HomeMy WebLinkAboutHYANNIS CONVENIENCE STORE - RETAIL FOOD 1
Hyannis Convenience Store,
IV 6:IU Main Street
Hyannis
� r Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BA3LNSTABLE. F.P.(Thomas)Lee,.
b q ,�� 200 Main Street, Hyannis, MA 02601 Daniel Luczkow M.D. Alt.
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofba rnsta ble.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: 715 Issue Date: 01/01/2022
DBA: HYANNIS CONVENIENCE STORE
OWNER: NOOR, INC.
Location of Establishment: 631 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. 202 2
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: GQ�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
��.ve
THE rq� For Office UsInitials:
ti Town of Barnstable .�
Date Paid AmtI'd$
r uN.(STAg],E, . Inspectional Services
v �'� �, 1659. Public Health Division Check#
ArEO MAy�
Thomas McKean, Director �� w -
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE jj,�Lqa I NEW OWNERSHIP RENEWAL V'."
NAME OF FOOD ESTABLISHMENT:�t(k��z ���1� � �j,�„�� �hy'eM CPUA %I P
ADDRESS OF FOOD ESTABLISHMENT: Lai,—
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: RA5\AM0c-R 42
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (SS_)-44r� - J a
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YES NO ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL:_IX 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
OWNER INFORMATION: 44
FULL NAME OF APPLICANT
SOLE OWNER: 6NO OWNERPHONE #
ADDRESS ��, — �,.� C>ale e1��7C,Pi� �ZrY�S� � c�---J k1A
CORPORATE OWNER:
CORPORATE ADDRESS: ���1_ ��^lPtir� (g,, �1� I, La
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
SIGNA RE F APP ICANT 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 APPLICATIONS)AND REQUIRED FEES BY DEC 1st.
QAApplication FonnsTOODAPP REV3-2019.doc
Town of Barnstable
BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
W��E�".STABLL Paul J.Canniff,D.M.D.
M
n.
� 200 Main Street, Hyannis, MA 02601 IF.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: 715 Issue Date: 01/01/2021
DBA: HYANNIS CONVENIENCE STORE
OWNER: NOOR, INC.
Location of Establishment: 631 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. 2021
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
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:
y
b
• Initials:
Town of Barnstable
Date Pai �11 (d $ fA/) /
, B� : Inspectional Services HAMS �
1639. `e� Public Health Division Check#
prED MAC h
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�f NEW OWNERSHIP RENEWAL V"'
NAME OF FOOD ESTABLISHMENT: ► GCS ��1[ D►3� _�ni ����_(�
ell-
ADDRESS OF FOOD ESTABLISHMENT: �I
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
`,, n 1^ (
E-MAIL ADDRESS: �C(6J )�� n � l�' , i'I AiA� 1 C'of Y, ty
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( )-F i -
TOTAL NUMBER OF BATHROOMS:C—
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 Forms\FOODAPP 2020.doc
f
A'
OWNER INFORMATION:
FULL NAME OF APPLICANT .��� W^-<\0, \r
SOLE OWNER: YES/NO OWNER PHONE#
ADDRESS 6 C I
f - -
CORPORATE OWNER: t.
CORPORATE ADDRESS: A3 VA uPt Oa.-6 r1
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
r
SIGNATU APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments, including mobile trucks must be inspected by the Health Div.
prior to openinP!! 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/apylications.asp.
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.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st.
Q:\Application FormsTOODAPP REV3-2014.doc
IKEh Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
BA F.P.(Thomas)Lee
M.A,W, Daniel Luczkow,Alternate
sb14. � 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: 715 Issue Date: 1/1/2021
DBA: HYANNIS CONVENIENCE STORE
OWNER: NOOR, INC.
Location of Establishment: 631 MAIN STREET HYANNIS, MA 02601
Type of Business Permit: Non-Flavored
Annual Seasonal
FEES YEAR: 2021
TOBACCO SALES: $85.00
Permit Expires: 12/31/2021
Thomas A. McKean, RS, CHO, Health Agent
Restrictions:
PLEASE POST CONSPICUOUSLY
mac.
` t For Office Use Only: Initials:
Town of Barnstable
y Date Paid 141 WAMLPd S,
BAMAB Inspectional Services
Public Health Division
''rEo ra►a'�"
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
E
TOBACCO ESTABLISHMENT PERMIT APPLICATION'(Non-F..lavored)
DATE * NEW BUSINESS OWNERSHIP RENEWAL 1,-' k
NAME OF TOBACCO ESTABLISHMENT:
ADDRESS OF TOBACCO ESTABLISHMENT: K (dq,"m
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: cSr 11U
a
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: �r►� p �`'j�
OWNER'S PH#
OWNER'S NAME: r� Itla,.„ 12 sqa,1 J.
OWNER'S ADDRESS:
CORPORATE NAME:
CORPORATE ADDRESS: 3/- 0, t\, j t 1 sMjo o.,:)�Lp`CORPORATE -
ANNUAL:�� SEASONAL: DATES OF OPERATION:_/_/ TO / / cfi�� S
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:
http s://maleeislature.gov/Laws/GeneralLaws/PartIV/TitleI/Chat,)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
F ALL APPLICANTS ARE REQUIRED TO SUBMIT.THE FOLLOWING REQUIRED DOCUMENTS:
i
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: txtts)
PRINTED NAME: � DATE: // U /. AO 1
Q:Wpplication Fonns\TOBACCO APP-NonFavor 12-18-19.docx
E ABLISHMENT'S NAME a
TOBACCO SALES
Employee Signature Form I
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:
r
s
�._ \A
Signature Printed Name Date 1
Si a e N a Date 1
A.A
,
!®
Signature Printed Name Date
Signature Printed Name Date
Signature Printed Name Date
Signature Printed Name Date
H
Signature Printed Name Date
Q:1Application Forms\TOBACCO AM NonFavor 12-18-19.docx
I
Commonwealth of Massachusetts E M
Letter ID:L2039909952
Department of Revenue
Notice Date:September 9,2020
❑:�..
Geoffrey E.Snyder,Contrnissioner Account ID:CRL-11711512-009
A 0 mass.gov/dor
RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO
111'III"I"1I111IIIttlll'Ilill'II"II"II"'ItItI'IIIII"'IIIINI
o�
NOOR INC
o�
HYANNIS CONVENIENCE
631 MAIN ST STE 3
HYANNIS MA 02601-5400
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
-------------------------------------------------------------__-----------_------------------•----------------------------------------------------
Nciftl, l MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T
Retailer License for Sale of Cigars and Smoking Tobacco
NI ov This license must be posted and visible at all times.'Che sale of tobacco
products to anyone render 18 years of age is prohibited.
