HomeMy WebLinkAboutDOLPHIN RESTAURANT - FOOD i
Dolphin Restaurant
325U Main St, Barnstable
�LR9- a31
I
A
��wrr Town of Barnstable BOARD OF HEALTH
John T. Norman
Board of Health Donald A.Gaudagnoli,M.D.
6ARNWABLE: F.P.(Thomas)Lee,.
MASS Daniel Luczkow,M.D. Alt.
200 Main Street, Hyannis, MA 02601
a ° Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstablems
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 271 Issue Date: 01/01/2022
DBA: DOLPHIN RESTAURANT
OWNER: DOLPHIN RESTAURANT INC.
Location of Establishment: 3250 MAIN STREET BARNSTABLE„ MA 02630
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IncloorSeating: 112 OutcloorSeating: 0 Total Seating: 112
FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2022
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Qn
FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
For Office Use Only: Initials:
'"Eto Town of Barnstable �
Date Paid Amt I'd$cz/�J
? BARNS. BM : Inspectional Services
'""�. check#Gb!'2�63
1639. Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE' NEW OWNERSHIP RENEWAL
� S I
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT:3 a� 6,k '�/63�
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): U. of 8� aA-U��' �� &0��� V
E-MAIL ADDRESS:
TELEPHONE NUMBER OF FOOD ESTABLISHMENT:
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES NO--�i ...(ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION: / /��TO
t�C
NUMBER OF SEATS: INSIDE:JQ13 OUTSIDE: TOTAL:1�3
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.
Q �
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? ®+eta►
TY 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 54$-8624644
Q:V\pplication FormsTOORAPP 2020.doc
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f
OWNER INFORMATION: (�
FULL NAME OF APPLICANT
SOLE OWNER(7YES/NO � OWNER PHONE#^j
ADDRESS
CORPORATE OWNER:
CORPORATE ADDRESS: �?a--�-D YV�aAI J
PERSON IN CHARGE OF DAILY OPERATIONS:
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have I Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div.will NOT use past years' records.You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Allergen Awareness Expiration Date
2.
AA-
D-3
fZ
SIG NATU 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%till 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.townotbarnstable.us/healthdivision/al)piications.asi).
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:1Applicalion Forms\FOODAPPREV3-2019.doc
°FTHE r° TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: ��n I Date: �� � Page: of
OFFICE HOURS
AR E.° PUBLIC 0 MAIN STREET
3:30-4:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
3:30-4:30 P.M.
MAC. HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
�p .e7s•e. 508-862-4644
FOOD ESTABLISHMENT INSPECTION REPORT
Name \ ; Date��,/� �qTyi3e of T of Ins a tion
Routi
Address t ��. Risk Food Se spection
Level ai Previous Inspection
r
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:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate corrective Tobacco' 590.009(F) ❑
Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands _ \
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures
❑ 5.Receiving/Condition ❑ 17.Reheating
❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling .
❑ 7.Conformance with Approved Procedures/HACCP Plans_ ❑ 19.Hot and Cold Holding 34
'i
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 �O
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations n
Critical(C)violations marked must be corrected immediately. (blue&red items) IQ� N Corrective Action Required: ❑ No es
Non-critical(N)violations must be corrected immediately or Overall Rating 1
within 90 days as determined by the Board of Health. oluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction,Based on an inspection today,. e 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 o 6 non-critical violations 9
26.Water,Plumbing and Waste (FC-5)(590:006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6von-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 sight to a hearing. Your request must C=2 critical violations and less than i non-critic . t 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 Snon-critical viol Ions. If 1 critical refrigeration..
28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8 non-critical violations=C
29.Special Requirements (590.009) within 10 days of receipt of this order.
3 .Other DATE OF RE-INSPECTION:
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
i toe
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sig Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT - PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 6 Cross-contamination 14 Food or Color Additives Law Cooled to 41'F/45'F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41'F/45'F
590.004(F)
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* *
Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F
2 590.003(C) Responsibility of the Person-in-Charge[0 7-102.11 Common Name-Working Containers* *
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F
7-201.11 Se aration-Stora e*
Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP
590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � )
Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and
FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and
3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served*
Y P 7-206.13 Tracking Powders,Pest Control and
3-201.13 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* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of
5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effect-1nn001
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 Surfaces of Equipment*Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec*
Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS
4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Ratites-165'F 15 sec*
,
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Held Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* . 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165`F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
* 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140'F* (Blue Items 23-30)
3-202.15 Package Integrity ( ) y Critical andnon-critical violations,which do not relate to the foodborne
* 12 Prevention of Contamination from Hands 3-403.11E Remainin Unsliced Portions of Beef Roasts*
3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000
3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70'F
* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41°F/45°F Item Good Retail Practices FC 590.000
3-203.12 Shellstock Identification Maintained
Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003
5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004
3402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005
3 402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006
590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007
7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC
HACCP Plans 6-301.12 Hand Drying Provision
29. 1 Special Requirements .009
3-502.11 Specialized Processing Methods* 130. 1 Other
3-502.12 1 Reduced-Oxygen Packaging Criteria*
8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc
'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
, I
OF ME Tp� TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: `.. \ \'� _ Date: J (�( Page: of
•^y/p� ti OFFICE HOURS
gpg E. PUBLIC
2 0 MAN STREET 3:30-4:30 P.M.
