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HomeMy WebLinkAboutMINI FOOD MART - RETAIL FOOD '`•1VIINT�FOOD;MART, rt,,252,1VIain Street Hyannis 7 IS OFF BOARD OF HEALTH Town of Barnstable $ John T.Norman Board of Health Donald A.Gaudagnoli,M.D. r' BA➢NSTABLE. F.P.(Thomas)Lee,. waa54 Daniel Luczkow,M.D. Alt. ��s• .� 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 317 Issue Date: 01/01/2022 DBA: MINI FOOD MART OWNER: SAM, INC Location of Establishment: 252 MAIN STREET 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: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Cn FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: i at For Office Use Only: Initials: Town of BarnstableAML Da PaidU S Inspectional Services MAN. *21jo 3(2 , 9� ;, ►`� Public Health Division _ Thomas McKean, Director 02 l 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 s. APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 1// J NEW OWNERSHIP RENEWAL l� NAME OF FOOD ESTABLISHMENT: �,�/YJ �l 1l // f ' y mk) ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM A7BOVE): E-MAIL ADDRESS: AS TELEPHONE NUMBER OF FOOD ESTABLISHMENT: Sa TOTAL NUMBER OF BATHROOMS: / WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO / 1_ NUMBER OF SEATS: INSIDE: �_ OUTSIDE: 0 TOTAL: D SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER* OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) OOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential ldtchen) 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'Appiication FonnsTOODAPP 2020.doc I r r. QWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES OWNER PHONE ADDRESS 36 / A� CORPORATE OWNER: CAM //V C CORPORATE ADDRESS: �� � S/� �LIA r I/ PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You ;prdst provide uew copies and COST THE CERTL�ICATES at your food establishrraent. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SIGNATURE OF P CANT 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 httg•//wwAr towi)ofbarnstable-us/healthdii'isionihl)1)Iicittions.asi). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc I Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. + ABLE, Paul J.Canniff,D.M.D. A F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 317 Issue Date: 01/01/2021 DBA: MINI FOOD MART OWNER: SAM, INC Location of Establishment: 252 MAIN STREET HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2 O21 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office Initials: �I"�'°yti� Town of Barnstable Date Paid Amt Pd$! MAS& Inspectional Services n ��• Check#3 3 i6'�'a.�e� Public Health Division ( CST I � tE0 MAy 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/ P NEW OWNERSHIP RENEWAL toll �¢ NAME OF FOOD ESTABLISHMENT: '5'w ellil'I ADDRESS OF FOOD ESTABLISHMENT: p'/;_ MAILING ADDRESS(IF DIFFERENT FROM ABOVE): S -f� E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: L TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO ✓ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO NUMBER OF SEATS: INSIDE: _9 OUTSIDE: p TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. �¢ IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?�1 TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) OOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc h OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/lei OWNER PHONE # ADDRESS_ 3d 7 SE,�rc otGsJl,�� �14r/I��LI�I�G �Ai���✓ lK CORPORATE OWNER: S�/� l�✓� CORPORATE ADDRESS: ��� / C /� J G/YV-�'445 „AW 14�� � PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. 07 i yf-4' SIGNATUIXOF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asi). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January I st to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNSrAnd.e. : F.P.(Thomas)Lee ' A 200 Main Street Hyannis MA 02601 Daniel Luczkow,Alternate 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: I Permit No: 317 Issue Date: 1/1/2021 DBA: MINI FOOD MART OWNER: SAM, INC Location of Establishment: 252 MAIN STREET HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY For Office I- Initials•-. Town of Barnstable en,wernara�.; Inspectional Services Date Paid Public Health Division � � - Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 4 TOBACCO ESTABLISHMENT. PERMIT APPLICATION;(Non-Flavored). DATE- �I,2�Z� NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: ADDRESS OF TOBACCO ESTABLISHMENT: . MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: t I TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 6W-i 771-1�1�141 OWNER'S NAME: �5�� T�IM�L OWNER'S PH# "Y�p�Y3i��� OWNER'S ADDRESS: /� !�l 3�7 �,� 1cam o S�•vdw�c ��©a��3 CORPORATE NAME: CORPORATE ADDRESS:p��+ //�1� -57&°�¢/,e CORPORATE FID# , ANNUAL:Iz_ SEASONAL: DATES OF OPERATION:_/ / TO A/ g DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS).. TOWN OF BARNSTABLE COMMA GENERAL.LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https:Hmalegislature. ov/Laws/GeneralLaws/PartIV/Ti`del/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 E 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 is SIGNATURE.) N PRINTED NAME: DATE: / l 2�G d QA1Application FormsUDBACCO APP-NonFavor 12-18-19.docx s a M lilac iy/N/eAW1 ESTABLISHMENT'S NAME TOBACCO SALES. Employee Signature Form.'r .rt , This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270'Sectiori 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco product`s 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.. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under 1 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. ff The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of t Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: ; _ � ; l`'l �/�/'� is �7 2�� Signature Printe d Name, �. Date i SfA gnature Printed Name Date i Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\"TOBACCO APP-NonFavor 12-18-19.docx THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I m /���C&E 'DATA ew sa�HUsFT� MASSACHUSETTS DEPARTMENT OF,REVENUE �VUy Retailer License for Sale of Electronic Nicotine Delivery Systems This license must be posted and visible at all times. The sale of - tobacco products to anyone under 2.1 years of age is prohibited. SAM INC MINI FOOD MART Account ID: EDL-11024510-017 SAM IN MINI FOOD MART License Number: 1130342400 252 MAIN ST HYANNIS MA 02601-4002 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: May 11, 2020 Expiration Date: September 30, 2022 MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-311 Retailer License for Sale.of Cigars and Smoking Tobacco r o��� This license must be posted and visible at all times: The sale of tobacco products to anyone under 18 years of age is prohibited. SAM INC MINI FOOD MART Account ID: CRL-1 10245 10-010 SAM IN MINI FOOD MART License Number: 1736452096 252 MAIN ST HYANNIS MA 02601-4002 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. F Effective Date:October 1, 2020. Expiration Date: September 30, 2022 FornCT-3 �. �SacHUSFT MASSACHUSETTS DEPARTMENT OF REVENUE Retailer License,for Sale of Cigarettes A J. y e a a This license must be posted and visible at all times.The sale of tobacco T products to anyone under 18 years of age is prohibited. o� AM INC MINI FOOD MART Account ID: CGL-11024510-007 S License Number: 1030795264 SAM IN MINI FOOD MART 252 MAIN ST HYANNIS MA 02601-4002 This certi fies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts or revoke ral d fors to sell at retail at the address shown above.This,license is non-transferable and may be suspended failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30, 2022 i ::'Department of Treasury., ic-q ti i _ °��, f Notice CP2768 - Internal Revenue Service r , C Tax period June 30, 2014 D Cincinnati OH 45999 0038;vs: /'� T` �" `.,r; Notice date September 8, 2014 IRS Employer,ID number . 