HomeMy WebLinkAboutWALGREENS - RETAIL FOOD WALGREENS v,)?- 63g-60a
3848 Falmouth Road, M. Millsi
FORMERLY RITE AID
I
�< Town of Barnstable BOARD OF HEALTH
John T. Norman
Board of Health Donald A.Gaudagnoli,M.D.
nxnN9 AB =` F.P.(Thomas)Lee,.
16
�639. 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt.
�
A Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 132 Issue Date: 01/01/2022
DBA: WALGREENS #19947
OWNER: WALGREENS CO.
Location of Establishment: 3848 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. 2 O2 2
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE- ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING: i
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
Ad ✓��,
dosFor Office Uso Qnlv-: Initials:
ti Town of Barnstable
(l
Q; Date Paid ` Amt Pd$ 1 _
. �ASS.B . : Inspectional Services '0 oj02- � 3
i 3 Public Health Division check#
Thomas McKean,Director
200 Main Street Hyannis,' 6 MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE tolls 24 NEW OWNERSHIP RENEWAL K
NAME OF FOOD ESTABLISHMENT: � eoAl S I_tih y 7
ADDRESS OF FOOD ESTABLISHMENT: 3W46 6-Imou f� r-d Zr-4 — MA 060 +�
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): fO goX 9101 , (,rplled� lL Iwo® is
E-MAIL ADDRESS: Tcx 1�ems'-re ^!T�pc.�a l ✓�t^S- tvn'1 - vv��
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: y'( oS ) q1j - S;1 S
TOTAL NUMBER OF BATHROOMS: k
WELL WATER: YES NO x ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: x 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
6 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 FortnsTOODAPP 2020.doc
OWNER INFORMATION: /
FULL NAME OF APPLICANT In , &0
SOLE OWNER: YE /NO D.O.B OWNER PHONE#
ADDRESS_ Pa B-o)C G1,011 D--,e,^F&jd It- *,00/T
CORPORATE OWNER: k4PL/2!:-e-^ f o. / (nc-
CORPORATE ADDRESS: P D PoX '10 1
PERSON IN CHARGE OF DAILY OPERATIONS: 'Ttwti9% G�bha l
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
1. / / 1.
2.
t4�& tT /25 Z�il
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townotbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January I st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st.
I
i
QAApphcanon FormsTOODAPP REV3-2019.1oc
i
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
BARN ABLF. i" Paul J.Canniff,D.M.D.
�r 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: 132 Issue Date: 01/01/2021
DBA: WALGREENS #19947
OWNER: WALGREENS CO.
Location of Establishment: 3848 FALMOUTH ROAD MARSTONS MILLS„ MA 02648
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2021
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
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:
i
oFTHE tq` For Office Use Only: Initials:
Town of
" � Barnstable Date Paid � $
BARNSTABLE Inspectional 1 Services !�71
—
MASS. go"Wi1&2g161
. a`�� Public Health Division Check# �
rEn Mn+
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT: �g Lkq ` O V kin 9-6, eax-Y-,S��V- Mjl`
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): p (boy q.c)
E-MAIL ADDRESS: taxlicenserenewais@walgreens.com
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (509)q2g - 3 Say
TOTAL NUMBER OF BATHROOMS:: C
WELL WATER:YES NO Y- ...(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)
OOD 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 For msTOODAPP 2020.doc
I -
OWNER INFORMATION: (0
FULL NAME OF APPLICANT-
J.,
SOLE OWNER: YES NO D.O.BOnW_NER PHONE#
ADDRESS k-�d (? oy- q 0 CORPORATE OWNER: U�Q Vpdn E"-ke—CVN Q�p - L
n,
CORPORATE ADDRESS: P6 12�0K
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 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
OIL
2.
k� A"t / -D-P—
SIGNATURE OF APPLICANT DATE
Lisa Hora
License Team Lead
847-527-4208 ***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/ai)plications.asi).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC I st.
