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HomeMy WebLinkAboutBARNSTABLE MARKET - FOOD (2) � BARNSTABLE MARKET 3220 Main.Street_. _- ' Barnstable' , '104�"'010 OE1W r Town of Barnstable BOARD OF HEALTH OJohn T.Norman Board of Health Donald A.Gaudagnoli,M.D. 0AMN9ranLe. F.P.(Thomas)Lee,. MAC Daniel Luczkow,M.D. Alt. a 6. 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 150 Issue Date: 01/01/2022 DBA: BARNSTABLE MARKET OWNER: SMITHFIELD MARKET OF BARNSTABLE Location of Establishment: 3220 MAIN STREET BARNSTABLE„ MA 02630 Type of Business Permit: RETAIL WITH FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: jFor OM Initials: Town of Barnstable 71IZZAAMLEd Date Pai $ Inspectional Services MAM `� Public Health Division Check#-3S s Thomas McKean,Director a (3 an 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: 3 44u2n ` /lliQPeea ADDRESS OF FOOD ESTABLISHMENT: -IRP6) /yI/�1i1J S�rQ % �.1':�C�sla9 �aL3a MAILING ADDRESS(IF DIFFERENT FROM ABOVE): j?fJ. 3,93 (� s 'zuli✓7 /17/� Oawa?G l� E-MAIL ADDRESS: 3 12 �1 / e;e 611406 4:i�w TELEPHONE NUMBER OF FOOD ESTABLISHMENT: i - TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO_..(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: Y SEASONAL: DATES OF OPERATION:,/Z-/VTO /Z/ X// ZZ 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)?�14 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 508-8624644 Q:\Application FonmsTOODAPP 2020.doc 'OWNER INFORMATION: TT FULL NAME OF APPLICANT ( %�/1� T"'� J/yI.I�ZW / SOLE OWNER: YES/6) OWNER PHONE# r&e' �o?� •�D(o ADDRESS 11,5 /rIA.W s God IJ74 D� CORPORATE OWNER: S/!IZ"I>< �!llrQQf.C.�of R� GGL n/ CORPORATE ADDRESS: ,6. ( 2' PERSON IN CHARGE OF DAILY OPERATIONS: List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records.You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. I GUr� 1SY.�Iud .3 1. &aay fmia 102/ 3 2. A�v��v,�H�au,� rc�t 3 /43 /A Iri P0,91. 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.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc 4 , Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BAWNS<'a���e Paul J.Canniff,D.M.D. 9 200 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: 150 Issue Date: 01/01/2021 DBA: BARNSTABLE MARKET OWNER: SMITHFIELD MARKET OF BARNSTABLE Location of Establishment: 3220 MAIN STREET BARNSTABLE„ MA 02630 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: For Office Use Only: Initials: TNETO`'ti� Town of Barnstable Date Amt-Pd$ � BAMMBLE. : Inspectional Services 1659. Public Health bivision CheckCYL 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_�f�0 NEW OWNERSHIP" RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: 3ZZo Aw" MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ?--O• ,ap/���2.3 W,1, E-MAIL ADDRESS: 600QSN9l.��A A01, 40#1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (A4_) TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO_)C...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_ SEASONAL: DATES OF OPERATION: / /_7/TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: AVIA 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?�/T IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE ---L,RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED& BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT Lanz& SOLE OWNER: YES/0 OWNER PHONE# 40 {� ADDRESS_ 11,S#4r41 .�� CA iVL E, IVII 02.3Sr CORPORATE OWNER: 491eZ411 f- rlV L' ��/rJL77fFL �h�ff/P. lo/JB�P✓Z1 3M LLG CORPORATE ADDRESS: 2.U- ��p'ci ��2.� , � A0 PERSON IN CHARGE OF DAILY OPERATIONS: &144-&4 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. T6/� 1A144 5 l A� / Z°Z/ 1. /3QZ94/ S%ri�1y Zo Z 2. A44W&V AWIAIRARW S //0 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 httv://www.townofbarnstable.us/healthdivision/applications.aso. 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. 3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Application FonnsTOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. « atra.�o.rrAULF, i F.P.(Thomas)Lee s 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 150 Issue Date: 1/1/2021 DBA: BARNSTABLE MARKET OWNER: SMITHFIELD MARKET OF BARNSTABLE Location of Establishment: 3220 MAIN STREET BARNSTABLE, MA 02630 Type of Business Permit: Non-Flavored Annual Seasonal FEES TOBACCO SALES: $85.00 YEAR. 2 21 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY r For Office Use Only: Initials i o ,. Town of For $ Date Paid 0 ' en�nersars Inspectional Services Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT :.PERMIT APPLICATION(Non-Flavored) DATE -Z4 NEW BUSINESS OWNERSHIP RENEWAL NAME OF TOBACCO ESTABLISHMENT: ,t��!/U�7✓ /jI/�I��/ ADDRESS OF TOBACCO ESTABLISHMENT: 0?2 b,?6 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �� E-MAIL ADDRESS: goy Qr��Q/j/S��/rl/�,�i�/ TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: Lab 2v--Alw OWNER'S NAME: ,f3iP�'�l/ OWNER'S PH#L 7oMJ4c&:yD. OWNER'S ADDRESS: _ i91/l/ i Z-M# Ad L19 CORPORATE NAME: t / CORPORATE ADDRESS:. ZZO, ,�S-, e�Q2Q/_,LjJJa� 1&t- CORPORATE FID# ANNUAL:_ SEASONAL: DATES OF OPERATION: l L Z/TO Zj�/ DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) . i TOWN OF BARNSTABLE COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: httpc://mate�,7-islature ov/I,aw.s/GeneralLaws/PartIV/Titlel/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY"* REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 FALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: r 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to ell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 E SIGNATURE: . PRINTED NAME: (SQ.TiQ/j/ f )/!1-ice - DATE.. ��l Z•�l Zlf Q:1Application Fonns\TOBACCO APP-NonFavor 12-18-19.docx ESTABLISHMENT'S NAME 4 TOBACCO SALES a Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: i Sales to Minors—S.371-9. Sale and Distribution of Tobacco Products.. 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. i The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: g i Signa Printed Name ' Date I ' f C&N!e6 %c1_TTQ.1_ / 2 St Printed a Date 1 r Sieh a Prin Name Date � �. Signa a Printed Name Date Y i v1`a, o rin e/ �ti G Si nature 2a Pri a ame .. Date 4 j Si nat re Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx o .© Commonwealth of Massachusetts Letter ID:L1805061696 Wl Department of Revenue Notice Date:September 1,2020 Geoffrey E.Snyder,Commissioner Account ID:CRL-10345457-010 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOII(INNG TOBACCO ilit�lll'Il�i�lll'IIi�'IIIII���I �� IIIII'l�l�llll�li��l SMITHFIELD MARKET OF BARNSTABLE L N BARNSTABLE MARKET PO BOX 323 3220 MAIN ST BARNSTABLE MA 02630-0323 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T).Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m.to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------- c�s'F� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigars and Smoking Tobacco 9 Frvr Olt This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SMITHFIELD MARKET OF BARNSTABLE LLC Account ID: CRL-10345457-010 BARNSTABLE MARKET License Number: 1838229504 3220 MAIN ST BARNSTABLE MA 02630-1107 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2020 Expiration Date:September 30,2022 00 Commonwealth of Massachusetts Letter ID:L1976055360 _ Department of Revenue Notice Date:September 1,2020 i M ' Geoffrey E.Snyder,Commissioner Account ID:CGL-10345457-007 mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARETTES 11�11'�I'�I'llll'I�'I111'I�'I"'lll'll�lll��l'll"�1111111"�II'� SMITHFIELD MARKET OF BARNSTABLE L 0 o BARNSTABLE MARKET N PO BOX 323 3220 MAIN ST BARNSTABLE MA 02630-0323 Attached below is your Retailer License for Sale of Cigarettes.(Form CT-3). Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800) 392-6089,Monday through Friday,8:30 a.m.to 4:30 p.m. DETACH HERE ------------------------------------------------------------------------------------------------------------------------------------------------ �PSS?cHUs" MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 * ;� Retailer License for Sale of Cigarettes i 9� ,EArr ov H This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SMITHFIELD MARKET OF BARNSTABLE LLC Account ID: CGL-10345457-007 BARNSTABLE MARKET License Number: 1389619200 3220 MAIN ST BARNSTABLE MA 02630-1107 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2020 Expiration Date: September 30,2022 JpSDEPARTMENT OF THE TREASURY 1ii4477 INTERNAL REVENUE SERVICE CINCINNATI OH 45999-0023 Date of this notice: 10-05-2011 Employer Identification Number: 45-3541296 45-3541296 Form: SS-4 Number of this notice: CP 575 A SMITHFIELD MARKET OF BARNSTABLE LLC BRIAN F SMITH MBR 699 MAIN ST _For assistance you may call us at: OSTERVILLE, MA 02655 1-800-B29-4933 IF YOU WRITE, dATTACH THE STUB AT THE END OF THIS NOTICE. WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER Thank you for applying for an Employer Identification Number (EIN) . We assigned you.. EIN 45-3541296. This EIN will identify you, your business accounts,.• tax returns, and documents, even if you have no employees. Please keep this notice in your permanent records. When filing tax documents, payments, and related correspondence, it is very important that you use your EIN and complete name and address exactly as shown above. Any variation may cause a delay in processing, result in incorrect information in your account, or even cause you to be assigned more than one EIN. If the information is not correct as shown above, please make the correction using the attached tear off stub and return it to us. Based on the information received from you or your representative, you must file the following form(s) by the date(s) shown. Form 940 01/31/2013 Form 1065 04/15/2012 Form 944 01/31/2013 If you have questions about the form(s) or the due date(s) shown, you can call us at the phone number or write to us at the address shown at the top of this notice. If you need help in determining your annual accounting period (tax year) , see Publication 538, Accounting Periods and Methods. We assigned you a tax classification based on information obtained from you or your representative. It is not a legal determination of your tax classification, and is not binding on the IRS. If you want a legal determination of your tax classification, you may request a private letter ruling from the IRS under the guidelines in Revenue Procedure 2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue) . Note: Certain tax classification elections can be requested by filing Form 8832, Entity Classification Election. See Form 8832 and its instructions for additional information. A limited liability company (LLC) may file Form 8832, Entity Classification Election, and elect to be classified as an association taxable as a corporation. If the LLC is eligible to be treated as a corporation that meets certain tests and it will be electing S corporation status, it must timely file Form 2553, Election by a Small Business Corporation. The LLC will be treated as a corporation as of the . effective date of the S corporation election and does not need to file Form 8832. 5 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. HARrgruiU& Paul J.Canniff,D.M.D. MA.%� F.P. Thomas Lee Alternate'° o '• 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 150 Issue Date: 12/10/2019 DBA: BARNSTABLE MARKET OWNER: SMITHFIELD MARKET OF BARNSTABLE Location of Establishment: 3220 MAIN STREET BARNSTABLE, MA 02630 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I � For Office Use Only: Initials: Town of Barnstable Date Paid Algid$ ? BAR,,,5IMIX : Inspectional Services ' 39. Public Health Division Check# Thomas McKean,Director 'n 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL I/ NAME OF FOOD ESTABLISHMENT: J,Q/MIZe /j1/ liL % ADDRESS OF FOOD ESTABLISHMENT: _?,Z20 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: d4Ld! � AZ : TELEPHONE NUMBER OF FOOD ESTABLISHMENT: O 301-_� TOTAL NUMBER OF BATHROOMS: Z WELL WATER:YES NO_X...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_ SEASONAL: DATES OF OPERATION: /// /,-7,TO /Z 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 508-8624644 Q:\Application FormsTOODAPP REV3-2019.doc r OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/ ( OWNER PHONE# ,S'00 ADDRESS f/l Ali rl/,rW+QFF7— CORPORATE OWNER: CORPORATE ADDRESS: �.U• �Oy ,3�3. / %� SYY /JI� LAG PERSON IN CHARGE OF DAILY OPERATIONS: 76K L/9i!%q 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. 7Ek G200 /v l YO 1. 2. SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp. OUTDOOR COOEING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January lst to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc ` THE Town of Barnstable Office For Use Only: Initials: � ' Date Paid A�p,�$ ,pgpgrpg,E i Inspectional Services Public Health Division cheek# ach ArFb�y° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE NEW BUSINESS OWNERSHIP RENEWAL L,�. NAME OF TOBACCO ESTABLISHMENT: ADDRESS OF TOBACCO ESTABLISHMENT: 3c�O/yl/ �S'�e61�i✓—" BMW MAILING ADDRESS(IF DIFFERENT FROM ABOVE): PO -;Z23 43� / oPkfa E-MAIL ADDRESS: TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 6DO)36a- G� OWNER'S NAME:�f �(� OWNER'S PH#(54),29- OWNER'S ADDRESS: /%/�/U.S�� GOTlJ ✓e 624fS- CORPORATE ADDRESS: Anvs • CORPORATE FID# ANNUAL: SEASONAL: DATES OF OPERATION: TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) dl///5� TOWN OF BARNSTABLE COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: hMs://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https://male islg ature.gov/Laws/GeneralLaws/PartIV/Titlel/Chuter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: DATE: /Zc� Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc `1ESTABLIS16W n'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—$371-9 Sale and(Distribution of Tobacco Products. { 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic - identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: gi��at_ure Printed Name Date Signatu Printed Name Date Sig nature Printed Name Date CC Si ae rusted Name Date 1 v, G1.i.�6, A i S�i cl ! 1 1 Z el, 19' turle Pintedme Date ALA—( Date e Printed Name Signature Printed Name Date C:\Uscrs\decoiiik\AppData\Local\Microsoft\windows\iNetcachc\Contcnt.Outlook\YZ.OF4J38\TOBACCO APP2019 dob.docx �* SF>j MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T y Retailer License for Sale of Cigarettes FM,0* This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. SMITHFIELD MARKET OF BARNSTABLE LLC Account ID: CGL-10345457-007 BARNSTABLE MARKET License Number: 546990080 3220 MAIN ST BARNSTABLE MA 02630-1107 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2018 Expiration Date: September 30, 2020 • c Sr�'gy�y Tj�C' Department of the Treasury 1�71�'�'�1�J11 IRS Internal Revenue Service CINCINNATI OH 45999-0034 _ 001590.134329.424256.775 2 AB 0.412 1180 SMITHFIELD MARKET OF BARNSTABLE LLC " BRIAN F SMITH MBR CRABTREE CPA & ASSOCIATES PO BOX 323 - BARNSTABLE MA 02630 001590 < d CUT OUT AND RETURN THE VOUCHER IMMEDIATELY BELOW IF YOU ONLY HAVE AN INQUIRY.\ DO NOT USE IF YOU ARE MAKING A PAYMENT. CUT OUT AND RETURN THE VOUCHER AT THE BOTTOM OF THIS PAGE IF YOU ARE MAKING A PAYJ4ENT, Q EVEN IF YOU ALSO HAVE AN INQUIRY. '*The IRS address must appear in the window. Use for inquiries only 0227356443 Letter Number: LTR3852C BODCD-SB Letter Date 2019-03-29 Tax Period 201712 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIlIIIII � *453541296* SMITHFIELD MARKET OF BARNSTABLE LLC INTERNAL REVENUE SERVICE BRIAN F SMITH MBR 7 CRABTREE CPA & ASSOCIATES CINCINNATI OH 45999-0034 PO BOX 323 BARNSTABLE MA 02630 453541296 TV SMIT 02 2 201712 670 00000000000 - �The IRS address must appear in the window. Use for payments 0227356443 Letter Number : LTR3852C BODCD-SB Letter Date : 2019-03-21. Tax Period : 201712 (IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIII) *453541296* SMITHFIELD MARKET OF BARNSTABLE LLC INTERNAL REVENUE SERVICE BRIAN F SMITH MBR CRABTREE CPA & ASSOCIATES OGDEN UT 84201-0102 PO BOX 323 BARNSTABLE MA 02630 453541296 TV SMIT 02 2 201712 670 00000000000 r COMMONWEALTH OF MASSACHUSETTS q DEPARTMENT OF REVENUE ` PO BOX 7010 BOSTON,MA 02204 403C 0 SMITHFIELD MARKET OF BARNSTABLE Notice Date: 03/10/12 LLC Taxpayer ID Number: 453 541 296 699 MAIN ST OSTERVILLE MA 02655-1903 Dear Taxpayer, Below please find your Sales and Use Registration Certificate (Form ST-1). Please cut along the dotted line and display at your place of business. Sincerely, Massachusetts Dept. of Revenue - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Massachusetts Department of Revenue -sT-1 Customer Service Bureau Pb Box 7010 Boston, MA 02204 ::;'::: <: ::<: <... ..... ..................................