HomeMy WebLinkAboutCVS - CENTERVILLE #1869 - RETAIL FOOD CVS - Centerville
1080 Falmouth Road
.25D-0,P7=X0)
t r Town of.Ba rn sta b I e BOARD OF HEALTH
aY John T. Norman
Board of Health Donald A.Gaudagnoli,M.D.
ti g�RNSTABLE F.P.(Thomas)Lee,..
MASS, Daniel Luczkow,M.D. Alt.
�b ay4. 200 Main Street, Hyannis, MA 02601
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstablems
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 43 Issue Date: 01/01/2022
DBA: CVS PHARMACY#1869
OWNER: CVS PHARMACY INC.
Location of Establishment: 1080 FALMOUTH RD. HYANNIS„ MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE- FOOD:
MOBILE-ICE CREAM: Cy?n
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:
For Office Use •
Town of Barnstable Initials
Date Paid Amt Pd S
BAMSTABM * Inspectional Services
MAS&
Public Health Division Check#
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601 /
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE 1 !7( NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: wJ k( I
ADDRESS OF FOOD ESTABLISHMENT: i 6�d ��� /�T '`-'
C
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): One CVS Drive
Mail Cede 1160
110n1 harmac e Woonsocket, Rt 02895
E-MAIL ADDRESS: p ypermits@cvsh.:alth.com
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 0�11) 77 Y- V4�1_6_"(
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES NO ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: _4�_ OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING
REQUIREMENTS. ,
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
TAIL 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
1
OWNER INFORMATION: Stephanie Cadorette
FULL NAME OF APPLICANT Licensing Coordinator
SOLE OWNER: YES/NO OWNER PHONE#
ADDRESS /_ - harmacY
Drive
CORPORATE OWNER: C "l rN`� c . OnMa��Code
Cod 1160
' _
Woonsocket,KI
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS:
List(2)Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/at)plications.asy.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st.
Q\Application FormsTOODAPP REV3-2019.doc
I
i
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
RNSTAOM : Paul J.Canniff,D.M.D.
.� 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 43 Issue Date: 01/01/2021
DBA: CVS PHARMACY #1869
OWNER: C.V.S. CORP/ LICENSING DEPT
Location of Establishment: 1080 FALMOUTH RD. HYANNIS„ MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2021
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM:
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
�0
�1HE rq� For Office • Initials:
y Town of Barnstable
Date Paid Amt Pd$�
,nnxseABLE, : Inspectional Services
v MASS'� Check#i63� `` Public Health Division
ptfD MPS A
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICCA)TION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE �' NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: _ .
ADDRESS OF FOOD ESTABLISHMENT: 1—
US/pharmacy
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): One CVS Drive
Mail Code 1160
E-MAIL ADDRESS: nonpharmacypermits@cyshealth.CORT woonsock6t, R1 02895
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS:
WELL WATER:Z�ASONAL:*YES NO ± ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application FormsTOODAPP 2020.doc
1�
OWNER INFORMATION: Stephanie Cadorette
FULL NAME OF APPLICANT Licensing Coordinator
SOLE OWNER: YES/NO OWNER PHONE#
CVS/pharmacy
ADDRESS S.Drive
Mail Code it )C ,���
CORPORATE OWNER: cket, RI 02895 L/ J
CVS/pharmacy
CORPORATE ADDRESS: One CVS,Drive
Mail Code
Woonsocket, RI 0289 PERSON IN CHARGE OF DAILY OPERATIONS: Vns� I L'
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
/l//6 /
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January I st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1 st.
Q:\Application Forms\F00DAPP REV3 2019.doc
s
- i
pgS Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
&UMSUBM Paul J.Canniff,D.M.D.
lk 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 43 Issue Date: 12/10/2019
DBA: CVS PHARMACY #1869
OWNER: C.V.S. CORP/ LICENSING DEPT
Location of Establishment: 1080 FALMOUTH RD. HYANNIS, MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
FOOD SERVICE ESTABLISHMENT: YEAR. 2020
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q�
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
�4ol s
For Office Use Only: Initials:
"�"�► Town of Barnstable �b6—
Date Paid � J Amt Pd$
MUMSTB,E, . Inspectional Services
1639. � 3 Ij 3-
Public Health Division Check#�a `,
fD MP a r IO
Thomas McKean,Director Ii
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304 *7
AP99PLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE 4 NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT: f—Au"' k �
ADDRESS OF FOOD ESTABLISHMENT: 0�/ f(el / Gf/ f4 4_
CVS/pharmacy
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
One CVS Drive
Mall e
rruT—
E-MAIL ADDRESS: nonpharmacypermits@cVShealth.com //��/ Woonsocket, RI 02895
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: �72i &6
TOTAL NUMBER OF BATHROOMS:
i
WELL WATER: YES NO ✓... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL:_Ie� SEASONAL: DATES OF OPERATION:_/ /_ TO
NUMBER OF SEATS: INSIDE/ OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE &NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application FormsTOODAPP 2020.doc
i-
OWNER INFORMATION: Stephanie Cadorette
FULL NAME OF APPLICANT Licensing Coordinator
e
SOLE OWNER: YES/NO OWNER PHONE#
CVS/pharmacy --
ADDRESS One CVS Drive `
Mail Cocie
CORPORATE OWNER: Woonsocket, RI 02895 CO
CVS/pharmacy
CORPORATE ADDRESS: One CVS Drive
Mail Code 1160
PERSON IN CHARGE OF DAILY OPERATION S I 02895 n �,o^ A l
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
1.
2. elk
Giro
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 openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
QAApplication FormsTOODAPP REV3-2019.doc
I
Town of Barnstable BOARD OF HEALTH
Paul J Canniff,D.M.D.
Board of Health Donald A.Gaudagnoli,M.D.
