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COTUIT LIQUORS - RETAIL FOOD
Cotuit Liquors 3858 Falmouth Rd. MM, I 4 r Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARNSTABM : F.P.(Thomas)Lee,. 6Q .. 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 471 Issue Date: 01/01/2022 DBA: COTUIT LIQUORS OWNER: OCEAN SHORES CORP. Location of Establishment: 3858 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. 2022 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: C�i FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: N4O� .� Town of Barnstable Initials: Date Paidd$ l�— ,,,MASSB�: Inspectional Services heck# : 1 0 ; q (I ( Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fait: 508-790-6304 �A'PPLICATION FOR PERMIT TO*OPERATE A FOOD ESTABLISHMENT DATE 1 l NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: OtX.i n we-,, G(p Al b) A D k& L ow o n ADDRESS OF FOOD ESTABLISHMENT: 3F 0 WmouAA 1V11 MA(5 b 0c7 M*" a& MAILING ADDRESS(IF DIFFERENT FROM ABOVE): k E-MAIL ADDRESS: as n V co�i r"a u o Y1S, Cam TELEPHONE NUMBER OF FOOD ESTABLISHMENT: L Ot)42D - 5 99 (/ TOTAL NUMBER OF BATHROOMS: -J WELL WATER:YES NO Y ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION ` O 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 FonmsWOODAPP 2020.doc — V l r r � OWNER INFORMATION: FULL NAME OF APPLICANT Dn yi i-6 - SOLE OWNER: YE OWNER PHONE# 50 D --131 ADDRESS (� S NO vXV,0WW �r & MA►A 02�P3 15 CORPORATE OWNER: oce4 h D V 1O Ise 5 ,at-D CORPORATE ADDRESS: N5 8 W MC>W 1 0 MAO�W c) . M(115 M—0 Z(Qgg PERSON IN CHARGE OF DAILY OPERATIONS: -1)ay) I eta `n List,(2)Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Mana ers 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 httv://www.townofbarnstable.us/healthdivision/applications.asy. 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.31S`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 OF THE rpk, TOWN OF BARNSTABLE -� :. .HEALTH INSPECTOR'S Establishment Name: - Date: .- .Page_: of . c 'OFFICE 0A.M. HOURS BARNSTABLE. ' PUBLIC HEALTH DIVISION.- 90o-s.30A.� -a.��.'' 200 MAIN STREET s so-a:so P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. g MON.-FRI. 9g +639•p.0 HYANNIS, MA 02601 508-862-4644 No Reference R Red Item PLEASE PRINT CLEARLY 'F°""a' `FOOD ESTABLISHMENT INSP CT ON REPORT Name ' Date�e Tyne of T 'Ins ectionIr /} '`�{ Ogeration(s) outme' ' F t Address Risk F�eta rvice: Re-inspection v Level Previous Inspection Telephone _al Kitchen, Date: Mobil Pr io e e-o erat n Owner HACCP Y/N Temporary,. Suspect Illness Caterer General Complaint C(f(/w e-� Person in Charge:(PIC) Time Bed&Breakfast HACCP. Other I" In: " -Inspector � Out: Each violation,checked requires an explanation on the narrative page(s):and a citation of specific.provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) . Anti-Choking' 590.009(E) ❑ I/1 4L - 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 FROMCHEMICALS e ! � � ❑ 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 l e i ❑ 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 is ❑ 11.Good.Hygienic Practices, ❑ 22.Posting of ConsumerAdvisories � - 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 O ❑ Voluntary Compliance ❑.Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency-Suspension C N Official Order for Correction:Based on an-inspection today,the items checked indicate.violations of 105 CMR 590.000/Federal Food Code. Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other. 23.Management and Personnel (FC-2)(590.003) This report,when signed'below by a Board of Health member or its agent A=Zero critical violations and no more.than 3 non=critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of,Health. Failure to correct violations regardless of the number of critical,results in an F. B=One critical violation and.less ha.n 4nori-critical violations 9 25.Equipment and Utensils (FC 4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6rion-critical violations=B. 26.Water;Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FG-6)(590.007) aggrieved by this order,you have a right to a.hearing. Your request must C=2 critical violations andless than 9 non-critical. -If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to on- ritical violations=C. 30:Other DATE OF RE-INSPECTION: Inspector's S' natur Print: 31 Dumpster reened from public view Permit Posted o `- Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's at a Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y.. N Dumpster Screen o Y N 71 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 �r. 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 590.004(F) EMPLOYEE HEALTH' 3-302.11(A)(2) Raw Animal Foods Separated from Each ? 7-101.11 Identifying Information-Original Containers* * 3-501.16(A) Hot PHFs Maintained At or Above 140,`F, r 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 3-501.16(A) Roasts Held At or Above 130°F * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Requirements 590.003(G) Reporting by Person in Charge 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 * 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* (. 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE 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 5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effe ctim 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-,, ^._ °Ji' J.`.Ivz•: 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practiceRequirements.sshould be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23.30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome 12 Prevention of Contamination from Hands E 3-101.11 Food Safe and Unadulterated* 3-403.11( ) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs followingsections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-203.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3AA2.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance �Withiin4Hours* 1 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 I 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. Op THE A TOWN OF BARNSTABLE _ HEALTH INSPECTOR-s Establishment Name: Date: - Page:. of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSfABLE. • 200 MAIN STREET 3.30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified e,y: �•� HYANNIS, MA 02601 nnoN.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPE TION REPORT 508-862-4644 Name Date `b Type o Tvoe of Inspection r Operation(s) me I Address XYry Risk Food Service = spection Level Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP0qJA(,bfv &d6a % In: L 3 �o other n�� Inspector Out: o ` Each violation checked req Tres an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations i „A Critical(C)violations marked must be corrected immediately. (blue&red items) l y'�b Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined b the Board of Health. Overall Rating Y y ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 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 6=One critical violation and less than 4non-critical violations 9 (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. violation,4 to a 29.Special Requirements (590.009) within 10 days of receipt of this order. nonc ritical violations C. = 30.Other DATE OF RE-INSPECTION: Inspector's i n Print; 31.Dumpster screened from public view j Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Prodided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N f�--.� .. _. - .-.- .�. •..-r-. --. •-.�-.^ .:vti--.�...,.. -..._.�..-...-.e<. ..K.'•�...-v ,- - -,..- -� -...,. c .-.---r•�.. .«....---'-•.-•--� ,,,. - ... '. ,.�-,�-s.`..�. .• �. v i -k�: � _�+.•...-......�.r-. ..-�-.-^....-=�-.^_r-r'" .---r--'_-.�-•,r ..--'.�._. .�. r Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* $ Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* * * 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives Cooked and RTE Foods.* 19. - PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 75 590.004(F) Other* 3-501.16(A) Hot PHFs Maintained At or Above Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH - 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C). .Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* "140°F* Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Se aration-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 _ Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 590.004(11) Variance Requirements 3-304.11 Food Contact with Equipment and Utensils* 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions � 3 590.003(D) Exclusions and Restrictions* Contamination from the Consumer 7-204.11 Sanitizers,Criteria-Chemicals* _ REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE;POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 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-Immediate is sec Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* PP Y Not Otherwise Processed to Eliminate Equipment* ( ) ) Pathogens 590.006(A) Bottled Drinking Water* 3-401.11 A(2 Comminuted Fish,Meats&Game * Effe cmc 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 of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* P 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Ho[Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. Other 590. violations relating to good retail 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices VFC-6 590.000 Tags/Records:Fish Products tdHand Numbers and Capacities* Within 4 Hours* 23. Management and Personnel .003 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45*F 25. Equipment and Utensils .005 3-402.12 Records,Creation and Retention* Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility .007 7 Conformance with Approved Procedures/ Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 'An I Other 3-502.12 1 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. U n Mate:'l THE Tp TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: ' A '�J)q Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE, • 200 MAIN STREET 3,30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. $ • MON.-FRI. °lFn Ma+"�0 HYANNIS,MA 02601 08-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY, FOOD ESTABLISHMENT INSPEIPCT N REPORT Name Date1. yoe of 015ROftfilnsDection IF f Operation(s) Routi Address 1 Risk ice -Inspectio Level Previou�l i Telephone Residential Kitchen Date: Q Mobile Pre-ope at' n Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast- HACCP Other lnspecto22214 Z�o 4(jh2&dk1;: I Each violation checked requires an explanation on the narra a page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 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 ElYes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. F] 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 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 (FC76)(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 viol lions. If 1 critical refrigeration. within 10 days of receipt of this order. vi 4 to 8 non-critical violatio s= 29.Special Requirements (590.009) y p 30.Other PATE OF RE-INSPECTION: Ins is S' nat a 4r' 31.Dumpster screened from public view J�I Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N (� #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI 's Si ature Print:,��j� Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N ^ _ 1.4 Dumpster Screen? Y N /d f 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* F8 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* Other* g 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 7-201.11 Separation-Storage** 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15. Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* ( )_ 590.004-11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* ,, A 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 1 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Tem erasures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(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* Eff°"°e t°no°t 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* faces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS ;s 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 3-201.17 Game Animals* Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity* g g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 3-501.14 A 3-202.18 Shellstock Identification 13 Handwashing Facilities ( ) Cooling Cooked PHFs from 140°F to 70°17 Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* I Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 1 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 1 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* Sr 590Forrnback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. pp THE Tpk, TOWN OF BARNSTABLE - .HEALTH INSPECTOR Establishment Name: 1 7 Li C� or Date: Page: of G ti OFFICE HOURS Aa E° PUBLIC 0 MAIN STREET DIVISION 8:00-9aoA.M. s:so-a:so P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. 3: �0� HYANNIS,MA 02601 MO8 -FRI. No Reference .R-Red Item PLEASE PRINT CLEARLY p MPS° 508W FOOD ESTABLISHMENT INSPECTION REPORT cp Name �� Date �a, I e o T of Inspection Ooeration(s) u Ine �Q��S Fito r 1 Address L Risk Food Service e-nspection �� I a I m d"" Level eta), Previous Inspection Telephone RINsidential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness k o Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector 2�qn .• I' (rY Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC . ❑ 14.Approved.Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating _ - ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP (/ [110.Proper Adequate Handwashing CONSUMER ADVISORY b6 _ 3-M (_/►` ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating Com❑ 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 B=One critical violation and less than Orion-critical violations 9 ( )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical,violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) PY 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: �:�I' 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N //%•/�� #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature �\ Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted. - Y N Dumpster Screen? Y N "V V_ .. Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 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* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140'F* 7-102.11 Common Name-Working Containers* 2 590.003(C) Responsibility of the Person-in-Charge to 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* 590.003(G) Reporting by Person in Charge* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reared or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155'F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145'F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* E$dive 1/I1200/ 4-602.11 Cleaning Frequency of Utensils and Food Animals-155'17 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165'F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practiRequices should be debited under 929-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165'F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'17 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140'F* Blue Items 23-30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the Foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41'F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(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 1 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. oF1NErpH TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Page: of 1 OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNS7'ABLE. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified Y MAC, g. MON.-FRI HYANNIS,MA 02601 sos-as2-as4a. No Reference R Red Item PLEASE PRINT CLEA Y rFO MPS FOOD ESTABLISHMENT INSPECTION REPORT Nam Date T e o T -A Inspection Operation(s) -Iqo-utin Address Risk Food Service pection Level JR-et-adb Previous Inspection Telephone sidential Kitchen Date: Mobile Pre-operation - Owner HACCP Y/N Temporary Suspect Illness If Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE 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) 1719.