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HomeMy WebLinkAboutBARNSTABLE BOTTLE - RETAIL FOOD BARNSTABLE BOTTLE 10 SEABOARD LN. , HY. "1 ►+ Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. R►A3i CADM, F.P.(Thomas)Lee Daniel Luczkow,200 Main Street, Hyannis, MA 02601 Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 144 Issue Date: 1/1/2021 DBA: BARNSTABLE BOTTLE SHOPPE OWNER: MARK BISSETT Location of Establishment: 10 SEABOARD LANE HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY I i For Office Use nl.ye Initials: Town of Barnstable �ypqT Date Paid j anxxernars�� Inspectional Services Check o Public Health Divisional - a Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT....PERMIT.APPLICATION Non-Flavored) DATE_I4t NEW BUSINESS OWNERSHIP RENEWAL V"' s NAME OF TOBACCO ESTABLISHMENT: -uwr—+k-)(bui ccep- Jk Q M46 A �0— 15D 1?-1 x 0 � b o� (x,- � a� n�5 c AA 6 �'►� ADDRESS OF TOBACCO ESTABLISHMENT: . MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: ©Ot A Ir Cbmchi' I e4... i TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: CM J11- 220 OWNER'S NAME: N la(4a 6fwm n OWNER'S PH#L-L_l/ IfY 663 P iA 21L 6 1$6-e`jt,, 'jj08 V7a r3 71 OWNER'S ADDRESS: Lv►. WAI'V3 OcIP NJ"M�)).5 b�6`I MA a �M�k1L CORPORATE NAME: � �� CORPORATE ADDRESS: �� 5=(',W� Kd C-P` CORPORATE ANNUAL:__ SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS).. TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: z t TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httos://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: hgps:Hmale�,islature gov/Laws/GeneralLaws/PartIV/Titlel/Chg,ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. s PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: z f 4 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 . � r / V SIGNATURE: � PRINTED NAME: DATE:. q / /-2WC) Q:1Apphcation Fonns\TOBACCO APP-NonFavor 12-18-19.docx r: '- I ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 3 71-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—k 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Si a re Printed Name Date Signature Printed Name Dat L 1-1 —?P --� gna r PnAt//ess ffaffine / Dane/ C Ll Pa Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx ------------------------------ MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T 'A ; .Retailer License for Sale of Cigars and Smoking Tobacco bF�.r01i This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. , DEER HOLLOW CORPORATION Account ID: CRL-11615327-009 BARNSTABLE BOTTLE SHOPPE License Number: 745940992 10 SEABOARD LN HYANNIS MA 02601-2345 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 8,2020 Expiration Date:September 30, 2022 SpyOCN(T. MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 `v y Retailer License for Sale of Cigarettes o��` This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. DEER HOLLOW CORPORATION Account ID: CGL-11615327-006 BARNSTABLE BOTTLE SHOPPE License Number: 738940928 10 SEABOARD LN HYANNIS MA 02601-2345 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 9, 2020 Expiration Date: September 30, 2022 i -w. .. . ' 1 1 4 4 _ F- r A r+ Cv�E W r545-0123 FOfm 1 1 20-5 U.S. income Tax Return for aril S Corporataf�t�i�, t�� ---- ► Do not file this form unless the corporation has filed or 20 Department of the Treasury Is attaching Form 2553 to elect to be an S corporation. L 19 Interrat Revenue Service ► Go to wwwJrs.gov1Form1120S for instructions and the latest information. For calendar year 2019 or tax year beginnin2 2019, ending D Employer identification number A S etecl+orr effectke date 1/01/1995 TYPE 04-3254061 B Buslnssattr-tym;,de Deer Hollow Corp. E Date incorpo'ated nu,rrW(see jnstruct,Drs) OR 10 Seaboard Lane 9(3t](19 9 A 445320 C Check if schedulePRINT Hyannis, MA 02601 I F Tota;assets(see _tructo-rsl' M-3 attached 11 1 1 $ G Is the corporation electing to bean S corporation beginning with this tax year? Yes X No If'Yes,' attach Form 2553 if not already filed H Check if: (1) Final return (2) LjName change (3) LJtAddress change (4) Amended return (5) Q S election termination or revocation f Enter the number of shareholders who were shareholders during any part of the tax year........................................ ► 2 J Check if corporation: (1)U Aggregated activities for section 465 at-risk purposes (2) 0 Lros�ped activities for section 469 passive activity purposes Caution:Include only trade or business income and expenses on lines to through 21.See the instructions for more information. 1 a Gross receipts or sales.................... ............. la ; b Returns and allowances...........................