' aARNaTABM John T.Norman
4
s639 � 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstablems
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 43 Issue Date: 12/20/18
DBA: CVS PHARMACY #1869
OWNER: C.V.S. CORP/ LICENSING DEPT
Location of Establishment: 1080 FALMOUTH RD. HYANNIS MA 02601
Type of Business Permit: RETAIL FOOD
Annual: YES Seasonal:
IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0
FEES
_
FOOD SERVICE ESTABLISHMENT: YEAR: 2019
RETAIL FOOD: $100.00
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: ��
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING: I
C
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
FTnE bye - Initials:
o� Town of Barnstable
Date Paid ,2i Amt Pd$
�ELUMMAskST^��� Inspectional Services
s63q. �0
�rE1659. s Public Health Division
Thomas McKean,Director /
200 Main Street, Hyannis,MA 02601 G'
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE q NEW OWNERSHIP 003
RENEWAL t
NAME OF FOOD ESTABLISHMENT: T /
ADDRESS OF FOOD ESTABLISHMENT: CVS
MAILING ADDRESS DIFFERENT FROM ABOVE): nne pharmacy
� ) anp MIS Drive
Mail Code 1160
E-MAIL ADDRESS: 5se�2 (�i15. 0C✓,'\,- Woonsocket, RI 02895
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (D�► )�D - l/�e
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES 1,--'NO ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: 1/ SEASONAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DINING REMINDER***
OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING
REQUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
500D 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 n)
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 Forms\FOODAPPREV2018.doc
- - - ----- - --- ----
.. n
i
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT G a-c ( gZq
SOLE OWNER: YES/NO OWNER PHONE
CVS/pharmacy
ADDRESS One CVS Drive
-�4ai+-Gede-1,60
nsocket, RI 02895
CORPORATE OVE�I�ER:C`� c�.vr►Gtfi� t '� _FEDERAL ID NO. : J'0-3y a /
CVS/pharmacy
CORPORATE ADDRESS: One CVS Drive
Mail CAde 1169
Woonsocket, RI 02895
PERSON IN CHARGE OF DAILY OPERATIONS: K 7s e—A j4
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
I`
i
2. / /
SIGNATURE OF APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
V
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN j
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application Forms\FOODAPPREV2018.doc
Op MET TOWN OF BARNSTABLE..-.. - HEALTH INSPECTOR's Establishment Name: Date: Page: - 'Of
.p �,..- : ,... - .. OFFICE HOURS _ .-
• BARN sSB�e. PUBLIC
200 MA N ST RETSION `< " I ` 3 MON 3FPM INoReferen�e
Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN-OF CORRECTION Date Verified)
SS. �•� HYANNIS,MA 02601 sos-ssz 4saa - R-Red Item PLEASE PRINT CLEARLY ..
"lE°MP�a FOOD ESTABLISHMENT INSPECTION REPORT -
Namei'/ Dat Tvoe of Tyoe of Inspection7.
Ooeration(ss). Ro ✓� ?>
Address ood Servce e-inspect) n
� Level a ai - "�` . - . ection
Telephone Risk esi ential Kitchen Date: _
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness S
Caterer- - General Complaint -
Person in Charge(PIC) Time Bed&Breakfast ' HACCP
In: �-
f . ^
Other
Inspector Out: -
Each violation checked re uires 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) ❑ � � � �
yy require immediate corrective Tobacco 590.009(F) ❑ ,Qf' o
Action'as determined n d b the Board of Health.alth hazard and re uir :Allergen Awareness •: 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
1.❑ PIC Assigned/Knowledgeable Duties ❑ 13.Handwash Facilities C�
S 1 r
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives G O�L Ov�Q- 1 7�91,-
❑ 3.Personnel with Infectious,Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) I
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
CtiC
❑ 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 a �p
PROTECTION FROM CONTAMINATION ❑20.Time Asa Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food.Preparation for HS
❑ 10.Proper Adequate Handwashing :. CONSUMER ADVISORY
Vi lat ons Related tocGood Retail Practices Blue Items Total Number of
Consumer Advisories
❑ Hygienic g
( ) ( -� Critical Violations
Critical C violations marked must be corrected immediately. (blue&red items
0
Corrective Action Reqwred: El No ❑ Yes
Non-critical(N)violations must be corrected immediately or
Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency_Suspe'nsion
C N Official Order for Correction,Based on an,inspection today,the items
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other.
23..Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9.or more non-critical violations,
24.Food and Food Preparation: . (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical, results in an F.
B=One critical violation and less than 4 non-critical violations
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation.of the food if no critical violations observed,4 to 6-non-critical violations=B.
26.Water,Plumbing and Waste: (FC-5)(590.006) establishment permit and cessation of food'establishment operations. If Seriously Critical Violation=IF is scored automatically if: no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have aright to.a hearing. Your request must C=2 critical violations and less than 9 non=critical. If no critical water,sewage back-up,infestation of rodents or,insects,or lack of
violations obse ed,7 to 8 non-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials : (FC-7)(590.008) within
in writing and submitted to the Board of Health at the above address violation,4 to n n-critical violations=C:
29.Special.Requirements (590.009) win 10 days of receipt of this order.
30.Other DATE OF RE-INSPECTION Inspector's Ign toe Print:
31.Dumpster screened from public view III
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
's Signa tu
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC Print: "
Self Service Wait Service Provided Grease Trap Size Variance:Letter Posted• Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food-•or_Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Not and Cold Holding'
2-103.11 Person-in-Charge Duties 3-302.14 Protection from'i�v�apaoved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information_-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other*: 7-102.11 Common Name-Working Containers* 3=501.16(A) Hot PHFs Maintained At or Above 140°F*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
* 7-201.11 Separation-Storage*
Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11, Restriction-Presence and Use*� 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
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) I Exclusions and Restrictions*590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or g
7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Resumed Food and Reted of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
or Contaminated
Food 7.204A4 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
4-501.111 Manual Warewashing-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 Pe 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective mrzow
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 > REQUIREMENTS-,A--
Stuffing `.SPECIAU
4-703.11 Methods of Sanitization-Hot Water and Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
* Ratites-165°F 15 sec* in mobile food,temporary and residential
Sources 10 Proper,Adequate Handwashing g' p �
Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
$ Receiving/Condition g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140*F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) y 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
590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs
8 Tags/Records:Shellstock P 9 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
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 1590.000
3-203.12 Shellstock Identification Maintained*
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2� .003
5-20411 Location and'Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
.
3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
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
Supplied with Soap and hand Drying Devices
590.004(J) Labeling of Ingredients' 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures I 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. Special Requirements 1.009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590:000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
`Op THE rpm TOWN OF BARNSTABLE HEALTH INSPECTOR-s Establishment Name: - Date: Page: of
4 OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
a3 9. �•� HYANNIS,MA 02601 M-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
508-862-4644
FOOD ESTABLISHMENT INSPECTION REPORT
1 F-
Name Ns. Date3 Tyne of T f Ins ec o
Ooeration(ss) outi
Address / Risk F rvice Re-inspection
Level Previous Inspection
Telephone Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint �7
Person in Charge(PIC) .� Time Bed&Breakfast HACCP In: Other
Inspector Out: 4
Each violation checked requ es 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) ❑ a � t
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) at CLL L4 f-- - g7,
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ ,t--
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
d- -k54,5b�
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ]
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical ViolationsV `
Critical(C)violations marked must be corrected immediately. (blue&red items) ��v Corrective Action Required: [:1 No El Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating 3
y y ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items Embargo
checked indicate violations of 105 CMR 590.000/Federal Food Code. F] Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations B=One critical violation and less than 4 non-critical violations regardless of the number of critical, results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B.
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t F is scored automatically lack of
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 9non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or la
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
violation,4 to 8 no -critl al violations=C.
