Loading...
HomeMy WebLinkAboutVILLAGE MINI MART - RETAIL FOOD F , VILLAGE il�/lli/✓�Ak 135, RT. 149,M.MILLS 0+7� DdD • f I � Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. aaRNMrABLF- Paul J.Canniff,D.M.D. MA- 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: 410 Issue Date: 01/01/2021 DBA: VILLAGE MINI MART OWNER: SUBODH BASNET Location of Establishment: 135 RT. 149 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: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Gt�/� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: l 1 +f For Office Use Only: Initials: �`"�'°wti� Town of Barnstable Date Paid�l �Z Atllt_Pd$ VW BAR,ASS. 039.,E : Inspectional Services ���)O v� 1 v pEE Public Health Division Check# 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 II O9 AD NEW OWNERSHIP RENEWAL t� NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS:_( WELL WATER: YES_NO ✓ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_�� SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: 0 OUTSIDE: y 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 �ETAIL 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: FULL NAME OF APPLICANT �Q p �up v SOLE OWNER: (r /NO �,,� OWNER PHONE# Ste—3 C-7— 739 O 'Y� ADDRESS J✓ D6l!��°z— g& jW t Mq D2-6 L{ CORPORATE OWNER: su&SDs/�e�T ?? CORPORATE ADDRESS: 1 K A-4- w-9 11 Y i7►S M�IIs; i`ha D2Gy�' 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.- k)fA- 2. GNATUR 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 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 htti)://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 I st to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. QAApplication FonnsWOODAPP REV3-2019.doc I opt" Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. gi,RNSTABM : F.P.(Thomas)Lee a 200 Main Street, Hyannis, MA 02601 Daniel Luczkow SS 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: 410 Issue Date: 1/1/2021 DBA: VILLAGE MINI MART OWNER: SUBODH BASNET Location of Establishment: 135 RT. 149 MARSTONS MILLS, MA 02648 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY For Office Town of Barnstable Initials: 2 / Date Paid Amt2d S�_ ;; anwcsrnars .•' Inspectional Services A }b3q. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION(Non-Flavored). DATE NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: V I,f( � ' ADDRESS OF TOBACCO ESTABLISHMENT: 13 - R0i4e 1 U9 4 114010(r75.44;11 et-a6 vy MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: [I Q'AP rY11YI olMar-)' l 3� 'O1'lGu� `(�. TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: (Lq-j OWNER'S NAME: �, ,�� ¢ �r OWNER'S PH#(-CM� q;90 OWNER'S ADDRESS: /��o P MaSA&Pl, Mq O L19 CORPORATE NAME: CORPORATE ADDRESS:I3�R.6U;�@_,I q� 1O ds f&l4 p4f)1 CORPORATE FID# � ANNUAL: 3! SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS). h � 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: hgps://malegislature gov/I,aws/CieneralLaws/partIV/Tit1PT/Cha�er270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT.THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 r SIGNATURE•- �`- ' - PRINTED NAME: DATE:. 2z lo QAApplication Fonns\TOBACCO APP-NonFavor 12-18-19.docx >: t Y bqE V inc Ma& k ESTABLIS ENf'S NAME TOBACCO SALES Employee Signature Form i 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—ia.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: 5WCS41. .............. oil 0 2!2"-.:) Signatur Printed Name Date Signature Printed Name 1 Date Nz�ir Signa Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date i Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx V Commonwealth of Massachusetts Letter ID:L1614734912 Department of Revenue Notice Date:October 1,2020 Geoffrey E.Snyder,Commissioner Account ID:CGL-10581677-007 mass.gov/dor T (J RETAILER LICENSE FOR SALE OF CIGARETTES Il�l�l�lnlil�il��hl�llll�l�llls�l�ll��l�ill��lll,���lll�kl�ll�l o= CAPE DELI INC o VILLAGE MINI MART A N 135 COTUIT RD MARSTONS MILLS MA 02648-1839 Attached below is your Retailer License for Sale of Cigarettes (Form CT-3). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at.(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. i DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ MASSACHUSET'TS DEPARTMENT OF REVENUE Form CT-3 Retailer License for Sale of Cigarettes '. This license must be posted and visible at all times. The sale of tobacco 'vr o p o products to anyone under 18 years of age is prohibited. CAPE DELI INC Account ID: CGL-10581677-007 VILLAGE MINI MART License Number: 2028630016 135 COTUIT RD MARSTONS MILLS MA 02648-1839 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1, 2020 Expiration Date: September 30, 2022 al O .O � Commonwealth of Massachusetts Letter ID:L0334196288 Department of Revenue Notice Date:September 29,2020 Geoffrey E.Snyder,Commissioner Account ID:CRL-10581677-0 10 i € ptit mass.gov/dor / RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO I�1IJIIIIh�lI1�Iu"IIIII�I11°IIIIIIIIIII��I�I�Ill�lll��Illl�l o= CAPE DELI INC 8 VILLAGE MINI MART o� 135 COTUIT RD MARSTONS MILLS MA 02648-1839 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco (Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 5:30 a.m. to 4:30 p.m. DETACH HERE •----------------------------------------------------------------------------------------------------------------------------------------------- s� sF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco ov4 This license must be posted.;and visible at all times. The sale of tobacco products to an, under 18 years of age is prohibited. CAPE DELI INC Account ID: CRL-10581677-010 VILLAGE MINI MART License Number: 1897908224 135 COTUIT RD MARSTONS MILLS MA 02648-1839 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1, 2020 Expiration Date:September 30, 2022 r Commonwealth of Massachusetts Letter ID:L1618924096 1] ❑ Department of Revenue Notice Date:May 6,2020 Geoffrey E.Snyder,Commissioner Account ID:EDL-10581677-013 ~ �y mass.gov/dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS o� CAPE DELI INC S VILLAGE MINI MART N� N 135 COTUIT RD MARSTONS MILLS MA 02648-I839 Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ MASSACHUSETTS DEPARTMENT OF REVENUE v Retailer License for Sale of Electronic Nicotine Delivery Systems This license must be posted and visible at all times. The sale of ov tobacco products to, anyone tender 21 years of age is prohibited. CAPE DELI INC Account ID: EDL-10581677-013 VILLAGE MINI MART License Number: 1040910336 135 COTUIT RD MARSTONS MILLS MA 02648-1839 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell electronic nicotine delivery systems at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:May 6, 2020 Expiration Date: September 30,2022 U U.S. Income Tax Return for an S Corporation OMB No.1545-0 Form 1. 