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Home My WebLink About19TH HOLE, THE - FOOD 19th HOLE, THE :11 Barnstable Rd.Hy Town of Barnstable BOARD OF HEALTHJohnT. Norman Board of Health Donald A.Gaudagnoli,M.D. RARNSrAase,�. : F.P.(Thomas)Lee,. IMAS& Daniel Luczkow,M.D. Alt. 4ys• �. 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: 217 Issue Date: 01/01/2022 DBA: NINETEENTH HOLE OWNER: C& D SHAMROCK, INC. Location of Establishment: 11'13ARNSTABLE ROAD HYANNIS„ MA 02601 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 119 OutdoorSeating: 0 Total Seating: 119 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: an FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent i FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE I Restrictions: For Office • Initials: . ' a.� Town of Barnstable — ��$ Date Paid Inspectional Services MASK 9�� Public Health Division Check# 6[d 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 t17� NEW OWNERSHIP RENEWAL X NAME OF FOOD ESTABLISHMENT: l q**��p lc-T"aver n ADDRESS OF FOOD ESTABLISHMENT: K-1 j4maAniz> MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ABOVE)nn: E-MAIL ADDRESS: [C� l p Ie,--� rn 1, G maj, . C.6Y11- TELEPHONE NUMBER OF FOOD ESTABLISHMENT: S( � - glod TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NOV ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: _ SEASONAL: DATES OF OPERATION: TO _/1)), NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) IXFOOD 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 508-8624644 Q:\Application FormsTOODAPP 2020.doc T OWNER INFORMATION:FULL NAME OF APPLICANT -Daf i SOLE OWNER:(AO/NO DU OB q'��' OWNER PHONE# ADDRESS /T I—A-d-,L I,Q A.A.A4pi U CORPORATE OWNER: 0 ✓-C y —TrG, CORPORATE ADDRESS: 1 U)CV A f ,Ljl PERSON IN CHARGE OF DAILY OPERATIONS: 1,� Cam ^ 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. 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.3151 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 f s Town of Barnstable BOARD OF HEALTH '~ John T.Norman Board of Health Donald A.Gaudagnoli,M.D. WNSTaUM Paul J.Canniff,D.M.D. 200 Main Street Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: 508 862-4644 Fax: 508 790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 30513, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 217 Issue Date: 01/01/2021 DBA: NINETEENTH HOLE OWNER: C & D SHAMROCK, INC. Location of Establishment: 11 BARNSTABLE ROAD HYANNIS„ MA 02601 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 119 OutdoorSeating: 0 Total Seating: 119 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: t� Town of Barnstable For Office Use Only: Initials: ��. r° - Date Paid Amt Pd$ 800— MASS. Inspectional Services 9M V� a 94' ' Check#� `�� Public Health Division ArED MAC Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE / NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: tie1M ADDRESS OF FOOD ESTABLISHMENT: S Re dP &)J6-')1 MAILING ADDRESS(IF DIFFEREiNT FROM ABOVE): f q E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (=ua )77 - TOTAL NUMBER OF BATHROOMS: WELL WATER: YES NO_.,, ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: --vim SEASONAL: DATES OF OPERATION:JILl,�(TO /3( /�r) NUMBER OF SEATS: INSIDE: Jli OUTSIDE: -10 TOTAL: 7 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? Nle.t 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 J• 1i R r , OWNER INFORMATION: FULL NAME OF APPLICANTav /NO D.O.B o9 a'3r 9(6 OWNER PHONE # SOLE OWNER: 0ADDRESS J.f Q�ftLfk 6; RayeipW e� k)" e4-66 f CORPORATE OWNER: 4 t0 CORPORATE ADDRESS: 9 9 14ml)�fqko�6cl PERSON IN CHARGE OF DAILY OPERATIONS: D(U0h/- ' w'/I Jzt,, 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 Axpiration Date Allergen Awareness Expiration Date �G11oi�y� f/ c�3 1. V v`�✓`fi Gl lY l�� 2. VV 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 oaenine!! 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/apl)lications.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.31'each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BaMNsztAO F.P.(Thomas)Lee 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 217 Issue Date: 1/1/2021 DBA: NINETEENTH HOLE OWNER: C& D SHAMROCK, INC. Location of Establishment: 11 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 -�Q' Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY For Office Use Only: Initials: Town of Barnstable $ _ Date Paid Amt Pd � - inspectional Services 1' BARNSURM �•� Public Health Division �'1eCk — - � — rfa tips" Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMEN..T.....PERMIT.APPLICATION(Non Flavored) DATE �,. - NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: I Q IaVe ADDRESS OF TOBACCO ESTABLISHMENT: 4C44 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 3 E-MAIL ADDRESS: e 1�i/dl TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: C-2ij i OWNERS NAME:, OWNERS PH# D.O.B —� OWNER'S ADDRESS: �]' �! ��`rf-C- a- CORPORATE NAME: hain"a/1 CORPORATE ADDRESS: CORPORATE FID# ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) . TOWN OF BARNSTABLE.CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httos://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: httos•//male=islature Gov/Laws/GcneralLaws/PartIV/TitleI/Cha:ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY;'** s 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 S: SIGNATURE: 01 PRINTED NAME: t►J DATE:. QAApplication Forms\TOBACCO APP-NonFavor 12-18-19.docx L ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—5 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: ? r : w Signature Printed Name Date TIA Signs_ e Printed Name Date is S" nature Printed Name Date . f Si ature Printed Name Date lA 1A Iiu ., !