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Goofs 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 8 red items) 3ki ++.Q < Corrective Action Required: ❑ No El Yes Non-critical(N)violations must be corrected immediately.or Overall Rating 1 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 B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590i006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot 0 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 2a.Physical Facility (FC-6)(59 .007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. violation,'4 to 8non-critical violations=C. w 29.Special Requirements _ (590.009) y p 30.Other - DATE OF RE-INSPECTION: Inspector's Signat re Print: 31.Dumpster screened from public view 4 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sig t e Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Chazge 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) 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) _ 7-202.11 Restriction-Presence and Use*Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 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 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 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Eggs Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef cti-11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-40L11(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 cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing kitc 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. * 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms ( )( )( ) * 11 Good Hygienic Practices 17 Reheatin for Hot Holdin practices should be debited under#29-Special 3-201.17 Game Animals g g Requirements. $ Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity* g g 3-403.11(C) Commercially Processed RTE Food-Roast Critical and non-critical violations,which do not relate to the foodbome * 12 Prevention of Contamination from Hands 3403.11E Remaining 3-101.11 Food Safe and Unadulterated ( ) g 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 Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 , 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices ; 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability r 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12, Reduced-Oxygen Packaging Criteria* 87-103.12 Conformance with Approved Procedures* S:590Forraback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. i Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARNSTAMY- :" Paul J.Canniff,D.M.D. MAn` 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate `� Phone: (508) 862-4644 Fax. (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 30513, 146, 189 and 189A;Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 471 Issue Date: 01/01/2021 DBA: COTUIT LIQUORS OWNER: DANIEL O' BRIEN Location of Establishment: 3858 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: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: `z Town of Barnstable� For Office Use Only: Initials: _ Date Paid S BMMSPABLE. ; Inspectional Services 9� MASS. 'b Check# 3U,IF '�.s,0 Public Health Division AtFO MAC Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 e APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE I' 12' O NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: CD 1 kl� U0,00o ADDRESS OF FOOD ESTABLISHMENT: 3S15Z i ( 00` M OV15 W' 1y W blS LA 01-1�0 MAILING ADDRESS(IF DIFFERENT FROM {ABOVE): E-MAIL ADDRESS: V � COj!`f-t�(4 �e,r Gcr-yw TELEPHONE NUMBER OF FOOD ESTABLISHMENT: U420 TOTAL NUMBER OF BATHROOMS: 3 WELL WATER:YES NO � —(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO 1 / 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 R�f A OWNER INFORMATION: T p� FULL NAME OF APPLICANT ✓a yi ieA O r7�,ty SOLE OWNER: YES AVO OWNER PHONE# .�0 1�7� — 14� I ADDRESS_ 'DPIjl �lY`©1�V�� IIJY • t.t:l1 02., S CORPORATE OWNER: 7L5 CORPORATE ADDRESS: 3$ D 1��1 �u' 1� 1 Y L S VLS 1►t`�``� I t Vim'0 �� PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. PI \ 2. / IZ / W SIGNATURE OF PLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openin2!! 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.asi). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 V 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 i Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. � i- sns.NsrAULF, 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: 471 Issue Date: 1/1/2021 DBA: COTUIT LIQUORS OWNER: DANIEL O' BRIEN Location of Establishment: 3858 FALMOUTH ROAD MARSTONS MILLS, MA 02648 i Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Q Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY For Office Use Onlv: Initials: .: Town of Barnstable % enttr'srABLS, Inspectional Services Date Pera( 25- am>�P�s_ MAM w� Public Health Division g4g � 3LPjM 2 Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT.APPLICATION (Non-Flavored). �f` A DATE I Z fill. NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: C4('U.1 ADDRESS OF TOBACCO ESTABLISHMENT: 6 IU(w►o l IlV1 ctc�5 f�y�s M 415 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ((-- E-MAIL ADDRESS: P TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: L fig, "I 70 OWNER'S NAME: It'/1 O Y��(P�In OWNER'S PH#f�W)?� -�Z-l� OWNER'S ADDRESS: . IN CW4o IA� yyr . Co tii- M A- 0205 yc- CORPORATE NAME: CD�.y1 wO yeS COS 2 Y►���5 CORPORATE ADDRESS: x6U ��MD A" �w.I CORPORATE FID# I ANNUAL: J� SEASONAL: DATES OF OPERATION:_/_! TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS). TOWN OF BARNSTABLE.COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360,com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https:Hmale�islature.gov/I.aws/GeneralLaws/PartIV/TitleI/Cha ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 q 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 ( r SIGNATURE:PRINTED NAME: No 1 ei Lo I y��(l en DATE: 1 I / 'Z/ 20 , i. QAApplication Forms\TOBACCO APP-NonFavor 12-18-19.docx f ESTABLISHMENT' AME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9.of the Town of Barnstable Board of Health Regulation: Sales to Minors—5.371-9.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: dtwm KA(Ago , Si &eU Printed 14fime Date )�7n1tl0 � pZ D � Signature i Printed Name Date 2-q/ Si ture Printed Name Date tore Printed Name Date Signature Printed Name r Date Signature Printed Name Date Em;l ;t !21 aK �ce— is l W t2-0 Signature Printed Ndme Date Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx s ESTABLISHME ' 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: Mao), D� q, S0130, Signature Printed Name ate AAL'Au- Yzlt 66 ln��i�Z e ed N e Date �,�AeX2 x, 2_� Signahu Printed Namej Da e . Signature Printed Name Date A Oofni 600701(2 l J 1 Z DZO Signature �— Printed Name Date Signature Printed Name Date . G�'� '1/l""f ix S gnature Printed Name Date Q:\Application FonnATOBACCO APP-NonFavor 12-18-19.docx I ESTABLISHMEMN NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 3 71-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—8 371-9.