HomeMy WebLinkAboutMINI MARKET CONVENIENCE STORE - RETAIL FOOD MINI MARKET 3 (�
CONVENIENCE STORE
507 Main St., HYA
' rtKE t BOARD OF HEALTH
Town of Barnstable
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
uAmsuuu- F.P.(Thomas)Lee,.
Mass. Daniel Luczkow,M.D. Alt.
by4 200 Main Street, Hyannis, MA 02601
°"tea 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: 1053 Issue Date: 01/01/2022
DBA: MINI MARKET CONVENIENCE STORE
OWNER: FRANCISCO FLORES
Location of Establishment: 507 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: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
i
w
oFtHE t� Town of Barnstable For Office Use Only: Initials:
� � Date Paidl� ��^
9 BMWSfABLE,D* Inspectional Services Amt Pd$
2g —3
Maes' Check#
A
1639. Public Health Division
ptFD 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 I2�2I NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: 1 1 ft`e W LO mV ex- d e-(\Ce- 5 hAe
ADDRESS OF FOOD ESTABLISHMENT: S O 9Y \P�q 5 (,Qd 02c®I
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
asp�� lc�oc�i�a � �•�0'"�
E-MAIL ADDRESS: 5
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (509 IS
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES NO V/ ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: 1_7./3I./Z TO 19- / ` / �-
NUMBER OF SEATS: INSIDE: �_ OUTSIDE: _CL 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?i No AA''
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? 7V
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED)
CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEETAGE#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 FottnsTOODAPP 2020.doc
i
,., .
OWNER INFORMATION: Ir
FULL NAME OF APPLICANT F p Q
SOLE OWNER: /NO OWNER PHONE #
ADDRESS 6 Tl(co MAS PQ 0-�
CORPORATE OWNER:
CORPORATE ADDRESS: G
PERSON IN CHARGE OF DAILY OPERATIONS:
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
1. I Ji
2.
A-1 T C 0 )EI g--V-s
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.ast).
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.3 1"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
�r ofs Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
+' a+&NSTAULL Paul J.Canniff,D.M.D.
MARE, 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: 1053 Issue Date: 01/01/2021
DBA: MINI MARKET CONVENIENCE STORE
OWNER: FRANCISCO FLORES
Location of Establishment: 507 MAIN STREET HYANNIS„ MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: C OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2021
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Qn
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
,f 4
For Office Use Only: Initials:
�FTNETp Town of Barnstable lgfz�
Amt Pd$
BARNSTABLE, Inspectional Services
v� ,MASS. `0� Check it / l
A,Eos Public Health,Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE ® NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: Mini HQMe
ADDRESS OF FOOD ESTABLISHMENT:50-7 Hdin s5d(-C-e4 f JNny)y),M'A Qo(G 0 1
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: -�"�—
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( 05 a co qg
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YES NO .... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: _0 OUTSIDE: _0 TOTAL: (`
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED& BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
_MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL, MOBILE & NEW FOOD ONLY***
REQUIRED TO CAL11 HEALTH DIV. FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
QAApplication FormsTOODAPP 2020.doc
`GWNER INFORMATION:
FULL NAME OFAPPLICANTf 1 QV)L, �n `` tt
SOLE OWNER: YES/NO - OWNER PHONE #s50�-(,1�- L4
ADDRESS r I I I��YYYrJIIr U�(� 1��� M n COX
CORPORATE OWNER:
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least (1) Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
1. P
2.
r �
I� t� /VCRs ® i� l � 1/ tq0
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Dv.
prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment isprohibited.
NOTICE: Permits run annually from January 1st to Dec. 3I't 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
` Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
BARNISTARM F.P.(Thomas)Lee
MAW,
A Daniel Luczkow,Alternate
ts� 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: 1053 Issue Date: 1/1/2021
DBA: MINI MARKET CONVENIENCE STORE
OWNER: FRANCISCO FLORES
Location of Establishment: 507 MAIN STREET HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2021
TOBACCO SALES: $85.00
Permit Expires: 12/31/2021
`:-E�Q k�
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
• ��'"E'Ow 20
Town of Barnstable ��ce U ' Initials:
Date Paid � U LC Amt Pd$�
• Inspectional Services
,'�: �� G_�'" Check# (K�
9�p,B1639. p Public Health Division Y;�� —�- `
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601 �—
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored)
DATE 12—5[o�® NEW BUSINESS OWNERSHIP RENEWAL
NAME OF TOBACCO ESTABLISHMENT: My)L Ma r y-Z4
ADDRESS OF TOBACCO ESTABLISHMENT: ESQ `z mc�n c5��2e y��n�5 1 lvl F� �pi�Q
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: 1°
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT:
OWNER'S NAME: IO j OWNER'S PH# L5-jq_q
OWNER'S ADDRESS: lQ R[La2mr � TO��l(� S, vtI� GD G1
CORPORATE NAME:
CORPORATE ADDRESS: CORPORATE FID#
ANNUAL: V SEASONAL: DATES OF OPERATION: / / TO
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)
TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/33996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
https:Hmalegislature.gov/Laws/GeneralLaws/PartIV/Titlel/Chal)ter270/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: F IZ �\ ` L y r C C9V-[ d ^F— S
PRINTED NAME: MA,/t/ ,5' 01F10 R t E DATE:
Q:\Applicafion Forms\TOBACCO APP-NonFavor 12-18-19.docx
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
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:
FRL� NC t1C_ atloP-�S
Signature Printed Name Date
Signature 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 APP-NonFavor 12-18-19.docx
f
Commonwealth of Massachusetts Letter(D:L052 79 7 1 904 OKI,
y sx Notice Date:October 9,2020 �i
s Department of Rcvcnuc
Geoffrey E.Snyder,Commissioner Account ID:CGL-11484636-009
mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
III"II�I�I�III�'ll�l�"11IItI"11'1'll'Jill III fill 1111111111111
FRANCISCO FLORES
o e FRANCISCO FLORES
FLORES MINI MARKET
507 MAIN ST
HYANNIS MA 02601-5407
Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line
- and display at-your-business location. At any time; you can-log into your MassTaxConnect account at
mass.gov/masstaxconnect to view and re-print a copy of this license.