30.Other DATE OF RE-INSPECTION: Inspector's Sign re Print
31.Dum ster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N r
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: 1
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen 7 Y N
-_ _ �, _-r. -..--�- vV•._-".--+-r^��..--i.- -*..-...•__-'�._ . _...--...may..,,-.. _, -..-� ���.,..-_� `. -_���. -- -� -w-'- �--... + ...y - .. - _ _ _ _ �, ..--... -,-- _ _ �.-. ._- � _._.. _
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 A[or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
590.003(C) Responsibility of the Person-in-Charge[0
Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Se aration-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 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 Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.I3- Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* gg Not Otherwise Processed to Eliminate
Equipment*
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* ER erne//11200/
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155°F 15 sec*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary
and - ide in cater-
* Ratites-165°F 15 sec* in mobile food,tern or and residential
Sources 10 Proper,Adequate Handwashing g' P
Game and Wild Mushrooms Approved By * 3-40 1.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401'.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 1 T Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
$ Receiving/Condition g, g g 3-403.11(A)&(D) PHFs 165°F 15 sec .
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) - Commercially Processed RTE Food-140°F* (Blue Items 23-30)
3-202.11 Package Integrity Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts*
illness interventions and risk factors listed above,can be found in the
8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140°F to 70°F
3-202.18 Shellstock Identification ( ) g
* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45'F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Supplied with Soap and hand Drying Devices
Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients*
27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
`oaTHE Tom TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name:_O l l.R p j Date: 2 Z Page:_ of
OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY n n FOOD ESTABLISHMENT INSP CTION REPORT 508-862-0644
Name �� Date - ,L Type of T f Inspection
Ooeration(s) Routine
Address e L Risk Food Service -nspection a `•
Level eta' � Previous Inspection
Telephone -Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) .S Time Bed&Breakfast HACCP
-� In: I' 30&I Other `
Inspector Out: G�
Each violation checked reWres an explanation on the narrative page(s)and a citation of specific provision(s)violated. I/
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ LW
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Vl/(( ..e. � 'n C
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 1 O
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories ll�s
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) �] 172 Corrective Action Required: ❑ No El Yes
Non-critical(N)violations must be corrected immediately or Overall Rating Oyvw
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 Embar o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations B-One critical violation and less than 4non-critical violations re9 ardless 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
2 .Water,Plumbing and Waste (FC-5)(590.00 ) establishment permit and cessation of food establishment operations. if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
C=2 critical violations and less than 9non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must
be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements
irements (590.0099)) days o receipt 28.Poisonous Toxic Materials (FC-7)(590.00 within 10 da f i t of this order. violation,4 to 8 non-critical violations=C.
30.Other DATE OF RE-INSPECTION: Inspector's Signatur Print:
31.Dumpst/er screened from public view �� �i
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'---
ignature Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
tYt � 11 Z
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
3-501
590.003(B)- Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* .15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F)
2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
Re uire Reporting b Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
Applicants* g Y3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use*
3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 3-304.11 Food Contact with Equipment and Utensils*
7.202.12 Conditions of Use 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge*
Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions*
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
590.003(E) I Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and *
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
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- mme is 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* 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* 3-401.11(B)(1)(2) 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source Pork and Beef Roast-130°F 121 min*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-I55°F 15 sec* Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec*
' Sources* - 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
2-301.11 Clean Condition-Hands and Arms the appropriate
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave PPriate sections above if related to
P
* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.0 4( Shellstock Identification Present * Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3 401.11(A)(1)(b) All Other PHFs-145°F 15 sec
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under 929-Special
Requirements.
2-401.11 Eating,Drinking or Using Tobacco* 3-403.11 A&D PHFs 165°F 15 sec*
5 Receiving/Condition ( ) ( )
2-4
3-202.11 PHF's Received at Proper Temperatures* 01.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-301.12 Preventing Contamination When Tasting* * Blue Items 23-30)
3-202.15 Package Integrity* g g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne
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 Food Safe and Unadulterated* � ound in the f
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained*
Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.148) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41'F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 special Requirements 1.009
3-502.11 Specialized Processing Methods* 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.
bf I q.
°F, r TOWN OF BARNSTABLE HEALTH wsPECTORs Establishment Name C�/�24��Il/ Date: Page: of '
'4 0�' OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. ` 200 MAIN STREET O - 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
Me3q: �e HYANNIS, MA 02601 f� ,�1 J 508-62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY
M FOOD ESTABLISHMENT INSPE T N REPORT
Name Date o of Ins ectio
Operation(s) Routt e
Address isk If- ervice pecti n
evel tail Previo a t�
Telephone esi ential Kitchen Date:
Mobile Pre-ope t n
Owner HACCP Y/N Temporary Suspect Mines
Caterer General Complaint -
Person in Charge(PIC) Time Bed&Breakfast HACCP (�
Other
Inspector ut
441
Each violation checked requires an explanation on the nar at a page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions an 'Risk Factors Red Items)) Anti-Choking 590.009(E) ❑ r, 11
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
A
❑ 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 i
❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
i
PROTECTION FROM CONTAMINATION ❑ 20.Time Asa Public Health Control -
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) _ .l
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP f V , W
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY _/t
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories IXJ��1� n
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) .In
: Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must becorrected immediately or
within 90 days as determined b the Board of Health. Overall Rating Voluntary Compliance
y y ❑ ry p ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Sus ;ion
C N Official Order for Correction:Based on an inspection today,the items o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embar g ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24,Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 6=One critical violation and less than 4n6n violations
�26.water,Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
C=2 critical violations and less than non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) within 10 days of receipt of this order.
violation,4 to 8non-critical ola' =C.
30.Other DATE OF RE-INSPECTION: I sp for Signatur c Print:'
31.Dumpster screened from public view / I
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N s Sign ure 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* S 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 1 g 590.004(F)
590.003(C) Responsibility of the Person-in-Charge to Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45`F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140'F*
P g
2
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
_ 7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004(11)
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions Variance Requirements
590.003(G) Reporting by Person in Charge -
Contamination from the Consumer *
3 590.003(D) Exclusions and Restrictions* 7-204.1 t Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR r-
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources F 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* -t 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 FluidMilk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(l)(2) Eggs-155' 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
F
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145'F 15 sec* Anal 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 1112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 316 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*
4-703.11 Methods of Sanitization-Hot Water and
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g �' 590.009(A)-(D)' Violations of Section 590.009(A)-(D)in cater-
Sources* Ratites-165*F 15 sec* ing,mobile food,temporary and residential,
10 Proper,Adequate Handwashing 3-0Ol.l1(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165`F* foodborne illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140'F* (Blue Items 23-30)
3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70'F
* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45'F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction* Temperature Ingredients to 41'F/45'F 25. Equipment and Utensils FC-4 .005
* 5-205.11 Accessibility,Operation and Maintenance *.
