HomeMy WebLinkAboutJENNY CRAIG-WEIGHT LOSS - CLOSED FOOD JENNY CRAIG-WEIGHT LOSS
1070
�► Town of Barnstable BOARD OF HEALTH
' lG John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
aanNNSTA€oE, :- F.P.(Thomas)Lee,.
d7AS& Daniel Luczkow,M.D. Alt.
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: 7 Issue Date: 01/01/2022
DBA: JENNY CRAIG
OWNER: JC USA INC.
Location of Establishment: 1070 IYANNOUGH ROAD, C-10 HYANNIS„ MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2022
RETAIL FOOD: $20.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: -
MOBILE- FOOD:
MOBILE-ICE CREAM: G
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE i
Restrictions:
I
0
`i
� Initials:
For Office
Date Pa
Town of Barnstable � (®o
id Amt Pd$
MRMA11 M : Inspectional Services 00 INIng
Public Health Division Check#
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE 10/14/21 NEW OWNERSHIP RENEWAL X
NAME OF FOOD ESTABLISHMENT: Jenny Craig Weight Loss Center#671
ADDRESS OF FOOD ESTABLISHMENT: 1070 lyannough Road, C-10 f�
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): JC USA,Inc.,Attn:Tax Dept.,5770 Fleet St.,Carlsbad,CA 92008-4700
E-MAIL ADDRESS: ictax@jennycraig.com
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( 08 ) 775 - 8005
TOTAL NUMBER OF BATHROOMS: 1
WELL WATER:YES NO X ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: X SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: 0 OUTSIDE: 0 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? N/A
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? N/A
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
X 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
r
/OWNER INFORMATION:
FULL NAME OF APPLICANT JC USA,INC.
CORPORATION \/
SOLE OWNER: YES/NO OWNER PHONE# 760-696-4000
ADDRESS_ Attn: Tax Dept., 5770 Fleet St., Carlsbad, CA 92008-4700
CORPORATE OWNER: Khuram Bhatti, CFO
CORPORATE ADDRESS: Attn: Tax Dept., 5770 Fleet St., Carlsbad, CA 92008-4700
PERSON IN CHARGE OF DAILY OPERATIONS: Patrick Ruffino, Market Director
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
I�W44e4l 10 / 14 / 21
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/aaalications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC I st.
Q:\Application FormsWOODAPP REV3-2019.doc
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BARNSTAUM Paul J.Canniff,D.M.D.
MIA$& F.P. Thomas Lee Alternate
�A 200 Main Street, Hyannis, MA 02601
' Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 7 Issue Date: 01 01 2021
DBA: JENNY CRAIG
OWNER: JC USA INC.
Location of Establishment: 1070 IYANNOUGH ROAD, C-10 HYANNIS„ MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2021
RETAIL FOOD: $20.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: G A
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
✓ Town of Barnstable For Office Use Only: Initials: ,
Date Pao d�� AmLP-d$
BAMWABLE, : Inspectional Services
163 9.a`�� Public Health Division Check# — --�
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE 11/19/20 NEW OWNERSHIP RENEWAL x
NAME OF FOOD ESTABLISHMENT: ,Jenny Craig Weight Loss Center#671
ADDRESS OF FOOD ESTABLISHMENT: 1070 lyannough Road, C10, Hyannis, MA 02601-8110
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Jenny Craig, Tax Dept., 5770 Fleet St., Carlsbad, CA 92008-4700
E-MAIL ADDRESS: jctax@jennycraig.com
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( O8 ) 775 _ 8005
TOTAL NUMBER OF BATHROOMS: 1
WELL WATER: YES NOX ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: X SEASONAL: DATES OF OPERATION:_ / / TO
NUMBER OF SEATS: INSIDE: 0 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.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? n/a
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? n/a
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 REV3-2019.doc
OWNER INFORMATION:
FULL NAME OF APPLICANT JC USA,INC.
CORPORATION 760 696-4000
SOLE OWNER: YES/NO OWNER PHONE#
ADDRESS Jenny Craig, Tax Dept., 5770 Fleet St., Carlsbad, CA 92008-4700
CORPORATE OWNER: Khuram Bhatti
CORPORATE ADDRESS: Jenny Craig, Tax Dept., 5770 Fleet St., Carlsbad, CA 92008-4700 •.1,/
PERSON IN CHARGE OF DAILY OPERATIONS: Patrick J. Ruffino, Market Director
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
g 11 /19 /20
SIGNATU E OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asi).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.31't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st.