-..................... 1 b + c Balance. Subtract line I from line I............................................. 1 c c 2 Cost of goods sold(attach Form 1125-A).....:...................... ...............................: 2 t9 # "..• aoa 3 Gross profit.Subtract tine 2 from line lc............... 3 e 4 Net gain (loss)from Form 4797,tine 17(attach Form 4797)........................................... 4 5 Other income(loss)(see instrs—aft statement)................... See,.Statement. l 5 6 Total income(loss).Add lines 3 through 5............... ► s t 7 Compensation of officers(see instructions -attach Form 1125-E)..................................... 7 ' E R 8 Salaries and wages(less employment credits)................................................ ....... 8 e 9 Repairs and maintenance.......................................................................... 9 ° 1(4 Sad debts.................... 10 11 Rents........ ; 1 12 Taxes and licenses................................................................ 12 N13 Interest(see instructions) .............................................. ... ...... 13 14 Deore6ation not claimed on Form 1125-A or elsewhere on return (attach Form 4562)................... 14 s 15 Depletion(Do not deduct oil and gas depletion.)..................................................... 15 E E 16 Advertising 16 t 17 Pension,IXOAk-sha6m3,etc.,ptaRs.................................................................. 17 s 18 Employee benefit programs......................................................................... 18 --- R 19 Other deductions(attach statement)............. ...S.ee.S.tatement.2 19 20 Total deductions.Add lines 7 through 19.......................................................... ► 20 21 Ordinary business income(loss).Subtract line 20 from line 6........................................ 21 22a Excess net passive income or LIFO recapture tax (see instructions).................................................... 22b A b Tax from Schedule D (Form 1120-S)....................)................. X. c Add limes 22a and 22b(see instructions for additional taxes) 22c N 23a 2019 estimated tax payments and 2078 overpayment credited to 2019...... 23a _ ° b Tax deposited with Form 7004........................................... 23b V, c Credit for federal tax paid on fuels(attach Form 4136)........... 23c Y d Reserved for future use.................................................. 23d M E e Add lines 23a through 23d.......................................................................... 23e N ►aa 24 Estimated tax penalty (see irstructions).Check if Form,2220 is attached....................... 24 25 Amount owed.If line 23e is smaller than the total of fines 27c and 24,enter amount owed ............................... 25 _ 0, 26 Overpayment.If line 23e is larger than the total of lines 22c and 24, enter amount overpaid......... ... 26 27 Enter amount from line 26:Credited to 2020 estimated'tax ► Refunded 27 t?nder penatt.es of penury;f declare that I have examined this return.ineiuding accompanying schedules and statements.and to the best of my knowledge and belief,it is true, correct,and complete. eci rat�9' er(Diner than taxpayer)is based on a;?jnro rnat1on o!K4-,icn preparer has any knowledge. Sign a he I pdiscuss tms return Here 0 d ® President See ins ore ns. spawn be aw? See instruct+ons. DSigaa of ett; r Date Title ){ Yes NO t PrintrType preparer's name Preparer's signature Date Check if PF": Paid Mark Gianno, CPA, CFP_ Mark Gianno, CPA, CFP �self.employeo P01228068 Preparer Firm'sname ► Gianno & Freda Inc. Firm'sEt,V ► 20-8305173 Use Only Flrm'saddress P. 235 Barnstable Road Hyannis, MA 02601 Phoneno. (508) 778-5555 BAA For Paperwork Reduction Act Notice,see separate instructions. SPSA0112 12130,19 Form 1120-S(2019) r Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. 1' ♦ g 4' B MNST ABM Paul J.Canniff,D.M.D. nss 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco ri granted b Sections 5 31 and 127A of the General In accordance with regulations promulgated under authority a d Y g p g Yg Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 144 Issue Date: 1/1/2020 DBA: BARNSTABLE BOTTLE SHOPPE OWNER: MARK BISSETT Location of Establishment: 10 SEABOARD LANE HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual — Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Q Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY + For 0 Initials: �FTHETp� Town of Barnstable Date Paidakhq Inspectional Services If * sax+vsrA. « 1 , '�^M r Public Health Division - s6Jq. �® r ATFD" � Thomas McKean, Director 5 200 Main Street, Hyannis, MA 02601 '�� Office: 508-862-4644 Fax: 508-790-6304 ro c+ s: TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) =0 Ar DATE ! 