3-402.12 Records,Creation and Retention Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients'
Supplied with Soap and hand Drying Devices
6-301.11 Handwashin Cleanser,Availabili 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ g ty 28. 1 Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code.or 105 CMR 590.000.
�p IKE r TOWN OF BARNSTABLE HEALTH INSPECTOR•s Establishment Name: �J � Date: Page: of
OFFICE HOURS
PUBLIC HEALTH DIVISION e:00'-9:30A.M.
% BARNSTABLE. • 200 MAIN STREET 3:3o-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
M6sv: HYANNIS,MA 02601 M-8 -FRI.sz asaa No Reference R-Red Item PLEASE PRINT CLEARLY
508-s
p'EDN1P�' FOOD ESTABLISHMENT INSPECTION REPORT 6 (Z
Name V Date � �� a of Tyoe of Insoection
Address
Oo �i
eration(s) n cS T dr�-a
Risk Food Service R-eTn ection
0 I Level tai Previous Inspection I O �s�
Telephone sidential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness - �� A -113
Caterer General Complaint f�1
Person in Charge(PIC) Time Bed&Breakfast HACCP -Q 1 -F W --1 0a
In: Other
Inspector Q �V 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`' n j�
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories JJ
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
Rating
Rang
within 90 days as determined by the Board of Health. Overall ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items Embargo Emergency Closure ❑ Voluntary Disposal Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4 590.005 B=One critical violation and less than 4non-critical violations 9
)( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a riglit 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 in or lack of
28.Poisonous or Toxic Materials_ (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration.
29.Special Requirements (590.009) PY
within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C.
.
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view4VAJV_,,�
,^ ✓�
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N ► I J
#Seats Observed Frozen Dessert Machines: Outside Dining y N PIC's Signature I Print:
Sell Service Waft Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N �N l
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives*
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45'F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
Other* g3-501.16(A) Hot PHFs Maintained At or Above 140`F*
2 590.003(C) Responsibility of the Person-in-Charge[0 7-102.11 Common Name-Working Containers* *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
Storage*-
Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized 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*
q Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
* Equipment
4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145F 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 rirrzoor
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 anpprove Ad Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs*
4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I Ratites,Injected Meats-155'17 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
4703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 8 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* Ratites-165'F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* 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 Requirements.
radicsshould be debited under#29-Special
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165"F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 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 3403.11E Remainin Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated ( ) 8 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* 3-501.14(A) Cooling 13 Handwashing Facilities Cooked PHFs from 140'F to 70°F
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 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand in Provision
Drying 29. Special Requirements 1.009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
°F.KE. TOWN OF BARNSTABLE HEALTH INSPECTOR-S Establishment Name: Date: Page: of
� ° -OFFICE HOURS
TH
ARN�rAB.E°i PUBLIC
2 0 MANLST STREET 3:3030-
SION : 4:30 P.M.:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS p MON.-FRI.
HYANNIS,MA 02601 sos-as2 asaa No Reference R-Red Item PLEASE PRINT CLEARLY
'fD"" FOOD ESTABLISHMENT INSP CTION REPORT -
Name Date pe of Tyne of Insnection
Oneration(sl Roub
Address isk Fo rvice e-
Level etail revlo pection
Telephone esidential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
01 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
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices Glue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items)
a Corrective Action Required: ❑ No TO Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑.Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.. ,
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 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 6uon-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of
violations observed,7 to anon-critical violations. If 1 critical refrigeration.
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address
within 10 days of receipt of this order. violation,4 to 8 non critical violations=G:
29.Special Requirements (590.009) Y P ,
30.Other DATE OF RE-INSPECTION: I spector's S/i�nature Print:
31.Dumpster screened from public view l.
40
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N I Y
Frozen Dessert Machines: Outside Dining N PIC's Si tune Print:Y#Seats Observed
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.) i
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
s r 3. 'a Law Cooled to 41°F/45°F Within 4 Hours*
1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination _ . .,„1q Food-or.Color Additives_,.,,,.,._.,- w -50
* 1 31.15 Cooling Methods for PHFs
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives
Cooked and RTE Foods* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients ' 15 . P
3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
- Poisonous or Toxic Substances 590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to
Other 7-102i11 Common Name-Working Containers** _ 3-501.16(A) Hot PHFs Maintained At or Above 140°F*-
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*-
7-201*11 Separation
Applicants* 3-302.11(A) Food Protection* p20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health.Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Requirements
3-304.11 Food Contact with Equipment and Utensils * ( ) q
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions
Contamination from the Consumer -
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chericals* -_u_ -_ _ REQUIREMENTS FOR.- _
3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for WashingProduce,Criteria*. HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition ofAduIterated 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* 3-80111(D) Raw or Partially Cooked Animal Food and
4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* .
Raw Seed Sprouts NotServed* ;" '� . 1' '
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and p
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS - - , -
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs
3-202.16 Ice Made From Potable Drinking Water* CONSUMER ADVISORY
,Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec
dness* 22 3-603.11 Consumer Advisory Posted for Consumption of
A11
Animal Foods That are Raw Undercooked or
-601. Clean Utensils and Food Contact Surfaces o *
5-101.11 Drinking Water from an Approved System* 4 ( t f f Eggs-Immediate Service 145'F 15 sec '
Equipment* t Not Otherwise Pto-Eliminate rocessed . . .
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Utensils and Food 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* E//°"°e uuzooi 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* Animals-155°F 15 sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
faces of Equipment*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites 165°F 15 sec* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 340i.l l(C)(3)- Whole muscle;Intact Beef Steaks 145 F* -'� kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165*F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices _ 17, Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
$ Receiving/Condition g, g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* -. 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercial] Processed RTE Food-140°F* (Blue Items 23-30)%
3-202.15 Package Integrity Y
12 Prevention of Contamination from Hands _ Critical and nonreritical violations;which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated* 3-003.11(E) Remaining Unsliced Portions of Beef Roasts*-
590.004 E Preventing Contamination from Employees* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock ( ) g18- Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501,14(A) Cooling Cooked PHFs from 140°F to 70 F
* Conveniently Located and Accessible Within 2 Hours and From 70 F to 41 F/45°F Item Good Retail Practices FC -590.000
3-203.12 Shellstock Identification Maintained
Tags/Records_:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501 14(B) Cooling PHFs Made from Ambient. 24. Food and Food Protection FC-3 -.004 -
3-402.11 Parasite Destruction Temperature Ingredients to 41 F/45'F 25. Equipment and Utensils FC-4 .005
3 402.12 Records,Creation and Retention* 5-205.11 Accessibility,O Operation and Maintenance _
P WithinA Hours* 26. Water,Plumbing and Waste FC-5 .006 -
590.00 J Labeling of Ingredients* Supplied with Soap and hand Drying Devices _
4O 9 9
6-301.11 Handwashin Cleanser,Availability 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ g ty ` 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 1 Hand Drying Provision 29. Special Requirements 009
3-502.11 Specialized Processing Methods* 30. Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* .. .. ;590Fformba-ck&2doc `
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in fhe federal1999 Food Code or 105 CMR 590.000. ' "
°p THE r, TOWN OF BARNSTABLE - HEALTH INSPECTOR,s Establishment Name: Date: Page: . ` of,
�I OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30A.M.