If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at
(800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
-----------------------------------------------------------------------------------------------------------------------------------------------
SacHts,r MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
Retailer License for Sale of Cigarettes
MF�Toti�� This license must be posted and visible at all,times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
FRANCISCO FLORES Account ID: CGL-11484636-009
FLORES MINI MARKET License Number: 1868453888
507 MAIN ST
HYANNIS MA 02601-5407
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 9, 2020 Expiration Date: September 30, 2022
I
3s rj� Commonwealth of Massachusetts Letter ID:L1676800320
Department of Revenue Notice Date:November 30,2020
t Geoffrey E.Snyder,Commissioner Account ID:CRL-1 1484636-012
�E�rps� mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
1�i�i��lilll�li�i11lnrn1l���l�l�l�llrrl1��n�l�i�lirl��ull
o=
FRANCISCO FLORES
o= FRANCISCO FLORES
N�
N_ FLORES MINI MARKET
507 MAIN ST
HYANNIS MA 02601-5407
Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut
along-the dotted line and display-at your business location. At any time, you can log into your
MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license.
If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at
(800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
------------------
Nis sF�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigars and Smoking Tobacco
0*4 This license must be posted and visible at all times.The sale of tobacco
products to anyone under 21 years of age is prohibited.
FRANCISCO FLORES Account ID: CRL-11484636-012
FLORES MINI MARKET License Number: 612427776
507 MAIN ST
HYANNIS MA 02601-5407
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 9, 2020 Expiration Date:September 30, 2022 V'
A
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
s,►aivs AUM = Paul J.Canniff,D.M.D.
MAM 6 ��+ 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, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 1053 Issue Date: 12/10/2019
DBA: MINI MARKET CONVENIENCE STORE
OWNER: FRANCISCO FLORES
Location of Establishment: 507 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: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Qn
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES: wa i
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
�3
f.
Town of Barnstable Office
For Use Onlv: Initials:
K.. �' Date Paid Amt Pd$ '
. BMWSPABLE. : Inspectional Service &:e
Public Health Division Check#
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
PPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL
P
NAME OF FOOD ESTABLISHMENT: l h(P )VIl V V-c—+ Co it UC 14 i,C y1 C e
ADDRESS OF FOOD ESTABLISHMENT: .Seo (I ,/CCit f C L{�eZ I
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS:v I✓rte I `PY/IpT j��a,/
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS: t
WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: _ SEASONAL: DATES OF OPERATION:_/ /_ TO
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application FormsTOODAPP 2020.doc
d-
t Z�
• 1
OWNER INFORMATION: I
FULL NAME OF APPLICANT
SOLE OWNER: ES/NO () OWNER PHONE# �'—
J
ADDRESS
CORPORATE OWNER: I �� _
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS: t� Y41)1, Flo YeJ
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.
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist.
QAApplication FormsTOODAPP REV3-2019.doc
For Office Us Initials:
�"E Town of Barnstable
Date Paid I Amt S✓
9 MAM. Inspectional Services Pd$
1639.
Public Health Division Check#
ArFp�a
4
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office; 508-862-4644 Fax: 508-790-6304
aa TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored)
DATE NEW BUSINESS OWNERSHIP RENEWAL
NAME OF TOBACCO ESTABLISHMENT: / 't( r)i' A k11 t C V `vt.f eP4 Cam. �-.! o y .
ADDRESS OF TOBACCO ESTABLISHMENT: S ® '6 1 h .� E' H kn /
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): n
E-MAIL ADDRESS: � I tq l�/� bc�6c,'/-
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT:
OWNERS NAME: �� 1/ ,� OWNERS PH# T �•
OWNER'S ADDRESS: t_ �T . J4 H j-H t4 l-r 1414k rc�
CORPORATE ADDRESS: + _ CORPORATE FID#
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS)
TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
https://www.ecode360.com/33996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
https://malegislature.gov/Laws/GeneralLaws/PartIV/TitleI/Chapter270/Section6
***NEW BUSINESSES AND NEW OWNERS ONLY ***
REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED.
PLEASE CALL 508-375-6621
ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS:
1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document
2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4
SIGNATURE: A (SNC 0 F1 w Es
PRINTED NAME: EY4 YL e" l S y e"
DATE: -.1/Al 47
Q\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc
f
4
Wit .
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
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:
Signature Printed Name Date
Signature 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 APP-NonFavor 11-21-19.doc
u u
y. 4cF� Commonwealth of Massachusetts Letter ID:L 1772136832 xa�
` s Department of Revenue Notice Date:January 30,2019
? ` Christopher C.Harding,Commissioner Account ID:CGL-11484636-009
mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
I. .I
IIII111JI1111 loll 11111111111'Il1l1l111lt1l111l1� lll�ll I II
FRANCISCO FLORES
o— FRANCISCO FLORES
FLORES MINI MARKET
507 MAIN ST
HYANNIS MA 02601-5407
Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T). Cut along the dotted line
and display at your.business location.At any time,.you can log-into your-MassTa-xCornect-account at—
mass.gov/masstaxconnect to view and re-print a copy of this license.