Q:\Application FormsTOODAPP REV3-2019.doc
°p IRE roy, TOWN OF BARNSTABLE _- HEALTH INSPECTOR'S Establishment Name: Date: - Page: of
OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS, MA 02601 MON.-FRI. No Reference R-.Red Item PLEASE PRINT CLEARLY
te3q•n 508-862 4644
'FDN1P` FOOD ESTABLISHMENT INSPECTION REPORT
Name Datei6 Tyne of T of Inspection
W S _ Cueration(s) .tine
Address /u RIk .� Food Service e-Inspection ,
Level etai Previous Inspection
Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
',,, Q Caterer General Complaint - II
Person in Charge(PIC) Time
�r (JGJ�i �e7 Bed&Breakfast HACCP
In: "Lf o Other
C.
Inspector Out: 0
Each violation checked.requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. t
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 ❑ 18.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 7 6L1�
❑ 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
171 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) �� Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating
Y y ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items Embargo
checked indicate violations of 106 CMR 590.000/Federal Food Code. ❑ g Emergency Closure Voluntary Disposal ❑ Other.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
B= reOne critical violation and less than 4non-critical violations g
25.Equipment and Utensils (FC4)(590.005) cited in this report may result in suspension or revocation of the food �
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7.to 8 no violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation;4 to 8 non-critical violations=C.
29.Speaa equirements (590.009) y p
30.Other DATE OF RE-INSPECTION: Inspect Signature in•
31.Dump Greened 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 IN
Dumpster Screen Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unappro'vedA S.iiti. *, 19 PHF Hot and Cold Holding
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or-Below 41°F/45°F
-
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 5Y0.02 (F) * -
590.003(C) Responsibility of the Person-in-Charge to +...
7-102.11 Common Name-Working Containers* .
Other* 3-501.16(A) Hot PHFs Maintained At or Above i�iir r" r
2
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*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and 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 Fre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
Pe 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* 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-155°F 15 sec Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec*
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef d-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) 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 Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cat er-
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 practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
5 Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C CommerciallyProcessed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
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
* 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70'F
3-202.12 Shellstock Identification ( ) P5.
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* Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F Equipment and Utensils FC-4 .005
3�02.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices Physical Facility FC-6 .007
7 Conformance with Approved Procedures I 6-301.11 Handwashing Cleanser,Availability Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
I
' Town of Barnstable BOARD OF HEALTH
John T.Norman
" Board of Health Donald A.Gaudagnoli,M.D.
BARN-S ABLE : Paul J.Canniff,D.M.D.
1as¢ 200 Main Street, Hyannis, MA 02601 F•P. Thomas Lee Alternate
� Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 132 Issue Date: 02/03/2020
DBA: WALGREENS #19947
OWNER: WALGREENS CO.
Location of Establishment: 3848 FALMOUTH ROAD MARSTONS MILLS, MA 02648
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2020
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
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:
I
1
Walgreen Co.
Corporate Offices
300 Wilmot Rd; MS#3215
Deerfield, IL 60015
www.walgreens.com
January 24, 2020
Barnstable Health Department
200 Main Street
Hyannis,MA 02601
RE: Food/Milk License#132 -Trade Name Change
To Whom It may Concern:
Please accept this letter as notification that RITE AID#10192 located on 3848 FALMOUTH RD in
BARNSTABLE,MA will be converted to Walgreens#19947 on February 21,2020. It is merely a trade
name change for the store. There has not been a change in ownership,possession,control or a change to
the FEIN number.
Would you please update your records and upon issuance of the updated Food/Milk License,please send
it to the mailing address below:
Walgreen Co.
300 Wilmot Road
Deerfield, IL 60015
Attn: Marie Mauclair, Licensing Specialist,MS#3215
Enclosed is a self-addressed envelope.
If you have any questions or concerns,please do not hesitate to contact me at the phone number or email
address below.
Thank you for your assistance with this matter.
Respectfully,
Marie Mauclair
License Specialist
Phone: (847)527-3979
Fax: (847) 368-6686
Mari e.mauclair@walgreens.com
Enclosure
p1?� Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
na►n.IMABM i Paul J.Canniff,D.M.D.
o a 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
a" p Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 132 Issue Date: 12/10/2019
DBA: RITE AID #10192
OWNER: WALGREENS EASTERN CO.
