HomeMy WebLinkAboutCVS PHARMACY #2322 - RETAIL FOOD CVS PHARMACY #2322
176 NORTH ST. , HYANNIS'
I
Town of Barnstable BOARD OF HEALTH
John T. Norman
Board of Health Donald A.Gaudagnoli,M.D.
'• BARNSTABLE, F.P.(Thomas)Lee,.
6 9• a` 200 Main Street, Hyannis, MA 02601 Daniel Luczkow M.D. Alt.
ga�x
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: 544 Issue Date: 01/01/2022
DBA: CVS PHARMACY#2322
OWNER: CVS PHARMACY INC.
Location of Establishment: 176 NORTH STREET HYANNIS„ MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IncloorSeating: 0 OutcloorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2022
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE- FOOD:
MOBILE-ICE CREAM: GQ�
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
For Office Use •
Initial� Town of Barnstable J
a Date Paid Amt pd$ /�
BARNSTABLE. ; Inspectional Services
9� Public Health Division Che
A
QED MAC
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
/ A/PP,LICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE_ll 117( NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT:
CVS/pharmacy
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): One CVS Drive
Mail Code 1160
E-MAIL ADDRESS: nonpharmacypermits@cvshealth.Com Woonsocket, RI 02895
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: -72 d � �
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES -' NO ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ]I
***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 SERVIC DO R(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
eD SERVICE
AIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED)
CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
QAApplication FonnsTOODAPP 2020.doc
A
OWNER INFORMATION: Stephanie Cadorette
FULL NAME OF APPLICANT Licensing Coordinator
SOLE OWNER: YES/NO OWNER PHONE # (46 t��l
ADDRESS I
CORPORATE OWNER: U-15 CVS/p ar
one CVS Drive
Mail cocle 1150
CORPORATE ADDRESS: Woonsocket,RI 02895
PERSON IN CHARGE OF DAILY OPERATIONS: 0l U
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION'"*
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at httn://www.townofbarnstable.us/healthdivision/aunlications.asu.
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 APPLICATION(S)AND REQUIRED FEES BY DEC 1 st.
Q:\Application FormsTOODAPP REV3-2019.doc
O�SF Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
Paul J.Canniff,D.M.D.
MA.S& 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, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 544 Issue Date: 01/01/2021
DBA: CVS PHARMACY #2322
OWNER: C.V.S. CORP/LICENSING DEPT
Location of Establishment: 176 NORTH 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: Qh
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:
�
THE► Town of Barnstable For Office Use Only: Initials:
Date Paid
W NSfAMASS.BLE, . Inspectional Services
`0� Public Health Division Check#SD���4�3
prFD PM�a
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 �4Z_
2.6J NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: v
ADDRESS OF FOOD ESTABLISHMENT: )f76 6w = CVS/pharmacy ( 7
One CVS,Drive v�
Mail Code 1160
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): et, RI 02895
E-MAIL ADDRESS: non,pharmacypermits@cvsheafth.com
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (JV � )
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: 'YE SEASONAL: DATES OF OPERATION:_/_/_ TO
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FO SERVICE
ETAIL 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
m
OWNER INFORMATION: Stephanie Cadorette
FULL NAME OF APPLICANT Licensing Coordinator
SOLE OWNER: YES/NO ( OWNER PHONE
ADDRESS CVS/pharmacy
r,.,e.rVc drive
Hail Code 1160 C�� CVS/pharmacy
CORPORATE OWNER: ri PT 02895�'�'d69F15961.6.- r
Mail Cody 1160
CORPORATE ADDRESS: Woonsocket, RI 02895
PERSON IN CHARGE OF DAILY OPERATIONS: 0,C i
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2. A 12� 2-0 2,X-j
r
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments, including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from?anuary 1st to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC I st.
Q:\Application FormsTOODAPP REV3-2019.doc
f
V
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BARNWADW. Paul J.Canniff,D.M.D.
MASS 1� 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: 544 Issue Date: 12/10/2019
DBA: CVS PHARMACY #2322
OWNER: C.V.S. CORP/LICENSING DEPT
Location of Establishment: 176 NORTH 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: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Gan
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
A
For Office Initials:
Town of Barnstable hh
Q' Date PaidI IqAII1tP�$ u� r f
,,ffrAB,� : Inspectional Services
Mesa C�
%s63y�F�0� Public Health Division d� "_j .'
ED MA
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601 '4
Office: 508-862-4644 Fax: 508-790-6304 �
AP LICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE �I NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:C S
ADDRESS OF FOOD ESTABLISHMENT: rls'tl
CvS/ armacy
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): One Cv5 Drive
Mail Code 1160
E-MAIL ADDRESS: non pharmacypermits@cvshealth.COm Woonsocket, RI 02895
TELEPHONE NUMBER OF FOOD ESTABLI,S/H/MENNT: (5w)
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YES NO (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: V SEASONAL: DATES OF OPERATION:_/_/_ TO
i
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***
OUTSIDE DINING REMINDER*
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
�ETAIL 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
t
v
r
OWNER INFORMATION: Stephanie Cadorette
FULL NAME OF APPLICANT Licensing Coordinator
SOLE OWNER: YES/NO OWNER PHONE#
CVS/pharmacy
ADDRESS One CVS Drive
Mai e
CORPORATE OWNER: Woonsocket, RI 02895
CVS/pharmacy
One CVS Drive
CORPORATE ADDRESS: �1
TC � 1360
Woonsocket, RI 02895 � J
PERSON IN CHARGE OF DAILY OPERATIONS: (
List(2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies!and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
r
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/al)plications.asi).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January I st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q\Application FormsTOODAPP REV3-2019.doc
4
f
WTI Town of Barnstable BOARD OF HEALTH
G Paul J Canniff,D.M.D.
A.Ga
Board of Health Donald A.Gaudagnoli,M.D.
o ;BLL :" John T.Norman
Mn F.P. Thomas Lee Alternate
A,e� 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: 544 Issue Date: 12/20/18
DBA: CVS PHARMACY #2322
OWNER: C.V.S. CORP/LICENSING DEPT
Location of Establishment: 176 NORTH 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: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: - — - ----- -- — --
MOBILE-FOOD:
MOBILE-ICE CREAM: G��
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
j PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
ppIKE � Initials.
Town of Barnstable
Date Paid Amt Pd$
' MAML Inspectional Services
1659-ATE��a Public Health Division Check# V
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601 D
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT UUUCCC
DATE 1 1, NEW OWNERSHIP
RENEWAL
NAME OF FOOD ESTABLISHMENT: l�lJ
ADDRESS OF FOOD ESTABLISHMENT:
CVS/pharmacy
MAILING ADDRESS (IF DIFFERENT FROM ABOVE): One CVS Drive
�y` p Mail Code 1160
E-MAIL ADDRESS: l C��,f,(�' WV �'� CC' /Y� Woonsocket, RI 02895
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: )775� BZG�z-
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES .. (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
_LRETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
Q:\Application Forms\FOODAPPREV2018.doc
4
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT � —
SOLE OWNER: YES/NO OWNER PHONE �--
CVS/pharmacy
ADDRESS one CVS Drive
-Gede !1.60
CORPORATE��'n&R: QJS 109 ��DERALIDNO. :
CV rmacy
CORPORATE ADDRESS: One CVS Drive
Woonsocket; RI 02895 ,
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
1.
2.
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1 st to Dec.3 I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application Forms\FOODAPPREV2018.doc
`oF* rogti TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: Date: Page: of
c OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-a:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS.
A .639.a�e� HYANNIS, MA 02601 sos-s2 asaa No Reference R-Red Item PLEASE PRINT CLEARLY
rFO MPS FOOD ESTABLISHMENT INSPECTIO N REPORT
Name Date a of a Ins ec ion L
7-17 on s Routin
Address Risk i R = ction
Leve Retail Previous Inspection
Telephone ntial Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness ( /
Caterer General Complaintit
L
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) ❑ 0
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No Yes
Non-critical(N)violations must be corrected immediately or ❑ ❑
within 90 days as determined b the Board of Health. Overall Rating
Y Y ❑ Voluntary Compliance- ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items Embar o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 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 4non-critical violations regardless of the number of critical,results in an 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 9 non-critical. If no critical water,sewage back-up, infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) receipt Within 10 days of recei t of this order. violation,4 to 8 non-critical violations=C.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view
Permit Posted Y N Grease Trap Previous Pumping Date Grease Rendered Y N r
#Seats Observed Frozen'Dessert Machines: Outside Dining Y N P,IC's Sig re TP
` ^
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Screen? Y
Dumpster N III 111 1
-. .,,...-_ .._. ,- .__, ... ----+,�-..r,...�-e-�.....-..-^.tav--'�-s-.. -.....-��.�-.�r� -.., .v�.. t-.�-.. �.w- _� +n. •...v^'-+�......-- _ ..�,. 'ice � .. -« _r,...-... � ._ . � _ r r
.y-...._.{ - -�._. �... �-, --4�.•---ten.+. ^-' - ... .. _.,.°-_-„�..
