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HomeMy WebLinkAboutCORNER FOOD MART - RETAIL FOOD f CORNER FOOD MART 640 Main Street, HYA I 30'X -a�3 i Town of Barnstable BOARD OF HEALTH John T. Norman Board of Health Donald A.Gaudagnoli,M.D. BAOLNSTABIX, F.P.(Thomas)Lee,. 0� ,m 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 912 Issue Date: 01/01/2022 DBA: CORNER FOOD MART OWNER: OM SHANTI INC. Location of Establishment: 640 MAIN STREET HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: (J6 01 C&" For Office Use Initials: Town of Barnstable Date Patd AmLPd$ W — + BAENBTABM Inspectional Services rFo aia'� Public Health Division Check# CaL Thomas McKean, Director j 200 Main Street, Hyannis,XfA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 0 r 6_2,021 NEW OWNERSHIP RENEWAL V n NAME OF FOOD ESTABLISHMENT: I S "1 �a j� 8 F-) CS � 0 ADDRESS OF FOOD ESTABLISHMENT: (�� D r q l c�-e'lr1 C., 1�I' el n I C MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: I1cp k_C�0 Z_ 0y9 k0riD. (_0" TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5 -�y TOTAL NUMBER OF BATHROOMS: WELL WATER: YYES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V SEASONAL: DATES OF OPERATION: / / TO LilNUMBER U 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 s a OWNER INFORMATION: FULL NAME OF APPLICANT Ky 1 S nQ 6 I J'Yn er ) !�, )0y) SOLE OWNER: YES/NO )OWNER PHONE # S O Q �� —3 ADDRESS_ 3 3 5 e k(n--rl a 4 CMd wQ YKoy P 0-2--6 7 CORPORATE OWNER: V1 S► 1 ll�T i3 r�l�'L(s?151 CORPORATE ADDRESS: CIA n 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 Manners Expiration Date A1lerEen Awareness Expiration Date 1• / / 1. / / 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to 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 htti)://www.townoft)arnstable.us/lieilthdivision/anolications.asn. 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. 3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc I Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. NgrAeLF Paul J.Canniff,D.M.D. t.n , F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 912 Issue Date: 01/01/2021 DBA: CORNER FOOD MART OWNER: OM SHANTI INC. Location of Establishment: 640 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: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: GQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r �tHE tqw For Office Use Only: Initials: �q Town of Barnstable Date Paid +` Amt pd$!�V BAMMBLE, : Inspectional Services Public Health Division Check 2,t�Z.- sh �x Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 11-&J— 72-0 NEW OWNERSHIP RENEWAL V NAME OF FOOD ESTABLISHMENT: Om G, omT► I"t- 1)Im 6y)ty l u u� �-Tc ADDRESS OF FOOD ESTABLISHMENT: 61-4® m"n S I-etlytj et w1 n f S ''1 kI 02-&® 1 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Set m� E-MAIL ADDRESS: n e-P k-t�Z(- hay- cp r"1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: IyA WELL WATER: YES NO ✓...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: t/ SEASONAL: DATES OF OPERATION: /_/_ TO NUMBER OF SEATS: INSIDE: &)�__ OUTSIDE: AL -TOTAL: NA 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 REOUIREMENTS. 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 �jRETAIL 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 .y OWNER INFORMATION: II� Q FULL NAME OF APPLICANT ��(�n nG p I 1 'i'Yt01 )S) " SOLE OWNER: I'ES/NO OWNER PHONE# 5 O�-g l --1 G?-39 ADDRESS_�� S,\ SI � "rr� \/,Q Y /�LOI J 1�1 m 41 CORPORATE OWNER: Ky 1 SIB r1A 6 11 1YA I S 9 YLr CORPORATE ADDRESS: W1A,1n lj trf—,e' ffil CL)IJ11 S M 2- (no ' PERSON IN CHARGE OF DAILY OPERATIONS: KTA<;� ria r2: le w.A)S1 " List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div: prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at httn://www.townofbarnstable.us/henithdivision/aipplications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:Application FonnsTOODAPP REV3-2019.doc t Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BAR,°uiKS'1'AII4lE. F.P. Thomas Lee ', Daniel Luczkow,Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 912 Issue Date: 1/1/2021 DBA: CORNER FOOD MART OWNER: OM SHANTI INC. Location of Establishment: 640 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 f For Office Use Only: Initials: .-, i Town of Barnstable �9 Date Peid Ami.Psl >iJ►ahABr 4Inspectional Services Public Health Division Check€f 2i S I Thomas McKean, Director 9 200 Main Street, Hyannis,N A 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION(Non Flavored). DATE�J _..,-...,,rLO� NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: Oyn Sh c��) le 1 D-80 C01t n,eX 1;V d ffl.a'� ADDRESS OF TOBACCO ESTABLISHMENT: .( po Yn�� 5,�r`-o .. 02 © � -t MAILING ADDRESS(IF DIFFERENT FROM ABOVE): m� E-MAIL ADDRESS: �� kclo \jy r P 1 n. co 1-wi . 