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QUICK STOP - RETAIL FOOD
]6-Y-7:7)7- OUICK STOP 3821 FALMOUTH ROAD MARSTONS MILLS, MA 0i Town of Barnstable BOARD OF HEALTH p John T.Norman +� Board of Health Donald A.Gaudagnoli,M.D. 4 y rsro F.P.(Thomas)Lee,. � Daniel Luczkow.M.D. Alt.,® 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: 647 Issue Date: 01/01/2022 DBA: QUICK STOP OWNER: HAS CONVENIENCE INC Location of Establishment: 3821 FALMOUTH ROAD-#5 MARSTONS MILLS„ MA 02648 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IncloorSeating: 0 OutcloorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE a Restrictions: ��� r� OM Initials: � Town of Barnstable w Date Paid Amt1S1 n}p) �wsrABLB, ; Inspectional Services $ 4W�f v� '�' Check# b6Z A 1639. ♦0 Public Health Division �EDMP�� Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE �Z ZI NEW OWNERSHIP ✓RENEWAL NAME OF FOOD ESTABLISHMENT: 5+o A Dort✓C aG ✓I - -Q- t �f ADDRESS OF FOOD ESTABLISHMENT: _��joZ� )r- ! /Wopyj -` n pt aJ /"!�/�TD✓t5 / ` l�S` MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: yt 7���� Cd LIDO GOB TELEPHONE NUMBER OF FOOD ESTABLISHMENT: S( Qg q70 - 0 3!2 TOTAL NUMBER OF BATHROOMS: I WELL WATER:/YES NO. ,-- ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: ✓ SEASONAL: DATES OF OPERATION:_/_/ TO NUMBER OF SEATS: INSIDE: l' OUTSIDE: 0( TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALER'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)? N,A TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FAOD SERVICE t,,'rRETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc is OWNER INFORMATION: ��J J FULL NAME OF APPLICANT /"[ Ifa fK/l�g P Z4 A ee r SOLE OWNER:CYES)NO OWNER PHONE 11 i"t Z ADDRESS E3 g7 /,�lat'l S�, /�Ct S�p�e} CORPORATE OWNER: e onileol;eot , .La CORPORATE ADDRESS: Yg 7 14(a PERSON IN CHARGE OF DAILY OPERATIONS: /�[OilcauCD GG� �tG List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SIGNATOAE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to.opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/at)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q1Application FormsTOODAPP REV3-2019.doc f - - Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNS ARM +` F.P.(Thomas)Lee MASS, 200 Main Street, Hyannis, MA 02601 Daniel L czkow 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: 647 Issue Date: 1/1/2022 DBA: QUICK STOP OWNER: HAS CONVENIENCE INC Location of Establishment: 3821 FALMOUTH ROAD MARSTONS MILLS, MA 02648 Type of Business Permit: Non-Flavored Annual Seasonal. FEES YEAR: 2022 TOBACCO SALES: $85.00 Permit Expires: 12/31/2022 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY For Office Use Onlv: Initials: 1 TNEtp Town of Barnstable - Date Paid Amt PdPd$ 18 ,�AB� : Inspectional Services tE„ ,a BAR Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE NEW BUSINESS OWNERSHIP VPL RENEWAL NAME OF TOBACCO ESTABLISHMENT: Ca y i G k S o p 6d>n ✓e r I G e ADDRESS OF TOBACCO ESTABLISHMENT: heg l ykoo+k ?C1 _ MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ; E-MAIL ADDRESS: 796 f(OF !&4 AO0, C 0 ►�►a TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: .( u f^42 - I Z y OWNER'S NAME: 10o6otweid ZAt hee f OWNER'S PH# .50&)41 OWNER'S ADDRESS: .597 Mu n St . /�u sltIPe-e- . /4 A% CORPORATE ADDRESS: 9'97 &►q S+ Malkege Mt4 CORPORATE FID# G` ANNUAL: SEASONAL: DATES OF OPERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) P®M-'O- TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https•//malegislature.gov/Laws/GeneralLaws/PartIV/Titlel/Chgpter270/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: 1� PRINTED NAME: /1/f p k"l�Gi R G 7 e'Aee r DATE: 9,/Z6o/,2 Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc I Qut``_ ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—&371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signatur Printed Name Date e e _ t 0, * _ ( Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Printed Name Date Signature e Q:\Application FortnATOBACCO APP-NonFavor 11-21-19.doc �v�c.k �✓-ro - 3�Z I �-a l itito v+ti► Gaoler s U U v N Ex�+ V s N C� Q4 VL V- d y 0 + L V 0 En f r&A eB��S� j�- I pWp y��r't Fi Commonwealth of Massachusetts Letter 1D: L17557301 12 i"�5 s Department of Revenue Notice Date:June 21,2021 (] f �; 1 GeoffreyE.Snyder,Commissioner Account ID:CGL-20373123-003 a 'I:. 1`5 y Y r 4; ,1, 'Qyipk� mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES I�III'III�III�IIIIIII"II � �� IIIIIIIII�II�II" I'll" III� I o= M ZAHEER HAS CONVENIENCE,INC. QUICK STOP CONVENIENCE 387 MAIN ST MASHPEE MA 02649-2053 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3). 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 ------------------------------------------------------------------------------------------------------------------------------------------------- s'`a SE�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes Vr o��` This license must be posted and visible at all times.The sale of tobacco products to anyone under 21 years of age is prohibited. HAS CONVENIENCE, INC. Account ID: CGL-20373123-003 QUICK STOP CONVENIENCE License Number: 1539913728 3121 FALMOUTH RD MARSTONS MILLS MA 02648-5701 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: June 21, 2021 Expiration Date: September 30, 2022 �.c}r 4'p Commonwealth of Massachusetts Letter ID: L0008474816 O s Department of Revenue ■+—I h yt t" Geoffrey Snyder,Commissioner Notice Date:June 18,2021 ❑.� Y E. dcr Y Account ID:CRL-20373123-007 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO I"'�'III'�I'I"I��IIIIII�"�""�I'I'I�IIIII'lll�ll'����IIIIIII' o M ZAHEER S= HAS CONVENIENCE,INC. N=_ QUICK STOP CONVENIENCE MOM 387 MAIN ST MASHPEE MA 02649-2053 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 ------------------------------------------------------------------------------------------------------------------------------------------------- ss�'"i1rS�T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco �yF:rrt.W This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. HAS CONVENIENCE, INC. Account ID: CRL-20373123-007 QUICK STOP CONVENIENCE License Number: 1707161600 3821 FALMOUTH RD MARSTONS MILLS MA 02648-5701 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:June 18, 2021 Expiration Date: September 30, 2022 Commonwealth of Massachusetts Letter ID: L0545345728 Department of Rcvc:nuc Notice Date:June 18,2021 O 'ris ,! D Geoffrey E.Snyder,Commissioner Account ID: EDL-20373123-012 ...... j4 mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS Ilttnlntttlll�tlnt�lt �lttttntt �ttllll�ittt �tttltll o= M ZAHEER o HAS CONVENIENCE,INC. QUICK STOP CONVENIENCE 387 MAIN ST MASHPEE MA 02649-2053 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. 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 ------------------------------------------------------------------------------------------------------------------------------------------------- act-fc'S�, MASSACHUSETTS DEPARTMENT OF REVENUE (�t Retailer License for Sale of Electronic Nicotine Delivery Systems This license must be posted and visible at all times. The sale of yF�ro��lc tobacco products to anyone under 21 years of age is prohibited. HAS CONVENIENCE, INC. Account ID: EDL-20373123-012 QUICK STOP CONVENIENCE License Number: 901855232 3821 FALMOUTH RD MARSTONS MILLS MA 02648-5701 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems 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: June 18, 2021 Expiration Date: September 30, 2022 Sr`'g�y IR(�DEPARTMENT OF THE TREASURY 1�iV"J'INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0023 Date of this notice: 01-09-2020 Form: SS-4 Number of this notice: CP 575 A HAS CONVENIENCE INC QUICK STOP CONVENIENCE STORE 387 MAIN ST For assistance you may call us at: MASHPEE, MA 02649 1-800-829-4933 IF YOU WRITE, ATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN) . We assigned you EIN 84-4231890. 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 940 01/31/2021 Form 944 01/31/2021 Form 1120 04/15/2021 Form 720 04/30/2020 If you have questions about the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year) , see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the'year at issue) . Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. IMPORTANT INFORMATION FOR S CORPORATION ELECTION: If you intend to elect to file your return as a small business corporation, an election to file a Form 1120-S must be made within certain timeframes and the corporation must meet certain tests. All of this information is included in the instructions for Form 2553, Election by a Small Business Corporation. r Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. :' xxsen AOLF, Paul J.Canniff,D.M.D. ib9 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: 647 Issue Date: 01/01/2021 DBA: QUICK STOP OWNER: H-R BROTHERS, INC. Location of Establishment: 3821 FALMOUTH ROAD MARSTONS MILLS„ MA 02648 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: QA FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office I Town of Barnstable Initials: P Inspectional Services � Public Health Division sue-' `0 C`° Thomas McKean,Director 200 Main Street,Hyannis,M,A,02601 Office: 508-862-4644 Fax: $08-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTA13LISHMENT DATE JL NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT; G ®P OZA 4 1 J ✓��7[� 3ie51Y1. ADDRESS OF FOOD ESTABLISHMENT; `3$ZI �h.)w1atJ� I�l�, � ,i'�l�-I , MAILING ADDRESS(IF DIFFERENT FROM.A]BOVE): A� E-MAIL ADDRESS: &Q/�Wz4La f'62y TELEPHONE NUMBER OF FOOD ESTABLISHMENT: c fiL k10 --1-M—y. TOTAL NUMBER OF BATHROOMS: _ WELL WATER:YES_NO V,(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: ✓ SEASONAL: DATES OF OPERATION: / / TO J I NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE PINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOP OUTSIDE DINING? ...............,.....,...,..,, IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES...(MONTHLY LAB ANALYSIS REQUIRED) CATERING...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE##2) *** SEASONAL,MOBILE&NEW FOOD ONLY*** REQUIRED TO C.L.H,EAL.TH DIV.FOR INSPECTION PRIOR TO PERMIT BEINGNSUEII PLEASE CALL 508-862-4644 Q\AppUcacion FormsTOODAPP I020,doc OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/NO OWNER PHONE gqQ (�70'6'q ADDRESS_ 6 6 CORPORATE OWNER:_ CORPORATE ADDRESS: 533 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 Protectiou Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div.will NOT use past years' records.You most provide itew copies and POST THE CERT-1- +�C...Ans-at-yourf'ood•estabtishment: Certified Food Managers Expiration Date Allergen Awareness Expiration Date 4 -/ 6 /J-a 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 openirta!! 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, �_....._...yritl�samp)e.xesult�:subtx>itt�ci.to.t1�. h�,��vr•);akdure tp do so uv�ll,result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. r..., _. .. CATERING POLICY: Anyone who caters within the Town ofBarnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at htto://www.townofbarostable.us/healthdivision/avulications.1m. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food estabUshment is prohibited. NOTICE: Permits run annually from January Ist to Dec.3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. Q\A,pplication Forrns\F00DAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. ¢asONSTABM " F.P.(Thomas)Lee 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,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: 647 Issue Date: 1/1/2021 DBA: QUICK STOP OWNER: H-R BROTHERS, INC. Location of Establishment: 3821 FALMOUTH ROAD MARSTONS MILLS, MA 02648 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 Town of Barnstable Initials: . Inspectional Services -- $ r Public Health Di'v ision Thomas McKean,Director 200 Main Street;H7aa,nis,MA 02601 Office: 508-862.4644 Fax: 508-790-6304 TOBACCO ES..TABLISHME,N.T.-PERMIT APPLICATIg&,', on-Flavored) DATE NEW BUSINESS OWNERSHIP RENEWAL-L/- NAME OF TOBACCO ESTABLISHMENT; Ad ��, e � (/ r ADDRESS OF TOBACCO ESTABLISHMI�NT:' _ {� e aQ�, d�1,A h�A9 j�Jq oZl' y "W if MAILING ADDRE'SS'(IF-lYIFFE1tENT F•ROM,A.BOVE);--- E-MAIL ADDRESS: __ � >�fl dl�l�,�lll • TELEPRONE NUMBER OF TOBACCO ESTABLISHMENT: ]4A- Q.2 /.'�rY OWNER'S NAME:_ 4/ 00AWL OWNER'S PH# o . Sbwl OWNER'S ADDRESS: . jait 61=6 CORPORATE NAME:—� ��'�ijej �, i CORPORATE ADDRESS- WMa7LA RD i./lAn I ! CORPORATE ANNUAL: SEASONAL: DATES OF OPERATION:/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(ER.MONDAYS), a TOWN,OF BARN'STABLE.CODE/NU.GENERAL.Y.A�i!.INT RNE.T LINKS:.r .... . ... r , - -- TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httgs://www.ecode360.com/33996392 7 s' MA GENERAL LAW CHAPTER 270/SECTION 6; 4 ttgis�/!ma'1'� islatuueavf€�ayusds�iealLa�Hcma�rTVlx'it]eUCha ter270/Section6, W°.NEW BUSINESSES AND NEW OWNERS ONLY 4** 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 RBQUIRBD DOC"NT$: � 1) MA State License to Sell Cigarettes 3) IRS Federal Tax IDN Document ;{ 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 r SIGNATURE: ell I . PRINTED NAW,,: � � DATE:.i2n/.4 !.. F Q;%Applioatiom 9orms\TOBACCO APP.NopFeyw 12-18-19,docx ' ii x . x ESTABLISHMENT' N 1ME F TOBACCO.SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 7 371-9.of the Town of Barnstable Board of Health Regulation; Sales to Mbiors—$.371-9.Sale and Distribution of Tobaccp Products 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimums legal sales age. The minimum legal sales age in-the Town of Barnstable ... ...,. is 21 yesi$of'age; ' _.