>< SALES: #d:�1�....::.Ali.R...-.-...........:........:. .... .................................-..-..............-.......................... ............ The vendor herein named is registered to sell tangible personal property at retail or for resale, pursuant to the General Laws, Chapters 62C, 64H and 641. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct ST-1 can be issued. IDENTIFICATION SMITHFIELD MARKET OF BARNSTABLE NUMBER LLC 453-541-296 3220 MAIN STREET BARNSTABLE MA 02630 ISSUE DATE 02/06/12 This registration must be displayed For customers to see and is not assignable or transferable. C'OMNIISSIONER OF REVENUE r COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF REVENUE ' PO BOX 7010 BOSTON,MA 02204 403C 0 SMITHFIELD MARKET OF BARNSTABLE Notice Date: 03/10/12 LLC Taxpayer ID Number: 453 541 296 699 MAIN ST OSTERVILLE MA 02655-1903 Dear Taxpayer, Below please find your Sales Tax on Meals and All Beverages Registration Certificate (Form MT-1). Please cut along the dotted line and display at your place of business. Sincerely, Massachusetts Dept. of Revenue Massachusetts Department of Revenue MT-1 Customer Service Bureau PO Box 7010 Boston, MA 02204 AID:.:BElE ;. . >::>::>::>::>:: .">:: :;.. ::» The vendor herein named is registered to sell meals and beverages pursuant to the General Laws, Chapters 62C and 64H. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct MT-1 can be issued. IDENTIFICATION SMITHFIELD MARKET OF BARNSTABLE NUMBER 453-541-296 LLC 3220 MAIN STREET BARNSTABLE MA 02630 ISSUE DATE 02/06/12 This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OIL REVENUE IKE, Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARNSTAUM Paul J.Canniff,D.M.D. MAa F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 150 Issue Date: 1/1/2020 DBA: BARNSTABLE MARKET OWNER: SMITHFIELD MARKET OF BARNSTABLE Location of Establishment: 3220 MAIN STREET BARNSTABLE, MA 02630 Type of Business Permit: Non-Flavored Annual k Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Q Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY SC Town of Barnstable BOARD OF HEALTH y Paul J Canniff,D.M.D. A.Ga Board of Health Donald A.Gaudagnoli,M.D. sARNSTA M, John T.Norman MASS. 200 Main Street Hyannis MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 150 Issue Date: 12/20/18 - DBA: BARNSTABLE MARKET OWNER: SMITHFIELD MARKET OF BARNSTABLE Location of Establishment: 3220 MAIN STREET BARNSTABLE MA 02630 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $250.00— YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: - - - - -- ---- - -- MOBILE-FOOD: MOBILE-ICE CREAM: GQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: I PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE j Restrictions: E: `4 of t � For Office Use Only: Initials: o� Town of Barnstable • Date Paid Amt Pd$ " MAS& Inspectional Services 0r p asz)- ms ; 7. Public Health Division Check# Cash- s Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLIICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: �O /�1�I MAILING ADDRESS(IF DIFFERENT FROM ABOVE): IDG a,;;�-323 91,V1yj1WM6,L11W&VK36 E-MAIL ADDRESS: I<✓��/S� ` y /�G% �(� G�//f7 TELEPHONE NUMBER OF FOOD ESTABLLISHMENT: TOTAL NUMBER OF BATHROOMS: C�— WELL WATER:YES NO ✓... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: l/ /iI TO ?1/�� NUMBER OF SEATS: INSIDE: OUTSIDE: /% TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) /FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED &BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) =TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL, MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q\Application FonnsT00DAPPREV2018.doc .n . PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES/6P OWNER PHONE#__ ADDRESS_ l��/yI/-�C/lI �� % ��Z�%, //l/� G G3-f CORPORATE OWNER: �i/l%f`Z /r/�� /LG FEDERAL ID NO. : , CORPORATE ADDRESS: /4iZP/l/f/Y /may PERSON IN CHARGE OF DAILY OPERATIONS: List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1- 7Z-Ek G19/l7A / l� / 1. // l ,�G lba/ 2. 1y74(76-CZ-� A lam/ 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 htti)://www.t6wnofbarnstable.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.315i each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FonnsT00DAPPREV2018.doc FTHE' Town of Barnstable o� Regulatory Services Department W BARNSTABLE, MAC. i679' Public Health Division �� 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health I, Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL DB/A STREET ADDRESS TELEPHONE# FID# 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 VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is p vided on the next page). Each employee who sells tobacco products must sign the mplo ee Si ture Form (provided herein). Si ature Date C:\Users\crockersh\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\K266YKRV\TOBA000 APP2018 dob.docx r' Establishment TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood sections VIIb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and the enclosed copy of Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of eighteen(18). Below are sections VIIb.and VIIc. of the Barnstable Board of Health Regulation: SECTION VII—SALE AND DISTRIBUTION OF TOBACCO PRODUCTS b. Sales To Minors—In conformance with the Massachusetts General Laws Chapter 270, Section 6, no person, firm, corporation, establishment, or agency shall sell tobacco products to a minor. Each employee working in an establishment licensed to sell tobacco product shall be required to receive a copy of the Board of Health regulations and State Law regarding the sale of tobacco and sign a form indicating that such regulations/laws have been received and understood, a copy of which must be placed on file, in the office of the employer and retained. Such signed forms must be made available for inspection, during the license holders normal business hours upon request of an agent of the Board of Health. c. All distributors/retailers of tobacco products or tobacco merchandise must require that, if a customer appears to possibly be wider 25 years of age, the customer present a valid State issued picture identification card or drivers license with appropriate photograph to confirm that the customer is of legal age to purchase the tobacco product. The following employee(s) received and understood Sections VIIb. and VIIc. of the Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: gnature Printed Name aie I�nhure Printe ame Da 17-0 I Si ure Printed Name Date Signature Printed Name Date Signature Printed Name Date Signature Printed Name Date _ Signature Printed Name Date Q:\Application FonnsJOBAPP.DOC �T"E' . Town of Barnstable For Office Use Only: Initials: C,� Date Paid Amt Pd$ • Inspectional Services Check# COIL Q RAMU" •` NAM �0� Public Health Division f% 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO:TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT ESTABLISHMENT NAME (DB/A) `3�0 /W 0)636 ADDRESS OF BUSINESS r�o Bif l�W, MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OWNER'S NAME: LAST FIRST MIDDLE EMAIL PHONE# FEDERAL ID# Do you currently possess a state license to sell tobacco products? Yes V/ No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00(a copy is provided on the next page). Each employee who sells tobacco roducts must sign the Employee Signature Form (provided herein). , Signature /i ✓v c Date /lc-/- Q:\Application Forms\TOBACCO APP2019 dob.docx ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—§ 371-9.'Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: i ture Printed Name Date igna Printe ame Date .:kk Sijnature Printed Name Date Signature Printed Name Date Si' ature Printed Name Date rn Signa Printed Name Date 01t\YJGk ��►� d IZ-rZ-V8 Signature Printed Name Date QA\Application FormATOBACCO APP2019 dob.docx �p INE►off TOWN OF BARNSTABLE HEALTH wSPECTOR's Establishment Name: &(7-SlAk- W'X '►ovate: C ), 1, Page_: of OFFICE HOURS BARNSTARLE, ` PUBLIC 2 0 MAIN STREET 3:30-4:30A.M. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified e39. `0� HYANNIS,MA 02601 508-862-4644 No Reference R-.Red Item PLEASE PRINT CLEARLY �FON1P�� FOOD ESTABLISHMENT INSPECTION REPORT Name f jyge o Inspection Too of Address Risk Food S Re-inspection Level Retail Previous Inspection Telephone Residential Kitchen Date: A> Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspecto Out: Each violation c ecked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Q� 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 Nrn EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives C e ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations ' Critical(C)violations marked must be corrected immediately. (blue&red items) ` Corrective Action Required: No Yes Non-critical(N)violations must be corrected immediately or Overall Rating 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 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or'lack of 28.Poisonous or Toxic Materials FC-7 590.008 be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If t critical refrigeration. ( )( ) 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 g atu a rint: Cry 31.Dumpster screened from public view . J Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N Sis na Print: #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC 9 Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N /A� Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 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* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7- Require Reporting by Food Employees and Contamination from the Environment 7-202.1101.11 Separation-Storage*Common Name-Working Containers 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003 Responsibility of A Food Employee or An 7-202.11 Restriction-Presence and Use* * (� P ty3-302.15 Washing.Fruits and Vegetables * 3-501.19 Time as a Public Health Control Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 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* 4d=cr;-11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec.* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009 A - D Violations of Section 590.009(A)-(D)in cater- Chemical ( ) ( ) Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11 C Game and Wild Mushrooms Approved By ( )(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 11 Good Hygienic Practices practices should be debited under#29-Special 3-201.17 Game Animals* y9 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 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 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 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3 402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability - 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6 2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. F. r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: 1L3 ate: / lG Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. • 200 MAIN STREET 3:3o-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified M .e� - HYANNIS, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY 6}9• �prFO Ma+% 508$62 4644 FOOD ESTABLISH ENT INSPECTION REPORT �� Name Dat Tyne of 1MRSp2Lpspection ions Routine Address '2 ry Risk < ood Sen/ ection I Ca_ Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness -� t✓�o�= Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector ® Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ y Action as determined by the Board of Health. Allergen Awareness 590.009(G) JQ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS rN ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑-3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control > ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items] Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection tod5tii�tems Embargo Emergency Closure Voluntary Disposal checked indicate violations of 105 CMR 590.000/Federal Food Code. RSLVoluntary g ❑ g y ❑ rY P 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 o la hot 27.Physical Facility (FC-6)(590.007) aggrigved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 9 30.Other DATE OF RE-INSPECTION: Inspector ig 31.DVter 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 Signat;�Pt�o Print: i Self Service Wait Service Provided Grease TripSize 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 r." 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs =r 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* g * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* P g 20 me as a Public Health Control 7-201.11 Separation-Storage** Ti 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* * Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(13) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/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.I IA(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* sg""ve inrzoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency r f ces of Equipment* of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A) oatons of . incater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* -(D) Violations f Si 590009A( )-(D) Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 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 R radices should be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301. revenng Contamination When Tasting* 3-403.11 * (Blue Items 23-30) 3-202.15 Package Ldcgrity 12 Preventing Ctiti Wh Tti (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 Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* (E) g 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 Handwashin g Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004 Labeling of Ingredients* Supplied with Soap and hand Drying Devices (J) 9 9 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 1 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. HEALTH INSPECTOR'S Establishment Name Date: TOWN OF BARNSTABLE Page: of �Y` ~o OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ' 200 MAIN STREET 3:30-4:30 F.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MON.-FRI. +e,v �• HYANNIS,MA 02601 508-862-4644 No Refere e R-Red item LEASE PRINT CLEARLY 'FDN1A�� FOOD E TABLISHM T INSP C ION REPORT , NamePACH ,� Date Type of I s ec io Iy<4�61_ �W_7,99_'q, fit Ig Routi Address v ` Risk ood Servi nspect" n tj Level eot Previo (� Telephone Residential Kitchen Date: (;�/ /CJ/) Mobile Pre-op a it on / Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint , Person in Charge(PIC) ® Time Bed&Breakfast HACCP t I 4r �n: Other Inspect t: Each violation checked requires an explanation on the narraf a pages)and a citation of specific provision(s).violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12,Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS _ c ❑ 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 Handwashirig CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical 8+ Violation3/Aq 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 regardless of the number of critical,results in an F. " 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 26.Water,Plumbing and Was} (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6ron-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility" / (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9ron-critical. If no critical " water,sewage back-up;infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials. (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 on-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. iolation,4 to 8 non-criti I vio ' s=C. 30.Other DATE OF RE-INSPECTION: 7ES sp ct r' S na re © Pri " 31.Dumpster screened from public view I DDUIII 77�� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y IN #Seats Observed Frozen Dessert Machines: Outside Dining Y N IC's Signature Print Self Service Wait Service Provided Grease Trap Size• Variance Letter Posted. Y N .. Dumpster Screen? Y N Ak 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 r Law Cooled to 41`F/45'F Within 4 Hours* * - - --. * y 3-501.15 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.