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WILLOW PACKAGE - RETAIL FOOD
WILLOW PACKAGE 003 696 YARMOUTH RD. ,HY. l Bellaire, Dianna From: Zahid Mubashar <z.mubashar@hotmail.com> Sent: Monday, October 25, 2021 2:28 PM To: Bellaire, Dianna Subject: Willow Package Store Good afternoon. As you know we did not sell any food in store . Please visit again . We sell only Soda and Energy drinks only . Thank you mubasher for Shakeel CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email addressand know the content is safe! i Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. s DARN I STAULL . F.P.(Thomas)Lee Daniel Luczkow,Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 320 Issue Date: 1/1/2021 DBA: WILLOW PACKAGE STORE OWNER: BILAL CORPORATION Location of Establishment: 696 YARMOUTH RD. 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 r i For Offic Initials: Town of Barnstable Date Paid Amt Pd S g i Inspectional Services .� . Public Health Division Check# Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 t Office: 508-862-4644 Fax: 508-790-6304 's TOBACCO ESTABLISHMENT_.PERMIT APPLICATION {Non Flavore). DATE l NEW BUSINESS OWNERSHIP RENEWALP" $ } NAME OF TOBACCO ESTABLISHMENT: zvdlmo !�&j<A-C4- ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE). 7d b hl fL/1� E-MAIL ADDRESS: U ba-S�a/Ka I(Af M aif ,,C k TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (Lvao--U—/- l w q.3 ° s� 633 ' . OWNER'S ADDRESS: l i CORPORATE NAME: CORPORATE ADD ESS: CORPORATE FID# ANNUAL: SEASONAL: DATES OF OPERATION: ll I I TO 1 / Z. ' DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) r TOWN OF BARNSTABLE CODE/MA GENERAL.LAW INTERNET LINKS: i TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httt)s://www.ecode360.com/33996392 g MA GENERAL LAW CHAPTER 270/SECTION 6: httos://malegislature.:gov/Laws/GeneralLaws/PartIV/Tirlel/`hQ,ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT.THE FOLLOWING REQUIRED DOCUMENTS: a ( 1) MA State License to Sell Cigare s 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigarg Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: e ��9 ��L� DATE:. // / Z/2-0 Q:1Application Forms\TOBACCO APP-NonFavor 12-18-19.docx u ESTABLISHMENT'S AME 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 I' 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable 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: VQA�► Ul �Cc_ �A trlA AR AS /o - 31- Za Zc� Sinature Printed Name Date r- Signii6r9V Printed Name Date -��-2 Signature Printed Name � d Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q\Application FormATOBACCO APP.NonFavor 12-18-19.docx �PssNC44 s MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco (j F�f j6l� >,..\.r O*i This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. BILAL CORPORATION Account ID: CRL-10815353-010 WILLOW PACKAGE STORE License Number: 2108934144 700 YARMOUTH RD HYANNIS MA 02601-2051 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30, 2022 s�cHcs�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 ' FA Retailer License for Sale of Cigarettes :,\ '"�� This license must be posted and visible at all times. The sale of tobacco products to anyone under 18 years of age is prohibited. BILAL CORPORATION Account ID: CGL-10815353-007 WILLOW PACKAGE STORE License Number: 1913563136 700 YARMOUTH RD HYANNIS MA 02601-2051 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. I Effective Dater October 1, 2020 Expiration Date: September 30, 2022 f i Z O O • C)'I N O ' O N Cn mom O CD IWASSACI-IUSETTS DEPARTMENT OF REVENUE � Retailer License for Sale of Electronic Nicotine Delivery Systems This license must be posted and visible at all times. The sale of tobacco pi oducts to anyone under 21 years of age is prohibited. CORPORATION Account ED: EDL-10815353-013 \k"ll-l-OW PACKAGE STORE License Number: 1759488000 700 Y'ARMOUTH RD This certilie, that the taxpayer named above is licensed u(Ider Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above. This license is non-uartat�rahle and may he >u,pended or revoked liar failure to comply with state laws and regulations. Ef ective Date: %•lav 27, 2020 Expiration Date: September 30, 2022 .AtlaCIIe(l hcluw IS yOur Retailer License ti)r Sale ol-Electronic Nicotine Delivery Systems. Cut i OY Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. W3 NSTAULL Paul J.Canniff,D.M.D. MAC F.P. Thomas Lee Alternate lit 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 320 Issue Date: 1/1/2020 DBA: WILLOW PACKAGE STORE OWNER: BILAL CORPORATION Location of Establishment: 696 YARMOUTH RD. HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY • '��.� oFa+e tq� • Initials: + Town of Barnstable Date Paid I a Amt Pd$ � BABNSI'ABIE. : Inspectional Services MA99. f At.b39.s�0� Public Health Division Check# U _ Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 t Office: 508-862-4644 Fax: 508-790-6304 T TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) a DATE� —�� NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: 91 L A L. C© 49 61!