•......... ti 2. Identification; Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371.9 of the Town of Barnstable Board of { Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: .r t} 4 t attire Pruated Name •'•l�aie - _., r� ghl Los 14 At0 --aA Sign a Printed Name Date Signature Printed Name Date Sighanire.. ......... rlhtedName Signature Printed Na—me Date `. s Signature `'Printed Name "" Date 3• y ' Signature " Printed Nonin r. QAA.pplication FonnsIOBACCO APP•NonFavor 12.18.19.docx •i I "- "..- - r —�:•`I:i:.l"fr.:N,rl ,r,in�n�'.:vr.•.f 'T.j�r[i,';r RJ,tii.'r�•.r;^!':tf+!'�• GOVCommonwealths of Massacbusetu Letter ID:LOS14944224 ; Department of Rc�•enuc Notice Date:November 30,2020 Geoffrey.E.Snyder,Commissioner A.ceouot ID:CGIr-1110Z4$3-006 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES 'Il'�'III'lll�l�l��l� l,�llll�lll'�II'I�I�I'I���I�II�II�II�1�1� H-R BROTHERS iNC 8 QUICK STOP CONVENIENCE W 21F M 38 ALMOUTH RD STE SA ® MARSTON$MILLS MA'02648-1868 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3).Cut along the dotted line ,and dasplay.at,y..our busi ness_lncation„At any,.xi�oo U.cat�lo -iet2Xo._ Ta cCont fount,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 -------------------------------------------------------------------------7-------------------------------------------------------------- wcHt'�,� MA.SSACHUSEtTS'DEPARTMENT OF'AEV)9NUE Form CT-3 Retailer License for Sale of Cigarettes z .y � rco . This license must be,posted and visible at all times.The sale of tobacco products to anyone under 21 years of age is prohibited. H-R BROTHERS INC Account ID: CGL-11102483-006 QUICK STOP CONVENIENCE License Number:2013145088 3821 FALMOUTH RD STE 5,A: MARSTONS'MILLS MA 02648-1868 This certifiq 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 nova-transferable and may be suspended or revoked for failure to comply with site laws and regulations. Effective Date: October 1,2020 Expiration Date: September 30,2022 .,u (;o)nmonweaun or msasacnmm" a N Department of Revenue Notice Duo:November 30,2020 �y ? Geoffrey E.Snyder,Commissioner Account ID:CRL-1 1 1 02483-009 o* mass,gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO '�I�I�'�"III'IIIIII�� II���I�II �I�III�I111► II II'llll�'llll�� o= H-R BROTHERS INC QUICK STOP CONVENIENCE 3821 FALMOU'rEi RD STE 5A ®" M0,$TONS MILLS MA 02648-1868 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form.CT-3T). Cut along the dottedline-md display at your business location..•A.t any time,you can log into your MassTaxConnect account at mass.gov/masstaxconneet 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. M DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------ MA.SSACHUSETTS DEPARTMENT OF REVENUE Forth.CT-3 Retailer License for Sale of Cigars and Smoking Tobacco � F 0 This license gust be posted and visible at all times.The sale of tobacco products to anyone under 21 years of age is prohibited. H-R BROTHERS INC Account IA: CRL-11102483-009 QUICK STOP CONVENIENCE License Number: 1120872448 3821 FA,LMOUTH RD STE SA, MARSTONS MILLS MA 02648-1868 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws sell at retail at the address shown above.This license is non-transferable and may be suspended or revolted for failure to comply with state laws and regulations. yy Effective Date:October 1,2020 Expiration pate:September 30, 2022 ✓` �r 3� MASSACI USE'1'TS DEPARTNitNT OF REVENUE Retailer License for Sale of Electronic Nicotine Delivery S stems oE� This license trust be posted and`visible at all times. ale o .q The f tobacco products to anyone under 21 years of age is prohibited. H-R BROTHERS INC i QUICK-STOP Account lb: FDL_11102483-0 l2 3821 F,A.LMOUTH RD STE 5A License Number:541583360 MARSTONS .MILLS MA 02648-1868 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above non-transferable and may be suspended or revoked for failure to comply with . This license is state laws and regulations. Effective Date:May 12, 2020 Expiration Date: September 30, 2022 „� f Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. t' HARNSTABL& Paul J.Canniff,D.M.D. 6 k 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: 647 Issue Date: 12/10/2019 DBA: QUICK STOP OWNER: H-R BROTHERS, INC. Location of Establishment: 3821 FALMOUTH ROAD MARSTONS MILLS, MA 02648 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: G A FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: - FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: o ' • For Office Initials: Town of Barnstable 2 V ��' Date Paid ' v Amt Pd BAMMBLB. : Inspectional Services Public Health Division Check# n Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 J "1 1> Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE IL �Z��� NEW OWNERSHIP RENEWAL V' NAME OF FOOD ESTABLISHMENT: 6?w a' - -S 16 p eomyi%/ iapno ADDRESS OF FOOD ESTABLISHMENT: 3$7-1 F-jMVAfV MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: C-66 17)�o - ��i TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO •✓ ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V SEASONAL: DATES OF OPERATION:_/ /_ TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** _REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc I OWNER INFORMATION: FULL NAME OF APPLICANT fzA YV SOLE OWNER: YES/NO OWNER PHONE # b d - 6 b 5-0©� ^ /) ADDRESS 11 C' 7 rTY�,v�J ��l T� Q �c5 a D C Ifh�, 1'c CORPORATE OWNER: A15AL QQ IZoSI C'�a'4&�f zs �T— Q6SI') r OZ�Lj� CORPORATE ADDRESS: ?i fd)MAk M,41UTM15 M`) b PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SI NATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/hcaIthdivision/applications.as[). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Application FormsTOODAPP REV3-2019.doc •4 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. AR$4 yaLe. Paul J.Canniff,D.M.D. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 647 Issue Date: 1/1/2020 DBA: QUICK STOP OWNER: H-R BROTHERS, INC. Location of Establishment: 3821 FALMOUTH ROAD MARSTONS MILLS, MA 02648 Type of Business Permit: Annual X Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY if c oF�Ne t For Office Use Only: Initials: Town of Barnstable Date Paid Amt Pd$ ,AR,,EMABLE Inspectional Services �cb MA W. 1 ' A,Fo9. , Public Health Division Check# a Thomas McKean, Director (213 200 Main Street, Hyannis,MA 02601 I p . Office: 508-862-4644 Fax: 508-790-6304 r, .b r�. TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE 1— NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: #')z iy>°.ts T �/ V 11 I ylz— P- ADDRESS OF TOBACCO ESTABLISHMENT: t1Wt6-v* MACQ—d t'JSiVJo 1 f M L O U 9 9 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: WjtA� 114z Ad- 6pl TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 'J7,6 -�> OWNER'S NAME: &, A& S wAtJ OWNER'S PH#f 5jb f40- -0 OWNER'S ADDRESS: ?.O GetnllWCEekl— 2AL4 L- CORPORATE ADDRESS: 3SIA F&6& k-ni ,M(1 j a 744?CORPORATE FID# 119�—6�— / ANNUAL:_ I/ SEASONAL: DATES OF OPERATION: / /_ TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https•//malegislature gov/Laws/GeneralLaws/PartIV/TitleI/Chgpter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document `2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: - PRINTED NAME: o DATE: It / . / Q:\Application Fonns\TOBACCO APP-NonFavor 11-21-19.doc ESTABLISHMEfiVS NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9, of the Town of Barnstable Board of Health Regulation: Sales to Minors—& 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: WAN-L I ature Printed Name Date xrlem ff 3 Sig re Printed Name Date - T of 3� Signature Printed N me Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Fonns\TOBACCO APP-NonFavor 11-21-19.doc 10612017°' 4474 4. ` a-�:'+'� l a� a. x � '^�;, •��€�' s��;,��;�a ,.,��. m „,ate,�.� . rltGO�C11 + 1'4f „ � wTblia b r . fO : _ *■ _�. i r.., d -„` � ERR_ 3• ��!{', _ 4� d$� bf+z h'- lol'�, e. .y ,�°�,��ti,' s -.: �• � � _ ,, a� ,�.- "� ..� gel ' � �� a � �,_�, �m- ���ZVI * z:> # 41 ✓ -' o rk �.m a� k`w r,•`• a F .;1"„ .n "a=. ,'�-•lyc�'.�.$_ �. � ;F:,.` ���, n' ��'.� , r. b.- m r �2 _ g 'y 9Fx. „ Via,. r ,. ., AN .....r... �J.r..n.•r. »(*tax f' S rr.g..� -, ', dk� A r TM s •'S,,> _ - .��� �.+cL ;., ' e° It .,...� - '�.'�.:1� .�°„w. ,ate � • .: '`r ' •` :�.. ,. ,; " ,.�,-- #s '`�.. s*:^ na _.t«.'S ,'w. .c;.1-�t,• �,.:.'� .;rz ;,; ,y .x... '�. v tl'r y, fIS }.,USET� s a ,. 4 , ,_ _ '�S.DEPARI'1VYENT r F - Forrn CT-3T -r. _ nZedaierYLieense :; . . , yti ( E . . ., �. fir ., , . n,. m; =x }., . . ,, ., • r. _. m.v . _ for Sale of Cl-jars and, nokia� >>obacco ,• b ,.r ram--� *;a... „. 'x a i� • v � r .. .- ..;.�,.a 5r�k �.,�::a� --:t• 1-�....&'s..-e+sT .,:$� y �j,,.' ,.i-- •'#f tr �v't , . s.license-mustbe° o k • . ar and v ble es.,.I' ft aeeo . sted isi at all yttm he sale"oG ob s . roduct s to an -one u . ;easfa ro _ hibted. , x r �. °.�.' ,&.. ,.�; _ >.... . 3 �` �..,. .z - ..„ �a ,.:,; .,,: '" x. - *a , r+ �`• a w "s,s °, 4a"._%c y' :.�, `� ,, s.• r e..- .;,.. Y, x ;, € im ,_.�' a9- i'`sa ve �f ,a,,., �« . t .. � TIIIC ° . �� _,. a T• _Act n' CRL 1102483,= 09 " VIA _ �. ����,.. � b I�reense Nurni`ber.: 34 4 r. STU ,,C l EW - 62 x 950 . "It 1. ' .rr .. ��' g � 7 r # ° Yli"�1? h� � ,�/s13 " q�s x. r?a ? �.` `4. ,n:`' a- ,��'- '', s , .� ._ ro26418o 8 8 �,� ..yiARSTONSlILLS ► ::: n d `" �. �� � � .rd •, ,T-.�' o-,x. �� � �.. - .• _ v.T �� �� �" _ *, .,r '.� u.r,� -� s - � b � �' >� tw n ., IT rwy' k >k e T certrfes,that'.the tax a, ernarnedabove,is lce d ku: ef:Cha ter.64C'of t111 e,A, assachu etas G neral Law 1 1 x W . . e his p� y _t . ou u m m W -*Tr Tr 1 w 'WIN, iwwo - , 1,17II. �,. y _ 1 k m 4,. ., lied for.. Uww ,: ; :,, ,f .mw , I ti, ,n �millmu. w ru �m, ro ma; be sus .ended or reuo`. ice e eagle and,. �. 5'ell atetatl at the ssr shown ab ngig P • a .dre , — r �. w � r failure toy corn :1 f�ywith state.�la,�us and regu�lat oris�..' PY f � w ._;,E, >w. � .. ..W •„ � ~e : .. .-.,i�::mun �mou.m wb ( +.. D'c`Lte•�4�� + 00, r,, 6, b a hnai 'n Mot 16ou .u I(I imlrimr�uNrn al�m&WU Ua N94m .iunw woo, t1 ul ywa tlUt'� ,. .- ` w i�kffcctYcte.��0 e,t�b� 1 12KWA �, f. • - x Ace,AMF .r 7-1 ' mVASSAC�IISETT , EpARTMENT OFREVE FCT`_� 3T } .s1 §„ Lice_ns =Sale of=C:i Retailer; a for garettesa This�license,mu �"�e �. st be ost Th ^ ale=�oftobacc m ., d ea ^e isibl tall times ti ssto anYone unde years, odprct ,U a _�is r, ohibLg ted PQ S t , n r, s. H-R BROTHERS e r t X __- _ ING - ccount.ID GL,11102483-006. �. _ w 44 ' 3 8.2`I FAk ��IMOIJT I _ . eNuer 2R 4QJICKSTOP:COI $EENCE �cen , a x m .�.� . � % � �-, Laws to T rtl { t ,, er narn6d,above:`x-s,licensed under.Goa tee,64C'=of the Massack usetts General a' hls,ce fies hat the. taxpay b P ri e'is: on -ansfez able and xxa` be sus ended gor revoked Tor -self at retails at the-address, ow, abo�!,e._Thstice s failure:to�com lw w�thstate laws and.re ulations. � _ .t _ P�Y _ g r , �..� t 6 } Effective T)ate:` October 1a; 201`8�y . ` �xrr=at�an Date. September 30, 2020 r a #a x u o- n —r r .•v „a .A v 14 y. - Y s ?"_ f d GEmpo�yeeignatttreFarn � s , xi g erstd�e=emptoYee s lsvnent recevndufon fu - Otls;'esab 4 ndooC haptera 37�1 �. of the Town+sofa Barn�tableCodeandClia`ter>270''Secton 6,of rtheMassachusetts,General'Lativs°w ' '� p k Y. hick describes the° enaltles ;or�sell ng� d/or, g�v=ing tobacco roducts to as .ersoi� underthea a of twee one 21 ` ,Below°i 371"9 �c: e Tovii�ofBarnstableBoardof�HealthRegulation F g tY , sSe n - Har . .. a A r � >�:. °Sales�to M hors-�37a1�-9"Sale�andp.Mfeibutiontof Tobacco Products:. #r r 1 NQ person shall sell�or prouide a�tobac 00rodddli s defineiE d hereui Ito a person,�under, � ti S tAs 3d o '4' a4t Ao£ L 3, k'E'atD'u'1 t &'- 'U yo«. 4 r mmmtmilegal,salesAage The minimuinlegalsales�age m theTownof Barnstable_ g _ _ s �x ��a .tom .� ,�,�. � ,� J �"�a.��. � "a � r � k a 2'.` Vera,icat bri �Each,persoxt�sellmg or disNibhting�tobaccaproducts,as definedlerem vs i0ty-ertfjr the�age of�the'purchas fr by means of a�vand overnmer t xssaed hoto a hie � " a _ g PP .x iden� cation contammg�the bearer�ssdate of bi�ft'A at'wthe purchaser;�s 21 years aid or.x x; ' - ,� a"` �� � ��,�;-��, - �olde� verifcation is requiredfor any�persontundertle�agea$f27 .°< Y _x 4='v r - h. _ T eten plcyee(s}�b`elcwrecervedandundexstoodSectio437f1-9`oftheT6wnoMafnstableBoar_dof gealthrohib�t�on=of Sm okingRegulation+and Chapter�270�Secton 64f=the Massachusetts GeneralLarovs�3 aF tin` i,x �� " � �`m �_ art � �z> �� do-+„ to'ar Fu: S e'—�..