27 1696134 r i .To contact us Phone 1-800-829-0115 Pagel.of 2 008042.482180 195076.11259,i AT 0 406 '370 ` IInII11r�Il��li�llli"i l�'�ihlll lllilll"1'.1q.l��llll'IIItI'�II'` t ; SAM INC MINI FOOD MART � 252 MAIN ST HYANNIS MA 02601-4002 42 Courtesy reminder about your June 30,2014 Form 941a;, Your red-era 1-11 ax-Deposit Wasr� tr subMlit 0fd C-rr6d1y Your Federal Tax Deposit for the quarter ending ,;'What-you need,to'd0` . June 30, 2014(Form 941)wasn't submitted correctly. To avoidf penalties Though we usually charge a failure-to-deposit • Be sure to penalty for incorrect deposits,we decided to, ,, Deposit the correctamount of tax,: waive the penalty for this period.We encourage Depositby the correct date,,j :. you to review the Federal Tax Deposit - Deposit according to your correct frequency(monthly or semiweekly) requirements so you can submit correct deposits Deposit electronically using the Electronic Federal Tax Payment.System(EFTPS) and avoid penalties in the future. ' • n.more..about.federal Tax.Deposit requirements Lear Visit:www:irs:gov and search: "Tax Topic..757".-You can also find the following online - Employer's Tax Guide,(Publication 15, "Circular E") -;Agricultural Employer's.Tax,Guide(Publication 51; "Circular.A") t Deposit Requirements forEmployment Taxes(Notice 931) If you.havetany questions about'this`notice or Federal Tax Deposit rules;please call us at1-800-829-0115.'' . <.M k Penalties } r Failure-to-deposit ` When you dOn'vmake your Federal Tax Deposit on time,in full;or.electronically,.we charg'e-a penalty (Internal Revenue Code,section 6656) The table,below shows the rates;used to calculate the failure-to deposit penalty. t ' Penalty rate Number of days deposit Is late 2% 1-5 days late' 5% 6-15 days late 10% ' Over 15 days late but no more than 9 days after we've billed you 10% Amounts not deposited electronically using EFTPS 15% More'than 10 days after we've billed you ,,.. y Continued on back.... Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARrrWABLE Paul J.Canniff,D.M.D. NAM F.P. Thomas Lee Alternate :639 , 200 Main Street, Hyannis, MA 02601 � Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G;L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 317 Issue Date: 12/10/2019 DBA: MINI FOOD MART OWNER: SAM, INC Location of Establishment: 252 MAIN STREET HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Gd FROZEN DESSERT: _ Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: of t Town of Barnstable For Officel Initials:Date Paid IT11IAR Amt PdPd$ I �' MASS. Inspectional Services asi y 1639. E, ' '�FOMpy16 Public Health Division check# Thomas McKean, Director '_€a 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: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: ✓/J/ J /U�/ tT�� �L� rely TELEPHONE NUMBER OF FOOD ESTABLISHMENT: �w� ► -1 TOTAL NUMBER OF BATHROOMS: Z - WELL WATER: YES NO__I,/... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/ /_ TO NUMBER OF SEATS: INSIDE: 0 OUTSIDE:�_TOTAL: 99 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? f/ IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?V�, TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE LIZRETAIL 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 QAApplication FormsTOODAPP 2020.doc r OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/0 OWNER PHONE # ADDRESS_ 3Z� CORPORATE OWNER: CORPORATE ADDRESS:,U pc. PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SIGNA LICANT 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.townotbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec. 3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Q\Application FormsTOODAPP REV3-2019.doc For Office Use Only: Initials: �FTMErgti, Town of Barnstable ti q" Date Paid Amt I'd ,,�AB,� : Inspectional Services ��,� 9� `� Public Health Division 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 //,J 17 .9-0 � NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: S,9N� //�/�-I�l��" / /�� �d ADDRESS OF TOBACCO ESTABLISHMENT: /1� J�ly MAILING ADDRESS(IF DIFFERENT FRrOM ABOVE): E-MAIL ADDRESS: IS r5r'F��b / � OI � � TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT:OWNER'S NAME: /� (�� OWNER'S PH# jq?- OWNER'S ADDRESS: CORPORATE ADDRESS: $5j9 11*115�V CORPORATE FID# �3 ANNUAL:�� SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) !✓ fA- TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https://malegislature.gov/Laws/GeneralLaws/PartIV/TitleliChapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: ►�" PRINTED NAME: Q— ✓� DATE: f/ / / PH Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors— § 371-9. Sale and Distribution of Tobacco Products, 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic g identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s) below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: ice'/ Sig ature Pr' ted Name Date Signatur PrMi ke�d Name Date Signature Printed Name Date �--� Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc 1 ;5` "USF��� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T a Retailer License for Sale of Cigarettes r ors' This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SAM INC MINI FOOD MART Account ID: CGL-11024510-007 SAM IN MINI FOOD MART License Number: 251815936 252 MAIN ST HYANNIS MA 02601-4002 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 n� ,..,.`+ ..+1..... .n V ntn.lnr 1 ...nr•.eP tr.r Vo1P nt/ '1nnrPttAc 1 Nnr I '1'_< IV 111t alnnn the flnttP/t IInP MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T s ° Retailer License for Sale of Cigars and Smoking Tobacco �Fh.r 01i This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SAM INC MINI FOOD MART Account ID: CRL-11024510-010 SAM IN MINI FOOD MART License Number: 33638400 252 MAIN ST HYANNIS MA 02601-4002 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 �. r O& F Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNSTABIM Paul J.Canniff,D.M.D. ,%A$& F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 317 Issue Date: 1/1/2020 DBA: MINI FOOD MART OWNER: SAM, INC Location of Establishment: 252 MAIN STREET 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, IRS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY S p*rrt 'ft Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. BARNSTABM John T.Norman MA55 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 317 Issue Date: 12/20/18 DBA: MINI FOOD MART OWNER: SAM, INC Location of Establishment: 252 MAIN STREET HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IncloorSeating: 0 OutcloorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - - - • • - - - MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: — --- -- ----- FINE Teti For Office Use Initials: o� Town of Barnstable Date Paid �� Amt Pd$ � MAE& $ Inspectional Services i6J� `0 Check# - 3 °lF�►�r" Public Health Division Thomas McKean, Director 3 IV " 200 Main Street, Hyannis,MA 02601 1 v H Y Office: 508-862-4644 Fax: 508-790-6304 pAPPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT �0 " DATE 1 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: 0AC/V 5r1Z11 /"% ®Av MAILING ADDRESS(IF DIFFERENT FROM ABOVE):10 M E-MAIL ADDRESS: / / TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( )-, L-/111 TOTAL NUMBER OF BATHROOMS: WELL WATER: ES NO � ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO / 1 NUMBER OF SEATS: INSIDE: 99 OUTSIDE: eV TOTAL: /, SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE _je!�11ETAIL 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) Z: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 r PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/�1V0 J - � OWNER PHONE ADDRESS 34 `�`�i�/�C CORPORATE OWNER: /V( FEDERAL ID NO. : CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: /l—5l T fo List (2) Certified Food Protection Managers AND at least (1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div.will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. 