* Additives*' PHF Hot and Cold Holding 2-103.11 - 'Person-in-Charge Duties - 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 , Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F - 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to - Other* g7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-201.11 Separation-Storage* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130'F* Applicants* 0 3-32.11(A) Food Protection* 20 Time as a Public Health Control -Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction3-501.19 Time as a Public Health Control* * Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* Contamination from the Consumer q590.003(E) 90.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* .. : .,. REQUIREMENTS FOR, �. 3-306.14(A)(B)Resumed Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 . Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* - - 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I lMonitoring* 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 Equipment* Not Otherwise Processed to Eliminate lu 590.006(A) Bottled Drinng Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef cnve 11112001 590.006 B) Water Meets Standards in 310 CMR 22.0* 4-602.11_ Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* ( Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source _ 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food- 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* - " " 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS - Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSS.P Listed- Chemical* g 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 Game and A Mushrooms Approved By 2-361.11 Clean Condition-Hands an Arms* d A * 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 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* Requirements. 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 * (Blue Items 23-30) 3-202.15 Package Integrity _ (C) Commercially Processed RTE Food-140'F Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventinns and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140`F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70`F to 41'F/45`F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3 402.11 Parasite Destruction Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 1 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans - 6-301.12 1 Hand Drying Provision 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. OF 1144E Tp� .f - • TOWN OF BARNSTABLE .�. _ ;HEALTH INSPECTOR'S Establishment Name: Date: Page: _C�of tia OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTAB�ESS. . 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified e;.. �0$ HYANNIS, MA 02601 508-862-4644 No Reference .R-Red Item PLEASE PRINT CLEARLY • N1 OD ESTABLISHMENT IN PE TI N REPORT T) Ch - Name Dat a of ]jfoe of Inspection eration s Routine it Address Food Service Re-inspection veI Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint - Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: /(IfV KAI planation on the narrative page(s)and a citation of specific provision(s)violated. Each violation checked requires an x _ 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 El Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal , ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC 4 590.005 B=One critical violation and less than 4 non-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 p,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 C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up, 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. viol "on,4 to 8 non- "ical violations=C. 30.Other DATE OF RE-INSPECTION: Inspe Pri 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 Signa 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 L14 Food or Color Additives _ Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 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 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 15 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* 3-501.16(A) Ho[PHFs Maintained At or Above 140°F Require Reporting by Food Employees and Contamination from the Environment 7-102.11 Common Name-Working Containers* 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* P g 20 Time as a Public Health Control 3-302.11(A) Food Protection* 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) q 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _ . . REQUIREMENTS FOR 3-306.14(A)(B)Resumed 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 Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. L16 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* e//crivc innom 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces 4-702.11 ' Frequency Sanitization of Utensils and Food 3-40L11(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 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- .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 B y_ 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.I1 Clean Condition-Hands and Arens* 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 as * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F IS sec 3-201.17 Game Animals* Fill 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 Commercial) Processed RTE Food-140°F* (Blue Items 23-30) 3-201.11 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours.and From 70_°17 to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 * 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 1 6-301.12 Hand Drying Provision - " 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging.Criteria* 8-103.12 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. Q/ . �p 1MET TOWN OF BARNSTABLE HEALTH INSPECTOR•s Establishment Name:BlA If n S tO 01 e MCA V k If T Date: 7 Page.: of p OFFICE HOURS BARNS7'ABLE. PUBLIc HEALTH 200 MAW STREETDMSION 3:30-4:30 A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. M639• HYANNIS, MA 02601 508-e62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY �'FON1P`� FOOD ESTABLISHMENT INSPECTION REPORT C l? C C 0 Name Q r Date ype of Type of Inspection Operation(sl Routine �/ (n 1 1'1 n S 1 Address ?, V (,.) t Risk Food Service✓ Re-inspection e ✓ Level Retail I/ Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation e e I' T 6EV Owner HACCP Y/N Temporary Suspect Illness PrOd 1) � ° ,� Caterer General Complaint L - Person in Charge(PIC) Time Bed&Breakfast HACCP c G( tu Cn e e e S MIN/ _Inspector In: Other Cn .r Out: ' Each violation checked requires an explanati the narrative page(s)and a citation of specific provision(s)violated. o f d Violations Related to Foodborne Illness Interventions and Risk Factors Red Items a e t h r ( ) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ ° t f "r S %/ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ r ' -1 k o S FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands (1�1 e CA t d S C,I U f'1 CA t ()a ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS U f a 1 I at q 0 ° ✓::S_w 0 tCr i s✓ ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives me v dell ose u �V ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) I, 0 Y 6 ❑ 4.Food and Water from Approved.Source ❑ 16.Cooking Temperatures y G e undevi-otlinqbo cu _`-p° ❑ 5.Receiving/Condition ❑ 17.Reheating T e rl ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling t- 2 o _ ✓ ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding J PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control vcnr .S ( k t ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) i 0 f V _ narldwaslo(AleMC4t_ ❑ 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 q t rn Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations .J.J i t r17 S I e f m e e) Critical(C)violations marked must be corrected immediately. (blue&red items) A-Afs �IZ�I�© Corrective Action Required: ❑ No J V 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 r ❑ 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 b a Board of Health member or its agent p 9 Y 9 A=Zero critical violations and no more than anon-critical violations. F=3 or more critical violations.9 or more rion-critical violations, Qood 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 B=One critical violation and less than 4npn-critical violations g (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed;4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste. (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9npn-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27. hysical Facility (FC=6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 8.