Location of Establishment: 3848 FALMOUTH ROAD MARSTONS MILLS, MA 02648
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2020
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: G A
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
Initials:
' .� Town of Barnstable
Date Paid ( �Amt Pd$
&UMS.,,B,.E. . Inspectional Services aXU_
MASS.
9. p�a� Check#
�fDMAt Public Health Division
Thomas McKean, Director `—/ � I S
200 Main Street, Hyannis,MA 02601 "'a I
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DACT Z 9 201g NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT: rtdR QY�Sblc �Q
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Deerfield, IL 60015
E-MAIL ADDRESS. taxiicenserenewals@walgreens.com
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: t 05j -
TOTAL NUMBER OF BATHROOMS:
WELL WATER: YES NO—V�. (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)
FAD SERVICE
.DETAIL 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
OWNER INFORMATION: Kaydynn De Los Santos.
License Specialist
FULL NAME OF APPLICANT 847=31ri-3376
SOLE OWNER: YES B010%1 Olz /' y OWNER PHONE #
Deerfield, IL 60015 P.O. Box 90
ADDRESS neerfieldr166i0015
CORPORATE OWNER: Wa on. Im
., ens
CORPORATE ADDRESS: Deerfield, IL '6001.5.
PERSON IN CHARGE OF DAILY OPERATIONS:
List(2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
OCT ,2 9 R019
SIGN OF APPLICANT DATE
Kaylynn.De Los Santos
Licens#Specialist
847-315-3376
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to openinE!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FormsTOODAPP REV3-2019.doc
OF THE ro TOWN OF BARNS,TABLE .HEALTH INSPECTOR'S Establishment Name: 1 I Date: Page: of
ry 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, g, - MON.-FRI.
,679. .0 HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY -
'FDN1Ay' FOOD ESTABLISHMENT INSPECTION REPORT
Name R,�{, j Date J��/ �(� Tyne of T g o Inspection
impe oion/s) outine - E I
Address 8y 0 5I a( Risk Service Re- ection _ �J' '4-11'10 *10 00--v/
Level etaiI Previous Inspection 7T�wl
Telephone RMIaential Kitchen Date:
Mobile Pre-operation o
Owner HACCP Y/N Temporary Suspect Illnesses(�B
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP QQny ✓
In: Other d r/
Inspector Q u JffiS Out: 40
Ic
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing. CONSUMER ADVISORY 46
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories . J
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) ® Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating ry p ❑ ❑ p ❑
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 Emergency Closure Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4 590.005 6=One critical violation and-less than 4von-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) within 10 days of receipt of this order.
violation,4 to 8 non-critical violations=C.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view Pjan &(O
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: -� n/� 0
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N ���--`J✓✓J
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12, 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* g3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
590.003(G) Reporting by Person in Charge*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 1 1590.003(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 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.I IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
Eggs 5-101.11 Drinking Water from an Approved System*
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 i
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg Sri-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 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 Surf 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* 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* I
165°F* foodbome illness interventions and risk factors.
2-301.14 When to Wash* * Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
$ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-301.12 PreventingContamination When Tasting* * (Blue Items 23.30)
3-202.15 Package Integrity* g 3 403.11(C) Commercially Processed RTE Food-140°F 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
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures l 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29: Special Requirements .009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
�°p tNE Thy TOWN OF BARNSTABLE �//�1 HEALTH IN fileSPECTOR'S Establishment Name: Date: jaj�ljq Page: of
9 1�
PUBLIC HEALTH DIVISION 1 / s:o0 OFFICEHOURS
-9:30A.M.
