HomeMy WebLinkAboutWHOLE FOODS-KIKKA SUSHI - FOOD 1
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Whole Foods-Kikka Sushi
990 Ivannough Rd,.Hyannis
I
Town of Barnstable BOARD OF HEALTH
John T. Norman
Board of Health Donald A.Gaudagnoli,M.D.
¢ARNAaUL. S F.P.(Thomas)Lee,.
MASS Daniel Luczkow,M.D. Alt.
200 Main Street, Hyannis, MA 02601
Ar�B �a Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 1022 Issue Date: 01/01/2022
DBA: , KIKKA SUSHI@ WHOLE FOODS HYANNIS
OWNER: ITO INC.
Location of Establishment: 990 IYANNOUGH ROAD HYANNIS„ MA 02601
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
Indoor5eating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2022
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B- FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Qn
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
f "� /y,C/ ,-X/
/I AN
For Offl.C_e
e.. I • initials:
Town of Barnstable Q
Date Paid O Amt Pd SCM
Inspectional Services
319. Public Health Division check# I3g5�
Thomas McKean,.Director
200 Main Street,14yannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE /30/a0;'4 NEW OWNERSHIP RENEWAL X
NAME OF FOOD ESTABLISHMENT: kIKKA Suslni at Whole F691's 4gom .ts
ADDRESS OF FOOD ESTABLISHMENT: qqo tyaOOUu A �d.Ayann(s , M A oa(o01
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 431 Isis Ave., Ian Iewood , CA 9001Ly
E-MAIL ADDRESS: koodsa jetq @ WrususW.cm \
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: C0%) 41b _ 5900
TOTAL NUMBER OF BATHROOMS: same Qs, WFM
Yin r ix %, *J)
WELL WATER;YES. NO s. :.:.;(ANNUAL'.WATEWANAI VSIS`REQUIREI)) 5°CllY1e Q$ WFM
ANNUAL:. ,,� . j~ • ';; SEASONAL: .- # 'DATES OVOPERATION: / ! TO
NUMBER OF SEATS: INSIDE: OUTSIDE: 0 TOTAL: �
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DIMING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REDUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)'I
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 I_NDUS'fRY(formerly residential kitche:i)
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 FormskFOODAPP 2020.doc
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OWNER INFORMATION:
FULL NAME OF APPLICANT go Inc• diva KIKKA
SOLE OWNER: YES CNJO D.O.B -_ OWNER PHONE# 310 _64,2 -1863
ADDRESS_ 43I ISIS Ave , Ino)lewooO , Ch go3o I
CORPORATE OWNER: Tonnu SoesavitO
CORPORATE ADDRESS: 431 IS(S Ave.-,') Inglewood , CA 9o3o-4
PERSON IN CHARGE OF DAILY OPERATIONS: Ke t+l� ra�r n ot p <
G
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 r-MRTIFICATES** The 111ealth Div. wiiil 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 5 5 a� 3 �� a3 ,
1. rl eU(Y1Q Nl Q f 1 t1�Q / / � 1._�`t'�'�1�'�61-�f6 ^ _ %--_!._-_—_,,
2. Pyae Auno ll / 10 / 2026 y
H / 30/ RON
SIGNAT 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/al)plications.ast).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist.
Q:\Application FonnsTOODAPP REV3-2019.doc
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INK Town of Barnstable BOARD OF HEALTH
John T.Norman'
Board of Health Donald A.Gaudagnoli,M.D.
BARNISTABLL * Paul J.Canniff,D.M.D.
A F.P. Thomas Lee Alternate
200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 1022 Issue Date: 01/01/2021
DBA: KIKKA SUSHI@ WHOLE FOODS HYANNIS
OWNER: ITO INC.
Location of Establishment: 990 IYANNOUGH ROAD HYANNIS„ MA 02601
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: C,��
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
I
E
w
�t r Initials:
. Town of Barnstable +
Date Paid la Amt Pd$
BABNWABLE, : Inspectional Services
1639. `�� Public Health Division
ArEp�ys
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 IY�f{ZO NEW OWNERSHIP RENEWAL V
NAME OF FOOD ESTABLISHMENT: "00A ISM t @ t ML-E VOOD i1 YANNAG-
ADDRESS OF FOOD ESTABLISHMENT: qq0 1'�AtiNOU6F4 ROAD , tik?A NIS , MA 0X60I
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 431 [StS AVE IK&LEW(Np ,CA CIO 30O
E-MAIL ADDRESS: �oodsa.l Lty@Ktt=%isk • cm ,9
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( 0a)
TOTAL NUMBER OF BATHROOMS: Sams Cis V Ao[e FUDds M.C9.rtcet' WOn'l Vue s ePam-ate ibafVmmn)
WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) sa`Ap- as I/OFM
ANNUAL: ✓ SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: OUTSIDE: _J2L 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
REOUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? NIA ,
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)-, N I A
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 FonnsTOODAPP 2020.doc
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1
OWNER INFORMATION:
FULL NAME OF APPLICANT ITO IPC•CRO6k lCtluCA
SOLE OWNER: YES ONO D.O.B OWNER PHONE#
ADDRESS 0 ISIS AWL> , Ivlglewobd CA 40301
CORPORATE OWNER: Tonng Soesant0
CORPORATE ADDRESS: 431 Ism Ave , Ihglewad , CA g0300 v(
PERSON IN CHARGE OF DAILY OPERATIONS: tCe.ttk Gra:i,-ra"
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. KKeAiin Gra tanx 9 KbAl Gfal-aN 3 / /3 23
2. 0sVVj1n ROCIVTque�i 10 a0at�
SIGNATURE F PLICANT 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 meta
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 1 st to Dec.3 V 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
w John T.Norman
• Board of Health Donald A.Gaudagnoli,M.D.
s,►aNsree Paul J.Canniff,D.M.D.
200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
a Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 1022 Issue Date: 12/10/2019
DBA: KIKKA SUSHI@ WHOLE FOODS HYANNIS
OWNER: ITO INC.
Location of Establishment: 990 IYANNOUGH ROAD HYANNIS, MA 02601
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Qn
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
t
• For Office Initials:
Town of Barnstable Date Pain (I 5 Amt Pd$
BARNsrmsm
Inspectional Services
�FMASS ►`� Public Health Division she '`# �-)O --
Thomas McKean,Director k( s-
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE W/9-9Ia01o1 NEW OWNERSHIP RENEWAL N/
NAME OF FOOD ESTABLISHMENT: yoma At Miole Foods -4qu lis
ADDRESS OF FOOD ESTABLISHMENT: qqo -Aipmlis Road , -lAtiant"s , MA oaW
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 431 ts(s Avenue , irigleWaod CA g0301
E-MAIL ADDRESS: �OOdW"@ V31:t aSV-W .CM
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( 50g ) q18 - 5g(;0
TOTAL NUMBER OF BATHROOMS: S"Ie QL5 V')1A0 .e f0vd 5
WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) -' same as wkae—WIS
ANNUAL: J" SEASONAL: DATES OF OPERATION:_/ /_ TO
NUMBER OF SEATS: INSIDE: j2� OUTSIDE: _�2L 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? NSA
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
V'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
OWNER INFORMATION:
FULL NAME OF APPLICANT _i T0'"1�lGGI�oOI<+: kllA
SOLE OWNERti YES ;ENO D.O.B °"*�- ` OWNER PHONE # a10 - 4,4a - 1863
ADDRESS ,ri3i lStS AVP-nQV , InCo M-W004 ,CFt C1030[
CORPORATE OWNER: _ Tffnvi� 50e&aw-o
CORPORATE ADDRESS: 4-31 ISIS RUQtwe , 1"tewood Ca 9o--3oi
PERSON IN CHARGE OF DAILY OPERATIONS: tN^ C^t�0.�t0.Yt0
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
1. K eli-1n amim o / / al 1. K e itl„ Gta llt +1 o / 13� / ao 3,3
2. LuCaS Q Li vL°r-a a / q / ` Wo :�.,
10 a8 / aol q
SIGNATURE APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to ovenine!! 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 htta://www.townofbarnstable.us/heaIthdivision/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 1 st 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.d6c
o Town of Barnstable BOARD OF HEALTH
Paul J Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
r ntx ABLF. y'' John T.Norman
�S` F.P. Thomas Lee Alternate
59 200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.towndbarnstable.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: 1022 Issue Date: 12/20/18
DBA: KIKKA SUSHI@ WHOLE FOODS HYANNIS
OWNER: TONNY SOESANTO
Location of Establishment: 990 IYANNOUGH ROAD HYANNIS MA 02601
Type of Business Permit: RESTAURANT
Annual: YES Seasonal:
IndoorSeating: 0 Outdoor5eating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: _ $250.00 YEAR: 2019
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: - -- — - - - — - —
MOBILE-FOOD:
MOBILE-ICE CREAM: C �
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
a
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
t
r=�
oF
------
THE yti For Office Use Initials: 1
Town of Barnstable
• Date Paid Amt Pd
MAS& s Inspectional Services qq
pi 1639.
s`0� Check# �I
Foy Public.Health Division91�9- 4+
Thomas McKean, Director 3 �.
200 Main Street,Hyannis,MA 02601 LOW
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE 11 a1f2IS NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: INKKA tit 001P, ibA fJQWW-
ADDRESS OF FOOD ESTABLISHMENT: q90 I,ann ouyh Dodd , t+,uannls , MO , 0)001
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): q31 1SL -AV.01W, 11)91f Md,Cp ,90301
E-MAIL ADDRESS: 100&o- etU e (.0m
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( M 41S - 500
TOTAL NUMBER OF BATHROOMS: Saw WFM (�dop t haue Nvomf C
WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED)— SCt(b-P of WrM .
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: OUTSIDE: Ql TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
--XltETAIL 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
--- ------- --
r��►
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLI
CANT— '-TO Inc.AW kWK<n
SOLE OWNER: YES D.O.B OWNER PHONE# (310)0}�1-i9(03
ADDRESS_ y l kfi AVer)uP,, tN1CW00d ,C0 , %50)
CORPORATE OWNER: Tonh�SoPsantp FEDERAL ID NO. :
CORPORATE ADDRESS: �;i lais Agnut 1n9lewood a , g030
PERSON IN CHARGE OF DAILY OPERATIONS: ! Qy a Chh Uq
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 ller en Awareness Expiration Date
Lyl --
1. MNO -, 1. 00w chho* 7 1 I�) i 9Od3
't 2. U1t�a Sct1�Q(, as do1�
(L
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/bealthdivision/applications.asl).
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.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st.
Q:1Application Forms\F00DAPPREV2018.doc
1
Op THE fq," TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: �` �\ Date: DI I's age: of .
. r OFFICE HOURS
AaNsrAa,Eo PUBLIC
2 0 MAN STREEETSION 3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
3:30-4:30 P.M.
M AA. q MON.-FRI.