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's SkInature Print: (+ L 31.Dumpster screened from public view \� �T n ( �j Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N A vlJ #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signal 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* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* - � 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11 A 2 Raw Animal Foods Separated from Each * 590.004(F) ( )O P 7-101.11 Identifying Information-Original Containers , 2 -590.003(C) Responsibility-of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F 7-102.11 Common Name-Working Containers * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 Separation-Storage* - - - Applicants* - - - - - - - * P g 20 Time as a Public Health Control 3-302.11(A) Food Protection 11 Restriction-Presence and Use* 590.003(F) I Responsibility of A Food Employee or An 7-202. 3-501.19 Time as a Public Health Control* 3-302.15 _ Washing Fruits and Vegetables Applicant To Report To The Person In Charge* 3-304.11 Food Contact with Equipment and Utensils* 7.202.12 Conditions of Use* 590.00411 Requirements 590.003(G) Reporting by-Person in Charge*-: . 7-203.11 Toxic Containers-Prohibitions* ( ) Variance -Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _ _REQUIREMENTS FOR ' 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP k 590.003(E) Removal of Exclusions and Restrictions g � Disposition of Adulterated or Contaminated - - - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources ' g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* - * 3-801.11(D) Raw or Partially Cooked Animal Food and 4-SOl.11I Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed Sprouts Not Served* 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and * 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13_ Shell Eggs* I_ Sanitization Temperatures* TIME/TEMPERATURE CONTROLS { 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 - Ice Made From Potable Drinking Water* - - - . Concentration and Hardness* 163-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System!. gg Equipment Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* E/f cn.•c uuzoor _- 4_-602.11 _ Cleaning-Frequency of Utensils and Fuud Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* _ Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3 401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS "- 4-703.11 Methods of Sanitization-Hot Water and 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- Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing - 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 Requirements.practices should be debited under#29-Special 5 - Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* * (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.:foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3 403.11(E} Remaining Unslieed 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* 1g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 " ? * 13 Handwashing Facilities 3-501.14 A 3-202.18 Shellstock Identification (.) Cooling Cooked PHFs from 140°F_to 70°F ConvenientlyLocated and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* + * Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient i 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 Labeling of Ingredients* Supplied with Soap and hand Drying Devices 590.004(J) 9 9 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. 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 590.00 1: 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. RE: Proposed Market Barnstab illage . Page 1 of 1 4 Stanton, David From: McKean, Thomas Sent: Friday, November 18, 2011 1:27 PM To: Stanton, David Cc: 'wamdoc@verizon.net' Subject: Fw: Proposed Market Barnstable Village From: Parsons, Roger To: McKean,Thomas Sent: Fri Nov 18 12:20:34 2011 ' Subject: RE: Proposed Market Barnstable Village Tom I changed my recommendation in the body of this email to the TZ 600 -----Original Message----- From: McKean,Thomas Sent: Friday,November 18,2011 10:27 AM To: Parsons,Roger Subject: RE: Proposed Market Barnstable Village Do you wish to change your recommendation to the larger model, the TZ-600? If yes, I will forward it to the Board of Health -----Original Message----- From: Parsons,Roger Sent: Tuesday,November 15,2011 6:43 AM 1� To: McKean,Thomas;Jenkins,Ed Cc: Doyle, Peter;Anderson,Dave Subject: Proposed Market Barnstable Village U Good Morning Gentlemen: I have reviewed the proposed method of grease containment at �Qd the proposed market(site of old village store) In my opinion the use of the Trapzilla TZ 600 � V external grease trap will be sufficient for the proposed use. It is my understanding that only "take out"food will be prepared on the premise. My approval is conditioned upon the need for a maintenance agreement to be entered into by the owner/operator-a copy of which should be provided to the Town. - Roger 2/27/2012 EII Crocker,.Sharon From: McKean, Thomas Sent: Tuesdayy; er 15, 2011 8:37 AM To: St David; Crocker, Sharon Subject: F : Proposed Market Barnstable Village -See Below- Its okay to issue a temporary food permit after the establishment satisfactorily passes a pre-operational inspection. -----Original Message----- From: Parsons,Roger Sent: Tuesday, November 15,2011 6:43 AM To: McKean,Thomas;Jenkins, Ed Cc: Doyle, Peter;Anderson,Dave Subject: Proposed Market Barnstable Village Good Morning Gentlemen: I have reviewed the proposed method of grease containment at the proposed market(site of old village store) In my opinion the use of the Trapzilla TZ 400 external grease trap will be sufficient for the proposed use. It is my understanding that only"take out"food will be prepared on the premise. My approval is conditioned upon the need for a maintenance agreement to be entered into by the owner/operator-a copy of which should be provided to the Town. - Roger s ib (, ocker,-Sharon 'From: McKean„ Thomas Sent: Tuesday-,- er 15, 2011 8:37 AM To: Stan David; Crocker, Sharon Subject: F : Proposed Market Barnstable Village -See Below- Its okay to issue a temporary food permit after the establishment satisfactorily passes a pre-operational inspection. -----Original Message----- From: Parsons, Roger Sent: Tuesday, November 15, 2011 6:43 AM To: McKean,Thomas;Jenkins,Ed Cc: Doyle, Peter;Anderson, Dave Subject: Proposed Market Barnstable Village Good Morning Gentlemen: I have reviewed the proposed method of grease containment at the proposed market(site of old village store) In my opinion the use of the Trapzilla TZ 400 external.grease trap will be sufficient for the proposed use. It is my understanding that only"take out"food will be prepared on the premise. My approval is conditioned upon the need for a maintenance agreement to be entered into by the owner/operator-a copy of which should be provided to the Town. - Roger I 1 RE` Proposed Market Barnstabl- Tillage Page 1 of 1 Stanton, David From: McKean, Thomas Sent: Friday, November 18, 2011 1:27 PM To: Stanton, David Cc: 'wamdoc@verizon.net' Subject: Fw: Proposed Market Barnstable Village From: Parsons, Roger