NOOK INC Account ID: CRL-11711512-009
HYANNIS CONVENIENCE License Number: 2059495424
631 MAN ST
HYANNIS MA 02601-5400
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
I
rs Commonwealth of Massachusetts O M
Lettcr ID:L0552658496 O�
m Department of Revenue Notice Date:September 10,2020
f Geoffrey E.Snyder,Commissioner Account ID:CGL:1 1711512-006
ui oF� mass.gov/dor
RETAILER LICENSE- FOR SALE OF CIGARETTES
I'I'll'I'III II11"'IIIIIIIIIIIIIII'llll'IIIIIIII"'I'IIIIIIII'II
a NOOR INC
o�
HYANNIS CONVENIENCE
W= 631 MAIN ST STE 3
HYANNIS MA 02601-5400
Attached below is your Retailer License for Salc of Cigarettes(Form CT-3). Cut along the dotted tine
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 MERE
------------------------------------------•--------------------- ---------------.,.----------------------------------------------------
`NcN°5��� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3
MRetailer I.,icense for Sale of Cigarettes
�';vr0* This license must be posted and visible at all times. The sale of tobacco
products to anyone under 18 years of age is prohibited.
NOOR INC Account ID: CGL-11711512-006
HYANNIS CONVENIENCE License Number: 1930856448
631 MAIN ST
HYANNIS MA 02601-5400
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
nue
^SyPcrut•i•f C4kStQ1„F:
s p( ,A7 01
115
II ProG,� ; at retail or for resale,pursuant to the General
the registrant at the location specified herein.
The vendor herein nab and 6144eTks registraio tangible
et _�tevenue so that a correct ST-1 can be issued.
Laws,Chapters 62C,
Any change of name or address must be reported to th : :'i �'t, �' l t IDENTIFICATION
NUMBER
h
0
i o
ISSUE DATE
z
..............._-- _-_�--
and is noi',assil7;na COMMISSIONER OF REVENUE
la ed fol ,l.� ,: . ble or transterab e.
n; ._.
Boca -- 5 1 — T .-'4-
S�.(;FIUC t
C ppp
Revenue
r „ Boston tPA
'ram•l s� [,q A
A A ® A
�,,, a; the i0';a;;c�n specified herein. Any change of name or
The vendor herein named is registered to sell meals al��faE ��P''Ia�� alrauant to the General Laws,
Chapters 62C
and 64H. This registration is effective only for the' regl
address must be reported to the Department of Revenrle G,.Ilaf a Corr'"'' can be issued.
IDENTIFICATION
NUMBER
eti 4 ° v E DATE.
ti _ L "
a
n
air np riisniaved for;'cusft it,s a- }aQ.d is not assignable OMMISSIONEFt OF REVENUE
` Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
�nivsree� Paul J.Canniff,D.M.D.
F.P.
200 Main Street, Hyannis, MA 02601 Thomas Lee Alternate
a
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: 715 Issue Date: 12/10/2019
DBA: HYANNIS CONVENIENCE STORE
OWNER: NOOR, INC.
Location of Establishment: 631 MAIN STREET HYANNIS, MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
Indoor5eating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2 O 2 O
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD: �y—
MOBILE-ICE CREAM: C'y�•m( /�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
TOBACCO SALES: ...
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
�s Town of Barnstable
BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Guadagnoli,M.D.
BJR, Paul J.Canniff,D.M.D.
'AS&~ F.P. Thomas Lee Alternate
200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Sell Tobacco
In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General
Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is
hereby granted to:
Permit No: 715 Issue Date: 1/1/2020
DBA: HYANNIS CONVENIENCE STORE
OWNER: NOOR, INC.
Location of Establishment: 631 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
d
oft Teti Town of Barnstable� For Office Use Only: Initials: _a �
Date Paid
BARNSrABL6. : Inspectional Services
MASS.
Public Health Division Check#
AIFo�y a
Thomas McKean, Director My- �
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304 t
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE J — o— NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: "dn?,T kAe OF3A 1A1 C
ADDRESS OF FOOD ESTABLISHMENT: 931_ N)Wn WID04�M"Ib—C MIA dr�7 7_� �
T 6 �
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): fff
E-MAIL ADDRESS:
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: _I— OUTSIDE: A 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
->QETAIL 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
OWNER INFORMATION:FULL NAME OF APPLICANT `_ l\ tk�Qt
SOLE OWNER: 'ES/NO OWNER PHONE #
ADDRESS_
CORPORATE OWNER: yL�jc.•r.w�n r . `2 /� S1A �'�
CORPORATE ADDRESS: k311— I -414 S�.C� /1 , TsZ d 2�-`r
PERSON IN CHARGE OF DAILY OPERATIONS: ;
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
SIGNATU F APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/apl)lications.asp.
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. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FormsTOODAPP REV3-2019.doc
For Office Us
dF'044E Initials:
Town of Barnstable
Date Paid l Amt Pd$
gp MASS.
0 9.9.
� Inspectional Services ��/
t63q. �m� Public Health Division
Thomas.erED�p
Thomas McKean, Director (.?,)2
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored)
DATE ] 3p—f NEW BUSINESS OWNERSHIP RENEWAL
NAME OF TOBACCO ESTABLISHMENT:
ADDRESS OF TOBACCO ESTABLISHMENT: G 3f— Main Sly n c!f �l rj/�., ,r,:S C �Lj l
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): --
E-MAIL ADDRESS: Rf)sN ��c- r1 } �,."9 • c'c,,,n
TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (5oB) -
OWNER'S NAME: J -jy m-►,-,pd Ref4tj OWNER'S PH#jam
OWNER'S ADDRESS: G — �/1-c.,n� 60ke Erna YD,S�C�I�Ci �1 a�L/L1
CORPORATE ADDRESS: 63/-afi,5 m�f 1,i�....�c Q6ol 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/Titlel/Chapter2.70/Section6
***NEW BUSINESSES AND NEW OWNERS ONLY***
REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED.
PLEASE CALL 508-375-6621
ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS:
1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document
2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4
SIGNATURE:
PRINTED NAME: 2rA "
DATE:
Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc
C^,
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— 8 371-9. 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:
Signatur Printed Name Date
SAiature Printed Name Date
_
Signature' 1 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
4 A
MASS"ACHUSETTS DEPARTMENT OF VEVENUE Form CT-3T
Retailer License for Sale ol'Cilyars and Smoking Tobacco
-nes
sible at- all th The sale of tobacco
This li"ese must be posted and vi
nder 18 years of age is prohibited.
products to anyone u
Account ID: CRL-t 1711512-009
INC Lic-ense Number: 178739200
1iN-.-kNNN1S COVENItNICE
6'3) 1 MAIN ST
HYANNNIS MA 02601-5-400
I'viassachusetts Gencrat Laws.to
Linder Chapter 64C of the
Tb-;;-z ce-ruftes L1.1at &je taxpaycr named abov s hecl-Ised
Tll";; I' non-transferable and may be suspended or revoked for
;;ej' at retall at ihe addiness shown above. icensc is
ec ions.