1 TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: OWNER'S NAME: Y j��nQ ) i M-Cl I S) nA OWNER'S PH#(-W AQ: OS OWNER'S ADDRESS: 33 5�eWeld mud lJa� Aypn"A M II- o-2. C7- CORPORATE NAME: -Q YY1 7) CORPORATE ADDRESS: (940 'YY1pU\h 57X��Q11.r►� l CORPORATE FID# `S2-0 7 ( U D ANNUAL:_V SEASONAL: DATES OF OPERATION:_/_/ TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS).. 1 TOWN OF BARNSTABLE CODER AA GENERAL LAW INTERNET LINKS: a i TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.comJ33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: http.s•//male�7iglatare gov/I aws/GeneralLaws/PartIV/Titlel/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 d ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1 I t 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document s 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 i � t SIGNATURE: . PRINTED NAME: Y1 S fVl W �feh'yA�S1 �1 �I DATE: 6:1Application FornnffOBACCO APP-NonFavor 12-18-19.docx I 3 C'b mom- ESTABLISHMENT'S NAME i TOBACCO SALES Employee Signature Form Y 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. i 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 E is 21 years of age. Z 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: K,�IS � l � ►ls� ► J.1 Signa a Printed Name Q Date o�,W 711A Val U �. -0 Signature Printed Name. Date Signature Printed Name Date Signature Printed Name Date i Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date t Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx 1'`Ht MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer Ljcense for Sale of Cigarettes r This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. OM SHANTI INC Account ID: CGL-10801659-003 640 MAIN STREET License Number: 1466910720 i HYANNIS MA 02601 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 ------------------ --------- -- — >cHt's;.. VIASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and vish)le at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. OM SHANTI INC Account ID: CRL-10801659-007 640 MAIN STREET License Number: 1989515264 HYANNIS MA 02601 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 TDC+DEPARTMENT OF THE TREASURY 111�WW INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0023 Date of this notice: 03--10-2017 Employer Identification Number: 82-0761401 Form: SS-4 OM SHANTI INC Number of this notice: CP 575 A CORNER FOOD MART 640 MAIN ST For assistance you may call us at: HYANNIS, MA 02601 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN) . We assigned you EIN 82-0761401. This EIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 1120 04/15/2018 Your Form 11C and/or 730 becomes due the month after your wagering starts. If you have questions about the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year), see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue) . Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. IMPORTANT INFORMATION FOR S CORPORATION ELECTION: If you intend to elect to file your return as a small business corporation, an election to file a Form 1120-S must be made within certain timeframes and the corporation must meet certain tests. All of this information is included in the instructions for Form 2553, Election by a Small Business Corporation. t Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARNStABI Paul J.Canniff,D.M.D. i6 , 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 912 Issue Date: 12/10/2019 DBA: CORNER FOOD MART OWNER: OM SHANTI INC. Location of Establishment: 640 MAIN STREET HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent ^F- TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office Use Only: Initials: cl J1� Town of Barnstable _ Date Paid Q Amt Pd$ _ . ,ABNSPABu, : Inspectional Services a I i!pt7 • s MASS' Public Health Divisions Thomas McKean,Director L11& 200 Main Street,Hyannis, MA 02601 . Office: 508-862-4644 Fax: 508-790-6304 7. APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE l t -2 S-I9 NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT:(Jw► S6,rM6.Tri.L DB9 Cft-tnty f;-nJ ADDRESS OF FOOD ESTABLISHMENT: 6(4® n)S M 1 ®2 6 01 " MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �q m E-MAIL ADDRESS: kd"®z- a Sao TELEPHONE NUMBER OF FOOD ESTABLIISHMENT: (5DS) - TOTAL NUMBER OF BATHROOMS: N A WELL WATER: YES NO Lf. (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: ✓ SEASONAL: DATES OF OPERATION:_/ / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: I1P SEATI NG: MUST OBTAIN A COMMON VICTUALLER'S LICENA FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REOUIREMENTS. 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 �GRETAIL 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 FortnsTOODAPP 2020.doc OWNER INFORMATION: n 1 FULL NAME OF APPLICANT K'Y s��1 RBI�I QesV �1 m� ' •�1 SOLE OWNER: YES/NO OWNER PHONE# G® La * 0 ADDRESS 33 5 p b�& 1 eAcl ac yLd We-3I t� Ya Y hag j)0L k 0 2 6 CORPORATE OWNER: KY Is K-n a 8 A H O BU Q `? J- V) 19 LC-,:IN J� CORPORATE ADDRESS: G Ll O ynal h S'`'Y e4. m� 0zba1 PERSON IN CHARGE OF DAILY OPERATIONS: K R T S M N A B O M R D 0 0, 7J—M A LS=N/ List(2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records.You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. /VM 2. V"" 1 SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http•//www townofbarnstable.us/healthdivision/applications.ast). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC Ist. Q:1Application FormsTOODAPP REV3-2019.doc p t Town of Barnstable BOARD OF HEALTH John T.Norman ' Board of Health Donald A.Guadagnoli,M.D. RNSrABLE, : Paul J.Canniff,D.M.D. z � 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 912 Issue Date: 1/1/2020 DBA: CORNER FOOD MART OWNER: OM SHANTI INC. Location of Establishment: 640 MAIN STREET HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual X Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY _ For Offic Initials: oFIKEr Town of Barnstable Date Paid M Amt Pd$ 19S i IMMSTABIE : Inspectional Services �C- q Public Health Division ED MPr Thomas McKean, Director 200 Main Street, Hyannis,N A 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE I 1 2S- 1 01 NEW BUSINESS OWNERSHIP RENEWAL tt i t -DOA- a n d-��F NAME OF TOBACCO ESTABLISHMENT:®1'� SI'�A riT I d�9'C. Y ADDRESS OF TOBACCO ESTABLISHMENT: (o C) YnOU tj L Ib e `-'" MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: _n Pp— k do Z E x CD° C0 vn TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (504 )? - v OWNER'S NAME: Ksis67� 6 i Yl1Gi l S)nu OWNER'S PH#�3a-3 -! OWNER'S ADDRESS: ��e�s� � �ar-od tj CORPORATE ADDRESS: Ay6 ICU n 17rf CORPORATE FID# ANNUAL: \— SEASONAL: DATES OF OPERATION:_/_/_ TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httl)s://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: htt s://male islature. ov/Laws/GeneralLaws/PartiV/TitleI/Cha ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT PLEASE N INSPECTION S N PEC ION PRIOR TO PERMIT BEING ISSUED. LEASE C 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: Iw PRINTED NAME: Y 1 S►1 ���m� S DATE: 1 I / 25/ I9 Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors — $ 371-9 Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic 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: Si atu . Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q\Application Forms\TOBACCO APP-Non'=avor 11-21-19.doc aCHLs S. F� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco Y i1 7 y .r 01i�`` This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. OM SHANTI INC Account ID: CRL-10801659-007 640 MAIN STREET License Number: 1398253568 HYANNIS MA 02601 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1, 2018 Expiration Date: September 30, 2020 � Nc H VsFT'r MASSACHUSETTS DEPAITMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes 01i This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. OM SHANTI INC Account ID: CGL-10801659-003 640 MAIN STREET License Number: 841680896 HYANNIS MA 02601 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 IRS DEPARTMENT OF THE TREASURY uuww INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0023 Sl Date of this notice: 03-10-2017 Employer Identification Number: 82-0761401 Form: SS-4 OM SHANTI INC Number of this notice: CP 575 A CORNER FOOD MART 640 MAIN ST HYANNIS, MA 02601 For assistance you may call us at: 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER n Thank youtif for applying for a a EIN 82-an614 This EIN will inEVloyer Identification Number (EIN) . We assigned you y you, your business accounts, tax returns, and documents, even if you have no records. employees. Please keep this notice in your permanent When filing tax documents, payments, and related correspondence, it is very that you use your EIN and complete name and address exactly as shown above. An variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. sed on the the following forms)bbyy thendate(s) showned m you or your representative, you must file Form 1120 04/15/2018 Your Form 11C and/or 730 becomes due the month after your wagering starts. If you have questions about the form(s) or the due date(s) shown, you can the phone number or write to us at the address shown at the top of this noti e.caIf yus ouat need help in determining your annual accounting period (tax year), see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from representative. It is not a legal determination of your tax classification, You r and is notr binding on the IRS. If you want a legal determination of your tax classification, you request a private letter ruling from the IRS under the guidelines in Revenue Procedure may 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at Certain tax classification elections can be requested by filing Form8832,1Entity Note: Classification Election. See Form 8832 and its instructions for additional information. INPORTANT TION FOR S CORPCRATICN ELEMON: If you intend to elect to file your return as a small business imefras and the corporation, an election to file a Form 1120-S must be made within certain t corporation must meet certain tests. All of this information is included in the Election by a small Business Corporation. instructions for Form 2553, Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. 