�A 7-1 a/V/1,h�y ADDRESS OF TOBACCO ESTABLISHMENT: IAI L ^e�/ 1z' <-r^ qa / MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 0 0 Y-Ag tg0 a Ra A I M A O r E-MAIL ADDRESS: + it)iXj �(C � CoCO � TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: ( o i ) _ 7 7! OWNER'S NAME:�4 j/Ak L•1M -F69WO, OWNER'S PH# OWNER'S ADDRESS: Z.i PAL me4,7h' A*Z©A-.n M4.4YPIP 471A &,:U�Lj CORPORATE ADDRESS: 7B[n�A lYIB �H !tl/V CORPORATE FID#;f `t q 93S ANNUAL: SEASONAL: DATES OF OPERATION: 611 711alo 0 1), / / 02 Got 0 DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) O k rid -rO /o mm To 6 t ell TOWN OF BARNSTABLE COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https•//malegislature.gov/-Laws/GeneralLaws/�art!V/Titiel/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTEDNAME: SHAV-594. M • FAR 2 DATE:l/ /A-j/ 1 Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc ESTABLISHMENT'S NAMY TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—4 371.-9. Sale and Distribution of Tobacco Products. i. 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: Signature Printed Name Date i ature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:Wpphcation Forms\TOBACCO APP-NonFavor 11-21-19.doc ' o a Commonwealth of Massachusetts Letter ID:L0272796288 Department of Revenue Notice Date:September 27,2018 ' Christopher C.Harding,Commissioner Account ID:CGL-10815353-007 co mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES �I'll�l��'„�„�I�Ilhlllllh'lllllul� llllllillllul�lnn�lll� BILAL CORPORATION WILLOW PACKAGE STORE 700 YARMOUTH RD HYANNIS MA 02601-2051 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T). Cut along the dotted line and-displarat-your-business cation-At-any-time;you-can-lvg-into-your-MassT-axCormect-account a mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089, Monday through Friday, 8:30 a.m,to 4:30 p.m. DETACP HERE 90* cfftj 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 products to anyone under 18 years of age is prohibited. BILAL CORPORATION Account ID: CGL-10815353-007 WILLOW PACKAGE STORE License Number: 749400064 700 YARMOUTH RD HYANNIS MA 02601-2051 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2018 Expiration Date: September 30, 2020 Commonwealth of Massachusetts Letter ID:L1739223680 Department of Revenue Notice Date:September 26,2018 • Christopher C.Harding,Commissioner Account ID:CRL-10815353-010 ca mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO I�I'�'�IIIIIII"'III"�I�IIIIII'I'��'I��IIIII�I'��'�II'llllll'll� BILAL CORPORATION WILLOW PACKAGE STORE N ME YARMOUTH RD HYANNIS MA 02601-2051 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE •----------------------------------------------------------------------------------------------------------------------------------------------- S5°` �'SF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco Nro44 This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. BILAL CORPORATION Account ID: CRL-10815353-010 WILLOW PACKAGE STORE License Number: 255930368 700 YARMOUTH RD HYANNIS MA 02601-2051 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1, 2018 Expiration Date:September 30, 2020 ` X RS DEPARTMENT OF THE TREASURY INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0023 Date of this notice: 02-21-2014 Employer Identification Number: 000230.417903.32445.3835 1 MB 0.435 850 46-4839835 Form: SS-4 Number of this notice: CP 575 A F�V BILAL CORPORATION WILLOW STREET PACKAGE STORE For assistance you may call us at: 111 PINE VIEW DR 1-800-829-4933 COTUIT MA 02635 100230 IF YOU WRITE, ATTACH THE STUB OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN). We assigned you EIN 46-4839835. This EIN will identify you, your business accounts, tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear-off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 1120 03/15/2015 Form 944 01/31/2015 Form 940 01/31/2015 If you have questions about the form(s) or the due dates(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year), see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 200471 I.R.B. . l (or superseding Re_xenue Procedure -for the year at issue). Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. Op 1NEr TOWN OF BARNSTABLE. ( HEALTH INSPECTOR,s Establishment Name: _ P i l.. _ .� %_ ate:',4n Page: Of q V 1 OFFICE HOURS 6 4- PUBLIC HEALTH DIVISION, 0 O 8:00-_9:30A.M. gpnE. : 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified .A55. �,. MON.