+✓ � -€„ � a a- a � r Si a r s Sign a Prmtedt ne e � ® _ Signa e `. - te Name _. ��DatDe4 � w 4, ee Sign ei . n , �;. Mted Dame . , Date - ,"knited�tATarne .. , W -:.Datee � ._ �-, : = ' t�ignatur �. ne -' ; DDate n > ., si ature ° w'Prulted Name g c'Date w gn k u _ . QztAppfibaior �rIT ms�lOBAt COA�P NonFavor>11 21 19do"c F 3 n w e 47 _ •, IKE Town of Barnstable Board of Health BARNsuBm y xAss. 200 Main Street, Hyannis MA 02601 i639 �0 CFO MA'S A ORice: 508-862-4644 John Norman. PAX: 508-790-6304 Donald A.Guadagnoli,M.D. Paul J.Canniff,D.M.D September 11, 2019 Quick Stop Convenience Store c/o. Caren Hazart-Roshan 20 Connecticut Avenue Harwich, MA 02645 RE: Quick Stop Convenience Store/ 3821 Falmouth Road, Marstons Mills Dear Ms. Hazart-Roshan, Your request dated August 22, 2019 to open and operate an adult-only retail tobacco store at your existing store, Quick Stop Convenience Store, located at 3821 Falmouth Road, Marstons Mills, Massachusetts, was withdrawn without prejudice by you on August 27, 2019. Sincerely yours, ohn Norman Chairman TOWN OF BARNSTABLE BOARD OF HEALTH Q:\WPFILES\AdultOnlyTobacco Quick Stop Marstons Mills WITHDRAWN Aug 2019.docx 'w r 20 Connecticut Avenue Harwich, MA 02645 Thomas McKean, Director Health Division Town of Barnstable Board of Health PO Box 534 Hyannis, MA 02601 August 12, 2019 Dear Mr. McKean: My husband and I have owned and operated the Quick Stop Convenience Store in Marstons Mills since 2015.We have worked hard to develop trusted relationships with our customers and the community-at-large.We have established a successful business and are grateful for the opportunity to serve our neighbors.As a family,we rely on the income generated from this business. As you know, Barnstable now restricts the sales of flavored tobacco products.This includes menthol cigarettes, flavored pods for Juul electronic cigarettes, and other vaping products. Its intention is to curb the epidemic of vaping among young people, an effort that we fully support.We are aware of the health risks associated with using tobacco and are committed to keeping it out of the hands of underage customers. Since July 29, 2019,when this restriction was put into place, we have seen a decrease in sales of approximately$500 per day. Because the restriction includes menthol cigarettes, we have lost long-time adult customers; regulars who came in daily. Not only did they buy cigarettes from us, but they also made food and household purchases while in the store. We are losing business every day that will amount to over$180,000 per year.We have a five-year lease on the property.We cannot absorb this loss and survive. We are a licensed lottery retailer.We strictly enforce state mandated age limits on all lottery purchases.The new tobacco rule allows businesses that restrict entry to customers over 21 to sell flavored tobacco products. We are asking for an accommodation or waiver to allow us to sell tobacco-of-choice products to our over 21 adult customers.As with the lottery, we will uphold strict identification checks to assure compliance. We firmly believe in preventing underage tobacco use and support the Town of Barnstable in this effort.We seek to save our family's livelihood and cont;nue to provide the town with a valuable service. Please feel free to contact me at 508-292-3458 or carenart2@yahoo.com.We are happy to provide any documentation or information you need.Thank you very much for your consideration. Sincerely, Caren Hazart-Roshan, Owner Quick Stop Convenience Store Marstons Mills, MA 20 Connecticut Avenue Harwich, MA 02645 Thomas McKean, Director Health Division Town of Barnstable Board of Health PO Box 534 Hyannis, MA 02601 August 22,2019 Dear Mr. McKean: The Barnstable Board of Health has asked us to provide additional information regarding our request for an accommodation or waiver that will allow us to sell tobacco-of-choice products to our adult customers.This is in reference to my letter dated August 12, 2019. My husband and I own the Quick Stop Convenience Store in Marstons Mills.The store is approximately 576-square feet. In addition to Massachusetts State Lottery tickets,the smoke shop will sell all tobacco- related items including smoking tobacco products,chewing tobacco products, CBD dispensary products, and electronic cigarette products. These products include the following items: • Tobacco bags • Fine cigars • Grinders • Lighters • Pipes • Cigarette rolling papers • Vaporizer products • Flavored hukkah products • CBD for pets • CBD edibles • CBD oils Thank h for your consideration. Please let me know if you require any more information. I can be reached at 508-2 458 or carenart2@yahoo.com. Caren Hazart-Roshan,Owner Quick Stop Convenience Store Marstons Mills, MA I , Q u�Ck Cj�o� ry-o'-s�D,r\ vv-6 W S act�k 170D� I C� D 6 Zl vl o E r► A I d o aa�� rov�m E 1 ' ` polof f ' o IKE Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. BARN-"ABA John T.Norman 'MAS& 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: 647 Issue Date: 12/20/18 DBA: QUICK STOP OWNER: H-R BROTHERS, INC. -ASHFAQ ROSHAN Location of Establishment: 3821 FALMOUTH ROAD MARSTONS MILLS MA 02648 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: Indoor5eating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019- RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - --- - - - ----- MOBILE-FOOD: MOBILE- ICE CREAM: FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: $85.00 I FOR ESTABLISHMENTS WITH SEATING: i PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: i o�`►ETWyti • Initials: o� Town of Barnstable a D Date Paid Amt Pd$/ MAN. ' Inspectional Services 9 9. eg i63� ♦0 // A lEo Public Health Division Check# —1 Thomas McKean, Director LDQ 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 7, —1e 41 NEW OWNERSHIP RENEWAL 1 / NAME OF FOOD ESTABLISHMENT: f � L- ;��V+�•{� S I �L I�'U�t/�°"�j� ADDRESS OF FOOD ESTABLISHMENT: 'FA-1 wta, Ar4 W1 i AAA 4 2,� MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: 476_ HH ,-J V)42, �1,�7G`�'ll o� 'C'�--- TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: i,� SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE i/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 c ye2, 2 �1�Ir �i� !� �'��+ iN1,�_ G CORPORATE OWNER: FEDERAL ID NO. : /( CORPORATE ADDRESS: SilpVllG j�� � �� PERSON IN CHARGE OF DAILY OPERATIONS: �S'11r,� ��S I ti►y List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at 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.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsT00DAPPREV2018.doc THE Town of Barnstable Regulatory Services Department • lARNBTABLE, t ,39�- 0� Public Health Division (� �fD1"°s 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 g 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT s. LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL 6&g:zj s9p DB/A V WnIkA )iD 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 loyee Signature Form (provided herein). Sign ure Date Q:\Application Forms\TOBACCO APP2018 dob.docx ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors— & 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The 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 Massac usetts General Laws: 1 tore Printed Name /) Date �J /! Sipatdre Printed Name Date Signature Printed Name Date e Signa rinted Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP2019 dob.docx `pF(ME Tp� TOWN OF BARNSTABLE . . HEALTH INSPECTOR'S Establishment Name: Date: Page: Of OFFICE HOURS T : BARNSTABLE. PUBLIC 0 MAIN STREET H DIVISION 3:30 4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION 1 PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. a�. �0$ HYANNIS,MA 02601 MON.-FRI. No Reference R-Red item• PLEASE PRINT CLEARLY �prFD MP'� 508-862-4644 - FOOD ESTABLISHMENT INSPECTION REPORT Name Date -� Tvoe of T f inspection OOgeration(s) RoutiA10 l�it.fTt- �6 Address 3f7i ,� /�7„ �� Risk Fo Service Re-inspection f w Level eta if Previous Inspection J Telephone esid.ntial Kitchen Date: ^' Mobile Pre-operation C= Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: �/l/t Other t✓/V�/� �XJ (� r �y Inspector ,_ fob Out: 7J Each violation checked r quires 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) ❑ YZ 2. 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 r e ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ` p ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals it t v FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures b ❑ 5.Receiving/Condition ❑ 17.Reheating _ ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling CAre ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding JJ � PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control `�Q r�.tJ ( ❑ 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 ` 1 I S cal q Yt Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations ` �L /mays 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 Overall Rating within 90 days as determined by the Board of Health. ❑t2_1) 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. I Embargo❑ g ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical, results in an F. 25.Equipment and Utensils (FC 4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-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 6von-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 8non-critical violations. If 1 critical refrigeration. = 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations C. 30.Other DATE OF RE-INSPECTION: Inspector's Signatu Print' 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N na Print: Si #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC 9 Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violation 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 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 3-20242 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE.Foods* 19 PHF Hot and Cold Holding 2-103.11 � � Person-in-Charge Duties - � - - - 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F - * - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 7-102.11 Common Name-Working 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 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 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* ' Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q " Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reted of Food* Produce,Criteria* HSP HIGHLY SUSCEPTIBLE POPULATIONS 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or or Contaminated 7-204.12 Chemicals for Washing ( ) 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* 7-265.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Roden[Bait Stations 3-201.12 Food in a Hermetical] Sealed Continer* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Equipment Eggs-Immediate Service 145°F 15 * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg mme ery sec* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* effe ce�e uuzoot 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)(I)(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 1 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 e ide in cater- Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-361.14 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(13) 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 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14 Cooling Cooked PHFs from 140°F to 70°F (A) g * Conveniently Located and Accessible Within 2 Hours and From 70'F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* 5-20411 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 29. 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:590Founbackfi-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. Pa _ r 't Qft��JO\Qate: i °FoHE TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: 9 Page: 1 of , O FICE 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 e39. `0$ HYANNIS,MA 02601 MON.-FRI. No Reference. R-Red Item PLEASE PRINT CLEARLY MPS n � 508-862-4644 FOOD ESTAB ISHMENT INSPIfCTlON REPORT - �t Name I ate Tvue of of Ins ection VA Operations) Routine Address Food Service spectio tai Previous,lcs vcti rf Telephone ntial Kitchen Date: 00 1 Mobile' Pre-opera o HACCP Y/N Temporary Suspect II� ss Owner P rY Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP t Other Inspector t Each violation checked requires an explanation on the na ati 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) ❑ 4q2, on Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ 1jr 7 FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands t ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities a f / EMPLOYEE HEALTH PROTECTION FROM CHEMICALS .1yu K45r' ❑ 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 U ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) ` Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee.Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction.Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 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 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 9ntin-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 vi ation 29.Special Requirements (590.009) within 10 days of receipt of this order. 36.Other DATE OF RE-INSPECTION: I s or S �ture tint: 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 Signature Print: ht Self Service Wait Service Provided Grease,Trap Size Variance Letter Posted, Y N - - - '✓� `I � I / Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination L14 Food or Color Additives _, Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* _ 19 PHF Hot and Cold Holding . 