HomeMy WebLinkAboutJAVA & JOKE SHOP - RETAIL FOOD I
JAVA&JOKE SHOP _ tF
634 Main Street t
Hyannis 3o�1-v6a
J
V IKE
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
ANSTA F.P.(Thomas)Lee
sM. �a Daniel Luczkow,Alternate
200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Sell Tobacco
In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General
Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is
hereby granted to:
Permit No: 869 Issue Date: 1/1/2021
DBA: JAVA AND JOKE SHOP
OWNER: WILD ORCHID ENTERPRISE, LLC
Location of Establishment: 624 MAIN STREET HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2021
TOBACCO SALES: $85.00
Permit Expires: 12/31/2021
Thomas A. McKean, IRS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
ti
For Office Use Only: Initials: .
Town of Barnstable
i Date Paid Amt Pd S
, M$LE
), Inspectional Services -
Public Health Division �D` CWh
9S
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT_.:.PERMIT.APPLICATION Non-Flavored
DATE,, a q- 9 NEW BUSINESS OWNERSHIP RENEWAL
NAME OF TOBACCO ESTABLISHMENT: t
ADDRESS OF TOBACCO ESTABLISHMENT:Li ouwy*1 51
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): -11-BeA so Yl, n—KE ea ab
E-MAIL ADDRESS: 25 0-0--U YnR==kA=Q r1eX (C m 1 V(qf '
v t
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 60-r` $'U
OWNER'S NAME: gj6p6� Q(p..Y`V-%0 OWNER'S PH# bt qO- 40
OWNER'S ADDRESS: -R,CL
CORPORATE NAME
CORPORATE AD SS:4 '—BeAson i�a Cm ORPORATE FID#,D(," S(.o 1 AC6Lk
ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO
DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS).. _.
a
TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS:
TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9:
htttps://www.ecode360.com/33996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
httns:Hmaleaislature, ov/1,aws/Gcnera]Laws/Par.tIVlTitleI/Cha 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
FALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS:
1) MA State License to Sell Ciga ettes 3) IRS Federal Tax ID#Document
2) MA State Licen to Sell Cig sand Smoking Tobacco 4) Payment of Fee(s) -see page 4
SIGNATURE:
v
PRINTED NAME: V: " c /� Ce DATE:. l/ / 01,J
Q:1Application Fonns\TOBACCO APP-NonFavor 12-18-19.docx
I
1_
f
.:. q14BFSTABLIS161MV9 NAME
TORAC CO SALES,
toy agn a
This form 5,f&T n�ckal ,to Indic 4t ' t the p oy s)of this b3 lueao�b.s ivcc[.ancf'u exsti�od.0 te, 3'71
the Towp,O : fit ode and dow 270 Scou,44,6 vf,the M sac cis Gtkml L w ich dawn the
penalties-f6r s tt .g— orr iy`in to A&W mod... y plan uesder the c &wctity (2 3eiow. is Secraon
311-9.66 "1 6f wastibi B=d ofHl egulati
1e. t a s of.Tc ces t6 ur
on*a, se. o prove a tobacco p cad tz dc: r dd h min,to,a 0c rrd r
The in-Win c. IQ- s i the To":;o �artts bl�
., i n c c��i �It person# eying"car distrih. tobac t3 prod cts,as ed f�erck,
Mal,v fy e c.sf;th pbas by zzzs of a clict r�ct�► at�issued ph�t€aic
a of t i co t is �the x's dad of WO that. puce „ is.21 old car
t t�tder. V f ttcrn. s ,`,` tr' y persan oaf r-do ap'of 2'
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` rrptc= s}be low ei �dc tcaod.S tsc 3'71� c� tlie; o of rczs# is aard`c
a,tt ro?ai i<ica Qtsihoi ; .. c >t ficr and Chapter,274.section 6 es?Et .amphuntu Cxcricrld I awe
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�YRVIO''Na
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o
Commonwealth of M. husetts ,cttcr ID: L0555836992
�s Department of Revenue ,.otice Date:September 17,2020
;, r p Geoffrey E.Snyder,Commissioner Account ID:CRL-10518149-010
f1vr0FV. mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
till I1I1'1"'11�111111'1"1j11111'I'�'11�111�1"�I���'�I'�I�I'lll
SUE COUTU
WILD ORCHID ENTERPRISE LLC
WILD ORCHID
44 BEDSON RD
CRANSTON RI 02910-4902
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
�SaGHi1s�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