4 BARNSTxnc John T.Norman MAn 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 30513, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 912 Issue Date: 12/20/18 DBA: CORNER FOOD MART OWNER: OM SHANTI INC. Location of Establishment: 640 MAIN STREET HYANNIS MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2019 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: C,�� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: r ' THE For Office Use Only. Initials: o„ Town of Barnstable c7 Date Paid 0 Amt Pd$ MASS�E Inspectional Services e _ gs Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,N A 02601 f 7 Office: 508-862-4644 Fag: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP FXNEWAL NAME OF FOOD ESTABLISHMENT:O°M q��► In C ( (pY YN 6 �—o d � ADDRESS OF FOOD ESTABLISHMENT: (OLi® fty n}S rl)11 D 2 "1 MAILING ADDRESS(IF DIFFERENT FROM ABOVE):: E-MAIL ADDRESS. TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (Sad) CJ TOTAL NUMBER OF BATHROOMS: A/A WELL WATER:YES NO ✓... (ANNUAL WATER ANALYSIS REQUIRED) i ANNUAL: ✓ SEASONAL: DATES OF OPERATION: / / TO / NUMBER OF SEATS: INSIDE: N t� OUTSIDE: A o TOTAL: �" I 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? of l IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) JY FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential ldtchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) y TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) WAS ON AL•MOBIILE&NEW FOOD_ ONLY*** REQUIRED TO CALL HEALTH DIV FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FomisTOODAPPREV2018.doc t ., PLEASEi`CALLU$=862-464d r„ O'VV INFORMATION: , _ t ,FULL NAM OF�.PPLICANT - _ + 1-a ; . `� ADDRESS, 3'� Sher�� a- n®,c� k��; ant 6ll m {4 - ? �tYIL�{� T5�� FEDERAL CORPORATE OWNER- KY S S . A kTE DDRE CORPOR SS.- } � U F ` jj PERSON-IN CHARGE Ol DAILY°OPERATIONS List Q)s,2ertified Food-Protection Managers AND at least (1) Allergen Awa"reness�Certifie F�aff` Al1FOOD ESTABLISHMENTS3musfhavelCertified Food Protection Manager PER SHI t ' record 3 **ATTACH COPIES OF CERTIFICATES**-TheHealth.'Div.* NOT use past years s You must providemew'co pies,and POST_THE CERT=IFICATES at your food establishment: Certujed Food Managers Expiration Date Allergen Awareness Expiration Date s r a P. m 2 , - i r y ` P a " !EI Y,.; 5 Y. e t OF APPLICANT , DATE- SIGNATUREh : , _ _ r - ***FOOD POLICY�INFOItMATION*** . y SEASONAL FOOD SERVICE:_All seasonal food establishments,mcludin' mobile trucks inu'stabe inspected b the Healtli Div. ' Dno to°opemn ! Please mll•Healt Div xat 508 862 4544{to schedule your mspecriom, aPlease call at least(7)days"in advance , C ax,� §atef ', " jai;° r'ae - ,:_ �'^wti ai FP.CZENDAYRY DE4,SERTS:�-Fro en=desserts must be tested by a State Certifie&lab prior to-Opening and monthly thereafter, , r wi.h sample results submitted to;the I ealtti=Di`v. Failuie to do so will`result in{the'suspenston or revocat on'Of your{Fioz`en Dessert " - Pe-w't until n 1 the above te;~ms Ere met CaTE12I1VGyPOLICY=Anyone,whf caters wtthin the°Town of Barnstable must notify theTown by fax or mail prior to catering even. You musbcomP -te a catermg�notice found at htt' //wwwaownofbarnstable:us/healthdivisionla �`lications:asA . OUTDOOR Cry a �„ , �OKINO: Outdoor cook*ng,Epre x4ation;or display of any,foodproduct by<a food estabh$hinent is°prohibi.ted..� " - § f . TGBx&0 EfTABLI3 HIVIENTS A11 tobacco"establishments-rrt EtW10Yee Signature�Form. ' P o for°Tobacco Sales Petmrt and et us orn 1 an Y pa e A $ tcati n NOTICE: " d Pests run Finnu�ll fro s� 1 T'l-,E COIvIpL a y tn:Jariu ry 1st to�Dec,31` each Galen ar�year:�IT,TS'YOUR RESPONSIBILITY. iE'I ED��1P_LI TION{S)�1ND,RE(�UIREDiPEES Y` E TO rRE'IURN � E, DEC lst: �- xr � Q:4a�hcationF` aa , � orns OODtI?PR1aV20'8 dQo i €„ t IT 71� _ r Ui tx p- . rVE 'down of Barnstable For Office Use Only: Initials: �e Date Paid AmiJM$ s • Inspectional Services Check# C'ach KASS.039.�r Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-7904644 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 n c- D/g/ji, Coy n e y VM cl �J- LAr j ESTABLISHMENT NAME (DB/A) 606 bnaan 1-� a�� MA o 2-6 6 1 ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERENT FROM ABOVE) -F:rM-AL5IN/9 , XRISH10 3 7)eP k4o-2- &)IC'6'LO*, 569 - '7-'�s- 15Ly EMAIL PHONE# FEDERAL ID# Do you currently possess a state license to sell tobacco products? E Yes No i I 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)t Each employee who sells tobacco products must sign the Employee Signature Yorm (provided r herein). Signature Date f Q:\Application Fom►s\TOBACCO APP2019 dob.docx I t � Y F 1 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—4 371-9.Sale and Distribution of Tobacco Products. l. 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. I . The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: KY)-s rwj IS-►Yr%Als)'-h tl 1? 