-Div th state laws and r gulati
10 cem�
Effective Date:Or-tober 1- 2018 Expiration Date: September 30, 2020
PT
Soo- 611A
THE FOLLOWING
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-- --------------------------- .,.... . - - -
y?,cHua y MASSACHUSETTS DEPARTMENT OF REVENUE
T F:etailer License for Sale of Cigarettes
_1A ,y
his license must be posted and visible at all time`ST he sale rohibi ed tobacco
of rOf T products to anyone under 18 years of age p
Account ID: CGL-11711512-006
NOOR INC License Number: 1055168512
HYANNIS COVENIENCE
631 MAIN ST
HYANNIS MA 02601-5400
that the taxpayer named above is licensed under Chaprah 64a a mtay be suspended o Massachusetts rJrev revoked foreneral
to
This certifies above. This license is non-trans
sell at retail at the addre
ss shown
failure to comply with state laws and regulations.
Effective Date: October 1,
2018 Expiration Date: September 30,2020
Y art►+ , Town of Barnstable BOARD OF HEALTH
Paul J Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
R,ANSTAaLL John T. Norman
{, +s 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 715 Issue Date: 12/20/18
DBA: HYANNIS CONVENIENCE STORE
OWNER: NOOR, INC.
Location of Establishment: 631 MAIN STREET HYANNIS MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
0 OutdoorSeat in : 0 Total Seating: 0
IndoorSeating: g g
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: �n
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
TOBACCO SALES: $85.00
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
rti
pFE For Office Use OnInitials:
"p Town of Barnstable
Date Paid Amt Pd$ 1(40
BARNSTABLE, Inspectional Services
''°rFo►163g6 & Public Health Division Check#
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE fa /o NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:W o o t \.N,-- ® 4` v l�J1
ADDRESS OF FOOD ESTABLISHMENT: s n Lv 1
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): I1
E-MAIL ADDRESS: 11)N C_12N
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (6QBj2g-
TOTAL NUMBER OF BATHROOMS:"-.
WELL WATER: YES V NO (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL:_v'^ SEASONAL: DATES OF OPERATION:Z/-4—/M TO
NUMBER OF SEATS: INSIDE: OUTSIDE: /2C 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)
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:Wpplication FormsTOODAPPREV2018.doc
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNER: 'E /NO - OWNER PHONE#
ADDRESS- '-' ' ��o, OdIG
CORPORATE OWNER. FEDERAL ID NO. :
CORPORATE ADDRESS: /3 I-- MG r-h S�rG�'� 1 Mil f' dY)�l�l �� �C)f
1.11
PERSON IN CHARGE OF DAILY OPERATIONS: IA Y\Cl�"1(na (
List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
SIGNA F APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asi).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1st to Dec. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st.
Q:\Application FonnsTOODAPPREV2018.doc
H
�114E ti Town of Barnstable
• Regulatory Services Department
* B"NSMLFn
s639. ♦0 Public Health Division
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 APPLICANT FIRST NAME MIDDLE INITIAL
VC, "C' "lam
D/B/A
6 31- cna1-,C I
STREET ADDRESS
TELEPHONE# FID#
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).
Pr '�Q --/ '
Signature Date
Q:\Application Forms\TOBACCO APP2019 dob.docx
E ablishment
TOBACCO SALES
Employee Signature Form
This form is for official use to indicate that the employee(s) of this establishment received and understood
Chapter 371 of the Town of Barnstable Code and the enclosed copy of Chapter 270 Section 6 of the
Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any
person under the age of twenty-one (21). Below are sections VII b. and VII c. of the Barnstable Board of
Health Regulation:
SALE AND DISTRIBUTION OF TOBACCO PRODUCTS
b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6,
no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor.
Each employee working in an establishment licensed to sell tobacco product shall be required to
receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and
sign a form indicating that such regulations/laws have been received and understood, a copy of
which must be placed on file, in the office of the employer and retained. Such signed forms must
be made available for inspection, during the license holder's normal business hours upon request
of an agent of the Board of Health.
c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a
customer appears to possibly be under 27 years of age, the customer present a valid State issued
picture identification card or driver's license with appropriate photograph to confirm that the
customer is of legal age to purchase the tobacco product.
The following employee(s)'received and understood Sections VIIb. and VIIc. Of the Barnstable Board of
Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws:
1 A"NOMM"I
Signature Printed Name Date
Signature Printe-a 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
�F THE ror, TOWN OF BARNSTABLE HEALTH INSPECTOR-s Establishment Name: Date: Page: of
4 OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET s:so-a:so P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
63• �0� HYANNIS,MA 02601 so ON.-FRRI. No Reference R-Red Item PLEASE PRINT CLEARLY
rFD MP�p FOOD ESTABLISHMENT INSPECTION REPORT - NI-A - - ' -
Name , i7 Dated Type of T f Inspect
ion
!%C/ ✓` eration s Ro ie3 i �
Address Risk Fo Service e-nspeEtion
Level etail `-Previous Inspection
Telephone esidential Kitchen Date: e
Mobile Pre-operation
Owner HACCP YIN Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP ' ;In: Other
Inspector ^ j` . Out:
Each violation checked requires an expldVation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations(/
Critical(C)violations marked must be corrected immediately. (blue&red items) ❑
Non-critical(N)violations must be corrected immediately or Corrective Action Required: ❑ No Yes
within 90 days as determined b the Board of Health. Overall Rating �/
y VDL. I ❑ Voluntary Compliance C] Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003)
This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than non-critical violations 9
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 observed,7 to 8von-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.Dump er 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 I Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N pt
Dumpster Screen? Y N
s
Violations related to Foodborne Illness Violation 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*
* * 3-501.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives ,
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 3-302.1l(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* 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 WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
1590.003(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 y 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 4-501.111 Manual Wazewashing-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 Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.1 l(A)(2) Comminuted Fish,Meats&Game Pathogens* Elf°"°e uuzoor
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155`F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* Proper,Adequate Handwashing Ratites-165°F 15 sec* ing'mobile food,temporaryand residential
_ �0
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* 16g'F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* - 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other es should
violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 1 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C 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
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
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 29. Special Requirements 1.009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR-590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
oF�HEr TOWN OF BARNSTABLE HEALTH INSPECTOR-s Establishment Name: Date: Page: of
P� "►� OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. ' 200 MAIN STREET - 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS. 0g HYANNIS,M MON.-FRi. No Reference R-Red Item PLEASE PRINT CLEARLY
�a i639• A 02601 508-862-4644
rED MP�a FOOD ESTABLISHMENT INSPECTION REPORT - -
Name Date V �Gf e o T of Ins ec ion
0..�j I'll' r/ era ions ,Routine
Address f '� Risk 'Food ice eEtion 00,
Level wall Previous Inspection
Telephone ial Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) ! T Bed&Breakfast HACCP
�L lIKjOther
Inspector ut: - r
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) PiA
❑
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 477/
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 y
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories L
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 q J�j�
„�--
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items
checked indicate violations of 105 CMR 590.000/Federal Food Code. ® Embargo 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
B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 4 to 6nnn-critical violations=B.