� ignat rePrinted Name ate AJrle 9 pp Signature Printed Name Date Signature Printed Name Date y_ i. Q\Appfication Forms\TOBACCO APP-NonFavor 12-18-19.docx L 4 '0-If£F Commonwealth of Massachusetts O'O Letter ID: L0916863296 Department of Revenue Notice Date:December 24,2020 1 , Geoffrey E.Snyder,Commissioner Account ID:CGL-11903362-007 �FvTc7��E mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES C&D SHAMROCK INC 19TH HOLE —_ 1 l BARNSTABLE RD ° HYANNIS MA 02601-5523 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line and display at your business location. At any time, you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license, call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ----------------------------------------------------------------------------------------------------------------------------=-------------------- `ss'` s��T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 1, i 1 Retailer License for Sale of Cigarettes ,A F;� � This license must be posted and visible at all times. The sale of tobacco products to anyone under 21 years of age is prohibited. C & D SHAMROCK INC Account ID: CGL-11903362-007 19TH HOLE License Number: 2025949184 11 BARNSTABLE RD HYANNIS MA 02601-5523 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: December 24, 2020 Expiration Date: September 30, 2022 Town of Barnstable' . , BOARDOFHEALTH John T.Norman Board of.Health Donald A..Gaudagnoli,M.D. Paul J.Canniff,D.M.D. iW - F.P. Thomas Lee Alternate .era 200 Maim 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: 217 Issue Date: 12/10/2019 DBA: NINETEENTH HOLE OWNER: C& D SHAMROCK, INC. Location of Establishment: 11 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 119 Outdoor5eating: 0 Total Seating: 119 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR: 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: '12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: � ) MOBILE-ICE CREAM: Q/ FROZEN DESSERT: Thomas A. McKean, RS,CHO, Health Agent -TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: 1 r For Office Use OWY. Initials: "�' ti Town of Barnstable � � C Q Date aid l 13 Amt Pd$ J Inspectional Services P ' i639' `` Public Health Division Ida �fDMA�A Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 ' Office: 508-862-4644 Fax: 508-790-6304 •' APPLICATION FOR PERMIT TO OPERATE AFOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL X NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: (� MAILING ADDRESS(IF �(�A DIFFERENT FROM ABOVE): 6�VL- E-MAIL ADDRESS: T "4-V6cvvv'l�C�'1'1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 69—J _- 104 TOTAL NUMBER OF BATHROOMS: d' WELL WATER: YES_NO V ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:�� SEASONAL: DATES OF OPERATION:_LL't-al TO NUMBER OF SEATS: INSIDE: U—IL 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?j_ 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 QAApplication FormsTOODAPP 2020.doc OWNER INFORMATION: D FULL NAME OF APPLICANT SOLE OWNER: YES/NO D.O.B OWNER PHONE # ADDRESS —ry Grp Pt CORPORATE OWNER: � � GAG 6Gd CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: %lti List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. 4in 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 openina!! 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 Ist to Dec.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC Ist. Q\Application FormsTOODAPP REV3-2019.doc BOARD OF HEALTH Town of Barnstable John T.Norman Board of Health Donald A.Guadagnoli,M.D. -BAP_-N8T"k8Lr' " Paul J.Canniff,D.M.D. MAC° F.P. Thomas Lee Alternate '16 16 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 217 Issue Date: 1/1/2020 DBA: NINETEENTH HOLE OWNER: C & D SHAMROCK, INC. Location of Establishment: 11 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual �_ Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: i PLEASE POST CONSPICUOUSLY �vl 7 („ of For Office Use Only: Initials: �- tr�' Town of Barnstable Inspectional Services Date Paid Amt Pd$ 39. = p ISao P i639� �•� Public Health Division Check# A�fD A1A'�A _ Thomas McKean, Director r�. 200 Main Street, Hyannis, MA 02601 =' Office: 508-862-4644 Fax: 508-790-6304 . TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE 13"� NEW BUSINESS OWNERSHIP RENEWAL, NAME OF TOBACCO ESTABLISHMENT: e-1-0 A6AaW, vrnC 9 ADDRESS OF TOBACCO ESTABLISHMENT: / Alkoita MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS:��-I�n�d�P1%Ul�ryy:4y I `(i✓"` TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: Of f 77( OWNER'S NAME: 4k 1kc OWNER'S PH#" - D.O.B OWNER'S ADDRESS: f A U( CORPORATE NAME: L Ct�'dla✓1 CORPORATE ADDRESS: Soi CORPORATE FID# (✓ I fD ANNUAL: 1 SEASONAL: DATES OF OPERATION: / /_ TO DAYS CLOSED EXCLUDING HOLIDAYS(EX. MONDAYS) TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https•//maleizislature.gov/Laws/GeneralLaws/PartIV/Titlel/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY *** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: �r DATE: Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx i �, � �ri • .!Of t, • ��`� .3°. � ,�xr w �► r � �� r' Iz�11 ZO �t .. � 1 pig g fib; t` 4�. iJn tl�4!b� spi•tl ' g 1 loll to ` ten rC� e (i � la i m10�. La a r N Th x aq _ :ate'9 e r 1 NEW 4 f i 1 r � �- Wk�"{F V� �W,,{p , & "/� '(�� k L} "4 }t✓ it it�t41 T, _ a hxxa _ 9 ,x r i KOS w~y^ x�� P tb � vff. 3�. 1..f'i �xnb ..�U. I ��•�i ,� �� ` � WiS k� F v Y r evj h - fil III 11)(111weall h of Mai-sachu-se-tis Let I er ID L Dep-oint-mi of Revenwr Nodcc Date.Scpicwnber 4,20 19 C. Chi istophcr C,IARTding.C0111111iS iVICI- Account ID CG L-I t 903 3 62-4)0", RETAILER LICENSE FOR SALE OF CIGARETTES C 11.�-D 51 'A NC 19'rif lac !% D I I BARNST ABLE 0 HYANN A 0 IS M26P,�-" Attached below is yi-Vur Retailer License f6r Sale of Cigarettes (Form CT-3T). Cut along the dotted line and display at your business location. At awry tirnC, You can log into your MassTaxConnect account at i-ilas;,;.gov?'ni,isstzi,xconiiect to view and re-print as copy of thisficense. If you have any questions about your license, call its at (617) 887-6367 or toll-fine in Massac.husetts at (800.) 392-6089, Nlonduy flu-01LIgh 'Friday, 8:30 a,.m. to 4:30 l,,).rn. DETACH IIERE ------------------------- ----------- ------ ------------------------------------- -----------------------------------------4 --------- MASSA C ITUS ETTS DEPkirrimENT OF' REVENIJE Form CY-Y I Retailer'License for Sale ol'Cigarettes This license must be posted and visible at all times. The sale of tobacco products to anyone under IN years (if age is, prohibited. C & D S>H.ANI.RO(K INC AcCOLItit ID: CGL.