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: zo sigmn'ttufe Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q\Application Forn ATOBACCO APP-NonFavor 12-18-19.docx i 5a sF� MASSACHUSETTS DEPARTMENT OF REVENUE 4J Form CT-3 Retailer License for Sale of Cigarettes o�� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. OCEAN SHORE - -- S CORP Account II): CGL 11485398 006 COTUIT LIQUORS F r License,Number:467003392 3858 FALMOUTH RD _ MARSTONS MILLS MA 026484.855 This certifies that the taxpayer named above is licensed under Chapter 64C'6f the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations: Effective Date: October 1,2020 Expiration Date: September 30;2022 s� 'OSF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoldng Tobacco This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited...' f„ I OCEAN SHORES CORD Account ID:CRL-11485398-009 COTUIT LIQUORS License Number:1402886144 3858 FALMOUTH RD MARSTONS MILLS MA 02648'1855 qq1 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 nontransferable and may be.suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2020 Expiration Date:September 30,2022 aCrrD,F MASSACHUSETTS DEPARTMENT OF REVENUE , z Retailer License for Sate of Electronic Nicotine.Delivery Systems 4� IN n This license, .must be posted and,visible at all times.'The sale of- 01i� tobacco-products to anyone under 21.years of age is.prohibited. ' OCEAN SHORES CORK Account LD: EDL4148539841Z .' a a } COTUIT LIQUORS License Number: 359639040 x = 3858 FALMOUTH RD { MARSTONS MILLS MA'02648-1855 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 w non-transferable and may,be suspended or revoked for failure to comply with state,laws,and regulations: Effective Date:May 27, 2020 Expiration:Date:: September 30,2022 i 'DEPARTMENT OF THE TREASURY :DATE .OF THIS NOTICE: 04-69=96 INTERNAL REVENUE SERVICE NUMBER OF THIS NOTICE:. :CP '575 6 . ANDOVER MA 05501 EMPLOYER IDENTIFICATION NUMBER: 04-3308589 'FORM:. . SS.-4 (TELE-�TIN') 0825505166: B :FOR. .ASSISTANCE CALL US :AT: 617-536=1040 LOCAL BOSTON OCEAN SHORES. CORPORATION. 1.=800=8.29.-4040 .OTHER MA COTUIT LIQUORS 136 LYMAN ST APT 7 WALTHAM MA 02154 OR: WRITE. TO THE ADDRESS SHOWN.AT THE.TOP LEFT. IF YO.U `WRITE, ATTACH THE STUB.OF THIS NOTICE. . i WE ASSIGNED YOU AN ENPLOVER IDENTIFICATION NUMBER (EIN) Thank .you .for your Tele-TIN .phone .call. We assigned.YOU.employer identification number (EIN) 04-3308589. This EIN will identify your business account,. tax .returns,, and documents,.even if you. have. no employees.. Please.keep this notice in .your permanent records. Use your complete name and EIN.shown.above on all. federal tax forms, payments,. and related correspondence. I;f you, use any variation in your name or EIN, it may cause a.delay in.:processing,.. ncorrect information in your.account, or. Cause: YOU to.be assigned more thanr one EIN If you're required to. deposit for. employment. taxes (Forms. 941.,: 943,. '940,,. 94:5, CT-:1, or 1042.),, excise :taxes (Form :72.0), -or. income taxes (Form:1120)., we .will .send.an initial supply of Federal. Tax Deposit (FTD) coupon books within .five; .to: six. weeks- You can use the enclosed. coupons if.you need'to.make a. deposit before you 'receive your supply. Based .on the .information .shown .on .your .Form SS-4, .YoUr must .file.the following forms(s) by the date we show. Form. 1120 :OS/15/9.7 If the .due date'has,passed please comp.lete.the form and. send. it to us by. 04=24-.96. 2f we don't. receive the form by that :date additional penalties -and interest will be charged. If you. weren.'t. . in business. or, di dn't.:hire employees for the .tax period shown,. please file the .form .showing .that.you .have'.n0. liability. If you need help in deternining.what:.your tax. year: is, .YOU can: gist -Publication. 538, Accounting Periods and Methods;,. atr yourrlocal 'IRS. .offices If you have any questions about the forms shown or the.date. they are due,. you.may Callr us at. 1-800-829=1040 or. .write_.to us. .at the Address shown above. t r BOARD OF HEALTH �. Town of Barnstable . John T.Norman Board of Health Donald A.Gaudagnoli,M.D. HARNSTA13M Paul J.Canniff,D.M.D. mma 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: 508 862-4644 Fax: 508 790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 471 Issue Date: 12/10/2019 DBA: COTUIT LIQUORS OWNER: DANIEL O' BRIEN Location of Establishment: 3858 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: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: f Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. B,, N'SFAB Paul J.Canniff,D.M.D. MAML F.P. Thomas Lee Alternate 10139. 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 471 Issue Date: 1/1/2020 DBA: COTUIT LIQUORS OWNER: DANIEL O' BRIEN Location of Establishment: 3858 FALMOUTH ROAD MARSTONS MILLS, MA 02648 Type of Business Permit: Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY f - 508-420-4799 10:08:16 a.m. 12-02-2019 3/9 For Office Use Only: Initials: d 99'0'�►� Town of Barnstable Date Paid ,,,, "M Inspectional Services w Check# . Public Health Division Thomas McKean,Director K 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE �' NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: cb w L` 0� ,I ADDRESS OF FOOD ESTABLISHMENT: 3 V5V al D Ma45 "r 'S MAILING ADDRESS(IF DIFFERENT FROM 1 A�B.}OVE):1 7 E-MAIL ADDRESS: 6A•h@ 6` "Ni' A'a�V or.p-s' Conm D� �n—/ TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (w0) l 2/- ✓� 1 fwfio`� TOTAL NUMBER OF BATHROOMS: WELL WATER:YES_NO� ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: _ SEASONAL: DATES OF OPERATION:_/ / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***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 jt 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 QAApplication For msTOODAPP 2020.doc 508-420-4799 10:08:39 a.m. 12-02-2019 4/9 c OWNER INFORMATION: a h tzl fit ,��1 FULL NAME OF APPLICANT � SOLE OWNER: YES/6% OWNER PHONE# 5D9--731— I )-Cl ADDRESS M ei VAn O t r Ur (OI U 4- MA— 01&3G CORPORATE OWNER: = Lc aki %pEeS Wp - CORPORATE ADDRESS: 5059 )WV lt�fn 9d 2 (0 PERSON IN CHARGE OF DAILY OPERATIONS: Dkj/7 D tl!J1r1 eY, 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 Dcssen 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 townofbarnsinble.us/henIthdivislon/appliestions-asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January Ist to Dec.30 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. Q\Application FonnsTOODAPP REV3-2019.doc L I508-420-4799 10:07:50 a.m. 12-02-2019 2/9 � For Off Initials: I, 'fit. Town of Barnstable bS� � �. D t2 - id amLPd S�_ Inspectional Services ,F,°;9.,•� Public Health Division Check# Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 5OB-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION(Non-Flavored) DATE -11 NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: 004 Uc S ADDRESS OF TOBACCO ESTABLISHMENT: -b 66 g fe MAILING ADDRESS(IF DIFFERENT MOM ABOVE): E-MAIL ADDRESS:— A&yl 0 ro fitkiauon- cayr, TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: OWNER'S NAME: Lat le'` d g 1 y r ' OWNER'S PH#(502)ia- 2'`v OWNER'S ADDRESS: jzct p,1s awev )C, Wt2�1f, 1OA- 62jr?55 rn t R � CORPORATE ADDRESS: SD f1vr�,& - ocy* RP # ou 3308 ANNUAL: _ SEASONAL: DATES OF OPERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: htti)s•//www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: httns•//malep,islature Eov/Laws/GeneralLaws/PartIV/TitleI/Cliapter270/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 Stale License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: n PRINTED NAME: Dawl 0%pjyll 1CVl DATE: 1-2/ 1 / ( t Q\Application FormATOBACCO APP-NonFavor 11-21-19.doc I i 508-420-4799 10:09:26 a.m. 12-02-2019 7/9 L a ESTABLISILVVIENT'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—6 371-9.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: av-010 0 Rfi ev-) /?,151)7 Signatu U Printed Nalhe D to ell 4 OA/'e/� /i%�h / 5igna a Printed Name Date Si a Printed Name Dat amit tjas IIIIA3 Date' Printed Name at—i nted Name Date Printed Name Date rrC� l Printed Name Date Q:1Application FamLMOBACCO APP-NonFavor 11-21-19.doc I r 508-420-4799 10:09:50 a.m. 12-02-2019 8/9 l.