2-103.11 Person-in-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* a 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* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits 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* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* - . REQUIREMENTS FOR w 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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* 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* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 183-401.11A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg°"°e uuzoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in Ratites-165°F 15 sec* 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* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 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 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 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* Ln 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°E 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 2g. 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. oF, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Gj a��('(4-6P Oyi Enew Date: V 90/q -.Page:, r! Of ti OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:90 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 .. - MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY 508-862-4644 'EON1P� FOOD ESTABLISHMENT INSPECTION REPORT. 6 Name Q d�ue�� raven i��� Date 7�1� )(� Tvoe o Type of Inspection 1 Ooeration(s) outine J G �n t/ ^ Risk Food Service Re- ection _ _ Address 3�21 �4l�rnau{' Level tai Previous Inspection / 4 �ri Li 0' Telephone Residential Kitchen Date: ._ L I D kq -PIT Mobile Pre-operation r Owner HACCP Y/N Temporary Suspect Illness - }�� I/' Caterer General Complaint L Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector P' Gl Qvrv� Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of,Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP, ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY j_t//t�� � �(� t(/ ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories J "C Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance ❑ .Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) checked indicate violations of 105 CMR 590.000/Federal Food Code. 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'-6UMber 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 tion of 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. within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) Y P 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: v��S D impster'screened from public view D Permit Postedd? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: (��lSelf Service Wait Service Provided Grease.Trap Size Variance Letter Posted: -Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from EachIdentifying * 590.004(F) 7-101.11 Information-Original Containers Other* g 3-501.16(A) Hot PHFs Maintained At or Above 140'F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage*g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* 3-304.11 Food Contact with Equipment and Utensils Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.00411 Requirements e9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* ( ) Variance Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 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 Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a 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 Wazewashing-Hot Water Monitoring* L3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(l)(2) ERRS-155'F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145"F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective mrzoot 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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 8 g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11 C Game and Wild Mushrooms Approved By ( )(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under 929-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g• 8 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 foodbome 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140'17 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 I Good Retail Practices FC 1590.000 Tags/Records:Fish Products L5-2O5.11 1 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 3-402.11 Parasite Destruction* 1 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 Accessibili O ration and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records Creation and Retention* Accessibility, Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004 J Labeling of Ingredients* Supplied with Soap and hand Drying Devices () 9 9 27. Physical Facility FC-6 .007 T Conformance with Approved Procedures 1 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 1 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. �p INE rok, TOWN OF BARNSTABLE ., HEALTH INSPECTOR'S Establishment Name: bate: page: of q OFFICE HOURS BARN STABLE. 2 PUBLIC 0 MAN STREET 3:30-4:30 P.M. DIVISION ' : 0- :30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MON.-FRI. ,639.per• HYANNIS, MA 02601 508-862-4644 No Reference R-Red.Item PLEASE PRINT CLEARLY , 'FDN1P� FOOD ESTABLISHMENT INSPECTION REPORT s Nam Dat Tvoe of T Inspection Operation(s) outi 5 Address Risk Food Service Re-inspection Level a ai Previous Inspection Telephone esi ential Kitchen Date: C Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint - Person in Charge(PIC) ime Bed&Breakfast HACCP Other Inspector I V`� `' Out:. Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP Elio.PtoperAdequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories ff 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) 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 Embar o checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑.Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005 B=One critical violation and less than 4non-critical violations g ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,Tto 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: - Inspector's Signature %/���' Print: 31.Dumpster screened from public view `ks Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signat I Print: Self Service Wait Service Provided Grease Trap Size- Variance.Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 •. Additives* 3-501.15 Cooling Methods for PHFs ` Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding ' 2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 7 5 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) 45 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* 590.003(C) Responsibility of-[he Person-in-Charge to 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 R uirements 3-304.11 Food Contact with Equipment and Utensils 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 ResetRese 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 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 Waiewashin 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 1 Eggs and Milk Products,Pasteurized* 4-501-114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(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 Sice 145' 15 * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg ervF sec Equipment Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* ery°"ve uuz°m 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 Stuffing ContainingFish,Meat,Poultryor 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - i e in cater- Ratites-165°F 15 sec* ' Sources* 70 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 Gamea and Wild Mushrooms 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* Otherfoodb 90 illness interventions and risk factors. * 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other es should violations relating to good retail 590.004(C) Wild Mushrooms ( )( )( ) 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 * 3-301.12 Preventing Contamination When Tasting* 3-403.11 * (Blue Items 2330) 3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 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 .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 THE T TOWN OF BARNSTABLE .. .. HEALTH INSPECTORS Establishment Name: _V L( V e (e Vate: 7Z I k - Page:�_Od OFFICE HOURS y ° PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. MON.-FRI. �p ,e3v.p�m HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'FON1" FOOD ESTABLISHMENT INSPECTION REPORT Name it f Date Tyne of f Inspection tt Q UO e ✓ j ) icye 'o Routin 1 Address _ Risk rvice e- spection Level etail Previous Inspection Telephone e I ential Kitchen Date: r e o f Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness - w Caterer General Complaint cJ Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other o r I Inspector '•t(�t t: (/ Out: U Each violation checked requires an expianatio n t e narrative page(s)and a citation of specific provision(s)violated. CkoD Violations Related to Foodborne Illness Intery ntions 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) yo cl A V Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ Stocyc d n J n5FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands n ` ( ( E ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities r P EMPLOYEE HEALTH PROTECTION FROM CHEMICALS 1 ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives r e ❑ 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 e� 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) Corrective Action Required: o ❑ Yes Non-critical(N)violations must be corrected immediately or �p within 90 days as determined b the Board of Health. Overall Rating �V\� �/ 1, �g Voluntary Compliance Y y ` ❑ ry p ❑ 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 g ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4non-critical violations 9 )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials S (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 8 non-criti I violations=C. 29.Special Requirements (590.009) Y P . 30.Other DATE OF RE-INSPECTION: Inspector's Signature - Print: �l e 31.Dumpster screened from public view \ CJ- (� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V a f f ( #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 : �e) L Dumpster Screen? Y N 4 Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to * 2 Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and AdulteReserrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 17.206.12 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 Wazewashing-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. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eU cri,urnoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 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 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 2-301.11 Clean Condition-Hands and Arms the appropriate sections above if related to Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercially Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity O Y * 12 Prevention of Contamination from Hands 3-403.11E Remainin Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to then the me 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 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. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. pF I"HE rpm TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: l Page: of e 9• OFFICE HOURS ` LIC HEALTH A Eo PUB2 0 MAN STREEETSION 3::30-0- :4:30 P.M.30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified '4A ,639.n.� HYANNIS,MA 02601 MON.-FRI. NO Reference R Red Item. PLEASE PRINT CLEARLY FOOD ESTABLISHME tF0 MPS T INSP CTION REPORT 44 508-862-46N Name G Date Type of ns ection Operation(s) Routine Address l \ Risk aFrvice ection L Previous Inspection Telephone F} l �� tial Kitchen Date: vv Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) t T• a Bed&Breakfast HACCP Other Inspector t: Ne- Z 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) (t ❑ 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 Require - ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance, ❑ Em loyee Restriction/Exclusio e-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 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 non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials. (FC-7)(590.008) 9 violation,4 to Snon-critical violations=C. 29.Yeened irements (590.009) within 10 days of receipt of this order. 