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions ]r
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 r: Law Cooled[0 41°F/45°F Within 4 Hours*
* 3-501.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives
Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F,
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information,-Ori oral Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
7-102.11 Common Name-Working Containers* 3-501.16 A
Require Reporting by Food Employees and Contamination from the Environment ( ) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
- - - Applicants* - - - 3-302.11(A) Food Protection* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An _ 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 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 Reate for 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* 3-80LI1(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* 21 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
( P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations *
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 AnimalConsu Fooer d That Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary
and - ide in cater-
* Ratites-165°F 15 sec* in mobile food,tem or and residential
Sources 10 Proper,Adequate Handwashing * g' P
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms*
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3AO3.11(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 foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
8 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
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 1590.000
3-203.12 Shellstock Identification Maintained*
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Supplied with Soap and hand Drying Devices
Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients*
27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 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:590Forrnback6-2doc
"Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
pF IME Tp� TOWN OF BARNSTABLE - - HEALTH INSPECTOR'S Establishment Name: Date: �/ Page: of
4 OFFICE HOURS
P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY Mph n 508-862�644
FOOD ESTABLISHMENT INSPECTION REPORT
Name G S Dat Tyne of T f Ins ection
Ooeration(s) outi
Address / �� / Risk Food S ice Re-Inspection
Level etail Previous Inspection
Telephone esI ntial Kitchen Date: 1 /✓L
Mobile Pre-operation mot/
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) 1 Time Bed 8 Breakfast Other
CP
In:
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 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
LO
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No Yes
Non-critical(N)violations must be corrected immediately or Overall Rating7 ❑
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:
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 4non-critical violations
26.Water,•Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 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 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) receipt within 10 days of recei t of this order. violation,4 to 8 non-critical violations=C. .
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view
i
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining y N PIC's Signature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted ' Y N
Dumpster Screen? Y N r
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
* 3-501.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives
PHF Hot and Cold Holding
Cooked and RTE Foods.* * 19
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 590.004(F)
590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers*Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
* 7-201.11 Separation-Storage*
Applicants 3-302.11(A) Food Protection* 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 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 Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and
P 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* 3-40L11A(1)(2) Eggs-155°F 15 sec Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec*
g PP Y Not Otherwise Processed to Eliminate
Equipment* ( )( ) Pathogens*590.006(A) Bottled Drinking Water* 3-40 L 11 A 2 Comminuted Fish,Meats&Game g * e ecn-inrzooi
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary
and - ide in cater-
* Ratites-165°F 15 sec* in mobile food,tem or and residential
Sources 10 Proper,Adequate Handwashing * g' P
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 6 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.
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* C Commercial] Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity* 3-403.11( ) Y Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within-4 Hours* 23. Management and Personnel FC-2 .003
3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
°F.HE rqr TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: ( t l� 1�� �,)ert f� Date: f �j Page: f of
4 OFFICE HOURS -1 -
°� PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARN STABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
;639: �0� HYANNIS,MA 02601 soa gs2 PaRsaa No Reference R-Red Item PLEASE PRINT CLEARLY.
p'EO1AP'p FOOD ESTABLISHMENT INSPECTION REPORT t
of s E
Name Mart ADate i T e o f Ins a tion
Operations) o
Address Risk F o' ervice Re-inspection /
kof Alf Level Re ai Previous Inspection t r
Telephone esidential Kitchen Date:
Mobile Pre-operation
Owner HACCP YIN Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP SC lk2 C (� , r?
In: Other ly
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 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 ADVISORYUtt
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) ( Corrective Action Required: No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating Wthitems
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 toda o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food
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 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observesk7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order. violation 8 n ritical violations=C.
30.Other DATE OF RE-INSPECTION: Inspector' Signat Pri t
31.Dumpster screened from public view V'
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's 7yulre Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 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 3-20T.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 Additive's
Contamination from Raw Ingredients 15 Poisonous or To Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F) - *
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2 590.003(C) Responsibility of the Person-in-Charge 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 Se oration-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR.
3-306.14(A)(B)Returned Food and 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*
q Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 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 3-801.11(C) Unopened Food Package Not Re-Served*
3-201.13 Fluid Milk and Milk Products 4-501.112 Mechanical Warewashing-Hot Water Monitoring
3-202.13 Shell Eggs* I Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg
Not Otherwise Processed to Eliminate
Equipment*
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef ctiw 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 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* 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
11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
3-201.17 Game Animals* Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
23-30)
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items Critical and non-critical
12 Prevention of Contamination from Hands violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A
3-202.18 Shellstock Identification ( ) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41'F/45'F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria* _
8-103.12 Conformance with Approved Procedures* �. S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
�p IKE roy, TOWN OF BARNSTABLE _ HEALTH INSPECTORS Establishment Name: Date: Page: of -
ti OFFICE HOURS
P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSIABLE, • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS, MA 02601 MON.-FRI. NO Reference R-Red Item PLEASE PRINT CLEARLY
rFD Mp+p 508 8624644 -
FOOD ESTABLISHMENT INSPECTION REPORT
Name " Date , T e of iyoe of Insloection
O er utine
Address Risk -Insp�on
Level 11,
Previous Inspection
Telephone ntial Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) me Bed&Breakfast HACCP ca
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 /f_
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) � L- , L
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
c
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
El 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 i�J /��
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations No El Yes
Critical(C)violations marked must be corrected immediately. (blue&red items) 1 Corrective Action Required: ❑
Non-critical(N)violations must be corrected immediately or 1r 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 o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ® Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below b a Board of Health member or its agent p 9 Y 9 A=Zero critical violations and no more than anon-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 re ardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 6=One critical violation and less than 4von-critical violations g
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 0
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.
28.Poisonous or To ( )( ) violation,4 to 8non-critical violations=C. �
29.Special equirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: \
31.Du ster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's ignature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Dudes 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH. 3-302:11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers*
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage
Applicants* 3-302.11(A) Food Protection* P g * 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use
590.003(P) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
3-304.11 Food Contact with Equipment and Utensils
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.00411 Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
( ) Variance
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sani[izers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual 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 1 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(l)(2) Eggs-155`17 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-6 01.11 A Cl Utild Food Ctt Surfaces of * Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* ( ) ean enss an onac Eggs-Immediate Service 145°F 15 sec
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 1112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or Ratites-165°F 15 sec* A 590.009 )-(D) Violations of Section 590.009(A)-ID)in cater-
(
Sources* Proper,Adequate Handwashing 1p ing'mobile food,temporaryand 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* N2-401.12
1.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
* 1.14 When to Wash* 3-401.l l 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 Hat Holding Requirements.practices o should be debited under 929-Special
5 Receiving/Condition 1.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 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* 3-463.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23.30)
3-?A2.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
590.004(J) 9 9 y ty
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* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the.federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
oF. r TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: Cys Date: G/loo D-411bl Page:�_of
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
HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
508-862 asaa
FOOD ESTABLISHMENT INSPECTION REPORT J
Name CM Date 61i8/11 e a of JXRe of Inspection ction FYiy _ ;L,511
Ooeration(s) 2In
Address 1�6 u0� Risk F' ervice Re-Inspection `�Q�ro Q
�r Level eta Previous Inspection
Telephone sldential Kitchen Date: -.S41 V I �t0
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint ,
Person in Charge(PIC) Time Bed&Breakfast HACCP ((�'i �S ��a0� �.(
In: Other
Inspector Jun sVir(YS Out: �Du�r► r
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FO PROTECTION MANAGEMENT [� .Prevention of Contamination from Hands
PIC Assigned/Knowledgeable/Duties V.Handwash Facilities
E LOYEE HEALTH P TECTION FROM CHEMICALS
Y
.Reporting of Diseases by Food Employees and PIC [ 4.Approved Food or Color Additives
.Personnel with Infectious Restricted/Excluded 15. Toxic Chemicals
�FO D FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
.Food and Water from Approved Source �y6.Cooking Temperatures
Receiving/Condition L_� 7.Reheating
Y7Tags/Records/Accuracy of Ingredient Statements 18.Cooling
'
.Conformance with Approved Procedures/HACCP Plans 9.Hot and Cold Holding
PR TECTION FROM CONTAMINATION 20.Time As a Public Health Control
Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP)
.Food Contact Surfaces Cleaning and Sanitizing OK21.Food and Food Preparation for HSP t�(�
0.Proper Adequate Handwashing CON UMERADVISORY79*
/ �a 0V1.Good Hygienic Practices 22.Posting of Consumer Advisories L l!/7L� iiIYYY
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) 0 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 9
if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to anon-cri
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address non-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,'4 to 8non-critical violations=C.
29.Special Requirements (590.009) Y P ,
30.Other PATE OF RE-INSPECTION: Inspector's Signature Print: /�
31.Dumpster screened from public view J J� Sara,
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign�Ure Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
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.*2-103.11 Person-in-Chazge Duties 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)
2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and AdulteReserrated
or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated 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 Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155'F 15 sec*
590.006(B) Water Meets Standards in 310 CUR 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* ( )'( ) (
Ratites-165°F 15 sec*
Sources* 1 p Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* Requirements.
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140'F* Blue Items 23-30)
12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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
3 402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501,14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
* 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices
2 Physical Facility FC-6 .00
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability
28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision
29. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures*
S:590Formback6-2doc -
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
°p INE•ok, TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: U , NrjrT,;�J- Date: G birrPage: of L
ti OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTAOLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS. g. MON.-FRI.
HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY
�'EON1P'p FOOD ESTABLISHMENT INSP CTION REPORT CCj
Name A 3 Date -Z4 l Type of T e of Ins pection
1 Operation(s) outi
Address dolma ��( Risk Food Service Re-inspection (A
Level ee Previou In pection o
Telephone F�esidential Kitchen Date: ljt(7 g
Mobile Pre-opera ion - J
Owner HACCP Y/N Temporary Suspect Illness ty V/ (JG
Caterer General Complaint C"
Person in Charge(PIC) Time Bed&Breakfast HACCP
` In: Other
Inspector 1 wr C'
S n /V Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM.CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY \, Lo (�
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations _
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating UI2-7 19
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 by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violati s o 7 to 8non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order. viol Ion,4 to 8 critical viol lions=C.