9 Si a Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP2019 dob.docx E `°FINE T TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: Date: ge: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARN ABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY - FOOD ESTABLISHMENT INSPECTION REPORT 508-862-4644 Name C Date` Ria ns ection BoutinAddress 9' � Risk e-inspection Level Previous InspectionTelephone l l Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE 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 Asa Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY 9 ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Relatedlo 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 within 90 days as determined b the Board of Health. Overall Rating Y Y F] Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on ginpection today,the items Embar o checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 Emergency Closure Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F 3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 6n violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writingand submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Si nature Print: 31.Dumps r screened from public view (/fin Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N v nature -4 9 #Seats Observed Frozen Dessert Machines: Outside Dining Y P s Si Print: N g Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N t� rf Dumpster Screen? Y N -- --� ..` _ -., .,.3-..- r .--._-. r�-�-..-.+ _..�r...v���..��--...a..-_.,- .-,-.ti-- ��. r - .,.�� r.y-.a-�-xr� ram,.- ��-. � r..-s'.'. :...�'- - . - - - .. _ � _ -.,..- •-•.- �-.. .- -.`.,L-lL! -_- . ,� Violations related to Foodbbrne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - 3-302:14 _ Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic$.uGt@rites 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information.-Original Containers* 590.003(C) Responsibility of the Person-in-Charge to Other 7-102.11 Common Name-Working Containers** 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F* Applicants* - - 3-302.11(:4) Food Protection* 7-201.11 Separation-Storage 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 3-304.11 Food Contact with Equipment and Utensils* 7.202.12 Conditions of Use* 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)Resumed Food and Reared or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 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 Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* PP Y Not Otherwise Processed to Eliminate Equipment* ( )( Pathogens 590.006(A) Bottled Drinking Water* 3-401.11 A 2) Comminuted Fish,Meats&Game + E ecnve runom 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* P 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 3-401.11 * 2-301.14 When to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms ( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-001.11 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) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodbore * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 1590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 26. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc `Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °p IKE► TOWN OF BARNSTABLE _ HEALTH INSPECTOR,s Establishment Name: - Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION .- 8:00-9:30 A.M. % BARNSI'ABLE. • 200 MAIN STREET 3:30-4:30 PM. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. 0g HYANNIS, MA 02601 - MON.-FRI i679• 508-862-4644. No Reference R-Red Item PLEASE PRINT CLEARLY s FOOD ESTABLIS MENT INSPECTION REPORT fflh Name / K Dat I ape o IMMMirsRection g outine Address Risk ion Level Previous Inspection Telephone ntial Kitchen Date: ��2�9 /"Y Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) /� �T � Bed&Breakfast HACCP LL ijnGOth C Inspector Out: JJ C ' 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 r FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations *n , Critical(C)violations marked must be corrected immediately. (blue&red items) " Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately orwithin 90 da s as determined b the Board of Health. Overall Rating ryp ❑ p Y ❑ p ❑ g yPY Y ❑ Volunta Com liance Em to ee Restriction/Exclusion Re-ins ection Scheduled Emer enc Sus ension C N Official Order for Correction:Based on aay,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 6=One critical violation and less than non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 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 anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to Snon-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Signat re Print: 31.Dumps r screened from public view Permit Posted? Grease Trap Previous Pumping Date Y N P P 9 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 .)�_i - 4 .