30. DATE OF RE-INSPECTION: Inspector's Signature Print: 31. from public view Permit Posted? N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N i Dumpster Screen Y N Violations related to Foodborne Illness - Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12' Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * . _ 19 PHF Hot and Cold Holding_ 2-103.11 - - Person-in-Charge-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 3-501.16(A) Hot PHFs Maintained At or Above 140°F 590.003(C) Responsibility of the Person-in-Charge to - - - Other* 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Separation Storage** 3-501.16(A) Roasfs Held At or Above 130°F* - Applicants* - - - 3-302.11-(A)- Food Protection* P g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use _ 590.004 11 -Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * +° ( ) 9 590.003(G)_ Reporting by Person in Charge*- - _ _ 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated 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 - - _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 - - - 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY * Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water 3 401.11A(1)(2) Eggs- mme is sec Animal Foods That are Raw,Undercooked or 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* _.5-101.11 -_ -Drinking Water froman 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* 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 Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g �' S90.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- * - Ratites-165°F 15 sec* in mobile food,temporary and residential Sources 10 Proper,Adequate Handwashing g' P � Game and Wild Mushrooms Approved By + - -- * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* - 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* r 11 Good Hygienic Practices 1 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 * (Blue Items 23-30) 3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F * 12 Prevention of Contamination from Hands 3-403.11 E 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 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 Hem Good Retail Practices FC 590.000 Within 4 Hours* 23. Management and Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 _005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Fonnback6-2doc - *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 r)l1 • Ordinance or Regulation WARNING NOTICE " Name of Offender/Manager v Y Address of OffenderA MV/MB Reg.# Village/State/Zip � ar Villa g P �r��,��R. �v1����,, �h� �z� ��� Business Name D,\. ►,Y,r ..,�" 4t V/pm, on 14h 20 :9 u _ 7r Business Address Sign'`ature of Enforcing Officer Village/State/Zip t �SrsS�i /1"5 � /14A t1 '8 Location of Offense '"? A 2 i �7'a I mo.A On (2A hA14mlnm-s 114 ' d))� ( +` Enforcing Dept/Division Offense -Toon A )R4 /iS1r,;4 r^AP Facts « 0111A,(A .A-fP 'cz,^ 1A 4n f)r t' ,tan(Vn A I,x.)I 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. I TOWN OF _BARNSTABLE . BAR- ' Ordinance or .Regulation WARNING 'NOTICE Name of Offender/Manager I to m ° Address of Offender_ 4, MV/MB Reg.# Village/State/Zip � ►�� _ M A " . t Via .' Business Name /pm, on # 20a: Business Address. �: � �« ve:. °----' � . R S qq; Sig atur_ a of Enforcing Officer .Village/State/Z'ip illy Z91FS�1)^I UN,1 A4'► v ; Locat on-'of `Offense - $ ,� .�d.$ .;,{4 s ,}$ ,ti {ins Enforcing Dept/Division Offense ' . . f' / d --gamy�+ f ✓ - .. ,� kV 4 This will serve only as-w& warning. At th.8s 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 a WHITE-OFFENDER CANARY ORD.IREG.-PROG PINK-ENFORCING OFFICER GOLD-.ENFORCING DEPT. � a I-- M s f I t 1 Town of Barnstable • Board of Health fa ram" 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Paul J.Canniff,D.M.D. FAX: 508-790-6304 Donald A.Guadagnoli,M.D. Junichi Sawayanagi Certified Mail# 7006-0810-000-3525-3770 May 7, 2018 Ashfaq Roshan, H.R. Brothers Quick Stop 3821 Falmouth Road Marstons Mills, MA 02648 NOTICE OF HEARING - BOARD OF HEALTH RE: Quick Stop 3821 Falmouth Road, Marstons Mills, MA— 1st Violation On 4/16/18, 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, revised on August 23, 2016, 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 fine of$100 may be issued for the first offense. A fine of $200 along with a 7-day suspension of their tobacco permit may be issued for the second offense, a $300 fine along with a 30-day suspension of their tobacco permit within a three year period may be issued for the third offense, and if a fourth violation occurs during a three year period, they will lose their tobacco license altogether. You are hereby notified to appear before the Board of Health on Tuesday, May 22, 2018 at 3:00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss any future plans you may have to comply with this regulation. The hearing will be held in the Town Hall, Selectmen's Conference Room, 367 Main Street, Hyannis, Massachusetts. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, RS, CHO Director of Public Health Q:\TOBACCO\WP Files\tobacco hearing letter Quick Stop Apr2018.DOC l m Ln ru u-i 0 F F C I A L U S, m Postage. $ p p Certified Fee p Postmark p Retum Receipt Fee �'9y Here (Endorsement Required) p p Restricted Delivery Fee B� co (E ndorsement Required) !� /Cl p Total Postage&Fees $ p Sent To p � Street,:4pt No. - or PO Box No. 3 92t_-. ............zip" :,. Certified Mail Provides: asBnab)ZOOZ�u�C`OOeE�o�Sd''■ A mailing receipt r A unique identifier for your mailpiece • A record of delivery kept by the Postal Service for two years Important Reminders: A Certified Mail may ONLY be combined with First-Class Mails or Priority Mail®. a Certified Mail is not available for any class of international mail. 0 NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail m For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt seance,please complete and attach a Return. Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested'.To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. .0 For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailplece with the endorsement"Restricted Delivery". ! If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mall receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry.- Internet access to delivery information is not available on mail addressed to APOs and FPOs. MTCP 1D: Tobacco Compliance Check Form 2014-2015 Section 1 Establishment Survey Participants t Name; 5ro 10 I Q l f ID of Purchaser: C- t Address: _ 0V Pry ljtA✓ F Age: ❑ 16 PT,17 SexAM.ale ❑Female Name of 4Ault Supervisor: City: Zip Code: 15(7,11 Time of Check: �/. S/ am pm❑ Type of Establishment: ❑ Chain O&Independent ❑ Not Known Date of Check: ✓ r Day of the Week:WMon ❑Tues❑Wed . C ❑Thurs_❑Fri ❑ Sat ❑Sun Style of Establishment(Check Only One): i Convenience Store ❑Grocery Store ❑Bar ❑ Department Store ❑Liquor Store ❑Private Club VFW,Legion,etc.) ❑ Gas Station Only ❑Pharmacy/Drug Pharmacy/Drug Store ❑Restaurant ❑ Gas Mini-Mart ❑Other(bowling alley,golf club etc, ❑Tobacconist Section 2: i Was Compliance Check completed? Yes �f-No ❑ If Yes please continue on to The next question, ifNo please.skip this section and go to section 3. F,,vas tobacco marketed? ver-the-counter:youth asks the clerk for the product. rom a vending machine with a lockout device. ❑ Other Describe: Was the Purchaser asked for ID? Yes❑ No4 Was this an ID-based check? Yes❑ Noy , j Was the Purchaser asked his/her age? Yes❑ No i Sex of Clerk: Mal — Female❑ Approximate age of clerk:❑Teen Cl Young Adult Adult ❑Older Adult Type of tobacco asked for: t4cigarettes Brand of cigarettes asked for: larlboro ❑Newport ❑OtherY ❑ Chew/Dip ❑ Cigars ❑ E-Cigarettes ❑ Other Brand: Was the product requested flavored(NOT Tobacco or menthol)? Yes ❑ No Was the sale made? Yes$-No❑ 1 If"Yes"how much did the product cost: $ !l• Was a receipt given?Yes❑ No Purchaser made payment using.,❑ bills ❑ , 5 bills ❑ .5 bill and S I bill or change❑ , 10 bills 0 bill ❑ change Section 3: If the youth did not enter the premises or did not attempt to purchase tobacco products please Indicate why: ❑ Out of Business ❑ Temp.long term closure ❑ In o eration,closed at time of visit ❑ Drive thru only ❑ Does not sell tobacco ❑ Unlocatable ❑ Unsafe to access ❑ Tobacco out of stock ❑ Inaccessible by youth ❑ Wholesale only/cartons ❑ Presence of potice ❑ Permit Suspended ❑ Private club/personal ❑ Machine broken ❑ Other residence ❑ "Don't sell"but tobacco seen in storElhas error 4/14115 � q 1 7BReceived ■ Complete items 1,2,and 3. natu■ Print your name and address on the reversere ❑Agent so that we can return the card to you. ❑Addressee ® Attach this card to the back of the mailpiece, y Printed e) C. D to of D livery or on the front if space permits. 5 i� 9 1. Article Addressed to: �� ` D. Is delivery ad ress i erent from item 1 ❑ .4 Y h ���� c h If YES,enter elivery address below: p No at 3 'i3.F /lJJ ❑dultrice Sgnat Signature 0 Priority❑RegisterediMaipMss® OAdult Signature Restricted Delivery ❑Registered Mail Restricted tified Mail® Delivery 9590 9402 1933 6123 1341 69 ❑Certified Mail Restricted Delivery ! Return Receipt for ❑Collect on Delivery '^Merchandise 2. Article Number(Transfer from service labeh ❑Collect on Delivery Restricted Delivery ❑Signature ConfirrnationTM �� ❑Insured Mail ❑Signature Confirmation tii 7 0 0 6 '0 810 0 0 0 0 3525 3 7�0 j ❑Insured Mail Restricted Delivery Restricted Delivery s A over$500) -Se- PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt USPS TRACK NG# Firet-Class Mail Postage&Fees Paid USPS j Permit No.G-10 9590 9402 AY 3 1341 69 United States •Sender: Please print your name,address,and ZIP+4®in this box• Postal Service akW dl Wel -zo � /-�? s i i I i'A L_ S2020 E PART Form CT-3T 03657 O MFti y� ro Massachusetts Department of Revenue 2014 - 201*6 n Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco � a DOf0. This License must be posted and visible at all times. Sales to persons under 18 years of age are prohibited by Of ISSU.: License Number: Application Number: AK465 03657 09/22/2014 4 Mailing address for license: Retail sale location(if different than mailing address) S INC QUICK STOP CONVENIENCE H R BROTHER 3821 FALMOUTH RD 20 CONNECTICUT AV BARNSTABLE, MA 02648 HARWICH, MA 02645 This certifies that the taxpayer to sell at retail at the address shown above until yer named.above has paid the required license fee and is licensed license is not transferable,and is subject to suspension for failure to comply with the law. September 30,2016. This NAMERaOFOFFENDERsh BAR 66727 TOWN OF ADDRESSOF'OFFENDER 0,A r(: 'S 4p� 3IA 2-1 F,3 is"a4 fir poaj BARNSTABLE CITY,STATE,ZIP t-Es�s ` �1 f� / .+A o z& BARNS 48 TABLE ip�hD [ ° /� MV/MB REGISTRATION NUMBER • OFF NSE - HAHNSTAHI.i:. 7 11ASS. A •0•�-f'• e�,c.� 7LU I X S4C-nj14 /,0D A CL �p 039• N0 O RFD MAI 0. lJJ r►,�or > TIME AND OfiTE OF VIOLATION LOCATION OF VIOLATION Z NOTICE OF j (A.M./(PM)ON C. 200.3 a SIGNATURE•OF ENFORCING PERSON ENFORCING DEPT. BADGE NO. N VIOLATIONUJI OF TOWN I HP.EBY ACKNOWLEDGE RECEIPT OF CITATION X CL Q ORDINANCE O Unable to obtain/signature Of offender. THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ �flQ.� Date mailed f/4k Al LU w OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w REGULATION ' (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, a Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this citation for a hearing. - (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or,to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature NAME FO ENDER hn ; avreS Cat BAR 6730 TOWN OF ADDRESS OFOFFENDE BARNSTABLE CIT ,STATE,ZIP CODE I' rc n� rA, 11s, mA o-Lblqg P`pf tNE r0 MV/MB REGISTRATION NUMBER r OFFENSE CLIASS 157e 2� 7 o 64& 9g3A +639 tFD IAPy .. 1l 4 --fib a t kvv _d J cLU - TIME AND DATE OF VIOLATIWj --- LOCATION OF VIOLATION z LU NOTICE OF . $ ( .n i . .)ON A 2"'1�20 aick S4-o 10iA P-j, Q SIG ATkI fs0 E FORCING PERSO ENFORCING DEPT. BADGE NO. LUl VIOLATION �t�f�1 ��"" ,�,� I�{ca� N 0 OF TOWN I FEE ,EBY ACKNOWLEDGE RECEIPT OF CITATION X a ORDINANCE Unable to obtasignatu.e of offender. THE NONCRIMINAL FINE FOR THIS OFFENSE IS Date mailed `?f y (7 l�J w LU OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION,WITH NO RESULTING CRIMINAL RECORD. ua REGU CATION (1)You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, LU before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, a Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST k BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET, BARNSTABLE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature r i Town of Barnstable goo Op THE Tp� do Regulatory Services Thomas F. Geiler,Director • BARNSTABLE, • MASS. � Public Health Division ATFD 1 APB A Thomas McKean,Director 200 Main Street Hyannis, MA 02601 - Office: 508-862-4644 Fax: 508-790-6304 July 18, 2006 Vaughn T. Lazarescu Quick Stop 3821 Falmouth Road Marstons Mills, MA 02648 NOTICE OF SHOW CAUSE HEARING .: - - On 11/17/04, and on 6/27/06, cigarettes-were sold to a--m_inor(a person who-was under-th_ e age of 18 years)by a person employed at your store. According to Section 371-7(B)of the Town of Barnstable Code,no person,.firm,corporation, establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town of Barnstable Code,"any proprietor(s)or other person(s) ... who fail(s)to comply with these regulations shall be subject to the following actions for each offense: A warning shall be issued for the first offense. A fine of$100 may be issued for the second offense,$200 for the third offense, $300 for the fourth offense, and$300 for any subsequent offense. - You are hereby notified to appear before the Board-of Health on Tuesday,-August 1, 2006,at 3:00 pm to - show-cause why your tobacco sales permit-should not be suspended and to discuss any future plans you Y may have to comply with this regulation.