DIVISION - - : 0- :30 A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
ASS. �0� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY
508-862-4644
"TFore"+a FOOD ESTABLISHMENT INSPECTION REPORT
Name ��' , Date a of ec io
outine *(�,\A
Address Risk od Servi ection
Level Retail Previous Inspection
Telephone Residential Kitchen Date:
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) Time
Bed&Breakfast HACCP �_\ \
In: Other
Inspector � Out:
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. C
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) ❑ 1\�
FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 1Y1 ; / yq
❑ 1.PIC Assigned/Knowledgeable/Duties F-] `
13.Handwash Facilities ALA
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS 1
❑ 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 !0
❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&.red items) Corrective Action Required: ❑ No Yes
Non-critical(N)violations must be corrected immediately or
within 90 days as determined b the Board of Health. Overall Rating ry p ❑ Employee ❑ P ❑ Emergency P
Y Y � ❑ Voluntary Compliance Em to ee Restriction/Exclusion Re-ins ection Scheduled Emer enc Suspension
C N Official Order for Correction:Based on an inspection today,th items o
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other:
23.Management and Personnel (FC-2)(590.003) This report,when'signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations,
24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F.
25.Equipment and Utensils (FC-4 590.005 6=One critical violation and less than 4non-critical violations 9
)( ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F_is scored automatically if: no hot
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and_cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must
28.Poisonous or Toxic Materials (FC-7)(590.0o8) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8non-critical violat'•ns. If 1 critical refrigeration.
within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C.
29.Special Requirements (590.009) Y P
30.Other DATE OF RE-INSPECTION: Ins=r , u rint:
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N
#Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sig tur Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen? Y N
Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions
Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.)
FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to
1 590.003(A) Assignment of Responsibility* 8 Cross-contamination L14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours*
590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs
Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding
2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved
Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F
EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*7-102.11 Common Name-Working 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
Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F*
7-201.11 Separation-Storage*
Applicants* � 3-302.11(A) Food Protection* � P20 Time as a Public Health Control '
590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control*
Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements
590.003(G) Reporting by Person in Charge
* 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q
Contamination from the Consumer
3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR
3-306.14(A)(B)Resumed Food and Rted 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 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 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY
Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of
3-202.16 Ice Made From Potable thinking Water* - 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or
5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec*
Equipment* Not Otherwise Processed to Eliminate
590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 11112001
4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec*
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs*
3-201.14 Fish and Recreationally Cough[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 Chemical* Ratites-165°F 15 sec*Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater-
Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential
Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors.
590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail
3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special
Requirements.
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*
3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23.30)
■ 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodbome
3-101.11 Food Safe and Unadulterated 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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 1590.000
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. 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.
i
Town of Barnstable BOARD OF HEALTH
John T.Norman
Board of Health Donald A.Gaudagnoli,M.D.
An-STAMx, Paul J.Canniff,D.M.D.
MAM
200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to:
Permit No: 271 Issue Date: 01/01/2021
DBA: DOLPHIN RESTAURANT
OWNER: NANCY JEAN SMITH
Location of Establishment: 3250 MAIN STREET BARNSTABLE„ MA 02630
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 112 OutdoorSeating: 0 Total Seating: 112
FEES
FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2021
RETAIL FOOD:
COTTAGE FOOD OPERATION:
Permit Expires: 12/31/2021
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM: Q� `
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
• Initials:
fit► rq�, For Office Use Only.
ti Town of Barnstable ( �(�
Date Paid 1 I Amt Pd$
&UNRrABLE, : p Ins ectional Services
9cbMASS. ,0$
prEo .a Public Health Division Check#�v����
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE NEW OWNERSHIP RENEWAL
NAME OF FOOD ESTABLISHMENT:
ADDRESS OF FOOD ESTABLISHMENT: ,v
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): • `bll;p`i�➢I(Q�
E-MAIL ADDRESS:
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: �' d 6 l
TOTAL NUMBER OF BATHROOMS:
WELL WATER:YES No .. (ANNUAL WATER ANALYSIS RE U
ANNUAL: SEASONAL: DATES OF OPERATION: l i Q T�!- / /) j
NUMBER OF SEATS: INSIDE: OUTSIDE: -r) TOTAL: \?j
SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LI ING
***OUTSIDE DINING REMINDER***
OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING
REOUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?