V 130-4:30 P.M.BARNSTABLE. • 200 MAIN STREET Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
�p MA-n�0� HYANNIS,MA 02601 _. MON.-FRI. NO Reference R-Red Item PLEASE PRINT CLEARLY
rFD Ma+ 508-862-4644
rJ OOD ESTABLIS ENT INSP T REPORT
Nameti-4 fal Date of s ectio
Operations) Routine
Address Risk Food Service pecti n
evel eta Previous 1 c i
Telephone : i; fi�ale Kitchen Date:
obile Pre-opt o
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Char a(Plc) Time Bed&Breakfast HACCP
Other
Inspector
IV
Each violation checked requires an explanation on the narrative p ge(s)and a citation of specific,provision(s)violated. Q
Violations Related to Foodborne Illness Interventions and Ri k 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 44 1
b
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations '
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ ❑No Yes
Non-critical(N)violations must be corrected immediately or Overall Rating 11D, (�I l co I� 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 ❑ 90 Emergency Closure ❑ Voluntary Disposal Other:
Embargo
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ ❑
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 6=One critical violation and less than n-critical violations 9
if no critical violations observed,4 too 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
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.-. f critical water,sewage back-up,infestation of rodents or insects,or lack of
( )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 no -critical iolations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials FC-7 590.008 9 on,4 to 8 non-critical vi ation C.
29.Special Requirements (590.009) within 10 days of receipt of this order. vt
30.Other PATE OF RE-INSPECTION: In or Sig tur int:
31.Dumpster screened from public view n,
L7
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign re Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y_ N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 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 Sepazated from 3-202.12" - Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties ' Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding _
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
590.003(C) Responsibility of the Person-in-Charge to
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2 - 7-102.11 Common Name-Working Containers*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
* 7-201.11 Separation-Storage*
Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
; _ 590.004 Variance Requirements
3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* (11) q
590.003(G) Reporting by Person in Charge*
Contamination from the Consumer i
490.003(E)
90.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR.3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food ind 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 Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145'F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to.Eliminate .
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective tnn°oi
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency r f ces Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-40 1.11(A)(3) Poultry,Wild Game,Stuffed PHFs. SPECIAL REQUIREMENTS
Chemical Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed s 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 - Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
5 Receiving/Condition g� g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Y
12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 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 Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* ocation an acemen
Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
* 5-205.11 Accessibili ,Operation and Maintenance
3-402.12 Records,Creation and Retention ty, Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. "Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
WE Town of Barnstable BOARD OF HEALTH
Paul J Canniff,D.M.D.
A.Ga
Board of Health Donald A.Gaudagnoli,M.D.
ns�aut John T. Norman
MASM F.P. Thomas Lee Alternate
200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 132 Issue Date: 12/20/18
DBA: RITE AID #10192
OWNER: WALGREENS EASTERN CO.
Location of Establishment: 3848 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. 2019
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: -- -- ----- -
MOBILE-FOOD:
MOBILE-ICE CREAM: C��
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
R
C.
FTHE Tp For Office'Use Only: Initials:
Town of Barnstable
Date Paid Amt Pd&UMSTA $ Q
9 MAS& . Inspectional Services �b '�
�'y�7j lJ
i63q �0 1
a'Fo►��° Public Health Division Check# S F
75
Thomas McKean Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NOV .2 8 101&Ew OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT: `1 8 �A WUVA rJ M 4
ox 01
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Deerfield, IL 60015
taxlicenserenewals@walgreens.com.
E-MAIL ADDRESS:
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (S )
s
TOTAL NUMBER OF BATHROOMS: 2
p WELL WATER:YES NO✓ ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO
-- — NA Pie ac�t�ec�-Food
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
a
***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? N
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
ZOOD 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 FormsT00DAPPREV2018.doc
PLEASE CALL 508-862-4644
OWNER INFORMATION: h
FULL NAME OF APPLICANT \ l 1
SOLE OWNER: -0/NO D.O.B D 1 Z?j Iq OWNER PHONE #
P.O. Box 901
ADDRESS_ f]eerfield, 11 6001 is n
CORPORATE OWNER: Y L1� Y�U�-,A' FEDERAL ID NO. :
. . OX-901
CORPORATE ADDRESS: Deerfield, U 60015
4 PERSON IN CHARGE OF DAILY OPERATIONS: tQ Qw �rto
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.
U i
2.
NOVWA82018
SIGN F APPLICANT DATE
Kaylynn De Los Santos
License Specialist
647-3.15-3376
***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 htty://www.townofbarnstable.us/healthdivision/ai)plications.ast).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1st to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1 st.