2�-$ 123 ent ►Do not file this form unless the corporation has filed or 019 D_�artm of the Treasury is attaching Form 2553 to elect to be an S corporation. Internal Revenue Service ►Go to www.irs.gov/Form1120S for instructions and the latest information. For calendar year 2019 or tax year beginning 2019, ending 20 A S election effective date Name D Employer identification number 01/01/2002 Cape Deli, Inc. 26-0002569 B Business activity code oR E Number,street,and room or suite no.If a P.O.box,see instructions. E Date incorporated number(see instructions) PRINT 135 Route 149 01/01/2 0 0 2 445120 City or town,state or province,country,and ZIP or foreign postal code F Total assets(see instructions) C Check if Sch.M-3 attached❑ Marstons Mills MA 02648 $ 314, 673. G Is the corporation electing to be an S corporation beginning with this tax year? ❑Yes X No If"Yes,"attach Form 2553 if not already filed H Check if: (1) ❑Final return M ❑Name change (3) ❑Address change (4) ❑Amended return (5) ❑S election termination or revocation Enter the number of shareholders who were shareholders during any part of the tax year . . . . . . . . ► 1 --------------------------- J Check if corporation: (1) ❑Aggregated activities for section 465 at-risk purposes (2) ❑Grouped activities for section 469 passive activity purposes Caution-Include only trade or business income and expenses on lines 1 a through 21.See the instructions for more information. 1a Gross receipts or sales . . . . . . . . . . . . . . . . is 3, 361, 000. b Returns and allowances . . . . . . . . . . . . . . . . lb ' c Balance.Subtract line 1b from line is . . . . . . . . . . . . . . . . 1c 3, 361, 000. E 2 Cost of goods sold(attach Form 11 25-A) . . . . . . . . . . . . . . . . . 2 2, 904,271. c 3 Gross profit. Subtract line 2 from line 1 c . . . . . . . . . . . . . . . . . . . 3 456, 729. 4 Net gain(loss)from Fora 4797,line 17(attach Form 4797) . . . . . . . . . . . . . 4 5 Other income(loss)(see instructions—attach statement) . . . . . . . . . . . . . . 5 6 Total income(loss).Add lines 3 through 5 . ► 6 456,729. " 7 Compensation of officers(see instructions—attach Form 11 25-E) . . . . . . . . . . . 7 48, 000. `o_ 8 Salaries and wages(less employment credits) . . . . . . . . . . . . . . . . . 8 34, 680. m 9 Repairs and maintenance . . . . . . . . . . . . . . . . . . . . . . . . 9 2, 826. E 10 Bad debts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 11 Rents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 75, 600. 0 12 Taxes and licenses . . . . . . . . . . . . . . . . . . . . . . . . . . 12 10, 758. t5 13 Interest(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . 13 y 14 Depreciation not claimed on Form 1125-A or elsewhere on return(attach Form 4562) . . . . . 14 4, 249. 15 Depletion(Do not deduct oil and gas depletion.) . . . . . . . . . . . . . . . . 15 16 Advertising . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 6,072. N 17 Pension, profit-sharing, etc.,plans . . . . . . . . . . . . . . . . . . . 17 c 18 Employee benefit programs . . .. . . . . . . . . . . . . . . . . 18 19 Other deductions(attach statement) , See Statement , . , , . . 19 81, 866. o 20 Total deductions.Add lines 7 through 19 . . . . . . . . . . . . . . . . . ► 20 264,051. 21 Ordinary business income(loss).Subtract line 20 from line 6 21 192, 678. 22a Excess net passive income or LIFO recapture tax(see instructions) . . . 22a +'} b Tax from Schedule D(Form 1120-S) . . . . . . . . . . . 22b y c Add lines 22a and 22b(see instructions for additional taxes) . . . . . . . . . 22c a 23a 2019 estimated tax payments and 2018 overpayment credited to 2019 23a E b Tax deposited with Form 7004 . . . . . . . . . . . . . . 23b 0. M c Credit for federal tax paid on fuels(attach Form 4136) . . . . . . 23c a d Reserved for future use . . . . . . . . . . . . . . . . 23d M e Add lines 23a through 23d . . . . . . . . . . . . . . . . . . . . . . . 23e 0. Fm 24 Estimated tax penalty(see instructions).Check if Form 2220 is attached . . . . . . . ► ❑ 24 25 Amount owed.If line 23e is smaller than the total of lines 22c and 24,enter amount owed . . . 25 0. 26 Overpayment. If line 23e is larger than the total of lines 22c and 24,enter amount overpaid . . . 26 27 Enter amount from line 26: Credited to 2020 estimated tax► Refunded► 27 Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and Sign belief,it is true,correct,and complete.Declaration of preparer(other than taxpayer)is based on all information of which preparer has any knowledge. May the IRS discuss this return Here , I , President with the preparer shown below? Signature of officer Date Title See instructions. ❑X Yes ❑No Paid Print/Type preparer's name Preparer's signature Date Check❑ if MINPreparer John A. Silva, Jr. self-employed p00564287 Use Only Firm'sname ► ABC INCOME TAX Firm'sEIN 1-04-3442509 Firm's address► 4464 Falmouth Rd Cotui- MA 02635 Phoneno. (508) 477-8200 For Paperwork Reduction Act Notice,see separate instructions.BAA REV 06/30f2O PRO Form I I20-S(2019) Town of Barnstable BOARD OF HEALTHJohnT.Norman Board of Health Donald A.Gaudagnoli,M.D. UARNSTABEX: F.P.(Thomas)Lee,. v MAS& Daniel Luczkow,M.D. Alt. 4, a9. 5.1 200 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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 410 Issue Date: 01/01/2022 DBA: VILLAGE MINI MART OWNER: SUBODH BASNET Location of Establishment: 135 RT. 149 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: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - MOBILE-FOOD: MOBILE-ICE CREAM: GrQ� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: "4 For OM • Initials: IKE Town of Barnstable `` t��- Q' Date Paid 1� s�l Amt Pd$'W MUMSPABLE. : Inspectional ServicesNAM P "+l(7 1639 ,0� # ArF .. Public Health Division Check 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 l I ( NEW OWNERSHIP RENEWAL v NAME OF FOOD ESTABLISHMENT: Vl In t a4 M)tq l' AnA-- ADDRESS OF FOOD ESTABLISHMENT: �S i qrOzo S/0 S���/4 Q me MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: ui Hwon,"nr'VMar•f- 13<-Ja TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (" )F TOTAL NUMBER OF BATHROOMS: l 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) *** 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 4 • L ' OWNER INFORMATION: FULL NAME OF APPLICANT �5u Isn" &P&AI C-T- SOLE OWNER YES/NO )-bWNER PHONE # 5 — .344- 613 9-0 ADDRESS �� P` "F"1��QS�I Q AA CU L/ CORPORATE OWNER: Ju A^ ��1 C AK ®,6�14, �- CORPORATE ADDRESS: 17.0 P614c,,l 4-1 r A40 7/ "S M/I a, OvW o2&Lt y 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 1. t 2. 