30.Other DATE OF RE-INSPECTION: Inspect is Sig a Prin
31.Dumpster screened from public view V1 �v
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PI �ign Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N1� _ �2'!/�� ✓nl i r;l
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B)jDe.onstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-30Z.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) * -
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*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15_ Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Requirements
590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
- - -
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR,
3-306.14(A)(B)Returned Food and 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 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
( ) P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical 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
4-601. Clean Utensils and Food Contact Surfaces of Animal Foods That we Raw,Undercooked or
11A
5-101.11 Drinking Water from an Approved System* ( ) Eggs-Immediate Service 145°F 15 sec*
Equipment* Not Otherwise Processed to Eliminate.
590.006(A) Bottled Drinking Water* I 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ery i-uu2ooi
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 1 _ 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* y 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009 A( )-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other es should
violations relating to good retail
590.004(C) _ Wild Mushrooms � ( )( )O
3-201.17 Game Animals* 11 Good Hygienic Practices _ 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11- Eating,Drinking or Using Tobacco* * Requirements.
5 Receiving/Condition g. g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30)
12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
590.004E Preventing Contamination from Employees* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock ( ) g18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A. CoolingCooked PHFs from 1407F to 70.7
3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
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
() 9 9 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 1 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I FC-7 1.008
HACCP Plans 6-301.12 1 Hand Drying Provision ` 29. 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 orA05 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
li
Op THE) TOWN OF BARNSTABLE HEALTH INSPECTOR s Establishment Name: CO- f 4 Af A t _ Date: / Page: of /
OFFICE HOURS �-
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
e39. ,0� HYANNIS, MA 02601 508-8 08-8MON -FRI.62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY
p'FDN1 FOOD ESTABLISHMENT INSPECTION REPORT '
Name Date Tvoe of f Inspection 1
Operation(s) R outine
Address / Risk Food Service Re-inspection _
p Level et I Previous Inspection �'
Telephone ential Kitchen Date: e
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint -
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector S ti S Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ 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.
B=One critical violation and less than 4non-critical violations re
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food
if no critical violations observed,4 to 6von-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
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
27.Physical Facility ( )( ) Y 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 anon-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order. vio n,4 to non-critical violations=C.
30.Other DATE OF RE-INSPECTION: Insp tor's ig ure nt:
31.Dumpster screened from public view v+ N C•
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N J
#Seats Observed Frozen Dessert Machines: Outside Dining Y N
PIC Signature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen Y N
Violations related to Foodborne-Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT_ PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) ignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) JAss
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 Poisonous or Toxic Substances 1$ 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*
° *
3-5 1.1 A Hot PHFs Maintained At or Above 140 F
2 590.003(C) Responsibility of the Person-m-Charge to Other* * 0 6( ) o
P tY7-102.11 Common Name-Working Containers *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
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(13) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR=
3-306.14(A)(B)Returned Food and Reated or of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources F 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
( ) P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations *
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef/cri a 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of o Section temporary
and - ide in cater-
* Ratites-165°F 15 sec* in mobile food,tam or and residential
Sources 10 Proper,Adequate Handwashing g' P
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requiremenactices ould be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165'F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* Blue Items 23-30)
3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome
12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts*
3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004 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 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria* _ -
8-103.12 Conformance with Approved Procedures* - S:590Forrnback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
f,
• TOWN OF BARNSTABLE • jBW2539
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager vs All". ,-)2��
Address of Offender MV/MB Reg.#
Village/State/Zip
Business Name C.- VS k"C-. //t %I_/pm, on /U/3i 20C;L--
Business Address 1 U. Alpyt in 5i. -.+ 9
Sig"nature of Enforcing Officer
Village/State/Zip J` 41r,, ,'j A4 d' ` y f
Location of Offense
Enforcing Dept/g'ivision
Offense /U> 12/V J
Facts
�?ooy
This will serve.'only as a warning. At this time n'o legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town
a
se' ., , ., _. ..a,...v.vens.. ... i�_ .. r. .... .�..... t>..-.s>> ........, sF ..._. l:.._..._._ ,..
TOWN OF BARNSTABLE B&,LW-
Ordinance or Regulation' '
WARNING NOTICE.
Name of Offender/Manager
Address of Offender -MV/MB Reg.#
Village/State/zip _
Business Name C r e,;r f ( 0
a!3/pm, on 2
Je
Business Address 1 1,
Sig-fiature of Enforcing Officer
Village/State/Zip A(a 0
-Location of Offense 1/1
Enforcing Dept/Vivision
Offense /J)> P/d
Facts 6 - /*- /) 0/(
This will serve only as a warning. At this time no legal a!(5tion has been' , taken.
It is the goal of Town agencies to achieve voluntary compliance "of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
TOWN OF BARNSTABLE �tPvl BW
Ordinance or Regulation {
WARNING NOTICE
Name of Offender/Manager i h
Address of Offender MV/MB Reg.#
Village/State/Zip
Business Name k/ � �;' = ERA : , a j`.tam/pm; on
Business Address 1 1 ( It], , 4
Signature of Enforcing Officer
Village/State/Zip /-
Location of Offense
Enforcing Dept/Division
Offense t�� �',_�•� '•`r. -� r ,
Facts +� •�
This will serve only as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are.,
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
OCT-31-2000 TUE 04:14 PM LEGAULICENISING FAX NO. 401 765 9304 P. 02
t •
FORM CT-2E MASSACHUSETTS DEPARTMENT OF REVENUE
1 IMPORTANT
EXCISES UNITNOTICE
APPLICATION FOR CIGARETTE RETAILER'S LICENSE Expires.June 30.2002 I
This application is for new and renewal licensas.Please read the instructions enclosed before completing this application.
License fee:58 for over the counter,55 for each vending machine.
Renewals:Please make all changes on the back of this form.
FEDERAL LD.,NO. :
C43—.3Z6 9 ArFLICATICIt s 4281z
New
FOR
LICENSE BOX 2:CIGARETrE SALE LOCATION(it difle,cnt)
applicant
complete IiVANhIS AAIh STREET CYS IhC LIIS FHARMAFII 823aa
reverse T Ly$ DR l7E Nr�FTh 9T
Side only. yGOJ15CCxcI R1 LEES5 "AANIS MA L24LI
❑Check box If Information shown is incorrect or Incomplete.write corrected Information on reverse side.
Mail to:Massachusetts Department of Revenue,PO Box 7012,Boston,MA 02204,
Awn of Barnstable ,
°FtNe Barnstable
Board of Health All-AmedtaCily
saRNSTABM
y Mass. �+ 200 Main Street,Hyannis MA 02601 t '
s63y ♦�
2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
Junichi Sawayanagi
BOARD OF HEALTH MEETING MINUTES
Tuesday, February 10, 2009 at 3:00 PM
Town Hall, Hearing Room
367 Main Street, Hyannis, MA
I. Hearing - Tobacco:
Tobacco violations as reported by Bob Collette of Barnstable County Tobacco
Control.
A. Mid-Way Garage, 981 Main Street, Osterville — First Offense,
tobacco products sold to a minor.
Marco was present and explained it was a new employee who, seeing
everyone busy, jumped in and waited on the customer. All employees have
to review the guidelines and the new customer has been instructed he will be
let go if it happens again.
Upon a motion duly made by Mr. Sawayanagi, seconded by Dr. Canniff, the
Board voted to issue a warning. (Unanimously, voted in favor.)
B. CVS #2322, 176 North Street, Hyannis — Second Offense, tobacco
products sold to a minor.
Store Manager Christine said that they have strict policies on the selling of
tobacco and they have now taken the step to put cigarettes behind a locked
glass door and only management can issue them.
Upon a motion duly made by Dr. Canniff, seconded by Mr. Sawayanagi, the
Board voted to issue a $100 fine. (Unanimously, voted in favor.)
C. Additional Tobacco Item:
Bob Collet recommended allowing his personnel to purchase other items with
the cigarette sales as they have been told that the owners are aware the
policy is to only purchase cigarettes when doing the spot checks. The
Department of Tobacco allows this.
Upon a motion duly made by Dr. Canniff, seconded by Mr. Sawayanagi, the
Board voted to approve the purchase of additional items when doing the
tobacco checks. (Unanimously, voted in favor.)
February 10, 2009 Page 1 of 9
°FI"E' Town of Barnstable
7.
Regulatory Services Barnstable
BARNSrABLE, * Thomas F. Geiler, Director
7V MASS. 0
039. Public Health Division
Thomas McKean, Director 2c,0
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
January 30, 2009
CVS# 2322
176 North Street
Hyannis, MA 02601
NOTICE OF HEARING - BOARD OF HEALTH
On 3/17/08, and on 12/3/08, cigarettes were sold to a minor(a person who was finder the age of
18 years) by a person employed at your store.
According to Section 371-7(B) of the Town of Barnstable Code, no person, firm, corporation,
establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of
the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s) to comply
with these regulations shall be subject to the following actions for each offense: A warning
shall be issued for the first offense. A fine of$100 may be issued for the second offense, $200
for the third offense, $300 for the fourth offense, and $300 for any subsequent offense.