Q:\Application FormsTOODAPPREV2018.doc
s
�w
132 BOARD OF HEALTH 11/06/2017
PERMIT TO OPERAT D ESTABLISHMENT
In accordance with r_ tI thority of Chapter 94,
Section 395A and Cha do G � �s' ermit is hereby granted to:
PF
' I
RITE AID HDQTRS. CORP/TANA SW ._ f-
LICENSING
PIP—
Whose place of business is: f R MOUT WPSTON 02648
�
4,v
Type of business and any re tr ', "
4' L - _
To operate a food establish6iernt in tle 1 u, y LE
RESTRICTIONS IF ANY: it _ F:
SEATING: 0. ANNUAL: E`P A--- ti P,��
SEASONAL: TEMPORA y jrEN
Y
Es r� RDPF HEALTH
t a a
RETAIL FOOD STORE: � �. � .00 �
FOOD SERVICE ESTABLISHMENT: ?; laanniff, D.M.D., Chairperson
AP
F } _
Al
RESIDENTIAL KITCHEN FOR RETAIL SALE: �, r 4 �I S8W8yan8gl.
RESIDENTIAL KITCHEN FOR BED+BREAKFA3 " =�: :} l R' o Id A. Guadagnoli M.D
MOBILE FOOD UNIT: _ ^'� { F' a`
TOBACCO SALES: 1 � - CSC•/n
. .; 1.q .
FROZEN DESSERT: A Thomas A. McKean RS CHO CATERER: Th
- � ��� � e .
Director of Public Health
I
i
r 10%26/2017 01 :54pm A 915084777028 106 On � e 03/05
Town of Barnstable C, WO
I�
Regulatory Services HAMffrMLFL, ; Richard V. Scab,Director, 006RM$DM Public Health Division
Thomas McKean,Director
j 200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-63041,
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISE MEN
i
DATE: /O
NAME OF FOOD ESTABLISHMENT: XTJ 10kq
ADDRESS OF FOOD ESTABLISNT:
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):PC7 &y. 31(.5-
P� t�cos-
i E-MAIL ADDRESS:
�SP100 (��c`��e caa--c�
i
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: o S
NUl!!(RFR OF SEATS*: INSIDE: OUTSIDE: TOTAL: --
*Note: If indoor seating provided, see Licensing regarding Common'Victuallers License
i TOTAL NUMBER OF BATHROOMS:
ANNUAL,OR SEASONAL OPERATION:
TYPICAL HOURS OF OPERATION MON-FRI: 0'&DA TO E S°J-
g'A-9�SvN
DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) jN a
IF SEASONAL: APPROXXMATE DATES OF OPERATION: I / TO I I
***REMINDER***
,, SEASONAL ESTABLISHMENT'S MUST CALL FOR INSPECTION PRIOR TO OPENING
TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY
FOOD SERVICE
_✓IIETAU,FOOD
BED & BREAKFAST
CONTINENTAL BREAKFAST *ZF SEATING: ALSO,MUST OBTAIN
i RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE
MOBILE FOOD FROM LICENSING DIVISION.
TOBACCO SALES
FROZEN DAIRY DESSERT MACHINES
-CATERING
OUTSIDE DINING - (OVER)
Q;1Applicadon FonnsVoodappldoc
!
10726/2017 01 :55pm A 915084777028 4813 Page 04/05
a
*�*REMINDER***
I IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE HEALTH DIVISION AND
LICENSING,AND N MET ALL OF THE OUTSIDE DINING CRITERIA
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
I IS AN AIR CURTAIN PROVIDED.AT WAITSTAFF SERVICE DOOR(S)?