-FRI. HYANNIS, MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY rFO1AP, FOQD ESTABLISHMENT INSP TI N REPORT 4 Name n Date4a of Type of Inspection , `/ peration(s) Routine Address ( Ris ce Re-inspection 1 / Level R�a- Telephone Previous Inspection ` Y l I� Kitchen Mobile ^-Pre-operation. Owner HACCP Y/N Temporary Suspe ess Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP _ Other i Inspector O Each violation c eckecl requires' n explanation on the narrative p ge(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) ❑ 11V RV FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands , ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS MG ❑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) C� / ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures v ❑ 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 VV 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 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 re ardless.of the number of critical,results in an F. Equipment and Utensils 590.005 q P )( ) 25.E ui (FC-4 6=One critical violation and less.than 4npn=critical violations 9 cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. ,Wol28.Poisonous or Toxic Materials (FC-7)(590.008) 9 ion,4 to 8 non-critical vi9)atio s,=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: nsp o Signatu e b -print: 31.Dumpster screened from public view ✓ Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign r 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* * * 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-Original Containers*7-102.11 Common Name-Working Containers* 590.004(F) * 2 590.003(C) Responsibility of the Person-in-Charge to Other* P g 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* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee 7-202.11 Restriction-Presence and Use*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 g with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501:111 Manual Wazewashing-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 Eggs-Idiate Service 145°F sec* * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* gg Immediate ery Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective tnrzooz 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContainingFish,Meat,Poultry 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* trY 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. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11 A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )�) 3-201.17 Game Animals* 11 Good Hygienic Practices 7 7 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 * 3-301.12 Preventing Contamination When Tasting* 3 403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* 3-403.11�) 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* O,5-205.11 Accessibility, 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. 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* 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. HEALTH INSPECTOR'S Establishment Name: ,`� �' - `oF;�rok� TOWN OF BARNSTABLE -OFFICE HOURS � �� Date: g/f1t �/( Page:� of PUBLIC HEALTH DIVISION 8:00-9:30 A.M. + BARNSTARLE, ` 200 MAIN STREET 3:30-4:30 P.M. _ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MONHYANNIS,MA 02601 -FRI. 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY- FOOD FOOD ESTABLISHMENT INSPECTION REPORT Name _ Date& I.I Tyne o T o Inspection , caj(` tOueration(s) outm F f d� f W7t Address �,( G Risk Food_Service spection 3�( r 4 U�e Level eta Previous Inspection d Telephone lieli ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness ..�,J�til.� tQ For r d t—t{0 Caterer General Complaint Person in Charge(PIC) Time i Bed&Breakfast HACCP Inspector q In: )t:),� Other $uan5 Out: v G1 h r; F✓ Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Qom,m i 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) rawy vl( t k Chi Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ 7PROTECTION MANAGEMENT d2.Prevention of Contamination from Hands PIC Assigned/Knowledgeable/Duties [r13.Handwash Facilities EMPLOYEE HEALTH PRO TECTION FROM CHEMICALS Lt^// .Reporting of Diseases by Food Employees and PIC 14.Approved Food or Color Additives 6[3.Personnel with Infectious Restricted/Excluded 15. Toxic Chemicals 7FO D FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) [ 4 Food and Water from Approved Source 6.Cooking Temperatures -.Receiving/Condition �7.Reheating [[� .Tags/Records/Accuracy of Ingredient Statements 118.Cooling .Conformance with Approved Procedures/HACCP Plans 9.Hot and Cold Holding PROTECTION FROM CONTAMINATION 20.Time As a Public Health Control � Separation/Segregation/Protection R QUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) .Food Contact Surfaces Cleaning and Sanitizing 21.Food and Food Preparation for HSP � Proper AdequateHandwashing C SUMER ADVISORY JI 1.Good Hygienic Practices r2.Posting of Consumer Advisories L Violations Related to Good Retail Practices(Blue Items Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ElNo ❑ Yes Non-critical(N)violations must be corrected immediately or I `�1 ''`` within 90 days as determined by the Board of Health. Overall Rating I ` N�1'7 ❑ 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. [E3 