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed, 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
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.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8 non-critical violations=C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature /�I Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N `\`1/ Y
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) Demonstration of Knowledge* - 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.*. 19 PHF Hot and Cold Holding
2-103.11 Person-in-Chazge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 590.004(F)
590.003(C) Responsibility of the Person-in-Charge to 7-102.11 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 * 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*
590.003(G) Reporting by Person in Charge*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Requirements
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 Rated or 7-204.12 Chemicals for Washing of Food* Produce,Criteria* HSP HIGHLY SUSCEPTIBLE POPULATIONS
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3 801.11(B) I Jse of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking 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* Not Otherwise Processed to Eliminate
Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* * g8
Equipment
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 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) I Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources 10 Proper,Adequate Handwashing g' P �S'
Game and Wild Mushrooms Approved By * 3-401.1 l(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 Requirements.practices should be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B), Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 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 foodbome
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* 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* r26.
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 6-30112 Hand Drying Provision Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 1 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
pF IME roy, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: �1 �1 ( Page: of
ti OFFICE HOURS ,
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. ' 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
s MASS 0g HYANNIS,MA 02601 MON.-FRL No Reference R-Red Item. PLEASE PRINT CLEARLY.
Yb �679• 508-8624644
FOOD ESTABLISHMENT INSPECTION REPORT
Name Dat T e o T f In ec io
Operation(s) Iti rA-
Address Risk j Food Service e-inspection c/V
Level etas I Previous Inspection
Telephone �f. ntial Kitchen Date: J
Mobile Pre-operation t`
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint 1
Person in Charge(PIC). Time Bed&Breakfast HACCP l lam. (�
In: Other
1
Inspector F 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) ® ro
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities C
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS /
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or ColorAdditives 1_1I
❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 4n
❑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 VVV•
Critical(C)violations marked must be corrected immediately. (blue&red items) lal co)1� ❑
Corrective Action Required: ❑ No Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel . (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005 B=One critical violation and less than 4non-critical violations g
) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 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 observed,7 to 8 non-critical violations. If 1 critical refrigeration.
qd29.Special Requirements (590.009) receipt within 10 days of recei t of this order. violation,4 to 8 non-critical violations=C.
30.Other PATE OF RE-INSPECTION:
Inspector's Signature Print:
31.Dumpster scree edfrom public view
Permit Posted? Y Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N 1 �Wad I
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)
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 7-201.11 Separation Storage** 3-501.16(A) Roasts Held At or Above 130°F*
-
Applicants* 3-302.11(A) Food Protection* P g 7-202.11 Restriction-Presence and Use*
20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 590.00411 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 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 Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) I Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. L16 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* EJfeorive ru/zoat
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan - Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009 A D. in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( )-( )
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources 10 Proper,Adequate Handwashing g' P �'
Game and Held Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165*17 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 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
* 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
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision
29. Special Requirements .009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical.item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
� f
�p,MFr TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name:�kailnZY COOMI"04 -Ckrf, Date: b1151 16I Page: l,- of _
'OFFICE HOURS
P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSI'ABLE. ' 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS,MA 02601 8-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
508-N.-4644
FRI'
rFD MP�p FOOD ESTABLISHMENT INSPECTION REPORT
Name Date y, a of T ge of Ins ection
}� C{PMr)�,S c��r0ntenu �orL b/ 1W ODeration(s) �M(CfElurCa n
Address t 6t Risk Food Service ction t3 D r -
Level eta) Previous Inspection / �'�" .
Telephone )dential Kitchen Date: ! I w �Fa*s
Mobile Pre-operation V/ w+r��-
Owner HACCP Y/N Temporary Suspect Illness �'� t�
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP TAQ
In: Other r66 CW n
Inspector lj 40 Rw ca Out: J r OV
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 - rrn
) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY LV I In
-�
❑ 11.Good Hygienic Practices ❑22.Postingof 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 90da s as determined b the Board of Health.
Voluntary arY Compliance Employee Restriction/Exclusion Re-inspection Scheduled Em
ergency enc 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 Emergency Closure . ❑ Voluntary Disposal Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by 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 suspensi on 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 g p,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 C=2 critical violations and less than i non-critical. . f critical ' water,sewage back-up,
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 anon-critical violations. If 1 critical refrigeration.
violation,4 to 8non-6ritical violations C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
=
t i P's Signature Print:
30.Other PATE OF RE-INSPECTION: Inspector Ayan
����31.Dump§ter 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 Sign ure ` Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N �
Dumpster Screen? Y N "��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* 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* 3-501.15 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)
7-102.11 Common Name-Working Containers
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130'F*
7-20L p g 11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control
Employee 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use*
590.003(F) Responsibilityof A Food Em to ee or An 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use*
3-304.11 Food Contact with Equipment and Utensils 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* - 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 590.003 D Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals*
( ) REQUIREMENTS FOR-.
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* -
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use.of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
* Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of
3-202.16 Ice Made From Potable Drinking Water 3-401.11A(1)(2) Eggs-155'F 15 sec 5-101.11 Drinking Water from an Approved System* 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* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effec"°e 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*
3-201.14 Fish and Recreationally Caught Molluscan
4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155`F 15 sec*
Contact Surr ffaces 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-
Sources* 10 Proper,Adequate Handwashing Ratites-165°F 15 sec* ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30)
3-202.15 Package Integrity g g 3 403.11(C) Commercially Processed RTE Food-140`F Critical and non-critical violations,which do not relate to the'foodbore
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* 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45'F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 004
3 402.11 Parasite Destruction Temperature Ingredients to 41'F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J-) Labeling of Ingredients' - I 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 1.008
HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1.009
3-502.11 Specialized Processing Methods*
_ 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures*
S:590Forrnback6-2doc
*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.
C.pp INC rpm TOWN OF BARNSTABLE HEALTH wsPECTOR,s Establishment Name: ✓I I - ve 1 a ate: .I Page:�__of
q. DI OFFICE HOURS '
i AR„srAa,Ep� PUB200 MAN SLIC TREET
EET VISION , 3: - :30A.M.
:300-4:30 P.M.
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
A 639, �0� - HYANNIS,MA 02601 - MON.-FRI. No Reference R-Red Item ,. PLEASE PRINT CLEARLY.