►1 ESTABLISHMENT'S NAME TOBACCOSALES 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: ,f Signa6 Printed Name Date Cm4ny rc,4I 1h5J, 9 Si a e Printed Name Date -1"ck (� a NA l z 1 -sibnature Printed Name Date pmi ISA Soran LP II �25�1 Si ej Printed Name Date a Printed Name U Date 12a ///0- ign e ' P ' ed Name Da zc Signature Printed Name 41Date Q:1Application FannATOBACCO APP-NonFavor I 1-21-19.doc i 508-420-4799 10:10:13a.m. 12-02-2019 9/9 a ESTABLISEMNT'S ' TOBACCO SALES Employee Signature Form rstood Chapter 371 This form is for official use to indicate that the em 0 Section 6 of the Mloyee(S)Of this bessachusetts Genernt received a(Lawsewhich describes the of the Town of Barnstable Code and Chapter 27 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: I s 371-9.Sale and Distribution of Tobacco Products. on shall sell or provide a tobacco product,as defined herein,toa person under imum legal sales age. The minimum legal sales age in the Town of Barnstable ars of age.cation: Each person selling or distributing tobacco products,as defined herein, rify the age of the purchaser by means of a valid government issued photographic cation containin thefor�any person under theage of 2 purchaser is 21 years old or older. Verification 1required The employee(s)below received and understood Section 371-9 of the Town of Barnstable B oar oral Laws: of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the ass achusetts 9 Ana W"�J& h 11 r� Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date �I Signature Printed Name Date Signature Printed Name Date Signature PrintedName Date Signature printed Name Date Q:\Application Fomts=BACCO APP-NonFavor 11-21-19.doc 1 508-420-4799 10:09:14 a.m. 12-02-2019 6/9 4%s MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. OCEAN SHORES CORP Account ID: CGL-11485398-006 COTUIT LIQUORS License Number,: 799606784 3858 FALMOUTH RD MARSTONS MILLS MA 02648-1855 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: January 3,2019 Expiration Date: September 30,2020 508-420-4799 10:09:02 a.m. 12-02-2019 5/9 'DAta lntegr tion Bureau l d0 tambrid8e:Street5586480 4EYi ll\ • Boston, MA;O22O4. CERTIFICATE NUMBER SALES AND USE TAX REGISTRATION The vendor herein named is registered to sell tangibip personal property at retail or for resale, pursuant to the General Laws, Chapters 62C, 64H and 641. This registration Is effective only for the registrant at the location specified herein. Any change of name or address renders this registration null and void. 043-308-589 t IDENTIFICATION NUMBER COTUIT LIQUORS 3852 . FALMOUTH RD 06/29/96 ISSUE DATE MARSTONS MILLS MA 02648 . MITCHELL ADAMS This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OF REVENUE �ECKEx Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. 13ARNSTAUM • ' John T.Norman MA;Sgq F.P. Thomas Lee Alternate i9 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590,000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 471 Issue Date: 12/20/18 DBA: COTUIT LIQUORS OWNER: DANIEL O' BRIEN Location of Establishment: 3858 FALMOUTH ROAD MARSTONS MILLS MA 02648 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 _ FEES _ T FOOD SERVICE ESTABLISHMENT: _ YEAR: 2019 RETAIL FOOD: $20.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - - - - - - MOBILE-FOOD: MOBILE-ICE CREAM: a� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: I PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: A j pp THE t � Initials: Town of Barnstable %a Amt Pd$ OS� s Date Paid MAM Inspectional Services r ' caC# )ArFD ,�e Public Health Division Check# Thomas McKean, Director j 200 Main Street, Hyannis,MA 02601 L* Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE I �b NEW OWNERSHIP RENEWAL �C NAME OF FOOD ESTABLISHMENT: I V VY ADDRESS OF FOOD ESTABLISHMENT: ✓ d1 51 l� d 1 S r S ' �KJY� MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: f r I a f" Y , Cayyl TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 0 "l - �ffl1 U TOTAL NUMBER OF BATHROOMS: 3 WELL WATER: YES NO � ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: ' / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***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) 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 l I I , PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT Tay I�/'/ (1 011 SOLE OWNER: YES 0 OWNER PHONE# ADDRESS_I V I C/►�vV l��'�V�1� (iv I q� 1� V`-r DZ�P3� CORPORATE OWNER: 7 FEDERAL IDNO. : CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: Dar ID PY)-elv-\ List (2) Certified Food Protection Managers AND at least (1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I 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. Iv SIGNATURE O 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/bealthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1 st. Q:\Application FormsTOODAPPREV2018.doc L f Town of Barnstable lnitiale $ Date Paid i $ Inspectional Services cheek# Public Health Division ►3 ? I 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street, HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED:FEE:OF:$85.00 APPLICATION FOR A TOBACCO SALES PERMIT ESTABLISHMENT Nu o (D/B/A) 2:2�53 H* out ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OWNER'S NAME: LAST FIRST MIDDLE bvkg' Chu.i�tc vo(51" SOV-73�-PY Do you currently possess a state license to sell tobacco products? Yes x No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign .the Employee Signature Form (provided herein). Signature a '1✓ Date Awl A C:\Users\office2\Desktop\TOBACCO APP2019 dob.docx ESTABLISHMENT' NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one(21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—4 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: 117 Signature Printed Name Date b1Awa ! S' ature Printed N e Date 7 t e Prmted Name Date zz,/ Si a Painted Name Date Ro(re, Cab-&( ( 2Z Si ature Printed Name Date Za S' ature Printed Name Date An-, z ) AAI WOV6 12 23 1100 Si ature Printed Name Date CAUsers\office2\Desktop\T0BACC0 APP2019 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 Massachusetts General Laws: Signature PrintW Name Date ture� Printed Name / Date c6A a-,j /�Az 2 ho- Signature or Printed Name V Date 1-? Z ignature Printed Name Date 5 do qn+tLA ") 11l g Signature Printed Nanie bate _ A- C/Ith 19' 13q118 Signature Printed Name Date Jpt Jmfn Cgtfip I 2A-1, Signature Printed Name Date Q:\Applicatiion Forms\TOBACCO APP2019 dob.docx it j 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 o age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws•- P1l Si a PrinM Name Date co *ZAA41 ignature Printed Narat tDate Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application FormATOBACCO APP2019 dob.docx �1HE Town of Barnstable Regulatory Services Department KAM Public Health Division CD !}3 i639. ♦� " . 200 Main Street, Hyannis MA 02601 1 -n Office: 508-7904644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health r0 Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT l .. o oylty -VA yl f el LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL D/B/A fMmo Mi ?A Ma(5�0 v15 Mill� Mk 02WY STREET ADDRESS TELEPHONE # FID# Do you currently possess a state license to sell tobacco products? Yes J 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 prov' ed_on t e next page). Each employee who sells tobacco products must sign th E e >< r m (provided herein). Si nature Date Q:\Application Forms\TOBACCO APP2018 dob.docx f —420-4799,-,, 09:43:46 a.m. 12-03-2018 1 /4 As UoYS Establishmeht TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood sections VU b. and VII c. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of eighteen(18). Below are sections VII b.and VII c.of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to.a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, it copy of which must be placed on file,in the office of the employer and retained. Such signed forms must be made available for inspection,during the license holders normal business hours upon request of an agent of the Board of Health. c. All distnbutors/retaikers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age,the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product The following employee(s) received and understood Sections VHb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: 0,b Moo 0`N'ten lk l a S' Prm' ted Nidne Date �a n ref D �r i-�V1 2g I� Si a Printed Name e N 3o I 1 a store Printed Name Date --t k IEBO(W A- WOVE . Ilba lie, Signature Printed Name Date Printed Name Date f e, �)U Tag- 11['3,) 1 ( ?) S a e Printed Name We ignatur Printed Name Date QAApplication FomiATOBACCO APP2018 dob.docx 508-420-4799R 09:44:11 a.m. 12-03-2018 214 1 t �fd Establishment TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood sections VII b. and VII c. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of eighteen(18). Below are sections VII b.and VII c.of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sala To Minors—In conformance with the Massachusetts General Laws Chapter 270,Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such rcgulations/laws have been received and understood, a copy of which must be placed on file,in the office of the employer and retained. Such signed forms must be made available for inspection,during the license holders normal business hours upon request of an agent of the Board of Health. c. All distnbutors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age, the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco producL The following employee(s) received and understood Sections VUb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: r true d Name Datd Sigma Printed Name l�1 • C . -air // 30 • ig Signature Printed Name Date 4�— L✓..._ ht,�j f.4 XS' ature Printed Name Date I IL Signature Prm�ed Name Date I ��o JGSi ca brttzo 12 1111 Signatu Printed Name Date Signature Printed Name Date C:\Usms\decollik\AppData\L.ocal\Microsoft\Windows\INetCache\Cont=LOudook\7NTC680MTOBACCO APP2018 dob.don Bellaire, Dianna From: McKenzie, Marybeth Sent: Friday, January 04, 2019 1:09 PM To: Bellaire, Dianna Subject: RE: Cotuit Liquors 2019 Permit The sell four seas ice cream so yes they will need a permit and I did speak with them about the difference now, but they want to keep it.They are all set for 2019 From: Bellaire, Dianna Sent: Friday, January 04, 2019 10:32 AM To: McKenzie, Marybeth Cc: Bellaire, Dianna Subject: FW: Cotuit Liquors 2019 Permit Hi Marybeth; Are you okay with them having a 2019 permit.The last 3 inspections have no grade and I wasn't sure if we should send the permit.They have everything in. They are one of the few retail people hanging out still. I am not sure if retail gets a grade either. Thanks. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us From: Bellaire, Dianna Sent: Tuesday, December 04, 2018 2:09 PM To: McKenzie, Marybeth Cc: Bellaire, Dianna Subject: Cotuit Liquors 2019 Permit Hi Marybeth; I just want to ask if Cotuit Liquors is good for inspection/2019 permit? I have all their paperwork and payment but, last inspection was 08/18. Please let me know. Thanks. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 1 } r � NAME OF OFFENDER DAD 673 0 8 kfl d � ?�" 1P✓1 Dnn V�'If VRU TOWN OF ADDRESS OOFEN.ER ES . `114 Io 9 A FAR I n%Oa fbS - BARNSTABLE CITY,ST TE,21P CODE I a(_56fls MMS 0210 yk pf�ME ' MVIMB REGISTRATION NUMBER ) OFFENSE o 3`1 I 1 ("1'1� 1F1C )d1e1A tt (ASb;�,P (. C o L .` J ff' t' 1A/e(e 0i� 4D a Y"IInOr Z4 sSCsn uAkr aft l0 f.�, � > TIME AND DATE,Q,LVIOLATION LOCATION OF VIOLATION e W NOTICE OF + 11 (A.M)/ P.M.)ON Hard, 2-q 20 I VIOLATION SIGNATURE'OEENFORCING- RSON ENFORCING DEPT. E BADGE NO. LU t bl,c o OF TOWN I H�EBY ACKNOWLEDGE RECEIPT OF CITATION XUj ORDINANCE ® Unable to obtain signature of offender. THE NONCRIMINAL FINE FOR THIS OFFENSE IS 1 S ,(, Date mailed Mc,4 267, 101 u OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL DISPOSITION WITH NO RESULTING CRIMINAL RECORD. w REGULATION a (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, J before:The Barnstable Clerk,230 South Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk,P. .Box 2430, Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF,THE DATE OF THIS NOTICE. 12 you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT,FIRST UBNSTABLE 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 com taint ma be issued a ainst ou. ❑ I HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature i� 1 Town of Barnstable Regulatory Services Barnstable F'IHE l Richard.V. Scali,Director A"mpAca City ti Public Health Division I ' I I_ Thomas McKean,Director Zoos snxivsrnsLE, ' 200 Main Street 639. .•� Hyannis, MA 02601 a C TEn � Fax: 508-790-6304 Certified Mail#7015 1730 0001 4990 1499 April 28,2017 Daniel O'Brien Cotuit Liquors 3858 Falmouth Road Marstons Mills, MA 02648 NOTICE OF HEARING - BOARD OF HEALTH On 3/28/17 and 4/02/16, 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 maybe issued for the first offense. A fine of$200 along with a 7-dampension 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 23, 2017, at 3.00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss any future plans you may have to comply with this regulation. The hearing will be held in the Town Hall, Hearing Room, 367 Main Street, Second Floor, Hyannis, Massachusetts. PER ORDER OF TH BOARD OF HEALTH as c e CHO Director of Public Health Q:\TOBACCO\WP Files\tobacco hearing letter Cotuit Liquor Viol Mar 28-17 BOH May2017.doc MTCP ID: Tobacco Compliance Check Form 2014-2015 Section 1: Establishment a Survey Participants Name: i-u i � q VQC V ID of Purchaser:�_ f Address:— ��'i�J �Gts lb Age: ❑ 16 -Z,17 Sex:VWale ❑Female Name of Adult SU erv-sor: City: �i�°� V`'L�U-5 Zip Code: C Ll al- D C_- riri , i Time of Check: _ ampm❑ Type of Establishment: ❑ Chain Independent ❑ Not Known Date of Check: Day of the Week:❑ Mon %Tues❑Wed ❑Thurs ❑Fri ❑ Sat ❑Sun Style of Establishment(Check Only One): ❑ Convenience Store 0 Grocery Store ❑Bar ❑ Department Store i uor Store ❑Private Club W,Legion,etc, ❑ Gas Station Only ❑Pharmacy/Drug Pharmacy/Drug Store ❑Restaurant ❑ Gas Mini-Mart ❑Other Q?owling alley,golf club etc.) ❑Tobacconist Section 2: Was Compliance Check completed? Yes No ❑ If Yes please continue on to the hart question, if No please sldp this section and go to section 3. How was tobacco marketed? -4�1-Over-the-counter:youth asks the clerk for the product, ❑ From a vending machine with a lockout device. ❑ Other Describe: Was the Purchaser asked for ID? Yes❑ NoYo, Was this an ID-based check? Yes❑ N� Was the Purchaser asked his/her age? Yes❑ Nd_F_ Sex of Clerk: Male❑ Femalax Approximate age of clerk:❑Teen .❑Young Adult �Adult gilder Adult Type of tobacco asked for: Cigarettes Brand of cigarettes asked for:❑ Marlboro Newport ❑Other: ❑ Chew/Dip ❑ Cigars ❑ E-Cigarettes ❑ Other Brand: Was the product requested flavored.(NOT Tobacco or menthol)? Yes ❑ N0A Was the sale made? Yes l!f No ❑ W f 50r\ If"Yes"how much did the product cost:. $ Was a receipt glven?Yes ❑ Nl�o' Purchaser made payinent using: ❑ 1 bills 5 ill ❑ 5 bill and 1 bills r change❑ 10 bill 0 bill 0 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 eratiou,closed at time of visit ❑ Drive thru only ❑ Does not sell tobacco ❑ Unlocatable ❑ Unsafe to access ❑ Tobacco out of stock ❑ Inaccessible by yefutb ❑ Wholesale only/cartons ❑ Presence of police d Permit Suspended ❑ Private club/personal ❑ Machine broken n Ynilth inspector limows salesperson ❑ Other residence ❑ "Don't sell"but tobacco seen in s or as erne 4/14/15 �. . ta r €: p— I. • f , as W-1 (17 p'° a _ : � Certified Mail Fee d S F�df�B"ery Ces&Fees(check box,add fee as appropriate) etum Receipt(hardcopy) $ 1 C3 ❑ m Receipt(electronic) $ I (Z•t rn)�Z t7 FledMail Restricted Delivery $ ,.•.. 4IOZ �I{ers❑Adult Signature Required $❑Adult Signature Restricted Delivery$ 0 1:J Postage Q r- 4i W S c Total Postage and Fees f I $ is �� Sent To Daniel O'Brien 4 N Stree�anc Cotult Liquors 4 city,state 3858 Falmouth Road Marstons Mills,MA 02648 Certified Mail service provides the following benefits: 1 u A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted 'return receipt for no additional fee,present this,r delivery. USPS®-postmarked Certified Mail receipt to the, ■A record of delivery(including the recipient's retail associate. 