(��v 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 I 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_._- _ _ _ __ -P_HF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection°from Unapproved Additives* Contamination from Raw Ingredients 1S Poisonous o►Yoz c Subs ricas 590.004(F) -- -*- - -- - - - - --- 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 Informatioa-®Aginal Containers* '� 3-501.16 A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to -- - - - - __ _ Other 7-10211 Common Name-Working Containers*. ( - Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held AI or Above 130°F - 1 Applicants* -- - - - - - '- 3-302.11(A) -' 7-201.11 Separation-Storage*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 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 - -Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in-Charge* _ _.,_ _ - Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3,306.14(A)(B)Returned Food-and Reservice of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetically 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-1 ook 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11 A) Clean Utensils and Food Contact Surfaces of Animal Fonds That are.Raw,t inrlercooked or 5-101.11 Dunkin Water from an Approved System* __ _ _ (. Eggs-Immediate Service 145"F 15 sec g PP Y --- � Not Otherwise Processed to Eliminate Equipment* ( )O Pathogens* �/ 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g : E ecnve tiuzoor 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* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Contact Surfaces of Equipment* * 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* Shellfish and Fish From an Approved Source _ _ gg pp 4-702.11 Frequency of Sanitization of Utensils and Food 9 Y * 3 401.11 A 2 Ratites Injected Meats-I55°F 15 sec 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* ( )( ) J Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* 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. 2-401.11 Eating,Drinking or Using Tobacco* 3,403.11 A&D PHFs 165°F 15 sec* 5 Receiving/Condition ( ) ( ) 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) Commercially Processed RTE Food-140°F* (Blue Items 23.30) 3-202.11 Package Integrity 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* F 10 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 5-205.11 Accessibility,Operation and Maintenance 3-402.12 Records,Creation and Retention* Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. THE row TOWN OF BARNSTABLE _ HEALTH INSPECTORs Establishment Name: cover Fjwd mql>- Date: Ell 0,11/Z,O uI Page: ' Of � q OFFICE HOURS . Eo3 PUB2 0 MAIN ST LIC HEALTH RETSION 8:00-9:30 A.M. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified BARNSTABL MASS HYANNIS,MA 02601 MON.-FRi. No Reference R-Red Item PLEASE PRINT CLEARLY �OrFO 39.ego 508-8624644 FOOD ESTABLISHMENT INSPECTION REPORT �q Name O` k/ Feod MA- Date 6_/g_t9 Type of jXge of Inspection Operations) outine w Address (O M �} Risk d Service ection �� 1"Qr Level Retai Previous Inspection Telephone idential Kitchen Date: Mobile Pre-operation / Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP 01 In: other -rt(rn NZ Inspector k Qn �V ,l 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) ❑ FO D PROTECTION MANAGEMENT [� Prevention of Contamination from Hands I 1.PIC Assigned/Knowledgeable/Duties ( .Handwash Facilities E PLOYEE HEALTH P�tOTECTION FROM CHEMICALS 2.Reporting of Diseases by Food Employees and PIC rud, 14.Approved Food or Color Additives 3.Personnel with Infectious Restricted/Excluded �15. Toxic Chemicals F D FROM APPROVED SOURCE 119. EITEMPERATURE 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 Hot and Cold Holding P OTECTION FROM CONTAMINATION &4'20.Time As a Public Health Control 8.Separation/Segregation/Protection R UIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 9.Food Contact Surfaces Cleaning and Sanitizing 721.Food and Food Preparation for HSP 10.Proper Adequate Handwashing CONSUMER ADVISORY l 11.Good Hygienic Practices . ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations 6 Critical(C)violations marked must be corrected immediately. (blue&red items) ( Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ 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 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007 aggrieved b 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 y ) 99 y 9 g' q 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. violation,4 to 8non-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 jwkl__V� j`� I ��rn� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: /� P I Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N D Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 590.004(F) Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F * 7-]02.