012 �� T PLICANT DATE ***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.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 1 st. Q\Application FormsWOODAPP REV3-2019.doc `oF.HE row TOWN OF BARNSTABLE _ _ HEALTH iasPECTOR s Establishment Name: Date: Page:.Of t 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 2 •� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY prFD Mp'1° - 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT _ Name - `1 � Date I Type of o sec io / " Operation(s) Routine ✓`�` ( StG�� Address I Risk Food Service Re7UMpULTion �St�L 111 �t/•v r ; w� Level etail Previous Inspection (i`�l )l Telephone Residential Kitchen Date: _ /D0 .�7'r Mobile Pre-operation 1 Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint n b - l Person in Charge(PIC)J V �5,� - i ime Bed&Breakfast Other A�� s D IA/J'G Inspector Out: �' \ "�'�l-,�, V V f�/t IJ�Ql✓� rib 0, Each violation checked requi s 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) ❑ t L� \ ) � \/� )/Li ` �\ I 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 �1 (� a� G ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals lyvott FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) i - I ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures �'7"� t Ci ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling L ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding JO a 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 Item) 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 o Embar 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) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i non-critical. If 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 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008 9 violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's ature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's ign ` e---_._ Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Vidlatibns 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 15 590.004(F)Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F * 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* 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* 2 Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A), Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage Applicants 3-302.11(A) Food Protection* 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 * ( ) q 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 3-306..14(A)(B)Returned Food and Reservice of Food* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 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 Wazewashin Ho[Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* i - 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* EJ/&" 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 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* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 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 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 * 13V5-205.11 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) g 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 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 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* Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc "Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Qp THE ro TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of .. Wo OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. _j BARNSTABLE. • 200 MAIN STREET 3:30-430 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified My39. �0� HYANNIS,MA 02601 8-8MON -FRI. No Reference R-Red Item , - PLEASE PRINT CLEARLY . 508-862�644 A FQPD STABLISHMENT INSP CT ON REPORT e Name Date fT a of ns ectio Ooeration(sl Routine Address isk Service ectio evel etail Previou Telephone ential Kitchen Date: Mobile Pre-op i n Owner HACCP Y/N Temporary Suspect III•es Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP Other Inspecto Each violation checked requires an ex 1 na ion on the narraf page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions an 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) ❑ w Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ / FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands V /- ❑ 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 Im All ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.CoolingIL ❑ 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 LD ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items Total Number of Critical Violations �h Critical(C)violations marked must be corrected immediately. (blue&red items) ' C�0o 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. ❑ ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 6=One critical violation and less than 4non-critical violations 9 )( ) cited in this report may result in suspension or revocation 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 9non-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-critic I viol. 'ions. If 1 critical refrigeration. 4 to 8 non-critical violatio - - 29.Special Requirements (590.009) within 10 days of receipt of this order. violati n, � 30.Other DATE OF RE-INSPECTION: Insp, is Si u Q 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N _V "k 13 #Seats Observed Frozen Dessert Machines: Outside Dining Y N Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives - Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202-.12-^• Additives* _ 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients +15 r 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* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* - * Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003 D Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* , ( ) 3-306.14(A)(B)Returned Food and Reservice of Food* � REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* 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* 3-401.1 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 + 1 Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ed-eye 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* t 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 3-20L15 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 3-40 1.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under- RegulatoryAuthority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to- _ 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* Ell Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under 929-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 * (Blue Items 23-30) 3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome * 12E5-203.11 Prevention of Contamination from Hands 3-403.11 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 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* 13Handwashing 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 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 in Provision 29. Special Requirements 1 .