Q:\Application Forms\FOODAPP REV3-2019.doc
"s.
p? Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.,
BARN ABLK Paul J.Canniff,D.M.D.
is ,+ 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: 7 Issue Date: 12/10/2019
DBA: JENNY CRAIG
OWNER: JC USA INC.
Location of Establishment: 1070 IYANNOUGH ROAD, C-10 HYANNIS, MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2020
RETAIL FOOD: $20.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD: �y—
MOBILE-ICE CREAM:
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
For Office I
lic'Only. UifialA K)
Town of Barnstable Vel
it 4
Inspectional Services
KA5%
.10.7 Public Health DiVisioll, Check
Thorn'"MeXcian,Director L06-
200 Main Street,Hyannis,MA 0260.1.
Office, 508-.862-4644 Fax:- 5.09-790-6.30.4
APPLICATION FOR PERMIT TO OPE,RATE A FOOD ESTABLISHMENT
DATE 10.28.2019 NEW OWNERSHIP RENEWAL X
NAME OF FOOD ESTABLISHMENT- Jenny Craig Weight Loss Center#671
ADDRESS OFFOOl)ESTABLISHMENT: 1070 lyannough Road, C-1 0, Hyannis, MA 02601-8110
MAILING ADDRESS(IV DIFFERENT FROM ABOVE):. Tax Dept., 5770 Fleet St., Carlsbad, CA 92008-4700
E-MAILA�DDRES . jctax@jennycraig.com
,
TELEPHONE NUMBER OF,FOOD ESTABLISHMENT; ( 508)775.8Q05
TOTAL.NUMBER 6F]3A't'ftkO.OMS:- 1
WELL WATER:YES' NO, ...(ANNUAL'WATER.ANALYSiS..kEQUIRF.D)
ANNUAL: SEASONAL, DATES_0F OPERATION=. .j r f6 SO, e 4aqh e_
NUMBER OF SEATS:INSIDE: 0 OUTSIDE- 0 TOTAL: 0
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING;-MUST 13E APPROVED B THE:HEALTH DIV..AND LICtNSING*.AND MEET OUTSIDE DINING
R1E,01jIREM1ZNTS.
IS.WAIT STAFF.PROVIDED FOR OUTSIDE DINING?
IS-AN AIR CURTAIN PROVIDED AT WAITSTAFF SEItVICEDOOR(S)?.
TYPE OF ESTABLISHMENT: (PLEASE CHECKALL THAT APPLY BE-LOW)
FOOD-SERVICE
XRE'TAEL FOOD'-ONLY required for TCSfoo.ds(foods reqkliriffg:ri6fliggratioulfreezer)
BED&BREAKFAST.
CONTINENTAL BREAKFAST
_COTTAGE FOOD INDUSTRY(formerly residtntiail kitchen)
MOBILE.-FOOD
.FROZEN DAIRY DESSERT IMACHINES-... (MONTHLY LAB.ANALYSIS REQUIRED)
CATERING ...(CATERING-NOT[CE;-kEQVI.RED-BEFORE, EVENT-(SEE PAGE#2)
SEASONAL;MOBILE&NEW FOOD ONLY***
REQUIRED TO CALL REAUTH.DlY.FOR-INSPECTION PRIOR TO FN ISSUED MIT-BEING
PLEASE CALL-50"_,62-4,641
Q\Appficafion Farms\FOODAPF2026,doc-
I
_s,.
OWNER INEORMATIOM
FULLNI AMEOFAPPLICANT JC USA, INC
CORPORATION 760.696.4000
SOLE OWNER: YES/NO OWNER PRONE#
ADDRESS Tax Dept., 5770 Fleet St., Carlsbad, CA 92008-4700
CORPORAM-OWNER: JC USA, INC
CORPORATE.ADDRESS: Tax Dept., 5770 Fleet St., Carlsbad, CA 92008-4700
Patrick Ruffino, Market Director
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 SIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div.will NOT use.pastyears' records. You
mtist provide now copies and POST THE CERTIFICATES.;at you r food.establishment'.
Certif:edFood Mangers Expiration Date Allergkti Awareness Expiration Date.
s I.
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATI N***
SEASONALYOOD'SERVICE:All seasonal food-establishments,includingmobile trucks must be inspected,by the Health Div.
prior to oneninir Please call Health Div.at 508'962-4644 to schedule'your Inspection. Please ca11 at least(7).days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts,niustbe tested by a State:Certified lab prlorto opening and monthly thereafter,
with sample resutts subriiitted'tb the Health Di"V: Failure to.do w.will result in.the suspension or revacatian of your Frozen Dessert
Permit until the dbbye.t6rins are met.