20 19 NEW BUSINESS OWNERSHIP RENEWAL 1� NAME OF TOBACCO ESTABLISHMENT: -504fle— ADDRESS OF TOBACCO ESTABLISHMENT: I C7 Ce 1000rd LAI y �y�h n i-'s MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: 5o4(dI.IrI= ' _ o \0a S+ 1 ry 'f - TELEPHONE NUMBER OF TOBACCO ESTABBL,ISHMENT: l JVD)jS- c-7(O- OWNER'S NAME: NI�V h ` J �S� T 1' OWNER'S PH#W)Aa- ` OWNER'S ADDRESS: `7qfa !leAmAin = CORPORATE ADDRESS: I O Sea boas G► CORPORATE FID# ANNUAL: SEASONAL: DATES OF OPERATION:_/_/_ TO DAYS CLOSED EXCLUDING HOLIDAYS(EX. MONDAYS) TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/3 3996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https:Hmalegislature.gov/Laws/GeneralLaws/PartIV/Titlel/Ch terM/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY *** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: l) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: DATE: / 'z Q:\Application Forms\TOBACCO APP-10-03-2020 draft2-NonFavor.doc ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—& 371-9. Sale and Distribution of Tobacco Products, 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. i The employee(s) below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 27 0 Section 6 of the Massachusetts General Laws: /JZjA,4,6 Pk *7 . Si nature Printed Name Date ` a ignature Printed Name Date/ �N, igna ure Printed Name at Signature Printed Name Dat_�— /,,/.9 )Z/ Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q\Application FormATOBACCO APP-10.03.2020 dray-NonFavor.doc try. This page intentionally left blank This page intentionally left blank This page intentionally left blank - :. MESSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco 12 yF�rly This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. DEER HOLLOW CORPORATION Account ID: CRL-11615327-009 BARNSTABLE BOTTLE SHOPPE License Number:470439936 10 SEABOARD LN HYANNIS MA 02601-2345 This certifies that the taxpayer named above is Licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: December 5, 2018 Expiration Date:S6ptembef'30;-2020_ MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T � Retailer License for Sale of Cigarettes This license must be posted and visible at all times. The sale of tobacco •pro products to anyone under 18 years of age is prohibited. DEER HOLLOW CORPORATION Account ID: CGL-11615327-006 BARNSTABLE BOTTLE SHOPPE License Number: 681338880 10 SEABOARD LN HYANNIS MA 02601-2345 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: December 6,2018 Expiration Date: -30,2020] I, Notice Date: 01/15/04 COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF REVENUE faxpatre€tD dumber; C04325 1-- i!totlt IB'Nutn�sr 00350 DEER HOLLOW CORPORATION 401 10 SEABOARD LANE HYANNIS, MA 02601 An important notice to the Owner/CEO/CFO. The Massachusetts Department of Revenue (DOR) has completed processing your request to establish a Business Master Administrator(BMA) account in our WebFile for Business electronic filing application for the following individual: Administrator's Name: BRAMAN MARTHA Administrator's Phone Number. 508-428-9108 Administrator's Email Address: goofdurf@comcast.net This individual now serves as your primary administrator for electronically filing your business taxes with DOR. In addition to having the ability to file and pay business taxes for you electronically, your master administrator may create, update or delete additional accounts in WebFile for use by other staff or designated tax professionals authorized to perform work on your account. Listed below is the business for which the Business Master Administrator has rights. Please review this information carefully to insure its accuracy: Tax►D: '043.25 0 Legal Name of Business: DEER HOLLOW CORPORATION Legal Address: 10 SEABOARD LANE City, State/Zip: HYANNIS, MA 02601 If any of the information contained in this notice is incorrect, immediately contact our Customer Service Bureau at (617) 887-6367, or toll-free in Massachusetts at(800) 392-6089. Thank you. The Massachusetts Department of Revenue Town of Barnstable BOARD OF HEALTH a Paul 1 Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. aARNSTABLL John T. Norman pan s 200 Main Street, Hyannis, MA 02601 F.P. Thomas lee Alternate �o3Q. 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 Yg permit is hereby ranted to: p Permit No: 144 Issue Date: 12/20/18 DBA: BARNSTABLE BOTTLE SHOPPE OWNER: MARK BISSETT Location of Establishment: 10 SEABOARD LANE HYANNIS MA 02601 Type of Business Permit: TOBACCO Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - ---------.