508-862-4644
.FOOD ESTABLISHMENT INSPECTION REPORT N� rl ��.
ap
Name I ����' o c ��� Date( T e o �e Inspection
Ooeration(s)
Address Risk Food Service Re-inspection
Level (Ie.-9 Previous Inspection
Telephone Ttegdential Kitchen Date: JrA
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector LAI. /4n A �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 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
f
❑ 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 �✓1
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: 40, 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,th T,iteems ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than.3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4non-critical violations 9
)( ) cited in this report_may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and Cessation of food establishment operations. If
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 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 8 non-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violati 4 to . cri cal violation =C.
29.Special Requirements (590.009) y P ,
30.Other DATE OF RE-INSPECTION: Inspector Signatur
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 Ignature
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y. N
Dumpster Screen? Y N
Violations related to Foodborne Illness - - Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives
* 3-501.15 Cooling Methods for PHFs
-
Cooked and RTE Foods.* _19. PHF Hot and Cold Holding
2-103.11 Person-in-Chazge 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 EachIdentifying
* 590.004(F)
7-101.11 Identi in Information-Original mal Containers
2 590.003(C) Responsibility of the Person-in-Charge to Other* g g * 3-501.16(A) Hot PHFs Maintained.At or Above 140°F*
7-102.11 Common Name-Working Containers
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
Storage*
-
Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits
Restriction-Presence and Use*its 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
3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR,
3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a 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
5-101.11 Drinking Water from an Approved System*
4-60L11(A) Clean Utensils and Food Contact Eggs t 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 cti a 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* 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* 590.009(A Stu Ratites-165ffi °F 15 sec*Stuffing Containing Fish,Meat,Poultry or Violations of Section 590.009(A)-(D)in cater-
)-(D)
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
2-301.11 Clean Condition-Hands and Arms* the appropriate ro riate sections above if related to
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* 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
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
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* 1 ti 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*17 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 Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
�p THE Tom TOWN OF BARNSTABLE .HEALTH INSPECTOR'S Establishment Name: ll -CFn�e �h Ce _Date: Page: ( of
v` o OFFICE HOURS
0," PUBLIC HEALTH DIVISION 6:00-9:30A.M.
BARNSTABLE, • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
.A-. HYANNIS,MA 02601 M-8 -FRI.62-4644 No Reference R-Red Item PLEASE P NT CLEARLY
RFD MPS°` 506
FOOD ESTABLISHMENT INSPECTION -8
- ECTION REPORT
_ G c
Name ^ CA V 2 Date Tvoe of TyfeQ Inspection
11 OOgeration(s) 11L
Address N. Risk Food Service spection
Level `ltg Previous Inspection Q
Telephone ential Kitchen Date: G
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector Out:
Each violation c ecked 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 POPULAT ONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ,l -
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories, -
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations.
Critical(C)violations marked must be corrected immediately. (blue&red items) - _ Corrective Action Required: No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. '' I ❑ 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 ode. ❑ 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.
(FC 4)(590.005) cited in this report may result in suspension or revocation of the food
25.Equipment and Utensils B=One critical violation and less than 4 non-critical violations g
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 9 than
d l ti l i violations and an 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 C=2 criticalg p,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, o n ritical violations=C.
PATE OF RE-INSPECTION: Inspector's ignatu rl
31.Dum PS C1/, 1 AV17
31.Dumpster screened from public view U/
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed PIC's nature Print:
Frozen Dessert Machines: Outside Dining Y N a
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* 3-501.15 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 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
g Information.,Ori coal Containers*
2 590.003(C) Responsibility of the Person-in-Charge to - - Other* 7-102.11 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
Common Name-Working Containers*
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants* ` - - 3-302:11(A)�� Food Protection* P g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 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 F.OR
3-306.14(A)(B)Returned Food and Reted of Foam* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) re
Removal of Exclusions and Restrictions Disposition of Adulterated or 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and
( - ) P 4-501.111 Manual Wazewashing-Ho[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* 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* 3-401.11 A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5401.11 Drinking Water from an Approved System* Eggs 4-601-11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef c&ry 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*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
f
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g M 590.009(A)-(D) Violations of Section temporary
and - ide 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
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* Requirements.
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 foodbome
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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked.PHFs from 140°F[0 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
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 P30.
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 Special Requirements .009
3-502.11 Specialized Processing Methods* 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.
r NAMEMIe- . 1�` ,,•4 k-aAAj / BAR .
TOWN OF ADORSSbFOFFENDER !!�.w>1N8lnn! 6 ffAien(,a. - }are,q 6' lYlarn Y i V -
BARNSTABLE CITY,SATE,ZIP CODE
14
. Will, �" 1aQ l
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TIME AND DATE OF VIOLATION LOCATION OF VIOLATION ` ' • LU
NOTICE OF - y=g (A.M./ '�,Mj))ONi 20 d ( / lhcai*► � 7 1 nn
SI jJA AE-OBE C CING PERSON ENFO CING DEPT. ' BADGE 0. w
VIOLATION b�,'C, o
CD
OF TOWN I HEP.EBY ACKNOWLEDGE RECEIPT OF CITATION X a
ORDINANCE Unable to obtain sign ture of offender.
<— THE NONCRIMINAL FINE FOR THIS OFFENSE IS
Date mailed (7 b w
OR YOU HAVE THE FOLLOWIN ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a
DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w
REGULATION
(1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, J I� before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, a
Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE.
(2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST
BARNSTABLE DIVISION,COURT COMPOUND, MAIN STREET,BARNSTABLE, MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this
citation for a hearing.
(3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing
to be due,criminal complaint may be issued against you.
❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$
Signature
*own of Barnstable
Regulatory Services
Thomas F. Geiler,Director
* BARNSTABLE, +
9�A Public Health Division
rFD1A0�� Thomas McKean,Director
200 Main Street
Hyannis,MA 02601
-Office: 508-862-4644 Fax: 508-790-6304
July 18,2006
Amir Nzair Chaudhry -
Hyannis Convenience Store
631 Main Street
Hyannis,Massachusetts 02601
NOTICE OF SHOW CAUSE HEARING
On December 21,2005, on March 28 2006,-and on June 27,-2006, cigarettes were sold to a minor(a
person who was under the age of 18 years)by a person.employed.at your store.
According to Section 371-7(B)of the Town of Barnstable Code,no person,firm,corporation,
establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town
of Barnstable Code, "any proprietor(s)or other person(s) ... who fail(s) to comply with these regulations
shall be subject to the following actions for each offense: A warning shall be issued for the first offense.