't_ signature)that is retained by the Postal Service' Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or- Important to the addressee's authorized agent. Important Reminders: Adult signature service,which requires the , ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age International mail. 4 and provides delivery to the addressee specified' •Insurance coverage is not available for purchase by name,or to the addressee's authorized agent I with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the a To ensure that your Certified Mail receipt is L7 insurance coverage automatically included with accepted as legal proof of mailing,it should bear aj certain Priority Mail items. USPS postmark.If you would like a postmark on m For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for y the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Retum Receipt:•attach PS Form 3811 to your mailpiece; IMPORTANT Save this receipt for your records. Ps Form 3800,Apol 2015(Reverse)PSN 7530-02-OOD-9047 • • ■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse X ! ❑Agent so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, B. R eived by(Prin d Name) C. D to of Delivery or on the front if space permits. 1:-ArticiP add.A� i.r^'-- - D. is delivery address different from item 1? ❑iles :Daniel O'Brien If YES;enter delivery address below: p No Cotuit Liquors I `3858 Falmouth Road Marstons Mills, MA 026418 II I illlll IIII III I III I II I II I I I I IIIII I III I L1 I 3. Service Type � 9oirst Mail Express® ❑Adult Signature EYrfegistered MaiITM' P❑Ad�Juult Signature Restricted Delivery ❑Registered Mail Restricted ertified Mail® livery'' '' 9590 9402 2480 6306 7770 77 0 Certified Mail Restricted Delivery Wetu'rn Receipt for ❑Collect on Delivery: Merchandise 2._Article Number(rransfer"from servicelabel) 0 Collect on Delivery Restricted Delivery P Signature Confirmation*^.+ ❑Insured Mail`` O Signature Confirmation 7015 1730 0001 t 4."IW 1 Insured Mail Restricted Delivery •Restn ry oted,Deli,e 14 9 5 t ❑(over$500 ) PS Form 3811,-July2015 PSN 7530-02-000-9053` Domestic Return Receipt_ ;; LISPS TRACKING# First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402 2480 6306 7770 77 Uhited States •Sender:Please print your name;address,and ZIP+4®in this box* postal5ervice PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE ) 200 MAIN STREET r HYANNIS, MA 02601 I I I I TOWN OF BARNSTABLE . wm-w Ordinance or .Regulation WARNING NOTICE Name of Offender/Manager } Address of Offender sf $- ,!IA_;A4 MV/MB Reg.# Village/State/Zip 4.1:^ ..lr "u , .10 11 tia SS:#'��� Business Name { r: (am/pm,' on .i�a 20 Business Address - if Signature of Enforcing Officer Village/State/Zip 1'3-sA-r'n ;lm'; k�S; AAA o,)��.ti'� . Location of Offense -b;, I I fj .i ��, .. r=_> ;�,,..j = 1, ; 1 i i..i,4� L l l of t !Lhl; Enforcing Dept/Division Offense "{r�n ll - � i •_i a; ,: ��:a 13.;f;1ti�� Yt Facts ✓ Jc;:Z),f' �� ;� .1� ;1"i ( ! P 9.i -''� 6 k. ' j i a.. a:.i("t .f;:1.�t"1 aA1�' t��.}y.-,. LJri�,•`t=ar This will'serve onlydas 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. t` .e.e IME > SMME, = Town of Barnstable y MASS. �a q�,, 1639• �� Regulatory Services Barnstable rEp Mp'l 6k.Richard V. Scali,Director ;;m Public Health Division 1111. Thomas McKean,Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 V s April 5, 2016 Daniel O'Brien Cotuit Liquors 3858 Falmouth Road Marstons Mills,MA 62648 NOTICE OF HEARING -BOARD OF HEALTH On 04/02/2016, cigarettes were sold to a minor(a person who was under the age of 18 years) by a person employed at your store. According to Section 371-7(B) of the Town of Barnstable Code,no person, firm, corporation, establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s)to comply with these regulations shall be subject to the following actions for each offense: A warning shall be issued for the first offense. A fine of$100 may be issued for the second offense, $200 for the third offense, $300 for the fourth offense, and$300 for any subsequent offense. You are hereby notified to appear before the Board of Health on Tuesday, 05/10/2016,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. :omas R ORDER OF BOARD OF HEALTH t! A. McKean,RS, CHO Director of Public Health QATOBACCOMP Files\tobacco hearing letter Cotuit Liquor Apr2016.doc 4, -.20 lY'��Ph� Hen th F'i st`, 'eha1c, No. 4024 P. 1 fiCF m: D Tabuc o Compr=ce Check Form 2014 2015 Section 1: i" \ .. ,. survey Participuts ��tbhshme�n� � —� -- ID of Purchaser: Address;_ 1". A e: 16 ❑ 17 Sexale ❑Female Name of Adult Supervisor; CRT �►IU Zip Cod@: { ' r-- ' Type of Establishment: 0 Cbain'g,.Independent ❑ Not Known Date of Check: ` /a l l o pay of the Wee U. Mon ❑Uos❑Wed ❑Thurs ❑Fri at ❑Sun Style of Betablishment(Cheok Only One); ❑ Convenience Store 110 Grubm Store ❑Bar © Department Store -%WTiquor Store ❑Privets Club lu ion etc. ❑ Gas Station Only ❑Fharmac Mrug Store ❑Restaurant ❑ Ges Mini-Matt ❑Other(bowling allgolf dub etc, ❑Tobacconist Section,I Was Compliance Check winpieted? Ya 'No E� if Yes please contimie on to the next question,f No please skip this section and go to section 3. ,W Kew�waa tabance marketed? Over-the-counter,youth asks the olerk for the product, ❑ From a vending maebine Utt at lockout device. ❑ tether DwAbe: Was the lt'orthaser asked for ID? Yea 13 IT464 Was this an ID-based check? Yes❑ NZ l Was the Purchaser asked his/her age? Yes❑ Nok es Sex of'Clerk- M Femala Q Approximate age-of clerk:0 Teen ❑Young Adult dult ❑Older Adult Type of tobacco asked for: 'Cigarettes Brand atcigaretteso asked:for:❑ Marlboro tewport ❑Men ❑ ChewM!p ❑ Cigars ❑ F Cigarettes ❑ Other Brand: Was the product requested flavored(NOT Tobacco or menthol)? Yes 0 Na`� Was the sale m de? YeVI.No 0 10., If"Yee"how much did the product cost: $ Was a receipt given?Yes❑ N�% pul!chgser madjk IjaMeat Using:0 S I bills 11 S5 billa Q $5 U1 and S1 bilW or change El 110 bj]l4S20 10111 chanue Section.I If the youth did not enter the premises or did not attempt to purchase tobacco products please Indicate why: ❑ Out of Business ❑ I)Lrq.longterm closure ❑ In,o erati4 closed at titne,of visit ❑ Driva thm onl ❑ Does not sell tobacco ❑ Unlocatable ❑ Unsafe to access ❑ Tobacco out of stock ❑ Inaccessible by auth ❑ Wholesale an /cartons ❑ Presence of pwico la Pon-At Sus ended Q Private clublpetsoeal ❑ Macbim broken 0 Youth ingpecter knMa rale Other residence ❑ "Don't sell"but tobacco seen in 4/14/1 a L,x President Comptroller Derek P. Fullerton, IRS, CHO Steven Baccari, IRS, CHO Middleton Westborough Vice President MHOA ` Secretary Samuel S. Wong, PhD, REHS a ....,, Sigalle Reiss, MPH, IRS Hudson Norwood September 26, 2017 Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Dear Barnstable Board of Health, The Massachusetts Tobacco Cessation and Prevention Program (MTCP) recently conducted a tobacco retail inspection/compliance check in Barnstable as part of the Food &Drug Administration (FDA) contract with Massachusetts. After the retail inspection/compliance check was completed in your community, MTCP submitted the results to the FDA. The FDA has determined that the following vendors have had violations of the Family Smoking Prevention and Tobacco Control Act: COTUIT LIQUORS 3854 FALMOUTH ROAD These vendors have received warning letters from the FDA for these violations. The inspection results are posted on the FDA website: http://www.fda.gov/ICECl/EnforcementActionsNVarningLetters/Tobacco/default.htm This letter is simply to inform you of the violation. No action on your part is necessary. If you have questions,please contact me at 413-636-6418 or at smccolgan@mhoa.com. Yours Truly, Sarah McColgan Tobacco Control Director Cc: Bob Collett, Barnstable County Tobacco Collaborative PublieHeelth www.mhoa.com Crocker, Sharon From: Sarah McColgan <smccolgan@mhoa.com> Sent: Tuesday, September 26, 2017 10:19 PM To: Health Cc: Bob Collett Subject: FDA Tobacco Violation Attachments: FDA Letter to Funded 2017.doc Please see attached notification. Sarah McColgan Mass. Health Officers Association Tobacco Control Program Director (413) 636-6418 i TOWN OF BARNSTABLE BAR-W Ordinance or Regulation WARNING NOTICE Name of Offender/Manager Address of Offender MV/MB Reg.