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. w Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. ILAW ABLA t Paul J.Canniff,D.M.D. MAM 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: 410 Issue Date: 12/10/2019 DBA: VILLAGE MINI MART OWNER: SUBODH BASNET Location of Establishment: 135 RT. 149 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: Qh FROZEN DESSERT: _ _ Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: t FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: �� x off rti Initials: Town of Barnstable For Office]aAmt Pd$1 Date Paid Inspectional Services 0 �E16 Public Health Division Check# Thomas McKean, Director 200 Main Street,Hyannis,Mt1 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: V Crf I!w M aq�r M'A- l- ADDRESS OF FOOD ESTABLISHMENT:(36- Rev P V q • IKC(K;'I1Is A (I M4 024Y MAILING ADDRESS(IF DIFFERENT FROM ABOVE): Saw- , C E-MAIL ADDRESS: VPl a4I' Q'1, TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (W) TOTAL NUMBER OF BATHROOMS: 1 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) *** 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 c� OWNER INFORMATION: FULL NAME OF APPLICANT �U t C,-T SOLE OWNER:jFS-/r�NNOO ZOWNER PHONE# 91D ADDRESS_ cq6y,. CORPORATE OWNER: CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: OL" ✓ ��r.%/ List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.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 APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc =,jam For Office Use Only: Initials: oFTMETp� Town of Barnstable Date Paid $ I ` Inspectional Services BA"SraBLE, Check# I r"(0 M^9- Public Health Division ArFD" p Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE / Ill9 NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: u t l� cad!-- M 4oy,I/M.grj- ADDRESS OF TOBACCO ESTABLISHMENT: a � IUD;11 S- 44A 02-fe 4X MAILING ADDRESS(IF DIFFERENT FROM ABOVE): S—ame.. E-MAIL ADDRESS: V il110=/ J ni Ma 6 (A Vf y*hkk 1, TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: Cw ) `lk - O q4 OWNER'S NAME: .` r1 6aC/7e'+ OWNER'S PH#(—") r( - 6 OWNER'S ADDRESS: J � L I'�f - / I S P� �L� og V CORPORATE ADDRESS: /3- ►-r 6 ,4-e-logy, Ot±tZ A4l'/l(IWCORPORATE FID# 9ZV © CVA�(I / ANNUAL:/ SEASONAL: DATES OF OPERATION / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX. MONDAYS) A11A TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https://maleizislature.gov/Laws/GeneralLaws/PartI V/TitleI/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY *** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 I ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE. ��` __ PRINTED NAME: DATE: I / r y / 241 Q\Application Forms\TOBACCO APP-10-03-2020 draft2-Non Favor.doc ESTAB HMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—§371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature Printed Na�me,�- / Date Signature Printed Name Date ' 'See r :'( aue„" K II Ili fig Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP-10-03-2020 draft2-NonFavondoc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. Paul J.Canniff,D.M.D. 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems 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: 410 Issue Date: 1/1/2020 DBA: VILLAGE MINI MART OWNER: SUBODH BASNET Location of Establishment: 135 RT. 149 MARSTONS MILLS, MA 02648 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 GQ m Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY HEALTH INSPECTOR'S Establishment Name: I Page: ' of pME r TOWN OF BARNSTABLE V IIAfi6ate:` ok�o PUBLIC OFFICE HOURS BARNSfABLE. 2 0 MAN STREEET 33 4 0- :30 P.M. DIVISION : 0- :30 A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified : Mph, g.�'0rtn r3Aa+"m HYANNIS,MA 02601 MON.-FRI.508-862-464a No Reference. R-Red Item PLEASE PRINT CLEARLY, 0 FOOD ES ABL SHME T INSP fiION REPORT. Name Dat T e Type of Inspection Ooeration(s) Routine Address Fo ervice Re-inspe 'on ] e e ai Previo I e 4 . Telephone. / ' ential Kitchen Date: Mobile Pre-op r t Sus ellnes Owner HACCP Y/N Temporary p Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP Other / Inspector Lt. Each violation requires an xplanation on the narrative p ( d ation of specific provision(s)violated. Violations Related to Foodb)rne Illness Interventions and Risk Facttthecl�ed s(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) AA ❑ FOOD_ PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS Mv/ (J ❑ 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 i ❑ 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 Asa 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 del ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Q'- �(r y Critical(C)violations marked must be corrected immediately. (blue&red items) Ve 1`� Corrective Action Required: ❑ No Ye Non-critical(N)violations must be corrected immediately or within 90 days as determined b the Board of Health. Overall Rating F[:IEombargo nta Compliance Employee Restriction/Exclusion Re-inspection Scheduled Emergency us ension Y Y � rY P ❑ ❑ P ❑ 9 Y P C N Official Order for Correction: Based on an inspection today,the items ❑ 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 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 4 non-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 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of be in,writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8 non-critical violations= 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector' igna (Tint: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature rint: 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) [Demonstration gnment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 . PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 590.004(F) 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140`F* 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* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003 D Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria Chemicals* ( ) 3-306.14(A)(B)Returned Food and Reservice of Food* REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 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 5-101.1.1 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 tnrzooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency r f ces of Equipment* of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-20L14 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 or590.009(A)-(D) 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 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* 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 practices should be debited under#29-Special 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 PreventingContamination When Tasting* * (Blue Items 23-30) 3-202.11 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 I Good Retail Practices FC 1590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 004 3 402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices (� 9 9 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, 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. �p 1ME T TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: V i 1�a Y"6 11� I Date: Page: . of 0 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 HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY _. 