A .639.s�o HYANNIS, MA 02601 508-8624644 No Reference R-Red Item PLEASE PRINT CLEARLY
'FDN1" FOOD ESTABLISHMENT INSPECTION REPORT
t
Name Ug Date U� Type o Ins ection
Qjaer Routin
Address Risk oo S -Inspection
Level Retail 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
In: Other
Inspect; Out:
Each violation Thecked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations IVI '
Critical(C)violations marked must be corrected immediately. (blue&red items) `$ r I Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating 666 tW
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 4 non-critical violations 9
)( ) cited in this report may result in suspension or revocation of the food =
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6n;n-critical violations B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to'a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C.
29.Special Requirements (590.009)
30.Other DATE OF RE-INSPECTION: In e o n ur
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature N 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 F 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*
7-102.11 Common Name-Working Containers*2 590.003(C) Responsibility of the Person-in-Charge to
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR.
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for 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 Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
* Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of
3-202.16 Ice Made From Potable Drinking Water 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec*
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg ct3v,1112001
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
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-
Ratites-165°F 15 sec*
Sources* 1 p Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
11 Good Hygienic Practices practices should be debited under#29-Special
3-201.17 Game Animals* 17 Reheating for Hot Holding Requirements.
5 ReceivingiCondition 2-401.11 Eating,Drinking or Using Tobacco* 3A03.11(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)
112 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. 1(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
ConvenientlyLocated 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
T 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 2j::::i Special Requirements .009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced.-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
oF. ►ow TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: ( ��'`� Date: d1 � age: of
c` b OFFICE HOURS
TH
�.arsrAa�E� PUBLIC
2 0 MAIN LST DIVISION 3:30-4:30 A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION /PLAN OF CORRECTION Date Verified
3:30-4:30 P.M.
9 M63q. �0� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
�grEo MPr n. 508-862-4644
FOOD ESTABLISHMENT INSPECTION REPORT
Name ( Date Tyne of i�E-- s e i n
Routi
Address Risk Food Se e-inspection
Level Previous Inspection
Telephone Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP YIN Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
In: Other
Inspector Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G)
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY L❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
t-6�
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) 1� Corrective Action Required: o El Yes
IA-
Non-critical(N)violations must be corrected immediately or Overall Rating I D
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusio ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,th items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food
if no critical violations observed,4 to 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
C=2 critical violations and less than non-critical. . f critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to anon-cri
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address non-critical violations. If 1 critical refrigeration.
590.009 within 10 days of receipt of this order. violation,4 to Snon-critical violations=C.
29.Special Requirements (590.009)
30.Other DATE OF RE-INSPECTION: Insp ct s S ur
31.Dump er screened fPom public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
Print:
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature J
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N / (C 10
Dumpster Screen? Y N lll/// III
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-contamination14 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
590.004(F)
EMPLOYEE HEALTH_ 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
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 8 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004(11 Variance Requirements
3-304.11 Food Contact with Equipment and Utensils * ) 4
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and
( ) P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations
3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y 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. Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* - Concentration and Hardness* 183-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* e�°"ve tarz°°i
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 ofP Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3AOl.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf
aces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Chemical Stuffing Containing Fish,Meat,Poultry or 590.009 ( j ( )
3-201.15 Molluscan Shellfish from NSSP Listed * (A)-(D) Violations of Section 590.009 A- Din cater-
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources 10 Proper,Adequate Handwashing g' P �'
Game and Wild Mushrooms Approved By * 3401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
RegulatoryAuthority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 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) Commercial] Processed RTE Food:-140°F* Blue Items 23-30)
3-202.15 Package Integrity Y Critical andwon-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.1](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 705 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. 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* 1 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes.critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
oF� r TOWN OF BARNSTABLE HEA TH.INSPECTOR�s Establishment Name: Date: `C �� Page: of
OFFICE HOURS
P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSfABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
9cbA .1. A 0� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY .
s08-8624644
FOOD ESTABLISHMENT INSPECTION REPORT
y
Name ; , Dat / e o Inspect ion
Address �� Risk E od Servi Re-inspection Ci
Level Retail 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 COD
In: Other
Inspector Out:
LLB
Each violation checked requires an.explanation on the narrative pages)'and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC. ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/.Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ��
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories J
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: No ❑ Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined by the Board of Health. Overall Rating Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,eitems
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than Orion-critical violations 9
)( ) cited in this report may result in suspension or revocation of the food =
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6rion-critical violations B. Seriously Critical Violation=F is scored automatically if:.no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address
violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to 8rion-critical violations=C.
29.Special Requirements (590.009) Y P
30.Other DATE OF RE-INSPECTION: Inspect s S at e 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'Wgvature Print: 1
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted.. Y N
Dumpster Screen? Y N ���14,/// V I/�J '`► V '
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11 A 2 Raw Animal Foods Separated from Each * 590.004(F)
( )O P 7-101.11 Identifying Information-Original Containers *
Other* 3-501.1 6(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*
3-304.11 Food Contact with Equipment and Utensils
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.00411 Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
( ) Variance
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and 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 Fg Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.1](D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils an Eggs d 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* Eg-ti-1112001
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 3-401.1](B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* P 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A Violations of Section 590.009 A cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) �) Vio ( )-�)in
Ratites-165°F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and 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* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
5 Receiving/Condition 8. 8 g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* E 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F hem Good Retail Practices FC 590.000
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 k30.
Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision Special Requirements .009
3-502.11 Specialized Processing Methods* 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.
Q
5 0
qL41
TOWN OF BARNSTABLE KHEINSPECTOR�s Establishment Name: Date: age: of
9 CE HOURS
PUBLIC HEALTH DIVISION -ssoA.M.
BARN STABLE. • 200 MAIN STREET -a:so P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MAC, �r. N.-FRI.
�prFDMp+e m HYANNIS, MA 02601 862-464a No Reference R,-Red Item PLEASE PRINT CLEARLY
F OD STA ISHMENT INSPE T N EPORT
Name Date ype of Type of Inspection
NO
O e P�re
Address Udi
d Se �Ion
vel Retail Telephone esi ential Kitchen
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
71
Person in Charge(PIC) Time Bed&Breakfast HACCP
y Other
Inspector
OCII
Each violation checked require an Axplanation on the narrativ pa (s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Rig Factors Red Items)) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ 9
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
OD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
PLOYEE 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 TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.'Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY L
fY"11.Good Hygienic Practices ❑22.Posting of Consumer Advisories ---"'(����
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. r,Wnj
❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based oon today,the items
checked indicate violations of 105 CMR 590.000/Federal Food Code. I ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 9
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility ( )( ) aggrieved y y g g. q C=2 critical violations and less than 9 n-n-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
FC-6 590.007 a rieved b this order,you have a right to a hearing. Your request must i
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-criti I violati ns. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order. a 4 to 8non-critical viola' =C
30.Other DATE OF RE-INSPECTION: 1 I nat r' t:
31.Dumpster screened from public view
If-ILI
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 q 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 L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
* * 3-501.15 Cooling Methods for PI-IFs
590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives
Cooked and RTE Foods.* * - 19 PHF Hot and Cold_Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives - -
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances ! 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
- - 590.004(F) *-
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
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 * J 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 Time
_ 20 me as a Public Health Control "
590.003(F) Responsibility of A Food Employee or An 3,302.15 7-202.11 Restriction-Presence and Use*Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
3-304.11 Food Contact with Equipment and Utensils
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590 1.004 -1 Requirements
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
( ) Variance
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals*- t - , , _ 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 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'Watei From Regulated Sdurces 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-SOl.li 1- Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed Sprouts Not Served*
3-201.12 Food in a Hermetically Sealed Container Sanitization Temperatures 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(TEMPERATURE CONTROLS a
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 Irmnediate Service 145°F 15 scc* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System __ gg'
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A - D Violations of Section 590.009 A - Din cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) ( ) ( )
Ratites-165°F 15 sec* in mobile food,tern and residential
Sources* 10 Proper,Adequate Handwashing g' temporary
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
( ) practices should be debited under#29-Special
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3 403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23.30)
* 12 Prevention of Contamination from Hands 3-403.11 Commerc lly Processed
Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated B) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock [5-203.11
0.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs! following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( ) g
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70'F to 41°F/45*F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
204.11 Location and Placement* Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3 402.11 Parasite Destruction* Temperature IngredientA to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 205.11 Accessibility,Operation and Maintenance
Within 4 Hours 1 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices _ 27. 1 Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 'Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials I FC-7 1.008
HACCP Plans 6-301.12 Hand Drying Provision ° ' '- 29. Special Requiremgnts 1.009
3-502.11 1 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.
W1W
q)<5A 1
�p IKE ni TOWN OF BARNSTABLE_ HEALTH INSPECTOR�s Establishment Name: Date: _7j Page: of
e 'Y OFFICE HOURS
PUBLIC HEALTH
AR'N"S�fAO�EO 2 0 MAW STREET SION : 0- :3 A.M.
3340 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
Mass. $ MO8 -FRI.
HYANNIS,MA 02601 sos-ss2-asaa No Reference R-Red Item PLEASE PRINT CLEARLY
110 tEO MPr , - FOOD T LISHMENT INSP N REPORTA '
Name Dat a of Ins ec ion
Routine
Address Risk !.:o�,rvi = ctio
Level Previo e o
Telephone Residential Kitchen Date:
Mobile Pre-o
Owner HACCP Y/N Temporary Suspect Ilness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
Other
InspectorZia
I
Each violation checked requires an explanation on the narrative pa (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) ❑ y
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Disease"s 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
r.
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding I jA I .
PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLEf OPULATIO S(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices, ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) %theit
Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating '`►fl+
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N ffi Ocial Order for Correction:Based on an inspection tod , Embargo Emergency Closure Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,.
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005 6=One critical violation and less than 4von-critical violations 9
) cited in this report may result in suspension or revocation of the food 4 to 6von-critical violations=B.