2. SIGNATURE 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 htti)://www.townofbarnstable.us/healthdivision/ai)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Q Upplication FormsTOODAPPREV2018.doc f Town of Barnstable • Regulatory Services Department `M A QC 1639. . Public Health Division 10 Fo °i . 200 Main Street, Hyannis MA 02601 Office: 508-79OA644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL.TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT TAMA ASS i� LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL S /�I AIC Milpr /:��o IlA 7— D/B/A M&/Y STREET ADDRESS gA7 Al 4 iz TELEPHONE# FID# Do you currently possess a state license to sell tobacco products? µ Yes V No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobaccp products must si the Employee Signature Form (provided herein). N4zll Signature Date Q:\Application Forms\TOBACCO APP2019 dob.docx - wA ON/ Establishment TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below are sections VII b. and VII c. of the Barnstable Board of Health Regulation: SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor. Each employee working in an establishment licensed to sell tobacco product 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 indicating that such regulations/laws have been received and understood, a copy of which must be placed on file, in the office of the employer and retained. Such signed forms must be made available for inspection, during the license holder's 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 27 years of age,the customer present a valid State issued picture identification card or driver's license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIIb-. and Vltc. Of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signa e Printed Name Date, Signa Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP2019 dob.docx pptNE Tp TOWN OF BARNSTABLE HEALTH 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 M639. `0� HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY pTED1Ax`' FOOD ESTABLISHMENT INSPECTION REPORT 508-862-4644 Name Date Type of T ns ec ion D OOReration(s) utine Address Risk Food Service Re- pection Level ad Previous Inspection Telephone R8%9-t ential Kitchen Date: V,- Vk- Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) \A. Time Bed&Breakfast HACCP Vuv In: Other Inspector V� 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 ejj ❑ 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 ju ❑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 1A \fjL ❑ 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 O 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 Non-critical(N)violations must be corrected immediately or Overall Rating ❑ Yes , �� 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. Embargo❑ g ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical, results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 6=One critical violation and less than 4non-critical violations 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. y 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violation related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) * - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) _Responsibility of the Person-in-Charge[0 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 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-Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) q 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 Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition ofAduIterated 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 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 P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperature's for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.1 IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of Equipment 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* * Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg crlve irozom 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* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- * Ratites-165°F 15 sec* in mobile food,tem or and residential Sources 70 Proper,Adequate Handwashing g' P Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004 C Wild Mushrooms* 2-301.14 When to Wash* 3-40 1.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under 929-Special 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* 3-403.1.1(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 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* Within 4 Hours* 26: Water,Plumbing and Water.. 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. 1 Poisonous or Toxic Materials I FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CF INE T TOWN OF BARNSTABLE.. _ HEALTH INSPECTOR's Establishment Name: Date: Page.: of HEALTH.. � OFFICE HOURS ' BE. PUBLIC 0 MAN STREEETSION 8:3:3 00-4- :30 P.M.:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PL N OF CORRECTION Date Verified Mph, q MON.-FRI. p ,63 HYANNIS,MA 02601 508-862-4644 No Reference- R-Red Item PLEASE PRINT CLEARLY lfoM"+' FOOD ESTABLISHMENT INSPECTION REPORT �- Name - ` ` Dat Type of iya%EofPection O er 'on s outine Address j Risk F - -nspection <) Level etai Previous Inspection Telephone ential 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 irx&41;t- Inspector �n / Out: , {V V V, [�' &, - - - 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 Asa 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 Item Total Number of Critical Violations 4 s) 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 Voluntary Compliance Employee Restriction/Exclusion Re-inspection Scheduled Emergency Suspension Y Y LJ� ❑ rY P 0 ❑ P ❑ 9 Y P 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 B=One critical violation and less than*4non-critical violations 9 )( ) cited in this report may result in suspension a 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 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. violation,4 to 8non-critical violations=C. w 29.Special Requirements (590.009) Y p 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpst screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V y r #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sig ature Print: Self Service Wait Service Provided Grease Trap Size Variance.Letter Posted Y N Dumpster Screen? Y N i 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 ColorAdditives 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 Coaling 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 41 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 2 EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 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 Se aration-Stora e* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 590.00411 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* _ 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 F9 Food Contact Surfaces 7-206.11 - Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meals&Game Pathogens* ey cnw innoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) 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- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 1 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* 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* 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 * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Within 4 Hours* 23. Management and Personnel FC-2 2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction*. Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance 3-402. eco ds,C Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Fomrback6-2doc *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. -71°FTC roi TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: ��-Jrage: of v` q 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 iORRECTION Date Verified MASS,679• .0� - HYANNIS,MA 02601 - M- -FRI. No Reference R-Red Item,. - PLEASE PRINT CLEARLY �A,EOM�e, Y FOOD ESTABLISHMENT INSPECTION REPORT 5os a sz as44 t�J Name ( �� - -- Dat- P 7 yoe of T Ins ec ion Onerationfs) outi e- Address - Risk ood Service �e in§pection Level e i 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: S 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) ❑ l 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) IA Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating ,M within 90 days as determined by the Board of Health. 111 ❑ 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 B=One critical violation and less than 4non-critical violations g ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically o la 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 i non-critical. If f 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 ti anon-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to S non critical violations=C. H1 29.Special Requirements (590.009) y p , 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dump s screened from public view � /� �/1/� Permit Posted? L Y N Grease Trap Previous Pumping Date Grease Rendered Y N V ��r t' #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N (� Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11 A)(2) Raw Animal Foods Separated from Each * 590.004(F) ( P 7-101.11 Identifying Information-Original Containers * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 590.003(C) Responsibility of the Pelson-in-Charge[0 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage*Applicants* 3-302.11(A) Food Protection* P g 7-202.11 Restriction-Presence and 20 Use* 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* 590.003(G) Reporting by Person in Charge* 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 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 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* I Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* g8 Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective///Wool 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 Surfaces of Equipment*4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* Shellfish* P 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) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and AutWildhority 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 8 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 3-202.1 3-202.1C Wild Mushrooms* 2-301.14 When to Wash* 3 40111(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( ) 11 Good Hygienic Practices . practices should be debited under#29-Special 3-201.17 Game Animals* 17 Reheating for Hot Holding 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* 3-403.1](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 ( ) 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 590.004(E) Preventing Contamination from Employees* Ln 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 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=C .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 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. pp THE Tp TOWN OF BARNSTABLE HEALTH.INSPECTOR's Establishment Name: I ► In t FcicJ MQ Date: 6�/1 ��( Page: L _Of _ OFFICE HOURS P ° 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 "'ARs. 0g HYANNIS,MA 02601 M- -FRI. 508862-4644 No Reference R-Red_Item PLEASE PRINT CLEARLY �p .ayq• . � reoM"�' FOOD ESTABLISHMENT INSPECTION REPORT Name ,n' .i-06�I l�ol�� Date�((/( e o s c io r nr Operation(s) ne mom S Address S.L M00 Risk F Service ection Level eta Previous Inspection Telephone idential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness d r i nk Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP P(fA)I In: Other - Inspector R4Qn &r Out: Dv _ rn r d 's t orq 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) ❑ FO D PROTECTION MANAGEMENT r13" � Prevention of Contamination from Hands PIC Assigned/Knowledgeable/Duties .Handwash Facilities EMPLOYEE HEALTH P TECTION FROM CHEMICALS VI.,J.,/, Reporting of Diseases by.Food Employees and PIC .Approved Food or Color'Additives 3 Personnel with Infectious Restricted/Excluded 15. Toxic Chemicals FO D FROM APPROVED SOURCE YTIE/TEMPERATURE CONTROLS(Potentially Hazardous Foods) [ Food and Water from Approved Source 16.Cooking Temperatures fReceiving/Condition [ 17.Reheating f"Tags/Records/Accuracy of Ingredient Statements 8.Cooling � .Conformance with Approved Procedures/HACCP Plans 9.Hot and Cold Holding 78. TECTION FROM CONTAMINATION 20.Time As a Public Health Control Separation/Segregation/Protection 71. UIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) i49.Food Contact Surfaces Cleaning and Sanitizing Food and Food Preparation for HS - 0.Proper Adequate Handwashing C NSUMER ADVISORY 11.Good Hygienic Practices F2.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items] Total Number of Critical Violations 1 I Critical( violations marked must corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical l(N)violations must be corrected rected immediately or within 90 days as determined b the Board of Health. Overall Rating ry p ❑ Employee ❑ P ❑ Emergency P y y ❑ Voluntary Compliance Em to ee Restriction/Exclusion Re-inspection Scheduled Emer enc 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 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 ti 8 n violations violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8 non critical violations=C. 29.Special Requirements (590.009) y P 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: � -n �Ur 31.Dumpster „screened from public view K T t& 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) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41"F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Chazge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers* 2 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*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 590.00 11 Variance Requirements i 3-304.11 Food Contact with Equipment and Utensils * � ) eq 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual 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 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 E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ey cti-11112001 L4-703.11 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* Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A D Violations of Section 590.009 A3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) ( )-(D)in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Mid Mushrooms Approved By 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* 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 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 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 PreventingContamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity* g 3 403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.1 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41*F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(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 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical Rem in the federal 1999 Food Code or 105 CMR 590.000. `°p1NE Tpk, TOWN OF BARNSTABLE. .HEALTH INSPECTORS Establishment Name: �'nr, rod MAr" Date:1 _Page:, of ti OFFICE HOURS PUBLIC HEALTH DIVISION 6:00-9:30A.M. % BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified `0l - _ HYANNIS, MA 02601 soe-862-4Rsaa No Reference R-Red Item PLEASE PRINT CLEARLY - 'FDN1P'' FOOD ESTABLISHMENT INSPECTION REPORT rf� , Ooerationls) Name n^ Date type of T Inspection it r l i , u T i ell s C' tine ; o u Address r1 Risk Food Service nspection / Level a ai Previous Inspection i l� d Telephone esidential Kitchen Date:. Mobile Pre-operation 4 1 f ) I Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector 0'1"-'1 n Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective .Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE.HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for.HSP ❑10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations , Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating � within 90 days as determined by the Board of Health. l ❑ 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 El 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 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,or1ack 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 observe to 8,non-critical violations. If 1 critical refrigeration. 29.Special Requirements. (590.009) within 10 days of receipt of this order. violation,4 to 8 n - ritical violations=C. 30.Other DATE OF RE-INSPECTION: Inspecto ' Signat P' t: 31.Dumpster screened from public view � ec ^'I^ ' (���• � I�J 0v �. ✓ l���4j lj�� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y IN #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC gnature 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) [Demonstration gnment of Responsibility* 8 Cross-contamination 14 Food or Color Additives 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 590.004(11) * 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* Variance Requirements uirements 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 Reated 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 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* 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* I 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* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg crave 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* 3-30'2.13 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* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffin Ratites-165°F 15 sec*g g Containin Fish,Meat,Poultryor 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- i Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wl/d 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* 3A01.12 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. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g, g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 3-003.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item I 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 1.009 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 ro TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: l` d-vrl � Date: v Page: of OI OFFICE HOURS �L 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 MASS.,639.. `0� HYANNIS,MA 02601 MON.-FRI. No Reference R-.Red Item PLEASE PRINT CLEARLY �A - 508-862-4644 tFO MA'�p FOOD ESTABLISHMENT INSPECTION REPORT Name rnr Date Tvne 0 Tyal2ILInspection Operation(s) Routi Address A,, Risk Food Service Re-inspection r Level a it Previou In pection , Telephone ential Kitchen Date: /ji Mobile Pre-op r I Owner HACCP Y/N Temporary Suspect Illness a ) Caterer General Complaint t uv� Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector vot i- W G S Out: d' Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22;Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C,)violations marked must be corrected immediately. (blue&red items7) Corrective Action Required: No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590,003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations B=One critical violation and less than non-critical 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 if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t F is scored automatically o la 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 i cal critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of be in writing and submitted to the Board of Health at the above address violations observed,7 to 8non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violatio 4 to on-critical violations=C. ' 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspec 's Sign to e P' t: � � 31.Dumpster screened from public view J :� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V J 10 #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC ignature 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) [Demonstration gnment of Responsibility* 8 Cross contamination 14 Food or Color Additives 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 1 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F *- EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 7-102.1 I 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 Se azation-Storage* Applicants* 3-362.11(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 Requirements . 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* A REQUIREMENTS FOR.,• 3-306.14(A)(B)Returned Food and Rated or 7-204.12 Chemicals for Washing of Food* Produce,Criteria* HSP HIGHLY SUSCEPTIBLE POPULATIONS 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* q 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 17.206.12 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. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.IIA(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 ctsw 11112001 4-602.11 Cleaning Frequency of Utensils and Fuud Animals-155°F 15 sec* 590.006(B) _ Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteuri-AA Fggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* in mobile food,temporaryand residential Sources* 70 Proper,Adequate Handwashing g' Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 1 T Reheating for Hot Holding practiRequices should be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A70*17 3-202.18 Shellstock Identification ( ) Cooling Cooked PHFs from 140°F to Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/4545°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24, Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Material 1.008 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 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. oFtR r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: OV.I Pv✓I i �0 Date: Page:�_of OFFICE HOURS �- PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSPABLE. ` 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �p MASS.9. `0� HYANNIS,MA 02601 508-8 08-8MON -FRI.62-4644, No Reference R-Red Item PLEASE PRINT CLEARLY , rFD MP�a FOOD ESTABLISHMENT INSPECTION REPORT I Name M Date Tvoe of jyMMInspection - e ) Oaefo s outi Address �; S - Risk ood inspection f ^ Level Retail Previous Inspection -e 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 CAV r- �J ^ Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating 3 within 90 days as determined by the Board of Health. r ❑ 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) cited in this report may result in suspension or revocation of the food B=One critical violation and less than non-critical violations if no critical violations observed,4 too 6 von-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 obsery d,7 to 8non-critical violations. If 1 critical refrigeration. ' 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 n critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: 7:V t: 31.Dumpster screened from public view IP 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 • s. Violations related to Foodborner11/ness 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* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12--_ Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties � - � 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F - * - -- EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 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* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* * Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) 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 WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* 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 Eggs 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or I Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3 401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg cti-um001 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* 1 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-1'55°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 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* Ratites-165°F 15 sec* in ,mobile food,temporary.and residential So 10 Proper,Adequate Handwashing3-401.11(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. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 77 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 403.11(C) Commercially Processed RT'E Food-140°F 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 590.004(E) Preventing Contamination from Employees 1$ Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Fonnback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000, *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. r Town of Barnstable 0- Board. of Health iOlEb p�y.4A 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 John T.Norman FAX: 508-790-6304 Donald A.Guadagnoli,M.D. F.E.(Thomas)Lee,P.E. Daniel Luczkow,M.D.,Alternate August 20, 2021 i Asim Jamal Mini Food Mart 252 Main Street Hyannis, MA 02601 Email: asijee167@hotmail.com NOTICE OF SHOW CAUSE HEARING Violation visit: # 1000533 On 08/02/2021,the humidor was unlocked. According to State of MA Tobacco regulations,"any proprietor(s) or other person(s) ... who fail(s)to comply with these regulations shall be subject to the following actions for each offense: Town of Barnstable tobacco violation of$100.00 for the first offense. You are hereby notified to appear before the Board of Health on Tuesday, September 28, 2021 at 3:00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss any future plans you may have to comply with this regulation. The hearing will be held in the Town Hall,James H. Crocker,Jr. Hearing Room,367 Main Street, Hyannis, Massachusetts. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, RS, CHO Director of Public Health Q:\Order letters\Tobacco\Tobacco Viol.Hearing Rev BOH 09-28-21 Mini Food Mart Hy.docx P 0 S T COUNTER a TOOLS POINT OF SALE TOOLKIT r'u"urcxi'na""S° Violation visit #1000533 summary: Retailer info: • Retailer name: mini food mart • Address line 1: 252 MAIN STREET • Address line 2: • City, State: Barnstable, MA • Zip: 02601 Submission info: • Survey Submitted Date: Aug 02, 2021 • Survey Submitted Time: 12:16:53 PM EDT (UTC +0400) • Visit Completed By: Bob Collett (# 821) Visit info: • If violations were found, check all that apply: Missing signage, Other (please specify) • Specify other violation: Humidor is unlocked • What action was taken? Check all that apply Referral given to another agency (e.g. Department of Revenue, Attorney General's office, local Board of Health) • Specify other fine: • Employee/merchant name: • Employee;merchant title: Owner • Enter field notes Unlocked humidor Visit link: https://mass.countertools.org/education/1000533 PDF generated on: Aug. 2, 2021 Town of Barnstable Board of Health 200 Main Street, Hyannis MA 02601 BAMSTABM 9 MASS. John T.Norman,Chair Office:508-862-4644 Donald A.Guadagnoli,M.D FAX: 508-790-6304 F.P.(Thomas)Lee,P.E. Daniel Luczkow,M.D,Alternate BOARD OF HEALTH MEETING MINUTES Original 9/23/21. 1:35 pm Tuesday, September 28, 2021 3:00 PM James H. Crocker Jr. Hearing Room, Town Hall 367 Main Street, 2"d Floor, Hyannis, MA A regularly scheduled and duly posted meeting of the Barnstable Board of Health was held on Tuesday,September 28,2021. The meeting was called to order at 3:00 pm by John Norman,Chair. Also in attendance were Board Members Donald Guadagnoli,Vice Chair,Thomas Lee,and Daniel Luczkow,M.D.,Alternate. Thomas McKean,Director of Public Health, and Sharon Crocker,Administrative Assistant,were also present. I. Tobacco Violations: A. Nilesh Patel, Hyannis Package Store —775 Main Street, Hyannis, tobacco violation Mr. Patel was present and explained there were two menthol cigars purchased prior to the change in regulations which an employee was to purchase and bring home. He admitted it was still on the shelf. Bob Collette, Barnstable County Tobacco Enforcement Officer stated the State of MA imposes the issuance of their fines in cases of menthol sales and stated all vendors had ample notice. Upon a motion duly made and seconded, with the acknowledgement of admission of violation, the Board voted to assess the appropriate fine of$1,000 for the first State offense. (Unanimously, voted in favor.) B. Asim Jamal, Mini Food Mart— 252 Main Street, Hyannis, tobacco violation Asim Jamal was present and stated an employee forgot to relock the cigar humidor. Bob Collette stated this violation falls under the local tobacco code and, thus, would be subject to the local regulation's fine — not the State. Dr. Guadagnoli stated with the past two years of hardship during Covid , he would be willing to reconsider the local regulations fines for tobacco at a future date. Upon a motion duly made and seconded, the Board voted to assess the appropriate local fine of $100. (Unanimously, voted in favor.) II. Variances —Septic: A. Daniel Ojala, Down Cape Engineering, representing Merrill Davis, owner—660 Main Street, West Barnstable, Map/Parcel 156-011, 45,000 square feet parcel, requesting three variances and a pump chamber. Page 1 of 5 BOH 09/28/2021 Mr. Ojala presented the septic plan and had a revised plan showing a filter for outlet on tank. Mr. Norman said that outlet will require cover to grade so the owner can service the filter. Mr. McKean brought up that the staff would like something from Brian Dudley if engineer wanted to use 3 feet separation without an Innovative/Alternative (I/A) system. Mr. Norman and Mr. Lee stated they would prefer the four foot separation as the perch level is constantly shifting and the effluent may go into the perched area and run into wetlands. They agreed it does not call for a strip-out. Upon a motion duly made by Dr. Guadagnoli, and seconded by Mr. Lee, the Board voted to grant the variances as presented with the following conditions: 1) a 2-bedroom deed restriction is required, 2) revise plan with a four foot separation from system to groundwater which includes 3.1 naturally occurring pervious material and the system will have an approximate one foot mound, 3) remove variance for 15.415 of separation to groundwater, 4) add sieve analysis, and 5) filter cover to grade so serviceable. (Unanimously, voted in favor.) B. John O'Dea, Sullivan Engineering, representing Hard-A-Lee, Inc, owner—299 Eel River Road, Osterville, Map/Parcel 115-003 1.06 acre parcel, requesting three variances from coastal bank. John O'Dea was present and discussed plan. Mr. McKean said the staff had no objections and mentioned the test hole done on August 27, 2021 should be included in the plan. Mr. O'Dea said he will adjust the plan. Upon a motion duly made by Mr. Lee, seconded by Dr. Guadagnoli, the Board voted to grant the variances as submitted. (Unanimously, voted in favor.) III. Innovative/Alternative (I/A) — Septic (NitROE): A. Daniel Ojala, Down Cape Engineering, representing Matthew MacKinnon, Trustee—33 Oyster Place Road, Cotuit, Map/Parcel 035-101, 14,571 square feet parcel, proposed using the NitROE innovative alternative septic system, requesting six variances. Mr. Ojala was present and discussed plan proposed. Upon a motion duly made and seconded, the Board voted to grant the I/A system and variances with the following conditions: 1) Health staff must verify a four bedroom permit exists and 2) plan needs to show water line. (Unanimously, voted in