-The_hearing,will-be held in the Town--Hall, Selectmen's Conference Room, 367 Main Street,Hyannis,Massachusetts. -- t PER ORDER OF THE BO OF HEALTH Thomas A. McKean,RS, C Director of Public Health gAtobacco\wp files\tobacco hearing letter.doc Bpi I JON-2e-2006 14:3e BARNS COUNTY HEALTH 15083756eeo P. 10i13 Section 1: an Establishment V14 u �� c' 1(7� Survey Participants Hamer 6u Ck Stop 3821 Falmouth Road ID of Ptumaser : v LI D0 Ate. Marstom Mills, MA.. 02648. Age:�15 ❑ 16 Q Sex: Male percale Name of Alt unetvisor- CitT. 1 r i 5 11 Tim of Check am¢ pm❑ Type of Establishment: ❑ Chain Independent ❑ Noc Known Dare of Check Day of the Wes: Q Mon XTaes Cl Wed ❑Thurs ❑Fri ❑ Sat ❑Sun S 1e of Establisluaew(Check Only One): Convenience Store ❑Grocery Store Q Bar ❑ Demutz=t Store ❑Uquor Store ❑Private Club(VFW. Lesion. etc.) ❑ Gas Station Only I ❑Phatmacv/Druff Store I ❑Restaurant ❑ Gas Mi -MM ❑Other(bowline allev.Elf club etc.) Q Tobaccamst Section 2: Was Compliance Check completed?Yes NO ❑ If Yes pierce continue on to the n=r question, if 11/o pleas skip this section and go to section 3. w was tobacco marketed? Over-the-==.. vourh asks the clerk for the produm ❑ From a vending machine with a lockout device. In Other Describe: Was the Parchaw asked for ID? Yes❑ No Was this au M-based check? Yes ❑ NO Was the Purchaser asked Mier age? Yes ❑ No�r sl a?a i sh/4bj Set of Cleric Mate❑ Female Approximate age of clerk ElTeen ElYoung AdultAdult ❑Olde=Adult - x Type of tobacco asked for. Cigarettes Brand of cigarettes asked for. ❑ Maribor _ ewpon ❑Other / 4 Chew/Dip ❑ Cigars ❑ Other __ B Was the sale made? Yes No ❑ If"Yes'how touch did,the pro&ct cost S Purchaser made payment using: Q S1 bills ❑ $5 bill(s) ❑ $5 bill and Sl bills/or cl=ge ❑ S10 bill(s) S20 bill E2 chance Section 3: If the_Youth did not enter the premise9 or did not attempt to purchase tobacco products please indicate why: ❑ Out of Business ❑ Tern. In term closure ❑ In operzitionciosed.at time of visit I ❑ Drive thru oniv Cl Does not sell tobacco ❑ Ualocatabie ❑ Unsafe to access I ❑ Tobacco out of stock I ❑ Inaccesstbie by youth ❑ Wholesale only/cumns ❑ Presence of poike I ❑ Permit Suspended I ❑ Private chib/perso aai ❑ Machine broken D Youth inspector kaows salesperson I CZ Other residence ❑ "Don't sell"but tobacco seen in 5126/05 C-COCUME-1\SSTLU-CCAIS-11Temv\FY 06 MTCF compliance check form-doc i_ ®• 0 Ln •. • A. ru e Ln L ul Postage $ Certified Fee Retum trn Reciept Fee /0 (Endorsement Required) C ere N O Restricted Delivery Fee tv co (Endorsement Required) c0 `0 rxl r o Total Postage 8.Fees � C� � A M (, SO- 3 T _ :.Quadir Bakshs - JV oo r,- � 11, Quick Shop 3821 Falmouth oad.�__ Marstons Mills, MA 02648 f . I Certifie )it Provides: J s� a�/) t:mod Sd ■ A mail' ipt ri,,;� i a an zooz ounr'oos ■ A uniq tifier for your mailpiece ■ A record o elivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery" ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information not available on mail addressed to APOs and FPOs. FINE 1p� Town of Barnstable • wuvsTnB Regulatory Services MASS. g g rY � 039• �0 Thomas F.Geiler,Director ptFD A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Telephone: 508-862-4644 Fax: 508-790-6304 November 29,2004 Mr. Quadir Bakshs Quick Stop 3821 Falmouth Road Marstons Mills, MA 02648 NOTICE OF SHOW CAUSE HEARING On November 17, 2004 at 11:03 a.m., cigarettes were again sold to a minor(a person who was under the age of 18 years) by a person employed at the Quick Stop located at 3821 Falmouth Road, Massachusetts. Tobacco product sales were made to minors at this same business location on the following four dates: November 17, 2004, December 5, 2003, December 30, 2002, and on June 25, 2002. According to Chapter 270, Section 6 of the Massachusetts General Laws "whoever sells a cigarette, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen(18) or, not being his parent or guardian, gives cigarettes, chewing tobacco, snuff, or tobacco in any of its forms to any person under the age of eighteen(18), shall be punished by a fine ...of not less than three hundred dollars ($300) for any third or subsequent offense. A $300.00 non-criminal ticket citation was mailed to you on November 29, 2004. The Board of Health Regulation PART IX, Section VII specifically states "Persons, firms, corporations, or agencies selling tobacco products to minors (or selling tobacco products without a Tobacco Sales Permit) shall be punished by a fine of not more than $300 per day for each day of such violation and/or suspension of the tobacco sales permit. You are hereby notified to appear before the Board of Health on Tuesday December 21, 2004 at 7:00 p.m. 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 second floor Conference Room , at the Barnstable Town Hall, 367 Main Street, Hyannis, Massachusetts. PER ORDER OF T E BOARD OF HEALTH Thomas A. McKean, RS, CHO Director of Public Health J:HEARNOT.DOC NOU-19-2004 10:48 BARNS TOBACCO CONTROL 15083622602 P.01i08 FACSUKILE FROM: Barnstable County Dept. of Health and Environment Cape Cod Regional Tobacco Control Program TO: DATE: # OF PAGES: f COM1VlENT: 111 Telephone#505-375-6621 Fax#508-362-2602 NOU-19-2004 10:48 BARNS TOBACCO CONTROL 15083622602 P.02i08 i 00W 4ompuance Lneck worm r All2UU4-ZUUS G� i 0 TAL Section x: j�1 job Z�s�a� y Establishment S '�g�°y urvey P ardcipan Name: — ----.. Qdick Stop - ID of Purchaser. 'o Address: 3821 Falmotrth.Road Age4r1S ❑ 16 13 17 Marston Mills, MA. 02648 Sex:❑MalegOT-emale Cit}r. Name of Adult Supervisor. � . Time of Check & ' 03 at pm❑ Type of Establishment: ❑ Chain 0itrdependmt ❑ Not Known Date of Check l!� 7 Oz Day of the Week:❑ Mon ❑TuMA:�Wed ❑Thm ❑Fri ❑ Sat ❑Sun Style of Establishment(Check OnWy Oise): venience Store ❑Grocery Store ❑Bar ❑ Department Store ❑Liquor Store ❑Private Club(VFW,Legion.etc.) ❑ Gas Station Only ❑Phasma 2ru Store Cl Restaurant(Bar Area) ❑ Gas Mini-Mart ❑Other(bow alley,-golf club etc.) ❑Restaurant(Other Area) Section 2: Did the youth enter the premises and attempt to purchase a tobacco Pr oduct?Ye&Ja_ io ❑ If Yes please continue on to the neat question, if No please skip this section and ga to section 3. H w was tobacco marketed? 05"0�er-the-' ounmr:Youth asks the clerk for the pradnct. ❑ From a vending machine with a lockout device. ❑ Other Describe: Was the Purchaser asked for ID? Yes ❑ N� Was ID accurately checked? Yes ❑ No❑ N/A❑ Was the Purchaser asked hisiber age? Yes❑ NX_ Sex of Clerk: Male male O Approxi=im age of clerk: ❑Teen ❑Young Adul�4Adult ❑Older Adult Type of tobacco asked for: 6gPegarenes Brand of cigarettes asked for: ❑ MarlboroAk-wport ❑ Other. ❑ Chew/Dip ❑ Cigars ❑ Other Brand: Was the sale made? Yes�o ❑ if"Yes"how much did the product cost: $ ,0 61) Purchaser made payment using: ❑Mills ❑ Mill ❑ SS bill and$l bills 4-4-1 O bill ❑ 320 bill ❑ quarters Section 3: If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why: ❑ closed for the day ❑ couldn't locate business ❑—buyer knows clerk/tnerchant ❑ admission char e ❑ closed for the season ❑ no lon er in business ❑ establishment inappropriate for youth ❑ other(specify) ❑ closed to the public ❑ doesn't sell tobacco ❑ unsafe establishment ❑ denied admission at door 113 vendin machine broken ❑ unsafe area 715104 5:1ShareG1TOBACCOISTAFFtSUWVAN1SynanMTCP compliance check form 04.doc NOU-19-2004 10:48 BARNS TOBACCO CONTROL 15093622602 P.03i08 t�,....��.� �...a.tr.awiata �.aab� a'UJI AM Uu"'4 uo Section l: Establishment Survey Pardeipants Name: K--MM — 768 Iyanouj6 koad M of Purchaser. Address _ Hyannis,MA _.02601. Age: ❑ 15 1. 1.66 p 17 Sew❑dale M Female City: Name of Adult Saaervisor. L Time of Check: am pm❑ Type of Establishment: ® Chain ❑ Iudepe,-ident ❑ Not Known Dam of Check I 117/7 OC��I Day of the Week:❑ Mon ❑Tues Oa Wed ❑Thurs ❑Fri.❑ Sat ❑SLm Style of Establishment(Check Only One): ❑ Convenieace Store 1 ❑ Grocery Store ❑]Aar I Deflarnaent Stogy i ❑ Liquor Store j ❑Private Club(VFW,Lesion. ete.l j ❑ Gas Station Only I ❑Pharmacv/Druz Store ❑Restaurant(Bar area) ❑ Gas Mini-Mart I ❑Other(bowlias allev. golf club etc.)Section 3: ❑Restaurant(Other Area) I Aid the youth enter the premises and attempt to purchase a tobacco product?'`r es ® No If Yes please continue on ro he n=question, if No ple=e skip this secs on and go to section 3. How was tobacco marketed? ® Over-the-counre::vcuth asks the tick for the product.❑ From a vending machine with a lockout device. 011f CA k 1-1 ❑ Other Descnbe: �Cl/W�" p Was the Purchaser asked for M? Yes ❑ No® Was ID accurately checked? Yes❑ vo ❑ vY/`A MWas the Purchaser asked his/her age? Yes ❑ No® �,3 L. Ses of Clerk Male❑ 0a Female lU Approximate age of clerk:&Teen ❑Young Adult ❑Adult ❑Older Adult Mani 2 r rP1) ,I Type of tobacco asked for: S Cgg=,Tes Brand of cigarettes asked for: !-Marlboro ❑Newport ❑Other: II J ❑ ChewiDip ❑ Cigars Cl Other �� Brand: Was the sale made? Ye. 9 No D If"Yes"hogs•much did the product cost: 3� _ Purchaser made payment using: G SI bills ❑ 35 bill ❑ SS bill and S 1 bills 1� S I0 bill C 320 bill G quarters Section 3: If the youth did nor eater the premises or did nor attempt to purchase tobacco products please indicate why: ' closed for the day ❑ c ouIdn't locate business j ❑ buys:kMows clerkfinerchant I ❑ admission charee I closed for the se-,sou i CO no lonse;in business ❑ establishment inaoprooriare for youth I ❑ other(specify 1 j closed to the public I ❑ doesn't sell tobacco I ❑ unsafe establishment denied admission at door 1 ❑ vendine machine broken I ❑ unsafe area 71VQ4 SASharW%T0BACC0\S T A�r�SULLIVAMSynanMTCP compliance check form Oa.doc NOU-19-2004 10:49 BARNS TOBACCO CONTROL 15083622602 P.04i08 Section 1: C.o.l Establishment Survey Participants ID of Puurhaser: �M 22 y . Address: Age: C 1 15 K 16 ❑ 17 Se=13 Male &Female Zip Code: City: Zip Name of Adult Supervisor. L � ) Time of Check am a 1m❑ Type of Establishment: ® Chain ❑ Independent ❑ Not Kuown Date of Check 11 - 17-2 0-U4 Day of the Week: ❑ Mon ❑Tues Z Wed ❑ Thum ❑Fri.❑ Sat ❑Sun Sryle ofFstablishment(Check Only One): ❑ Convenience Store ( 2 Grocery Store p Bar Q DevarCmeat Store I ❑Liquor Store ❑Private Club(VFW,Lesion,etc.) ❑ Gas Station Only 1 ❑Pharmac /Drug Store Q Restaurant Bar Area) O Gas Mini-Mart I ❑Other(bow alley,Zolf club etc.) ❑Restaurant(Other Area) Section ?: Did the youth enter the premises and attempt to purchase a tobacco product?Yes No ❑ If Yes please continue on to the nea question, if No please skip thir section and go to section 3. How was tobacco marketed? K Over-the-counter.youth asla the clerk for the product. ❑ From a vending machine with a lockout device. ❑ Other Descnbe: Was the Purchaser asked for ID? Yes M No❑ Was ID accurately checked? Yes ❑ No ® N/A❑ Was the Purchaser asked his/her age? Yes ❑ No Ill gro�Yl h Sex of Clerk Male k Female❑ [3Approximate age of clerk: Teen ❑Young Adult ® Adult ❑ Older Adult�'�t rt Type of tobacco asked for: ® Cigarettes Brand of cigarettes asked for:,4- Marlboro ❑Newport ❑Other- 0 ChewrDip ❑ Cigars C7 Other Brand: Was the sale made? Yes 9 No D If"Yes"how much did the product cost: 3_5. Purchaser made payment using: ❑31 bills ❑ S5 bill ❑ $5 bill and 31 bills ❑ 310 bill ® S20 bill ❑ quarters Section 3: If the vouth did not enter the premises or did not attempt to purchase tobacco products please indicate why: O closed for the day ❑ couldn't locate business ❑ buyer knows clerk,merchant I ❑ admission charse ❑ clo sed for the seasonI ❑ Ito loner in business ❑ establishment inanpro riate for vouch ❑ other(sDeci ) ❑ closed to the piphr I ❑ doesn't sell tobacco I ❑ unsafe establishment denied admission at door I ❑-vending machine broken ❑ unsafe area 7/5/04 S:1Sharetl\TOBACCO\STAFRSUWVANISynar�KrCP compliance check form 04.doc r NOU-19-2004 10:49 BARNS TOBACCO CONTROL 15083622602 P.05i08 �v �� .....r.r..raa�.�. v.......�� va a►� ru�rru V./ Section 1: l , 3 VPy"'4 Estabhibment Survey Participants Name: seaatget- 231 Sea Street ID ofPutrhaser: - . 03�Z Address: Hyanrus�,.MA. .02601 Age: ❑ 15 ® 16 ❑ 17 Sex: ❑Male EFemale CiN Name of Adult Supervisor. aA` Time of Check: am 12 pm❑ Type of Establishment: Q Chain ❑ Iud=endent ❑ Not Known Date of Check Day of the Week; ❑ Mon ❑Tues 13 Wed ❑Thurs ❑Fri. ❑ Sat ❑Sun Style of Establishment(Check Only One): ® Convenience Store ❑ Grocery Store 113 Bar ❑ De°artment Store ❑Liauor Store 1 ❑Private Club(VFW,Legion. etc.) ❑ Gas Station Only ❑Pharmac /Drug Store ❑Restaur�tat(Bar Ares) ❑ Gas Mini-Man ❑Other(bo!jing alley, golf club etc.) C]Restaurant(Other Area) Section ?: Did the youth enter the premises and attempt to purchase a tobacco product?Y cs 91 No ❑ brYes please continue on ro the nea question, if"Vo please sddp this section and goo to section 3. How was tobacco marketed? 