If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at
(800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
---------------------------------------------------------------------------------------=-------------------------------------------------------
°Ssfs�2a MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
r Ail, � "7 Retailer License for Sale of Cigarettes
0*� This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
FRANCISCO FLORES Account ED: CGL-11484636-009
FLORES MINI MARKET License Number: 799109120
507 MAIN ST
HYANNIS MA 02601-5407
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: January 30, 2019 Expiration Date: September 30, 2020
ouo
Cttt;, Letter ID: L0725440896 �r
Commonwealth of Massachusetts
Department of Revenue Notice Date:January 29,2019
Account ID:CRL-1 1 48463 6-0 1 2
Christopher C.Harding.Commissioner
c mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
�11111�1'�"'IIII�I�'I.I.I��I'�'ICI"'I�I'�IIIIIIII�II'll'lll�"�
FRANCISCO FLORES
FRANCISCO FLORES
A= FLORES MINI MARKET
507 MAIN ST
HYANNIS MA 02601-5407
Attached below is.your Retailer License.for.Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut
along the dotted line and display at your business location. At any time, you can log into your
MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license.
If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at
(800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
------------------------------------------------------------------------------------------------------------------------------------------------
sXXcHv T� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
a Retailer License for Sale of Cigars and Smoking Tobacco
���'� This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
FRANCISCO FLORES Account ID: CRL-11484636-012
FLORES MINI MARKET License Number: 869183488
507 MAIN ST
HYANNIS MA 02601-5407
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:January 29, 2019 Expiration Date:September 30, 2020
5KE Town of Barnstable BOARD OF HEALTH
+� John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
NSTAU L Paul J.Canniff,D.M.D.
11
�R 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee 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:
Permit No: 1053 Issue Date: 1/1/2020
DBA: MINI MARKET CONVENIENCE STORE
OWNER: FRANCISCO FLORES
Location of Establishment: 507 MAIN STREET HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2020
TOBACCO SALES: $85.00
Permit Expires: 12/31/2020
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
AKE Town of Barnstable BOARD OF HEALTH
C Paul J Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
t' BARNSTABL& John T.Norman
MASM
F.P. Thomas Lee Alternate
200 Main Street, Hyannis, MA 02601
�$ct ° Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstablems
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 1053 Issue Date: 12/20/18
DBA: MINI MARKET CONVENIENCE STORE
OWNER: FRANCISCO FLORES
Location of Establishment: 507 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: 2019
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: - — - - - -
MOBILE-FOOD:
MOBILE-ICE CREAM: Gi
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES: $85.00
FOR ESTABLISHMENTS WITH SEATING:
i PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
1
rl
Op THE} � • Initial .
o� Town of Barnstable i
. '"a'A Inspectional Services Date Paid Amt Pd$ IG
1S&16 98- o
AIEo�° Public Health Division Check# J� -`�
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601 I l
Office: 508-862-4644 Fax: 508-790-6304
/ APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE �G Z� NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: /"�' v✓"k it L&x
e r
ADDRESS OF FOOD ESTABLISHMENT': I �L VL te,6 ,fA x f `�
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
(� 1 A
E-MAIL ADDRESS: IYG�✓ So4 Ui
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YES NO__)�_ ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: _ SEASONAL: DATES OF OPERATION: /_/ TO
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM L CENSING 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(Sp
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
Q:\Application FonnsT00DAPPREV2018.doc
Ems`
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT YA'vLCi( S s
SOLE OWNER: YES NO OWNER PHONE
ADDRESS_ t Y� ��° `� L NG A 14 is- 140- 216 0 l
CORPORATE OWNER: iwPLSC FEDERAL ID NO. :
-
CORPORATE ADDRESS: 7
PERSON IN CHARGE OF DAILY OPERATIONS: �~(,s C,0 Fba / ev
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• / / 1. / / j
2.
tll�l A*c tsc a 1 oRTy
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1 st to Dec.3 I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC I st.
Q\Application FormsTOODAPPREV2018.doc
Town of Barnstable For Office Use Only: Initials:
Inspectional Services Date Paid Amt PdCheck# Cash
r BARNBTABLE,
KASS.1639. Public Health Division
10
200 Main Street, Hyannis MA 02601
Office: 508-790-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
Fee: $85.00
MAIL TO: TOWN OF BARNSTABLE
PUBLIC HEALTH DIVISION
200 Main Street
HYANNIS,MA 02601
FAX 508 790-6304
PLEASE INCLUDE THE REQUIRED FEE OF$85.00
APPLICATION FOR A TOBACCO SALES PERMIT
I Yk'\ MLtjY"&+ convayl C Y, Lr'
ESTABLIS NT NAME (D/.B/A)
-5
ADDRESS OF BUSINESS
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
/0 )"AA
- ---
f-m'* Y I'C"+5 0+9 9 m;' *_
EMAIL t.01PHONE# FEDERAL ID#
Do you currently possess a state license to sell tobacco products?
Yes No
Each employee who sells tobacco products must receive and understand Chapter 371 of
the Town of Barnstable Code (copy provided herein) and the Massachusetts General
Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee
who sells tobacco products must sign the Employee Signature Form .(provided
herein).Signature q�, FIR
IR kf/CJ `C o F/(,k e SS Date
Q:\Application Forms\TOBACCO APP2019 dob.docx
f
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
identification containing the bearer's date of birth that the purchaser is 21 years old or
older. Verification is required for any person under the age of 27.