-1190..'062-00'1' I 9T 1-1 1-1()1.F License Number: 202877542-1' 1, 1 BARNSTABLE R.D HYANNIS NIA 02601-5523 This Certifies that(he taxpayer named above is licensed under Chapter 64C of the Nlas-sachu-setts General L.aws to sell at retail at the address shown,above, This license is non-transferable aild may be Suspended or revoked for failure to comply with state I-aws and regulations. Effective Date: October l, 20B Expiration Date: September 30, 2020 1/1312020 Mass.Corporations,external master page � ,�jx')` p�;� E .4�k�t.'F'�'t�F „rt „'kg;4 s'�> �( a ^.' "Y t "'9+#9'',"Sva� •;°�i��. i ' ask' .rw^ ; ', { • raw.. 'Swix4 i (rr L�M,L}',r 4k t' Y 1{. .f . ;,i .. ,.r.,...,wc ;.,a. wse.;:TYq.�+'t-.,t„"'�4.rn� .. cic"kS"`: w.°,,...;: S.w,. ^^3�a—'.-»:''+: ,d..-.t�;=',.3.. `=-•i--,—.. Corporations Division Business Entity Summary ID Number: 043313180 Request certificate New seearch.l Summary for: C & D SHAMROCK, INC. The exact name of the Domestic Profit Corporation: C & D SHAMROCK, INC., Entity type: Domestic Profit Corporation , Identification Number: 043313180 Old ID Number: 000535916 Date of Organization in Massachusetts: 05-02-1996 Last date certain: Current Fiscal Month/Day: 12/31 Previous Fiscal Month/Day: 00/00 The location of the Principal Office: Address: 11 BARNSTABLE RD. City or town, State, Zip code, HYANNIS, MA 02601 USA Country: The name and address of the Registered Agent: Name: DAVID F. CRONAN Address: 55 BILTMORE PLACE City or town, State, Zip. code, WEST BARNSTABLE, MA 02668 USA Country: The Officers and Directors of the Corporation: Title Individual Name Address PRESIDENT DAVID CRONAN 55 BILTMORE PLACE W BARNSTABLE, MA 02668 USA TREASURER CHRISTOPHER DOHERTY 15 DENVER DR C-4 W YARMOUTH, MA 02673 USA SECRETARY DAVID CRONAN 55 BILTMORE PLACE W BARNSTABLE, MA 02668 USA DIRECTOR DAVID CRONAN 55 BILTMORE PLACE W BARNSTABLE, MA 02668 USA DIRECTOR CHRISTOPHER DOHERTY 15 DENVER DR C-4 W YARMOUTH, MA 02673 USA Business entity stock is publicly traded: ' corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=043313180&SEARCH_TYPE=1 1/2 1/13/2020 t , _ + Mass.Corporations,external master page m The total number of shares and the par value, if any, of each class of stock which =this business entity is authorized to issue: „ F Total Authorized Total issue;and otutsta�ir�inr� Class of StockPar value per share Ne. of shares Total p,4r' No. 6f shares vain CNP $ 0.00 200,000 $ 0.00 200 q. , `a4 a Confidential - Merger _. Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS .' Administrative Dissolution Annual Report-, Application For Revival Articles of Amendment ' ! •� View fil g '- • . .� f, h Comments or notes associated with this business entity: ##9 New sea rch ,. core.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=043313180&SEARCH_TYPE=1 2/2 Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. rt Board of Health Donald A.Gaudagnoli,M.D. Dn 'STnaLL t John T. Norman Q Hyannis MA 02601 F.P. Thomas Lee Alternate 200 Main Street, , Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 30513, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 217 Issue Date: 12/20/18 DBA: NINETEENTH HOLE OWNER: C& D SHAMROCK, INC. Location of Establishment: 11 BARNSTABLE ROAD HYANNIS MA 02601 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 119 OutdoorSeating: 0 Total Seating: 119 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: ------ - - MOBILE- FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 I FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE i--- I Restrictions: THE • Initials: Town of Barnstable Date Paid ( Amt Pd S3 _ �BARNEMA MAS& Inspectional Services �' P i63q. `0 ,elFp�`�s 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 FOOJ>ESTABLISEMENT DATE NEW OWNERSHIP RENEWAL 11 fit NAME OF FOOD ESTABLISHMENT: LE ROAD ADDRESS OF FOOD ESTABLISHMENT: 1a4 h pZgp1` MAILING ADDRESS(IF DIFFERENT FROM ABOVE): JC E-MAIL ADDRESS: AA (i�) ,1< a D(9,,�i , (� 4A , TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BAT OOMS: WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: Zl SEASONAL: DATES OF OPERATION:J/J/ 17TO NUMBER OF SEATS: INSIDE: OUTSIDE: Z 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)9 0 TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FormsTOODAPPREV2018.doc ;S PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT ,/ Q SOLE OWNER: YES NO, D.O.B OWNE PHONE # / w p � � ADDRESS �/✓(J U� �, �j � CORPORATE OWNER: A)P FEDERAL ID NO. : CORPORATE ADDRESS: NMI) 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 Chess -AN _ a� 1 R 1. 5 / / 1. 2._ j?4'- ,� SIGNATURE dF APPLIC DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1st to Dec. 3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1 st. Q:\Application FonnsTOODAPPREV2018.doc of twe r �, Town of Barnstable For Office Initials: $ Inspectional Services Date Paid Check 9 * E"NSTABM MASS. 01 Public Health Division qllq Oar[ 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Heald z 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 T APPLICATION FOR A TOBACCO SALES PERMIT ESTABLISHMENT NAME (DB/A) ADDRESS OF BUSINESS MAILING ADDRESS (IF DIFFERINt FROM ABOVE) - --OWNER'S NAME:--L-AS --FIST— MIDDLE----- ---DAT F b3i _------ --- Amh& 6OPH04A, 3L— EMAIL FEDERAL ID# Do you cu7��No ss a state license to sell tobacco products? Yes 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:(pro ided Signature ate 1 Q:\Application Forms\TOBACCO APP2019 dob.docx ESTABLISHIVII;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 of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: 164 1-11, , "La -Y Signature Printed NanTd Date 3j Printed Name Date Sign Printed Name Date Prin e' ame Date 1/49—J Illollq Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP2019 dob.doex oFVK4F TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: (r(/ Page: of q. OFFICE HOURS P °\ 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 9�a .6}9: 00a HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY < 508-8624644 0. FOOD ESTABLISHMENT INSPECTION REPORT t Name Date Type of jXn&AInspection p outi Address Risk'/ od Servic spection Level ai Previous Inspection77 .�- Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint 0 Person in Charge(PIC) Time Bed&Breakfast HACCP Idg Ad 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) A ^10 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 r4lE`y 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 Foo ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures i ❑5.Receiving/Condition ❑ 17.Reheating L ❑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 v ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE P PULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY t ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violation Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: o Y Non-critical(N)violations must be corrected immediately or Overall Rating ��J , within 90 days as determined by the Board of Health. �{ (�-{ ❑ Voluntary Compliance ❑ Employee Restriction/Exc usion ❑ Re-inspection Scheduled ❑ Emerg ncy Suspension C N Official Order for Correction: Based on a ins ection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4non-critical violations g )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically o la 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 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 anon-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatu a 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* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 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 * 590.004(F) 7-101.11 Identifying Information-Original Containers 2 590.003(C)- Responsibility of the Person-in-Charge to Other* 7-102.1 l 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 Separation-Storage* 3-501.16(A) Roasts Held At or Above 130°F* 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* * 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food 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* 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* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(I)(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 Eggs 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* �-��'��Ve t�t�2nni 590.006(B) Water-Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(I)(2) Pork and Beef Roast-130°F 121 min* s 4-702.11 Frequency of Sanitization of Utensils and Food * 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec* Egg Shellfish* 4-703.1 I Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 15 sec* in mobile food,temporary and residential 10 Proper,Adequate Handwashing g• P Y 3-401.11 C 3 Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 17 Reheating for Hot Holding 11 Good Hygienic Practices practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. g Receiving/Condition g, g g 3-403-11(A)&(D) PHFs 165°F 15 sec 3,202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* F 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* i 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 * 3-501.14 B Cooling 3-402.11 Parasite Destruction* 5-204.1 I Location and Placement ( ) €PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 5-205.11 Accessibility, Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* Operation and Maintenance Supplied with Soap and hand Drying Devices Within 4 Hours 2 . Water,Plumbing and Waste FC-5 .00 590.004(J) Labeling of Ingredients` 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Mated als FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. `Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. �F114E r TOWN OF BARNSTABLE. .. HEALTH INSPECTORS Establishment Name: Date: Page: of W OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ;'bsq: `0$ HYANNIS,MA 02601 MON.-FRI. No Reference R Red Item PLEASE PRINT CLEARLY ,rf, �+e, 508-8624644 FOOD ESTABLISHMENT INSPECTION REPORT wr Name f Dat Tyne of Tyoe of Inspection 41) 91 p Routine Address Risk ood a Re-inspection Level a ai Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast H In: her Inspector Out: L 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) WV Ovill 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 AL ❑3.Personnel.with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potenti y Hazardous Foo ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating f ❑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 C ntrol ❑8..Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY USCEPTIBL L S(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparati n for HSP , ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advi vies Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violat s Critical(C)violations marked must be corrected immediately. (blue&red items) 1 ., Corrective Action Required: ❑ No I ❑ Yes Non-critical(N)violations must be corrected immediately or rl Weitems within 90 days as determined by the Board of Health. Overall_Rating `n�r)t� ❑ Voluntary Compliance"1 I�J�JJ ry p ❑ Employee Rest riction/Exclusion ❑ Re-inspection Scheduled ® Emergency Suspension C N Official Order for Correction: Ba ed on an inspection toda Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. ® go ❑ 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 4npn-critical violations g )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of )( ) 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 = 29.Special Requirements. (590.009) within 10 days of receipt of this order. violation,4 to 8npn-critical violations C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N MAI #Seats Observed Frozen Dessert Machines: Outside Dining y N PIC's ignature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N (/ Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 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 590.004(F) EMPLOYEE HEALTH,_, 