CONTACT INFORMATION:
FULL.NAME OF APPLICANT
SOLE OWNER: YES 1 NO ^ 1 L D.O.B r
ADDRESS_��`� �eS ti: 1`� C—.S i a 1TG IPA
i PHONE#gt2)aL-A _8Sti3
IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL
PARTNERS:
f
i
i -
! IF APPLICANT IS A.CORPORATION: FEDERAL IDENTIFICATION NO.04a (.C:n --N
I
i
STATE OF INCORPORATION: D E
FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES
RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL
BREAEFAST):
EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMMNT IS REQUIRED TO
RAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE
CERTIFMD FOOD PROTECTION MANAGER IS REQUIUD TO BE ONSITE DURING ALL
HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH
OF THE CERTIFICATES***
LIST THE NAVIES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS(I.E. SERVSA,r �}
E321R.A.TION DATE:
2. MIRATION DATE: I 1
EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES,
OR SERVES FOOD 1NT NDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE,
PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS
i TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHNINT ON
THE CERTIFICATE"*
LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF.
X, EXPIRATION DATE: ! /
• 01,11E
SIGNATURE OF APPLICANT AND DATE
Q,.1Appliution Fomis\Foodupp3.doc
oF� r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of
o 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
MASS' `0$ MON -FRI.
e,. HYANNIS, MA 02601 so8-8sz�s44 No Reference R-Red Item PLEASE PRINT CLEARLY
MP,a FOOD ESTABLISHMENT INSPECTION PORT s-s
Name " Date :(� e o T n ection
v outine
Address Risk - pection
Level ious Inspection
Telephone ential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint -
Person in Charge(PIC) a Bed&Breakfast HACCP
Other
Inspector ` Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Food
❑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
Vi lations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations rF
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected.immediately or Overall Rating '�
within 90 days as determined by the Board of Health. I ��0 I� ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based o an in 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 25.E regardless of the number of critical,results in an F.
Equipment and Utensils (FC-4)(590.005 B=One critical violation and less than 4raon-critical violations 9
q p ) 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 litical. If no critical water,sewage
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must ons and than 9 non-critical. 9a back-up,infestation of rodents or insects,or lack of
be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8 non-Critical violations=C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION: Inspector�s�Srignature Print:
31.Dumpster screened from public view VV
,Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign t rint: 'n
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
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* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4Hours*
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 Toiric 5Ltistances 3-501.16(B) Cold PHFs Maintained At or Below 41
-- - 590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 3-501.16(A) Hot PHFs Maintained At or Above 140°F 590.003(C) Responsibility of the Person-in-Charge to - � - Other* 7-102.11 Common Name-Working Containers*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Se azation-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 WashingFruits and Vegetables .';t 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* g 3-304.11 Food Contact with Equipment and Utensils* 590.00411 7.202.12 Conditions of Use* _. Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
( ) Variance
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _. - - REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Reservior of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions g � )
Disposition ofAdulterated or Contaminated
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness*° 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Edecri,e 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency r f Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3A01.11(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 ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Proc ure* 165°F* foodborne illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
$ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30)
* 12 Prevention of Contamination from Hands 3 403.11E Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodborne
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* 1 g 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
3-203.12 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 Handwashing Cleanser,Availability 28• Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Fom7back6-2doc
`Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
°p IKE ro TOWN OF BARNSTABLE _ HEALTH INSPECTOR'S Establishment Name: Date: 1 Page: _ .of
PUBLIC HEALTH DIVISION OFFICE-HOURS
8:00-9:30 A.M.
BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS.
3. �0� HYANNIS,MA 02601 8-8MON -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
�iOTFD MP'�° 508-862-4644
FOOD ESTABLISHMENT INS T O EPORT
Nameeol IS
Date e of Type of Inspection 10,
peration(s) Routine
Address Risk Food Service Re-inspection
Level 7--tail Previous Inspection
Telephone ential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) me Bed&Breakfast HACCP
n: Other
Inspecto Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures -
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-Inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items Embargo
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 Emergency Closure Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4(590.005 6=One critical violation and less than 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
C=2 critical violations and less than non-critical. . f 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 8 non-critical violations. If 1 critical refrigeration.