The following employee(s) received and understood Section 371-9 of the Town of Barnstable
Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the
Massachusetts General Laws:
%. FRa41c�-uco FLOWS �r►�
Signature Printed Name D to
Signature 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
PERMIT NO: TOWN OF BARNSTABLE 01/01/2018
1053 BOARD OF HEALTH
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to:
FRANCISCO FLORES D/B/A: MINI MARKET CONVENIENCE STORE
Whose place of business is: 507 MAIN STREET , HYANNIS MA 02601
Type of business and any restrictions: RETAIL ESTABLISHMENT
To operate a food establishment in the TOWN OF BARNSTABLE
RESTRICTIONS IF ANY:
SEATING: 0 ANNUAL: YES
SEASONAL: TEMPORARY:
F E E S BOARD OF HEALTH
RETAIL FOOD STORE: $100.00 Paul J. Canniff, D.M.D, Chairperson
FOOD SERVICE ESTABLISHMENT: Junichi SBwayanagi
RESIDENTIAL KITCHEN FOR RETAIL SALE: Donald A. Guadagnoll, M.D
RESIDENTIAL KITCHEN FOR BED+BREAKFAST 1
MOBILE FOOD UNIT: Permit expires:
TOBACCO SALES: $85.00 12/31/2018
FROZEN DESSERT: Thomas A. McKean, RS, CHO
CATERER:
Director of Public Health
Nil Town of Barnstable c,&,*113'S
�pF THE Tp��
Regulatory Services
w . = Richard V. Scali Director `u
BAMSTABLE
9 ems. s .�
anar'srneaF.ce+rennuE•mnm•vmxnrs
i639• �0 wwroswu.wMBIF•r,4,P"ST"'�
'°Teora Public Health Division 1639-2014
Thomas McKean,Director �Dg ramIS
200 Main Street,Hyannis,MA 02601
M.
Office: 508-862-4644 Fax: 508-790-6304 _:
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT 03
DATE: I
NAME OF FOOD ESTABLISHMENT: l K4" Potw_e� (Mawooce
o p
ADDRESS OF FOOD ESTABLISHMENT: So a �,C� Pq,S
MAILING ADDRESS ff DIFFERENT FROM ABOVE):
E-MAIL ADDRESS:
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
NUMBER OF SEATS*: INSIDE: OUTSIDE: TOTAL: `
* Note: If indoor seating provided, see Licensing regarding Common Victuallers License
TOTAL NUMBER OF BATHROOMS:
ANNUAL OR SEASONAL OPERATION: A ymyoO
TYPICAL HOURS OF OPERATION MON-FRI: TO
DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) YNO_V�
IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO
***REMINDER***
SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING
TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY
FOOD SERVICE
AIL FOOD
BED & BREAKFAST
CONTINENTAL BREAKFAST *IF SEATING: ALSO,MUST OBTAIN
RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE
BILE FOOD FROM LICENSING DIVISION.
TOBACCO SALES
FROZEN DAIRY DESSERT MACHINES
CATERING
OUTSIDE DINING (OVER)
Q:Wpplication Forms\Foodappldoc
f
***REMINDER***
IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE HEALTH DIVISION AND
LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
CONTACT INFORMATION:
FULL NA OF APPLICANT r Oo v\
ME C-SC 0
SOLE OWNER: S NO
ADDRESS troav" ICJ- 07-tV61
PHONE#
IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL
PARTNERS:
IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO.
STATE OF INCORPORATION:
FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES
RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL
BREAKFAST):
EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO
HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE
CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL
HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH
OF THE CERTIFICATES***
LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.)
1. EXPIRATION DATE:
2. EXPIRATION DATE:
EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES,
OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE
PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS
TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON
THE CERTIFICATE***
LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF.
1. EXPIRATION DATE: / /
i SCO F)C RR
SIGNATURE OF APPLICANT AND DATE
Q:\Application Forms\Foodapp3.doc
' T
Town of Barnstable
Regulatory Services Department
K Public Health Division
200 Main Street,Hy nnis MA 02601
Officc: 508-790-4644 Thomas A.WK=4 RS,CHO •
FAX: 508-790-6304 Director of Public Health i.
N1
Fee: $85.00
MAIL TO:TOWN OF BARNSTABLE
PUBLIC HEALTH DIVISION
200 Main Street
HYANNIS,MA 02601
FAX 508 790-6304
PLEASE INCLUDE THE REQUWD FEE OF$85.00
APPLICATION FOR A TOBACCO SALES PERMIT
re
WT NAME OF APPLICANT VIRST NAME MIDDLE INITIAL
CovwewA-e- oc?
DB/A
Sca �4qky-N
STREET ADDRESS
TELEPHONE# FID#
Do you currently possess a state license to sell tobacco products?
Yes %Oe� No
Each employee who sells tobacco products must receive and understand the Sections
VTYb. and V'Hc. of the Board of Health Prohibition of Smoking Regulation, (copy
provided herein) and the Massachusetts (General Law Chapter 270, Section 6.00 (a
copy is provided on the next page). Each employee who sells tobacco products must
sign the Employee Signature Form (provided herein).
Signature bat
Q:1Applie2von Forms�TOBAPP.DOC
TOBACCO SATES TO MINORS
PROMBYTED BY MASSACHUSETTS GENERAL LAWS
Sales to Minors — Massachusetts General Taws Chapter 270, Section 6, whoever sells a
cigarette, chewing tobacco, snuff or any tobacco in any of its forms to any person under
the age of eighteen (18) or, not being his parent or guardian, gives a cigarettes, chewing
tobacco, snuff, or tobacco in any of its forms to any person under the age of(18), shall be
punished by a fine of not less than one hundred dollars ($100) for the first offense, not
less than two hundred dollars ($200) for the second offense, and not less than three
hundred dollars ($300)for any third or subsequent offense.