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed, Seriously Critical Violation=F is scored automatically if: no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7. 8 non-criti I viol ions. If 1 critical refrigeration.
within 10 days of receipt of this order. viol n, 8non-critical violati
30.Other DATE OF RE-INSPECTION: 's=
29.Special Requirements (590.009) y P
Inspe or' ign to a Print:
1
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 ignature rint:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness - - Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) ,
FOOD,PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* F8 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 Additive*s -' - -
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
- -
� EMPLOYEE HEALTH - 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)-
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F*
r
590.003(C)- Responsibility of the Person-in-Charge to- - - � - - - - - 7=102:11 Common Name-Working Containers* _ *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
Applicants* - 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use* F.590.003(F) Responsibility of A Food Employee or An _3-302.15 _Washing Fruits and Vegetables *
3-501.19 Time as a Public Health Control
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use
3-304.11 Food Contact with Equipment and Utensils* - 590.004(11) Variance Requirements
590.003(G) Reporting by Person in Charge* - - - - - - 7-203.11 Toxic Containers-Prohibitions*
Contamea if on from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* e „ „ REQUIREMENTS FOR
3-306.14(A)($)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria* ry. t 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(A7B) Compliance with Food Law* 4-5b 1.111-- Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-20213 Shell Eggs* _ Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From_Poiable Drinking Watei* - ' - Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Equipment Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective ioizooi
_. .4-602.11 __ Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
- Shellfish and Fish From an Approved Source _ _ 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 -Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact 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 m cater-
3-201.15 _ Molluscan Shellfish from NSSP Listed. _ _ _ .Chemical* ( )-( ) ( )-( )
Ratites-165'F 15 sec*
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By - - _ 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
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* fodborne 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*
03
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* _ 3-4 .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 Items
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:Shelistock 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* y
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5204.11 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
() g g 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 t
29. Special Requirements 1.009
3-502.11 Specialized Processing Methods*
30. Other
3-502.12 1 Reduced-Oxygen Packaging Criteria* _• __- _
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
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Avocado Roll $4.39 Allergen Alert
Tuna Rot) $4.99 All Items have been produced on shared equipment
Salmon Roll* E that may contain allergens such as Wheat (gluten), '
4.99 peanuts, Tree Nuts, Milk, Soy, Eggs, Fish, and
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SUSHI RICE HACCP PLAN FOR KIKKA/
NATURAL STORES,MA
Firm Name: Intended Use and Consumer:
Kikka Used for preparing sushi rolls and is
intended for the general public.
Product Description:
This product is acidified, sweetened, cooked rice with sugar and salt. Honey is used in brown rice. It is used as
a base for various dishes using cooked and raw seafood, vegetables, and other ingredients. For culinary reasons
sushi rice is held without refrigeration after cooking and for up to 36 hours before further preparation,
refrigerated display, and consumption. It has successfully undergone microbial challenge testing to validate up
to 5 days storage time without temperature control.
Ingredients:
Medium grain rice (milled or brown),rice vinegar, and honey
Batch composition for natural brown sushi rice:
Ingredients and Specifications Weight
Medium grain brown rice 6 lb.
Vinegar solution* (mixed with 36 oz. honey) 1000 ml.
Water 10 lb.
Batch composition for milled sushi rice:
Ingredients and Specifications Weight
Medium grain milled rice ..................... 6 lb.
Vinegar Solution* 800 ml.
Water 8 lb.
*Vinegar solution contents:rice vinegar 56%,Sugar 39%, and Salt 5%
Processing Steps:
1. Receiving: All ingredients are received from approved suppliers. Dry ingredients are inspected for
signs of insects,rodents, or other contamination upon receipt. Rice vinegar has a minimum acetic acid
content of 4.2%by volume.
2. Storage: All ingredients, except water, are stored off the floor and on racks. Rodents and insects are
excluded from the storage area through a pest control program.
a. Preparation Wash in room temperature water several times until water runs clear. After washing, soak
rice in water for approximately 40 minutes for milled rice and three to four hours for brown rice.
Soaking is done at ambient temperature. Drain water and place the rice in an automatic rice cooker
along with proper amount of water.
b. Approximately 10 to 15 minutes after the automatic cooking cycle is over, transfer the rice from the
cooker to a stainless steel mixing bowl. For milled rice, the rice is thoroughly mixed with 800 ml
vinegar, sugar & salt mix. For brown rice, 1000 ml. rice vinegar, sugar, salt and honey are added and
mixed thoroughly. To ensure complete distribution of the acid, the rice is mixed with a cutting, straight
movement for approximately 10 minutes.
1
Prepare two samples of rice for gH testing as follows:
(1) Transfer 2 ounces of rice from two random locations of the rice mixture into a clean food preparation
container. These locations shall be changed from time to time and randomly selected so that they represent
at least any 2 points on the surface (1 top, 1 bottom, 4 sides) and any 4 points in the interior.
(2) Check pH of the slurry with litmus paper. The litmus paper should be accurate within the range of pH 2.5 -
4.5 with 0.3 interval color range. The sushi rice pH is measured by placing the 2 oz. portion into a clean cup,
then adding an equal portion of distilled water. Mix the rice and distilled water in the cup with a spoon/
fork/chopstick for 10 seconds. Allow the mixture to stand for 10 seconds. Gently tilt the plastic cup so
water is separated from the rice. Stick the pH strip to the liquid portion, not the rice. If any pH check points
indicate a pH of greater than 4.2, record the results, then add more vinegar solution to the mixture and
recheck pH with the above method until pH of the entire batch is 4.2 or less. Record the pH of the adjusted
rice on the Rice Acidity Log. See the corrective action section of this document for further actions on rice
that has already been packed.
Transfer the rice into an insulated rice box. The rice will be allowed to cool to approximately 70-90 F to make
it ready for sushi preparation. The rice will expire 36 hours after manufacture. All unused portions must be
discarded and may not be used after the expiration time.
Sushi Preparation:
To reduce the risk of contamination, the chef shall wear clean disposable gloves at all times when handling the
rice. Proper hand washing and sanitation practices are followed to minimize the opportunity for contamination.
Sushi Cooling:
Prepared sushi is cooled rapidly after preparation by wrapping it with saran (plastic)wrap before placing it in
the freezer/cooler or by fitting it into the product package before placing it in the freezer/cooler.
Monitoring and Corrective Actions for prepared sushi:
Prepared sushi is cooled to an internal temperature of 41 F or below within 2 hours of being made, and prior to
refrigerated display. The chef notes the date and product name, the cooling start time, cooling end time, and the
internal temperature. The internal temperature is measured by placing a probe thermometer into the core of the
prepared sushi. The temperature reading is observed and recorded on the Prepared Sushi Cooling Log. The
chef then initials and dates his measurements.
If the internal temperature of the prepared sushi has not reached 41 F or below within 2 hours, the prepared
sushi is disposed.
Verification:
A weekly thermometer calibration is performed to ensure that monitoring measurements are accurate. A cup is
filled with ice. Water is added to about the 3/4 mark of the ice. The probe is placed into the ice water and the
temperature reading is observed. The temperature reading must be within 32 +/- 1 F for the thermometer to be
considered acceptably calibrated. If the thermometer is not acceptably calibrated, it shall be adjusted. In the
event that the thermometer cannot calibrate properly after adjustment, a calibrated replacement thermometer
from the WholeFoods Deli Department shall be used. The sushi chef shall immediately contact the supervisor
for a new thermometer. Frequent weekly calibration failures will cause the need for the frequency of ice point
measurements to increase to more than once per week. Any time the thermometer is dropped or bumped hard,
it must be calibrated before its next use.
A weekly records review of the Prepared Sushi Cooling Log is conducted by"Authorized Reviewer" (from here
on the terms "Authorized Reviewer" shall pertain to Kikka supervisors or any WholeFoods HACCP trained
personnel including Service Deli Team Leader/Store Team Leader). Proper completion of the forms,
2
adherence to critical limits, and appropriate documentation, including corrective action, is assessed. The
"Authorized Reviewer" signs the form and dates it after review and appropriate corrective action.
Prepared Sushi Display Temperature:
Prepared sushi is displayed under refrigeration at 41 F or below. It will be discarded the following morning
when the chef arrives. The temperature control program for refrigerated display cases verifies proper air
temperatures throughout the store for proper storage of potentially hazardous foods.
Documentation:
Records are retained on-site for a period of 3 months. After that time, records will be disposed of in a proper
manner.
SUSHI RICE HACCP MONITORING, CORRECTIVE ACTION,AND VERIFICATION
PROCEDURES
I. HACCP MONITORING PROCEDURE
Monitoring is necessary to ensure the process is in control. It must be done at the frequency specified in
the HACCP plan. Records of monitoring activities must be made and kept. After mixing the vinegar
solution into the sushi rice, the pH is analyzed. The chef is responsible for the proper measurement.
Transfer 2 ounce of rice from two random locations of the rice mixture into a clean food preparation
container. These locations shall be changed from time to time and randomly selected so that they
represent at least any 2 points on the surface (1 top, 1 bottom, 4 sides) and any 4 points in the interior.
The pH of each sample is measured with a pH strip. The sushi rice pH is measured by placing the pH
strip into a slurry of sushi rice. The slurry is prepared by placing the 2 oz. portion of prepared sushi rice
into a clean mixing container. An equal portion of distilled water is then added. Mix the rice and
distilled water in the cup with a spoon/fork/chopstick for 10 seconds. Allow the mixture to stand for
10 seconds. Gently tilt the plastic cup so water is separated from the rice. Stick the pH strip to the
liquid portion, not the rice and observe the reading.
Results are recorded on the Rice Acidity Log. The results are considered in conformance if the pH is
below the critical limit of 4.2 on all samples representing the batch.
II. CORRECTIVE ACTION PROCEDURE
In the event the rice pH fails to meet the critical limit, the chef must take necessary corrective action,
which involves re-stirring the acidified rice, adding more vinegar, or holding the product under
temperature control for further evaluation. Records of all corrective actions must be made and recorded
in the corrective action column.
Additional corrective action must be done in the event the critical limit is exceeded. Product packed
since the last conforming result is immediately placed on hold. Collect one random sample from each
batch and measure pH. If the critical limit is exceeded for any of the samples, all rice boxes packed
since last conforming monitoring result must be checked for pH and adjusted accordingly.
III. VERIFICATION PROCEDURES
MONTHLY RECORDS REVIEW
All monitoring, corrective action, and verification records are reviewed monthly by the person-in-
charge. The review process involves checking whether critical limits were met, that monitoring was
3
done at the proper frequency, that appropriate corrective actions were completed and documented, and
whether data and initials are properly being recorded. The monthly records reviewer signs their name
and dates the review signature space at the bottom of the monitoring forms. They will also sign the far
right column on the Daily pH Meter Calibration Form. The reviewer will also check to ensure that all
verification activities, such as third party laboratory testing, is completed, results are within limits, and
that appropriate corrective action was done, if necessary, and documented.
HACCP SELF AUDITS
Self-audits to verify adherence to the HACCP plan will be conducted quarterly. Records of the audit
will be maintained on file. Corrective actions for any non-conformances are necessary. Documentation
concerning all corrective actions will be made, including the action, date, and who completed the action.
PLAN VERIFICATION
The HACCP plan will be verified at a minimum frequency of annually by the HACCP team. If any
changes are made to the product or process, re-verification of the plan is done. Records of plan
verification are kept on file.
EXPERT THIRD PARTY AUDITS
An audit will be conducted by a third party expert. The purpose of the audit is to critically evaluate the
HACCP plan itself, and adherence to the plan. Records of the audit and corrective action for non-
conformances, if any, will be kept.
4
f
r
Our Experience is Your Protection
ar�rr
Michelson Laboratories, Inc.