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Se 3-501.16(A) Roasts Held At or Above 130°F* Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge*- 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR . 3-306.14(A)(B)Returned Food and Rrated orce,of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g � ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a 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. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-lOLl1 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meals&Game Pathogens* Effective urnoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g Ratites-165°F IS sec* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 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* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g, g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 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* Lu 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 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* 5-204.11 Location and Placement* 3 402.12 Records,Creation and Retention * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices Within 4 Hours 27. Water,Plumbing and Waste FC-5 .007 (n g g 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 Conformance with Approved Procedures* S.-590Formback6-2doc *Denotes critical item in the federal 1999.Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. t I i °p IKE r°� TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: Ll le rl Date: 11 bbe _Page: t of�[ q 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. g A ,e3y.a 0 HYANNIS,MA 02601 MON.-FRI. 508-862-4644 No Reference Y R-,Red Item . PLEASE PRINT CLEARLY. 'fD1AP' FOOD ESTABLISHMENT INSPECTION REPORT ( �n �,� Date/ / Tyne of T of Ins tion o Name OCIA4,/ i o 9�t Ooeration(s) Routirie 4,4 Address S - Risk Foo Service - spection 0 �Nrv1 f Level etail Previous I(�sl coon C Telephone I ential Kitchen Date: /7 Mobile Pre-opel/ati Owner HACCP YIN Temporary_ Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Vr. �� Out: _ a Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP J ❑ 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: o ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating ( 0 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 ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:. checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical, results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address violations ob 7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) g violation, o 8 non-c'tical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector' ignature P n 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V Frozen Dessert Machines: Outside Dining N Y PIC's Signature Print: #Seats Observed 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 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 15 Cooling 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501. g 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 Fond-.Separated from Each. 7-101.11 Identifying Information-Original Containers* 590.004(F) - Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F * 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR- 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* q Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashing-Ho[Water 7.206.12 Rodent Bait Stations * 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Fond Contact Surfaces of E s-Inunediate Service 145°F 15 see* Animal Foods That are Raw,Undercooked or 5=101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate_ 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* EJjecfice 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 Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* _ Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and�/d Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* RegulatoryAuthority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition 8. g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* - 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C CommerciallyProcessed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) 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 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* . Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices (J) 9 9 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 1 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 1 Reduced-Oxygen Packaging Criteria* 8-103.12 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. FTC r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of OFFICE HOURS UBLIC HEALTH DIVISION 8:00-9:30 A.M. BARN5rABLE. • MAIN STREET 3:MON.-FP.M. - Item Code. C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MAC, �, MON.-FRI. 'gyp ,639.e m HYA S,MA 02601 508-862-4644 No Reference R-Red Item PL ASE PRINT CLEARLY 'FON1P� FOOD ESTABLISHME INSPECTION REPORT Name ate Type of Type of Inspection c Operation(s) Routine, Address Risk Food Service Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ d Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ cftAction as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands in em ❑ 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 V1 `. 