TYPE OF ESTABLISHMENT: (P EASE CHECK ALL THAT APPLY BELOW)
LFOODSERVICE( 1�
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE & NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:\Application FormsTOODAPP 2020.doc
j
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNSC- YE�S)0 OWNER PHONE
ADDRESS
CORPORATE OWNER: V
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS:
List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness-Certified-Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Expiration Date Aller en Awareness Expiration Date
,
1
1. �
c
2. a
1� /3o Ul
KJ
SIGNATU OF APPLICANT DATE
I
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments, including mobile trucks must be inspected by the Health Div.
prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec.3 V each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Apphcation FormsTOODAPP REV3-2019.doc
Town of Barnstable BOARD OF HEALTH
John T.Norman
+7 Board of Health Donald A.Gaudagnoli,M.D.
BARNS AB Paul J.Canniff,D.M.D.
MAM 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections
305A, 3056, 146, 189 and 189A;Chapter 111, Sections 5 and 127A, a permit is hereby granted to:
Permit No: 271 Issue Date: 12/10/2019
DBA: DOLPHIN RESTAURANT
OWNER: NANCY JEAN SMITH
Location of Establishment: 3250 MAIN STREET BARNSTABLE, MA 02630
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 112 OutdoorSeating: 0 Total Seating: 112
FEES
FOOD SERVICE'ESTABLISHMENT: $300.00 YEAR. 2020
RETAIL FOOD:
COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST:
MOBILE-FOOD:
MOBILE-ICE CREAM:
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
f.
For Office Use Onlye Initials:
Town of Barnstable Date Paid EL Amt I'd$ �
MUMrABLE, : Inspectional Services
Public Health Division cheek#
gFD MAC►
Thomas McKean,Director
J
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:
IDA,6A )
ADDRESS OF FOOD ESTABLISHMENT: /
MAILING ADDRESS(IF DIFFERENT FROM ABOVE): I Do -�"l' � o� 3v
E-MAIL ADDRESS:
TELEPHONE NUMBER OF FOOD E TABLISHMENT: v
TOTAL NUMBER OF BATHROOM
WELL WATER: YES N04 ... (ANNUAL WATER ANALYSIS REQUIRED)
ANNUAL: SEASONAL: DATES OF OPERATION:I/ /�-TO f�'3//a4 OL1-0-k
I
Of
NUMBER OF SEATS: INSIDE: OUTSIDE: / TOTAL:
SEATING: MUST OBTAIN A COMMON VICTU LER'S LICENSE FROM LICENSING DIV.
***OUTSIDE DI G REMINDER **
OUTSIDE DINING MUST BE APPROVED BY THE H AL DIV.AND LICE AND MEET OUTSIDE DINING
REOUIREMENTS.
IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? �W
IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOORS)?
TYPE/OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)
FOOD SERVICE
RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer)
BED&BREAKFAST
CONTINENTAL BREAKFAST
COTTAGE FOOD INDUSTRY(formerly residential kitchen)
MOBILE FOOD
FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED)
CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2)
*** SEASONAL,MOBILE &NEW FOOD ONLY***
REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED
PLEASE CALL 508-862-4644
Q:Vlpplication FormsTOODAPP 2020.doc
f
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNER: ES/NO - OWNER PHONE# u u J� a' i3�►:Co
ADDRESS Cl0
CORPORATE OWNER:
CORPORATE ADDRESS:
PERSON IN CHARGE OF DAILY OPERATIONS:
List (2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff
All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT.
**ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You
must provide new copies and POST THE CERTIFICATES at your food establishment.
Certified Food Managers Ex iratio Date Allergen Awareness Ex iration Date
2.
3 � -3 Z
SIGNATURE APPLICANT DATE
***FOOD POLICY INFORMATION***
SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div.
prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance.
FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter,
with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert
Permit until the above terms are met.
CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering
event. You must complete a catering notice found at httt)://www.townofbarnstable.us/healthdivision/applications.asp.
OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food.establishment is prohibited.
NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st.
Q:\Application FormsTOODAPP REV3-2019.doc
1
1.
MAIL-IN REQUESTS
Please mail the completed application form to the address below. Also include copies of your employees'
food protection manager training certificates (at least two) and food allergen awareness training certificate (at
least one.) In addition, please include the required fee amount (see fees at bottom of this page). Make check
payable to: Town of Barnstable. Our mailing address is:
Town of Barnstable
Public Health Division
200 Main Street
Hyannis,MA 02601
FOR FAXED REQUESTS
Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax copies of your
employees' food protection manager training certificates (at least two) and food allergen awareness training
certificate (at least one.) In addition, you must mail the required fee amount(see box below). Please make the
check payable to: Town of Barnstable. The check must be mailed to the address listed above.