6280 Chalet Drive, Commerce, California 90040-3761 Telephone: (562) 928-0553 /Fax(562)927-6625
Kikka Restaurant
Challenge Study
March 6, 2012
I. Objective:
A challenge study is conducted in a laboratory environment to determine if the prepared
sushi rice manufactured by Kikka Restaurant will support the growth of Staphylococcus aureus
and Bacillus cereus to any log increase when stored at 98°F (36°C) over 5 days.
** Experimental storage temperature of 98°F was selected as the worst case scenario based on
the actual storage condition of the manufacture facility. The optimum temperature for S. aureus
growth is 95-104°F and for Bacillus cereus is 82-104°F (ICMSF 1996; Lund and others 2000;
Doyle and others 2001).
II. Procedure:
a. Inoculum Preparation
i.Staphylococcus aureus (ATCC 6538, 14458, 13566)
ii. Bacillus cereus (ATCC 33019, 11778, 13061)
iii.Organisms were purchased from ATCC and were cultured according to the
manufacture's instructions: The dry pellet was added into 1 Oml of TSB (BBLTM
Trypticase Soy Broth, Becton, Dickson and Company, Sparks, MD) and
incubate at 35°C for 24hours. The stock culture was then kept at refrigeration
temperature (0-4°C) for a week.
1
Our Experience is Your Protection
,rrr�
Michelson Laboratories, Inc.
6280 Chalet Drive, Commerce, California 90040-3761 Telephone: (562) 928-0553 /Fax(562)927-6625
iv.Fresh culture for inoculation was prepared by transferring a loopful (10µ1) of
stock culture to 10ml TSB and incubate at 35°C for 18-24hrs prior to the day of
testing. Each strain was grew independently in 1 Oral and combined at the end of
incubation to make a cocktail inoculum of 30ml each for S. aureus and B.
cereus.
b. Inoculation of Samples
i. A 5 lbs freshly prepared sushi rice was picked up by Michelson Laboratories,
Inc. and delivered back to the lab within 2 hours from the time rice was
prepared. The product was delivered in a retail blue rice bin.
ii. Inoculation method: Fresh cocktail culture (18-24hr) was diluted to 1:100
by transferring 10ml of cocktail culture to 90m1 phosphate buffer twice. From
the diluted cocktail a total of 1 ml was used for inoculation of 500g sushi rice.
The inoculum was delivered by pipeting small amounts throughout the matrix.
The inoculated rice was mixed thoroughly. The target inoculum level is
approximate 103 - 104 CFU/gm bacterial load.
iii. Receiving temperature of sushi rice was 18.6°C. Water activity was
measured as 0.93 and pH of rice was 3.75-3.78.
c. Treatment
i. The sushi rice samples were kept in sterile containers and kept at 98°F for 5
days.
d. Sample Evaluation
i. Bacterial count of inoculated samples were analyzed on: Initial, Dayl, Day2,
Day3, Day4, Day5
ii. Staphylococcus enterotoxin tests were performed on DayO and Day5.
2
w
Our Experience is Your Protection
Michelson Laboratories, Inc.
6280 Chalet Drive, Commerce, California 90040-3761 Telephone: (562) 928-0553 /Fax(562)927-6625
e. Organism analysis
i. Each sample was aseptically prepared and 25 grams was removed from the
sample for analysis. Serial dilutions were made by adding 225m1 of phosphate
buffer to 25g of sample and stomached (Masticator,Neu-Tec Group, Inc.) at
high setting for 2 minutes for 10-1 dilution. Other dilutions were made by
pipetting 10 ml of the previous dilution into 90 ml of sterile buffer. All dilutions
were shaken 25 times in a one-foot arc within 7 seconds.
ii. Each sample was plated for Staphylococcus aureus in duplicates using
Baird Parker agar (Acumedia. Neogen, Lasting, MI) for 10-1 to 10-3 dilutions.
One ml of 10" was spread pleated onto 3 BP plates and 0.1m1 of 10-2 to 10-3
dilution buffers was spread plated on one BP plate. Incubated all plates at 35°C
for 48 hours.
iii. Each sample was plated for Bacillus cereus in duplicates using MYP agar
(Acumedia. Neogen, Lasting, MI) for 10-1 to 10-3 dilutions. One ml of 10-1 was
spread pleated onto 3 MYP plates and 0.1 ml of 10-2 to 10-3 dilution buffers was
spread plated on one MYP plate. Incubated all plates at 30°C for 48 hours.
3
Our Experience is Your Protection
Michelson Laboratories, Inc.
6280 Chalet Drive, Commerce, California 90040-3761 Telephone: (562)928-0553 /Fax(562)927-6625
I11. Results:
a. Raw data:
Tablel: Bacterial count of inoculated sushi rice sample at 98°F over 5 days
Bacterial Count CFU/ of inoculated rice sample
S. aureus B. cereus
linitial Inoculum level 12000 4400
Time 0 within 1 hour 11000 <10
Day1 <1.0 <10
Day2 <1.0 <10
Da 3 <10 <10
Da 4 <10 <10
Day5 <10 <10
Table2: Bacterial count of control sample at 98T over 5 days
Bacterial Count CFU/ of control sample
S. aureus B. cereus
linitial Inoculum level <10 <10
Time 0 (within 1 hour) <10 <10
Dayl N/A N/A
Day2 N/A N/A
Da 3 N/A N/A
Da 4 N/A N/A
Da 5 <10 <10
TWO. Staphylococcus enterotoxin of inoculated sushi rice sample
Staphylococcus enterotoxin (by BioMerieux VIDAS
Time 0 within 1-hour) Negative
Da 5 Negative
4
Our Experience is Your Protection
Michelson Laboratories, Inc.
6280 Chalet Drive, Commerce, California 90040-3761 Telephone: (562)928-0553 /Fax(562)927-6625
IV. Discussion:
The pH of the sushi rice is selected as a critical control point per Kikka restaurant's
HACCP program. A final pH of 4.2 or lower is selected based on literature review about growth
and toxin production conditions for these organisms. The pH of the sushi rice received for this
study was around 3.75-3.78. Based on a pH stability study performed by Food Safety Solution,
pH value does vary in different parts of the same sushi rice batch. Kikka restaurant performed
pH test in house for each batch and they also conduct outside lab testing for pH verification on a
monthly basis.
It was observed that Bacillus cereus was inactivated to less than detectable level (<10
cfu/g) within one hour of inoculation. Bacillus cereus was more susceptible to the acidity in this
sushi rice than Staphylococcus aureus.
V. Conclusion:
The sushi rice sample manufactured by Kikka Restaurant does not support the growth
of Staphylococcus aureus and Bacillus cereus to any log increase when stored at 98°F for 5 days.
Lab Director: Wendy Lu Date: 3/6/12
5
State of California—Health and Human Services Agency
Department of Health Services
s Food & Drug Branch
California
Department of
Health Services
DIANA M.BONTA,R.N.,Dr.P.H. GRAY DAVIS
Director Governor
August 12, 2002
Paulus Lukas
Kikka Sushi
733 S. Hindry Avenue
Inglewood, CA 90301
Paulus -
The Department of Health Services'Food and Drug Branch(FDB) has reevaluated and reviewed
the additional information provided by Kikka Sushi regarding the approval of Hazard Analysis
Critical Control Point(HACCP) Plans. These plans include both the plan for the wholesale
central kitchen and for each of the retail store partners. All these evaluations were done
considering the requirements of California Health and Safety Code section 114055 and 114056.
I have also considered the numerous conversations and meetings we have had jointly and
severally with Akiko Tagawa and Terrance Powell of Los Angeles County Environmental
Health, Tony Kwan and Jane Pettit of the California Food and Drug Branch, as well as
discussions with other persons regarding the proposed HACCP plan.
These HACCP plans had received a conditional approval on January 14, 2002. The approval
was withdrawn after some concerns were raised regarding training of the designated employees.
The training program was revised and another training was given to all employees. The
instruction of all Kikka Sushi Chefs will be conducted in English and/or Indonesian unless
otherwise agreed. Other language instruction will be provided for those individuals in their own
language when requested. The training will be documented and include a post training field
evaluation.
Inspections at several retail locations as well as the central kitchen prompted additional
revisions to the several HACCP plans. After examining the information, I am granting
conditional approval to proceed. These conditions include:
1. The operation shall be conducted pursuant to the revised HACCP plans submitted. If
changes to the plan occur, those changes must be submitted to both Los Angeles
County Environmental Health and the California Department of Health Services,
Food and Drug Branch, prior to implementation.
Page 1 of 3
flf"X your Do our art to help California save energy.To learn more about saving energy,
POWER
y p p gy. g gy,visit the following web site:
91. www.consumerenergyicenter.orci/flex/index.html
4840 Market Street, Suite D,Ventura, CA, 93003
(805)654-4887
Internet Address: www.dhs.ca.gov
Kikka Sushi
August 12,2002
2. The operation must be conducted following the requirements for HACCP Plans in
Health and Safety Code Sections 114055 and 114056, as well as all other applicable
sections of the California Uniform Retail Food Facilities Law.
3. Results of the monthly random samples which were submitted to a third party
laboratory for pH analysis shall be submitted to a state Food and Drug Branch until it
can be determined that the process adequately meets the pH 4.2 level.
4. Once operational, the facility will be evaluated on an ongoing basis by both Los
Angeles County Environmental Health and the California Department of Health
Services, Food and Drug Branch.
I am in receipt of the results of the microbial challenge conducted on the acidified rice. The
conclusion of the study is that no rapid and progressive growth of either Bacillus cereus or
Staphylococcus aureus was observed during the five days of the study. While this appears to
demonstrate that the rice could be held for a five-day period, I think that it would be prudent to
only extend the current 24-hour limit on non-refrigerated holding of the acidified rice to 36
hours. This will allow for the use of rice prepared the day before in the preparation of sushi the
following day. This practice should be conducted with great care and limited to those sites that
do not receive a fresh delivery of acidified rice until after they have begun production of the
day's sushi. The quality of the day-old rice may adversely affect the quality of the finished
product.
Operating pursuant to this HACCP plan is in lieu of the temperatures required for holding
potentially hazardous foods as required in California Health and Safety Code section 113995.
The HACCP plan has been developed in order to safely handle the rice outside of these
temperatures. If the HACCP plan is not followed in any particular, then the rice must be held
within the temperature requirements of section 113995 i.e. greater than 140°F or less than 41'F.
The HACCP requirements in the Health and Safety Code also require trained personnel present
during operations so that the HACCP plan is adhered to, including monitoring of critical control
points, corrective action if necessary, and periodic verification of the effectiveness of the plan.
All of these issues will be reviewed during the evaluations conducted as #4 above.
If you have any questions, please call me at(805) 654-4887.
Sincerely,
�ZtM�� /V1 O.X S9'�
Bruce Morden
Retail Food Program Specialist
Page 2 of 3
f
Kikka Sushi
August 12,2002
Cc: Terrance Powell
Los Angeles County Environmental Health
5050 Commerce Drive
Baldwin Park, CA 91706-1423
Akiko Tagawa
Los Angeles County Environmental Health
5050 Commerce Drive
Baldwin Park, CA 91706-1423
Milissa Calicchia
Food Safety Solutions, Inc.