BARNSTABLE. ` 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
MASS. MON.-FRI.
94, ,639•per• HYANNIS,MA 02601 soa-asz 4644 No Reference R-Red Item PLEASE PRINT CLEARLY
'FDN1P� FOOD ESTABLISHMENT INSPEC ION REPORT
Name Dat a of T s e do
Ooeration(sl Routine
Address Ris , Foo ervice -Inspection
Le el etai Previous Inspection
Telephone sI ential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint �-
Person in Charge(PIC) _ Time Bed&Breakfast HACCP
In: Other
Inspector I Out:
:z 2U�
Each violation checked req res-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 A "
❑ 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)
I
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Itemsl Total Number of Critical Violations I
Critical(C)violations marked must be corrected immediately. (blue&red items) I ' Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. FOEmbat
olunary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based on an inspection today,the itemsr ochecked indicate violations of 105 CMR 590.000/Federal Food Code g ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non=critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations g=One critical violation and less than 4nonscritical violations regardless of the number of critical',results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B.
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot
FC-6)(590.007 aggrieved b 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
27.Physical Facility ( ) g9 Y Y 9 g• q
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to 8non-critical violations=C.
29.VDumps
iremerits (590.009 Y P
30. DATE OF RE-INSPECTION: Inspector's Signature Print:
31. eened from public view
Permit Posted? N Grease Trap Previous Pumping Date Grease Rendered Y N
i P Signat Print:
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's -
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted . . Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination - 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41'F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers*
3-501.16(A) Hot PHFs Maintained At or Above 140°F*
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants* - '" 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use*
590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions*
3-304.11 Food Contact with Equipment and Utensils*- 590.004(11) Variance Requirements
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 AdulteReserrated
or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* - 4-501.111 - Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.111 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS- -
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment
5-101.11 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 uuzoor
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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
Stuffing Containing Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites
Sources* 10 Proper,Adequate Handwashing -165°F 15 sec* ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
_ _ ( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-0Ol.11 Eating,Drinking or Using Tobacco* * Requirements.
$ Reeeiving/Condition g, g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* * (Blue Items 23-30)
3-202.15 Package Integrity g g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate:to the 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 TagsiReeords:Shellstock 590.004(E) Preventing Contamination from Employees* Lis Proper Cooling of PHFs ' I Ifollowing sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from.140-F to 70°F. .
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41"F/45°F Item Good Retail Practices FC 590.000
Within 4 Hours* 23. Management and Personnel FC-2 2 .003
Tags/Records:Fish Products 5-203:11 Numbers and Capacities*
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices
(n 9 g
6-301.11 Handwashin Cleanser,Availability 28. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ g ty � 28. Poisonous or Toxic Materials FC-7 .006
HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000;
p THE► TOWN OF BARNSTABLE - HEALTH INSPECTOR'S Establishment Name: Date: Page: Of
° °Hq OFFICE HOURS
eAaN�rAaLE° PUBLIC
2 0
00 MAN STREEETDIVISION 3:3 - :30A.M.
4: 0- :3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
ME7q:s�m HYANNIS,MA 02601 MON.-FRi. No Reference R-Red Item. PLEASE PRINT CLEARLY
rEo Mn+ 508-862-4644
FOOD ESTABLISHMENT INSPECTION REPORT
v1
Name Dat Tyne of Ins ection
Operation(s) Ro
Address Risk Foo rvice e-inspection
Lev I etail Previous Inspection
Telephone esi ential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP
14- In: Other
Inspector Out:
�"W' 01
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 S`
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures IV
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑ 7.Conformance,with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or Overall Rating
within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
checked indicate violations of 105 CMR 590.000/Federal Food Code.
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical.violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B.
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t F is scored automaticallytion of rodents or insects,or lack of
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 non-critical. If no critical ' water,sewage back-up,infestation
28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to 8non-critical violations=C.
29.Special Requirements (590.009) Y P
30.Other DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N VA
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PI 'S,,8jgn e Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45`F Within 4 Hours*
PHFs
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-262.12_` Additives* 3-501.15 Cooling Methods for ldin
.Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
2-103.11 - Person-in-Chazge�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
590.004(F) -
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*
2
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 590.003(C) Responsibility of the Person-in-Charge to - 7-102.11 Common Name-Working Containers* _ _JI 7-201.11 Separation-Storage* _
Require Reporting by Food Employees and Contamination from the Environment 3-301.16(A) Roasts Held At of Above 130°F*
__ _ - _ _ _ _ __" _
- Applicants*- 3--302.11(A) Food Protection* 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An _ 3-302.15 _ _ Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements
3-304.11 Food Contact with Equipment and Utensils * ( ) 9
590.003(G) Reporting by Person in Charge* _ _ __ _ 7-203.11 Toxic Containers-Prohibitions
Contamination from the Consumer
3 590.003(D) I Exclusions and Restrictions* 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 8 ( )
Disposition of Adulterated or Contaminated
-I -- - - 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 Regdlated'Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* _ 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y * _ P 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-Served*
3-201.13 Fluid Milk and Milk Products 4-501.112 Mechanical Wazewashing-Hot Water Monitoring
3-202.13 Shell Eggs* _ _ _ Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 1 Eggs and Milk Products,Pasteurized* r 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
4-601.11(A) Clean'Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* _ . _ __ _ Equipment* gg Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* � 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eb-"ve uuzoor
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMI.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 StuffingContaining Fish,Meat,Poultry or
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165°F 15 sec*
Sources* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3 401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F' kitchen operations should be debited under
ut Game and A Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
* 2-301.14 When to Wash* 3-401.11 A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
590.004(C) Wild Mushrooms ( )( )( )
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
$ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3A03.1I(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) Y
* 12 Prevention of Contamination from Hands 3-403.11 Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodborne
3-101.11 Food Safe and Unadulterated (E) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstoek 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
* 13 Handwashing Facilities 3-501.14(A) 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 1590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction*.. Temperature Ingredients to 41`F/45°F 25. Equipment and Utensils FC-4 .005
3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance- Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I FC-7 008
HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements 1 .009
3-502.11 Specialized Processing Methods* 30. 1 Other
37502.12 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.
pp IKEr TOWN OF BARNSTABLE HEALTH,INSPECTOR'S Establishment Name: Date I Page: of
W OFFICE HOURS
PUBLIC HEALTH DIVISION 8:00-9:30 A.M.
BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
�p 67.p�0� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
lFD MPS 508-862-4644
FOOD ESTABLISHMENT INSPECTION PORT
Name Da �� e o Tyoe of Inspection
Ooeration(s) Routine `G/ E
Address (� Ris Food Service -Ins ecf
v Level etail revious Ippection
Telephone ential Kitchen
Mobile Pre-operation
Owner HACCP Y/N hemporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time Bed&Breakfast HACCP .�sL�
In: Other
Inspector Out:
f
Each violation checked requires an explanation din the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding
PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control
❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined by the Board of Health. Overall Rating Voluntary Com❑ ry Compliance p ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction: Based on an inspection today,the items Embargo
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 9 Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 9 ardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in,suspension or revocation of the food B-One critical violation and less than non-critical violations re
26.Water,.Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot
C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 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.
violation,4 to 8non-critical violations C.
29.Special Requirements (590.009) within 10 days of receipt of this order.
=
30.Other. DATE OF RE-INSPECTION: Inspector's Signature Print:
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signet - Print: .
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N +
Dumpster Screen? Y N ,.
,` r.r _ _ s•yl-fir -`i,+l-. R�-�.1'\.^.r'� er- tic':.-rr--�. ,•��t �.-.✓"`-'�ti.. _ - - .. ..
Violation related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives
Contamination from Raw Ingredients 15 - Poisonous or Toxic Substances ,' 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* *
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers*. *
Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F
7-201.11 Separation-Storage*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
7-202.11 Restriction-Presence and Use*
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
590.003(G) Reporting by Person in Charge* Contamination from the Consumer '
3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
P 7-206.13 Tracking Powders,Pest Control and
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served*
3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS
3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
Eggs
5-101.11 Drinking Water from an Approved System*
4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
_
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3 401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* EX ctive inn001
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 Surr ffaces 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* ing,mobile food,temporary and residential
10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms*
Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
2-401.11 Eating,Drinking or Using Tobacco* * Requirements.
5 Receiving/Condition g, g g 3-403.11(A)&(D) PHFs 165°F 15 sec
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3 403.11 * (Blue Items 23-30)
3-202.15 Package Integrity (C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbore
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3,103.11(E) Remaining Unsliced Portions of Beef Roasts*
g illness interventions and risk factors listed above,can be found in the
8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F
3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008
HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009
3-502.11 Specialized Processing Methods* 30. 1 Other
3-502.12 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
f
R Town of Barnstable
tHE t
Regulatory Services Barnwe CS .
Thomas F. Geiler,Director 3i
+ BARNSfABLE,
9
MASS. Public Health Division 1639' �0 2007
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE:
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT:_
MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: PARCEL(S)
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ) TIC- 4lo f
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
TOTAL NUMBER OF BATHROOMS:
ANNUAL OR SEASONAL OPERATION: _AIWI IfA,41-
TYPICAL HOURS,OF OPERATION 3J9 : TO /D
DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS)
IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO
***RENHNDER*** `4-
t C
SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO 6PENINIG
�1
TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY ' v3
FOOD SERVICE a'
RETAIL FOOD "' M
BED & BREAKFAST
CONTINENTAL BREAKFAST
RESIDENTIAL KITCHEN
MOBILE FOOD
TOBACCO SALES
FROZEN DAIRY DESSERT MACHINES
CATERING
OUTSIDE DINING
QAHealth\Application Formffoodappl.doc
l_
***REMINDER*** _ s
IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND ,
LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?h///0v
CONTACT INFORMATION:
FULL NAME OF APPLICANT Dianne Lackey Licensing Coordinator
SOLE OWNER: YES(S)
ADDRESS
PHONE #C_ , -
IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL
PARTNERS:
IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION
STATE OF INCORPORATION
FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES
RETAIL FOOD ESTABLISHMENTS-THAT DON'T PREPARE FOOD AND CONTINENTAL
BREAKFAST):
LIST THE NAMES-OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE)
.EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED
TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE
FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS
OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE
CERTIFICATE***
1• EXPIRATION DATE:
2• EXPIRATION DATE: / /
3. EXPIRATION DATE: / /
4• EXPIRATION DATE: / /
SIGNATURE OF APPLICANT AND DATE
Q:\Health\Application Forms\Foodappl.doc
Town of Barnstable
OF tHE Tp�
Regulatory Services
Thomas F. Geiler,Director
+ BARNSrABLE, Public Health Division
MASS. a
1639• ,��� Thomas McKean Director AJ�O MAC a 200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
FEE: $50.00
MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION
200 MAIN STREET
HYANNIS,MA 02601
FAX: 508-790-6304
PLEASE INCLUDE THE REQUIRED FEE OF$50.00
APPLICATION FOR A TOBACCO SALES PERMIT
LAST NAME FIRST NAME MIDDLE INITIAL
D/B/A
W j d e" i
STREET ADDRESS
T LEPHONE.NUMBER
Do you currently possess a state license to sell tobacco products?
Yes No ❑
Each employee who sells tobacco products must receive and understand the Sections
VIIb. and VIIc. of the Board of Health Prohibition of Smoking Regulation, (copy
provided herein), and the Massachusetts General Laws Chapter 270, Section 6.00 (a copy
is provided on the next page). Each employee who sells tobacco products must sign the
Eml#yee Sig Vatuor (provided herein).
9f J
Signature Date
q:\tobacco\wp files\tobacco forms\tobaccoapp.revised 10.3 1.2006.doc
T oin ronwealth. of IMIa>ssachuse'tts •
iartn ent of Iild-ustrial Accidents
Off ce of, Investcgatzons
600 Washington Street
y` Boston,-MA 021 11
b4'1'4 w.P'ass::a ovIdia.
Workers' Compensatio;m Insurance Aff:davit: General Businesses
Applicant ]information Please Print Le-ibly
Business/Organization Name: CVS/:phartnacv
Address: One CVS Drive, Mai 1 Drop 23062A
.City/State/Zip: Wmnsankor. Ri o?895 Phone #: «,) 7.65_1.500.
Are you an employer? Check the appropriate box: Business Type (required):
1.2 I am a employer with_�employees (full and/ 5. Q Retail
or part-time).'" 6. ❑ Resiaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no �. Office and/or Sales (inch. real estate, auto,etc.)
employees working for me in any capacity.
[No workers' camp.insurance required] S. ❑ Non-prof'[
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we-have 10.7 Manufacturing
no employees. [No workers' comp. insurance required]`
4.❑ We are a non-profit organization,staffed by volunteers, II.❑ Health Care
with no employees. [No workers' comp..insurance.req.] 12.0 Other
`Any applicant that checks box 91 must also Cll out the section bdl'ow showing ihcir workers"eonipegsation p6licy information.