You are hereby notified to appear before the Board of Health on Tuesday, 2/10/09, at 3:00 pm
to show-cause why your tobacco sales permit should not be suspended and to discuss any ,
future plans you may have to comply with this regulation. The hearing will-be held in the
Town Hall, Selectmen's Conference Room, 367 Main Street,Hyannis, Massachusetts.
4PER 0 THE BOARD OF HEALTH
. McKean, RS, CHO
Director of Public Health
Q:\TOBACCO\WP Files\tobacco hearing letter CVS North St Jan09.DOC
3117101
`P,-04 -2008 14.01 BARNSTABLE COUNTY HEALTH P.02
'ii a Li i
J�Cl�';I���n TO ace®Compliance Check Fo in 2007-2008
Surrey Palrteelpa®lls
1D of user: l
, ( s Ate: 5 ® 16 ® 1 i�
Ste:0 Male,.&Femwe
i try , Namof du t Supervisor: i
' r" N re� �•�,;' zip Code-
Time of Check, nm pat C!
Date of Check: A
68ishment: Chairs ❑ independent ® Nat 11 rte�mra
ofthe Week.- ® Man 13 TUes ed
❑Thurs ®F}i ❑ Sat 0 Suva
iyle of sub jwfienj(Check orjy One): _
S� ®r Stare �r
5i' �aa a
? : ® i aor Store 0 Private Club VFW.L ion,etc.
i : aRretaEMt Store ®Resmurant
_ .:s �tium®nl an !Area Stare :.
other bawlin ails , lf.club e%o. ®Tobacconist
'3i.Ma�t
r
#, ';r' ,, a� pfl'lanee Check eomplt te0yes. o
jili+s ;
'';Ne:t,pleose cantiewe on to the next gues8doer. r�IV®please skip r6tGs section and g®to section I
" aaa ruas tobacco Hasa'keted? 9
t 4,�6�•�19 �1$E946't:?18utp6.mks the clerk SDP the product.
a.vending machine�a I�cout devise.
{'tigq�m�il '_
,': Yes® N Was this an -based check? Yes® No�
Vas the-ft ehasor asked f®r ID? I
l i s 'a �6yan Ahe.0mahoser asked hidher age? Yes® No Pam' RL4 C� 1
'! �Q e::.oi'V iae:k: Male® Feaeaale AppromMate age of clerk®Teen uat�?adult 0 Adult Older Adult
, s 6. Cigarettes Brand of cigarettes asked for:❑ Marlboro lervpon ❑Ozher:_ _.
$ '. I jtit.r.of(;¢tba�mceP asked fbt
ip Cl ❑Cigars Other Broad.
® Chew/D
the sale made?
�„hover much did the pr®door cost: was a receipt liven"�' No 13
� s lv
�� ! i �,Il"i a�ylvetar made Pa?Envut twiug:®S1 bills E3 S5 bill(s) ® SS bill and$l bills!or change® $10 bill(s) 0 bill CI chani;,_I
t E:.i kk
I!I ll'tlia>youth did not Ghter the prennisea of dad not attetdtlat to purcloRse tobacco prmdttcea please iaedicaaGc malty:
® bean .1� tin clasure ® in o cratian,erased.as time of visit 0Drive thru oN1
® Tobacco out of stcu ;❑ uns
r s rat sell too ® Unlocaablo
® Pesmit Sus egaded �I
iS ly��ac:1; --Ribl®hut a ® VYtaolesal®anl only/cartons ® Pr�rE�of lip ® ®trier m
°l."I IflriVWt cq>alalg rs®n� ® Machine broken 16 seen in
Ia i
® "Don't sell but tobacco
S i. f Y 6ti iYll'�EE� storeJhas ularmix 9
I
q&SVIS
FEB-17-2011 19,:40 From:BRRNST HEAL 15067906304 To:Fa*rver P.2/7
Town of. Barnstable
HE Regulatory Services 5ulrnztob
Thomas F. Gei}er, Director ""'mC°�;
A Eukwsrabi.R
MAM �� Public Health Division
0r�sV9- Q.
°"'p Tb omas Mclean, Director .
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 5087790-6304
APPLICATION FOR PERNffT TO OPERATE A FOOD ESTABLISHMENT
DATE:
r `
NAME OF FOOD FSTABLISXXIVSENT:
ADDRESS OF FOOD ESTABLISHMENT: / ,l0 IS��/�
MAY AND P'A.RCEL OF FOOD ESTABLISHMENT: MAP. PARCEL(S)
'TT:1,U;I'I"I6NE,NYJMBEIt OF FOOD ESTABLISHMENT:
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:—6---.^^
f
TOTAL NUMER OF BATl-fROOMS:
.ANNUAL OR SEASONAL OPERATION: Z&%'t-4
s
TYPICAL HOURS OF OPERATION MON-FRI: _ TO
IDAYS CLOSED EXCLUDING I:10LIDA S (J..E.MONDAxs)
i k'SEA'ONAL-- ,APPROXIMATE DATES OF OPERATION: ! /._� TO
k**REMINDER*REMINDER"*
SEA
SONAL ESTA.BLISHM.ENTS MUST CALL FOR INSPEi;LION PRIOR TO OPENING
TYPE OF ESTABLISHMENT: PLEASE CII.E✓CK ALL THAT APPLY
FOOD SE:FIVICF ,
RETAIL FOOD
BED & BREAKFAST
CONTINENTAL BREAKFAST
RESIDENTIAL KITCHEN
MOBILE;FOOD
—W-'1'OBACC-70 SA-LES
--FROZEN DAIRY DESSERT MACHINES
CATERING'
_—OUTSIDE DINING (OVER)
�:�]irn4E,\Applicatipn FoiriulFnndo�pl.Joc
FEB-i7-2011 11:40 From:BARNST HEAL, 15087906304 To:Fa rver P.3/7
IF 017SIDE DINING, YQU MUST BE APPROVED BY THE BOARD,OF HEM.TH AND
LICENSING, AND MEET A.L.L OF Tl'IE OUTSIRE DINING QkITERIA
TS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN .PROVIDY'l) AT• WAITSTAY'F SERVICE DOORS)?_-
CONTACT INFORMATION:
PULL NAME UY APPLICANTS US A .._^4e4l ✓i t✓'
SOr1E ONVNER: YES/
ADDRESS 4VZ'-'(y/ ,�117,9
PFIONE # .� 'i zzn�
IF APPLICANT IS A PARTN'RSHIP, FULL NAME AND ROM,ADDRESS OF ALL
PARTNERS.
IF APPLICANT IS A CORPORATION: FEDERAL UMNTIFICATION NO.
STATE OF INCORPORATION
FOOD SlERNgC.'E ESTABLISHMENTS CONDUCTING FOOD PREPARATION LUD;S
RETAIL FOOD ES`FABLIS:CIM.ENTS THAT DO NOT PREPARE FOOD AND
CONTTNE'NTAL BREAKFAST):
IGIST THE NAMFS OF YOUR FOOT) SANITATYON CERTIME.D STAFF (,I-x SERV-SAFl,)
EFFECTIVE JANUAR'Y 1, 2004,.EACH FOOD SERVICE ESTAI3LUS.11 ENT IS .REQTJi12ED
TO HAVE AT L.T%.AST Two FOOD ,SANI'I.'A lON CERTIF ED STAFF. AT LEAST ONE
FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE D'(WNC ALL HOURS
OF OPERATION.*"PLRASE PUT THE NAME OF TH.E ICS'T'ARLISE. M.-ENT ON THE
C.E:RTIMCATE***
a• _„� EXPIRATION DATE
i
21 k+XPYRATION DATE:
.3• EXPIRATION DATE:
4-_—_ .__....__ EXPIRATION 1)A AT / I
X1,41lumfi.1
/�—
SfGNATURI O APPLICANT A.NI) llA'1
��:1il:allhl°valir.Atipn Fnrm;\Foodopnl.doc
FEB-17-2011 11:40 From:BARNST HEALS 15097906304 To:Fa rver P.4/7
WE-1- 'Town of` Barnsta ble
Regulatory Services
Thomas F. Geiler,Director
{ fi"NSPABLE. 3 :Public Health Division
MASK.
1639. Thomas McKean,Director
r D MA�a 200 Main Sweet
.FIyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
FEE: $50.00
MAILTO: 'iO"CIFRARNSTABLE
III-91JUC HEALTH DIVISION''
200 M A IN STREET
RVANNIS,MA 02601
FAX: 508-790-6304
PLEASE INCLUDE TRY R1:(11J1 RED I,'XE Or$50.00
APPLICATION FOR A TOBACCO SALES PERMIT
TA..ST.NAME FIRST NAME MIDDLE INiT1A1.
D/B/A
STREET ADDRESS -
TELEPHONE* NUMBER FID#
Do you currently possess a state license to sell tobacco products?
Yes No
Each employee who sells tobacco products must receive and understand the Sections
VIIb. and VIIc. of the Board of health Prohibition of Smoking Regulation, (copy
provided herein), and the Massachusetts General Laws t'.hapter 270, Section 6.00 (a copy
is provided on the next page). Each employee who sells tobacco products must sign the
Employee Signature Form rovided herein).
Signature Date
y:\iobacrxo wp fclmMobaccu lbrms\tobaccoapp.re.vised10.31.2006.doc
FEB-17-2011 11:40 From:BARNST HEAL# 15087906304 To:Fa rver P.6/7
TOBACCO SALES FERMIT ACKNOWLEDGMENT
This form must be initialed sud signed by the owner/operator of the establishment applying fora
Barnstable Board of ITealth Tobacco Sales Permit. No pernut will be issued until this checklist has
been initialed and signed.