508-862-4644 'FDN1P` FOOD ESTABLISHMENT INSPECTION REPORT. �q 0 Name V n j �"-4(4' Date 1/l q Tvoeo Type of ns a ion Operation(s) outine I�qi-i 0 d 04d ✓ �j I Risk Food Service ection Address _ ' rr Level etai Previous Inspection Telephone a Idential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness D` Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP 14 IC Ovdq NOn In: Other Inspector Qn �(n� Out: �,�ia ✓ ��4 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 ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories 6 Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No ❑ Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 6=One critical violation and less than 4non-critical violations 9 )( ) cited in this report may result in suspension or revocation er the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of violations observed 7 to 8 non-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 8 non-critical; violations=C. . 29.Special Requirements (590.009) y p i's Signature 30.Other PATE OF RE-INSPECTION: Inspector Print: ��an n✓�,�� 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: Is N Self Service Wait Service Provided Grease Trap Size Variance Letter Posted. Y N Dumpster Screen 7 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* 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 EMPLOYEE HEALTH 3-302.11 A(2) Raw Animal Foods Separated from Each * 590.004(F) ( ) P 7-101.11 Identifying Information-Original Containers * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 590.003(C) Responsibility of the Person-in-Charge[0 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g * 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 1 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. 1 g Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of 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* 4-602.11 Cleaning Frequency of Utensils and Food 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 1112001 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* Animals-155°F 15 sec* 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 aces 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 Violations of 5 A f S90.009 in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009(A) (D) Vio ( ) �) 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 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 * (Blue Items 23-30) 3-202.15 Package Integrity (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 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* �) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 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. oFtKWE roti TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date. L Page: of PUBLIC HEALTH DIVISION OFFICE HOURS8:00-9:30A.nn. BARNSrABLE. • 200 MAIN STREET 3:MON. o FRI. N Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLA OF CORRECTION Date Verified sos8 -s2-asaa HYANNIS, MA 02601 M- No Reference R•Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT Name Date a of T g of I Isgection 1' Operation(s) o / ! cvr� J n � Address 6 Risk Fo Service nspection I Level etai Previous Inspection V`� Telephone esldential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) �� ( � , nrna Bed&Breakfast O HACherCP L' Inspector Out: r 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 Asa 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 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 �v within 90 days as determined b the Board of Health. I Voluntary Compliance Employee Restriction/Exclusion ❑ Re-inspection Scheduled Ej 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) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations if no critical violations observed,4 too 6 von-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 be ri wed 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 Signature Print: 31.Dump er screened from public view AA 4111V Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted. Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 142) 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 �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.* , 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 1 5 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* Other* 2 590.003(C) Responsibility of the Person-in-Charge to - 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Se 3-501.16(A) Roasts Held At or Above 130°F* Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use _ 590.004 11 - Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 4 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 27 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 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not.Served* _ P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical 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 E Equipment* s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Eggs Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* sryecn°e iiuzooi 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 cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential A 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 Authority Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Aut 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. * 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 Requirements.practices ould 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°17 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3 403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* Ll 8 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°17 i Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'r Town of Barnstable BOARD OF HEALTH v� Paul J Canniff,D.M.D. A.Ga