Posting State Law — In conformance with Massachusetts General Laws, Chapter 270,
Section 7, a copy of Massachusetts General Laws Chapter 270, Section 6 shall be posted
conspicuously by the owner or other person in charge thereof in the shop or other place
used to sell cigarettes at-retail. The notice to be posted shall be that notice provided by
the Massachusetts Department of Public Health. Such notice skull be at least 48 square
inches and shall be posted at the cash register which receives the greatest volume of
single cigarette package sales in such a manner so this may be readily seen by a person
standing at or approaching the cash register. Such notice shall directly face the purchaser
and shall not be obstructed from view or place at a height of less than 4 feet or greater
than 9 feet from the floor. For all other cash registers that sell cigarettes, a notice shall be
attached which is no smaller than 9 square inches, which is the size of the sign provided
by the Department of public Health. Such notice must be posted in a manner so that it
may be readily seen by a person standing at or approaching the cash register. Such notice
shall directly face the purchaser and shall not be obstructed from view or laced at a height
no less than 4 feet or more than 9 feet from the floor.
Q:1Application FormATOBAPP.DOC
Establishment
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s)of this establishment received and understood
sections V11b. and VIIc. of the Barnstable Board of health Prohibition of Smoking Regulation 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 eighteen(18). Below are sections
V11b.and VIIc.of the Barnstable Board of Health Regulation:
SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
b. Sales To Minors—Jja 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 holders normal business hours upon request
of an agent of the Board of Health.
c. All distributors/retailers of tobacco products or tobacco merchandise roust require that, if a
customer appears to possibly be under 25 years of age, the customer present a valid State issued
picture identification card or drivers 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 V11b. and V1Io. of the Barnstable Board of
Realth Prohibition of Smoking Regulation and Chapter 270_Section 6 of the Massachusetts General Laws:
Signature nted Name / Date
O / VO4 1 a a0 I
i ture 'PrinteA Name Dat
Signature printed Name Date
Signature Printed Name Date
Signature Printed Name Date
Signature Printed Name Date .
Signature Printed Name Date
Q:\Application Forms70BAPP.DOC
`Op OIE row TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: Date: Page: of
ti OFFICE HOURS
BAR E, PUBLIC
2 0 MAN STREET
EEVT 3:30-4:30 P.M.
DIVISION : 0- :3A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
.639. �0� HYANNIS,MA 02601 M-8 -FRI. No Reference R-Red Item. PLEASE PRINT CLEARLY
�prED MPS p 508-662-4644 '
FOOD ESTABLISHMENT INSPECTION REPORT
bo
Name ^ ate i' e o r o section
g Routin
Address Risk -inspection
V�1 Level Previous Inspection _
Telephone ffenti!!Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness r
Caterer General Complaint
Person,in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector y /\pzr 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) ❑
c
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 n
Critical(C)violations marked must be corrected immediately. (blue&red items) v Corrective Action Required: ❑ No El 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 9 ardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than non-critical violations re
if no critical violations observed,4 too 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
2 .Water,Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8non-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C.
29.Special quirements (590.009) y P
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dump er screened from public view
Permit Posted? - Y N Grease Trap Previous Pumping Date Grease Rendered Y N
Print:
/'®
#Seats Observed Frozen Dessert Machines: Outside Dining Y N i 9nature C A ( �
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N `
Dumpster Screen? Y N PIC's
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
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 7-102.11 Common Name-Working Containers* *
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130'F*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _ REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use.of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff true 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 3-40 1.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* 1 p Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practiceRequues rhos ld be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
* 12 Prevention of Contamination from Hands 3 403.11E Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* Lill- Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
Handwashing Facilities
13
3-202.18 Shellstock Identification* 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41*F/45°F
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
.
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999,Food Code or 105 CMR 590.000.; *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
`°ptNE Tow TOWN OF BARNSTABLE _ _ :HEALTH INSPECTOR'S Establishment Name: Date: _Page: of _
ti PUBLIC HEALTH DIVISION :OFFICE HOURS6:00-9:30A.M.
BARNSTARLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS,MA 02601 _ .. MON.-FRI. No Reference R-Red-item. PLEASE P INT CLEARLY
... -. 508-862-4644 .
FOOD ESTABLISHMENT INSP CTION REPORT
Name Dat Type of Type of Insoection
OOgeration(s) R
Address Risk Foo ervice Re-inspeoon
Leve eta' pection
Telephone &Rasidential Kitchen Date:
Mobile Pre-operation
Owner HACCP YIN Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time �p Bed&Breakfast HACCP
In:;;, / Other
Inspector Out:.
.
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness"Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009 ❑
Action as determined by the Board of Health. Allergen Awareness 590.00 G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 44
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
i
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous oods)
❑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 Of
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP /r1
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories 1
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) I Corrective Action Required: S ❑ es
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❑ ry p ❑ ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation a re9nd less than 4 non-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 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility I (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) receipt within 10 days of recei t of this order. violation,4 to 8 non-critical violations=C.
30.Other DATE OF RE-INSPECTION: Ins ector'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 SC
/�a� }F^ ] ��
Dumpster Screen Y N v l l
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.* - - - 1.9- _ _ _ PHF.Hot.and.Cold Holding_ .