--- ---- - - -- -- . -----— - MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: A r�S Dz1�t- sit Pk n -6b - '114E Town of Barnstable Regulatory Services Department , ��1�� C 9BARMABLE. Public Health Division s63Aim 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO '• FAX: 508-790-6304 Director of Public Health C.5 Nw Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION , 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL rn sia h i tv Sh e (1)&r �b► vj (oppi DB/A 10 '5eQ, bonro. 6,--t 0 STREET ADDRESS ( TELEPHONE # FID# Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand the Sections VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided-on the next page). Each employee who sells tobacco products must sign the E plo ee Sig ture Form (p vided herein). Signature Date Q:\Application Forms\TOBACCO APP2018 dob.docx a ESTABLIS DUNT°S NAW TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General .Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Heath Regulation: Sales to Minors—§371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product,as defined herein,to a person under e mini dales age. The minimum legal sales ago in the Town of Barnstable pis 21 years of age. 2. Xdentt ica ton; ach person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is.required for any person under.the age.of.2.7. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of. Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: tur 1' sine Date na . 41 Signs re P rinted Name Date G;,Vof JG -011, 9 igna a -Printed Name Date � mature Printed Name bate Si ture Printed Name Date I a o- Signature Printed Name Datc Signature Printed Name Date Q\Application FormATOBACCO APP2019 dob.docx TOO Z %V3 CO:TT MUZT/Z r Estdblishxntirl 10yVe sign re orm rmp `rliis 1'urra is for at'f r to iodicate t�iat the ipl � � � estabi�s ierit rived acid 4 s+etic ns 4r1 f b, aril dlf . cal'theBarnstable Board lcalti oWbsti n 0 � u ti n iiclt�st�tl 'Copy cil" apter 270 Se tiun 6i cif the ssa hwett ei 0M � big �}pMI for soiling, and/or will OWN pr�aducts is any'lie c �iid rr tli� nl*ei � A Vll And 1'l e,of the Ba stable'Board of Health Fe latts� s a o k ��l*f"f`ICEN Vl1 SALE AND DtS "l�UTlON 'OBA b, Sales Minors In st f►a ittnce 1 e M chus s cab ... g zap . 70 rsr �� curperaticn, esbishit, bra cy sbl'sellr#sa r ,*­­ no - a aph employee woiking in an estab is ent H000,504" ,self to, t � an rc vc a copy c t]ae�c rci t l�le lth x6golatibi r tat rem � .the � l : z l ; w s.i a arari ndica a that. Such,re laticitsl s have, z re d d _ eTstc�z � r , which must be placed on file, in �Off=Of e e �alcyer� f �� it:b : ya be made available for irapectiri, di thef risrc d �. ti ark went c xb- oard o flealtb. { ax bay ad rust f r c. All,disu ibutcrsOretiler a tdbacc prcdu „. customer ppeai th possibly be under'25`years of , tb. coos er a valid c driers;licee`Jwitlt Gr p Pl ,t ni , �$ picture identification d .o. ' Customer is of ie al e to rriaie tb baeca rodut. a S ` ,• rece�red end��iwle�st.�pd�; ei l�r ey ei �e The following employes ` 4 ,�� lade `a�Ctr�,'�A" etapd. c ' b Health Prohibition of- V. ek, u e "I s rted 1Gt ipatureDa - + i 11 _ Pr Name, � 0 , m tuTe Printer am x 4 turn - 1���_ ipte : z r g _ aatux �; 1. e. y 'ritcd N A e sivature y � ' °FTHE r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of OFFICE HOURS BA °_ PUBSION � - : 0- :30A.M. RRNSTABE 200 MAN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified -•N�� .A.- g, MON.-FRI. A ,639,a. HYANNIS, MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'FDM FOOP ESTABLISHMENT INSPECTION REPORT J Name �115 �� / Date o T Inspection�' era ions outine /' Address 6L k P1 Risk 1, rev ervice s�ction Level t Previous Inspection Telephone ntial Kitchen Date: Mobile Pre-operation ell - Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint 114 Person in Charge(PIC) / �7 Time Bed&Breakfast HACCP CSC/ In: Other Inspector Out: I AA 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 El Yes Non-critical(N)violations must be corrected immediately or Overall Rating �' within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑-Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 6=One critical violation and less than 4non-critical violations g )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t F is scored automatically o la 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 i cal violations. 