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 6=One critical violation and.less than 4nOn-critical violations 9 ( )( ) cited in this report may result in suspension or revocation er the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if:.no hot 26.water,Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. violation,4 to 8 non-critical violations. C. 29:Special Requirements (590.009) within 10 days of receipt of this order. = 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: {� 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature 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 1q 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-Charge 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 I 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* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g * 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004(11) * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* Variance Requirements 590.003(G) Reporting by Person in Charge ' Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 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 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 I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* ' Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* I 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* Equipment* 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 3401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed at,P SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 11 Cl Game and Mid Mushrooms Approved By 2-301. Clean Condition-Hands and Arms* 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under 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 should be debited under#29-Special 3-201.17 Game Animals* 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 PreventingContamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity g 3-403.11(C) Commercially Processed RTE Food-140°F * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the g 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* L13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 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. i r Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. i; 13ARNsrABLL John T.Norman MAn 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate. a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 320 Issue Date: 02/25/2019 DBA: WILLOW PACKAGE STORE OWNER: BILAL CORPORATION Location of Establishment: 696 YARMOUTH RD. 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: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: - MOBILE- FOOD: MOBILE- ICE CREAM: Cn FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: I PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. BARNS'AB John T. Norman MASS. F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 320 Issue.Date: 12/20/18 DBA: WILLOW PACKAGE STORE OWNER: BILAL CORPORATION Location of Establishment: 696 YARMOUTH RD. 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: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - - MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: W aloes �e � • . �ZHE Town of Barnstable -- Regulatory Services Department _BAMA�M - Public Health Division 9 i63 ' a 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,M,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT k-a 2- LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL — L0 /k-' DB/A ate/ STREET ADDRESS / LEP ONE# FI # Do you currently possess a state license to sell tobacco.products? Yes jz 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-- 4 loyee Si ature Form (provided herein). i natu e Date C:\Users\crockersh\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\K266YKRV\TOBA000 APP2018 dob.docx w Establishmen TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood sections VIIb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of eighteen(18). Below are sections VIlb. and VIIc.of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file, in the office of the employer and retained. Such signed forms must be made available for inspection, during the license holders normal business hours upon request of an agent of the Board of Health. c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age, the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIIb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: �naYl An1dgg 3 --CX® C9 Signature Printed Name Date SignafM Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Fonns\TOBAPP.DOC Commonwealth of Massachusetts Letter ID:L0272796288 Department of Revenue Notice Date:September 27,2018 tr' ' Christopher C.Harding,Commissioner Account ID:CGL-10815353-007 �s C�7 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES �I'll�l��"'�"�I�III�111111��11111��1��111111�1111��1�1�����11�� BILAL CORPORATION _ WILLOW PACKAGE STORE 