A fine of$100 may be issued for the second.offense, $200 for the third offense, $300 for the fourth
offense, and$300 for any subsequent offense
You are hereby notified to appear before the Board of Health on Tuesday,August 1,2006 at 3:00 pm to
show-cause why your tobacco sales permit should not--be suspended and to discuss any future plans you
may have to comply with this regulation. The hearing-will be held in the Town Hall, Selectmen's
Conference Room, 367 Main Street Hyannis,Massachusetts: -
PER ORDER OF THE BO OF HEALTH
as A. McKean,RS, CHO
Director of Public Health
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JUN-28-2006 14:36 BARNS COUNTY HEALTH 15oe37568eo P.04i13
Section 1:
Esmbiishmeat...._... ._. . — _ _ _ - — Survey Participants
Hyannis Convenience Store
Name: 631 Main Street 3�yj�v C�►
Hyannis,MA 026GI ID of?urcba.ser 60 1
Addles:_ - Ate: ❑ 15 ❑ 16 Rd.T
Sea.:!Awake ❑Female
Name of t Super4sor-
City: Zip Code: C-
Time of Checit: 73100 am❑ pmV,
Type of EMblishmeat: ❑ Chain 4v&peodam ❑ Not Known Date of Check: 0
Day of the Week: Q Mo ;rWed
Q Thuts ❑Fri ❑ Sat
Style of Establishment(Check Only One): .
Coaveaience Store 0 Grocery Stare ❑sar
J
❑ Depam=Store ❑ummr Store ❑Phvare Club(VFW. Legion.etc.)
❑ C735 Stanon Only ❑Phm=cv/Drug Stone 1 ❑Restaurant
t] eras Mitii-Mart ❑Other(bowline allev, golf dub etc.) f3 Tobacconist
Section 2:
Was Compliance Check completed?Yesi- do ❑
If Yes please continue on to the nesr questmon, if No please skip this section and go ro section 3.
w was tobacco marketed?
-the-=Mter youth asks the clerk for the product.
❑ From avending machine with a lockout device.
❑ Other
Describe:
Was the Pnrshsser asked for ID? Yes in Npol Was this an ID-based check'! Yes ❑ No�
Was the Purchaser asked his/her age? Yes ❑ No�• /
Sex of Cleric Male--Female Q Approximate age of clerk:;KTeta ❑Young Adult Q Adult ❑Older Adult
Type of tobacco asked for. �. 'Cigarettes Brand of cigarettes asked for ❑ Marlbom ❑Newport 0 Other.
❑ Chew/Di i ❑ Other Brand:
Was the sale made? Yes;;-No rl
If"Yes"how much did the product cost: $ 0
ParChaser made payment using: ❑$1 bills ❑ $5 bill(s) 12 S5 bill and Sl bills/or chaug U bill(s) ❑ $20 bill ❑ cbange
Section 3:
If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why.
❑ Out of Business I 0 Tema_long term closure ❑ In operation.closed at time of visa ❑ Drive thin only
❑ Does not sell tobacco Q Unlor able ❑ Unsafe to access 1 ❑ Tobacco out of stock
❑ Ina le by vouth I ❑ Wholesale ouiv/charms ❑ Presence of Police I ❑ Permit Susaended
❑ Pavate 1?ersoDal ❑ Machine broken 0 Youth inspector knows salesperson I ❑ Other
rsid®ce ❑ "Don't sell"but tobacco sees in
512Q/05
C_1DOCUME-i 1SSTLIOCALS•11Temc)Fy 06 MTCp comallance check form.doc
! NAMED{ j.� '`1 A - ��d y�r BAR 70067
T CPW N OF ADO ESS OF OFFENDER Y
BARNSTABLE CITY„Sd�1fE.ZIP CODE /� 0 ! /�
but�5� mA QZ(nd l
P`Of IHf rqN� MV/MB REGISTRATION NUMBER
OFFENS
RARN\TARI.E. �-1Q�y�/�y^�� {///��j )/� f�{//+� ]y/�Jy (/",�,�[p/{� U.J
y_p MASS. `0g. �'�°�+ "t�,V ��.�..w. �••1�,/ , {iRv, (,�/7 V rr/ ' �-0Fi� O
NOTICE O F TIME AND DATE OF VIOL(AN P.M.)ON r 21 LOC TION OF VIOLATION i z
r 2 a 8 0 j ^�, c nnJs Mfl Q
SIGNATOBE.OF ENFORCING P SON ENF CINGAEP. -7 BADGE NO. N
VIOLATION o
OF TOWN I HEREBY ACKNOWLEDGE RECEIPT OF CITATION X a
ORDINANCE b Unable to obtain signature o offender.Date mailed l0& THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ /O,0,00
LU
OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a
DISPOSITION WITH NO RESULTING CRIMINAL RECORD. LL.1
REGULATION (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w
before:The Barnstable Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, d
Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE.
(2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST
BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this
citation for a hearing.
(3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the
hearing to be due,criminal complaint may be issued against you.
❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$
Signature
r Town of Barnstable
TIME tp�
o Regulatory Services
Thomas F. Geiler, Director
• saxxsrasLE, •
9� "�: � Public Health .Division
ArFD 1A°� Thomas McKean,Director
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 7,2006
Amir Nzair Chaudhry
Hyannis Convenience Store
631 Main Street
Hyannis, Massachusetts 02601
NOTICE OF SHOW CAUSE HEARING
On December 21, 2005, and on March 28, 2006, cigarettes were sold to a minor(a person who was under
the age of 18 years)by a person employed at your store.
According to Section 371-7(B)of the Town of Barnstable Code,no person, firm, corporation,
establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town
of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s)to comply with these regulations
shall be subject to the following actions for each offense: A warning shall be issued for the first offense.
A fine of$100 may be issued for the second offense, $200 for the third offense, $300 for the fourth
offense,and $300 for any subsequent offense.
You are hereby notified to appear before the Board of Health on Tuesday,April 18,2006 at 3:00 pm to
show-cause why your tobacco sales permit should not be suspended and to discuss any future plans you
may have to comply with this regulation. The hearing will be held in the Town Hall,Hearing Room, 367
Main Street, Hyannis,Massachusetts.
PER ORDER OF THE ARD OF HEALTH
Thomas A. McKean S, CHO
Director of Public Health
gAtobacco\wp files\tobacco hearing letter.doc
I�
51AR-28-2006 15:17 BARNS TOBACCO CONTROL 15083622602 P.03i10
• Section 1: 0
Establishment -Survey Participants Vt0o
Name: Hyannis Convenience Store
631 Main Street _ ID ofPnshasw..
Addrew. Hyannis,MA. 02601 . . . Age: ❑ 15 046 O 17
S=Jfmale ❑Female
Name of Adult Supervisor.