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. within 10 days of receipt of this order. violation,4 to 8non-critical violations=C. 29.Spyiaquirements (590.009) y p 30.Ot DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Duscreened from public viewPermit Posted? N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N IC's ignat re Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y IN - _."�' ---._ _�� _ .;__ _.. .. ._ :__ _ _ _ _ .. � _ _ _- .,� .. .- �. ,. _ �-•-v r ..>zits ` _ .. � -_ _'. � ..-�__ .- - _ ..Zr+�� - 7 _ _ _.j _ _ 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 2-103.11 Person-in-Charge Duties - Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* .19 - - - - PHF.Hot and Cold Holding_ _ Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) *- - - 2 590:003(C)- -Responsibility of the Person-in-Charge to - - - - Others*_ 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* Applicants* - '' 3-302.11(A 7-201.11 Separation-Storage*) Food Protection* P 8 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-501.19 Time as a Public Health Control* 3-302.15 Washing Fruits and Vegetables Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* - 3-304.11 Food Contact with Equipment and Utensils* -590:004(11) Variance Requirements 590.003(G) Reporting by Person in Charge*- Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a 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 1 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. 1 g Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155`F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* 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* 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* aces of Equipment* Shellfish* 3-401.1](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* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11 A 1 All Other PHFs-145' 15 sec* Other 590.009 violations relating to good retail ( )( )(b) F 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 3-003.11(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 Commerciall Processed RTE Food-140'F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Y 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the Foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140'F to 70`F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41°F/45°F Item Good Retail Practices FC 590.000 - - Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41'F/45'F 25. Equipment and Utensils FC-4 .005 3402.12 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 O 9 g 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials I FC-7 .008- HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12. _ Reduced.-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* _ S:590Formback6 2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. �p 114E. TOWN OF BARNSTABLE .HEALTH INSPECTOR'S Establishment Name: Date: Page: of Pia 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 MAs �, MON.-FRI. �q ,6,q• �0 HYANNIS,MA 02601 sos-ss2 4644 No Reference R.-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSP CTION REPORT Name Da e o T Inspection !� Operation(s) Xoutine Address i r Se ° Risk Fo Service ction Level etail Previous Inspection L Telephone esldential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness <` Caterer General HACCP Complaint Person in Charge(PIC) Time Bed&Breakfast Other 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 y ❑ 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 ,VX` Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue 8,red items) I _ 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. v ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 9 ardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 6=One critical violation and less than non-critical violations re 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed;7 to anon-critical violations. If 1 critical refrigeration. violation,4 to 8non-criticl violations C. 29.Special Requirements (590.009) within 10 days of receipt of this order. = 30.Other DATE OF RE-INSPECTION: I spector's Signature Print: 31.Dumper 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 P 's Sign re 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives*' 19 - I?HF"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 C * 590.004(F) ontainers 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* P g Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* 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 Eggs mme Service sec Utensils and Food Contact Surfaces of E s-Immediate Sice 145°F 15 * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * , Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg""e mrzooi 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 Stu Ratites-165ffi °F 15 sec*ng Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 1590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction*" Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J)L 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 INE r°y, TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Page: of q OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ` 200 MAIN STREET 3: N.