700 YARMOUTH RD HYANNIS MA 02601-2051 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE •----------------------------------------------------------------------------------------------------------------------------------------------- ,ssciiij SF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes ov This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. BILAL CORPORATION Account ID: CGL-10815353-007 WILLOW PACKAGE STORE License Number: 749400064 700 YARMOUTH RD HYANNIS MA 02601-2051 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2018 Expiration Date: September 30, 2020 ter. • , rAA oFzwEr°�ti Town of Barnstable Initials: Vf� O4 Inspectional ServicesDate Paid $ • p Check# �� r BARNST" 9� MASS. Public Health Division �F0 39. a 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT 81L A L , (o1?A*1?A7'tP1v ESTABLISHMENT NAME (DB/A) ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERENT FROM ABO ) - -- --OWNER'S NAME:-----LAST J--FIST —MIDDLE - — - 2 - ri►u�7�ls �'(��n�9YluiiD•��sC�o --1 71" to 1`3 EMAIL PHONE# FEDERAL M# Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form..(provided -----herein). — r - - --- - Signature Date Q:\Application Forms\TOBACCO APP2019 dob.docx ESTABLISIEWENT'S TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—&371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The 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: Signature Printed Name Date y" Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Apphcation Forms\TOBACCO APP2019 dob.docx FIKE rp Town of Barnstable For Office Use Only: Initials: o„ Date Paid Amt Pd$ 9 MAS& Inspectional Services 'E%6yg. Public Health Division Check# Cash Thomas McKean,Director fqd& 200 Main Street,Hyannis,MA 02601 �l�f(�J�� Office: 508-862-4644 Fax: 508-790-6304 --// � l�l M�l APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL V v NAME OF FOOD ESTABLISHMENT: N-Pr L CO OR 1 v14 / /1-Ldlla Gkk(f g ADDRESS OF FOOD ESTABLISHMENT: 7e'p 7A-, AA7 /GIN 4D' MAILING ADDRESS(IF DIFFERENT FROM ABOVE): a E-MAIL ADDRESS: A D ty AAN A to u'E( R 74c'J YA 1-+t n- r a. ()1-C TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (S0$)77 1--3 TOTAL NUMBER OF BATHROOMS: / G WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: _ SEASONAL: DATES OF OPERATION: C l / la TO l31 / 02m 9 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)?1 TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL, MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FormsTOODAPPREV2018.doc PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT- SOLE OWNER: YES/NO OWNER PHONE ADDRESS CORPORATE OWNER: FEDERAL ID NO. : �= CORPORATE ADDRESS: 7,0 � 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. AIIA 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 openin-!! 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 1st to Dec.I V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1 st. Q\Application FormsTOODAPPREV2018.doc oFVE r TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: r 6 YOWDate:'C 1Y Page: Of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M.• BARNSTARLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MAss. MON.-FRI. HYANNIS,MA 02601 508-862-4644 No Reference R.-Red-Item PLEASE PRINT CLEARLY FOOD BLISHMENT INSPE I N REPORT Name ate a of -R lot T f I s action � eration Address i v ervice Re-ins ionVU evel Retail Previous Inspection Telephone esi ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP feA Q7 Other Inspector Each violation checked requi es an explanation on the narrati a 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 `vX\ ❑ 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 f within 90 days as determined by the Board of Health. \� ��IEay, ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension ffiC N Ocial Order for Correction: Based on an i the items ❑ Embargo ❑ Emergency Closure Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel . (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC 4 590.005 B=One critical violation and less than 4 non-critical violations 9 )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8rion-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. 4 to 8 n -critical violations=C. 30.Other DATE OF RE-INSPECTION: Ins a is ig u Print: 31.Dumpster screened from public view . Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N P C's Sign ure Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N c - Dumpster Screen? Y N i Violations related to Foodborne Illness- - Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 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 Cooked and RTE Foods.* _ _19_.._ _ _ PHF Hot and Cold Holding_ _ 2-103.11 Person-in=Charge Duties - 3-302.14 Protection from Unapproved Additives*- ' Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F * 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* * 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance-Re uirements - 3-304.11 Food Contact with Equipment and Utensils * ( ) q 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, e 3.