favor.) B. Daniel Ojala, Down Cape Engineering, representing Donald MacKinnon, Trustee —910 Main Street, Cotuit, Map/Parcel 035-090, 30,443 square feet parcel, proposed using the NitROE innovative alternative septic sy requesting 9 stem uestin two variances. Mr. Ojala and Mr. D.J. MacKinnon were present. Upon a motion duly made and seconded, the Board voted to grant the variances as presented with no conditions. (Unanimously, voted in favor.) Page 2 of 5 BOH 09/28/2021 C. Joseph Henderson and Mark Nelson, Horsley Witten Group, representing 2 owners, requesting septic variances using the NitROE innovative alternative (I/A) septic system: 1. Mary and Dennis Healy, owners —26 Barberry Lane, Marstons Mills, Map/Parcel 102-145, 0.21 acre parcel, requesting three variances. Mr. Henderson and Mr. Nelson presented the proposed plan. Upon a motion duly made and seconded, the Board voted to grant the use of the NitROE I/A System and the three variances with the following conditions on a revised plan: 1) show the test pit log on plan, 2) remove the liner that is around the soil absorption system (SAS), 3) install two sections of liner— one to protect the.water line close to SAS, and one to protect the drainage area. (Unanimously, voted in favor.) 2. Roger and Celeste Derosier, owners —295 Lakeside Drive, Marstons Mills, Map/Parcel 102-163, 0.23 acre parcel, no variances requested. Upon a motion duly made and seconded, the Board voted to grant the use of the NitROE I/A System with the following conditions: the engineer must verify that the storage room is unfinished. (Unanimously, voted in favor.) IV. Informal Discussion — Fuii Clean System (Pilot Program): Brian Braumgaertel, Alternative Septic System Test Center and a representative from Fuji Clean will have informal discussion on system. Brian Braumgaertel said the proposed system is similar to the Fuji Pilot Program in how it addresses reduction in nitrogen and the FujiClean is also designed to help reduce phosphates and would be interested in putting a system in at 125 Blantyre Avenue, Centerville. He is submitting to the State for consideration and the State would like to know whether the Board of Health would consider the product before going further with application for a pilot program. V. Sewer Connection — Exempt: William Swift, owner— 32 Bow Lane, Barnstable, Map/Parcel 299-049-001, 86,472 square feet parcel, requesting an exemption from connecting to town sewer due to difficulty connecting with natural obstacles. Mr. Swift stated he spoke with an engineer and the cost to connect to sewer due to difficult obstacles along with the connection of water which the water company told him would require digging under the drainage ditch and would require a new 8" main with an estimated cost of$40- 50K. It currently has a 2" main put in around 1930-1940s. That cost was estimated at $40-50K. It is his understanding that to be connected to town sewer; he must also be connected to public water and is, thus, looking for an exemption. Mr. Norman stated this is a vacant piece of land in a nitrogen sensitive area and sewer has been available since 1975. The connection to sewer cost should have been factored into the cost of building home. It is not required to be hooked up to water in order to hook up to sewer. Mr. Norman stated that owners are not required to connect to public water in order to connect to sewer. Therefore, the additional cost to put in the water main should not factor in. The property can have well water. Page 3 of 5 BOH 09/28/2021 The Board expressed confusion and wondered whether the builder was actually issued a building permit for the home without a septic permit in hand. The builder was not in attendance. John Norman asked Tom McKean to obtain a copy of the building permit and septic permit, if applicable, prior to the next meeting. Upon a motion duly made and seconded, the Board voted to continue this to the next meeting, October 26, 2021.. (Unanimously, voted in favor.) VI. Bedroom Count Determination: Attorney Jeffery Johnson representing Robin Kroopnick, owner— 175 Scudder Avenue, Hyannis, Map/Parcel 289-167, requesting a determination as a four- bedroom. Attorney Johnson along with Robin Kroopnick and her brother, Jonathan Rosen, were present. He stated the original purchase paper did state it was a four bedroom and field card showed in 1988 Assessor's visited house and identified as four bedroom home. Upon a motion duly made by Mr. Lee, seconded by Dr. Guadagnoli, the Board voted to approve as a four-bedroom dwelling with the following conditions: 1) the septic plan will be redesigned to include a denitrification system with a monitoring plan of quarterly monitoring/year for a minimum of two years, at which time the Board may review for a reduction, and 2) the permit may be approved by staff at the Health counter. (Unanimously, voted in favor.) VII. Hearing: Uninhabitable Audrey and Miguel Gomes, owners —42 Tonela Lane, Barnstable, Map/Parcel 336-066, Their MicroFast Innovative/Alternative (I/A) Septic System has not been operating with an Operation and Maintenance (O&M) contract in effect. Mr. Gomes said he had begun using a contractor; however, the contractor has not been responding to owner and has not cashed his payment. The Board instructed him to seek out other contractors and begin testing so the system may be evaluated. Mr. Gomes also mentioned his pump broke two weeks ago and expects it may take time to get a replacement due to supply chain. He inquired into how many tests/year may be required. Mr. Norman suggested to let a contractor know the initial test will be required and depending upon results, testing may be required once a year or up to four times a year. Upon a motion duly made by Dr. Guadagnoli, seconded by Mr. Lee, the Board voted to continue this item for one month to October 26, 2021 to see any progress and if contract in hand, will await first test results. (Unanimously, voted in favor.) • Board member Tom Lee recused himself from the next item and will not be returning. Vill. Food —Variance (Grease Trap): Page 4 of 5 BOH 09/28/2021 Dan O'Rourke, Jr., owner, Jake's Clambakes —3821 Falmouth Rd, Windmill Square, Unit# 6, Marstons Mills, Map/Parcel 057-004, requesting a grease trap variance. Dan O'Rourke expressed that there will not be any tables. His main business is catering, along with some pickup and deliveries. He is planning to purchase the Big Dipper from his prior landlord and install at this location. The property is on a septic system; not on sewer. Mr. McKean said the staff felt the menu, including the Italian sausage, was extensive the Italian sausage. Big Dipper Grease Recovery Device should be fine with proper maintenance and ensuring it is plugged in. Upon a motion duly made by Dr. Guadagnoli, seconded by Dr. Luczkow, the Board voted to grant the grease trap variance with the use of the Big Dipper grease recovery device. (Unanimously, voted in favor.) IX. Body Artist (New): Sorivel Rosario, West Yarmouth, MA, is applying to L'Atelier Permanent Makeup, 8 West Bay Road, Osterville, is requesting a variance from the N.E. accredited college course of Anatomy and Physiology course, has completed the Anatomy, Physiology and Skin Course for Body Art Practitioners" course through "Save Each Life ". Sorivel Rosario was present, submitted all necessary documents, and is looking forward to training at L'Atelier Permanent Makeup. Mr. McKean stated her application was all set and he had no issue. Upon a motion duly made by Dr. Guadagnoli, seconded by Dr. Luczkow, the Board voted to approve the variance for Body Artist Sorivel Rosario. (Unanimously voted in favor.) X. MINUTES: Voted to continue the Minutes to October 24, 2021 meeting. VOTED TO ADJOURN — 5:50pm Notice of Recording: This meeting of the Board of Health will be recorded and transmitted by the Information Technology Department of the Town of Barnstable on Channel 18. Under MGL Chapter 30A Section 20, anyone else desiring to make such a recording or transmission must note the Chair. Page 5 of 5 BOH 09/28/2021 - BAR • , NAM a F OFFENDER ' ADDRES F FFENDER } /` ' TOWN OF S� t rR j} tpn 6 b CITY,$TdTE,ZIP CQDE ¢� BARNSTABLE Q'��. A MVIMB R ISTRATIO NUMBER �i E rpm P��.