P.O. Box 61037
Los Angeles, CA 90061
Tony Kwan
Food and Drug Branch
1449 W. Temple Street
Los Angeles, CA 90026
Page 3 of 3
Massachusetts Department of Public Health
Guideline For Validating Acidified Rice HACCP Plans
Prerequisites and Standard Operating Procedure(s) (SOPs)
❑ Most recent inspection reports indicate compliance with all regulations. Any pre-existing violations,
which may result in.biological, physical or chemical contamination of this product, have been
corrected.
❑ Manufacturer specifications and calibration instructions for pH meter or pH paper used/provided
(.1 scale)
❑ 4:01 or 7.0 buffer solution used (based on manufacturer's recommendations)
❑ Instruction for measuring pH of rice slurry provided
❑ Distilled water provided for making rice slurry (when required by pH testing instructions)
Recipe/Formulation Provided
❑ Brand(s)/concentration of vinegar identified
❑ Preparation steps identified
Hazard Analysis Included
❑ Growth of B.cereus and production of toxins identified
CCP Identified
❑ Acidifying step (addition of vinegar to rice)
i
'Critical Limit Identified i
❑ pH of acidified rice not to exceed 4.6
i
Monitoring Procedures Identified -
❑ Calibrated pH meter or pH papers used to measure each batch of acidified rice i
❑ Person(s)identified for testing pH of rice
II
Corrective Actions and Documentation Procedures Identified
If rice has not been tested with the pH meter, do not,use until it is tested.
If PH of rice is noted above 4.6:
❑ Discard rice if not made within the hour
❑ If rice was made within the hour, add additional vinegar and re-test pH
❑ Verify use of correct recipe and procedures
❑ Verify calibration and proper use of pH meter or pH test papers
Verification Process Identified (Short Term/Long Term) i
❑ pH meter calibrated daily when used
❑ Monitoring records reviewed, on a weekly basis, or as needed, by PIC
❑ Recipe/formulation (</= pH 4.1)validated, signed and dated by a food laboratory
• when recipe is modified, or
• when daily pH levels are consistently higher than the laboratory validated pH measurement
❑ Signed and dated HACCP plan reviewed and modified at least annually or as needed by PiC
Records are Identified
❑ pH log for each batch of rice (sample page included) maintained for 30 days
❑ Daily calibration log maintained for pH meter
❑ Corrective actions recorded in log (sample page included)
❑ Laboratory test results, conducted annually, maintained for one year
Employee Training Plan Documented (sample of training log provided)
❑ Employee Health and Hygiene ❑ Use of pH meter or pH papers
❑ Cleaning and Sanitizing Procedures ❑ Corrective Actions
❑ Cross-contamination Prevention Procedures ❑ Recordkeeping Requirements
❑ Monitoring Procedures for Acidified Rice
I
tion and Verification of HACCP Plans in Retail Food Establishments(August 2003) 26
I
Background Page 1 of 2
Special Food Operations: Sushi
LOCAL. PUBLIC HEAfft H
INSTITUIrE OF MnssA(:HU$es"rs
Background
There are multiple pathogens associated with sushi which can be present in either the fish,the rice, or any of the other
ingredients, or introduced during preparation, storage,or service. For example,fish may be contaminated with certain bacteria,
toxins, or parasites that can cause illness and death. Or,food handlers could introduce bacteria or viruses via bare hand
contact or other unsanitary practices. Certain toxins may be activated with age or temperature abuses.
Pathogen Hazards
Bacteria, Toxins Parasites
Salmonella Scombrotoxin Anisaidasis
Vlbrio species (histamine) (herring worm disease)
Listerla monocytogenes ! Helminths
Bac+llus cereus
Shown is an image of Bacillus cereus which has the potential for growth and toxin formation in cooked rice products.
q� uS 140
.w
' 4
1
r
i
i
In 2012,the CDC investigated a multi-state outbreak involving sushi consumption.A total of 425 people were infected with
Salmonella bareilly(410 of the 425)or Salmonella nchanga(15 of the 425). 55 of the victims were hospitalized;fortunately, no
deaths were reported.
This was the first documented outbreak of human salmonellosis linked to raw, scraped tuna product in.the US.As a result of the
outbreak, Moon Marine USA Corporation of Cupertino, California voluntarily recalled 58,828 Ibs of a frozen raw yellowfin tuna
product.
http://wwwapp l.bumc.bu.edu/lphi/publichealthtraining/onlinecourses/sushi/Sushi4.html 8/11/2015
Accessible Activity Page 1 of 2
This is an alternate content page containing a Tabbed Info Activity. It has opened in a new window.
The tabs have an information section with a title and might have additional content and/or images.
Tab Title: Inspection
Tab Content:
Call ahead of time to make an appointment for inspection. This is not a routine inspection that is done
unannounced and the establishment must be prepared to demonstate the entire rice acidification and
sushi assembly process.
Tab Title: Menu Review
Tab Content:
The menu should be reviewed to verify required statements.
Tab Title: Personal Hygiene
Tab Content:
As with any other type of food establishment, the operator must demonstrate good employee hygienic
practices. Note that in Japan, typical sushi preparation is done with bare hands, so the elimination of
bare-hand contact may require education, monitoring, and enforcement.
Tab Title: Cleaning/Sanitizing
Tab Content:
All equipment and food contact surfaces must be properly cleaned and sanitized.
Tab Title: Contamination
Tab Content:
Ask the operator to explain how they will prevent cross contamination.
Tab Title: pH Testing
Tab Content:
Make sure the brand of rice and vinegar mixture match the HACCP plan. Observe the operator testing
the pH of the rice.
Tab Title: Examing Records
Tab Content:
Review log books and records. Don't forget to ask for fish receipts and parasite destruction letters.
Look for these types of statements in a parasite destruction letter
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Accessible Activity Page 2 of 2
4
}
1. We certify that the frozen fish we provide you has been frozen according to FDA requirements (-4°
F or below for 7 days or-31° F or below for 15 hours).
2. We certify that the fresh farm-raised fish we sell has been formulated with feed, such as pellets,
that contain no live parasites infective to the aqua-cultured fish.
Close this window.
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Massachusetts Department of Public Health
Bureau of Environmental Health
305 South Street
Jamaica Plain, MA 02130-3597
(617) 983-6712 (617) 983-6770 - Fax
Food Protection Program
Policies, Procedures and Guidelines
Issue: General Guideline for the Safe Preparation of Sushi No: RF 3-2
Background
There are several food safety concerns, which are unique to the preparation and service of sushi in
the retail setting. The rice handles best at temperatures between 700 and 80' F, which is a favorable
temperature range for pathogen growth. In addition, many people,prefer to eat sushi at room
temperature, which makes refrigeration storage less desirable. Raw fish is a common ingredient in
sushi and may contain harmful bacteria and viruses. Many species of fish are known to harbor
harmful parasites. Sushi made with raw fish is often prepared alongside sushi prepared with cooked
and vegetable ingredients which increases the risk for cross-contamination of cooked products from
raw ingredients. Lastly, sushi is in demand. Once found only in Japanese restaurants, sushi is now
commonly prepared and sold in many restaurants, smaller retail markets and large supermarkets.
Sushi rice
Many sushi chefs prefer to use the rice at room temperature. Since cooked rice is a potentially
hazardous food (PHF), this practice can pose a significant health risk. There are three basic
strategies that can be used to prepare and hold the rice safely.
I. Sushi rice is typically acidified with rice vinegar. If the pH of the rice is brought down to below
4.6, the rice will no longer support the growth of pathogens and can be considered a non-PHF.
Rice that has been properly acidified can be left out at room temperature. However, if an
establishment wants to rely on acidification to make the rice safe, the pH of every batch must be
checked to insure that the rice has been rendered a non-PHF in accordance with the
Department's guideline on Making Cooked Rice a Non-PHF.
2. An establishment that chooses not to use acidification to make the rice a non-PHF must use
approved time and temperature controls to prevent pathogen growth.
3. Establishments which prepare.sushi for immediate consumption may obtain a variance to use
Time as a Public Health Control to hold the rice at room temperature during preparation and
service. The variance must be in accordance with the Department's guideline on using Time as a
Public Health Control.
Parasites
Many species of finfish naturally contain parasites. These parasites do not harm the fish or hurt the
quality of the meat, but they can cause illness in humans. Because freezing kills parasites, most
finfish needs to be frozen prior to being served raw. The U.S. Food and Drug Administration (FDA)
requires that fish be frozen at-4° F for 7 days or at-35°F for 15 hours in order to insure parasite
destruction. The only raw fish, which does not need to be frozen, are those species in which
Date Issued: 5/9/2001 Date Revised: 04-26-13 .
parasites are not a natural hazard'. The establishment can freeze the fish on the premises but must
document that proper freezing temperature and times were achieved. The time and temperature
records must be kept for 90 days. Alternatively, establishments can purchase fish which has already
been frozen if they first obtain.a letter from the supplier stating that the fish was frozen according to
the required time and temperature specifications.
Consumer advisory
Freezing does not destroy bacterial or viral pathogens. Therefore,when sushi containing raw fish is
served or sold, the consumer should be advised of the increased risk of foodborne illness as required
in section 3-603.11 of the 1999 Federal Food Code.
Cross-contamination
Care must be taken to avoid cross-contamination between raw and cooked ingredients that are being
prepared. Each ingredient should be kept in separate containers and held at proper temperatures.
There should be separate set-ups for raw and cooked products if possible. A set-up consists of a
bamboo mat, a knife and a cutting board. If separate set-ups are not possible,then the utensils
should be cleaned and sanitized between preparation of sushi containing raw fish ingredients and
sushi containing other ingredients.
The bamboo mats are hard to clean and sanitize. Therefore the mats should be wrapped in plastic
and rewrapped in new plastic wrap at least every four hours or after use on raw fish.
No Bare-hand contact
Traditionally,the preparation of sushi requires good hand dexterity and traditionally involved a lot
of bare hand contact. Bare hand contact with the ready-to-eat ingredients must be avoided.Nitrile
gloves (non-latex) can.be used without sacrificing the "feel" and dexterity needed. Sushi chefs shall
not use their bare hands, and must be informed that the Department's policy on Alternative to Bare-
hand Contact with Ready-to-eat Foods has been suspended since July, 2004 due to an increase in
Hepatitis A at that time.
Sushi has become increasingly popular in Massachusetts. Done correctly, the risks can be
minimized and the safety of sushi can be assured.
See the exceptions in section 3-402.11(13) of the food code. For a complete list of fish in which'parasites
are not a hazard, see the FDA's Fish and Fisheries Products Hazards &Control Guide. The guide can be
found on line at http://vm.cfsan.fda.gov/—dms/haccp-2.html.