-306.1A(A)(B)Resumed Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP . 590.003(E) Removal of Exclusions and Restrictions g ( � Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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 HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* _ . Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* _ Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Equipment* 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 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg°"°e ionom 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 r f ces of Equipment* 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 g' 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By Clean Condition-Hands an 2-301.11 Cl CditiHdd Arms* P 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. * 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 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* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A). Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45'F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser;Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* 4 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. No w� � Op THE*oq, TOWN OF BARNSTABLE., _ _ ,HEALTH INSPECTOR,s Establishment Name: Date: I��/_ a( Page: of" ti OFFICE HOURS - PUBLIC HEALTH DIVISION 8:00-9:30 A.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 M-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY iOrFo MA'S° 50862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name O k Date�o J1� Tvoe of section Ooeration(s) Routine Address Risk Foa Service ection Level etas Previous Inspection Telephone Resid-ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time 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 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 B=One critical violation and less than 4non-critical violations 9 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) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Ins ture 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signa Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y - N Dumpster Screen? Y N A. .... - a$n�-... .-�:_....,r...,..,: -. :-y-� _-,�_. ._. _�gym. � .�--^^ ,... _. ,r � .°-,..,.,� <.,_. _._... -.... ....-,H--,....-r. ,�.-.-.. � .�.. r-••---• --_.r .,.. .... .� ` v -..F. •--.--�-..-+,-' :..._�.--.� r+. �:v�_. -:•r.'Y. - � _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* F 8 Cross-contamination 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* * * 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3.202:12"'� Additives Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 _ Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers*ated from Each 7-101.11 Identifying Information-Original Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* 590.003(G) Reporting by Person in Charge* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 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 Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of 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* Eg°'i"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 Gamea and Wild 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 practices should be debited under#29-Special 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.11 Package Integrity ( ) Y 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* 3AO3.1I(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 ( ) g 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item I Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 5-205.11 Accessibility,Operation and Maintenance 3-402.12 Records,Creation and Retention* Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 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. TOWN OF BARNSTABLE BAR-W 1052 Ordinance or Regulation WARNING NOTICE y Name of Offender/Manager `56e'w mn�a m"a'4 }" Itno Address of Offender MV/MB Reg.# :. Business Name \blktho 1ae �=t� r ' ` � am/, , on a 2015 Business Address �� Ee'�trn�E u1� d. � nn,K� M►1 •. Signature of Enforcing Officer Village/State/Zip - axn,A, AAA Location of Offense \jA,,..,,jA jeJ. 1 r�rw+�,.t Mf, y Enforcing Dept/Division Offense S ,orl 371-7661 Or Pv- —rD+✓-, � (MAJAWc f:c Facts Ir-arro or .-w4y, I uo-a,l '4,44 4 et P\wn.,r / , n• —?N o4, r M, aor r � � 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. TOWN OF BARNSTABLE BAR-W Ordinance or Regulation P WARNING NOTICE Name of Offender/Manager It r"k ` Address of Offender Business Name �, � .. Out =�$,cue j- ; . " - ! ,{� }. -1 am/pm, on -_?