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* g3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g * 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR- 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(3) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* ' Raw Seed Sprouts Not Served P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME(rEMPERATURE 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(l)(2) Eggs-155'F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145F 15 sec Equipment ° * Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meals&Game Pathogens* ef/crroe;nnoo; 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 Surfaces of Equipment* 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 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* foodbome illness interventions and risk factors. C ( ) 590.004 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 L7 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g• g g 3�03.11(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 Commerciall Processed RTE Food-140°F* (Blue Items 23.30) 3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the g Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 ti 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: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 Supplied with Soap and hand Drying Devices Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 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. ;,4 OF 114E►per TOWN OF BARNSTABLE, _ HEATH INSPECTORS Establishment Name: Date: _ Page: . of •^yip.-w}�` q. PUBLIC OFFICE HOURS - BARNS'rABLE,O` PVB2 0 MAN STREET SION - 3:00- :30 A.M..M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:3030-4:30 P.M. A ,619. -8s2 s�0� - HYANNIS, MA 02601 - - M -FRI. No Reference R-Red Item - - PLEASE PRINT CLEARLY _ 50a-a �saa FOOD ESTABLISHMENT INSPECTION REPORT Name Date one of Tyoe of Inspection O e Routine Address Risk F �section r Level Retail Prevlou- s Inspection Telephone Residential Kitchen Date: x 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: s Aa� A - Each violation checked requires an explanatio 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) ❑ _TD ye- 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 PULATIONS(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 1b �3 � 1q Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) i Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal - ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health..Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4npn-critical violations g )( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26:Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 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 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 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 violation,4 to 8npn-critical violations=C. - 29.Special.Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signatur . Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y: N Dumpster Screen? Y N N , Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11. Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working 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 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* Requirements * 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Re q 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g � ) Disposition of Adulterated or Contaminated ` Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization 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. 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 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* Effective 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 4-702.11 Frequency Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 9 Y of Sanitization of Utensils and Food 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* Shellfish* 4-703.11 Methods of Sanitization-Hat 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- Sources* 10 Proper,Adequate Handwashing Ratites-165°F 15 sec* ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under 2-301.11 Clean Condition-Hands and Arms the appropriate sections above if related to Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave 9 rY tY 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* g g 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should he 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 PreventingContamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity* g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1I3 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock.ldentification* 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 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs.Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 * 5-205.11 Accessibility,Operation and Maintenance 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 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 THE ro TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date: ,Page: Of .. -{. 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 9 MASS. HYANNIS,MA 02601 5 08-808-8 -FRI.62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY �, +a3q•s 'F FOOD ESTABLISHMENT INSPECTION REPORT Name Dateq111 Tyne of T ns ec ion r r�►� rati n outine CI� I r� Address Risk tWod Se ion ��l��l Z)tl Level ai Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP P 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) ❑ _ V` Action as determined by the Board of Health. Allergen Awareness _ 590.009(G) c FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities b� EMPLOYEE HEALTH PROTECTION FROM CHEMICALS I` ❑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 TIMEfrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ L� 5.Receiving/Condition ❑ 17.Reheating `� \ s ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding nY��`� L PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control k.�' 1718.