5' Over-the-couarer.youth aslo the cleric for the product. ❑ From a vending machine with a lockout device. ❑ Other Describe: Was the Purchaser asked for ID? Yes 15 No❑ Was 1D accurately checked? Yes❑ No ❑ N/A J1 Was the Purchaser asked his/her age? Yes❑ No❑ Sex of Clerk Male 5: Female❑ Approximate age of clerk: ❑Teen ❑Young Adult ❑Adult ❑Older Adult Type of tobacco asked for: M Cigarettes Brand of cigarettes asked for: 9 Marlboro ❑Newport ❑Other. ❑ ChewrDip ❑ Cigen ❑ Other Brand: Was the sale made? Yes 6 No r-1 If"Yes"how much did the product cost: Srj<<S� Purchaser made payment using: ❑S I bills ❑ SS bill ❑ S5 bill and S I bills ❑ S 10 bill ld S20 bill ❑ quarters Section 3: If the vouch did not enter the premises or did not attempt to purchase tobacco products please indicate why: ❑ closed for the day 0 couldn't locate business ❑ buyer lmows clerkrmerchant 1 C2 sdmissiou charge ❑ closed for the season I ❑ no longer in business I ❑ establishment inannro riate for youth 1 ❑ other(snecifv) ❑ closed to the public ❑ doesn't sell tobacco ❑ unsafe establishment 1 ❑ denied admission at door 1 ❑ vending machine broken ❑ unsafe area 715/04 S_\sh2red\TOBACCOISTAFRSUWVAN1Synaa4TCP compliance cneex form Oa.doc II� NOU-19-2004 10:49 BARNS TOBACCO CONTROL 15083622602 P.06i08 I ulna u -umpimnce c.nt:cx r urm Luu%-zuuZ Section 1: Establishment Survey Participants Name: 1149 North Street f Ue rJ ID ofPurchaser. Address: Age: ❑ 15 M 16 ❑ 17 Hyannis,MA 02601 Sex:❑Male 19 Female Naive of Adult Supervisor. Time of Check: ��� 1' am pm p Type of Fstablishment: ❑ (ham 201adependent ❑ Not Known Date of Check (^ 1 Day of the Week❑ Mon ues®Wed ❑'Ihurs ❑Fri ❑ Sat ❑Sun Style of Establishment(Check Only One): IT Convenience Store ❑ Grocery Store ❑Bar ❑ Department Store ❑Li uor Store ❑Private Club VFW,Legion.etc.) ❑ Gas Station Oal ❑Pharmacy/Drug Pharmacy/Drug Store ❑Restaurant(Bar Area) ❑ Gas Mini-Mart ❑Other(bowline alley, if club etc.) ❑Restaurant(Other Area) Section 2: Did the youth enter the premises and attempt to purchase a tobacco product?Yes 91 No 0 If Yes please continue on to the neat question, if No please slap this section and go to section 3. How Was tobacco marketed? Ck Over-the-countez youth asks the clerk for the product ❑ From a vending machine with a lockout device. ❑ Other Descnbe: Was the Purchaser asked for ID? Yes :No Was ID accurately checked? Yes ❑ No ❑ N/A Was the Purchaser asked his/her age? Yes❑ No (ta QXI b Sex of Clerk: Male❑ Female Rr Approximate age of clerk ❑Teen Young Adult ❑Adult ❑Older Adult Type of tobacco asked for: ❑ Cigarettes Brand of cigarettes asked for: eMarlboro ❑Newport ❑Other_ C7 Chew/Dip ❑ Cigars ❑ Other Brand: Was the sale made? Yes eNo 0 If"Yes"how much did the product cosy. $ - S / Purchaser made payment using: ❑$I bills ❑ $5 bill ❑ S5 bill and S 1 bills ❑ S 10 bill la S20 bill D quarters Section 3: If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why., ❑ closed for the da ❑ couldn't locate business ❑ buyer knows clerk/merchant ❑ admission charge ❑ closed for the season ❑ no Ion er in business ❑ establishment inn riate for youth ❑ other(specify) ❑ closed to the public ❑ doesn't sell tobacco ❑ unsafe establishment ❑ denied admission at door I-0yanding machine broken ❑ unsafe area 715/04 S:1Shamci\TOBACCO\STAFFISUWVAN\Synai�MTCP compliance check form dd_doc f NOU-19-2004 10:50 BARNS TOBACCO CONTROL 15083622602 P.07i08 a vvrr...r .�v+yr+iAYbG �r�av�.p X VA AM �llU`l�LUU� Section l: NnL-ALA Establishment Survey Participants Name: T ya=s F�aekageee�tore;=Inc.—:.... __ 775 Main Street ID ofPurchase�_ C JU z Address: Age: ❑ 15 316 ❑ 1� Hyannis; litlA 02601 Sex: ❑IMale 1S Female Name of Adult Stmervisor.�- City: Time of Check: Z . Q am❑ pm 3. Type of Establishment: ❑ Chain i7 Independent ❑ Not Known Date of Check-_ ,l'17 -6 u Day of the Week: D Mon ❑Tues®Wed ❑Thurs ❑Fri,D Sat ❑Sun Style ofFstablisament(Check Only One): 1 ❑ Convenience Store I ❑ Grocery Store ❑Bar ! ❑ Deflartment Store i H Liquor Store I ❑Private Club(VFW,Le2ion, etc.) I M Gas Station Only I ❑PharmacvtDru2 Store ❑Resmutaut(Bar Area) ❑ Gas Mim-Mart I ❑ Other(bowfin--alley, golf club etc_) 0 Restaurant(Other Area) 1 Section 2: Did the youth enter the premises and attempt to purchase a tobacco product?Y zs No ❑ If Yes please continue on to the nett question, if No ple=e skip rhis sec.-ion and oo to section 3. How was tobacco marketed? ❑ Over-the-�couar::Youth asks the cit.:k for the product. Q From a vending machine with a lockout device. ❑ Other Describe: I Was the Purchaser asked for ID? Yes M No Was ID accurately_ checked? I'es ❑ No p N/A Z. j Was the Purchaser asked his/her age? Yes❑ No Sex of Clerk: Male i- Female❑ Approximate age of clerk: G Teen D Young Adult d�-dult 0 Older Adult Type of tobacco asked for: �Cigseues Brand of cigarettes asked for: k Marlboro ❑Newport ❑ Oth=- ❑ ChewtDin ❑ Cigars ❑ Other Brand: Was the sale made? Yes t No Q If"Yes"how much dial the product cost: S_C Purchaser made payment using: ❑SI biils ❑ SS bill OL SS bill and SI bills 19 SI0 bill ❑ 520 bill C quarters Section 3: If the Youth did not enter the premises or did not attempt to purchase tobacco products please indicate whv: closed for the day I ❑ couldn't locate business I L buyer(mows elerkimerchant ❑ sdtnissiou charge closed for the season I 0 no lonee;in business j es esmblisament inappropriate for youth I n other(sflecifv i j ❑ closed to the Public I ❑ doesn't sell tobacco I G unsafe establishment ❑ denied admission at door I ❑ vending machine broken j ❑ unsafe area i 715/04 S.Shared\TOSACCO�STqFr-kSUWVAN1SynanMTCP compliance cneex form u.doc NOU-19-2004 10:50 BARNS TOBACCO CONTROL 15083622602 P.08i08 Section : Establishment Survey Participants Name:--Route 28 Convenience• . . I675 Falmouth Road ID of Purchaser. �Q �Z 0? Address: Age: ❑ 15 ® 16 0 17 — Centerville,-MA 02632 Sex:❑Male ®-Female Cl[V: Name of Adult Supervisor. h Time of Check ;Z I �1 IV ❑ pm S Type of Establishment: ❑ Chain ❑ Independent ❑ Not Known Date of Check If// / // Day of the Week- 0 Mon ❑Tues P�Ved ❑Thurs ❑Fri ❑ Sat ❑Sun Style of Establishment(Check Only One): Convenience Store ❑Grocery Store ❑Bar 4 Departraimt Store ❑Liquor Store ❑Private Club(VFW,Levion.etc.) ❑ Gas Station Only ❑pharuta 1pru¢Store ❑Restaurant(Bar Area) ❑ Gas Mini-Mart ❑Other(bowiiam alle , .olf club etc.) I Cl Restaurant(Other Area i Section 2: Did the youth enter the premises and attempt to purchase a tobacco product`'Ye;O—No ❑ ff Yes please continue on to the nett question, if No please slap this section and go to section 3. How was tobacco marketed? 2 Over-the-counter:youth asks the clsrk for the product. ❑ From a vending machine with a lockout device. ❑ Other Describe: Was the Purchaser asked for ID? yes o Was ID accurately checked? Yes ❑ No❑ NIA Was the Purchaser asked his/her age? Yes No is Sex of Cle&- Male A Female M Approximate age of cleric 0 Teen ❑Young Adult I Adult ❑ Older Adult Type of tobacco asked for: ❑ Cig=ars Brand of cigarettes asked for:% Marlboro ❑Newport ❑Other- 0 Chew/Dip ❑ Cigars ❑ Other Brand: Was the sale made? Yes If No O If"Yes"how much did the product cost. S Purchaser made payment using: 0 S1 bills ❑ SS bill ❑ S5 bill and$1 bills ❑ 310 bill I$ S20 bill ❑ quarters Section 3: If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why: i ❑ closed for the day ❑ couldn't locate business ❑ buyer knows cle&-merchant ❑ admission charge ❑ closed for the season ❑ no loner in business ❑ establishment inatroro riate for youth ❑ other(soecifv) ❑ closed to the public I 0 doesn't sell tobacco G unsafe establishment ❑ denied admission at door I Cl vending machine broken ❑ unsafe area 7/5/04 3:\Shared1TOBACCO\STAFF\SUWVAN\SynarkWCP compliance check form 04.doc TOTAL P.08 NAME OF OFFENDER d BAR TOWN OF ADD SS ERA fc. I _, BARNSTABLE CITY, TATE,ZIP CODE 1HE i MV/MB,REGISTRATION NUMBER OFNSE — ..P i.' • unx.arnxI.e. � Q { _ 63 w$ le"c4) �9 P" V , 1 ...'y L:^ d ff° }�t� — aLLJ V CD TIME AND DATE OF VIOLATION. L ATION OF VIOLATION W NOTICE OF 1,'OS kM./ P.M.)ON 20L' L4,i. #,C SIGNATp6E 0 .OBCI,NG PERSON EN RCING DEPT. BADGE NO. W - VIOLATION "lo<�,;.f 4-� a N OF TOWN I HEREBY ACKNOWLEDGE RECEIPT OF CITATION X a ORDINANCE 13Unable to obtain Signature 9f offender. ~ THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ „ � W �• k, Date mailed OR YOU HAVE THE FOLLOWI ALTE NATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL w a DISPOSITION WITH NO RE LILTING CRIMINAL RECORD. w REGULATION a (1)You may elect to pay the above fine,either by appearing m person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, LLJ < before:The Barnstable,Clerk,200 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P.O.Box 2430, . Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. a I G <<' (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST S; BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BAR LE,MA 02630,Attn:21D Noncriminal Hearings and enclose a copy of this I n citation for a hearing. 3 If you fail to a the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to a an fine determined at the f ) y PY q 9 Y Y PP 9 PY Y hearing to be due,criminal complaint may be issued against you. -- f; ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature i � t Town of Barnstable Board of Health P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,RS. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. Mr. Quadir Bakshs February 26, 2004 Quick Stop 3821 Falmouth Road Marstons Mills, MA 02648 Dear Mr. Bakshs, On February 17, 2004, a show-cause hearing was held due to recurring violations of tobacco sales to minors at Quick Stop, 3821 Falmouth Road, Marstons Mills, Massachusetts. Three (3) tobacco product sales were made to minors at this business location on the following dates: December 5, 2003, December, 30, 2002, and on June 25, 2002. None of the charges were disputed by the owner/operator of this establishment. Mr. Bakshs indicated during the hearing that he has implemented the use of a date sign near the cash register which indicates the proper birth date for purchasing tobacco products to the cashier prior to each sale. It is apparent that Quick Stop, in spite of its previous violations, has failed to take the necessary steps to ensure that its employees do not sell tobacco products to minors. The serious history of violations coupled with the owner's failure to implement effective employee training and internal controls compels the Board to issue this warning. Mr. Bakshs is hereby warned that if tobacco products are sold to minor(s) in the future, his tobacco sales permit may be suspended or revoked by the Board of Health, after providing a show-cause hearing in this regard. PER DER THE BOARD OF HEALTH yneAF ler, M.D., Chairman BAR HEALTH TOWN OF BARNSTABLE QuickStopWaming oFt"E'°w Town of Barnstable p� ti v)wl �4 Department of Health, Safety, and Environmental Services BAkt Srnsi.s, MASS. r 1639. Public Health Division �0 367 Main Street,Hyannis MA 02601 Office: 508-8624644 Thomas A.McKear FAX: 508-775-3344 Director of Public 1 January 23,2004 Mr. Quadir Bakshs Quick Stop 3821 Falmouth Road Marstons Mills,MA 02648 NOTICE OF SHOW CAUSE HEARING On December 5, 2003, cigarettes were sold to a minor(a person who was under the age of 18 years)by a person employed at the Quick Stop located at 3821 Falmouth Road, Massachusetts. According to Chapter 270, Section 6 of the Massachusetts General Laws "whoever sells a cigarette, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen(18) or, not being his parent or guardian, gives cigarettes, chewing tobacco, snuff, or tobacco in any of its forms to any person under the age of eighteen (18), shall be punished by a fine of not less than one hundred dollars ($100) for the first offense,not less than two hundred dollars ($200) for the second offense, and not less than three hundred dollars ($300) for any third or subsequent offense. Also,Board of Health Regulation PART IX, Section VII specifically states "Persons, firms, corporations, or agencies selling tobacco products to minors (or selling tobacco products without a Tobacco Sales Permit) shall be punished by a fine of not more than $300 per day for each day of such violation and/or suspension of the tobacco sales permit. You are hereby notified to appear before the Board of Health on Tuesday February 17, 2004 at 7:00 p.m. 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 second floor Hearing Room (Council Chambers), at the Barnstable Town Hall, 367 Main Street,Hyannis, Massachusetts. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, RS, CHO Director of Public Health copy J:HEARNOT.DOC O O U T E (L.O.VARIES) 28to ( �� .� EDGE OF PAVEMENT Be — 1• G ��1 / L + . PROPOSED 4-IN SCH.40 SEWER PIPE / PROPOSED H-20 1500 GALLON SEPTIC TANK SLOPE 1% MIN. (TYP.) / INVERT IN EL.=94.00° Omit gN EXISTING EDGE OF PAVEMENT - PROPOSED SE .= B.M. EXISTINGISEPTIC LEACH PIT TO BE PUMPED INVERT OUT EL.= OBSERVATION � WYE-TYPE CONNECTION(TYP.) Hydrant Spindle WELL AND FILL�D WITH CLEAN SAND (TYP. OF 5) Elev. = 104.89' "' Assumed "' p CATCHBASIN ® - RIM EL.= 99.81, o161± CD { O 99.9 00.1 o INV. OUT EXISTING 1000-GAL. GREASE TRAP =€ 'ROPOSED H-20 2000 GALLON PUMP :~yam ` " : EXISTING 1500-GAL. CHAMBER INVERT IN EL.=93.75' J _x, 1 (CONTRACTOR TO _ _ TANK(CONTRACTOI ry`V EXISTING 1500-GAL. SEPTIC VERIFY) TANK(CONTRACTOR TO -.IN_ OUT EL.