FEES: Bed &Breakfast Permit= $55; Food Service Permit 0-49 seats=$250; 50 or more seats $300;
Continental Breakfast=$30; Retail Food (only TCS Foods)= $20; Retail Food Store—Less than 8,000 S.F. _
$100, more than 8,000 S.F. =$285; less than 1,000 S.F.; Retail Food Combo/Limited Prep. - $200.00; Cottage
Food Industry= $75; Mobile Truck=$50; Mobile Ice Cream Truck=$35; Frozen Dessert License=$30;
Additional non-refundable Fee for New Establishment or New Ownership= $100-$500(see staff), Late Fee=
$10
Q\Application FormsTOODAPP REV3-2019.doc
Town of Barnstable BOARD OF HEALTH
8 Paul J Canniff,D.M.D.
° Board of
Health Donald A.Gaudagnoli,M.D.
Baaa� rAuM John T.Norman
Mnss 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate
t439
Phone: (508) 862-4644 Fax: (508)790-6304
www.townofbarnstable.us
Permit to Operate a Food Establishment
Inaccordance 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: 271 Issue Date: 12/20/18
DBA: DOLPHIN RESTAURANT
OWNER: NANCY JEAN SMITH
Location of Establishment: 3250 MAIN STREET BARNSTABLE, MA 02630
Type of Business Permit: FOOD SERVICE
Annual: YES Seasonal:
IndoorSeating: 112 OutdoorSeating: 0 Total Seating: 112
FEES
FOOD SERVICE ESTABLISHMENT: $300.00 YEAR: 2019
RETAIL FOOD:
COTTAGE FOOD.OPERATION: Permit Expires: 12/31/2019
B&B-FULL BREAKFAST:
CONTINENTAL BREAKFAST: -- ---- - - --------
MOBILE-FOOD:
MOBILE-ICE CREAM: ��
FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent
TOBACCO SALES:
FOR ESTABLISHMENTS WITH SEATING:
i
PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE
Restrictions:
� F
r FIHE Toyti Town of Barnstable For Office Use Only: Initials:
o� -
Date Paid ����Amt Pd S t
�ST"M Inspectional Services
0,wo. �0� W a J 1
alFDe Public Health Division W
Thomas McKean, Director ".
200 Main Street,Hyannis,MA 02601 xis
Office: 508-862-4644 Fax: 508-790-6304 _Yi
APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
DATE'( 1 NEW OWNERSHIP RENEWAL Y
NAME OF FOOD ESTABLISHMENT: Q'1_�
ADDRESS OF FOOD ESTABLISHMENT: 3� ' 1 xk4__)SZ+ 2+41t V4A-Alh �J A I o a
MAILING ADDRESS(IF DIFFERENT FROM ABOVE):
E-MAIL ADDRESS: s ' " (2, .rY`gJ-U/VL --
TELEPHONE NUMBER OF FOOD ESTABLISHMENT: c3ba- 61 a
TOTAL NUMBER OF BATHROOMS:
(,�
WELL WATER:YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) �Q
ANNUAL: SEA NAL: DATES OF OPERATION: / / TO
NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:
SEATING: MUST OBTAIN A C MMON 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 FormsT00DAPPREV2018.doc
PLEASE CALL 508-862-4644
OWNER INFORMATION:
FULL NAME OF APPLICANT
SOLE OWNE : YES NO !+ OWNER PHONE #
ADDRESS � Gtca�ru/"�-
CORPORATE OWNER: FEDERAL ID NO. :
CORPORATE ADDRESS: ��� /�
PERSON IN CHARGE OF DAILY OPERATIONS: 1 1�
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 Ex iration Date 1--�llm en Awareness Expiration Date
2.
SIGNATIT6 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.
TOBACC
O ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and
Employee Signature Form.
NOTICE: Permits run annually from January 1 st to Dec.3 l't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN
THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st.
Q:\Application Forms\FOODAPPREV2018.doe
r
I No. - ------
F
ICE OF THE BOARD%F HEALTH
OF THE
o TOWN OF BARNSTABLE, MASS.
a 139HHSTABLE,
MASS.
_t
RFD MAY �` SEWAGE DISPOSAL I iMIT
Permission is granted to V- o to construct
Aq
Sketch
Upon the Premises of
---------------- ---— _ -dw�a.i
1----- ----- --- - - -----------
In the village of
f �
I � O`U P5. or more feet from any source of water supply
M feet from building J
10 feet from property line , oLG
P _
--- - Health OfFicerr.. ' f
i J\