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TOWN OF YARMOUTH BOARD OF HEALTH
1146 ROUTE 28
FOOD ESTABLISHMENT INSPECTION REPORT SOUTH YARMOUTH, MA 02664
Name
r'�
Date
Type of.Operationfsl
Type of Inspection
Food Service
sAddress
e
LI Retail
11 Residential Kitchen
U Re -inspection
Previous Inspection
Telephone 2 f�
2
�o
--rj p�
Jam/
❑ Mobile
Ll Temporary
❑Caterer
❑ Bed & Breakfast
Permit No.
Date:
Ll Pre-operation
❑ Suspect Illness
❑ General Complaint
l] HACCP
U Other
OwnerHACCP
�� GL
Y/N
Person in Charge (PIC)
Tim e
In:
Out:
Inspector / PtonC, VSA
Each violation check6d requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti -Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate 590.009 (E) ❑ 590.009 (F) ❑
corrective action as determined by the Board of Health.
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 Employee and PIC Cl 14. Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source
❑ 5. Receiving/Condition
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/HACCP Plans
DDn'r1=f TIr1N COnRA r`r1BIT ARAI KI ATIr%K1
❑ 8. Separation/Segregation/Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
Cl 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
❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories
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 IN
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)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.006)
29. Special Requirements (590.009)
30. Other
Number of Violated Provisions Related to
Foodborne Illnesses Interventions and Risk
Factors (Red Items 1-22):
Off icial 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: 1 2 vv6-C✓K S
Inspector's at ^ Print f-77 1, e ��"
r
PIC'snatured -' / rintX
e- .,Ey`aG
Page 4- of -V-Pages
Item Code C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date
No. Reference R - Red Item PLEASE PRINT CLEARLY Verified
Discussion with Person in Charge: Correction Action Required: ❑ No Ll Yes
O Voluntary Compliance ❑ Employee Restriction /
P Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary
Disposal
❑ Other