CATERING POLICY: Pinyon who caters within the Town of Barnstable must notify theTown by.fax bt-nail prior to catering
event. Y.6u must complete a catering notice found at Mtn•/hvww:towno&arnsthbie:us/hcalthdivision/analicatio6s.asn.
OUTDOOR COOKING: Outdoor cooking;,preparation;or display bf any food.product by.a.food.establishment is prbhibitetl.
NOTICLr: .Permits run annually from January Ist:to Dec.3l't'each calendar year. IT IS YOUR RIaSPONSIBILITY70 RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC Ist.
0:1Applicsrion r.06 t?00DAIT REV3.201:9'.doc.
o
Jenny Craig
5770 Fleet Street
rCRAIG Carlsbad,CA 92008-4700
PLEASE MAIL ALL PERMITS, CERTIFICATES and LICENSES TO:
JC USA, INC.
TAX DEPT.
5770 FLEET STREET
CARLSBAD, CA 92008-4700
Or
Email: ictax@ienUcraijz.com (PREFERRED)
FIN 30-0800028
Questions? Contact us at 760.696.4000/760.696.4569
BOARD OF HEALTH
F Town of Barnstable Paul J Canniff,D.M.D.
71
° Board of Health Donald A.Gaudagnoli,M.D.
v
BARNSTABL& . John T.Norman
ynsss 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
'��foJx�A Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstablems
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 7 Issue Date: 12/20/18
DBA: JENNY CRAIG
OWNER: JC USA, INC
Location of Establishment: 1070 IYANNOUGH ROAD, C-10 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: $20.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: -- - - - --- --
MOBILE-FOOD:
MOBILE-ICE CREAM: G•
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
9
rs A
' FTHE Tp For Office Use Only: Initials:
Town of Barnstable
o� f
• Date Paid I y Amt Pd$ /
9 �A8 � Inspectional Services q
ib3q. �0
°TEpA"�`A Public Health Division Check#
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT: (b O ,� �' O Q r1��i M A
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):TAX - T 5- v T .
E-MAIL ADDRESS: �) C.—�Ci C� C")C—Caa�
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 3- V�
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: ` SEASONAL: DATES OF OPERATION: /_/_ TO
NUMBER OF SEATS: INSIDE: OUTSID TOTAL:
SEATING: MUST OBTAIN A OMMON VICT ALLER'S LICEN FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
Q:\Application FormsTOODAPPREV2018.doc
— - -- -. _ --------- -
. L
r PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OVVN R. Y I NO � OWNER PHONE#. �� F.
ADDRESS_
CORPORATE OWNER: FEDERAL ID NO. :
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Ce ed Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Mana SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div.will NOT u s records. You
must provide new copies and POST THE CERTIFICATES at your foo stablishment.
Certified Food Managers Expiration Date Allergen Aw ness Expiration Date
2.
-SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! 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. 3152 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st.
QMpphcation FonnsTOODAPPREV2018.doc
oFtr TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: �\ ate: Page: of
ti OFFICE HOURS
P °+ PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3:3o-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
e,y: �0� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
prFU MA.n -FOOD ESTABLISHMENT INSPECTION REPORT 508-862-4644
Name ` Date./2;` e of ns ec io
Operation(s) outin
Address Risk Fo ervice Re-inspection
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) ❑
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 POPULATIO (HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY I
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories IvV]D
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N. Official Order for Correction:Based on 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 4 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 to 6von-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
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. v' ton no - ritical violations=C.
_
30.Other DATE OF RE-INSPECTION: Inspe or'�Siat r rint:
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 D �\
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) TD�.-.onstrationof
signment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12- . Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives '
Contamination from Raw Ingredients 15 Poisonous or Toxic'Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)-
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 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* 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* - - 590.004 11 Variance Re uirements-
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) 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* * 37801.11(D) Raw or Partially Cooked Animal Food and
( ) P 4-501.]11 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing.-Hot Water I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
* 4-60L11(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 * Eggs Not Otherwise Processed to Eliminate
Equipment
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* E.0 cNve 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 3-401.1](B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or 590.009 A - D Violations of Section 590.009(A)-(D)in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( )
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources 10 Proper,Adequate Handwashing g' P �Y
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
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23-30)
3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
13 Handwashing Facilities
3-202.18 Shellstock Identification* 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 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
5-20411 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 1.009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 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.
oF, r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: QlNhc11 �_ Date: Page: of
OFFICE HOURS
PUBLIC HEALTH DIVISION 6:00-9:30A.M.