# r-.T.D." Village/State/Zip waysk,>A% m3ls., MA g2r_,419 _ q��'j t�_) n 44 )!7- 2-OLI,� Business Name 4,40rr-, — 1i • Business Address_---?,'9S'R 12J mlll�1 Mt) Signature of Enforcing Officer Village/State/Zip AAA Q Location of Offense CAA,I J_wtkwo s .1p2w rr-Amoall., i2a 1� 01S, AAA Enforcing Dept/Division Offense T?,-A'(ACAa WC Facts Ublfrf "7--(11,4 4-n :=t i-A.r\o r (;� r-r. A1,111 -a AP -A This will-serve onlyl As & warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE , BAR—W ' j 16 Ordinance or Regulation WARNING NOTICE Name of Of fender/Manager Address of Offender MV/MB Reg.# Village/State/Zip ' '��-� •,i � .1t,li " , M ��/ • ` Business Name r ., t "�? am/pm, on 1 20/6) Business Address --72 �It7lwi4 ki Signature of Enforcing Officer Village/State/Zip Ma("3'1'T)AS M , kkS, AAA x £ Location of Offense Co�o, l 1"t 111II C- t(-r_V I i 11 �,.,. ,w• IN :,t E i A Enforcing Dept/Division Offense ` .�.a �)r► 1� e tt Facts 14 a ?: )l-( -'oC f i `it"i_.'0A 1.4t111;:1 iA) tc111 This will''serve onlyv as awarning. 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. BALIMSTABIX. _ Town of Barnstable �iOTEp 116, Regulatory Services Barnstable Richard V. Scali,Director ;;m Public Health Division I I I f. Thomas McKean,Director 2007 200 Main Street Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 5,2016 Daniel O'Brien Cotuit Liquors 3858 Falmouth Road Marstons Mills,MA 02648 NOTICE OF HEARING -BOARD OF HEALTH On 04/02/2016, cigarettes were sold to a minor (a person who was under the age of 18 years) by a person employed at your store. According to Section 371-7(B) of the Town of Barnstable Code,no person, firm, corporation, establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s)to comply with these regulations shall be subject to the following actions for each offense: A warning shall be issued for the first offense. A fine of$100 may be issued for the second offense, $200 for the third offense, $300 for the fourth offense, and$300 for any subsequent offense. You are hereby notified to appear before the Board of Health on Tuesday, 05/10/2016, 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 BOARD OF HEALTH omas A.McKean,RS, CHO Director of Public Health QATOBACCOMP Files\tobacco hearing letter Cotuit Liquor Apr2016.doc Hea th First iehab, 11c, Vo. 4024 P. 1 MICP M! 0) Poo Tobacco CQ1AP era Ce Check ForM 2014-2015 Section 1: Esf�tblishmeol Survey Fortldpants Name C.aku�}- �•-.f fi C ID of Purchaser: Address,• ai-• I6 1317 S e, ale ❑Female Name of A At Supervisor: C trlty; Zip Code: ami54m 13 - Type of Establishment: 13 Chain' g.Independent ❑ Not Known Data of Check:y)a 110 1]ay oftho Week. Mon ❑Toes❑Wed ❑Thugs ❑Fri at ❑Sun Style of Establishment(Check Only Ono); Cl Convenience Store 110 Grocery Store ❑Bar ❑ Department Stara or Store ❑Private Club Legion,etc. ❑ Oas Station Onk ❑Pharrnac /Div Store ❑Restaurant ❑ oil Mini-Matt ❑otber(bowling all 21f club eta ❑Tahaccardst Section I: Was Compliance Check coMpleted? Yet9 No� If Yes please contime on to the next question,if No please skip this section and go to section I aw was.tubanco marketed? ' Over-the-counten youth asks the clerk for the product, ❑ From a vending machine�t a lockout device. 0 er Descri Qtb be: Was the Purchaser aslmd for ID? Yee 11 Was this an ID-based check? Yes El N Was the Purchaser asked his/her age? Yes 13 Nil 1 �� Sex oi;Cleck: M fo-&Pemals❑ Approximate age-of clerk:0 Teen ❑Young Adult dolt ❑Older Adult Type of tobacco asked for: '-Cigarettes Brand of elgarettes asked for:❑ Marlboro- ewport ❑Other: ❑ Chow/Dip ❑ Cigars ❑ &Cigarettes ❑ other Brand Was the product requested flavored(NOT Tobacco or menthol)? Yes C] Ne � Was the sale made? YeT;2-,N0 0 10 a",a If"'des"how pouch did the product cost S Was a receipt given?Yes 0 " Section 3: Ifthe youth did not enter the premises or did not attempt to purchase tobacco products please indicate why: M Out of$usiness ❑ Tom .long term closute ❑ in a erati4 closed at limo of visit ❑ Drive A,-d ❑ Dons not sell tobacco ❑ Unlocatable ❑ Unsafe to access ❑ Tobac stock ❑ Inaccessible youth Ca Wholesale on /cartons CI Presence of police ❑ Pan-d Q Private club/persoual ❑ Macbim broken 0 Other residence 13 "Don't sell"but tobacco seen in -15wrws poia 4/14115 r * BARNSTABLE. * Town of Barnstable yQ MASS. 0 o i639'S A Regulatory Services Barnstable ArED MA Richard V. Scali,Director A"mericacny Public Health Division 1 I I kF Thomas McKean,Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 5, 2016 Daniel O'Brien Cotuit Liquors 3858 Falmouth Road Marstons Mills,MA 02648 NOTICE OF HEARING - BOARD OF HEALTH On 04/02/2016, cigarettes were sold to a minor(a person who was under the age of 18 years) by a person employed at your store. According to Section 371-7(B) of the Town of Barnstable Code, no person, firm, corporation, establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s)to comply with these regulations shall be subject to the following actions for each offense: A warning. shall be issued for the first offense. A fine of$100 maybe 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, 05/10/2016, 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. tiomas ORDER OFT BOARD OF HEALTH A. McKean, RS, CHO Director of Public Health Q:\TOBACCO\WP Files\tobacco hearing letter Cotuit Liquor Apr2016.doc r 4r. 4. 2016 1 5PM Heath First rehab, Iic, Vo. 4024 P. 1 MICF m: 10) Poo TaImmo Complim►ce Check FOrIn 2014 2015 Sectiau 1: sE>it�►lishmeol� survey Participants Name: ID of Purchaser; _ Address Q e, 16 ❑ 17 Sale ❑Female Name of AU Supervisar: City �'1/1A Zip Code: • �.. . g �Tme of Cberdc; o.(,� am prn 13 Type of Establishment: El C'bain'�Independent ❑ Not Known Data of Check,:!Q � �" pay of the W-1 Mon ❑Tim 13 Wed ❑Thurs ❑Fri_gat ❑Sun Style of Establishment(Cheek Only One); ❑ Convenience Store Store ❑Bar ❑ De ent Store i or Store ❑private Club FW L ion etc. ❑ Gas Station Ordy ❑pharmac 1Dru Store ❑Restaurant ❑ Gis Mini-Matt ❑Other bowlin .all olf club dr- ❑Tobscmdat Section,2: Was Compliance Check completed? . Yell NO if Yes please contInue on to the next question,if No please skip this section and go to section I Wow was tbbame marketed? Over-the-•counter:youth asks the olerk for the product, 13 From a vending maebine!d&a lockout device; ° ❑ Qtfaer Describe: Was the Purchaser asked for ID? Yes El 1* Was this an ID-based check? Yes Cl Ni� Was the Purchaser asked his/her age? Yes❑ N shy,� Sex of Cl : Male Female❑ Approxuroate age-of clerk:lI Tee ❑Young Adul#.Adult 13 Older Adult Type of tobacco asked for: Cigarettes Brand of cigarettes asked for:❑ Marlboro' iowport Q Other: ❑ ChmOlp 0 Cigars ❑ F Cigarettes ❑ Other Drand: bras the product requested flavored(NOT Tobacco air menthol)? Yes 0 NIA Was the sale made? Ye a CI i d a,3a If`'Yea"how much did the product cost: $ Was a receipt given?Yes 0 9% Panhaser madg paymcat Using: St bills 11 5 bill�j LI $5 WIl and$1 hitld or change E1 10 bjll(§I7i4.S20 bill Q chaniza Section 3: If the youth did not enter the premises or did act attempt to purchase tobacco products please indicate why: Q Out of Buainesa ❑ TenM.long term closute 0 la a mdo closed at titno of visit ❑ Driva thru onl ❑ Does not sell tobacco ❑ Unlocatable ❑ Unsafe to access ❑ Tobacco out of stock 13 inaccessible by youth Cl Wholesale onl 1caltons ❑ Framce of Pcdico ❑ Pondt Suspended Q Private clublpersottat ❑ Machine broken 1171 Youth ingnector knW salespWon ❑ Otha— residence ❑ "Don't sell"but tobacco seen in 4/14115 s �,:n . r, I[1�t�.Irkt[�-:LI ,�rIrI I.I I II�I 1 II..I 1 I-�I�II."�II.-"I II I,r 1.,II rII,�I��.I I.I I�I I�I�I.�-I.1I-.I1..�I�.I-I��r�4-I.�_I I1I.-,��I.II1 I.I�IrI.-�-I I I.1�1.I�I�.-III rI II III I�1.-I,,,�,�I�-I�.",.�I:I II II-_IT,�II4i!�IifIII'!I t,IrI I I..-'.��%I II I r.. ..v. ,� I . ,. , �Iy��I�,,II%I",I�'II*�I�I.,�,-WI",,!�I�.�-1iI IIe..��I.(,�,tl.��TIrI1 j 11�FI"�AIII I4,n,%IQ'I�Q'a I "�I:�r,r I���I",I.4I��.I.I1,�I,1...,��'�I��1-",����"�l'�""�'�,.l,III rI"r�I�.4.,.r,,,,,�I.a�r�Ir,�I',rII�',r�III1r r�"I..1I I,II.;I��fI.-II I�I,-,,,j�I III II,�,�,�.�,�[��1,�I,1 I I"I�II�I"I I-17 I%,�I II r I�,I:�1'1�_.��,I I.,1�_:I�1��-rI,.�.-_- 'i . ,o-: ,. 1. t' -. _..., ram:::',,..,a _., ...--..s-«.._.-....-. a,..r....r..__. 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