To: McKean,Thomas Sent: Fri Nov 18 12:20:34 2011 Subject: RE: Proposed Market Barnstable Village Tom I changed my recommendation in the body of this email to the TZ 600 -----Original Message----- From: McKean,Thomas Sent: Friday, November 18,2011 10:27 AM To: Parsons,Roger Subject: RE: Proposed Market Barnstable Village Do you wish to change your recommendation to the larger model, the TZ-600?? If yes, I will forward it to the Board of Health -----Original Message----- From: Parsons,Roger Sent: Tuesday, November 15,2011 6:43 AM To: McKean,Thomas;Jenkins, Ed Cc: Doyle, Peter;Anderson, Dave Subject: Proposed Market Barnstable Village Good Morning Gentlemen: I have reviewed the proposed method of grease containment at the proposed market (site of old village store) In my opinion the use of the Trapzilla TZ 600 external grease trap will be sufficient for the proposed use. It is my understanding that only "take out" food will be prepared on the premise. My approval is conditioned upon the need GA I for a maintenance agreement to be entered into by the owner/operator- a copy of which should be provided to the Town. - Roger 4 2/27/2012 EXCERPT FROM BOARD OF HEALTH MEETING MINUTES 1/10/12: I. Variance — Food (New): A. Kathy Murray, owner, Barnstable Market— 3220 Main Street, Barnstable, Map/Parcel 300-010, grease trap variance, has limited menu and is a small market. Board Member Mr. Sawayanagi recused himself and stepped out of the room. Kathy Murray was present, along with Roger Parsons, Town Engineer: Barnstable Market proposed to use both the Big Dipper (a grease trap interceptor) and a grease trap known as the Trapzilla which will be outside the building. Roger Parsons, Town Engineer, suggested the larger Trapzilla which holds 600 pounds versus the 400 pound container. Mr. Parsons suggests using the Trapzilla because the grease is able to cool down before the grease is separated. Kathy Murray said their three restaurants will all be maintained by the same contractor and the Barnstable Market will begin by being on the same schedule, emptied every six weeks, until they assess the actual need which will probably be less frequently. Upon a motion duly made by Dr. Canniff, seconded by Dr. Miller, the Board voted to approve the grease trap variance with the condition that Roger Parsons, Town Engineer, will take a look at the grease situation for the first two months.. (Unanimously, voted in favor.) MR6 SOAP, vfAS 1 /WF-P llr�RlkGUr��t Eur6# '77,to ' zo -VAN/I Pill +. �°,L�IGari�"�G t��•�4Brf`d�y8 �f���` �` j� i Mottfil,L l D l �, 3 - 1 17 is t p F ''n ? 8 . a:a� .:.." �S�N 4""x' ~ 'Q.. " ' v/ i—F '7�7 -71,` Tite Town of Barnstable— Health Department "1""" ' 367 Main Street, Hyannis, MA 02601 ,61 Office 508-790-6265 Thomas A. McKean FAX 308-775-3344 Director of Public Health Ms. Brenda Ferraro 30 Preakness Way Marstons Mills, MA 02648 RE: Village Soft Serve Dear Ms. Ferraro, You are granted conditional variances on a trial basis from the Board of Health "Revised Supplement to Minimum Sanitation Standards for Food Service Establishments Regulation" which stateS "separate facilities must be provided for male and female employees and male and female patrons" at 3220 Main Street, Barnstable, MA with the following conditions: ( 1) Immediate family members are authorized to be employed at the food establishment. If non-family members are employed, then only all female or all male employees, exclusively, shall be allowed to work at the food establishment at the same time. (2) This conditional variance, expires November 1, 1993. You must either install a second bathroom before November 1, 1993 or apply to renew this variance on or before November 1, 1993. (3) This conditional variance may be revoked should unsanitary conditions be observed during the operation of the food establishment. In addition you are granted a conditional variance from the Board of Health Regulation #10: "Revised Supplement to, Minimum Sanitation Standards . for Food Service Establishments" that requires a minimum of a 1,000 gallon grease interceptor at all food establishments. This variance will allow you to operate a food service establishment at 3220 Main Street, Barnstable, with the following conditions: r ( 1) No cooking of food will be allowed. Only two (2) frozen dessert machines are authorized at the establishment. (2) Only disposable single service paper, plastic, and other disposable dishes and utensils are authorized. (3) The under-sink grease interceptor shall be cleaned monthly (instructions enclosed) . (4) This conditional variance expires November 1, 1993. This variance is not transferable and will not be voided if the establishment has a change in use, change of ownership, or leased to a party other than an applicant. Mr. Joseph Ferraro, a trustee, was present during the June 23, 1992 Board of Health meeting and is aware of the above conditions. He will also be responsible for notification to any future food establishment operators who will be interested. in purchasing the food establishment. Sincerely yours Jo eph C. Snow, M.D. C airman BOARD OF HEALTH TOWN OF BARNSTABLE cc: Edward Jenkins, Plumbing Inspector Peter Doyle, Water Pollution Control Thomas Mullen, DPW Superintendent Edward Barry, Health Inspector TM/jml Stanton, David From: McKean, Thomas Sent: Tuesday, November 15, 2011 8:37 AM To: Stanton, David; Crocker, Sharon Subject: FW: Proposed Market Barnstable Village -See Below- Its okay to issue a temporary food permit after the establishment satisfactorily passes a pre-operational inspection. -----Original Message----- From: Parsons,Roger Sent: Tuesday, November 15, 2011 6:43 AM To: McKean,Thomas;Jenkins, Ed Cc: Doyle, Peter;Anderson, Dave Subject: Proposed Market Barnstable Village Good Morning Gentlemen: I have reviewed the proposed method of grease containment at the proposed market(site of old village store) In my opinion the use of the Trapzilla TZ 400 external grease trap will be sufficient for the proposed use. It is my understanding that only"take out"food will be prepared on the premise. My approval is conditioned upon the need for a maintenance agreement to be entered into by the owner/operator-a copy of which should be provided to the Town. - Roger V_J 1 6 For office use only TOWN OF BARNSTABLE 10 �oF T"f rot Received by < � OFFICE OF DAUST"L s BOARD OF HEALTH DateNABI .� . 039 0 w�e0 3fi7 MAIN STREET HYANNIS, MASS.02601 VARIANCE REQUEST FORM All variance requests must be submitted fifteen (15) days prior to the scheduled Board of Health Meeting. NAME OF APPLICANT L�i:2Pt llh1 f2�Z R 6 R O TEL. ADDRESS OF APPLICANT 30 PQe h kNe-Ss U) f�� �/�R NAME OF OWNER OF PROPERTY fill t I2fy•Two TweN*y mft r N St l zo sf SUBDIVISION NAME DATE APPROVED ASSESSORS MAP & PARCEL NUMBER R300 - 010 +LOT SIZE LOCATION OF REQUEST 32a0 MAN 5T. I3ARN S ,41� W(ne_ VARIANCE FROM REGULATION (List Regulation) e m'ptb!< e-e- rrrl A4 e. REASON FOR VARIANCE (May attach letter if more space is needed) PLAN - FOUR COPIES OF PLAN MUST BE SUBMITTED CLEARLY OUTLINING VARIANCE REQUEST. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPROVAL Joseph C. Snow, M.D. , Chairman Susan G. Rask Brian R. Grady BOARD OF HEALTH TOWN OF BARNSTABLE N r Town of Barnstabl Health Department 367 Main Street, Hyannis, MA 02601 1679• � Office 508-790-6265 Thomas A. McKean FAX 308-775-3344 Director of Public Health Ms. Brenda Ferraro 30 Preakness Way Marstons Mills, MA 02648 RE: Village Soft Serve Dear Ms. Ferraro, You are granted conditional variances on a trial basis from the Board of Health "Revised Supplement to Minimum Sanitation Standards for Food Service Establishments Regulation which stateS "separate facilities must be provided for male and female employees and male and female patrons" at 3220 Main Street, Barnstable, MA with the following conditions: ( 1) Immediate family members are authorized to be employed at the food establishment. If non-family members are employed, then only all female or all male employees, exclusively, shall be allowed to work at the food establishment at the same time. (2) This conditional variance expires November 1, 1993. You must either install a second bathroom before November 1, 1993 or apply to renew this variance on or before November 1, 1993. (3) This conditional variance may be revoked should unsanitary conditions be observed during the operation of the food establishment. In addition you are granted a conditional variance from the Board of Health Regulation #10: "Revised Supplement to Minimum Sanitation Standards for Food Service Establishments" that requires a minimum of a 1,000 gallon grease interceptor at all food establishments. This variance will allow you to operate a food service establishment at 3220 Main Street Barnstable . with the following conditions: r ( 1) No cooking of food will be allowed. Only two (2) frozen dessert machines are authorized at the establishment. (2) Only disposable single service paper, plastic, and other disposable dishes and utensils are authorized. (3) The under-sink grease interceptor shall be cleaned monthly (instructions enclosed) . (4) This conditional variance expires November 1, 1993. This variance is not transferable and will not be voided if the establishment has a change in use, change of ownership, or leased to a party other than an applicant. Mr. Joseph Ferraro, a trustee, was present during the June 23, 1992 Board of Health meeting and is aware of the above conditions. He will also be responsible for notification to any future food establishment operators who will be interested in purchasing the food establishment. Sincerely yours Joph C. Snow, M.D. C airman BOARD OF HEALTH TOWN OF BARNSTABLE cc: Edward Jenkins, Plumbing Inspector Peter Doyle, Water Pollution Control Thomas Mullen, DPW Superintendent Edward Barry, Health Inspector TM/jml 11(Pur. Gc7,"r-A- /Lc - ;S liura1c¢.-` C O 11aJ�G¢ WC�PiS a�u o CVW 9-rev.-,. •✓4 Dj1n� _ . _ ,}-��„�.w�� ��,�� w-s-•w,�crS --� -_v.s,�_-�t-_ .�--�o� ? _ IN,.(-C - Vie- . _ /� 176`c i/C✓r_��� 4/�'S l -- ec�r off-ec� 6AJL �G oVAA, i j 4 _ - _ ._ _ _ -�= s --- ���►��c� -ire 5 c�►c�-v►��� �a-�Da�,s �� .. _ _.. � "' L �=� _- � - _ .. �. 1. .� � � I ,�! ` �� � i � t —^�_ mow—a 7 -. e � ��.. ��.� __ + .�s, , . • ��l r � * f j _ i — — � -_-- 1-+ _ _ � __._..�—___ _._ _�. —.�.— � t / = 1_ TOWN OF BARNSTABLE CF TN E t0 i 6�Qy���o OFFICE OF � IAHISTAIL i BOARD OF HEALTH NAG& moo 1639. 367 MAIN STREET �a wnY k' HYANNIS,MASS.02601 r January 26, 1990 Robert W. Medelros 3220 Main Street Barnstable, MA 02630 Dear Mr. Medeiros: You are granted a conditional variance from the Board of Health Regulation #10ion andards for Service Esta "- men s" that a minimum of ent to Minimum tat l 000t gallon grease interceptor Establishments tha q at all food establishments. This variance will allow you to operate a food service establishment at 3220 Main Street, Barnstable, with the following conditions: (1) No cooking of food will be allowed Only the following activities are allowed onsite: - "Store bought" prepared soups may be heated. - Sandwiches may be prepared with "store bought" pre-cooked, meats and tuna f Ish. - Premade sandwiches may be microwaved. - Hot dogs may be steamed. (2) The under-sink grease Interceptor shall be cleaned monthly (instructions enclosed). This conditional variance expires February 1, 1991 and will be automatically renewed if all the above conditions are met. This variance Is not transferable and will be voided if the establishment has a change in use, change of ownership, or leased to a party other than this applicant. Yours tr ly, Grover C. M. Farris , .D. Chairman Board of Health Town of Barnstable GF/bs Da Fee / b G.dI� TOWN OF BARNSTABLE aftHrro� OFFICE OF t BABI7TABLE BOARD OF HEALTH M"ea1639. 367 MAIN STREET am k HYANNIS. MASS. 02601 , VARIANCE REQUEST FORM All variance requests must be submitted fifteen (15) days prior to the scheduled Board of Health Meeting. YAB� /� ✓�''�S Sya/� 7 ,,3 TEL. N0. NAME OF APPLICAN ADDRESS OF APPLICANT J.2.Z0 NAME OF OWNER OF PROPERTY DATE APPROVED SUBDIVISION NAME LOT SIZE ASSESSORS MAP AND PARCEL NUMBER /f E W 5 �OAC /H�•`/ fj CiiAO.r/1 YARG E AO LOCATION OF REQUEST �il1P.�s>A1g[ �� VARIANCE FROM REGULATION (List Regulation) AEG /G �i'd�S� /rc-410 REASON FOR VARIANCE (May attach letter if more space is needed) //V G�ou.✓0 '��it PLAN = TWO COPIES OF PLAN MUST BE SUBMITTED CLEARL OUTLINING VARIANCE REQUEST. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPROVAT � . C,�� .,�w�c�nes VS �u S(7 ` �y� SZ,•� wi c Grover C. t(i: Parr lsh,Chairman >S )P 5 NW, , � 6 �° Ann Jane Eshbaugh V rr►i Grp o James H. Crocker, Sr. P-,-e -,�'' ! f�® � n BOARD OF HEALTHVIT �� F_ U 3�Byyisus�,e'�n�ol TOWN OF BARNSTABLE J -PEAS, TRAP --- ----------- -------- STORE o pe_iz6rlON " To t3E 5 TOR flGE TO K c o v'T b 1`1 L-y ,� :50�' SeRvL F►�av �s�obrj.l��� CovH1'eR U i iLIT'y o ' SINK v 0 ° H4nD SiNK 0 3 (3►��/ S�auc p'1Rrin��e SINK To 3 O RY SINK T-oTA,I - `NYC tZ E. H 12 E(A � �� !2o x i vn A Q �� �}- a- s y 1? es1' l?ooM T14K Iz ov T Co u til IZ it�DO y� F � s v1=n- v o 0 IrR�AsE rR AP n WADE 5100E \AJ A o F- 5"1 i o B +0 (b GREASE tyl?.P f .5 w ST`oGt o �e..R6TION To esE 5TOR9 &E T14 K E O UT 0 t`l l-y mom ep, i4M D A ov IT EOM pwneiz oP�>a ,�fep s R-les CoH v i st'i r� a� J` O� �@(Zvi- RNU �t`UtP13�tt�/ CovK1'eR U T II- IT-y o e SINK Te R v " 9 ° hAND SoFt �n�u,Z� o ..li 0 3 i3�Y NK S��uc MACH►�e SINK a GRehst �t1'ezc�Pfie�:z To be ro c#;--te o nc K T _��_.► c To 3 (3 RY s i N is s PTO RE «Q.cA 11+pp lox i vnA��(y �oo� TAt<6 our ._..t_ � Doo►Z "? 'l•l �+ ^'B A N Un RT�s T 6 51-E V k �,O q a i �v E nT 0 0 0 Al CrR6R5� WADE 5100E +0 lb GREASE T1lpP c; Bellaire, Dianna From: Bellaire, Dianna Sent: Thursday, December 03, 2020 3:36 PM To: Barnstable Market Cc: Bellaire, Dianna Subject: RE: 2021 Food and Tobacco Permits- Barnstable Market Hi, Thank you. I will make a note on the tobacco account that you don't sell. I've updated the allergen. I will mail your permits to the store tomorrow, Dec.4th. There is no inspection requirement this year due to COVID. Thank you again and happy holidays. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bellaire@town.barnstable.ma.us The information contained in this electronic transmission("e-mail."),including any attachment(the"Information"),may be confidential or otherwise exempt from disclosure..It is for the addressee only.Th s Information may be privileged and confidential work-product or a privileged and confidential communication.The Information may also he deliberative acid pre-decisional in nature..A1.s such,it is for internal use only.The Information may not be disclosed without the prior written consent of the Director of Public I Iealth and;or the Town Attorney's Office of the Town of Barnstable.If you have received this e-mail by mistake,please notify the sender and delete it from your system.Please do not copy or forward it.1:'h.arilr you for your.cooperation. From: Barnstable Market [mailto:barnstablemarket@aol.com] Sent: Thursday, December 03, 2020 1:48 PM To: Bellaire, Dianna Subject: Re: 2021 Food and Tobacco Permits Hi Dianna, We do not sell "Electronic Delivery Systems" of any sort;just regular cigarettes. I've just taken the Allergen Training and have attached the certificate. Thanks for sharing the class information. -Brian- -----Original Message----- From: Bellaire, Dianna <Dianna.Bellaire(a)town.barnstable.ma.us> To: barnstablemarket(cD-aol.com <barnstablemarket(a�aol.com> Cc: Bellaire, Dianna <Dianna.Bellaire(a)town.barnstable.ma.us> Sent: Mon, Nov 30, 2020 12:59 pm Subject: 2021 Food and Tobacco Permits 1 MAIN STREET - RT. 6A 12' SHELVING FIRE EXIT 4x4 p S' DRY H DI�Y w I END DISPLAY COFFEE REAL ESTATE OFFICE o v 4x4 Lu Ili L) UJ � p O 4' 4' CNI It p. °-y END DISPLAY f 4x4 p a U-1 7c W ■4K4 2'Xb'DOW 4x4 w F ICE V v 4'X4' i'-0' T-0• � U °"'• FLORAL RE AKE 0 I�• B' CARTS N a a 17' SHELVING SIDE 4 ENTRY PES 5 , ■4x4cd S 4 S 4x4 Q II,-(r S VIC COUNTER _ , ® W W 2 DR. 10E "' w. W w qREA ( Id ® ® GATE 4 `U IC 84x4 sT ap co Ww ICE N (E) >Oco H B AIR Wo-0 HANDLER �' (DV_ L--- R !0' LEVEL■■FLOOR 4x4 IOx 0 ---------Iaxx13------ 1p. 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