ennNsrnatE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
019. �m� HYANNIS, MA 02601 08-8MON -46FRI4 No Reference R-Red Item PLEASE PRINT CLEARLY
�prFG MPv a, 508-862-4644
FOOD ESTABLISHMENT INSPECTION REPORT
Name Date(, l5 Tyoe of T e" I e Ion
OReration(s) Dunne
Address z�J Risk Food Service Re-inspection
Level a ail Previous Inspection
Telephone esidential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector �,� Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. V ®��^
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
1719.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 �'7
Critical(C)violations marked must be corrected immediately. (blue&red items) '1'( i 1 )9 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 Voluntary Compliance y y ❑ ry p ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspe/deral
ay,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board ofHealtr 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.E Equipment and Utensils B=One critical violation and less than 4non-critical violations 9
q (FC-4)(590.005) 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 non-critical. . f 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 anon-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 to anon-critical violations=C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: Insp c s t e rint:
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y
#Seats Observed Frozen Dessert Machines: Outside Dining Y N P i ature � Print: �j u//� f �y Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N G� �\ l/D
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) 4-Demonstration
Assignment of Responsibility* 8 Cross-contamination 1q Food or ColorAdditives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* *
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 7-102.11 Common Name-Working Containers* 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*Applicants* 3-302.11(A) Food Protection* P 8 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
3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Requirements
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*
( ) 3-306.14(A)(B)Returned Food and Reservice of Food* REQUIREMENTS FOR
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 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 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 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
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean ContactEggs Utensils and Food 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* �°twe 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(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment"
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or 590.009
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* (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
2-301.11 Clean Condition-Hands and Arms* the appropriate sections above if related to
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodbome illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )( )
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 * (Blue Items 23.30)
3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 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
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 1.003
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* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures*
S:590Formback5-2doc
*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.
13�
oFTHE Tp TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: h'n Date: Page: of
p` p� OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
94 a3q:a e� HYANNIS, MA 02601 M-8 -FRI.s2 asaa No Reference R Red Item PLEASE PRINT CLEARLY
5oa-a
FOOD ESTABLISHMENT INSPECTION REPORT .
Name Dates �� Type of T Ins ction
Routin
Address �^� t'vti1 i Risk spection
Level Previous Inspection
Telephone esidential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In- Other
Inspector Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. blue&red items)) SM � Corrective Action Required: o El Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating ry p ❑ ❑ p ❑ Emergency p y y ❑ Voluntary Compliance Employee Restriction/Exclusion Re-inspection Scheduled Emer enc Suspension
C N Official Order for Correction:Based on an inspection to y,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Fed I Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005 6=One critical violation and less than 4non-critical violations 9
) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must
be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 0 8non-Critical violations=C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: �Ins�pect �ig �tre P' `�
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 Signa 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 Subsiances 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)
2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
7-102.11 Common Name-Working Containers
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage*g 7-202.11 Restriction-Presence and Use*
20 Time as a Public Health Control
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*-
tensils 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 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 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* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
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* eJfecrrve mnom
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 r f ces of Equipment*
of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or 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* FProper,Adequate Handwashing ing,mobile food,temporary and residential
10
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* 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 practices should be debited under#29-Special
17 Reheating for Hot Holding
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
* 3-301.12 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
12 Prevention of Contamination from Hands g illness interventions and risk factors listed above,can be found in the
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
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/ 6301.11 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. 1 Other
3-502.12 1 Reduced-Oxygen Packaging Criteria*
8-103.12 1 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.
IZ�
THE r TOWN OF BARNSTABLE #_,.WANTH INSPECTOR'S Establishment Name: •_ Date: Page: of
► OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30•A.M.
BARNSTABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
.639. �0� HYANNIS,MA 02601 58-8 08-8 -FRI.62-4644
No Reference R-Red Item PLEASE PRINT CLEARLY
A'EO"""�° FOOD ESTABLISHMENT INSP CT ON REPOR
Name Date IN Ri yne of T Inspection
Operation(s) outin_
Address 1sk F ce e-irl pecti
evel etail Previo In A t II I- ZIY2,�'11s
Telephone ntial Kitchen. Date: AI
Mobile Pre- I zie-1,, Mnil'-3 lnInJ
Owner HACCP Y/N Temporary Suspect In s
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
Other
inspecto
Each violation checked requires an explanation on then rra ive age(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP, /
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY lv�[`
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories (1r�
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations \-
Critical(C)violations marked must be corrected immediately. (blue&red items) �1�1 Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating 1
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 )(590.005 B=One critical violation and less than 4non-critical violations 9
(FC-4 ) 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
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 Snon-critical v" lations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
violation,4 to 8 non-critical viol ions
30.Other DATE OF RE-INSPECTION: I to Sign re (?j Print:
i
31.Dumpster screened from public view
1P
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N w
Frozen Dessert Machines: Outside Dining
Self Service Y N I
#Seats Observed C's Sign Print: e_
Wait Service Provided Grease Trap Size Variance Letter Posted Y N / 1
Dumpster Screen Y N �\''/
_.�•��: __� ,tea _.-,_� 1 _ _� .. _ _. _. _._ _. _-_ ____.__ .__ __ .. _
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) [Demonstration
gnment 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) of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202:T2�-. Additives
Cooked and RTE Foods.* * . 19 PHF Hot and Cold Holding
2-103.11 Person-in-Chazge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
15 Poisonous or Toxic Substances t 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) i Responsibility of the Person-in-Charge to- _ Other* g g * 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
7-102•.11 Common Name-Working Containers
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
* 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
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 590.003(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 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* Raw Seed Sprouts Not Served*
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. Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From PotablE Drinking Water* Concentration and Hardness* 183-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean ContactEggs Utensils and Food 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* Eg cti e 1/I12001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source. 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* _ Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11' Frequency Sanitization of Utensils and Food 3-401.1 I(A)(2) Ratites,Injected Meats-155°F 15 sec*
faces of Equipment*
Shellfish* - 4-703.11 Methods of Sanitization-Hot Water and 3-401.1](A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* 10 Ratites-165°F 15 sec*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
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30)
3-202.15 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 fuodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of.Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
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 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria* _
8-103.12 1 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. `
! `
40
,.fJhlSie)�,.
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P
0
Jenny Craig
5770 Fleet Street
Carlsbad,CA 92008-4700
rC R"Al G
tt7
March 19, 2019 _ yy
5aF
Via Certified U.S. Mail
+4
Town of Barnstable
Public Health Division
200 Main Street
Hyannis,MA 02601
RE: Request to update permit records for Food Establishment(s),JC USA, Inc.
Jenny Craig Weight Loss Center# 671,License# 7
To whom it may concern:
Notice is hereby provided that the ultimate owner of the above-referenced permit will change on or about April
1, 2019. The Food Establishment's sole owner, Craig Holdings, Inc., among others, entered into a stock
purchase agreement with Jenny C Acquisition, Inc. As a result of this transaction, Jenny C Acquisition, Inc.
will acquire all of the stock of Craig Holdings, Inc.
The transaction will not change Food Establishment's name, location, operations, management, or direct
ownership by Craig Holdings,Inc.,and the Food Establishment will continue to operate under the name Jenny
Craig.
Accordingly,we are notifying you of the Food Establishment's change in ultimate ownership for your records.
Food Establishment's contact address is listed below, and all communications, including updated permits,
should be sent to this address or email:
JC USA, Inc.
5770 Fleet Street
Carlsbad, CA 92008-4700
Attn: Tax Dept.
jctax@cjc.com
We understand for a traditional "change of ownership" a new application is required. However, in this
circumstance, neither the Food Establishment, as licensee, nor its immediate owner is changing. The change
of ownership is twice removed from the Food Establishment and does not affect the license information.
Therefore, we believe a new application is not required. If you disagree, kindly let me know so that we can
submit appropriate applications to you. I can be reached at 760.696.4570. If you have any questions or need
additional information,please do not hesitate to contact us.
Vza;ll
Bonnie Noble,Director, Global Tax
cc: Jenny C Acquisition, Inc.
JENNY CRAIG OPERATIONS,INC.
5770 Fleet Street
Carlsbad,CA 92008
760-696-4000
BOARD OF DIRECTORS
Matthew Bronf nan
Sidney Craig
Ezra Field
Kent Kreh
Kevin Penn
Robert Sharp
Eric Shuey
Dick Wenz
OFFICERS
Kent Kreh, Chairman
Dick Wenz, C.E.O.
Patti Larchet, President
James Kelly,V.P. & Chief Financial Officer
Lewis Shender, V.P. & Secretary
r nny Craig,Inc.
5 70 Fleet Street
C .Isbad,CA 92008 9446
(7 0)696-4000
`( 0_ (7 0)696-4001 Fax
C
s
To Whom It May Concern:
This letter is to request that all correspondence be mailed to the following
address:
Jenny Craig-Inc.
Attn: Finance
5770 Fleet Street
Carlsbad, CA .92008
Please update your records to reflect this change.
Sincerely,
Sirena Madden
Accounting Coordinator
760-696-4341