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP \�� 4t ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORYO vf ❑ �AJ* I 11.Good Hygienic Practices ❑22.Posting of Consumer Advisorie Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violatiorf� �y� (� Critical(C)violations marked must be corrected immediately. (blue 8+red items) VI at l "1 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/Federal Food Code. Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. 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 back-up,C=2 critical violations and less than 9 non-critical. If no critical water,sewage 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must p,infestation of rodents or insects,or lack of violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8non-critical violations=C. 29.Specia equirements (590.009) within 10 days of receipt of this order. 30.Ojuej DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: 1 Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of'Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 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 Anima]Foods Separated from Each 7-101.11 Identifying Information-Original Containers*Other* 590.004(F) 590.003(C) Responsibility of the Pelson-in-Charge to 7-102.11 1 Common Name-Working Containers* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* 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 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 Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and * 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* I 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(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate Equipment ( )( ) Pathogens*590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * Effective 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) 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 see* 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 1] Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 3-202.11 Package Integrity Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3 403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 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* * 23. Mana ement and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours 9 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* 126. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 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 1b5 CMR 590.000. oFVE roi TOWN OF BARNSTABLE HEALTH INSPECTOR•s Establishment Name: Date: Page: of y OFFICE HOURS P ° PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 MON.-FRI.as2 asaa No Reference R-Red Item PLEASE PRINT CLEARLY 508 FOOD ESTABLISHMENT INSPECTION REPORT - Name Date ky e of Tvoe of Inspection e Routi Address Risk od Service -Ins Level vlous Inspection Telephone , Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness L .� Caterer General Complaint Person in Charge(PIC) a Bed&Breakfast HACCP Other Inspector ut: 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 5 ^•`*��"�1/ EMPLOYEE HEALTH PROTECTION FROM CHEMICALS C` ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 12 C A-V ❑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 Q 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 HSIt, ❑ 10.PropefAdequate 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) O 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. III ❑ 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) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 6.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6von-critical violations=B. Seriously.Critical Violation=F is scored automatically if: no hot 2 2 .Physical Facility (FC- )(590.007) aggrieved a 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 anon-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 Signature Print: 31.Dumpster screened from public view 4/15 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N P's Signatre Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N �v 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* a Cross-contamination 14 Food or Color Additives Law Cooled to 41'F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Chazge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH e 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 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* 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 Re uirements 590.003(G) Reporting by Person in Chazge * 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 Reated or of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) I Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEIrEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155'F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145'F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System * gg Not Otherwise Processed to Eliminate Equipment 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective rarzooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.l l(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* Sources* 10 P Ratites-165°F 15 sec* ing,mobile food,temporary and residential Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Mid 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-145'17 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. radicssho ld be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165'F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23.30) 3-102.11 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140'F to 70'F 3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41'F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 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 lConformance 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 IMF r° TOWN OF BARNSTABLE . . HEALTH INSPECTORS Establishment Name: A t/ne,,4 7R tT73 Date: Page;._�of OFFICE HOURS BAR E. PUB2 0 MA N HEALTH DIVISION 8:00-9:30 A.M. 