- P.M.M Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified FUMn+°0� HYANNIS,MA 02601 Ma 62-4M4 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD TABLISHMENT INSPECTION REPORT. Name Date OTvoe of Tvoe of Inspection oerationfs) Routine Address Risk Foo ervice Re-inspection Level eY ' Previous Inspection Telephone sidential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: er r Inspector Out: L Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ 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 l41k J / C� FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) J C ❑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 SI Overall Rating �f!� within 90 days as determined by the Board of Health. V ,� ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on a inspection today,the items Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 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 (FC4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. 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 be in writing and submitted to the Board of Health at the above address non-critical violations. If 1 critical refrigeration. )(590.008) violation,4 to 8rion-critical violations=C. 29.Special Requirements (59o.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector s Signatur 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 P C's Signa lure Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted - Y N Dumpster Screen? Y N KZ 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.) a- FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to f I". 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties - Cooked and RTE Foods.* 3=302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F * 7-201.11 Separation-Storage* ApplicantsProtection* 20 Time as a Public Health Control 3-302.11(A) Food 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An _° 3-501.19 Time as a Public Health-Control* 3-302.15. Washing Fruits and Vegetables * Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* - - 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions _ Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water'Froin 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 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(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 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* sg°"°e 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Ho[Water and Stuffing Containing Fish,Meat,Poultry or A)-(D) Violations of Section 590.009 A D incater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009( ( )-( ) Ratites-165°F 15 sec* ing,mobile food,temporary and residential Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.l l A 1)( )6 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ 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 illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 3-501.14 Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11. Parasite Destruction* 5-204.11 Location and Placement �) g * 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 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. 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. I certify.under the penalties of per that 1, to my best knowledge and belief0e filed all state tax returns and paid all state taxes required under law. •Signature ofln n7dual By: Corporate Officer or Corporate Name(Mandatory) (Mandatory.if Applicable) t t - This license will not be issued unless this certification clause is signed by the applicant.-- Your social security number,will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non-filing or delinquency will be subject to license suspension or revocation. This request is made under the autho ' f ass.G.L.c. 62C s.49A. Received 19 Signature of Applicant A.M. Hour Add—, P.M. Approved 19 Licence Granted. 19— FORM 460 HOBBS&WARREN,INC.PUBLISHERS BOSTON REVISED FIRE FIRE FIRS ExiT tXiTXiT �d<r t3EVERAG- E O \ ) _ MAN AGE R'5 0 COO L_ F_ FZ EO = OFFICE Dor�K li-•7LITY S/NK O O c o-r- ` C DUN rE R F EX I T ON Ly E NTRANC-E O N LY