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 04 ❑ 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 Overall Rating Corrective Action Required: ❑ No ❑ Yes within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ 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 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations- If no critical violations observed, 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 9 or more non-critical violations=F. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (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 4non-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=C. refrigeration. 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 r Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N 01 #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatur Print: . Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) fAssignment of Responsibility* 8 Cross-contamination 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* - 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods 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 1$ Poisonous or Toxic Substances 590.004(F) _3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F * EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 590.003(C) Responsibility of the Person-in-Charge to 7-101.11 Identifying Information-Original Containers* 2 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* -Storage* Applicants* _ _ 3-302.11(A) . Food Protection* 7-201.11 Separation 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 590.00411 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* _ -REQUIREMENTS 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Boftled Drinking Water* ' 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef crave 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g Ratites-165°F 15 sec* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 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* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 3-401.11 2=301.14 When to Wash* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )ro) 3-201.17 Game Animals*, 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under 929-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Y 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13 Handwashing Facilities 3-202.18 Shellstock Identification* 3-501.14(A) g Coolin Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70'17 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 3-412.12 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 m Provision Drying 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 C� �Z E vo✓�G yea IV A ly fz A Tel) I�A W& op THr v/l 2 i A N c r F O A TKE G 1e&ks r.- 7-/W ,�T-��yo. .� �� s 7;, (� To ��T o�� 1� A/6 THE � a Ss '1 I �b o _ _ _ _ ��q �.2 D�= �D �, �,.. . I� OFTNE Tp� DATE: / D yP �� FEE: * BARN STABLE, MAS 16 y S' , 1639- REC. BY 8e Town of Barnstable SCHED. DATE: J Board of Health 0 200 Main Street Hyannis MA 02601 .Office: 508-862-4644 Wayne A.Miller,M.D. FAX: 508-790-6304 Paul J.Canniff,D.M.D. � [-�—VARIANCE REQUEST LOCATION Property /y�'� Property Address: 640 N Sf 14YANN.141 #X (2)40( Assessor's Map and Parcel Number: Size of Lot: Wetlands Within 300 Ft. Yes Business Name: C/A fC No V Subdivision Name: y /, APPLICANT'S NAME: G P GA P 66V O R G YA N Phone �(�S ' 6�s r 'f�7 Z -Did the owner of the property authorize you to represent him or her? Yes V No PROPERTY OWNER'S NAME CONTACT PERSON Name: A L I% I. COL L EL A Name: 1)G4 X 64 V OR 61M,'l Address: 3ZO STGI/rN ST i/YprI 44 Address: 21, GIRGAT 101g5H 1 Phone: r g — 3 6 y —2,9�O Phone: Soy 49 5_ 1/t Z VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) NATURE OF WORK: House Addition El 00000 House Renovation �2f Repair of Failed Septic System El Checklist (to be completed by office staff-person receiving variance request application) Please submit copies in 4 separate completed sets. :. i Four(4)copies of the completed variance request form i j _* — Four 4 copies of en ineered plan submitted e.g�septic s stem 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 him/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 (fog Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) CD ; Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewal's[same own_e/leaseej only], outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems [only, .if no Lxpansidr.to the building proposed]) co tit Variance request submitted at least 15 days prior to meeting date r—t-rt VARIANCE APPROVED Wayne Miller,Chairman NOT APPROVEDJ_Gannif;-D:M D REASON FOR DISAPPROVAL Q.\Applicatiori Forms\VARIREQ.DOC `hey ` a'"R y• \ pa's� 74, E cam- , CIO AIX - . �qp ) O LAZ&/h-i - . 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