rA �' Retailer License for Sale of Cigars and Smoking Tobacco 1 ,
�M0� This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
WILD ORCHID ENTERPRISE LLC Account ID: CRL-10518149-010
JAVA& JOKE Location ID: 10518149-0014
624 MAIN ST License Number: 225079296
HYANNIS MA 02601-5412
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date:October 1, 2020 Expiration Date: September 30, 2022 _.\
` }tt sF Commonwealth of M: ausetts ,ctter ID: L1385920064 O O
Y= Deparimcnt of Revenue —otice Date:September 21,2020
o 6 t,
Geoffrey E.Snyder,Commissioner Account ID:CGL-10518149-006
iy ff:,s
f�jov. mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
III���I��IIII����11�11'�II�11111�1��11�1�11��1�111111111�"��IIII
WILD ORCHID ENTERPRISE LLC
JAVA&JOKE SHOP
44 BEDSON RD
CRANSTON RI 02910-4902
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
------------------------------------------------------------------------------------------------------------------------------------------------
sS'' MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
al Retailer License for Sale of Cigarettes..
y �Q
� x:vroF� This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
WILD ORCHID ENTERPRISE LLC Account ID: CGL-10518149-006
JAVA &JOKE SHOP License Number: 1869656064
624 MAIN ST
HYANNIS MA 02601-5412
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date: October 1, 2020 Expiration Date: September 30, 2022 11
Commonwealth of Massachusetts Letter ID:Ll 142626624
El 10`
Department of Revenue Notice Date:January 7,2021
Geoffrey E.Snyder,Commissioner Account ID:EDL-10518149-017
@Zomass.govtdor
LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS
llll �lldl�llnl�linlllnllhlli� nlml�inlulllinlll
WILD ORCHID ENTERPRISE LLC
S WILD ORCHID
g— 4413EDSON RD
CRANSTON'RI 02910-4902
Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. 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.
1f 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
-----------------------------------------------------------------------------------------------------------------------------------------------
st ►us� MASSACHUSETTS DEPARTMENT OF REVENUE
V Retailer License for Sale of Electronic Nicotine:Delivery Systems
p4 This license must be posted and visible at all times. The sale of
Ar7'
tobacco products to anyone under 21 years of age is prohibited.
WILD ORCHID ENTERPRISE LLC Account ID:EDL-10518149-017
JAVA& JOKE Location ID: 10518149-0020
624 MAIN ST License Number: 194521088
HYANNIS MA 02601-5412
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts
General Laws to sell electronic nicotine delivery systems at the address shown above. This license is
non-transferable and may be suspended or revoked for failure to comply with state laws and regulations.
Effective Date:January 7,2021 Expiration Date: September 30,2022
` ems Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BAILMAOLK Paul J.Canniff,D.M.D.
MAM 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 3056, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 869 Issue Date: 12/10/2019
DBA: JAVA AND JOKE SHOP
OWNER: WILD ORCHID ENTERPRISE, LLC
Location of Establishment: 624 MAIN STREET HYANNIS, MA 02601
Type of Business Permit: TOBACCO
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES: $85.00
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
i
Town of Barnstable
BOARD OF HEALTH
John T.Norman
Board of Health Donald A,Guadagnoli,M.D.
BARNnABLL Paul J.Canniff,D.M.D.
� q. 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: 869 Issue Date: 1/1/2020
DBA: JAVA AND JOKE SHOP
OWNER: WILD ORCHID ENTERPRISE, LLC
Location of Establishment: 624 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
0, _
� _ owri. of Barnstable { �._ - _� -In�nal
T
I - ;f
. • � .ate_Pai . 13 �
' snu"varescs
Inspectional ServicesMAN
-- ---
p` Public Health Division .