I have read and understand)all subsections within Bamstablc Board of Health Regulations reggding the sale
and distribution of tobacco products.
Initials `
I understand that it is against the law to sell cigarettes or any tobacco product to anyone less in[n eighteen
(1 S)years of age,regardless of how old the person looks.
4
Tnitials /�dc
1 understand)that the Barnstable regulation regttires anyone selling tobacco products to conclusively
establish the customer's age. This means the clerk rnnst ask for and see identificatimn provin c person is
at least eighteen(1 S)years of age.
Initials
T understand that the Barnstable Tobacco Control program conducts frequent compliance checks of r+ll
tobacco merchants'businesses to ensure that tobacco products arc not being sold to minors. This means;
a. The Barnstable'Tobacco Control Progratu will send m.Wors into my establishment to attempt
the purchase of tobacco.
b. These winors will not possess any ident cation,but will respond truthfully when asked their
age.
c. Any reported confrontational behavior towards the mitxir or the enforcement a eent during or
after the compliance check may result in a permanent revocation of the t.obaccq aale9 permit.
Initials,
I understand that if I am caught selling tobacco products to minors,T will be Subject to a warning,fine,
and/or pennit suspension as set forth in tie Board of Health Tohar.o Sales Regulations.
Initials
I understand that the Ramstablo regulations prohibit self-service displays of all tobacco prod is from
which any tobacco Products may be selected.
Initials
l understand that my tobacco sales permit Wt st be posted at all t.imcs in a manner conspicu6u6jo tbo public.
Initials
1 understand that wy Tobacco Sales Ernployee Signature Form must be read and signed by all employees
selling tobacco products,kept on site at sell times, and be in a known location by all employeesftr
inspection.
Initials
By signing this form;I acknowledge that I have read and understand all of the above statements,and
I further understand that failure to abide by these condlitions way jeopardize my Tobacco Sales
Permit.
Lau
eA r
(Name o" usiness) �` (0 Tier/Operator Signatur (Date)
FEB-'21-201'1 MON 11 :51 AM CVS/pharmacy 2322 FAX NO, 508 8611096 P. 01/01
- —..r nil %,V J 'fVl!lVJGyJ
212
> �manc
TOBAccosALts
Eimployee,signature yonn
This fmin is.for official use to Mcp m that the empia (a)of estab 0041nc Vrlb. and Vlxo. Of tie llnxtabla Board of Hearn prOL-bition of�xOQ° 0d�d w,clars The
MWO30d OOPY Of Chpta 270 Sematim 6 of the rl�nsBa4h11getta mngRo�ulatiou mod.the
fey aarl$g atid/M givlttg tobacco:prodactu to,nay pcesoa under bq aP of 0 which aea�xb��e pry
VIIb, lid VM,of ft Bmmtabk Board ofHealqt Rna1a�,; �° (19). B49W arb sectloms.
7b,0
SALE AND DIb"[ BU�'xOI�I 41?TdBACCQ PkQDUG`I'S
o Min= In aoaforZeRma v4th te Ainaac C#saernt t a�va
k&nl,-omPmttav,0stabrfishmmk or.agency eba11 sell tbacco. star 270.SecdcAS,
aa'Worldug m am cstabha�lt Hoemad to BG11,t6baoca Product$�im t or. djwof pxoduot the$ betxewad of�Iee11h sagvlst0nn sad State gttired to recotycT.aw xedipati�t1,atnCt = tlatl=a/iaws,haV4 bdt�nLeD6jV0a t1feBaleq tt �CC4a Uudarato placed ou to in th od, a copy Of
�• 4 mice of tits et�loyar� L Snap a d Py rich
o. n a o �moo.du&g dm liamm herders nnWW bU0imasa hum upon of as
All dis'trlbU%ft ftleYa of tobnooa produ* or tobacco, nmrcbAudw
mast ra
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Th ommonwealth of Massachusetts Print Forme g
Dee artment of Industrial Accidents
Office of Investigations
' I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:CVS/pharmacy#
Address: One CVS Drive, Mail Drop/23062A
City/State/Zip: Woonsocket, RI 02895 Phone #: 401-765-1500
Are you an employer? Check the appropriate box: Business Type(required):
1. ✓❑ I am a employer with employees (full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] g• Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: National Union Insurance Company of Pittsburgh, PA
Insurer's Address: 70 Pine Street
City/State/Zip: New York, NY 10270
Policy# or Self-ins. Lic. # 488-05-63 Expiration Date:01/01/2012 '
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, unde the pains a p alties ofperjury that the information provided above is true and correct.
Signature: Date: O�
Phone#: 401-765-1500
Official use only. Do not write in this area, to be completed by city or town officiat
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
www.mass.gov/dia
Marsh • Page 1 of 5
MEMORANDUM OF INSURANCE DATE
27-Dec-2010
This Memorandum is issued as a matter of information only to authorized viewers for their internal use only and
confers no rights upon any viewer of this Memorandum. This Memorandum does not amend, extend or alter the
coverage described below. This Memorandum may only be copied, printed and distributed within an authorized
viewer and may only be used and viewed by an authorized viewer for its internal use. Any other use, duplication or
distribution of this Memorandum without the consent of Marsh is prohibited. "Authorized viewer" shall mean an
entity or person which is authorized by the insured named herein to access this-Memorandum via
http://www.marsh.com/moi?client=0860. The information contained herein is as of the date referred to above.
Marsh shall be under no obligation to update such information.
PRODUCER COMPANIES AFFORDING COVERAGE
Marsh USA Inc.
("Marsh") Co.A See Additional Information Section
INSURED Co.B
CVS Caremark Corporation &All Subsidiaries and Co.0
Affiliates, including without limitation CVS Pharmacy Inc.
rCo.D
COVERAGES
HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE
POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY
CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MEMORANDUM MAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID
CLAIMS.
CO TYPE OF POLICY NUMBER POLICY POLICY LIMITS
LTR INSURANCE EFFECTIVE EXPIRATION LIMITS IN USD UNLESS
DATE DATE OTHERWISE INDICATED
GENERAL B - GL 4406199 (Prem/Ops - 01-Jan-2011 01-Jan-2012 GENERAL USD
LIABILITY incl. Liquor Liab.) 01-Jan-2011 01-Jan-2012 AGGREGATE 28,000,000
COMMERCIAL B - GL 4406200 (Druggist) PRODUCTS - INCLUDED
GENERAL LIABILITY COMP/OP AGG ABOVE
OCCURRENCE PERSONAL USD
AND ADV 4,500,000
INJURY
EACH USD 4.5M
OCCURRENCE (PREM); 4M
DRUG
FIRE DAMAGE USD
(ANY ONE 1,000,000
FIRE
MED EXP (ANY
ONE PERSON
AUTOMOBILE B - CA 4309360 (AOS) 01-Jan-2011 01-Jan-2012 COMBINED USD
LIABILITY B - CA 4309361 (VA) 01 Jan-2011 01-Jan-2012 SINGLE LIMIT 2.000.000
ANY AUTO B - CA 4309362 (MA) 01-Jan-2011 01-Jan-2012 BODILY INJURY
HIRED AUTOS PER PERSON
NON-OWNED BODILY INJURY
AUTOS (PER
Self Insured - CCIDENT
Physical Damage PROPERTY
DAMAGE
EXCESS EACH
LIABILITY OCCURRENCE
AGGREGATE
GARAGE AUTO ONLY
LIABILITY (PER
CCIDENT
OTHER THAN AUTO ONLY:
EACH
ACCIDEN
AGGREGATE
WORKERS C - WC 061967163 01-Jan-2011 01-Jan-2012 WORKERS Statutory
COMPENSATION /(AR,GA,HI,IL,IN,KS,KY,LA, 01-Jan-2011 01-Jan-2012 COMP LIMITS
EMPLOYERS MD,MO,MS,NM,OK,PA,SC,SD,TN)I
01-Jan-2011 01-Jan-2012 EL EACH USD
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Marsh • • " Page 2 of 5
J`
LIABILITY B - WC 061967167 (AL,AZ, 01-Jan-2011 01-3an-2012 ACCIDENT 2,000,000
HE PROPRIETOR/ CO,DE,ID,IA,ME,MI,MT, EL DISEASE - USD
PARTNERS/ NE,NH,NV,UT,VT,WV) POLICY LIMIT 2,000,000
EXECUTIVE B - WC 061967162 (CA Only) EL DISEASE - USD
OFFICERS ARE: B - WC 061967160 (MN ONLY, EACH 2,000,000
EXCLUDED WI) EMPLOYEE
A PROPERTY Refer to Additional Information 30-3ul-2010 30-3ul-2011 ALL RISK OF
Property Section DIRECT
PHYSICAL
LOSS OR
DAMAGE
INCLUDING
FLOOD AND
EARTHQUAKE,
SUBJECT TO
POLICY TERMS
AND
CONDITIONS
EXCESS E - 488-05-63 01-3an-2011 O1-3an-2012 WC - EMPLOYERS
WORKERS STATUTORY LIABILITY:
COMPENSATION USD 500,000
(CT, DC, MA, NC,
N) OH RI VA
WORKERS D - WC 061967165(OR only) 01-Jan-2011 01-Jan-2012 WC - EMPLOYERS
COMPENSATION STATUTORY LIABILITY:
USD
2 000 D00
The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage. Any
modifications hereto are not authorized.