Board of Health Donald A.Gaudagnoli,M.D. DAMSTABM. John T.Norman * 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: 410 Issue Date: 12/20/18 DBA: VILLAGE MINI MART OWNER: SUBODH BASNET Location of Establishment: 135 RT. 149 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: Q,� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I oFVE royr For Office Use Only: Initials: 2D22_ Town of Barnstable &UMST" LE Inspectional Services Date Paid Apt Pd$� MAM p A,Eo , Public Health Division Check# Cash Thomas McKean, Director -P#-32--D 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 1 � NAME OF FOOD ESTABLISHMENT: �f �I a"),,); m a y� ADDRESS OF FOOD ESTABLISHMENT: I W- D`^mk I , Mears �j MAILING ADDRESS(IF DIFFERENT FROM ABOVE):: E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (2 ) TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO ✓ . (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: 01/a 1/i2 TO NUMBER OF SEATS: INSIDE: b OUTSIDE: 0 TOTAL: O 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) L1-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 i - --- ----- ---- ---------- -- -------- PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT U G SOLE OWNER{ YES NO OWNER PHONE# -93- 341 , 1W ADDRESS_ 3 JOC-f:�rL 9j ► KiU M,� 01C`1 j CORPORATE OWNER: SAW FEDERAL : CORPORATE ADDRESS: )3� �7 1 R , Marr*o4 (141� 14, (144 024 q 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 p 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 openinz!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January I st to Dec. 3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPPREV2018.doc r 20 �FIKE Town of Barnstable Regulatory Services Department = enxxsraHt�, _ i639•39- Public Health Division 95 �� 200 Main Street, Hyannis MA 02601 wy ico -fxdee nd 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 LAST*NAME OF APPLICANT FIRST NAME MIDDLE INITIAL \!1 I I DB/A 113-C tiqay-�'� lm;tl�, n14 Ou M STREET ADDRESS 9 am TELEPHONE# FID# Do you currently possess.a state license to sell tobacco products? Yes Ven No Each employee who sells tobacco products must receive and understand the Sections VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form (provided herein). I/hLI� Signature Date C:\Users\crockersh\AppData\Local\Microsoft\Windows\INetCache\Content.0utlook\K266YKRV\TOBACCO APP2018 dob.docx TOBACCO SALES TO MINORS PROHIBITED BY MASSACHUSETTS GENERAL LAWS Sales to Minors — Massachusetts General Laws Chapter 270, Section 6, whoever sells a cigarette, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen (18) or, not being his parent or guardian, gives a cigarettes, chewing tobacco, snuff, or tobacco in any of its forms to any person under the age of(18), shall be punished by a fine of not less than one hundred dollars ($100) for the first offense, not less than two hundred dollars ($200) for the second offense, and not less than three hundred dollars ($300) for any third or subsequent offense. Posting State Law — In conformance with Massachusetts General Laws, Chapter 270, Section 7, a copy of Massachusetts General Laws Chapter 270, Section 6 shall be posted conspicuously by the owner or other person in charge thereof in the shop or other place used to sell cigarettes at retail. The notice to be posted shall be that notice provided by the Massachusetts Department of Public Health. Such notice shall be at least 48 square inches and shall be posted at the cash register which receives the greatest volume of single cigarette package sales in such a manner so this may be readily seen by a person standing at or approaching the cash register. Such notice shall directly face the purchaser and shall not be obstructed from view or place at a height of less than 4 feet or greater than 9 feet from the floor. For all other cash registers that sell cigarettes, a notice shall be attached which is no smaller than 9 square inches, which is the size of the sign provided by the Department of Public Health. Such notice must be posted in a manner so that it may be readily seen by a person standing at or approaching the cash register. Such notice shall directly face the purchaser and shall not be obstructed from view or laced at a height no less than 4 feet or more than 9 feet from the floor. Q:\Application Forms\TOBACCO APP2016.docx � 7 I 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. Sales To Minors—In conformance with the Massachusetts General Laws Chapter.270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file, in the office of the employer and retained. Such signed forms must be made available for inspection, during the license holders normal business hours upon request of an agent of the Board of Health. c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be under 25 years of age, the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIIb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature Printed Name Date IJV Signature Printed Name Date Signature Printed Name Date 5 P� tt/l'14/l? Signature Printed NaYne Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q\Application Forms\TOBACCO APP2016.docx .y�VEti Town of Barnstable F r Office Initials:�� y �.. Date Paid Inspectional Services �BAR `� Public Health Division fn H'p'r 200 Main Street, Hyannis MA 02601 Office: 508-7904644 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 ESTABLISHMEN AME (DB/A) ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERENT FROM ABOVE) 'eksh4 sl-)' -o4 1-\ lea: Vi r1a/,* 4b"'41,con L--2) 055� EMAIL P HONE# FEDERAL ID# Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form (provided herein). Signature 6�(rd�\ / Date Q:\Application Forms\TOBACCO APP2019 dob.docx H ESTABL NT'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 g g p of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Sign tare Printed Name Date Si Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Applicarion Forms\TOBACCO APP2019 dob.docx °p IHE r°� TOWN OF BARNSTABLE HEALTH.INSPECTOR-s Establishment Name: Date: Page;_ of 4 OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �p 639,p 0� HYANNIS,MA 02601 .. - M-8 -FRI.62-4644 No Reference R Red Item - PL SE PRINT CLEARLY , tF0 MP'� 508-8 FOOD ESTABLISHMENT INSPECTION REPORT Name �: I V�L l Dal 1 e o Type of Inspection Iv- ( a 1 ration(s) Routine Address - Risk Food Service e-inspect" Level etail nspection Telephone ential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors Red Items)) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals. FOOD FROM APPROVED SOURCE 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(H P) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP LIDS ( ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories I Violations Related to Good Retail Practices(Blue Itemsl 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 checked indicate violations of 105 CMR 590.000/Feder, El Embargo El Emergency Closure ❑ Voluntary Disposal ❑ Other: al 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 B-One critical violation and less than o 6 non-critical violations von-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to =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.7to 8 than i non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 violation,4 to 8rion-criticall violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature, Print: 31.Dumpster screened from public view f/� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N V� Frozen Dessert Machines: Outside Dining PIC' Signature Print: #Seats Observed 9 Y N 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 - PHF Hot and Cold Holding Contamination from Raw Ingredients 15 _ Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 890:004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* * 7-201.11 Separation-Storage* 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 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* 4-501111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* - 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. L16 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-OFF 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* Eu°1-Jni2o01 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces of Equipment* Shellfish* 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* Proper,Adequate Handwashing ing,mobile food,temporary and residential 10 Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 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* 3-403.1](B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 * (Blue Items 23-30) 3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne . 12 Prevention of Contamination from Hands 3-101.11 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* 1t3 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* _ 8-103.12 Conformance with Approved Procedures* S:590Fonnback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. iNE roh, TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date: Page: of ti OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:M N. F P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 6 508-8 -62-4644 p , ,p�m� HYANNIS, MA 02601 RI No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION rFD MP'� REPORT 8-8 �' Name ( Date e f T s ction era io s outine Address Risk ce spection Level Previous Inspection Telephone Resien Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) ( �^ Time Bed&Breakfast o HACherCP In: Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ _ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands �° (_ e ❑ 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 _ i ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals , FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) VAA ❑4..Food and Water from Approved Source ❑ 16.Cooking Temperatures r, ❑ 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 T1429 _ ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) J ❑ 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 Itemsl 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. g I Otoday, Voluntary Compliance ❑ Emp estri xclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on insI 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 (FC-4 590.005 B=One critical violation and less than 4non-critical violations 9 )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of t 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dump er screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y NA(AN ' i #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature I Print Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N 1' Violations related to Foodborne Illness - Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 142) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 31202.12•- 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 P 590.004(F) * - 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 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* Applicants* j -3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 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* 3-304.11 Food Contact with Equipment and Utensils* - - - 590.004(11) Variance Requirements - 590.003(G) -Reporting by Person in Charge* I - Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions, Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 ' Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* _ `- 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* ! 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* - Sanitization Temperatures* - _ - TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-40L11A(1)(2) Eggs-155°F]5 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.1](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* Eg°i-11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 ' Frequency of Sanitization of Utensils and Food * 3-201.14 Fish and Recreational] Caught Molluscan' * t 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec Y g Contact Surfaces of Equipment Shellfish*' ' ' 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g 590.009(A)-(D) Violations-of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 1 p Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under 2-301.11 Clean Condition-Hands and Arms* 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* f r 2-30.1.12 Cleariirig Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-01.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail * 11 Good Higienic Practices practices should be debited under#29-Special 3-201.17 Game Animals 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 - Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 PreventingContamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,*which do not relate to the foodbome * 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* 3-101.1] Food Safe and Unadulterated �) S 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 3-202.18 Shellstock Identification*- 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 1590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1.009 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 114E r TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30.A.M. BARNSrABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified � ,Ass.a (A HYANNIS,MA 02601 M-862 4644 N.