- _
Thomas McKean,Director '_ Y
YY
200 Main Street,Hyannis,MA 02601 .
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT PERMIT APPLICATION' on Flavored r
_ .-
DATE fir ._
-U c3GI�j NEW BUSINESS OWNERSHIP RENEWAL !`I
NAME OF TOBACCO ESTABLISHMENT ILL CL
ADDRESS OF TOBACCO ESTABLISHMENT:., L a I CL i n 5l 1,44a p n"S M A
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ,`4`-f.1.� p r� p� ��yt n @3�r�D ?
I �t ...........
E-MAIL ADDRESS:—5(Q_dl)t1 C�' �fY1.� -c�_ A (l: i t
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT:
OWNER'S NAME:--a E OWNER'S PH#(4I)may- 1/Ytb
OWNER'S ADDRESS, 44
CORPORATE ADDRESS.Ii"zcp(y;s.C>n !(Z-C�--(CCC-,.y_gS+_Ea.n _R�,- CORPORATE ), _
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:
hqt 0/www.ecode360.cortV33996392
MA GENERAL LAW CHAPTER 270/SECTION 6:
https //malegislature}gov/Laws/GeneralLaws/PartIV/TitleI/Chater270/Section6
_-
***NEW BUSINESSES AND NEW OWNERS ONLY***
REQUIRED TO CALL HEALTH DMSION 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
c, 2),MA State Licensii to Sell C' ars and Smoking Tobacco 4) Payment of Fee(s) see page 4 1 ,
t.
SIGNATURE --
..
PRINTED NAME:
DATE:
Q:1Application FormsITOBACCO APP-NonFavor 11-21-19.doc
I
ESTABI:tSN'I'S i!1A
T(JBAC.CO S.AL�S
Empoyee°Signature Foram: 4
This form is for official use to uidicate that the employee(sJ of this establtshment received and understood Clltapter 37.I
of the Town of Barnstable Code Aod Ct apter 3 Section 6 of tlie:Mussacltusetts General Laws whYch.describes the
penaltYes for sellmg andlor JR. tobacco pod -any person under the age of tr�at�;y one (2t). Below 1s Section
37I 9 of the,Town of Barristab a Board.of Udih-Regulat ari:
Sales t6..Mnio it: $371..9 Sale and Aistribntion of Tobacco Pra acts
personthall.selI or prov*-A tobacco product,as..defined herein;:to a person under
They mihht legal sal'es'ago. The miniiAwb legal sales age in the Town of Btmstabl'e
is U years of age.
2 Identxficat on Essah person seal ng or d�str b.16 tobacco products,as defined 1 er in,
shall venfy the age of.the purchaser bymeans of a valid government=issuedphotographtc- ? -.
Wonttficat on cot#a ngAlit orer's'date of ixirth that the puuchaser„is 21 years,old or
olds,r Verification is requu ed-for any:person;under p ageofg !::
The etriployee(s).below_recelved and..understood 5oOO) oiof the Town of.Barnstsbla Board of
� . .
T�ealth,prohiia boil`of Smoking> gula#ton and Ci aptei 2fi0 Section 6>of�e 1Vlaswhusetts General
4 Lai r � (2 1 q
Slpa.IF Z rinted'Namc Date
Y T y
WIN
".-- -
yy
• Prin 7+T�ae . ..
e vutted Name bate
atura TERN— Date l
Signature Panted Natrro Date
Signature Printed Name Date
QWpplicafion:Fotms1T08ACCOAE?P-A1onF8V_or1J 21=i9doc
Commonwealth of Mass ___-._.tts O
rID:L1440842368 W
�"�� t
Department of Revenue No._. Date:September 4,2018
•, .1. Christopher C.Harding,Commissioner Account ID:CGL-10518149-006
Efi1 pg mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARETTES
WILD ORCHID ENTERPRISE LLC
JAVA&JOKE SHOP
e S�
44 BEDSON RD
CRANSTON RI 02910-4902
Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T). Cut along the dotted line
and display at your business location. At any time,you can log into your MassTaxConnect account at
mass.gov/masstaxconnect to view and re-print a copy of this license.