MEMORANDUM OF INSURANCE DATE
27-Dec-2010
This Memorandum is issued as a matter of information only to authorized viewers for their internal use only and
confers no rights upon any viewer of this Memorandum. This Memorandum does not amend, extend or alter the
coverage described below. This Memorandum may only be copied, printed and distributed within an authorized
viewer and may only be used and viewed by an authorized viewer for its internal use. Any other use, duplication or
distribution of this Memorandum without the consent of Marsh is prohibited. "Authorized viewer" shall mean an
entity or person which is authorized by the insured named herein to access this Memorandum via
http://www.marsh.com/moi?client=0860. The information contained herein is as of the date referred to above.
Marsh shall be under no obligation to update such information.
PRODUCER INSURED
Marsh USA Inc. CVS Caremark Corporation &All Subsidiaries and
("Marsh") Affiliates, including without limitation CVS Pharmacy Inc.
ADDITIONAL INFORMATION
PROPERTY- Retail Stores
Policy Limits : $50,000,000
ADDITIONAL PARTICIPATING INSURERS: Lexington Insurance Company Policy # 066095392 Ironshore Specialty
Insurance Company Policy # 00596101 FM Global Policy #AG461 Lloyd's of London Policy #DP778010, Allied World
Assurance Company, Ltd Policy # P010154/002 and others
NAMED INSURED
CVS Caremark Corporation
One CVS Drive
Woonsocket, RI 02895
and its allied, affiliated, subsidiary, and associated companies and/or corporations through ownership or
management and the insured's interest in trusts, partnerships, limited liability companies, and joint ventures as now
exist or may hereafter be constituted or acquired including their interests as owners, nominees, mortgagees, agents
for others or otherwise as indicated and any party in interest which the insured is responsible to insure. hereinafter
i
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Marsh • • Page 3 of 5
referred to as "the insured". it is further agreed that as respects joint ventures and partnerships entered into by the
named insured, that at the option of the named insured, these entities are insured under this policy
c/o Mr. David Huntley
Director - Risk Management
CVS Caremark Corporation
One CVS Drive
Woonsocket, RI 02895
EVIDENCE/CERTIFIACTES OF INSURANCE
Any evidence of insurance issued in connection with this policy, including electronic memorandums of insurance,
shall be issued solely as a matter of convenience or information for the addressee(s), holder(s) or viewer(s) of said
evidence of insurance, except where under written contract with a third party the Insured is required to provide
property insurance for the benefit of a third party and include the interest of such third party under said property
policy as either additional insured, loss payee or mortgagee pursuant to said contract. In such event, the interest of
such third party as either additional insured, loss payee or mortgagee as its interest may appear shall be covered
under this policy as of the inception date of this policy if the contract had been entered into by the Insured prior to
the policy's inception date, or as of the date the Insured enters into contract with the third party if such date occurs
subsequent to the policy's inception, subject.otherwise to all of the policy's, terms, conditions and exclusion.
Further, the inclusion of such additional interest(s) shall not increase this Company's limit of liability under this
policy.
It is also agreed that in the event of loss or damage to property insured under the Insured's property policy where
the third party has an interest in said property per contract with the Insured as either additional insured, loss payee
or mortgagee and is not otherwise specifically named under the policy or made known to the Company prior to loss,
such interest will be notified to the Company on the date of the notice of loss per the policy's conditions or as soon
as reasonably practicable thereafter. Failure to timely notify the Company in such event will not relieve this
Company of any liability for said additional interests, but will be corrected as soon as possible.
The Company also authorizes Marsh USA Inc. to issue certificates of insurance or to display Memorandum of
Insurance including any mortgagee, loss payee and additional insured clauses consistent with the foregoing.
STANDARD MORTGAGEE CLAUSE
Loss or damage, if any; under this policy, shall be payable to any mortgagee, (or trustee) as designated herein by
endorsement or certificate of insurance, as interests may appear, under all Present or future mortgages upon the
property herein described in which the aforesaid may have an interest as mortgagee(or trustee), in order of
precedence of.said mortgagees, and this insurance, as to the interest of the mortgagee or trustee only therein, shall
not be invalidated by any act or neglect of the mortgagor or owner of the within described property, nor by any
foreclosure or other proceedings or notice of sale relating to the property, nor by any change in the title or
ownership of the property nor by the occupation of the premises for purposes more hazardous than are permitted
by this policy; provided, that in case the mortgagor or owner shall neglect to pay any premium due under this
policy, the mortgagee or trustee, shall, on demand, pay the same. Provided also, that the mortgagee (or trustee)
shall notify the Companies of any change of ownership or occupancy or increase of hazard which shall come to the
knowledge of said mortgagee, (or trustee) and, unless permitted by this policy, it shall be noted thereon and the
mortgagee (or trustee) shall, on demand, pay the premium for such increased hazard for the term of the use
thereof; otherwise this policy shall be null and void. The Company reserves the right to cancel this policy at any
time provided by its terms, but in such case this policy shall continue in force for the benefit only of the mortgagee
(or trustee) for 90 days after notice to the mortgagee (or trustee) of such cancellation and shall then cease and the
Companies shall have the right, on like notice, to cancel this agreement.
Whenever the Companies shall pay the mortgagee (or trustee) any sum for loss or damage under this policy and
shall claim that, as to the mortgagor or owner, no liability therefore existed, the Companies shall, to the extent of
such payment, be thereupon legally subrogated to all rights of the party to whom such payment shall be made
under all securities held as collateral to the mortgage debt, or may, at its option, pay to the mortgagee (or trustee)
the whole principal due or to grow due on the mortgage with interest accrued thereon to the date of such payments,
and shall receive a full assignment and transfer of the mortgage and of all such other securities; but no subrogation
shall impair the right of the mortgagee (or trustee) to recover the full amount of said mortgagee's (or trustee's)
claim.
CANCELLATION
A. This policy may be canceled at any time at the request of the Insured or it may be canceled by the Company by
mailing to the Insured at:
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f
Marsh Page 4 of 5
Director of Risk Management
One CVS Drive
Woonsocket, RI 02895
and to the additional named insureds/loss payees or mortgagee indicated on the certificates of insurance issued
during the term of this policy, written notice stating when, not less than 90 days thereafter, such cancellation shall
be effective. The earned premium shall be computed on a pro-rata basis.
B. The mailing of notice as aforesaid shall be sufficient proof of notice and the effective date and hour of
cancellation stated in the notice shall become the end of the policy period. Delivery of such written notice either by
the Insured or by the Company shall be equivalent to mailing.
C. Cancellation shall not affect coverage on any shipment in transit on the date of cancellation. Coverage will
continue in full force until such property is safely delivered and accepted at place of final destination.
D. In the event of non-payment of premium this policy may be canceled by the Company by mailing to the Insured
at the address shown in A. above stating
when, not less than 10 days thereafter, such cancellation shall be effective. Reinstatement of coverage shall be
effective immediately upon receipt of
premium by the Company,
ADDITIONAL INSURED, LOSS PAYEE, OR MORTGAGEE
Any party which the Named Insured is contractually required to include as an Additional Insured, Loss Payee, or
Mortgagee is granted such status under this policy as such interest may appear. Coverage under the policy applies
only to the extent of the coverage required by such contractual requirement and for the limits of liability specified in
such contractual requirement, but in no event for insurance not afforded by the policy nor for limits of liability in
excess of the applicable limits of liability of the policy.
The existence of more than one insured, Additional Insured or other interests shall not serve to increase the limits
of liability of the policy.
PERILS: "All Risk" of direct physical loss or damage including Earthquake, Flood, and Wind, subject to policy terms
and conditions. Boiler and Machinery Perils, Terrorism, Mold and Business Interruption are excluded.
PROPERTY COVERED
Real and Personal Property, Extra Expense, Improvements and Betterments, Structures in the Course of
Construction, Newly Acquired Locations and as more fully described in the policy.
PROPERTY VALUATION
Replacement Cost, if replaced, for Assets other then inventory. Inventory is insured at sales price less normal
discounts and adjustments. Policies include a waiver of subrogation to the extent agreed to by the Named Insured
in any lease, agreement or written contract.
PROPERTY - Other than Retail Stores
POLICY LIMITS: $500,000,000 subject to various sublimits for named wind storm, flood and earth movement.
INSURER: FM Global Policy Number AG459
PERILS: "All Risk" of direct physical loss or damage including Earthquake, Flood and Wind subject to policy terms
and conditions. Boiler and Machinery perils and business interruption are included. Terrorism and Mold are excluded.
PROPERTY COVERED: Real and Personal property, improvements and betterments, structures in the course of
construction, newly acquired locations and extra expenses and as more fully described in the policy.
PROPERTY VALUATION: Replacement cost, if replaced, for all assets. Policies include waiver of subrogation to the
extent agreed to by the Named Insured in any lease, agreement or other written contract.
ADDITIONAL INSURED, LOSS PAYEE OR MORTGAGEE: Any Party which the Named Insured is contractually required
to include as an Additional Insured, Loss Payee or Mortgagee is granted such status under this policy as such
interest may appear. Coverage under this policy applies only to the extent of the coverage required by such
contractual requirements and for the limits of liability specified in such contractual requirement, but in no event for
insurance not afforded by the policy nor for limits in excess of the applicable limits of liability of the policy.