Date Issued: 5/9/2001 Date Revised: 04-26-13 .
SUSHI RICE HACCP PLAN FOR KIKKA/NATURAL STORES
Product Description:
This product is acidified, sweetened, cooked rice with honey or sugar and salt. It is used
as a base for various dishes using cooked and raw seafood, vegetables, and other
ingredients. For culinary reasons sushi rice is held without refrigeration after cooking
and for up to 36 hours before further preparation, refrigerated display, and consumption.
It has successfully undergone microbial challenge testing to validate up to 5 days storage
time without temperature control.
Ingredients:
Medium grain rice (milled or brown), rice vinegar, and honey
Batch Composition for natural brown sushi rice:
Ingredients and Specifications Weight
Medium grain brown rice .............................. 6 lb.
Vinegar solution (pre-mixed with 36 oz. honey) (Mizkan KS-100).... 1000 ml.
Water ..................................................... 10 lb.
Batch Composition for milled sushi rice:
Ingredients and Specifications Weight
Medium grain milled rice ................................................ 6 lb.
Vinegar Solution (rice vinegar 56%, Sugar 39%, and Salt 5%) (Mizkan KS-100) ..800 ml.
Water ..................................................................... 8lb.
Processing Steps:
1. Receiving: All ingredients are received from approved suppliers. Dry ingredients
are inspected for signs of insect, rodent, or other contamination upon receipt.
Rice vinegar has a minimum acetic acid content of 4.2%by volume.
2. Storage: All ingredients, except water, are stored off the floor and on racks.
Rodents and insects are excluded from the storage area through a pest control
program.
a. Preparation Wash 6 lb. of rice grains in water at room temperature several times
until water is clear. This is achieved by placing the rice in a sanitary vessel, then
filling with water, manually agitating, and pouring off the water from the top
surface. The washing process takes approximately 5 minutes. After washing,
soak rice with water for approximately 40 minutes for milled rice (3 or 4 hours for
brown rice). Soaking is done at ambient temperature. Drain the water. Put the
rice in a rice cooker along with 6 lb. of water and activate the automatic rice
cooker unit. This is a commercial 20-cup rice cooker unit.
b. Approximately 10 to 15 minutes after the automatic cooking cycle is over,
remove the rice by placing the contents into a sanitary stainless steel mixing bowl.
For milled rice,the rice is thoroughly mixed with 800 ml vinegar, sugar& salt
I
mix. For brown rice, 1000 ml. rice vinegar and honey mix are added and mixed
thoroughly. To ensure complete distribution of the acid, the rice is mixed with a
cutting, straight movement for approximately 10 minutes.
Prepare two samples of rice for pH testing as follows:
Transfer 2 ounce of rice each from two random locations of the rice mixture into a
clean food preparation container. These locations shall be changed from time to time
and randomly selected so that they represent at least any 2 points on the surface (1
top, 1 bottom, 4 sides) and any 4 points in the interior.
Check pH of the slurry with litmus paper. The litmus paper should be accurate within
the range of pH 2.5 -4.5 with 0.3 interval color range. The sushi rice pH is measured
by placing the 2 oz. portion into a clean cup, then adding an equal portion of distilled
water. Mix the rice and distilled water in the cup with a spoon/fork/chopstick for
10 seconds. Allow the mixture to stand for 10 seconds. Gently tilt the plastic cup so
water is separated from the rice. Stick the pH strip to the liquid portion, not the rice.
If any pH check points indicate a pH of greater than 4.2, record the results, then add
more vinegar solution to the mixture and recheck pH with the above method until pH
of the entire batch is 4.2 or less. Record the pH of the.adjusted rice on the Rice
Acidity Log. See the corrective action section of this document for further actions on
rice that has already been packed.
Transfer the rice into sheet pans and allow the rice to cool down to approximately 70-90
F to make it ready for sushi preparation. The rice will expire 36 hours after manufacture.
All unused portions must be discarded and may not be used after the expiration time.
SUSHI RICE HACCP MONITORING, CORRECTIVE ACTION, AND
VERIFICATION PROCEDURES
I. HACCP MONITORING PROCEDURE
Monitoring is necessary to ensure the process is in control. It must be done at the
frequency specified in the HACCP plan. Records of monitoring activities must be
made and kept. After mixing the vinegar solution into the sushi rice, the pH is
analyzed. The chef is responsible for the proper measurement. Transfer 2 ounce
of rice each from two random locations of the rice mixture into a clean food
preparation container. These locations shall be changed from time to time and
randomly selected so that they represent at least any 2 points on the surface (1 top,
1 bottom, 4 sides) and any 4 points in the interior.
The pH of each sample is measured with a pH strip. The sushi rice pH is
measured by placing the pH strip into a slurry of sushi rice. The slurry is
prepared by placing the 2 oz. portion of prepared sushi rice into a clean mixing
container. An equal portion of distilled water is then added. Mix the rice and
distilled water in the cup with a spoon/fork/chopstick for 10 seconds. Allow
the mixture to stand for 10 seconds. Gently tilt the plastic cup so water is
separated from the rice. Stick the pH strip to the liquid portion, not the rice and
observe the reading.
Results are recorded on the Rice Acidity Log. The results are considered in
conformance if the pH is below the critical limit of 4.2 on all samples
representing the batch.
II. CORRECTIVE ACTION PROCEDURE
In the event the rice pH fails to meet the critical limit, the chef must take
necessary corrective action, which involves re-stirring the acidified rice, adding
more vinegar, or holding the product under temperature.control for further
evaluation. Records of all corrective actions must be made and recorded in the
corrective action column.
Additional corrective action must be done in the event the critical limit is
exceeded. Product packed since the last conforming result is immediately placed
on hold. Collect one random sample from each batch and measure pH. If the
critical limit is exceeded for any of the samples, all rice boxes packed since last
conforming monitoring result must be checked for pH and adjusted accordingly.
Corrective action must be done within one hour after critical limit-has�been
exce` eded..In.the-event-that-the corrective`action-fails-to-be-applied-withinathe time
limit;the-riceTrnusbe dis ac rded.
III. VERIFICATION PROCEDURES
MONTHLY RECORDS REVIEW
All monitoring, corrective action, and verification records are reviewed monthly
by the QC supervisor. The review process involves checking whether critical
limits were met, that monitoring was done at the proper frequency, and that
f appropriate corrective action was completed and documented, and whether data
and initials are properly being recorded. The monthly records reviewer signs their
name and dates the review signature space at the bottom of the monitoring forms.
HACCP SELF AUDITS
Self audits to verify adherence to the HACCP plan will be conducted quarterly.
Records of the audit will be maintained on file. Corrective action for any non-
conformances is necessary. Documentation concerning all corrective actions will
be made, including the action, date, and who completed the action.
r
PLAN VERIFICATION
The HACCP plan will be verified at a minimum frequency of annually by the
HACCP team. If any changes are made to the product or process, re-verification
of the plan is done. Records of plan verification are kept on file.
EXPERT THIRD PARTY AUDITS
An audit will be conducted by a third party expert. The purpose of the audit is to
critically evaluate the HACCP plan itself, and adherence to the plan. Records of
the audit and corrective action for non-conformances, if any, will be kept.
Plastic Cover Change Log
Date Start Change Corrective Action Initial
Notes: - Plastic wrap cover on bamboo mats for must be changed every 4 hours.
-Plastc wrap cover on bamboo mats must be changed when torn or contaminated.
-If plastic wrap is not changed for more than 4 hours, product that is prepared with the
bamboo mats after 4 hours must be discarded.
Reviewed by: Date:
l
Sushi Rice Time Log
Date Batch Cook(Time) Dispose Wse(Time) Notes Initial
Notes: - Sushi rice can only be kept for 36 hours at room temperature from the cooking time
- If rice is not used up within 36 hours, it must be discarded and record the discad time.
Reviewed by: Date:
ALBACORE TUNA
August 1, 2015
1CREST INTERNATIONAL LLC
1240 E.Victoria Street
Carson,CA 90746
Tel:310-886-3521
Fax:310-886-3532
Email :James.Kata,�a�ma@icrest-llc.com
Company : Icrest Customers
Attention : QC/R&D/HACCP Administrators
From : James/Icrest International LLC
Re : HACCP Compliance 2015
Dear Valued Customer
This letter is our guarantee that all seafood that Icrest International LLC supplies to your
company has been produced and stored in a facility, which is in compliance with the
United States Food and Drug Administration(FDA)guidelines for Hazard Analysis
Critical Control Points(HACCP)under the CFR 21, Section 123,
All records required by the regulations are maintained at the office of Icrest International
LLC for at least 1 year after the date they were prepared in the case of refrigerated
products, and at least for 2 years after the date they were prepared in the case of frozen,
preserved,or shelf stable products.
The goal of this program is to provide an effective and rational means of assuring food
safety from acquisition from our suppliers to delivery to our customers. HACCP
compliance is monitored by an Icrest staff member certified and trained in the HACCP
program.
Please include this document as a part of your HACCP and compliance certification file.
For any inquiries,please feel free to contact me anytime.
Best regards,
i n
J mes Katayam
hief Complia cc fficer
crest Internati pal LC
CRAB MEAT
2025 First Avenue
Suite 200
u Seattle,WA 98121
206.448.5400
206.448.2818 fax
Certificate of Compliance
This letter certifies that the cold water crab meat products provided to:
Kikka Sushi
431 S. Isis Ave
Inglewood, CA 90301
are in full compliance with the U.S. Food and Drug Administration's Seafood HACCP regulations
(21 CFR 123). Plants and vessels processing Aqua Star product have conducted a hazard
analysis for each product as required in 21 CFR 123 and implemented a HACCP plan as well as
Good Manufacturing Practices (21 CFR 110) and Sanitation Standard Operating Procedures (21
CFR 123.11(a)) as per U.S. regulations.
Jeremy Schmidt
Company Official(Print Name)
Quality Assurance Manager
Title
August 1, 2015
Signature Date
Aqua Star
Company Name
2025 First Avenue Suite 200
Street Address
Seattle WA 98121
City State/Region Postal Code
CX G S��
_ .
SUSHI RICE HACCP PLAN FOR KIKKA(NATURAL STORES
Product Description:
This product is acidified, sweetened, cooked rice with honey or sugar and salt. It is used
as a base for various dishes using cooked and raw seafood, vegetables,and other
ingredients. For culinary reasons sushi rice is held without refrigeration after cooking
and for up to 36 hours before further preparation, refrigerated display, and consumption.
It has successfully undergone microbial challenge testing to validate up to 5 days storage
time without temperature control.
Ingredients:
Medium grain rice(milled or brown), rice vinegar, and honey r,
Batch Composition for natural brown sushi rice:
Ingredients and Specifications Weight
Medium grain brown rice .............................. 6 lb.
Vinegar solution (pre-mixed with 36 oz. honey)..... 1000 mi.