-FRI. NO Reference R-Red Item_ PLEASE PRINT CLEARLY p 39•p. 508-8 'FON1P� FOOD ESTABLISHMENT INSPECTION EPORT Name l\ �� Dat ef e of In ectio Ro 'Address Ris e-inspection ` Level C. a ail Previous Inspection Telephone esidential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) Ci,Q el A �az�F A 4 ❑ 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) ❑ b j ` 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 _A_ ❑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 Asa 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 c ❑ 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. j 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 (FC73)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than non-critical violations 9 26.Water,Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. violation,4 to 8von-critical violations C. 29.Special Requirements (590.009) within 10 days of receipt of this order. = 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view ZIA 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 6 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 Interventio►is 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) Asignment of Responsibility* 8 Cros3-contamination 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) JDesr onstration 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.* t * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - -- - - - - 3-302.14 Protection 14orii Unapproved Additives - Contamination from Raw Ingredients 15 Poisonous&r Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) * EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information=•Original Containers* 2 Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*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 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* 3-304.11 Food Contact with Equipment and Utensils ( ) Variance Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Requirements 590.003(G) Reporting by Person in Charge*- - - - -- - - - Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g � ) Disposition of Adulterated or Contaminated - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 . Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use.Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-11) 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 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 Fiom 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* Efect-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 I- Shellfishand_Eish From an Approved Source _ _ 3-401.11(B)(1)(2) Pork and Beef Roast-1 155 121 min Eggs* 4-702:11 - Frequency of Sanitization of Utensils and Food' 3-401.11(A)(2) Ratites,Injected Meals- 55°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* - . Shellfish* - ' - '' 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Mopuscan Shellfish from NSSP Listed- _Chemical* Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved-By- _ 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clear?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* 5 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* _ _ 3-40L11(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. 5 Receiving/Condition 1=, 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 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 3-003.11(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 3-202.12 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:FisMProducts 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* 5-204.11 Location and Placement 3-501.14(B) Cooling * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 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* 30. 1 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. f of Barnstable -'THE T°� !1�own Barnstable ti Regulatory Services Thomas F. Geiler, Director edcaC EA MASfA %BLE, * Public Health Division R� Thomas McKean,Director Zoos 200 Main Street Hyannis, MA 02601 Office: 508-862-46414 Fax: 508-790-6304 'January 13, 2009 Mr. Naresh Thapa Village Mini Mart 135 Route 149 Marstons Mills, Massachusetts 02648 Dear Mr. Thapa: Enclosed is your check number 792 in the amount of$50 for the tobacco permit for your establishment. You had previously paid $150 ($100 for retail establishment and $50 for tobacco permit). If you have any questions,please feel free to contact me. Very truly yours, Ellen J. Wadlington, Division Assistant / August 2019 RE: CBD in Food Products Dear Business Owner, The Health Department has recently received many inquiries regarding the sale of cannabidiol (CBD) and CBD infused food products in restaurants and retail stores. In order to educate ourselves and local businesses, we have done substantial research on this subject and would like to inform you of the most current information and potential next steps. The Federal Food and Drug Administration (FDA) has concluded that federal law prohibits the addition of CBD to food products due to the fact that CBD is an active ingredient in FDA approved drugs. In a document released in April 2019 titled FDA Cannabis and Cannabis-Derived Products:Questions and Answers they state clearly that their agency has "concluded that it is a prohibited act to introduce or deliver for introduction into interstate commerce any food (including any animal food or feed)to which THC or CBD has been added." Similarly, in June 2019 the Massachusetts Department of Public Health (MDPH) released information on CBD products in food (for your reference, please find this informational sheet enclosed) reiterating the FDA's position on the subject, stating that "since CBD is not an approved ingredient under federal law, it may not be added to manufactured foods." According to both the FDA and MDPH hulled hemp seeds, hemp seed protein and hemp seed oil are exempt from federal prohibitions. In Massachusetts,these products can be legally added to human food and sold at retail provided they comply with all other requirements. This letter is to inform local businesses of the above, and advise you to consider the information prior to engaging in the sale of food products containing CBD or other unapproved ingredients. Enforcement action may be implemented in the near future by the FDA, MDPH or your local board of health.The Health Department will provide further information as it becomes available. Please feel free to contact the Health Department with any questions or comments. Sincerely, References: https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-deriver,_ products-questions-and-answers https://www.mass.gov/info-details/cbd-in-food-manufactured-or-sold-in-massachusetts C:\Users\crockersh\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\K266YKRV\CBD Letter DRAFT 2019-8-06.docx