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 rFO MPS FOOD ESTABLISHMENT INSPECTION REPORT ► a G, Name Date Tyne of T ea Inspection I '? Oggration(s) u °/ Address 1 Risk o6d ervice Re-inspection `� Level Retail Previous Ins ection J' - �f Telephone Residential Kitchen Date:(;/3,, 7 d, Q Mobile Pre-op ratYn y°1 Owner HACCP Y/N Temporary Suspect Illness t P Caterer General Complaint -36 Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector a7lout: ` H / Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Ll D c f 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) ❑ CI q / Action as determined by the Board of Health. Allergen Awareness 590.009(G)� FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands t/ oo °` rP r' [it ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities , EMPLOYEE HEALTH PROTECTION FROM CHEMICALS CIO ❑ 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) a(� ❑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 ( � 92 IV PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) L ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP lA ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY LO ❑ 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 e ees Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. v I ` �� ❑ 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. ob s if no critical violations observry 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 e than o 6 non-critical violations re 9 than 4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. . If 1crrtic water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed 7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation no - itical violation C. - 30.Other PATE OF RE-INSPECTION: Inspector';;Signat P' 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 Sig 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)+De-m, signment of Responsibility* 8 Cross-contamination 14 Food or.ColorAdditives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) nstration 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.* * 19 PHF Hot and Cold Holding g 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F - 590.004(F) *- EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* g7-102.11 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(.4) 7-201.11 Separation-Storage*Food Protection* P g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use*An 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)Resumed Food and Reservice of Food* REQUIREMENTS FOR, 590.003(E) Disposit Removal of Exclusions and Restrictions ion of Adulterated orContaminated 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 Regu/ated'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 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 1 Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* - Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved gg Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eH-eNe rorzoor 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g �' 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By - 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* --_ 3-403.11(B) Microwave-165°F me 2 Minute Standing Ti * 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 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 * 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. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 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. MAR-3-2011 16:04 FROM:HYANNIS TRANSMISSION 5087718801 T0:15087906304 P.1/7 Mir w APPU@D COAMS BAKED ON COATINGS 104 lcAP WRIST RaAV RYANNI'S.,44 02601 sob-771.8830 OFFZCl; 508-367.8822 CELL Attention:Mary Beth Regarding:The 1911-Hale Restaurant Kitchen floor and seamless Rr,or installation These are the data sheets thatwere requested for the 194h Note R4sttturant Wnrk completed In the Barnstable area: + Barnstable School Coolers ■ STK 5teakhouso(rear kitchen and Z bar floors) • Scotties Pizza(rear kitchen&cooler) ■ Blue Moon Sisva Any questions or concerns plowe feel free to contact me at 508.367-8822 cell or$00-771.8830 Sincerely, Chris Van Gelder c� MAR-3-2011 16:04 FROM:HYANNIS TRANSMISSION 5@87718801 T0:15087906304 P.2/7 CUSTOM COATINGS ��Xd APPIJ90 COAMOS 104 ENTERPRISE ROAD BAlICDON COAZINc5 HYANNIS, MA 02601 508-367-8822 TECHNICAL_QATA WQRKSHET .QESCRIPTION: The vortex material developed by Vortex Applied Liners, Inc,compromises of a Plural Component, Polyurethane/Pleurae blend base component with a low viscosity,non- temperature sensitive isooctane catalyst formulation. Vortex and Granitex materials meetthe guidelines set for FDA/USDA applications for incidental food contact which is certified by the manufacturer. The unique exclusive cross linking blend of materials results in an incredibly durable surface coating of extremely high impact resistance and durability normally found in very expensive pleurae blends normally 4-8 times the cost. High chemical resistance,abrasion resistance and wear ability lead to a long lasting industrial coating known as Vortex. USES: Sealing of rubber boots used in fiberglass sumps utilized in service station environments, waterproofing and sealing of hard surfaces that have high impact resistance needs and water sealing capabilities. Excellent for the lining of containment ponds, pick up truck beds,steel ranks,pipes,flooring,concrete,fiberglass and virtually any hard surface that needs protection impact,moisture protection and heavy wear. MAR-3-2011 16:04 FROM:HYANNIS TRANSMISSION 5087718831 TO:15087906304 P.3/7 TFCHNICAL_DAJA Hardness of Vortex material Shore 0 Hardness of 55+(ASTM-D2240) Tensile Strength 3,025+PSI (ATSM D638-94B) Elongation 27S%+(ATSM D-412) Tear Resistance Factor 475 PLI(TEAR)(ASTM D624) Flexural Modules(Compaction/Impact Factor) 52,000+PSI(ASTM D790) Abrasion Resistance(Taber Test/Grams Removed) (FIA No. 2,302 and 800) >0.075-250 cycles >0.075.500 cycles >0.14-1000 cycles Impact Resistance/Ft.Lbs. 4.5(ASTM 0256) Impact Resistance/Ft. lbs. -40 F 0.4(ASTM D256) Viscosity Average in Centipoises Scale 371(cps) Color Various Set up time for spray gun Approximately 4 seconds Volatile organic Compounds -0- Percent Solids 100% Flammability(DOT Shipping