"If the corporate officers have exempted themselves,but the eorporaiion has oilier cmpl'oyces,a workers'conipcnsa.uon policy is required and such an
organization should check box 91.
I am an erg:plover that is providing workers'coiiiperasat on"irzsiirance for irry employees. Below is the policy infonnation.
Insurance Company Name: Ame. rican Iim-e Assurance
Insurer's Address: 70 Pine Street
City/State/Zip: New York. NY 1027
Policy# or Self-ins. Lic. # a75 39-50 Expiration Date: 01/01/M
Attach a copy of the workers' compensation.policy,declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of:M.GL c. 152 canaead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year im.prisonrnent; as well as civil penalties it-,the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this.statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ccrtifi,, u.n r the pains aazd p ties of perjury that the info:rmatioz:provided above is true and correct:
Signature: Date:
Phone #:
Official use only. Do not write inn this area, to be:completed by:city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. ]Board of Health 2. Building Department 3. City/Town Clerk 4.Licensing Board 5. Selectmen's Office
6. Other
Contact Person: Phone#:
e wwwv;mass.gov/dia
i
p
Date: June 17, 2004
Barnstable Massachusetts
Department of Health
200 Main Street
Hyannis, MA 02601
RE: Food Establishment License
Centerville Falmouth St. CVS,Inc.
dba CVS/pharmacy#1869
1080 Falmouth Rd
Centerville,MA 02632
Dear Madam or Sir:
Please find enclosed a check in the amount of$50.00 for a New
Establishment Permit for the above referenced store. The original second page of the
application is also enclosed.
Please send the original license directly to the store as they will be relocating on
June 19, 2004 and will need it in their possession at that time.
Thank you for your cooperation in this matter. If you have any questions, please
feel free to contact me at 401-765-1500, extension 4192.
Sincerely,
Catlynn R. Cabral
Licensing Coordinator
Licensing Department
/crc
Enclosures
UPS NEXT DAY
ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500
j
DY YW�LJ I..I LJW V
t
Date: June 11, 2004
Barnstable Massachusetts
Public Health Division o
s- as
200 Main Street c
Hyannis, MA 02601 C)
w
RE: Tobacco Sales Permit c, M.
Centerville Falmouth St. CVS,Inc.
dba CVS/pharmacy#1869 w
1080 Falmouth Rd co rn
Centerville,MA 02632
Dear Madam or Sir:
Please accept this letter as official notification that the above referenced store is
scheduled to relocate to 1080 Falmouth Rd, Centerville,MA 02632,on approximately
June 19,2004.
Enclosed please find completed applications, and checks in the amount of($50.00)
for a Tobacco Sales Permit for the above referenced store.
Thank you for your cooperation in this matter. If you have any questions, please
feel free to contact me at 401-765-1500, extension 4192.
Sincerely,
C
�
Catlynn R. Cabral
Licensing Coordinator
Licensing Department
/crc
Enclosures
UPS NEXT DAY
ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500
L , a
o G�aC�G�i aC�
c�c Hot �51 - Oag3
Date: June 11, 2004
Barnstable Massachusetts
Department of Health
200 Main Street
Hyannis, MA 02601
RE: Food Establishment License r
Centerville Falmouth St. CVS,Inc. C= c
dba CVS/pharmacy#1869 �_ -n
1080 Falmouth Rd p,
Centerville,MA 02632 C) -
Dear Madam or Sir: _
rn
Please accept this letter as official notification that the above referenced st a is
scheduled to relocate to 1080 Falmouth Rd, Centerville,MA 02632,on approximately
June 19,2004.
Enclosed please find completed applications, and checks in the amount of($75.00)
for a Food Establishment License for the above referenced store.
Thank you for your cooperation in this matter. If you have any questions, please
feel free to contact me at 401-765-1500, extension 4192.
Sincerely,,
ea*a'�—
Catlynn R. Cabral
Licensing Coordinator
Licensing Department
/crc
Enclosures
UPS NEXT DAY
ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500
JUN-15-2004 TUE 02:40 PM US LEGAL 01 FAX NO. 401 765 7887 P. 02/03
CVS/pharmacy
e
Date: June 15, 2004
Barnstable Massachusetts
Department of Health
200 Main Street
Hyannis,MA 02601
r
0
RE: Food Establishment License
Centerville Falmouth St. CVS,Inc. ' �'
dba CVS/pharmacy#1869 �� c.n-
1080 Falmouth Rd o -�
Centerville,MA 02632 a
w �
r—
Dear Madam or Sir: � rn
Please accept the attached document as a coirection to the original request for a
1?ood Establishment License. The above referenced store is scheduled to relocate to 1080
Falmouth Rd, Centerville MA 02632,on approximately June 19,2004.
In addition, a check in the amount of$50.00 will be sent for a New Establishment
Permit for the above referenced store.
Thank you 11or your cooperation in this matter. If you have any questions, please
feel free to contact me at 401-765-1500, extension 4192,
Sincerely,
Catlynn R. Cabral
Licensing Coordinator
/crc Licensing Department
Enclosures
-UPS NEXt-DA-y
ONE CVS DRIVE, WOONSOCKET RI 02895 401-765-1500
JUN-15-2004 TUE 02:40 PM CUS LEGAL 01 FAX N0, 401 765 7887 P. 01/03
1 CVS Drive,Woonsocket,RI 02895—(401)770-1500
CVS Pharmacy, Inc.
Fmax
To: Bamstable Dept of Health From: Catlynn Cabral
Fax: (508)790-6304 Pages:
Phone: Date:
Re: Back half of food license app.#1869 CC:
❑ Urgent X For Review ❑Please Comment ❑Please Reply ❑ Please Recycle
• Comments:
Please see attached affidavit.
N --i
Thank you, � C�
rZE
c_
Catlynn R. Cabral ►, C)
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P. 1
COMMUNICATION RESULT REPORT ( JUN.15.2004 2:08PM )
TTI BARNSTABLE BOARD OF HEALTH
FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE
----------------------------------------------------------------------------------------------------
342 MEMORY TX 914016520293 OK P. 1/1
- -----------------------------------------------------------------------------------------------
REASON FOR ERROR
E-1) HANG UP OR LINE FAIL E-2) BUSY
E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION
* �eRENffNDIE R
O LJTSIDE D ING U T RE PRO ri EY PIE BO OF HEALTH An
LICENSING, T ALL OF THE OUTSIDE DINING CRITERIA
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)7
CONTACT INFORhMION.
FULL NAME OF APPLICANT
SOLE OWNER: YES/NO
ADDRESS
PHONE#
IF PLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL
F TNERS:
IF APPLICANT IS A CQRPORATION: FEDERAL IDENTIFICATION NO.
