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1
TOWN OF YARMOUTH BOARD OF HEALTH
1146 ROUTE 28
FOOD ESTABLISHMENT INSPECTION REPORT SOUTH YARMOUTH, MA 02664
Name
Print
❑ 13. Handwash Facilities
Date
I`j cj
Type of Operation(s)
Type of Inspection
6 Food Service
U Retail
U Residential Kitchen
-W Routine
U Re -inspection
Previous Inspection
Address 5L
❑ Other
Telephone
P
5
2 - % �j % 7
U Mobile
U Temporary
U Caterer
❑ Bed & Breakfast
Date:
U Pre-operation
U Suspect Illness
U General Complaint
U HACCP
Owner
HACCP Y/N
Person in Charge (PIC)
Time
In:
❑ 20. Time as a Public Health Control
Inspector
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
'CSE'
Out:
Permit No.
U Other
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) Non-compliance with:
Anti -Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate 590.009 (E) U 590.009 (F) U
FOOD PROTECTION MANAGEMENT
❑ 1- PIC Assigned / Knowledgeable / Duties
EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded
FOOD FROM APPROVED SOURCE
U 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
PROTECTION FROM CONTAMINATION
❑ 8. Separation/Segregation/Protection
LJ 9. Food Contact Surfaces Cleaning and Sanitizing
10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
Violations Related to Good Retail Practices (Blue Items)
Critical (C) violations marked must be corrected immediately
or within 10 days as determined by the Board of Health.
Non-critical (N) violations must be corrected immediately
or within 90 days as determined by the Board of Health.
C N
23. Management and Personnel (FC -2)(590.003;
24. Food and Food Protection (FC -3)(590.004;
25. Equipment and Utensils (FC -4)(590.005;
26. Water, Plumbing and Waste (Fc 5)(590.006;
27. Physical Facility (FC -6)(590007.
28. Poisonous or Toxic Materials (FC -7)(590.008
29. Special Requirements (590.009)
30. Other
❑ 12. Prevention of Contamination from Hands
Print
❑ 13. Handwash Facilities
_,.
PROTECTION FROM CHEMICALS
❑ 14. Approved Food or Color Additives
Print o, s e . ti
❑ 15. Toxic Chemicals
❑ Other
TIME/TEMPERATURE CONTROLS (Potentially Hazardous
Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
❑ 20. Time as a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
LJ 22. Posting of Consumer Advisories
Number of Violated Provisions Related to
7F, C� 0`�7
Foodborne Illnesses Interventions and Risk
Factors (Red Items 1-22):
sLA1 c3 tx�S
Official Orderfor Correction: Based on an inspection today,
the items checked indicate violations of 105 CMR 590.000/
federal Food Code. This report, when signed below by a
Board of Health member or its agent constitutes an order of
the Board of Health. Violations not corrected are subject to
fines per Yarmouth Board of Health. If aggrieved by this
order, you have a right to a hearing. Your request must be
in writing and submitted to the Board of Health at the above
address within 10 days of receipt of this order.
DATE OF RE -INSPECTION:
Inspec)or!s.Sig at re
Print
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date
PRINT CLEARLY Verified
_,.
PIC's Signature
r
Print o, s e . ti
Page `__ d' Pages
Item Code
No. Reference
C - Critical Item
R - Red Item
DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date
PRINT CLEARLY Verified
l- //PLEASE
Com- TS
Disposal
❑ Other
7F, C� 0`�7
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A-- C_
C,
W t A.,-- r I 6//K4 /V E Yi, i 2
Discussion with Person in Charge:
Correction Action Required:
❑ No
LJ Yes
❑ Voluntary Compliance ❑ Employee Restriction /
Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary
U`
O
Disposal
❑ Other