOR ESTABLISHMENTS WITH SEATING: {
i
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
� J
Restrictions:
�1ME, Town of Barnstable c Vb3f/l� Zq'S
Regulatory Services Department
9' "� l� Public Health Division 2q
039. ♦0 (�� r.
200 Main Street, Hyannis MA 02601
UU
Office: 508-790-4644 Thomas A.McKean,RS,CHO r"D
FAX: 508-790-6304 Director of Public Health :
PQ
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$85.00
APPLICATION FOR A TOBACCO SALES PERMIT
a.
LAST N OF APPLICANT FIRST NAME MIDDLE INITIAL
P"P y'S r—ln/E W IA167 5VI l c ZS
DB/A
STREET ADDRESS
_ - 'fro - �3Z�
TELEPHONE # FID#
Do you curren possess a state license to sell tobacco products?
Yes No
Each employee who sells tobacco products must receive and understand the Sections
VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy
provIhmployee
rein) and a ssachusetts General Law Chapter 270, Section 6.00 (a
copyided_on the nex page). Each employee who sells tobacco products must
sign Si t Form (provided herein).
Signa re Date
Q:\Application Forms\TOBACCO APP2018 dob.docx
Establishment
TOBACCO SALES Ai '
Employee Signature Form (�
This form is.for official use`to indicate.that the employee(s):of this esiablishment;received and,understood
sections V.II.band V:II c. of the Barnstable Board.of.Health Prohibtion of Smoking.RegulaCon and-the
enclosed copy of Chapter 210 Section 6"of`the Massachusetts General-Laws;which describes the:penalties.
for selling and/or`giving tobacco products to'any person under:the,zge<91 eighteen(18);. Below are.sections.
VII b:and VIl c:of the'Barnstable Board of Healtlilegulatiom
SECTION VII SAT E`AND,DISTRIBUTION OF TOBACCO PRODUCTS
b;: Sa1,es To Minors—.In;conforn ante with`the Massachusetts Generat.Laws Chapter M.:,Section.6
no person, 'firm, aorporatian, establiglipient,,or, ag$ncy shall sell tobacco products:to;a minor.
Bach employee working ' an establishment licensed to sell tobaccoproduct shall be required to
receive a copy of the'Board of Health,regulations and..State Law regarding the'sale.of tobacco:and,
sign;a form:ndicating that such regulations/laws have been received and understood,.a copy of
which must tie placed oii file. in the office of the emn oyes.and.retained. :Such signed.forms:must
be`made available for':inspection, telnHoldrs.normil..buinesshoursponreuestduringh ic of:
an;agent of•the Board of.Health,
c. All distributors/retailers of tobacco products or tobacco merchandise must require: that; if:a.
customer appears to possibly:be under 25`:years of'age,-the customer, resent a valid State issued
picture identification.card, or`drivers license with appropriate:photograph:to:confirm that:the;
customer is of legal a e tq, urchase the tobacco,product.
The,following;employee(§)received and understood Sections;VIIb;-and VIIC1 of the Barnstable Board of
Health Prohibition gf`Smol uh,RegulatioA ind.Chapter;270 Section 6 of the Massachusetts General.Laws:
lAq
Printed Najne. Date
Si a d.Name,: \' Date`
Signatur Printed Name CC Date
►Q4A A-, /Nr
S' a ' e Printed Name. Da
S,ignaturo. Printed Name: -Date
Signature Printed Name: Date
Signature; '"' Printed.Name:. ,Date
Q;1Apglication Formsl.TO$ACCO APP241�&Aob.docx
9
UVI A1E
fi
Establishment
TOBACCO SALES
Employee Signaturre'lj.orm
This form is:for official use to mdicate.that the employee(s)of this esiablishment.received and understood
sections VIi b ,and-VII c.,of the Barmstable Board of Health Proh-ibition of Smoking.Regulation and.#he.
enclosed copy. of'Chapter 270`Section 6'ofthe Massachusetts:General Laws which describes the,pp
for selling and/or giving tobacco products to any person under:the age;:of eighteen(18).- :Below are:;sections
VII b.and VII:c:of the Barnstable'Board of Health Regdlation:
SECTION VII SALE A'IMVSTRIBUTION,OP TOBACCO PRODUCTS
b. Sales To Minors. In;conformance with'the,Massachusetts General:Laws Chapter.270,Section-6,
h no.person 'f'Wn,,corporation; establishment; or'agency shall sell tobacco products,to;a minor.
Eacli employee working in;an establishment licensed.to sell tobacco:product shall be required to
receive a copy ofthe Board of Health,regulations and:State Law regarding the sale.of tobacco:.and,
i
sigIn A form indicating that.such regulations/laws have been received and:understood, a:copy.of
which must be placed on file;-in the offce of the emplbyer and.,retained. Such signed.forms;must
be.made available for:inspect on,-during the:.license liolders..normal.,business hours upon:request of. .
.an agent of the Board:of Health.
c:. All distributors/retailers of tobacco products or tobacco merchandise must require that; if a..
customer appears to possibly be under.25 years of age,the customer present a valid'Staie.issued.
picture identification card, or drivers license with appropriate photograph to :confirm that the-
customer is of legal a a to -urchasethe tobacco product.
They:following:employee(§)'received Arid understood.Sections:Vllb:-and VIIc. of the Barnstable Board of
Health Prohibition of'Smokin& egulatio.a Chaptef 270 Section 6 of the Massachusetts General Laws:
S,rgn , Printed Naive. Date.
f/
Printed Name:: D_fe,
G
V`\ o-
Sign e. Printed Name Date
Sign Printed Name Date.