violation,4 to 8rion-critical violations C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
=
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dump er 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 tratr__
G Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* t 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additive*s
Contamination from Raw Ingredients 15 Poisonous or 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 IdentifyingInformation-Original Containers* *
590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* 590.004(F)
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
2
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 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 Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203. Toxic Containers-Prohibitions* q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer '�
3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and
( ) P 4-501.111 Manual Wazewashing-Hot Water. 7.206.12 Rodent Bait Stations
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y Ire 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System*
4-601.11(A) Clean Utensils and Food ContactEggs 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* Elf'i-11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 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 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 Aut Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements. i
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30)
Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 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 Handwashin Facilities 3-501.14 A Cooling
3-202.18 Shellstock Identification* g ( ) g Cooked PHFs from 140°F to 70°F 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 Handwashing Cleanser,Availability
pp 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
Town of Barnstable p����✓
Regulatory Services
soar,&%. Richard V. Scali,Director � BARNSTABLE
t6 9. Public Health Division 1639-2014 "f
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE:
NAME OF FOOD ESTABLISHMENT: RITE AID#10192
ADDRESS OF FOOD ESTABLISHMENT:
3848 FALMOUTH ROAD MARSTONS MILLS 02648
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): PO BOX 901 DEERFIELD, IL 60015
E-MAIL ADDRESS: LICENSEADMINISTRATION@WALGREENS.COM
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( 08.4?8-3525_
NUMBER OF SEATS*: INSIDE: OUTSIDE: TOTAL: NA
* Note: If indoor seating provided,see Licensing regarding Common Victuallers License
TOTAL NUMBER OF BATHROOMS: NA
ANNUAL OR SEASONAL OPERATION: ANNUAL- RETAIL
TYPICAL HOURS OF OPERATION MON-SAT: 7 00 TO 10 • 00 SUN- 8-9
DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) NA
IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO
***REMINDER***
SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING
TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY
FOOD SERVICE
X RETAIL FOOD
BED &BREAKFAST
CONTINENTAL BREAKFAST *IF SEATING: ALSO,MUST OBTAIN
RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE
MOBILE FOOD FROM LICENSING DIVISION.
X TOBACCO SALES
FROZEN DAIRY DESSERT MACHINES
CATERING
OUTSIDE DINING (OVER)
Q:\Application Formffoodappldoc
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***REMINDER***
IF OUTSIDE DINING, YOU MUST BE APPROVED BY THE HEALTH DIVISION AND
LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? NA
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? NA
CONTACT INFORMATION:
FULL NAME OF APPLICANT WALGREEN EASTERN CO
SOLE OWNER: YES/NO D.O.B
ADDRESS 300 WILMOT RD MS 3215 DEERFIELD, IL 60015
PHONE# 847 527 _ 4669
IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL
PARTNERS: SEE ATTACHED
IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 36-1924026
STATE OF INCORPORATION: NEW YORK
FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES
RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL
BREAKFAST):
EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO
HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE
CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL
HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH
OF THE CERTIFICATES***
LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.)
1. NA EXPIRATION DATE:
2. EXPIRATION DATE:
EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES,
OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE
PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS
TRAINED STAFF MEMBER. ***.PLEASE PUT THE NAME OF THE ESTABLISHMENT ON
THE CERTIFICATE***
LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF.
1. NA nAEXPIRATION DATE:
11 Poo /
SIG RE OF APPLICANT AND DATE
Q:\Application Forms\Foodappldoc
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LOCATION �Vf 9f gi SEWAGE # r
VILLAGE IhA���lll� SSESSOR'S MAP & LOT�0*-
A & B CANCC
INSTALLER'S NAME & PHONE NO. 350 Main Street
armou A 02673
SEPTIC TANK CAPACITY /��
LEACHING FACILITY:(type) Z ? /0 0 0 (size)
NO. OF BEDROOMS PRIVATE WELL OR LIC WAT) R.-
-BUILDER OR OWNER 1 u-74 elor?1
vi/ icy
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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LOCATION SEWAGE # `
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VILLAGE �- is y SSESSOR'S MAP & LOT �
A & B CANCC
INSTALLER'S NAME PHONE NO. 350 Main StreeL
W. Yarmouth, A 02673
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) L h /D d O (size)
NO. OF BEDROOMS PRIVATE WELL OR 7FbCWATjER--�
BUILDER OR_OWNER _`' i? �>
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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