2-103.11 -Person-in-Charge Duties- - - - - - -- - - - - - - 3-302.14 Protection from Unapproved Additives* - -
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F) -
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge[0
Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants*- - - - -- - - -- 3=302a1(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*
ApplicanfTo 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-Prohibi[i ns* 590.004(11)) Variance Requirements
590.003(G) Reporting by Person in Charge Contamination from the Consumer Q
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
_ 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) 1 Removal of Exclusions and Restrictions g ( )
Disposition ofAdultereted or Contaminated
_ Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
4-501.111 Manual Wazewashing-Hot Water - - 7.206.12 Rodent Bait Stations
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
1� 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* I 1 TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1IS Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 IcE Made From Potable-Drinking Water* - '-- - Concentration and Hardness* - 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* _ _ * gg Not Otherwise Processed to Eliminate
Equipment
590.006(A) Bottled Drinking Water* 3-40LI1(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001
_ _ 4-(02.11-- _ 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)(I)(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 StuffingContainingFish,Meat,Poultryor
3-201.15 Molluscan Sh_el_lfish from_NSSP Listed_ __ _ Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* ing,mobile food,temporary and residential
A 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Authority Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Aut 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 - Shellstock Identification Present*- _ _27301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
i 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
-5 Receiving/Condition -- 2-40.1.11 _ Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165'F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* "t 2401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items non-critical
23-30)
3-202.15 Package Integrity ( ) y
* 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated ( ) g 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 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* K28.
Management and Personnel FC-2 .003
*' 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient Food and Food Protection FC-3 .004
3 402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6 2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 1 *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
v
IKE row TOWN OF BARNSTABLE HEALTH iNSPECTOR,s Establishment Name: Date: Page:,. of
OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. ` -n /�� 200 MAIN ST ET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS.
�. e� • �'✓�1/y M-8 -FRI. No Reference R-Red item. _. , PLEASE PRINT CLEARLY
�•rFD MP+ i V'� FOO ESTABLISHMENT I SPECTI EPORT � 5oe-Ssz-4s4a
Name Data Type of Type of Inspection
Operations) Routine ^� .
Address Risk Food Service inspection. ,
Level etail Prevous nspection
Telephone a ential Kitchen Date:
Mobile Pre-operation
Owner / HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) `� Bed&Breakfast HACCP ��
In. Other ' a �Y
Inspector Out: l'�
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) ❑ Qt/
Action as determined by the Board of Health. Allerge Aware 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination fr
❑ 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) SiA
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating _X /�'I❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling vsY04
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding %� e/
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
t r
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE.P_OPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ��
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY 1
❑ 11.Good Hygienic Practices ❑22.Posting of ConsumerAdvisorie`s.
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations UA
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Noncritical violations must be corrected immediately or //� ]���
within 90 days
as determined by the Board of Health. Overall Rating / 1/� .1 Compliance❑ Voluntary ❑ 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 B=One critical violation and less than non-critical violations 9
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009)
within 10 days of receipt of this order. 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 ;PI '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/4 I 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 PHHF s
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*
2 590.003(C) Responsibility of the Person-in-Charge to
Other 7-102.11 Common Name-Working Containers** 3-501.16(A) Hot PHFs Maintained At or Above 140°F- --
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A)T Roasts- Held At or Above 130°F* -
I
- Applicants* - - - - 3-302.11(A) 7-201.11 Separation-Storage*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 3-304.11 Food Contact with Equipment and Utensils To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004(11)- - uirements
q
590.003(G) Reporting by Person in Charge* - - _ 7-203.11 Toxic Containers-Prohibitions*
Variance Re
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* _ .- REQUIREMENTS-FOR-
3-306.14(A)(B)Resumed Food and Reservice of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
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* * 3-801.11(D) Raw or Partially Cooked Animal Food and
* 4-501.111- Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations
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. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate
Equipment*
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effecn�uinooi
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and I 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* _ Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in ca[er-
Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12. Cleaning Procedure* 165°F* 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 Requirements.
radicsshould 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
12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts*
3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
13 Handwashing Facilities
3-202.18 Shellstock Identification* 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
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:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
oF. roy TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of
v` ti •
PUBLIC HEALTH DIVISION OFFICE HOURS8:00-9:30A.M.
ennrsrneLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
;'79: HYANNIS,MA 02601 M°rv.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
�a -862A644
rfDM�p FOOD ESTABLISHMENT INSPECTION REPORT so6
Name Dat !Moe of T section
Operation(s) out' o �i
Address �^ Risk sp coon
Level etas Previous Inspection /
Telephone ✓ ential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness Lill ,
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
Other n
Inspector 11 AL
Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
p.
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) ❑
57
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 of Color Additives 1
❑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 ' j
❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding I 1
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) k,
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP/
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ('�D
❑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) 1 F::� Corrective Action Required: K4 r, I OVOIj Vr ® 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 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 4ron-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. 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. . f 1 critical refrigeration.
violation,4 critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to anon-cri
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address o C.to 8ron-critical violations non-critical violations. If
29.Special Requirements (590.009) within 10 days of receipt of this order.
=
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
P]
31.Dumpster screened from public view , V "l
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N /i
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PI s Signatur _ �y�a Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y NP,14,/<�Xo '` !/ ` }e +sDumpster Screen Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41'F/45'F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved
Contamination from Raw Ingredients 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
15 Poisonous or Toxic Substances 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
Storage*-
Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rered or of Food*Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Roden[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* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. LiL 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 Eggs 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* * - __ Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effe°"Oe 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155'17 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources* 10 Proper,Adequate Handwashing g' p �
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms When 3-401.11
* 2-301.14 Wh to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Radices should be debited under#29-Special
5 Receiving/Condition 2-401.11 Ea F ting,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165' 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 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 91Hand
Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41'F/45'F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27, Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans m Provision
Drying 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 1 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the_fedeial 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
oFt r TOWN OF BARNSTABLE. HEALTH wSPECTOR's Establishment Name: M In►' ("VW CO(W1971f Si dit Date: (&A2S/I q Page:_ Of l
q OFFICE HOURS
° PUBLIC RSION : 0- :30A.M.3:3o-4:3o P.M.