�.bj 201 Business Address eo-9 7 Signature of Enforcing Officer Village/State/Zip Location of Offense r4'`r1„ 1:;.,�. R .n.,. t } p • r t , Enforcing Dept/Division Offense Wit:{ c}_.ti Factst 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. �oFtHe,�ti Town of Barnstable y + ,P o Regulatory Services Barnstable BARNSTABLE, Thomas F. Geiler,Director A -Americaeit0 kSS. 4 Public Health Division �A 39 rFD MA'S a Thomas McKean,Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 1, 2015 Shakell Mohammad Faroo Willow Package Store 696 Yarmouth Road Hyannis, MA 02601 NOTICE OF HEARING -BOARD OF HEALTH On 03/29/2015, cigarettes were sold to a minor(a person who was under the age of 18 years) by a person employed at your store. According to Section 371-7(B) of the Town of Barnstable Code, no person, firm, corporation, establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s) to comply with these regulations shall be subject to the following actions for each offense: A warning shall be issued for the first offense. A fine of$100 may be issued for the second offense, $200 for the third offense, $300 for the fourth offense, and $300 for any subsequent offense. You are hereby notified to appear before the Board of Health on Tuesday,April 14, 2014, 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, Second Floor, Hyannis, Massachusetts. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, RS, CHO Director of Public Health Q:\TOBACCO\WP Files\tobacco hearing letter Willow Package Store new own Mar2015 1st V1ol.DOC uoi,suiio Lu:4uyn hF LASERJET FAX P. rr>r rcr 10t Tobacco Compliance Check Form Section h t> biishme>at Survey Participants Name: �4C Ts ID of Pyrchaser: Address: Age:{t}--!5 ❑ 17 Sex:❑Male ❑Female Name of Adult Supervisor: City M T Y1 J Zip Code: Time of Check: / - am❑ pn4 Type of Establishment: ❑ Chain kndgpendent ❑ Not Known Date of Check: Day of the Week:Q Mon ❑Tires 0 hued ❑Thum ❑Fri ❑ Sat tAull Styla of Establishment(Check Only Otte): ❑ Convenience Store ❑Groce Stony Ca liar i 0 1Je rtment Store i uor Store ❑Private Club FW Le 'on etc. ❑ Gas Station Only C3 Pttarmac lDrug Store ❑Restaurant' ❑ Gas Mimi-Mart 0 Other(bowlin&al! olfalub etc. ❑Tobaoconist i i Section 2: Was Compliance Cheek completed; Yes�No CI If Yes please continue onto the next question, if No pleases ep this section and ga to section 3_ Pwas tobacco marketed?er.the-counter:youth asks the clerk for the product. m a vending machine va. 1 a locleaut device. ❑ Other Describe, Was the Pumbaser asked for ID? Yes Q No Was this an HD-based check? Yes❑ No Was the Purchaser asked his/her age? Yes 0 N0 Sex of Clerk: Mal 4 Female C] Approximate age of clerk:❑TcY n ❑Young Adult §4Adult ❑Older Adult .Type of tobacco asked for: Cigarettes, Brand of elgarettes asked for.❑ Marlboro Newport ❑Other: _-__ ❑ Chew/Dip ❑ Cigars C3 C-Cigmmttees ❑ Other _ Brand: . Was the sale made? Yesa4-No Q If"Yes"how much did the product cost: $- 11a,Q 0 Was a receipt given?Yos C2 Noon Purchaser trade payment using:❑$1 bills ❑ $5 bill(s) 0 S5 bill and$1 bills/or change.$10 bill(s) ❑ $20 bill M change Section.3; If the youth did not enter the premises or did not attempt to purchase tobacco products please Indicate why: i 0 Out of Business 0 Temp.long terns closure 0 in o oration closed at time of visit 0 Drive thru only Q Does not sell tc=baeco Q Unlocatable ❑ Unsafe to access ❑ Tobacco out of stock i ❑ Inacce!Ek!±Z jouth ❑ Wholesale only/cartons ❑ Presence of police T❑ Permit Suspodo ❑ Private club/personal ❑ Machine broken ❑ Youth ins ector knows salesperson ❑ Other residence E3 "Don't sell"but tobacco seen in store/has rmit i Form:May 2014 i I _ .............................:__...................._... .. i YOU WISH TO.OPEN A BUSINESS? For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. DATE 2. 2 4, / Fill in please: _ APPLICANT'S YOUR NAME/CORPORATE NAME ZOV JO BUSINESS TYPE: .S*-o-r"e BUSINESS YOUR HOME ADDRESS: !f! i wt V:C W Di, A SO S-77S-AR 0 s� 6'O Sr- Al-2Cd— V 7?f,> TELEPHONE # Home Telephone Number NAME OF NEW BUSINESS W i((out S 1-+�c•�i'. . aGku!/d S-1-p+� EIN: 6 6 — y83 9'83 s' Have you been given approval from.the building division. YES NO ADDRESS OF BUSINESS bD e.,4 w;3 MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth. Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual hays j en info=edf then a quirements that pertain to this type of business. Authorized ignature** ✓� COMMENTS: MUST�:OMPLY WITH ALA ZARDGUS MATIw RIAl.S RFGI II ATinw 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Dba: WILLOW PACKAGE STORE Assessor Map Parcel: 345 010-003 Address: 696vYARMOUTH RD. I Permit Number: 320 Village: HYANNIS, State �MA Zip: 02601 Phone: 508-771-1093 Contact: ,SHA KEEL MOHAMMAD FAROO Owner: BILAL CORPORATION Owner Addr: r696 YARMOUTH ROAD, HYANNIS, MA 02601 Owner Phone: 508-364-5597 Grease Trap Sewage: { No.Of Seats: Former Dba: Fids 4 4839835j M Restaurant: RET ._' Seasonal . . AIL Annual.YES �! ' Temporary: Print permits{All} Inspected By Marybeth Coverage Area Blue - Print Permits{ u} , 1 f r close