If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at
(800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m.
DETACH HERE
----------------------------------------------------------------------------------------------------------------------------------------------
MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigarettes
NI oF� This license must be posted and visible at all times.The sale of tobacco
products to anyone under 18 years of age is prohibited.
WILD ORCHID ENTERPRISE LLC Account ID: CGL-10518149-006
JAVA&JOKE SHOP License Number: 412919808
624 MAIN ST
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date: October 1,2018
Commonwealth of Mass. tts r ID:L0063722112
( , Department of Revenue
#'c} P Noi,��Date:September 4,2018
+fit 114 ; ' P g,Commissioner
Christopher C.Hardin Account ID:CRL-10518149-010
�Nrp�`k mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
��I�""III,II�II'1'��'ICI"I.�I'��I'�Ill�il"II'I..I"IIIIIIIII�
SUE COUTU
o WILD ORCHID ENTERPRISE LLC
—_ WILD ORCHID
44 BEDSON RD
CRANSTON RI 02910-4902
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
----------------------------------------------------------------------------------------------------------------------------------------------
55" SF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigars and Smoking Tobacco
knrov This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
WILD ORCHID ENTERPRISE LLC Account ID: CRL-10518149-010
JAVA&JOKE Location ID: 10518149-0014
624 MAIN ST License Number: 729585664
This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to
sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for
failure to comply with state laws and regulations.
Effective Date:October 1, 2018 2020
Town of Barnstable BO,ARDO HEALTH
Board of Health Donald A.Gaudagnoli,M.D.
RAAJXLus A 0 M John T. Norman
Ass 200 Main Street Hyannis MA 02601 (Thomas Lee Alternate
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: 869 Issue Date: 12/20/18
DBA: JAVA AND JOKE SHOP
OWNER: WILD ORCHID ENTERPRISE, LLC
Location of Establishment: 624 MAIN STREET HYANNIS MA 02601
Type of Business Permit: TOBACCO
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES —
FOOD SERVICE ESTABLISHMENT: YEAR: 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: - - ---
MOBILE-FOOD:
MOBILE-ICE CREAM: Gr�p
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:
Oj— ciig
'THE Town of BarnstableG
o�
• - Regulatory Services DepartmentBARNSTAB
MASS.163196.
.�' Public Health Division
�Fc" 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
LAST NAME OF APPLIC FIRST NAME MIDDLE INITIAL
44 � 56
STREET ADDRESS rnC' Y\- aI cl-kt.'0-3
TELEPHONE # FID#
Do you currently possess a state license to sell tobacco products?
Yes e� No
Each employee who sells tobacco products must receive and understand the Sections
VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy
prow'' ed herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a
copy provid on the next page). Each employee who sells tobacco products must
sign E o e Signature Form (provided herein).
Signature Date
Q:\Application Forms\TOBACCO APP2018 dob.docx
sB tablishment
TOBACCO SALES ,s
Employee Signature Form
This form is for official`use to indicate that the employee(s).of this establishment received and understood
sections VII b. and VII c. 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(19). Below:are sections
VII b.and VII c.of the Barnstable Board of Health Regulation:
SECTION VrI--SAFE AND;DISTRIBUTION OF TOBACCO PRODUCTS '
b, Sales.To Minors-In conformance with the Massachusetts General.Laws Chapter 270,Section 6,.
no person, firm,'corporation, establishment, or agency shall sell'tobacco:products. to.a:minor:
Each employee working is 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 I
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 distributorstretailers of tobacco products or tobacco merchandise must require that, if a
customer appears to possibly be under 25 years of age,the customer present;a.valid State issued
picture identification card or drivers: license with appropriate p{otograph to confirm that the
customer is of legal age to 2ur0ase the tobacco Product.
The followin
g employee(s)receive
d and.understood
od Sections V1Ib. and VIIc. of the B arnstable Bo
ard of
Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws:.
er—
Simacure Z10e, Printed Name
Si turd Prin Name I?ate
Si ature Printed Name Date
Signature s P erm erm dew Date:
S' store Printed Name Date
La�a Al Ay r i ',e r .nez
Signkure Printbd Name Date;.