�� , �•. 1- Ill i OFFENS d HAR\SIAR1.F.. �PrED MP'�► i d R D 1 aa ,i�ty' �'e. - r L i', •�1l ,t Z TION OF VIOLATION ��.� TIME AND DATE OF VIOLATION 20hi+, LR/"4 �'Y<'StA�.�.5's' IQ j ° a •+r iii•�• BADGE NO. NOTICE OF GPERS P °N a E�6FORCINGDEPT t �1 N SLGNA'91y9RENFORCING PERSON. tY}/`' .+ VIOLATION UJI F TOWN I HER. Y ACKNOWLEDGE RECEIPT OF CITATION X 0 ®�UnaBble to obtaiq signature of offender. THE NONCRIMINAL FINE FOR THIS OFFENSE IS S.� - w ORDINANCE Date mailed i1:2.� OR YOU HAVE THE FOLL ING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FIN W rA DISPOSITION WITH NO RESULTING CRIMINAL RECORD. REGULATION (t)You may elect to pay the above fine,either by appearing in person between 6:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, a 1 Hyannis,MA 0260 The ab1le WITHIN TO NTn Street, t,Hyannis, MA OF T0:2601 or HE DATE by mailit F THIS NOTICE.money order or postal note to Barnstable Clerk,P.O.Box 2430, i I (2)If you desire to contest this matter in a noncriminal proceeding you may do so by making written request to DISTRICT COURT DEPARTMENT,FIR ST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET BARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. in the amount of El HEREBY ELECT the first option above,confess to the offense charged,and enclose payment 1 Si nature -- --- ----------__--_.-_-_..�---------------------— .. _....._.._..._gn � THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I A M E DATA MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T m y Retailer License for Sale of Cigars and Smoking Tobacco ` r& This license must be posted and visible at all times. The sale of tobacco "D products to anyone under 18 years of age is prohibited. `= SAM INC MINI FOOD MART Account ID: CRL-11024510-010 SAM IN MINI FOOD MART License Number: 33638400 252 MAIN ST HYANNIS MA 02601-4002 = r ti 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 ` �'�>S CH� MASSACHUSETTS DEPARTMENT OF REVENUE 1P Form CT-3T m Retailer License for Sale of Cigarettes y � • & This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. SAM INC MINI FOOD MART Account ID: CGL-11024510-007 SAM IN MINI FOOD MART License Number: 251815936 252 MAIN ST HYANNIS MA 02601-4002 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 n"'•^'^� `^ ^••• •� ••.�.•r Vntn.l nr I ^n.�on ter Vnlo r,t I 'innra ttac f I+nrm I `I_< I 1 1 "it ninnn the flnttP�I1nP ` J f J } LICATION No. 02661 08276 c 55��SF, Form CT-3A 2006-2008 z Cigarette Excise Unit Retailer's License for Sale of Cigarettes This license must be posted and visible at all times.Sales to persons under 18 years of age are prohibited by law. Federal Identification , License number: Date of issue: 33`1-4 76-1 38 CA 2 76 06I2712t 7 Mailing address for license: Cigarette sale location(if different than mailing address): SRAJYS INC MINI FOOD MART ?52 '�A.I ST 252 MAINST H Y A N N I S MA G26' 100(1G HYANNIS AMA 1026010000 This certifies that the taxpayer named above has paid the required license fee and is licensed to retail cigarettes at the ad- dress shown above until June 80,2008.This license is not transferable,and is subject to suspension for failure to comply with the law. 12M 2/06 2006JBPRINTOFF150041 ®printed on recycled paper Invoice Intelli-Check, Inc. Invoice Number: 246 Crossways Park West 004308 Woodbury, NY 11797 USA Invoice Date: Aug 3, 2007 Voice: 516-992-1900 Page: Fax: 516-992-1918 Sold To: Ship to: Mini Food Mart Mini Food Mart 252 Main Street 252 Main Street Hyanis, MA 02601 Attn: Sahid Chauudry USA Hyanis, MA 02601 USA Customer ID Customer PO Payment Terms 1-2052 IDCheck POSx Prepaid-ck#1046 Sales Rep ID Shippinq Method Ship Date Due Date Larry McGonagle UPS Ground 8/3/07 8/3/07 Quantity Item Description Unit Price Extension 1.00 IDCheck POSx Verifone 3730 w/built in printer, 1, 040.25 1, 040.25 mag stripe reader & 1 Megs Memory. DC'M/1 with Verifone cable for 2D'bar code reading. Includes 1YR HW/JUC 1.00 SOFTWARE WTY - 2 YR Software Warranty - 2 year 190.00 190.00 1.00 HARDWARE WTY - 2 YR DCM Hardware Warranty - 2 year 89.00 89.00 1.00 Verifone Warranty Verifone Hardware 2 YR Hardware 150.00 150.00 Warranty-Includes Verifone Unit and Print OES NOT INCLUDE 2D Bar Cod r 1.00 SHIPPING - UNITS SHIPPING 15.00 15.00 v O Subtotal 1, 484 .25 Sales Tax 74 .21 Total Invoice Amount 1,558.46 Payment Received 0.00 TOTAL 1,558.4 6 NAME-OF OFFENDER BAR 69809 9-:4.01 `lama TOWN OF ADDRE5SNDER 6�FE5;?fy Q Road, "SaJmistcl e rAA BARNSTABLE CITY STAZE,ZIP CODE 1401c4 , (AA INE rpw MV/MB REGISTRATION NUMBER OFFEN E HARNSIABLE. • /\+M¢lr . ©+(/'/�I'r �1! /4►, 1� r, � / �y�/ ry L. 1AIS, s hc -Town V 1 0 a-lED MP+ '� � \ � dl:•{ � �rS � 3 1�..1�`� �� L..QGst�E?� > LU TIME AND DATE OF VIOLATION , LO TION OF VIOLATION '� �.}, LU NOTICE OF ! I J.( (A.M./ P i ON Uq, 20 � # in; pe,d �l r E t o �n SIGNATURE..O,ENFORCINGPE S0 ENFORCING T�� �,+ E BADGE NO. Cn VIOLATION to c Woo, 1 tl/A 0 OF TOWN I HERBY ACKNOWLEDGE RECEIPT OF CITATION X Q ORDINANCE ® Unable to obtain signature of offender. t2 r THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ Date mailed Id 1-2 1 Uj w OR YOU HAVE THE FOLL®WING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. LU REGULATION (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w before:The Barnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, a Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature Town of Barnstable pa,0,�� snterisraeLe, Board of Health Ep ° 200 Main Street,Hyannis MA 02601 Office: 508-8624644 John T.Norman FAX: 508-790-6304 Donald A.Guadagnoli,M.D. F.E.(Thomas)Lee,P.E. Daniel Luczkow,M.D.,Alternate August 20, 2021 Asim Jamal Mini Food Mart 252 Main Street Hyannis, MA 02601 Email: asijee167@hotmail.com NOTICE OF SHOW CAUSE HEARING Violation visit: # 1000533 On 08/02/2021, the humidor was unlocked. According to State of MA Tobacco regulations,"any proprietor(s) or other person(s) ... who fail(s) to comply with these regulations shall be subject to the following actions for each offense: Town of Barnstable tobacco violation of$100.00 for the first offense. You are hereby notified to appear before the Board of Health on Tuesday, September 28, 2021 at 3:00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss any future plans you may have to comply with this regulation. The hearing will be held in the Town Hall,James H. Crocker,Jr. Hearing Room,367 Main Street, Hyannis, Massachusetts. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, RS, CHO Director of Public Health Q:\Order letters\Tobacco\Tobacco Viol.Hearing Rev BOH 09-28-21 Mini Food Mart Hy.docx i POST ++COUNTER ++TOOLS POINT OF SALE TOOLKIT 1=xK",N°"uo Violation visit # 1000533 summarv: Retailer info: • Retailer name: mini food mart • Address hne 1: 252 MAIN STREET • Address line 2: • City, State: Barnstable, MA • Zip: 02601 Submission info: • Survey Submitted Date: Aug 02, 2021 • Survey Submitted Time: 12:16:53 PM EDT (UTC +0400) • Visit Completed By: Bob Collett (# 821) Visit info: • If violations were found, check all that apply: Missing si.gnage, Other (please specify) • Specify other violation: Humidor is unlocked • What action was taken? Check all that apply Referral given to another agency (e.g. Department of Revenue, Attorney General's office, local Board of Health) • Specify other fine: • Employeeimerchant name: • Employee/merchant title: Owner • Enter field notes Unlocked humidor Visit link: https://mass.countertools.org/education/1000533 PDF generated on: Aug. 2, 2021