AR E 20 MAN STET
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
�p 639.a m� HYANNIS,MA 02601 M-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
rFG MPS 508-862-4644
FOOD ESTABLISHMENT INSPECTION REPORT
Name 1n -r►y( ,�, Go!►�cn,e�nc� b+o Date OW )(� Type of T e of Inspection
Operation(s) ou In - G r O
Address 5O l M411 n Risk o Service Re-i ection „. ')�� /` F1�
J Level tail Previous Inspection !/J 1
Telephone Resl ential Kitchen Date: e 1 W
Mobile Pre-operation
Owner HACCP YIN Temporary Suspect Illness _ ( ree r- I o 0
Caterer General Complaint -
Person in.Charge(PIC) Time Bed&Breakfast HACCP -
In: ' ��a Other ` �t L,
Inspector gUplS Out: d c�`I�tlVll�(
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.rood and Food Preparation for HSP ppp
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY i ,
❑ 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. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items Embar o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 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 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,
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 9 p,infestation of rodents or insects,or lack of
be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008 9 =
29.Special Requirements . (590.009) within 10 days of receipt of this order. violation,4 to 8non-critical violations C.
Inspector's Signature Print:
30.Other DATE OF RE-INSPECTION:
31..Dumpster screened from public view Bur��
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 O Print:
Self Service Wait Service Provided Grease Trap Size. Variance Letter Posted Y . N �����ls� J, l.•
Dumpster Screen? Y N
-. .. :. - _.._.._.. � .-,. .. _a, .. _.. ...,.. _ .�._ _ :_ may.. -....,y-.-.�, ��xr .. -v-^ _ ,�,,,.,.; - -.. . . .. �-w.+.. --• � ..
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 1 q 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 far 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 15 590.004(F)
590.003(C) Responsibility of the Person-in-Charge to 7-]02.11 Common Name-Working Containers*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*
2
Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Se 3-501.16(A) Roasts Held At or Above 130'F*
Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) I Exclusions and Restrictions*590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rated or of Food*Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
y 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* TIMEMEMPERATURE 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-155'17 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* -W"nvc 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155'F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3 401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency r f Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165'F 15 sec*
Sources* 1 p Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* When 2-301.14 Wh 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
practices should be debited under#29-Special
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* 3-403.11(B) Microwave-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30)
3-202.15 Package Integrity g g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the 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* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* L13 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
6-301.11 Handwashin Cleanser,Availability 27.8. Physical Facility FC-6 .008
7 Conformance with Approved Procedures/ g ty 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision
29. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures*
S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
`oF.Na.o TOWN OF BARNSTABLE . HEALTH wSPECTOR's Establishment Name:y v l i rl / lArl(RT(,OA A ,r`egg(B Date: ,2 Page:�_Of
�. OFFICE HOURS
AR Eo PUBLIC
MAIN STREETSION 8:00-9:30A.M.
3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MARS� 639 HYANNIS,MA 02601 -FRI.
,a3v 508-862�3644 No Reference R-Red Item PLEASE PRINT CL LY n� 8-8
'FOM FOOD ESTABLISHMENT INSPECTION REPORT
Name ('n� ka�Q Date Tvoe of T e Inspection _
Operation(s) out)
Address Risk Food Service Re-inspection
G1l - Level ATe,15:ip Previous npsp ction
Telephone sldential Kitchen Date:V� ?(/F Jv P'�
Mobile Pre-op atio
Owner HACCP YIN Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC Time Bed&Breakfast HACCP
In: Other
Inspector G^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
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS d
❑ 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 V`
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 ��j p
Overall Rating Q
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 Inspect) n 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
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 ery 7 to 8raon-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
violatio ,4 to n- ritical violation =C.
Signa gin30.Other PATE OF RE-INSPECTION: Inspe o s 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 N P ' Signature E rint:
Y
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
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*
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*
* 7-201.11 Separation-Storage*
Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use*
3-304.11 Food Contact with Equipment and Utensils 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 590.003 D Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals*
( ) 3-306.14(A)(B)Returned Food and Reservice of Food* REQUIREMENTS FOR
590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g iFood Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I 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
5-101.11 Drinking Water from an Approved System*
4-601.11(A) Clean Eggs 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 rn-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.ou Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3AW.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
12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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
3-203.12 Shellstock Identification Maintained* y Convenientl 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(1) 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. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:59OFormback6-2doc
*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.
�F THE fp�l- TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Mr Date: 0 Page:_�of
ti 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
MASS. .m� HYANNIS, MA 02601 sos-sz asaa No Reference R-Red Item PLEAS PRINT CLEARLY
'FDN ' FOOD ESTABLISHMENT INSPECT ON REPORT
Name I Date TvDe of T Ins ection
' w �9 Operation(s) out' �� lJ
Address 9 7 )pnN�h Risk F Service Re-inspection
/' ( G' Level Ret ' Previous Ins ct'on d '��
Date: �)
Telephone esidential Kitchen (I �y � U
Mobile Pre-ope tl
Owner HACCP Y/N Temporary Suspect Illness
.Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP c C.