Printed Name Date
Signature Printed Name 'Date
Signature; PrintedaVame Date
Q:IApptication Forms4TOBACGO,,'APPZOl8:dob.d9cx
o•o
Commonwealth of Massachusetts Letter ID:L0336884352 �,
Department of Revenue Notice Date:October 2,2018
z " uTu Christopher C.Harding,Commissioner Account ID:CGL-18026594-011
mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
HYANNIS WINE&SPIRITS,INC. ®P�
o= KAPPY S FINE WINE&SPIRITS HYANN
o-
333 fYANNOUGN RD BLDG
HYANNIS MA 02601-2035
Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T). Cut along the dotted line
1 and display at your business location. At any time,you can loglinto your MassTaxConnect account at
- ___._- �_ w.... ___..�
mass.gov ma s axconnec to view`an re=pent a copy o�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
-----------------------------------------------------------------------------------------------------------------------------------------------
. "c"i'sF __MASSACHUSETTS DEPARTMENT OF REVENUE
Form CT-3T
Retailer License for Sale of Cigarettes
FNT OV This license must be-posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
HYANNIS WINE & SPIRITS, INC. Account ID: CGL-18026594-011
KAPPY'S FINE WINE& SPIRITS HYANNIS License Number: 982255616
333 IYANNOUGH RD
HYANNIS MA 02601-2035
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 2, 2018 Expiration Date: September 30, 2020
oF,NE r TOWN OF BARNSTABLE HEALTH INSPECTORs Establishment Name: VAff V L15 Date: Page: . Of
ti OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSfABLE.g• 200 MAIN STREET 3:30-4:30 P.M. _ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS,MA 02601 508 N.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
'FDN1A� FOOD ESTABLISHMENT INSP TIO REPORT
Name Date Opp era of
Rouinof Inspection / VIA
Address Risk Food Service Re-iris n
Level etail Previous1 s chip
Telephone ential Kitchen Date: /' vrj(tJ�tMobile Pre-oper ti -,a
Owner HACCP YIN Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP AN
Other
Inspector F 1,MIAlh Z� 91'1(Nu : , `
Each violation checked requires an explanation on the narrativ pages)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 I-----
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) p,
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures "
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling /
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP -=
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories -
Violations Related to Good Retail Practices(Blue Items Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating P= ry p ❑ ❑ p ❑
Y y ❑ Voluntary Compliance Employee Restriction/Exclusion Re-inspection Scheduled Emergency Suspension
C N Official Order for Correction-,Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4 590.005 6=One critical violation and less than 4non-critical violations 9
)( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
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 i cal violations.
If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
lion,4 to 8 non critical viOlations C.
30.Other DATE OF RE-INSPECTION: Ins p for Sig atur nt:
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions -•
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1q Food or Color Additives Law Cooled to 41°F/45'F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH - "3-302.11(?.)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)
590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* *
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* _ REQUIREMENTS FOR _
3-306.14(A)(B)Returned Food and Reservice of Food 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated g
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
q 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 Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201'.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 , Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.I lA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate
Equipment* ( )( ) Pathogens*590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * Effective vvzooi
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-1 1 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-0 155Ol.l1(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec*
Sources* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whale-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* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other es sho9 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the Foodborne
12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts*
3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the
g Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 1590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 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.
p 114E► -� TOWN OF BARNSTABLE HEALTH.INSPECTORS Establishment Name: Date• ,
Page: .. of
.° k$ OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. ` 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS,MA 02601 eoa-862-4Rs44 I. No Reference R-Red Item PLEASE PRINT CLEARLY
grED MP�a FOOD ESTABLISHMENT INSPkCTI REPORT -
Name Date Weo ec ion
RoutinAddress Risk ctionLevel Previous Inspection
Telephone hen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
Other
In:
Inspector Out:
Each violation checked requires an ex l;nation on the narrative page(s)and a citation of specific provision(s)violated.
z-.
Violations Related to Food borne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ 181
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) ❑
O /7
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable I Duties ❑ 13.Handwash Facilities .a
JK
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) SIM 0!!�� I (W /V Vol
❑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
ION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating Volnta Com fiance.
y y ❑ ry, p ❑ 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ g Y ❑ rY P ❑ 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.
Equipment and Utensils (FC-4)(590.005 25.E ui B=One critical violation and less than 4non-critical violations
q P ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to anon-cri
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address non-critical violations. If 1 critical refrigeration.
Within 10 days of receipt of this order. violation,4 to 8 nog,-critical violations=C.
29.Special Requirements (590.009) Y P
30.Other DATE OF RE-INSPECTION: Inspe is i a 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 Signatur Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
cS L
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*
* 3-501.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives
d k Cooe and RTE Foods.*
oos. * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 1 g 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 EachIdentifying 590.004(F)
( P 7-101.11 Information-Original
2 590.003(C) Responsibility of the Person-in-Charge to Other* g7-102.11 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
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) I 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 Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions g � )
Disposition of Adulterated or Contaminated
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a 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 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* Equipment* 88 Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective//t/zoo/
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A D Violations of Section 590.009 A D in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) ( )-( )
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* 3-401.11 2-301.14 When to Wash* A 1 All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail
( )( )(b)
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 8� g 8 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 foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3 403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock [55-204.11
0.004(E) Preventing Contamination from Employees* 1g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140`F to 70°F
3-202.18 Shellstock Identification ( ) g
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41*F/45*F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(,n Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures I 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. Special Requirements 009
3-502.11 Specialized Processing Methods* Fin Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures*
S:590Fomiback6-2doc
*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.