Water ..................................................... 10 lb.
Batch Composition for milled sushi rice:
Ingredients and Specifications Weight
Medium grain milled rice ...... .. ......... ..................... 6 lb.
Vinegar Solution(rice vinegar 56%, Sugar 39%,and Salt 5%) ... 800 mi.
Water ................................... . .... .................. . ... 8lb.
Processing Steps:
1. Receiving.: All ingredients are received from approved suppliers. Dry ingredients
are inspected for signs of insect, rodent, or other contamination upon receipt.
Rice vinegar has a minimum acetic acid content of 4.2%by volume.
2. Storage: All ingredients, except water, are stored off the floor and on racks.
Rodents and insects are excluded from the storage area through a pest control
program.
a. Preparation Wash 6 lb. of rice grains in water at room temperature several times
until water is clear. This is achieved by placing the rice in a sanitary vessel.-then
filling with water, manually agitating, and pouring off the water from the top
surface. The washing process takes approximately 5 minutes. After washing,
soak rice with water for approximately 40 minutes for milled rice (3 or 4 hours for
brown rice). Soaking is done at ambient temperature. Drain the water. Put the
rice in a rice cooker along with 6 lb. of water and.activate the automatic rice
cooker unit. This is a commercial 20-cup rice cooker unit.
b. Approximately 1.0 to 15 minutes after the automatic cooking cycle is over,
remove the rice by placing the contents in the cooler to a sanitary stainless steel
mixing bowl. For milled rice, the rice is thoroughly mixed with 800 ml vinegar,
1�
sugar& salt mix. For brown rice, 1000 mi. rice vinegar and honey mix are added
and mixed thoroughly. To ensure complete distribution of the acid; the rice is
mixed with a cutting, straight movement for approximately 10 minutes.
Prepare two.samples of rice for pH testing as follows:
Transfer 2 ounce of rice each from two random locations of the rice mixture into a
clean food preparation container. These locations shall be changed from time to time
and randomly selected so that they represent at least any 2 points on the surface (I
top, 1 bottom, 4 sides) and any 4 points in the interior.
Check pH of the slurry with litmus paper. The litmus paper should be accurate within
the range of pH 2.5 - 4.5 with 0.3 interval color range. The sushi rice pH is measured \jA_�
by placing the 2 oz. portion into a clean cup, then adding an equal portion of'distilled
water. Mix the rice and distilled water in the cup with a spoon/fork/chopstick for
10 seconds. Allow the mixture to stand for 10 seconds. Gently tilt the plastic cup so
water is separated from the rice. Stick the pH strip to the liquid portion, not the rice.
If any pH check points indicate a pH of greater than 4.2, record the results, then add
more vinegar solution to the mixture and recheck pl-1 with the above method until pH
of the entire batch is 4.2 or less. Record the pH of the adjusted rice on the Rice
Acidity Log. See the corrective action section of this document for further actions on .
rice that has already been packed.
"Transfer the rice into an insulated rice box. The rice will be allowed to cool to 1 •
approximately 70-90 F to make it ready for sushi preparation. The rice will expire 361
hours after manufacture. All unused portions must be discarded and may not be used
after the expiration time.
SUSHI RICE HACCP MONITORING,CORRECTIVE ACTION,AND
VERIFICATION PROCEDURES C\
�C C G�,T
1.HACCP MONITORING PROCEDUREQj
Monitoring is necessary to ensure the process is in control. It must be done at the
frequency specified in the HACCP plan. Records of monitoring activities must be
o made and kept. After mixing the vinegar solution into the sushi rice,the pH is
analyzed. The chef is responsible for the proper measurement. Transfer 2,ounce
of rice each from two random locations of the rice mixture into a clean food
preparation container. These locations shall be changed from time to time and
randomly selected so that they represent at least any 2 points on the surface (1 top,
1 bottom, 4 sides) and any 4 points in the interior.
The pH of each sample is measured with a pH strip. The sushi rice pH is
measured by placing the pH strip into a slurry of sushi rice. The slurry is
prepared by placing the 2 oz. portion of prepared sushi rice into a clean mixing
container. An equal portion of distilled water is then added. Mix the rice and
distilled water in the cup with a spoon/fork /chopstick for 10 seconds. Allow
the mixture to stand for 10 seconds. Gently tilt the plastic cup so water is
separated from the rice. Stick the pH strip to the liquid portion, not the rice and
observe the reading.
Results are recorded on the Rice Acidity Log. The results are considered in
conformance if the pH is below the critical limit of 4.2 on all samples
representing,the batch.
II. CORRECTIVE ACTION PROCEDURE
In the event the rice pH fails to meet the critical limit, the chef must take
necessary corrective action, which involves re-stirring the acidified rice, adding
more vinegar, or holding the product under temperature control for further
evaluation. Records of all corrective actions must be made and recorded in the
corrective action column.
Additional corrective action must be done in the event the critical limit is
exceeded. Product packed since the last conforming result is immediately placed .
on hold. Collect one random sample from each batch and measure pH.. If the
critical limit is exceeded for any of the samples, all rice boxes packed stnce last
conforming monitoring result must be checked for pH and a justed accordingly.
111. VERIFICATION PROCEDURES V'
MONTHLY RECORDS REVIEW
�1 All monitoring, corrective action, and verification records are reviewed monthly ``��l
J by the QC supervisor. The review process involves checking whether critical
limits were met, that monitoring was done at the proper frequency, and that
appropriate corrective action was completed and documented, and whether data
and initials are properly being recorded. The monthly records reviewer signs their
name and dates the review signature space at the bottom of the monitoring forms.
HACCP SELF AUDITS ` a
Self audits to verify adherence to the HACCP plan will be conducted quarterly.
Records of the audit will be maintained on file. Corrective action for any non-
conformances is necessary. Documentation concerning all corrective actions will
be made, including the action, date, and who completed.the action.
PLAN VERIFICATION
The HACCP plan will be verified at a minimum frequency of annually by the
HACCP team. If any changes are made to,the product or process,re-verification
of the plan is done. Records of plan verification are kept on file.
EXPERT THIRD PARTY AUDITS
An audit will be conducted by a third party expert. The purpose of the audit is to �.
critically evaluate the HACCP plan itself. and adherence to the plan. Records of
the audit and corrective action for non-conformances, if any, will be kept.
f
Jun 04 2015 6:18AM HP Fax Pa9Q 2
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lWchelsom Laboratories, Inc.
6280 C6akt Drtve,Om merle.CFs 90040-3704,Telephone(.552)4MOS53! FAX (%2) 027-"25
LABORATORY CERTIFICATE
Printed : 05252015
Subm#W By. KIKKA Lab No.: 0520154=877
431 S 1SIS AVE Report No.: 052015=877A
INGLEWOOD,CA 90301 Order No.
Attn : PAULUSLUKAS Reov&,vd: 52=15
Rapor r a PIUMUCT I TEUT M1fmti mmmlr Mrs irrAmw
M382877-01 MLIED RICE
Ph AOAC 981.12 1.88 5r2p12095
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M382877-03 MIR.TK3iM RICE
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M362877-N BACK WCE
PH AOAC 981.12 4.13 5r20/2015
MICHELSON LABORATORIES, INC.
Y Mawn. MlaolaWM Aft M r 9t25t2015 10 29:07 AM
Senipaes wwv recoom ri pod cwdtWn Id13tS0 noLo cftrOse.As a mike pmdeceon to C6 M am ems,all repo ti are U&rMW as Qt0 cxMftnW V40"W
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Team leader Daily Check list
page 1
Mid Shift must be completed between 1:30-4:30pm.
Store name,: Wk starting
Mo Tu We Th Fr Sa Su
Sanitizer in place and correct.
no equipment in sanitizer bucket(knife,benrinner,etc.).Only towels are allowed.
Uniforms clean & neat.
personal hygiene,hat,shoes,name tag visible,etc.
Work area clean.
no dirty towels laying around,no abundant empty boxes,not too much trash.
Hand sink (HAND WASHING ONLY).
clean,not blocked,stocked with paper towels and soap.
No personal items in the dept. or storage area.
food,bag,jacket,etc.
Drink with lid & straw.
in a designated area away from food prep.
Display case clean and all signs posted.
sales,allergen,consumer advisory,mercury and mercury pamphlet.Glass&shelf clean.
Display case,product check.
expiration dates 60 fresh pack and sushi case(all product must be pulled on same work day).
Reach in and walk in coolers :
1.all product labeled and dated not to exceed 7 days shelf life.
2.Proper food stacking in coolers.
stacking order: top 5.ready to eat
4.fish .
3.beef 9
2.pork x: J
bottom 1.poultry
r,
3.cleanliness.
door handles,shelves,floor,etc. d
4.thermometer in place and working properly.
Display case completed in a timely manner.
between 10am to clam.
Product quality
1.right label,price.
2.right ingredients. ,
3.right sauces,color&taste.
4.right size,shape&weight.
Check log book to ensure its filled out properly : 10:30
1:30
4:30
7:30
Display case re-stocked in a timely manner.
Dept. area clean.
equipment,display case,floors,drains,walls,etc.
*REMINDERS:
Hand washing(NO EXCEPTIONS).
TMs going in/out of dept, changing jobs, removing trash, restroom, etc.
f
page 2
NO PHONE USE on sales floor in entire store (NO EXCEPTIONS).
Phones must be set on vibrate.
Customer service interaction being done :
smile &greetings must be done with customers within 5 feet&5 seconds.
be helpful.
be thankful.
Mon inspected by : Name : Title: Time :
Tue inspected by : Name : Title: Time :
Wed inspected by : Name : Title: Time :
Thur inspected by: Name : Title: Time :
Fri inspected by : Name : Title: Time :
Sat inspected by : Name : Title: Time :
Sun inspected by : Name : Title: Time :
'Mark all boxes with a checkmark to ensure job is being done. Write any comments below if a job is not able to be
completed,be specific with incident&date. The completed form will be collected each week by your district manager.
Jun 04 2015 6:18AM HP Fax page i
Our Eve7fente It Yoxr Nwe*Yoo
Michelson Laboratories, Inc.
6280 Cbakg Dive,Cammerco,CA 90 -3704,Tebpbom(562)928-0553 / FAX (562) 927-605
LAB®RA TORY CERTIFICATE Printed : 04rM015
Submitted By. KIKKA Lab No.: 041615-M358011
431 S ISIS AVE - Report No.: 041615-[ 11A
INGLEWOOD,CA 90301 Order No.:
Attn: PAULUS LUKAS Recehed: 4/16M15
page: 1 of 1
RErPOUf1 PR00UCTlTW'V RmL1r umn S'TAMMT
A7358811-01 MR I ED RICE
PH AOAC 981.12 3.55 41ISM15
M3W811-02 BROWN RICE
PH AOAC 98 1.12 3.87 4/18f20/S
M358811-0 MULT*RAFI RICE
PH AOAC 981.12 4.04 4lM015
W35861144 BLACK RICE
PH AOAC 981.12 3.91 4/1512015
MIICHELSON LABORATORIES, INC.