GENERAL LIABILITY; AUTOMOBILE; WORKERS COMPENSATION; EXCESS WORKERS COMPENSATION:
COMPANIES AFFORDING COVERAGE:
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Marsh Page 5 of 5
B - New Hampshire Insurance Company
C - Chartis Casualty Company
D - Insurance Company of the State of Pennsylvania
E - National Union Insurance Company of Pittsburgh, PA
TEXAS WORKERS COMPENSATION DEDUCTIBLE POLICY:
Policy # WC 061967161 (via New Hampshire Ins. Co.).
Effective January 1, 2011 - January 1, 2012
Limits: WC - Statutory/ Employers Liability $2MM
FLORIDA WORKERS COMPENSATION DEDUCTIBLE POLICY:
Policy # WC 061967164 (via New Hampshire Ins. Co.).
Effective January 1, 2011 - January 1, 2012
Limits:—WC— -Statutoryy-Employer-s-Lia.bility_._$2MM
NY, OH, WA, WI, WY WORKERS COMPENSATION RETRO POLICY: !�
Policy # WC 061967166 (via New Hampshire Ins. Co.). \
( Effective January 1, 2011 - January 1, 2.012
Limits: Employers Liability $2MM
Te orr rism coverage included on General Liability, Automobile Liability, Workers Compensation and Excess Workers
Compensation policies.
Virginia Garage Liability coverage is included on General Liability policy GL 4406199
SELF-INSURED RETENTIONS:
General Liability -
USD 500,000 Prem/Ops - Including Liquor Liability
USD 1,000,000 Druggist
Excess Workers Compensation:
USD 500,000 - DC, MA, OH, RI
USD 1,000,000 - CT, NC, NJ, VA
NEW HAMPSHIRE INSURANCE COMPANY ENDORSEMENT CLAUSE FOR ADDITIONAL INSURED: FORM 61712 (12/06)
ADDITIONAL INSURED - WHERE REQUIRED UNDER CONTRACT OR AGREEMENT
SECTION II - WHO IS AN INSURED, IS AMENDED TO INCLUDE AS ADDITIONAL INSURED:
ANY PERSON OR ORGANIZATION TO WHOM YOU BECOME OBLIGATED TO INCLUDE AS AN ADDITIONAL INSURED
UNDER THIS POLICY, AS A RESULT OF ANY CONTRACT OR AGREEMENT YOU ENTER INTO WHICH REQUIRES YOU
TO FURNISH INSURNACE TO THAT PERSON OR ORGANIZATION OF THE TYPE PROVIDED BY THIS POLICY, BUT
ONLY WITH RESPECT TO LIABILITY ARISING OUT OF YOUR OPERATIONS OR PREMISES OWNED BY OR RENTED TO
YOU. HOWEVER, THE INSURANCE PROVIDED WILL NOT EXCEED THE LESSOR OF:
-THE COVERAGE AND/OR LIMITS OF THIS POLICY, OR
-THE COVERAGE AND/OR LIMITS REQUIRED BY SAID CONTRACT OR AGREEMENT.
The Memorandum of Insurance serves solely to list insurance policies, limits and dates of coverage.Any
modifications hereto are not authorized.
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HEALTH INSPECTOR'S �j / 7_ Q Pa
t TOWN OF BARNSTABLE OFFICE INSPECTOR'S Establishment Name: �[ S Date Page: of
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
1:00-2:00 P.M.
r ) 367 MAIN STREET MON.-FRI.
„ HYANNIS,MA 02601 ssz as4a ii8ttt mod@ GIIhE�I!Itet3E�RPK %inQU71t�N iL1lN IiF fQEtET� t38t+v@rtfleC
f639
,. ,F;8f8r811 R tRed Ala Y
glnrtNrrtty F r £:
FOOD ESTABLISHMENT INSPECTION REPORT / /
Name Date T e of O eration s T e fps ection `` 5f0.003 4✓ (� "` 04� a u
Address Risk ❑ Fo ervice outine
HN Level etail ❑ Re-inspection d-
Telephone ❑ Residential Kitchen Previous Inspection
❑ Mobile Date:
Owner HACCP Y/N ❑ Temporary ❑ Pre-operation
❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
In: _ ❑ HACCP IV
Inspector / Out: Permit No. YY ❑ Other cr
G:fD"eG
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: 0
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F)❑
Action as determined by the Board of Health. L
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
113.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
❑ 5.Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6.Tags/RecorcWAccuracy of Ingredient Statements ❑ 17. Reheating
❑7.Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑ 20. Time As a Public Health Control
❑ 9.Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 10.Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP
❑ 11.Good Hygienic Practices CONSUMER ADVISORY
Violations Related to Good Retail Practices(Blue Items) ❑ 22• Posting of Consumer Advisories
Critical(C)violations marked must be corrected immediately. Number of Violated Provisions Related
Non-critical(N)violations must be corrected immediately or To Foodborne Illnesses Interventions
within 90 days as determined by the Board of Health. and Risk Factors(Red Items 1-22)•
Official Order for Correction: Based on an inspection today,
23. Management and Personnel (FG2)(590.003) the items checked indicate violations of 105 CMR 590.000/federal
24. Food and Food Protection (FG3)(590.004) Food Code.This report,when signed below by a Board of Health
25. Equipment and Utensils (FG4)(590.005) member or its agent constitutes an order of the Board of Health.
.::..,.,. . \....�. .....\ \\ .: . .. \\ems e.\• ."` .. \. a:
Failure to correct violations sled In this report may result in sus �. .. a\ .......\ \\. \..._...
In and Waste FGS 590.006 ` :_�.:.. . ::.:> �•• .r.�. _ ��\\• .\ .a\ ..� \ .\.•.:...::.26. Water,Plumbing ( )( ) �:: �\ \ �$ \ \�.. �. .. \ \
pension or revocation of the food establishment permit and ces fr A�ti� \ ., a..• ...,..��-,..,, ....a .��.,�;�� �,.,�,, ��;\.�.�;� :�\\�..
27. Physical Facility (FG6)(590.007) sation of food establishment operations. If aggrieved by this or �' '• •\`' " •° `'•s �? �•aa '\
28. Poisonous or Toxic Materials (FG7)(590.008) der,you have a right to a hearing. Your request must be in writ- ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
29. Special Requirements (590.009) ing and submitted to the Board of Health at the above address __
30. Other within 10 days of receipt of this order. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: �'.:
DATE OF RE-INSPECTION:
;LAP'.;LAP'.D Inspector's Signature Print:
Permit Posted?_,,�y N Grease Trap Previous Pumping Date Grease Rendered? Y N _ ` C."t-7 C, G
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print:J,�� •..:.rr. 1u
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N ' 1 'v l a ra
1Yo/adons Related to FILe Illness 3-501.14(C) PHFs Received at Temperatures
Interventions and Risk Factors(Red Items 1-22) Violat/ons Related to Foodbome Illness Interventions and Risk According to Law Cooled to
PROTECTION FROM CONTAMINATION Factors(Red Items 1-22) (Cont.) 41°F/45°F Within 4 Hours.
FOOD PROTECTION MANAGEMENT 8 Cross-contarrrnadon 3-501.15 Cooling Methods for PHFs
1 I 590.003 A) J_Assignment of Responsibility* 3-302.11(AXI) Raw Animal Foods Separated from PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding
590.003 B Demonstration of Knowl e` Cooked and RTE Foods* 14 Food or Color Additives
2-103.11 Person in charge-duties Contamination from Raw Ingredentis 3-202.12 Additives* 3-501.4(F) Cold PHFs Maintained at or below
3-302.11(Ax2) Raw Animal Foods Separated from Each 3-302.14 Protection from Unapproved Additives* 590.0016( 41°/45°F'
EMPLOYEE HEALTH Other* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
Contamtnation from the Environment 7-101.1 1 Identifying Information-Original 140°F.
2 590.003(C) Responsibility of the person in charge to fy g g�
require reporting by food employees and 3-302.1 I A Food Protection* Containers* 3-501.16(A) Roasts Held at or above 130°F.
applicants* 3-302.15 Was hum Fruits and Vegetables 7-102.1 1 Common Name-Working Containers* 20 Time as a Public Health Control
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and 7-201.1 1 Separation-Storage* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Utensils' 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
Charge* Contarination from the Consumer 7-202.12 Conditions of Use*
590.003 G Reporting by Person in Charge* 3-306.14 A B Returned Food and Reservice of Food* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
3 590.003D Exclusions and Restrictions* Disposition of Adulterated or Contaminated 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP)
590.00 Removal of Exclusions and Restrictions Food 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.1 1(A) Unpasteurized Pre-packaged Juices and
3-701.1 I Discarding or Reconditioning Unsafe 7-204.14 Drying Agents,Criteria* Beverages with Waning Labels*
FOOD FROM APPROVED SOURCE Fes* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs'
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.1 1 Restricted Use Pesticides,Criteria* 3-801 A 1(D) Raw or Partially Cooked Animal Food and
590. A-B Compliance with Food Law` 4-501.111 Manual Warewashing-Hot Water 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served.*
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) I.Unopened Food Package Not Re-served.