Signature Printed Name Date
Q:\rlpplicabon Forms\TOBACCO APP20I8 dob:doex
dptNE Town ®f Barnstable For Office Use Onlvt Initials:
q� Date Paid $
• Inspectional Services Check# EMIL
► 1ARNSTAEM "
MAN. Public Health Division
°i 200 Main Street,Hyannis MA 02601
Office: 508-790.4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
Fee: $85.00
MAIL TO: TOWN OF BARNSTABLE
PUBLIC HEALTH DIVISION
200 Main Street
HYANNI:S, MA 02601
FAX 508 790-6304
PLEASE INCLUDE THE REQUIRED FEE OF$8.5.00
APPLICATION FOR A TOBACCO SALES PERMIT
r..
ESTABLISHMENT NAME (DB/A)
ADDRESS OF BUSINESS
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
OWNER'S NAME: LAST FIRST MIDDLE
EMAIL - PHONE# FEDERAL ID#
Do you currently possess a state license to sell tobacco products?
Yes r'l 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 tobacfy produ s must sign the Employee Signature Form (provided
herein).
Signature Date
C:\Users\SCoutulAppDataV.oca1\Microsoft\Win owsVi'emporary Internet Files\Content.outlook\A02RXQII)\TOBACCO APP2019
dob.docx
ESTABLISHMENT'S h •< ;'
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s) of this establishment received4
understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 t
Massachusetts General Laws which describes the penalties for selling and/or giving
products to any person under the age of twenty-one (21). Below is Section 371-9. of the Toy
Barnstable Board of Health Regulation:
Sales to Minors—-4 371-9.Sale and Distribution of Tobacco Products
I. No person shall sell or provide a tobacco product, as defined herein,to a person un.det
The minimum legal sales age. The minimum legal sales age in the Town of Barnstab ,
is 21 years of age.
2. identification: Each person selling or distributing tobacco products,as defined herei'
shall verify the age of the purchaser by means of a valid government-issued photon, 1 _.:
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 Bami. .7 1k.
Board of Health Prohibition. of Smoking Regulation and Chapter 270 Section 6 o' ._
Massachusetts General haws;
S' atur. Printe Name Date
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Sign turre w � Printe8 Name
Date
Signature Printed Name -"
Date
Si laf 1 P rote Name Date
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�ignatu Print d Name Date
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Signature Printed Name Date
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I
oF. rqr TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: TC,✓tom 6 Date: 3 1 ( Page: / of
ti OFFICE HOURS -PUBLIC -T-
HEALTH DIVISION 8:00=9:30A.M.
BARNS'TABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
A Mbs HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
'FON1P' FOOD ESTABLISHMENT INSPECTION REPORT saa-as2�s4a
( C. (� !/
Name N�� v Date / T e o T e o s Pc ion
Operation(s) ?Mipe
Address Risk Food Service -Inspection
Level al Previous Inspection
Telephone esidential Kitchen Date: iV
tA
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector r Out:
V /I
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) II�)/ Corrective Action Required: o ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating J
within 90 days as determined by the Board of Health. 1" ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the i s ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005 B=One critical violation and less than 4nori-critical violations 9
) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9rion-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 violatio se ed,7 to 8 non-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. viola' n,4 to on-critical violation C.
29.Special Requirements (590.009) y p
30.Other DATE OF RE-INSPECTION: Inspe )r's Sign re Pri t:
31.Dumpster screened from public view r
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatu Print:
Self Service Wait Service Provided Grease Trap Size Variance.Letter Posted Y N f ��
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* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* * _ 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
7-102.11 Common Name-Working Containers*
590.003(C) Responsibility of the Person-in-Charge to
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
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* e_ REQUIREMENTS FOR.
3-306.14(A)(B)Returned Food and Rlated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
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
( ) P 4-501.t11 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations
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
-601.11 A Clean Utensils and Food Contact Surfaces of * Animal Foods That arc Raw,Undercooked or
4
5-101.11 Drinking Water from an Approved System* ( ) Eggs-Immediate Service 145°F 15 sec Not Otherwise Processed to Eliminate
Equipment* ( )( ) Pathogens*590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * E eorEve vinooi
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* 2 * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source - 3 401.11(B)(1)O Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency rf 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 Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec*
Sources* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and 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.
* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms practices should be debited under#29-Special
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodborne
* 12 Prevention of Contamination from Hands 3-403.11E Remainin 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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F_
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* 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
Supplied with Soap and hand Drying Devices
590.004(J) Labeling of Ingredients* 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria* -
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. "
�� L� l -Op1NE °�t- TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: < ,�R� f'l.v/1 Date Page: Of;
q OFFICE HOURS
TH
i ARNsrna�e.o� PUBLIC
2 0 MA NLST STREET
3:3030-4:30 P.M.
DIVISION :00-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MAC,� MON.8s2-asaa-FRI.
HYANNIS,MA 02601 soa- No Reference R-Red Item PLEASE PRINT CLEARLY •..A ,,39,a m
IFOM� FOOD ESTABLISHMENT INSPECTION REPORT s
O s -"F-c.p
Name Date Tvoe of Type of Inspection
Operations) Routine ✓ G+ i
Address Risk Food Service Re-inspection
Level IMe SI> Previousin sp ction
Telephone residential Kitchen Date:3 4 f/� Q
Mobile Pre-ope atio/i, `
Owner HACCP Y/N Temporary Suspect
Caterer eneral Com lai
Person in Charge(PIC) Time Bed&Breakfast r
Other
In:
Inspector Out:
s
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORYl_��
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations I
Critical(C)violations marked must be corrected immediately. (blue&red items) 8��i �;g i Corrective Action Required: o ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
Ea
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) cited in this report may result in suspension or revocation of the food B-One critical violation and less than 4 non-critical violations
if no critical violations observed,4 to 6pon-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8
28.Poisonous or Toxic Materials (FC-7)(590.008 be in writing and submitted to the Board of Health at the above address -critical violations. If 1 critical refrigeration.
) violation,4 to 8,potr-Uriti apiolations=C. -
29.Special Requirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: Inspector's Sig ature Print� J--,. :
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 Pri
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 L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) IDemonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge-Duties - ' Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives*"- 19 - PHF Hot and Cold Holding.,
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45`F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*7-102.11 Common Name-Working Containers 590.004(F)
*
2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-50116(A) Hot PHFs Maintained At or Above 140°F
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
* �-7=201.11 � Separation-Storage*
Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11.. Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
* 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11)) Variance Requirements
590.003(G) Reporting by Person in Charge Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR-
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* 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* Ef cdw 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155`17 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and 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* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165"F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
5 Receiving/Condition g, g g 3�f13.11(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-Q3.1I(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 Items23-30)
3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70`F
* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41'F/45'F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained
Within 4 Hours* 23. Management and Personnel FC-2 .003
Tags/Records:Fish Products 5-203.11 Numbers and Capacities*
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41'F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance
590.004(J) Labeling of Ingredients'
Supplied with Soap and hand Drying Devices Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006
27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S;590Formback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
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PLICATI0N N0. 58947 06882
Form CT 3A 2006-2008
Cigarette Excise Unit
Retailer's License for Sale of Cigarettes
This license must be posted and visible at all times.Sales to pFrsons under 18 years of a9p are.prohibiteri Uy law.
Federal Identification License number: Nile ut issue:
:-,43-4' 32-790 06882 06/16/2006
Meiling address for license: Cigarette sale location UI(hllurunt than m,irtrnii aaldlu'us):
JAVA AND JOKF SHOP JAVA AND JOK: SHOP
624 MAIN ;JT 624 MAIN ST
h Y A N N I S F1A ,;?.S^1'?!:0 ; I HYANNIS MA 02601J10001
This certifies that the taxpayFr named above has paid the rFqulred license fee and is licensed to retail cigarelles 31 Tho,,d-
dress shown above until June 30,2008.This license is not transferable,arid is subjer.,T to suspension for failure to roinply w1u,
the law.
I,W 2N6 2uu6jul-'HINIO1+1506-11 !I'