In: Other
Inspector o LI/4 S 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 POP LATIO 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 /1
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations 7 1
Critical(C)violations marked must be corrected immediately. (blue&red items) / 1
Corrective Action Required: ❑ No �es
Non-critical(N)violations must be corrected immediately or Overall Rating n-
within 90 days as determined by the Board of Health. _� IT ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items Embargo
checked indicate violations'.of 105 CMR 590.000/Federal Food Code. ❑ 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 B=One critical violation and less than 4non-critical violations 9
)( ) cited in this report may reessati suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 t non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
violation,4 n-cn I violations=
30.Other DATE OF RE-INSPECTION: Inspector' S nature Pr'
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 Sig ure Print: JL �//�I �`( Flo?,
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* 6 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-SOL15 Cooling Methods for PHFs
--Cooked and RTE Foods.* * _ 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties - - - 3-302:14 Protection from Unapproved Additives - -- -'
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F) * -
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* *
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140'F
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 L.2O_ Time as a Public Health Control
590.003(F) _ Responsibility of A Food Employee or An 3 7-202.11 Restriction-Presence and Use*-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge ._
* Contamination from the Consumer 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
-
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rered or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a Hermetically Sealed Container Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System*
4-601.11(A) Clean Eggs Utensils and Food Contact Surfaces of E s-Immediate Service 145'F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff ctsw 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155'F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec*
' 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS t
s 3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* . ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145`F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* 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.
5 Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items non-critical
23-30)
3-202.15 Package Integrity ( ) Y
3-101.11 Food Safe and Unadulterated 12 Prevention of Contamination from Hands ( ) g Critical and non-critical violations,which do not relate to then the me
* 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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* _ 13 Handwashing Facilities 3-501.14(A) Cooling Cooke&PHFs from 140°F to 70`F
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41'F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance
Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices _ 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability
28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1 .009
3-502.11 Specialized Processing Methods* 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.
t n, emm-
Bellaire, Dianna
From: Joseduglas Diaz <joseduglasdiaz@gmail.com>
Sent: Friday,January 14, 2022 4:35 PM
To: Bellaire, Dianna
Subject: Re: FW: Mini Market Email
Cancel tabacco license and proceed with product license thank you.
El vie., 14 ene. 2022 3:03 p. in., Bellaire, Dianna<Dianna.Bellairegtown.barnstable.ma.us> escribi6:
Please send reply email with message below.
i
i
i
Dianna Bellaire
Permit Technician
`]:'own of Barnstable
i
Health.Division
i
200 Main. Street
Hyannis, MA 02601
P:508-862-4643
Fax:508-790-6304
I
Email:Dianna.Bellaire 2town.barnstable.ma.us
i
The information contavled in this electronic transinission("e-mail"),including any attachment(the"Information"),may be confidential or
other\vnse exempt from d.isclosureAt.is for the addressee only-.1:1.1s Information may be privileged and confidential work-product or a.
privileged and confidential communication.The Information may also be deliberative and pre decisional in nature.As such,it is for
internal use only.The Information may not be disclosed without the prior written consent of the Director of Public Health and/or the
"Town Attorrrev's Office of the Town of Barnstable. If you have received this e-mail by mistake,please notify the sender and delete it from
your system.Please do not copy or forward.it.Thank.you for your cooperation.
i
I
s
From: Bellaire, Dianna
Sent: Friday, January 14, 2022 3:02 PM
1
MINI MARKET CONVENIENCE
507 Main St Hyannis MA 02601
LOCATION AND BUSINESS DESCRIPTION
This place is a retail space in 507 Main st in Hyannis, was a regular cloth store (monomoy Island)all the
place have a sprinklers installed for a fire emergency,two bathrooms(no Public),two emergency exit
doors, and a space in the basement for services stuff(gas, electric panel and boiler),our business will be
regular Convenience store, everything that will be for sale is coming in a packaged from our distributors,
nothing will be cooked or prepared in the place, because the building don't have a kitchen or extra
space for that, any way this is not our intention, so we will be able to sale chips, sodas, drinks(no
Alcohol) bread, milk,can foods, eggs and other basic products of regular consume, this business is open
for 5 years in the Town of Yarmouth al 24 E Main st West Yarmouth MA and we are looking the way for
move to Main St, so it is not a new business, we have experience with that services, also a scale map is
attached for better description of our space.
Business Owner:
FRANCISCO FLORES
19 Franklin Ave Hyannis MA 02601
Phone(508) 815-7441
Business Manager:
RAFAEL VALLE
84 park St#A Hyannis MA 02601
Phone (508)408-7732
Email: rafaelvalle29@gmail.com
507 Main st Hyannis Mini Market Convenience store
Floor plan
Bathroom Bathroom door
no public
door
she
sh Ive
elv s
es
Groceries Groceries
shelves shelves
freezer Reg
iste
r
fridge cou
me
r
fridge
door
507 Main st Hyannis Mini Market Convenience store
Floor plan
Bathroom Bathroom door
no public
door
she
sh Ive
elv s
es
Groceries Groceries
shelves shelves
freezer
Reg
iste
r
fridge cou
me
r
fridge
door
FEE: Depending on Size of Store and type of business(Pre-Packaged Food for Resale Only)
RETAIL FOOD ESTABLISHMENTS(No cooking food,
No food Preparation)
APPROVED NOT APPROVED
PLANS—RECEIVED AND APPROVED
SEWAGE UPGRADED OR TOWN SEWER
UTILITY SINK
BATHROOMS—(VENTED)
FLOORS, WALLS,& CEILINGS
LIGHTING
REFUSE CONTAINERS
Notice: Handwash sink required if handling any unpackaged food.
Double or Triple sink required if food contact utensils and equipment utilized(e.g.—coffee machine,tongs,etc.)
gAapplication forms\retail.food.establishment.checklist.revised.03.24.1i-.doe