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashmg-Hot Water Monitoring*
3-202.13 Shell Eggs* San°tization Temperatures* CONSUMER ADVISORY
* 4-501.114 Chemical Sanitization-temp.,pH 22 3-603.11 Consumer Advisory Posted for Consumption of
3-202.14 Eggs and Milk Products,Pasteurised TIME/TEMPERATURE CONTROLS r7' P
concentration and hardness.' Animal Foods That are Raw,Undercooked or
3-202.16 Ice Made From Potable Water* 16 Proper Cooking Temperatures for
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and PHFs Not Otherwise Processed to Eliminate
Utensils Clean' Pathogens.*E"161 a001
590. A BottledDrinkingWater* 3-401.I 1 A(1)(2) Eggs- 155°F 15 Sec.
4-602,11 Cl F of Equipment Food- 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs*
590. Water Meets Standards in 310 CMR 22.0* �Frequency Pm Eggs-Immediate Service l45°F15sec• gg gg
Contact Surfaces and Utensils'
Shemfish and Fish From an Approved Source 3401.11(A)(2) Comminuted Fish,Meats&Game
4-702.11 Frequency of Sanitizatiom of Utensils and Animals-I55°F 15 sec ' SPECIAL REQUIREMENTS
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* . 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
Shellfish' Methods of Sanitization-Hot Water and 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* catering,mobile food,temporary and
4-703.11
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec.
Sources' Adequate Handwash . residential kitchen operations should be
Game and Wild Mushrooms Approved by iU 2-301.11 Clean Condition on-Hands and Arms* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections
R ula Authority
3-202.18 Shellstock Identification Present' 2-301.12 Cl Procedure- Stuffing Containing Fish,Meat,' above n related to f k factors.
illness
* 2-301.14 When to Wash* Poultry or Ratites-165°F 15 sec.' interventions and risk factors. Other
3-2 C Wild Mushrooms 3-401.11 C 3 Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail
3-201.17 Game Animals' 11 Good Fiyglerttc Practices ( )( ) g
2401.11 Ea' or Using Tobacco* 145°F* practices should be debited under#29-
5 Recelvl riditlort 3-401.12 Raw Animal Foods Cooked in a Special Requirements:
3-202.11 PHFs Received at Tem lures* 2401.12 Discharges From the Eyes,Nose and
3-202.15 Package Integrity* Mom* Microwave 165°F*
3-101.1] Food Safe and Unadulterated*
3-301.12 Preventing Contamination When Tasting* 3401.11(A)(1)(b) All Other PHFs-145°F 15 sec.• VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
6:. TagslRecords•Shellstot3r 12.:: Prevention of Contamination from Hands 17 Reheating for Hot Holding Blue Items 23-30)
590. Preventing Contamination from 3-403.11 A D * Critical and non-critical violations,which do not relate to the
3-202.18 Shellstock Identification* 004(E) ees ( )&( ) PHFs 165°F 15 sec. foodborne illness interventions and riskfactors listed above,can be
3-203.12 Shellstock Identification Maintained` Employees* 3403.11(B) Microwave-165°F 2 Minute Standing found in the following sections of the Food Code and l 05 CMR
13" Handwash Facilities Time*
Parasite Destruction*
Fish Products Conveniently Located and Accessible 3-403.11(C) Commercially Processed RTE Food- 590.000.
3.402.11 Parasite Destruction* Item Good Retail Practices FC 590.000
3402.12 Records,Creation and Retention* 5-203.11 Numbers and ties* 140°F* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-403.11 E Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004
590. J Labeling of Irgredierrts' ( ) g
.: Cordormance with Approved Procedures 5-205.11 Accessibihty,Operation and Maintenance Roasts* 25. Equipment and Utensils FC-4 .005
/NACCP Plans Suppled w/tlt Soap and Wand Drying Devices 18 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 .006
3-502.11 Specialized Pr Methods* _ 3-501.14(A) Cooling Cooked PHFs from 140°F to 27. Physical Facility FC-6 .007
6-301.11 Handwas Cleanser,Availability28. Poisonous or Toxic Materials FC-7 .008
3-502.12 Reduced oxygen criteria` 70°F Within 2 Hours and From 70°F 29. S ecial Requirements 009
8-103.12 Conformance with Approved Procedures* 6 301.12 Hand Provision to 41°F/45°F Within 4 Hours.*
30. Other
3-501.14(B) Cooling PHFs Made From Ambient
Temperature Ingredients to 41°F/45°F
Within 4 Hours*
'D®des 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.
TOWN OF BARNSTABLE. BAR-w 5834- --
ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager
Address of Offender MV/MB Reg.#
Village/State/zip rAA n n
Business Name r JOAA /101pM, On A40,.,117200-0
Business Address (1) Al Of-dA S t AA-P,14�1--1-- 4
Signatdl-46f 'Ehf orcing Officer
Village/State/Zip MA 0-76 0 1
Location of Offense 1-1 /o
j Enforcing Dept/Division
Offense 63 1 `ig .AA f) &31 in C>17' b(P rn ck
Facts 'z'Q
This will serve only as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices ate
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
III WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
TOWN OF BARNSTABLE0 BAR-W 55 0 3 ti.
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager k'( ,Tjn
Address of Offender (V S,, -71 f l tr r MV/MB Reg.#
Village/State/zip _
Business Name r -1-) 1 -3 (alpm, on A?� 2 O;.;'-'
Business Address r Ott f >-1
Sig6adttfr—e 'bf Enforcing Officer
Village/State/Zip -C-")
Location of Offense
Enforcing Dept/Division
,
Offen
se -I P
Facts LA-P
This will serve only as a warning. At this time no legal action has been taken,.,...
It is the goal of Town agencies to achieve voluntary compliance of Town -
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
Q VE T° o g
wti Town of Barnstable
Regulatory. Services Bari�table
- BARNSTABLE. = Thomas-F. Geiler,Director
MASS. a
1639. ,�� Public Health Division , r
°ATfD MPy A, Thomas McKean, Director
200 Main Street
Hyannis, MA,02601
Office: 508-862-4644 Fax: 508-790-6304
March 19, 2008
CVS# 2322
176 North Street
Hyannis, MA 02601
NOTICE OF HEARING - BOARD OF HEALTH
On 3/17/08, cigarettes were sold to a minor(a person who was under the age of 18 years) by a
person employed at your store.
According to Section 371-7(B) of the Town of Barnstable Code, no person, firm, corporation,
establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of
the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fails) to comply
with these regulations shall be subject to the following actions for each offense: A warning
shall be issued for the first offense. A fine of$100 may be issued for the second offense, $200
for the third offense, $300 for the fourth offense, and $300 for any subsequent offense.
You are hereby notified to appear before the Board of Health on Tuesday, 4/08/08, at 3:00 pm
to show-cause why your tobacco sales permit should not be suspended and to discuss any
future plans you may have to comply with this regulation. The hearing will be held in the
Town Hall, Hearing Room, 367 Main Street, Hyannis, Massachusetts.
ORDE THE OARD OF HEALTH
Thomas A. McKean, RS, CH
.Director of Public Health
Q:\TOBA000MP Files\tobacco hearing letter CVS North St Mar08.DOC
M�R--18%-21 UEI 10.'40 EARNS COUNTY HEALTH 15083756830 P.02i0`5
, lip➢ ��l�m�� SwNey Pardeiparb.
1�� ►�a : 11)OfPurchas ® �
Age:C1 l5 a 16 '�
t$c Seer iv1 Female
Nam .ofAdult 3upW-as0r:
� Code: �� t✓ ��'P Time of Check
`"pr ®:I.':E 1�1'a,clmeeut: ain. Q independent: El NotKno nn
Dam of Check:
Day of the W on Q Tues Q Wed
Q 7burs i? Q: Sag Et Sun
y,i1FrctF>:stB!bli! aat(Check Only Orie). GBar
( i;otavet!e; ca Sty Q G 5tor>u LAPrivate Club on,eta)
f 'I T,�sauna gnu a or Stove
P.
arm �Drn Store
Q Restaeara�at
Star®
1'1,rya!L St ai.a n®rnl 11 Tobam onist
Q Other(bowling±Lq
VIf club etc.
i --,_ Blm,pUanea Cbeek eampleted?Yes o �
�jf F?s,piecuie c(axnrime on to the next gvestfon if No Please sbP this section and go io sectfon 3.
XvFri !svrl tobacco m etedg
b,,,!er-bo—c3u nter:youth asks the clerk for the product.
t3 From a vsaxditng machine LoAa lockout device.
! E3 Ober
+ �,,/ Was this an M based check? Yes Q N
!u nihaser aid for M? Yes�] N
',Jr311-hm E�!urt.haser asked hislher ago?' Yes®.N �$S 1�t D h���; At 5�iYl
cr.F CbzN-k: Male Female 11 Approximate age of clerk:E3 Teat Dung Adult El Adult ®Older Adult
EX , Brand of cigarettes asked ibr: aErorlla
lb 111Vei4rpQM Q Other:
'T!f die!cot'trol�rac:�ststo�fbr: �
13 Chew/Dip El Cigars Q Other nd: ---
Mal•l ie sale made? Yes PkID
jf,-f es"how much did the pnduet cagt S Was a receipt given?YC04M® s ® ��bill ❑ r��anng
made l»aymaatai using:M S 1 bills Q SS bill(s) Will
bill and SI billst or change Q S10 ( )
]lf tb n yotu!ih did not enter the premises or did not attempt to purchase tobacco Products please indicate why:
C? C:►r�cal;l� sitns Q. Ten ,ton term closure Q. In aaon,dared at time of visit ® Tlri�re thru onl
,.re.. ° ( �m 13 Unsafe tea Cl �°ci out of stock
]: .not sdl tat16cca Q Un_ocatable limit S ded
iile ®ntth 12 )WOlesale cant Icartons 13 m of ice
I �l;�aacc + Cl father
fn'( is etvat�!,e dublpffsond [- Machine broken
rc,,rlt:ncte El 'can't sell"buttebacce Sean iff
1 stomfhaa. 'r