= 98.48' — — — — — — — VERIFY) INV. OUT El SB/DH E MAP 57 — — �T FND N — - - EXISTING 1500-GAL:SEPTIC.. i D _ TANK(CONTRACTOR TO I PARCEL 3 1] VERIFY) INV. OUT EL.=97.61'± W LOT 2 J i J W (21 TP 2 1 BLD 4 Z t 100.7 +I J DUNKIN DONUTS j ' BLD 5 BLD 6 TOF=102.1 T TOI LL I QUIK STOP PAK MAIL \ N (459 GPD) TOF=101.93's /� PROPOSED 80' BY 20' 10.5 20.0, (174 GPD) (236 GPD) PRESSURE-DOSED 36.5' TOF=102.03' O DISPOSAL FIELD 10 f in TP 1 ^_ ' 100.60 :L_ ' , CONNECTION INVERT EL.=96.85 MAP 57 m y Q I •� ti EXISTING LEACHING J 30.2' v' PARCEL 4 rn PIT AND SPOILEDBLD 9 SOIL TO BE J :: - `� G'ystn� 108,109 S.F± OFFICE �r GP5 REMOVED OFFSITE o == =` _ � BLD 3 *� I I (174 GPD) TANNING, / n� PERFORATED b". '~p 0 \ -- = =1=='. OFFICE ETC 4 \ PVC PIPE j \ Z '` ` { `° (160 GPD) 101 6 TOF=101.95' P� 3 ,, EXISTING 1500-GAL. TOP OF FOUNDATION GENERAL NOTES FINISH GRADE OVER D-BOX= 69.8'+ ELEV= 71 .3 PROP.VENT WITH CHARCOAL FILTER TO ABOVE GRADE 1. UNLESS OTHERWISE NOTED ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE OVER CHAMBERS= 69,4 - 70,2 METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE PROVIDE H-20 CONCRETE RISER WITH PROVIDE H-20 RISER w/SECURE SLOPE @ 2%MIN.OVER SYSTEM 3/4"TO 1-1/2"DOUBLE WASHED SECURE CAST IRON FRAME&COVER TO F:G. STONE TO CROWN OF PIPE ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES. OVER TANK COVERS AS SHOWN (TYP. OF 5) CAST IRON FRAME& COVER TO F.G.. 4"SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD MIN SLOPE 1% BOX TO F.G.(SEE NOTE 20) 2"'OF 1/8"TO 1/2"DOUBLE WASHED OF HEALTH AND THE DESIGN ENGINEER. 5"DIA. OUTLET(S) STONIE OR GEOTEXTILE FILTER FABRIC 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED. F.G. OVER GREASE TRAP EL.= 70.3' - 7O.T F.G. OVER TANK EL.= 70,4' - 70.8' , PLACE IRISERS ON ALL 4. TO PREVENT BREAKOUT,THE PROPOSED FINISH GRADE SHALL NOT BE LESS THAN 9"MIN. TOP OF SAS= 67.20 CHHAMBERS WITH 4"PVC TEE " " ELEVATION=66.70'FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. PROPOSED 9"MIN. 36 MAX. 66.20' 36"MAX. BREAKOUT EL= 66.70' INLET IPIPES TO 6"OF UNLESS A 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. 36"MAX. PROPOSED 9"MIN. 4"SCH.40 PVC 4"SCH.40 PVC 36"MAX. PROP.4" FIINISHED GRADE AND THE TOP OF THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. SCH.40 PVC 3" 3" L-6�+ To D-BOX L=77't PROVIDE WATERTIGHT o 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. _ 2"DROP MAX. g" "mm. 6" 3" 3" g" 3 l 4"PVC IN FROM JOINTS(TYP.) oo 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. 3 DROP MAX. 69.00' - ----9" _ ____ - E 1 min. SEPTIC TANK 4"PVC OUT TO _ O 0 O 7. LOCAL BOARD OF HEALTH TO BE NOTIFIED PRIOR TO BACK FILLING WHEN ' 10"� " O LEACHING FACILITY o 0 �' 48" 36" 67.75 + 14" 10 14" o0 o SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS NOT TO LIQUID MI 111 4-0 " " oo __� 0 0 0 0 0 0 0 0 BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM 68.00' LEVEL SUPPORT 67.4•O� 12 6 00 00 S G ROYAL O BOARD OF HEALTH. INLET OUTLET TEE LIQUID- 66.60 MIN• 66.43 STRAP(TYP) 67.65 (in from g.t.) ' ' 2' o 00 p =' 00 8. ELEVATIONS BASED ON APPROXIMATE U.S.G.S. DATUM. ELEVATION OF 71.00' TEE 1 MIN 67.65' in from bld oo 00 � ESTABLISHED ON TOP OF A STONE BOUND w/DRILL HOLE AS SHOWN ON PLAN. ( g) (1,500 GALS.) (500 GALS.) TEE LET OVER SHED STONE MECHANICALLY o O 0 0 0 0 0 0 0 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION GAS BAFFLE o THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE 8"DIA.ZABEL FILTER COMPACTED BASE 6"CRUSHED STONE MODEL#A100-8x18-VC 4.0 � _ 4.0' - AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY OVER MECHANICALLY INLET TEE (GAS BAFFLE ON BOT.) 5 OUTLET DISTRIBUTION BOX 8.5 (TYP) 4't©� 4.83' 4'0' DISCREPANCIES TO THE DESIGN ENGINEER. COMPACTED BASE 6"CRUSHED STONE TO BE INSTALLED ON A LEVEL STABLE 42.0' (TYP.) 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE STRUCTURES SHALL BE MADE WATERTIGHT. OVER MECHANICALLY LENGTH 2'-2" WIDTH .6'-8" DEPTH 6'-2" BASE. FIRST TWO FEET OF OUTLET r GROUND WATER ELEV.= < 59.00' 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR COMPACTED BASE PIPES TO BE LAID LEVEL. 64.20 12.83' ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH PROPOSED 1 ,000 GALLON PROPOSED 1 ,500 / 500 GALLON CROSS SECTION VIEW 4 500 GALLON CHAMBERS 5'MIN. CHAMBER END VIEW DETERMINATION FROM APPROPRIATE AUTHORITY. H-20 GREASE TRAP 2-COMPARTMENT H-20 SEPTIC TANK H-20 DISTRIBUTION BOX DETAIL TY'ICAL CHAMBER PROFILE H-20 CHAMBER DETAILS? 12• ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE q THEY SHALL WITHSTAND H-20 LOADING. a r' t , `t' r ' TEST PIT, DATA 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. FALMOUTH ROAD (ROUTE 28) REMOVE ALL UNSUITABLE MATERIAL DOWN TO"C"SOIL& REPLACE w/CLEAN PERC NO. 14493 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND (VARIABLE WIDTH-STATE HIGHWAY) COARSE SAND PER 310 CMR 255(3) �*` ---------------------=----------- >, Q ,.:' r$ INSPECTOR: Donna Miorandi, RS F _-__-__-__ - EDGE OF PAVEMENI(TYP) - OW WITH CLEAN O ,.--------�--'--- _------------------- -------------------- LEACHING FACILITY.IREPLAC REPLACE UNSUITABLE MATERIAL /- -- -- -70 --69- - EVALUATOR: Michael Pimentel, EIT,CSE • t _ � . r rr COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN -j 8.48' _ 7600-05'15"E . _ - Oct. 1999ACCORDANCE WITH 310 CMR 15.255 3 . -SPOT LIGHT --GRASS-- ,w C.S.E.APPROVAL DATE: ( )GRASS- - 70 - 1 ' DATE: September 12,2014 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN -71 \ tiYo � -, • =y ¢ ..'�` SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. ZONE 2 TEST PIT#: 1 and 3 DO N\OT ENTER/STOP SIGN \ x 16. PROPOSED PROJECT IS LOCATED WITHIN: � N89'5445"E ' F {,. ,Y ,i s P''` ELEV TOP= 172.00' -- 120.34' • a ELEV WATER= LAND COURT LOT#1 SIT xr \ <59.00 FORMERLY PORTION OF ASSESSORS MAP 54 PARCEL 4 LAND COURT -----.___---- ---- L.P. (TYP) -71- ¢' rZ5710r ., 3 , rj I -------- ----------- --------- - -------------- o /- o TP 4 _ +, u 'r C c PERC RATE_ <2 min./inch LOT 2 /- --- -- 0 72 yf OWNER OF RECORD: WINDMILL SQAURE LIMITED PARTNERSHIP _ 48"-66 297 NORTH STREET Iz OVERHANG ISLAND TO BE REMOVED p �� ADDRESS.AREA-93,254 s.f. � \ � ----------- ' 72x0' � � `�d� of.� ""`Q� � ' _ �, �. � DEPTH OF PERC- w o m HYANNIS, MA 02601 - ip cm TEXTURAL CLASS: 1 X '' a cn ISLAND(under overhang) RESERVE AREA r' U LOCUS 17. FEMA FLOOD ZONE X Q \ (CAPACITY=542.6 gpd) m AS SHOWN ON COMMUNITY PANEL# 25001CO543J Z I PROPOSED 4-500 GALLON _ _.! 0" 72.00' \ 7 W 1 _ T. ,. ;,, ;. , s M H 20 LEACHING CHAMBERS „ :., y. n by _Q 18. DEED REFERENCE: LAND COURT CERTIFICATE NO. 137678 � rn \ Cl) WITH AGGREGATE ' v� r ����.� � �y t b Fill < �' - �e co 19. PLAN REFERENCES: , 1 �1 � ,vim. �:��;..:. _ _ �.�:t 1. L.C. PLAN 15069A S89 12 22 u � F o « " ) cn w \ - �.� � � �� .. . `�� x `cs 24 70.00 ((t^, -��` � �` s 2. L C. PLAN 39483A B w � � r � - ;�� � =� � � . PR. 4 PVC t ) , :..n' ,r: ,yF, x : • 3Wikl . L. . PLAN 38112A 0 „ t_r Loam Sand C WSPECTION F # ,.. ) .u. . �,.:' BC 3 <.._ „ ..., RT 10Yr 5!6 L C:_.PLAN 39614E L.C. PLAN 22824A-J v 1 , 4 11 CY, ,< 48 PR. 4 PVC r .. � 6. 1975 COUNTY COMMISSIONERS ALTERATION .,.. :f _ . PROP.WIN ,.. ., _. .r. ,,:. ...,. .,:� �. w_. � . , _ . _ T PIPE ,_ _. n _._. >.__ _ ,TO PUTNAM AVENUE RECORDED IN PLAN BOOK DOW ,.. ,, . �. . .. .,. � ,._ - � ._ .�, ._ Eta _P E ,. ..., r O W, _ 20.8 66 66.50 ao 7.) DEFINITIVE SUBDIVISION PLAN OF LAND LOCATED - ..,., . . •.. 1 ,..,„ ,, , . ::�: ,,: _. , .. . ... N ,. ...,N , . _ , , .. ....:< IN BARNSTABLE MARSTONS MILLS MASS. a ,. .. . , -.,-. M... st_.. .. _,. _.. .. -I 4 _ me � ANT TO BE � . f -. .. � _ .. �. .� , � .,_,. _� .- ,, _.,. � _., : EXISTING BANK AC Q- N ) ems , _.. : ,...� ... _ � _,... .�.,..�. ,� , -, ,.> , . .r, v .:;. ;.,,. PREPARED FOR REAUPROPERTY SERVICES INC., �\ CONVERTED INTO A DUNKIN DONUTS PROP. H-20 5-OUTLET iv_ Med.to Coarse Sand SCALED 40-FT TO AN INCH, DATED JUNE 28, 1995, I w/DRIVE 81 15 EATS ; >0 DISTRIBUTION BOX C 2.5Y 6/6 AND RECORDED IN PLAN BOOK 518,PAGE 35. I ' TOF=71.3 t I EX. LEACH. CBN TO 8.) 1931 STATE ALTERATION OF RTE.28(FALMOUTH ROAD) 1 ^o N P OPOSE� BE REMOVED 81 I LAND COURT LOT E CLOSE44 �' REPLACED w!NEW LOCUS PLAN 20. A 4"PERFORATED SCH.40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A RAMP/WA K J ; 1 D MPSTEk ON NON-LEACH.CBN DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3"OF FINISH GRADE. A I AREA=14,860 s'<f. C NCRETE P AS SHOWN SCALE: 1"= 1000' REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. I ( \ 1 1 I �,� 156" 59.00' FORMERLY PORTION OF MAP 57 WALK ,,l DESIGN DATA No Mottling, Standing or Weeping Observed LEGEND / PARCEL 4 ' 1p� Benchmark 1 t ( / Top of SB/DH EXISTING USE: x 50.0 EXISTING SPOT GRADE I 108,114 S F Q Elev. =71.00' TEST PIT DATA TYPE OF ESTABLISHMENT OFFICE SPACE(i.e. bank) 15 EXISTING CONTOUR I ao PR. MENU BOARD Approx. U.S.G.S. OFFICE SPACE AREA= 6,000± S.F. (PER OWNER) PERC NO. 14493 n D �,/ 50 PROPOSED SPOT GRADE DESIGN FLOW= 75 GAUDAY/1,000 S.F. INSPECTOR: Donna Miorandi, RS 0 - c1 PROP. 11000 GAL. 1 / TOTAL DESIGN FLOW= (6,000 S.F./1,000 S.F.)x 75 GPD= 450 GPD 50 PROPOSED CONTOUR _ - I H-20 GREASE TRAP PR. ORDER-SPEAKER - / EVALUATOR: Michael Pimentel, EIT,CSE r- ' 4NV.-E0.0 / PROP. CBN - PROPOSED USE: C.S.E.APPROVAL DATE a� rn w �' -<; T. _ _ / BC-2 (NON-LEACHING) / / /' / - Oct. 1999 w w EXISTING WATER SERVICE September 12 2014 v, } -� GRATE EL.=69.20' ,/ TYPE OF ESTABLISHMENT= RESTAURANT FAST FOOD)w/THRU-WAY DATE: 0 M w t9 cfl M � t�_.j BC-1J i -'� ./ / � / / EXISTING OVERHEAD UTILITIES , I ( CO CO o (1 / /- �/ INV.(12")=66.70' / /Pl NUMBER OF SEATS= 15 c� `< C ' TEST PIT#: 2 and 4 GAS W n ' / o / /�(l DESIGN FLOW = 20 GPD PER SEAT EXISTING GAS LINE CO < i o, o o - �P�' /- i ,-/ PROP.6'DUB. L.P.w!2' /'BEN ELEV TOP= 72.00' I co Ww < , o �+ o �G� Z / 3g0 CRUSHED STONE; / -jQp�l� DESIGN FLOW = 150 GPD PER THRU-WAY SERVICEE AREA TEST PIT LOCATION U w / O TOTAL DESIGN FLOW = (20 GPD x 15 SEATS)+ 150 GPID=450 GPD <59.00' INV.(in)-66.00 /"� ELEV WATER= < / S 9 OC' e 10.T 4 \ �. GREASE TRAP SIZING: PERC RATE= O O PROPOSED 1,000 GALLON H-20 GREASE TRAP ,Q �s / ) o .G / ' (3)- USE PROPOSED 1,000 GALLON H-20 GREASE TRAP TANK - » 15 GPD PER SEAT= 15 x 15=225 GPD(REQUIRED) DEPTH OF PERC- °D in EXISTING�RAINAGE , 9f,� /' 1� 0 0 PROP. 1,500/500 GAL.2-COMP. H-20 SEPTIC TANK I I M °' LEACHI G PIT P. ( / /'' ,L` ld� EUECTRIC METER / /-�/ USE 1,000 GAL.TANK(PROPOSED) TEXTURAL CLASS: 1 N o / ) 2 .'� jp � °�0 0 i0 SEPTIC TANK SIZING: O PROPOSED 500 GALLON H-20 LEACHING CHAMBER GUYWIREo� � ,(�� �/CO USE PROPOSED 1,500/500 GALLON 2-COMPART. H-20 SEPTIC TANK 0" 72.00' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE -/ .��' / s -/- __AA ��`" COMPARTMENT 1: D ' ' �G�� s /�� PROP. 1 500/500 GAL / /� Q�`v`P`��J�0�1 DESIGN FLOW x 200%=450 x 2= 900 GAUDAY(RE:QU'IREp) Fill ❑ PROPOSED 5-OUTLET H-20 DISTRIBUTION BOX O O = - r � (', / / �`� 6 DESIGN CAPACITY 1,500 GAUDAY(PROPOSED) PR BRI�CI _, :/- ���(. - 2-COMPARTMENT Q� �Ov� COMPARTMENT 2: THRU SIGN /' i H-20 SEPTIC TANK 24" 70.00' EXISTING DRAINAGE (��.� 93�� DESIGN FLOW x 100%= 450 x 1 = 450 GAUDAY(REQUIRED) Loamy Sand REV. DATE BY APP'D. DESCRIPTION CATCH-BASIN(TYP.) --� EXISTING 1,500 /� l�` - DESIGN CAPACITY = 500 GAUDAY(PROPOSED) B 10Yr5/6 PROPOSED IT P GALLON SEPTIC TANK ,,� ►.� O OSED SITE LAN TO BE REMOVED / 48" 68.00 H PREPARED FOR: LEACHING FACILITY SIZING: �, z • ,-/ / ' COUTO MANAGEMENT GROUP, LLC INSTALL 4 - 500 GALLON H-20 LEACHING CHAMBERS SWING-TIES WITH AGGREGATE o cHN 48�«JR. LOCATED AT: DESCRIPTION BC-1 BC-2 BC-3 X �y�'%. /" \--EXISTING LEACHING PIT TO ,./ SIDEWALL CAPACITY 3821 FALMOUTH ROAD POUTS 28 'PGF BE PUMPED & FILLED IN wl. ,-'i GREASE TRAP COV IN 1 23.0' 34.9' - (LENGTH +WIDTH)(2 SIDES)(2'HIGH)(0.74 GPD/SF)=GPD C Med.to Coarse Sand ��` CLEAN COARSE SAND / ( ) 2.5Ysls MARSTONS MILLS, MA 02648 , (42'+ 12.83')(2)(2')(0.74 GAUSQ.FT.) = 162.3 GPD NOTES: GREASE TRAP COVE OUT(2) 27.0' 37.7' -- lopr ,-�-' 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP SEPTIC TANK COVE BOTTOM CAPACITY SCALE: 1 INCH = 10 FT. DATE: OCTOBER 2 2014 RV (3) 29.7 29.1 -' (LENGTH x WIDTH)(0.74 GPD/SF)=GPD i� Ss ' ' ' ���� ./ EDGE OF EACH SEPTIC SYSTEM COMPONENT. H o,-r'Z 0 5 10 20 ao FEET SEPTIC TANK COVEDUT(4) 37.8' 22.0' -- (42'x 12.83')(0.74 GAUSQ.FT.) = 398.8 GPD � �` �oHN L. yc�G 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION PREPARED BY: 61 OF THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY CORNER OF STONE Q -- 40.T 21.5' 156" 59.00' CHUB ILL R. yg ro30 \�_•___ _ WITH THE TEST PIT DATA SHOWN ON THIS PLAN. REPORT TO TOTALS: No Mottling, Standing or Weeping Observed 418 JC ENGINEERING, INC. ENGINEER AND LOCAL BOARD OF HEALTH IF SOILS ARE NOT CORNER OF STONE(f 52.1' 22.1' TOTAL NUMBER OF CHAMBERS: 4 `'�A 2854 CRANBERRY HIGHWAY �C FIST CONSISTENT WITH TEST PIT DATA. TOTAL LEACHING AREA: 758.2 SQ.FT. s 4, CORNER OF STONE Q - 78.9 63.2 TOTAL LEACHING CAPACITY: 561.1 GAUDAY(PRIMAARY SAS) EAST WAREHAM, MA 02538 SITE PLAN 3.) ENTIRE PROPERTY IS LOCATED WITHIN THE ESTUARINE CORNER OF STONE) - 71.9' 63.0' $ 508.273.0377 SCALE: 1"=10' WATERSHEDS AND NOT LOCATED WITHIN A DEP APPROVED ZONE 2. TOTAL LEACHING CAPACITY: 542.6 GAUDAY(RESERVE AREA) Drawn By: MCP Designed By:MCP Checked By:JLC JOB No.512-B .i1,;