Time of Check .� am -$m❑
Type of Establishment: ❑ Chain (3 Not Known Date of Che c 31/4r/O�
Day of the week Q Mcg0fli'ies❑Wed
❑Thurs Q Fri ❑ Sat ❑Sun
Style of Establishmeut(Check Only One):
. OCkycery Store ❑Bar
❑ pgartment Store ❑Ligm Store Q Privm Club(VFW, 'om etc
❑ Gas Station Only ❑Pharmacy/Drug Store ❑Remurant
• Gas Mini-Mart la Other tin alley,golf club etc.) ❑Tobacconist
Section 2:
Was Compliance Cheek;completed?Yes�NO ❑
If Yes please candnue on to the net#question. if No please slap this section and go to section 3.
was tobacco marketed?
-the-counter.youth asis the deck for the product
❑ From a vending machine with a lockout device.
❑ Other
Describe:
Was the Purchaser asked for ID? Yes❑ No� Was thia an M-b eck? Yes❑ N%—
Was the Purchaser asked hislher ?- Yes❑ N p
Se:of Clerk: Male❑ Female Approxinme age of clerk ❑Teen ❑Young Adult PAdvlt ❑Older Adult.
I'nw of tobacco asked for. kCigarettz Brand of ciprettes asked for.0- iaiiboro Q Newport ❑Other- _
❑ Chew)Dip ❑ Cigars ❑ Other Brand:
Was the sale made? Yes6�-No ❑
If"Yes"how much did the product cost: S
Purchaser made payment using;❑$1 bills 5 bill(s) ❑ $5 bill and$1 bills/or change❑ S10 bill(s) ❑ S20 bill ❑ change
Section 3:
If the youth did not enter the premises or did not sttenrtpt to purchase tobacco produce please indicate wkY-
❑ Out of Business ❑ Tem.long term closure ❑ in operanonclowd at time of yisit ❑ Drive thru onl
❑ Does not sell tobacco Q Unlocatable Q Unsafe to ac= D Tobacco out of stock
❑ Inac 4e by yowh ❑ Wholesale only/canons ❑ Presence of polige ❑ Permit Suspended
❑ Private clnb/pumual Q Machine broken ❑ Youth inspector knaves salesperson 0 Other
residence ❑ "Don't sell"but tobacco seen in
5/26/05
=C3CUME-11SSTUL0CAl-'%-1\TemWFY os mTCp eom Dune check furl.doe
*Town of Barnstab
Regulatory Services
Thomas F. Geiler,Director
snxivsTns�, •
Mom. Public Health Division
i6gq. 10
ArF°N/°r A Thomas McKean,Director
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 7,2006
Amir Nzair Chaudhry
Hyannis Convenience Store
631 Main Street
Hyannis,Massachusetts 02601
NOTICE OF SHOW CAUSE HEARING
On December 21,2005, and on March 28,2006, cigarettes were sold to a minor(a person who was under
the age of 18 years)by a person employed at your store.
According to Section 371-7(B)of the Town of Barnstable Code, no person, firm,corporation,
establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town
of Barnstable Code,"any proprietor(s)or other person(s) ... who fail(s)to comply with these regulations
shall be subject to the following actions for each offense: A warning shall be issued for the first offense.
A fine of$100 may be issued for the second offense, $200 for the third offense, $300 for the fourth
offense,and$300 for any subsequent offense.
You are hereby notified to appear before the Board of Health on Tuesday,April 18,2006 at 3:00 pm to
show-cause why your tobacco sales permit should not be suspended and to discuss any future plans you
may have to comply with this regulation. The hearing will be held in the Town Hall, Hearing Room, 367
Main Street, Hyannis,Massachusetts.
PER ORDER OF THE ARD OF HEALTH
Thomas A. McKean S,CHO
Director of Public Health
gAtobaccolwp files\tobacco hearing letter.doc
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Section 1:
Establishment -Survey Participants (o�
Name: Hyannis Convenience Store
631 Main Street ID of Pmrlraw-
Address: Hyannis,MA— 02.601 . . Age: ❑ 15 046 ❑ 17 (t3
Seac�h�Sele ❑Female
Name of Adult Supervisor.
City- 4AF
Time of check ❑
Type of Establishment ❑ Chain ❑ Not Known Dart of Check: /O�o
Day of the Week-
. ❑ Mon4ji= ❑wed
❑Tb= ❑Fri ❑ Sat ❑ Sun
Style of Fstablishmeut(Check Only One):
Store. 13 gMM Store ❑Bar
❑ Department Store 0 Liq=Store ❑PrMite Club(VFW,Legion.etc
❑ Gas Station Only ❑PhazmacyAD2f Store ❑Restaurant
❑ Gag Mlai-Mart ❑Other kin alley, golf club etc.) ❑Tobaccaaist
Section 2:
Was Compliance Check;completed?Yes�No ❑
if Yes please condmie on fa the nett question, if No please skrp this section mrd go W section 3-
Hqrw
was tobacco marketed?
theootmzer youth asks the cleric for the product•
❑ From a vending machine with a lockout device.
❑ Other
Descnbe:
Was the Parchaser asked for M? Yes❑ N� Was this an ID-b eck" Yes❑ N --
Was the Purchaser asked his/her age?, Yes❑ N� f�,J` �� ,jY
P
Sex of Cleric Male❑ Female Approximaz age of cleric ❑Teen ❑Young Adult PlAdult ❑Older Adult.