Reg.)Non-Flammable (OSHA Cade 173.120) Combustibility Non-Combustible (OSHA Code 173.120) Chiorofluorocarbon(CFC)Release None 150 Release from Product <1/100 of 1%by volume USDA/FDA incidental Food Contact Meet Standards Fire Rating(Flash Point)on wet Resin=342 F(172C) Non-Catalyzed material Activator Greater than 230F(110C) MAR-3-2011 16:04 FROM:HYANNIS TRANSMISSION 5087718801 TO:15087906304 P.4/7 CHEMICAL RESISTANCE ACetone C Diethyl Form amide NR Gasoline, Unleaded A Brake Fluid C Methanol A 5% Methanol/Gasoline B Hexane A Hydraulic Oil B Motor Oil B Propylene Carbonate C Sulfuric Acid, Concentrate NR Sulfuric Acid 50% NR Sulfuric Acid 10% B Water A CODE: A= No Damage 6= Little Damage, Discoloration Cm Some Effect-swelling, discoloration, cracking NR= Not Recommended MAR-3-2011 16:05 FROM:HYANNIS TRANSMISSION 5087718801 TO:15087906304 P.5/7 ETHYL ALCOHOL RESISTANCE EMMERSION TEST June 16, 2001 Saturation of Vortex Flex and Vortex Industrial samples into solution of 12.5% concentration of Ethyl Alcohol. Insertion of samples fully immersed @ 2:4S pm 6116/01 3:45 pm No Effect 4:50 pm No Effect June 19, 2001 8:30 am No Effect 11:20 am No Effect 2:30 pm No Effect 5:00 pm No Effect June 20, 2001 8:00 am No Effect The degradation of product, elasticity or flex. MAR-3-2011 16:05 FROM:HYANNIS TRANSMISSION 5087718801 TO:15087906304 P.6/7 QUIESTIONS.AND ANSWERS • How thick is Vortex liners? The average liner is about 1/8 in.thick. Because Vortex Is sprayed using low pressure approximately 10 psi we can build to a thickness of 1 in or more for special applications. • What colors can I get? Vortex has over 200 different colors. • Is this process environmentally safe? The great thing about Vortex Liner Materials is that they are 100% solvent free and even though they are liquid they are considered 100%solids.There is no V.O.C.s or C.F.C.s emitted into the atmosphere. • Can I spray concrete/ cylinder block surface to help seal off moisture? Yes.The Vortex material can be sprayed on virtually any hard surface. Some types of surfaces may require that a sealer be applied first,to lock out certain oils and lock out moisture in concrete. • How strong is Vortex? Vortex can impact resistance to over 50,000 psi. Perfect for industrial and home applications. • What surfaces can be coated with Vortex? Any hard surface such as garage floors, decks, industrial flooring, marine applications, tile floors with dirty grout lines, wood surfaces and much more. r MAR-3-2011 16:05 FROM:HYANNIS TRANSMISSION 5067718801 TO:15087906304 P.7/7 • How long must I wait before I can use my surface? In most cases areas that are not subject to vehicle traffic and do not require UV top coat can be used almost immediately. For services such as garage floors, we recommend that you wait 24 hours. * Is Vortex slippery when wet? No more than a smooth concrete floor, but when wet, it can be a little slippery. In areas that experience a lot of moisture, we can apply 3 different levels of non-skid to eliminate this situation. • How much time is required to complete a job? The time it takes to complete your job depends on the surface we are coating. A new 600 sq.ft. garage floor can be completed in'as little as 2 days where as an old cracked and oil stained floor may take up to S days to complete. • Can you make my old and stained concrete look like new? That depends on how large the cracks are. Hairline cracks when coated with Vortex will not be seen at all.The Vortex material unlike the epoxy coatings will expand and contract with the surface it is applied to. Larger cracks and expansion joints can be filled with our vinyl concrete repair material before coating with Vortex for an almost invisible repair. j 5 f . REF. riRILt� ' I ' ul , y wN F — t . fIN6ALt YIPFo ji-u Aj t' viPro I " A'2.0c AFs4V E -- -' F----------- — ------ ---- �' i cr -�-� (. a I w e -- o'`OPDEIN b •-.: ?': .Pool TA L't c-rY rlc�A lL o-MT . 3p(o ��f Y I II 1. �7 ITA6LE I _ 111 t.Sr:WALI fNIGKN.SS FtR-ST:_:F.t Exiz T coNDITI.QNS rr 3 rK ,� -'%-�°I E.X1.571N� '.CoN171TtoNs . t HY'ANNIS MA . I GRATTAN :GILL, . I ARC+4ITFCT — v° NALL 'rdIcKNE55 Bellaire, Dianna 19. From: 19thholetavern@gmaill.com Sent: Wednesday, December 23, 2020 5:55 AM To: Bellaire, Dianna Subject: Re: 2021 Food and Tobacco Permits- 19th Hole- REVISED LIST SS Dianna all we sell is cigarettes.Thanks. Dave Sent from my iPhone On Dec 22, 2020, at 9:01 AM, Bellaire, Dianna <Dianna.Bellaire @town.barnstable.ma.us>wrote: Is that her name and spelling? That is my spelling and my middle name. That is funny. 1 am waiting for SS from other food manager Tobacco: 1 need copies of MA licenses for cigarettes, cigars and electronic delivery systems. Send in copy of licenses of what you sell and then please reply to this email that states what you DON'T sell and I will make a note for the future. Happy holidays!! Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us The information contained in tbis electronic transmission("e-mail"),irrcktd.ing any attachunent(the"Information"),may be confidential or otherwise exempt from disclosure.It is for the addressee only.Thus Information may be privileged. andd confidential work-product or a prit-ileged and.confidential communication.The Information may also be deliberative and pre-decisional in nature.As such,it is for internal use only.The Information may not be disclosed without the prior written consent of the.Director of public Health and/or the'Town Attorney's Office of the Town of Barnstable.I:.f you have received this e-mail by mistake,please notify the sender and delete.it from your system.Please do not copy or forward it.Thank you for your cooperation. From: 19thholetavern@gmail.com [mailto:19thholetavern@gmail.com] nn Fnn �4 Sent: Monday, December 21, 2020 6:33 PM To: Bellaire, Dianna Subject: Re: 2021 Food and Tobacco Permits- 19th Hole- REVISED LIST Dianna Marie is taking test this week I will email her certificate as soon as it is done. I passed in all cigarette info let me know what else you need.Thanks. Dave Cronan I