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Evaluation Tool for Acidified Rice HACCP Plans
- Last Updated W&W
❑ Standard Operating Procedures(SOP)
Most recent inspection report indicates compliance with 105 CMR 590.000. Any pre-
existing violations,which may result in biological,physical or chemical contamination of
this product, have been corrected.
❑ SOP for pH measurement
— Manufacturer specs and calibration instructions for pH meter or pH paper (.3 or
less scale) used provided
— Instruction for measuring pH of rice slurry made with distilled water provided
— If a pH meter is used:
■ Buffer solution, which has not passed expiration date, used ,
4.0 Buffer solution (unless manufacturer recommends otherwise)used
❑ Recipe/Formulation Provided
— Strength-of vinegar identified (%by volume)
— Preparation steps identified
— Recipe/formulation (target pH at or below 4.1) validated, signed and dated by a
food.laboratory
❑ Preparation Steps Identified
❑ Hazard Analysis Included
Growth of B.cereus and production of toxins identified`
❑ CCP Identified
Acidifying step (addition of vinegar to rice)
❑ Critical Limit Identified
pH of acidified rice must be tested prior to use. If using pH paper, the pH shall not
exceed 4.3. If using a pH meter, the pH shall not exceed:
■ 4.3 if tested within 2 hours of preparation, or
4.6 if tested after 2 hours of preparation.
a L
❑ Monitoring Procedures Identified
— Calibrated pH meter or pH'papers used to measure each batch of acidified rice
— Person(s) identified for testing pH of rice
❑ Corrective Actions and Documentation Procedures Identified
If rice not tested, do not use until tested. If rice is above 4.6 (or 4.3 using pH papers),
— Discard if rice not made within the hour
— If rice made within the.hour, cool immediately or add additional vinegar, re-mix
and re-test pH
— Verify use of correct recipe and procedures
— Verify calibration and proper use of ph meter or ph papers
❑ Verification (Short Term/Long Term) Process Identified
— pH meter calibrated daily when used
— Monitoring records reviewed daily or as needed by PIC
— Recipe/formulation (target pH at or below 4.1) validated, signed and dated by a
food laboratory
■ lab validation updated annually or when recipe is modified,
■ when daily pH levels are consistently higher than the laboratory validated pH
measurement
Signed and dated HACCP plan reviewed and modified at least annually or as
needed by PIC.
❑ Records to be Maintained Identified
— pH log for each batch of rice (sample page included) maintained for 30 days
— Corrective actions recorded in log (sample page included)
— Daily calibration log maintained for pH meter
— Laboratory test results maintained for one year
❑ Employee Training Plan Documented (sample of training log provided)
— Employee Health and Hygiene
— Cleaning and Sanitizing Procedures
— Cross-contamination Prevention Procedures
— Monitoring Procedures for Acidified Rice
— Use of pH meter or pH papers
— Corrective Actions
— Recordkeeping Requirements
' I
J
Guidelines for Preparing Sushi
These are guidelines and recommendations for sushi preparation and what is required by
code if vinegar is being used as a preservative to leave rice at room temperature. If they
are not using vinegar as a preservative then they are not required to submit a HACCP
plan, but it is good practice to incorporate these guidelines into their process.
1. The standard documentation that you'll need is the HACCP plan for the acidification of the
rice, if the rice is left at room temp.
• A list of the staff that has been trained in the HACCP process of making sushi. These
individuals should be Servsafe Certified.
• A list of the products being used in the rice acidification process. Example rice
vinegar or other additives. The brands they use must be specified in the HACCP
plan.
• Frozen Fish Records or Letter from Fish Vendor verifying frozen method used by the
facility.
• Flow Diagram of the Sushi Rice Process. Beginning with receiving and ending with
serving of the product.
• Standard Operating Procedures for the Sushi Rice Process. Beginning with washing
the rice, how they wash the rice, cooking, cooling, equipment used, adding the
vinegar, checking the pH, and storing the rice.
• Standard Operating Procedures for pH Measurement(If using a pH meter then
directions in use must be provided in the HACCP. If they use a meter then they must
have pH paper on hand as a back up They must be trained in how to use both items.)
• Corrective Action Procedures Decision Tree
• HACCP Table (Demonstrates CCP and Corrective Actions)
• pH log.
• Recommended Analytical Laboratories for pH or where rice formula was tested.
• Vendors for Supplies (Optional)
• Employee Training Record. What exactly where the employees trained to do and
what do they do if there is a problem.
• Certificate of Analysis of Sushi Rice Sample
Attached is an evaluation tool for acidifying rice. Parasite destruction records will be required
from the fish supplier. If the vendor doesn't change, then they don't have to update that
documentation every year, but check the menu to verify that the fish they are using is on the
menu. Attached is a list of names of fish that are sometimes sold under a different name.
2. Each recipe, rice to vinegar solution, must be laboratory tested. It must be tested yearly or if
there is a change in the recipe that was originally tested. If a product is changed, for instance,
a different type of rice or vinegar mixture then the recipe must be laboratory tested again. If
the facility makes a smaller amount in the slow season then this recipe must also be tested.
3. Bamboo mats can't really be cleaned well so they should always be wrapped in a plastic
cover. They may use multiple wraps, but the wrap that contacts food must be discarded every
4 hours. Mats that are used for raw fish product should not be used for making sushi with
cooked product.
4. "Clorox"type sanitizing wipes are recommended for wiping rather than the sanitizing buckets.
5. An appointment should be made with the facility and the sushi chef to demonstrate
the whole process of making the sushi. Some facilities make their own vinegar
o =-7
p
of jHE ToiY - Barnstable
Town of Barnstable
*
sax Ameriea0v
tv sTaBi.E. l-A
9� f �,�� Board of Health 1I I.F
200 Main Street, Hyannis MA 02601
2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
Junichi Sawayanagi
January 17, 2014
Mr., Kelli Burke
The Wilder Companies, Ltd.
800 Boylston Street
Suite 1300
Boston, MA 02199
Dear Mr.. Burke,
You are granted a variance from t eder 00 o e, ,
Time as a Public Health Contro at Whole Foods Market, 990 Iyannough Road, Hyannis.
This variance will authorize you, and your emp oyee , r✓s-anpa gs
in-a blanket at room temperature for up to three hours.
This variance is granted with the following conditions:
(1) Only pizzas, calzones, and pigs-in-a-blanket are authorized to use Time as a
Public Health Control. All other foods shall be maintained at proper
temperatures in conformance with the 1999 Federal Food Code.
(2) These approved foods (within condition#1 above) may remain at room
temperature.for no more than three hours. After three hours, the foods shall be
disposed of.
(3) A time/temperature log shall be maintained on the premises and shall be kept
on file for a minimum of six months. The log shall be made available for viewing
by a health inspector immediately upon request.
(4) This variance decision letter shall be posted on the wall adjacent to the food
service permit for viewing by a health inspector during inspections.
Sincexel j
/ /`
z z.
Wdyne 1 elr, .D..
Q:\WPFILES\WholeFoodsVarianceDecision2Ol4.doc
jHyannis—Whole Foods Market Pizza Menu
Fresca-roasted corn, black beans,red onion, bell pepper, avocado, cilantro, shredded mozzarella
Hawaiian-hoisin,pineapple, bacon(or ham), and shredded mozzarella, green onion
BBQ Chicken-BBQ sauce. chicken, smoked gouda, red onion, shredded mozzarella, green onion
Mediterranean-black olive, artichoke, garlic,roasted bell pepper,shredded mozzarella, and feta cheese
The Buddha(Vegan)-Thai peanut sauce,mushrooms, onion,bell pepper, snow peas, shredded carrot,
fresh lime, cilantro,vegan c_ieese
Fig&Prosciutto -Croatian=ig spread,thin sliced prosciutto, shredded asiago, baby arugula
Margarita-sliced roma tomato, fresh mozzarella,basil
Taco Pizza- diced chipotle grilled chicken, fresh in-house salsa, black beans, bell pepper,tomato,tortilla
chips,jalapeno, avocado
Garden Vegetable- squash, zucchini, onion, garlic, shredded mozzarella, green onion(available with no
cheese or vegan cheese)
Eggplant Parmesan-eggplant parmesan, shredded mozzarella&asagio,basil
Florentine- grilled chicken, sauteed spinach, roasted garlic, sliced mushrooms, shredded mozzarella&
ricotta,fresh parsley
Potato Skin-thin sliced red bliss, bacon, sour cream, shredded mozzarella, green onion
The Game Changer-whiskey BBQ sauce, shaved steak,red onion, smoked gouda, shredded mozzarella,
green onion
The Rustic- fresh roma tomatoes, garlic, shallots, fresh thyme,shredded mozzarella and ricotta,..fresh
parsley
Buffalo Chicken-buffalo styli chicken, crumbled blue cheese,with green onion
White Pizza- shredded mozzarella, parmesan, asagio,ricotta, fresh parsley
Breakfast Pizza- bacon,egg;anion, bell pepper, green onion
BBQ Steak&Eggs - shaved steak, eggs, green onion
Pumpkin Pizza-pumpkin, bacon, shredded mozzarella, honey drizzle
Brunch Pizza- honey sweetened cream cheese spread, macerated mixed berries, crushed walnuts
Scallop and bacon Pizza- scallops, bacon, shredded mozzarella
Shrimp Pesto Pizza-,shrimp,pesto, fresh tomato,shredded mozzarella
Pizza Bagels- a bagel with sauce and shredded mozzarella
Brunch Calzone-with brie,pear, dried figs, dried apricots,raisins,walnuts, pistachios, and drizzled with
honey.
Pretzel Baguette Bruschetta-fresh sliced tomato,fresh mozzarella,basil, balsamic vinagrette drizzle
Cheesy Garlic Bread- our Classic Garlic Bread toasted in our hearth oven and smothered with shredded
Mozzarella
Sausage Peppadew-Caramelized onion spread,mozzarella, sausage, peppadew,
Mushroom Sirloin Creme fraiche,mozzarella, sirloin,red onion, mushroom
Carbonara Pizza-Alfredo sauce, prosciutto, eggs, parsley
Ingredients -
The following items will be cooked and cooled in the prepared foods department spinach, shaved steak,
red bliss potatoes, mushrooms,bell peppers, onions, grilled chicken,pork sausage,bacon
The following items will be cooked on top of the pizza, or inside the calzones from raw state:
Raw FruitsNeggies: cilantro, scallions, onions, arugula, spinach, shallots,bell peppers, mushrooms,
olives, corns, snow peas, carrots, zucchini, summer squash, limes,pears,berries.
Protein Items: eggs,raw shrimp, raw scallops,brie, chicken,pork sausage
All other toppings or.fillings will be purchased from a commercial vendor.
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