STATE OF INCORPORATION
F!gOD, SERVICE UJARLISHMENTS COMUCTING FOOD PRE ARAT (EXCLUDES
rwl.TT T,ra•%n r,Orr A yr IrCXMtVW rQ TAAT nAVOT PRiF,PART. roan AND CONTINENTAL
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SIDEWALK LAYOUT AND
1 -1/2" TYP. INFORMATION. °NNU
CANOPY DIMS BKA13-3" 13-3" 7-0 uARCHITECT S, INC.
32'-1 3/4" WINDOW 5'-4 1/ " MASONRY DIMS 142 Crescent Street
-7.2 YBrockton, MA02302
— - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Phone: 555-5605
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5 R�
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. OBSERVATION
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Z FLOOR PLAN NOTES PARTITION TYPES PLANNING MGR.
.
N WATER TILE DRAWING BY: _
.._-K_L__-
--PO NOTUSED 3 5/8" METAL STUDS (20 GA.) ® 16" O.C. TO
COMPACTOR BY CVS a OE UNDERSIDE OF THE ROOF W/ 5/8" G.W.B. BOTH4" CONCRETE FILLED PIPE BOLLARD, PAINT SIDES, DATE: 09/26/03
CHAIN-LINK FENCE ENCLOSURE AROUND COMPACTOR. O6" METAL STUDS (20 GA.) ® 16" O.C. TO UNDERSIDE OF(SEE SHEET A-4.1) ROOF STRUCTURE W/ 5/8" MOISTURE RESISTANT NOT USED JOB NUMBER: 202107FACE OF SOFFIT ABOVE SEE WALL COMPACTOR CHUTE BY CVS VENDOR GYPSUM WALL BOARD BOTH SIDES. PROVIDE SOLID
SECTIONS. WOOD BLOCKING AS REQUIRED FOR PROPER TI TLE:FIXTURE/ACCESSORY ATTACHMENT OF CANOPY ABOVE GAS METER 3 5/8" METAL STUDS (20 GA.) ® 16" O.C. TO
3 5/8" METAL STUDS (20 GA.) @ 16" O.C. TO UNDERSIDE UNDERSIDE OF ROOF STRUCTURE W/ 5/8" GWB FLOOR PLAN6" CONC. FILLED PIPE BOLLARD, PAINT, TYP. SPLIT SYSTEM WALL MOUNTED (COORDINATE WITH
FIRE TROUBLE PANEL AND BULLETIN BOARD) OF ROOF STRUCTURE W/ 5/8" MOISTURE RESISTANT GYPSUw
QOF SECURITY GRILLE TRACK WALL BOARD INSIDE OF RESTROOM. 5/8" GYPSUM WALL
ELECTRICAL DISCONNECT BOARD OUTSIDE OF RESTROOM. PROVIDE SOLID WOOD
6 THICK CONCRETE COMPACTOR PAD WITH W.W.F. BLOCKING AS REQUIRED FOR PROPER FIXTURE ATTACHMENT. SHEET NUMBER:FLOOR PLAN
SCAM: 1/8"=1'-0" 3 5/8" METAL STUDS (24 GA.) @ 16" O.C. TO S-6" ABOVE--
S.O.A.
FLOOR W/ 5/8" GYPSUM WALL BOARD BOTH SIDES. o
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13-3 13-3 13-3 7-0 CANOPY DIMS I
" , „ ARCHITECTS, INC.
32-1 3/4 WINDOW 1 _8 5-4 1/ " 1 MASONRY DIMS
1 142 Crescent Street
1 I I 1 Brockton, MA 02502
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MASONRY DIMS 1 17'-3" 6'-0" -5.1 4 -5.1 3 1 REVISIONS:
V. I I A-4.1 I SECURITY I A-6.3
I I 1 OBSERVATIONA.
4'-7" AFF.
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A-5.3 0
o I LAYOUT COORD: -
STEEL DIMS 13'-2" 12'-8" FLOOR PLAN NOTES PARTITION TYPES PLANNING MGR. -
O WATER TILE
A. NOT USED F 3 5/8" METAL STUDS 20 GA.) 0 16" O.C. TO DRAWING BY: KLP
F E.6 E O COMPACTOR BY CVS O ( " o
O 4" CONCRETE FILLED PIPE BOLLARD, PAINT UNDERSIDE OF THE ROOF W/ 5/8 G.W.B. BOTH
(SEE SHEET A-4.1) J CHAIN-LINK FENCE ENCLOSURE AROUND COMPACTOR. O 6" METAL STUDS (20 GA.) ® 16" O.C. TO UNDERSIDE OF SIDES. DATE: 09/26/03
0
O FACE OF SOFFIT ABOVE - SEE WALL ROOF STRUCTURE W/ 5/8" MOISTURE RESISTANT O NOT USED o JOB NUMBER: 202107
10 COMPACTOR CHUTE BY CVS VENDOR GYPSUM WALL BOARD BOTH SIDES. PROVIDE SOLID
SECTIONS.
O FACE OF CANOPY ABOVE 11 GAS METER WOOD BLOCKING AS REQUIRED FOR PROPER
O r TI TLE:
FIXTURE/ACCESSORY ATTACHMENT 0 3 5/8' METAL STUDS (20 GA.) 0 16" O.C. TO
O 6" CONC. FILLED PIPE BOLLARD, PAINT, TYP. 12 SPLIT SYSTEM WALL MOUNTED (COORDINATE WITH O 3 5/8" METAL STUDS (20 GA.) ® 16" O.C. TO UNDERSIDE UNDERSIDE OF ROOF STRUCTURE W/ 5/8" GWB FLOOR PLAN
FIRE TROUBLE PANEL AND BULLETIN BOARD) OF ROOF STRUCTURE W/ 5/8" MOISTURE RESISTANT GYPSUM
O 4 OF SECURITY GRILLE TRACK WALL BOARD INSIDE OF RESTROOM. 5/8" GYPSUM WALL
1 FLD 0^ PLAN
13 ELECTRICAL DISCONNECT BOARD OUTSIDE OF RESTROOM. PROVIDE SOLID WOOD
K r 7O 6 THICK CONCRETE COMPACTOR PAD WITH W.W.F. BLOCKING AS REQUIRED FOR PROPER FIXTURE ATTACHMENT. SHEET NUMBER:
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A-1.1 SCALE: 1/8"=l'-O*
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O3 5/8" METAL STUDS (24 GA.) @ 16" O.C. TO 3'-6" ABOVE
S.O.A. FLOOR W/ 5/8" GYPSUM WALL BOARD BOTH SIDES. g `
IF
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E NOT USED COMMENTS:
a RELEASED FOR CONSTRUCTION
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