Type of tobacco asked for. kagareaes Brand of ciprettes asked for.57arlboro ❑Newport ❑Other_
❑ Chew/Dip ❑ Cigars ❑ Other Brand: - -
Was the sale made? Yes�Mo 0 ` D
If"Yef how much did the product cost: S-
Purchaser made paymeat using:❑$l bills�-f5 bill(s) ❑ $5 bill aad S1 bills/or change ❑ S 10 bill(s) ❑ S20 bill ❑ change
Section 3:
N the youth did act ewer the premises or did not attempt to purchase tobacco products please indicate witty:
❑ Out of Business ❑ T .long=m.clMM ❑ In ration.closed at time of visit ❑ Drive thra only
j ❑ Does not sell tobacco ❑ Unlocatabke ❑ Unsafe to accm ❑ Tobacco out of stock
❑ Inaccessible tah ❑ wholesale onl /=tons ❑ Presence of "ce ❑ ��S
❑ Private club/petsonal ❑ Macbme broken ❑ Youth inspector kanws salespehson ❑ Other
reddc= ❑ "Don't self'but tobacco seen in
5I26/05
MCCUME-1 ZSTMOCALS' 17empfY oe MTCP COmpllanw check formAm
0 TOWN OF BARNSTABLE BAR-W 4,875
Ordinance or Regulatio
WARNING NOTICE
Name of Offender/Manager j M r r h)e- Z r r ( � a vA H r o
Address of Offender 15-k Wk, �p ,.'� iNG(,.r MV/MB Reg.#
Village/State/Zip t-nn ' J. 0� 4 U )
r /`
Business Name 0JA a.,1- l f UA vrr^,f1"( am/pm on 4/3 2016 5—
Business Address � � 5�r-�[ � . �rn,nra,1
/ Signature .of Enforcing Officer
Village/State/Zip j /'�r A
Location of Offensetr ('y"lHr`�/ �,�
Enforcing Dept/Division
-� f
Offense �4, �,� _r ,, e 3 l,r r]r � �' � 3f3 - 'S-_ AA rafctf
Facts ^wr y kAS-er-Pd v^ rf rt t2lotf'Ag (`n ScrfxP?rc/f r ,t ,I ,s ,
fs Jc ,"6V-V rr c1F TU �wur (1 r r� � ( �tyrrlc ft rQr r� �a s/ r��} "r z;/r,� r/t�4v� A, r`r
This will serve only as atwa'rning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of TownU�a
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in /
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
TOWN OF BARNSTABLE BAR-W h78
Wrdinance or Regulati*
WARNING NOTICE
Name of Offender/Manager LU k; MIAAAa�h
"-- -
#
Village/State/Zip
Business Name R �.�.. ,-�,,�;�►n n �rp �I'1 &/pm, on, 10e>y 21 20
Business Address (0r'�) MA;A �,,,,� '-
Signature of Enforcing Officer
Village/State/Zip A
Location of Offense L1L„ MA � 2�;� (a`"'"u��,lj+'� t4e'r'lfo1
Enforcing Dept/Division
Offense _.r•A t)^ r� I . �,.AA n C GV&C fe,01'r r -� �e
Facts �c . l"� ,r?_cra � 1�1 "rama%� xa
This will serve only as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
ry TOWN OF BARNSTABLE AR
`B _W e 3
:;- -�rdinance or Regulatial' t
I WARNING NOTICE � /05
Name of Offender/Manager J„.t U jo4o).'# LA etA -)M
Address of Offender #
Village/State/Zip
Business Name 1 eA4,Ncr PI , dam/pm, on ( ec t 20.E
Business Address CGS?! n- Signature of Enforcing Officer
Village/State/Zip I 'llN 11%n tl�dt Zla 9
Location of Offense f- f.t /! AA(\
Enforcing Dept/Division
Offense
Facts ly,) . r7r-
This will serve only as a warning. At this time no legal action has been taken.
It is the ' goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
m A
7'X'�C& L
DATA
r
ti
�FIHE 1p� # DATE:
c7�
�� yV'P�' O^ ✓
FEE:
* BARNSCABLE,
9qj i6 q ��� REC. BY i
AIFDMAIA Town of Barnstable o
CHED. DATE:
Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kau&nan,M.S.P.H.
Wayne A.Miller,M.D.
VARIANCE REQUEST FORM
/l/A Joe
LOCATION
PropertyAddress: (�
Assessor's Map and Parcel Number: ,,Size of Lot:
Wetlands Within 300 Ft. Yes Business Name: ' s�N_VU.o
No-41-- Subdivision Name:
APPLICANT'S NAME: Phone
Did the owner of the property authorize you to represent him or her? Yes k.-- No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: Pra-A I-C'ui c Name: -{—
Address:�Ip"T� �(,{/Vl Address:
Phone: l�" s7s�7 Phone: 57o y^
VARIANCE FROM REGULATION(List Reg.) �REASONeFQR VARI ANCE-(Mav attach_if_more$.pace needed)
NATURE OF WORK: House Addition 11
nuuac-nvnovaei�rr�nvEan-orranvu wpei�-5ysrcrn-�
Checklist(to be completed by office staff-person receiving variance request application)
Four(4)copies of the completed variance request form
_ Four(4)copies of engineered plan submitted(e.g.septic system plans)
_ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
_ Signed letter stating that the property owner authorized you to represent hire/her for this request
_ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense
(for Title V and/or local sewage regulation variances only)
_ Full menu submitted(for-grease trap variance requests only)
_ Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same
owner/leasee only],outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems
[only if no expansion to the building proposed])
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED Susan G.Rask,R.S.,Chairman
NOT APPROVED Sumner Kaufman,M.S.P.H.
REASON FOR DISAPPROVAL Wayne A.Miller,M.D.
Q:\HEALTH\Application Forms\VARIREQ.DOC
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Hyannis Convenience Store
Proposed menu
-Turkey & Cheeses- lettuce, tomatoes, pickles, onions
-Ham & Cheese- lettuce, tomatoes, pickles, onions
-Roast-beef- lettuce, tomatoes, pickles, onions
-Tuna Salad- lettuce, tomatoes, pickles, onions
-Chicken Salad- lettuce, tomatoes, pickles, onions
-Italian cold cut- lettuce, tomatoes, pickles, onions
-Chicken Breast- lettuce, tomatoes, pickles, onions
-Vegetarian Roll-up- 3 kind of cheese, lettuce, tomatoes, pickles, onions
Roasted red peppers
-Steamed hotdogs
Breakfast Sandwiches
Eggs, Ham, Bacon, or Sausage, on a Biscuit or Bagel.
Pre made just needs to be heated.
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Town of Barnstable
HMO
1639. , Board of Health
200 Main Street,Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,RS.
FAX: 508-790-6304 Sumner Kaufman,MSPH
Wayne Miller,M.D.
Mr. Brad Lowe June 27, 2003
649 Main Street
Hyannis, MA 02601
a
Dear Mr. Lowe,
You are granted a conditional variance from the Board of Health Regulation,
PART II SECTION 1.00, which requires minimum 1,000 gallon capacity grease
traps at all food establishments. This variance will allow you to operate a food
establishment, utilizing an under-the-sink grease interceptor at the Hyannis
Convenience Store located at 631 Main Street Hyannis with the following
conditions:
(1) The menu is restricted to sandwiches as listed on the undated listing
of foods submitted attached with your variance application form on June
17, 2003.
(2) Only sandwiches requiring little or no mayonnaise are authorized to be
prepared onsite. Tuna salad, chicken salad, and other products requiring
higher amounts of mayonnaise must be prepared offsite from an approved
source.
(3) All breakfast sandwiches shall be purchased as pre-made, only
requiring reheating as proposed.
(4) The under-the-sink grease interceptor shall be installed in accordance
with the State Plumbing Code.
(5) Foods shall be served to patrons in take-out form only. No seats
are authorized at this establishment
GRDVariance
(6) This variance decision letter shall be posted on the wall adjacent to
the food permit in an area which is easily accessible to be read by
a health inspector anytime routine inspections are conducted.
(7) This variance are not transferable to anyone other than the
applicant. In the event,that this business is sold or transferred, both the
owner of the building and the licensee have the duty to inform any and all
potential purchasers of the existence of these variances and the fact the
Board has explicitly made them non-transferable.
r
Sin rely your ,
J
ayn Miller, M.D., Chairman
r
GRDVariance