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TOWN OF YARMOUTH Q BOARD OF HEALTH
1146 ROUTE 28
FOOD ESTABLISHMENT INSPECTION REPORT SOUTH YARMOUTH, MA 02664
Name_�Y
PrintNic AMA
S jn
Date
� /� � �
{
Type of Operation(s)
Type of Inspection
LJ�Foocl Service
Retail
U Residential Kitchen
U Mobile
U Temporary
U Caterer
❑ Bed & Breakfast
Permit No.
Routine
U Re -inspection
Previous Inspectionection
Date:
U Pre-operation
U Suspect Illness
U General Complaint
U HACCP
U Other__
AddressU
I � �
Telephone
OZ
Ownerf f F t
HACCP Y/N
Person in Charge (PIC)
Time
In:
Out:
Inspector ){'�1 �� ^C,(
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
PrintNic AMA
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) a 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
❑ 14. Approved Food or Color Additives
❑ 3. Personnel with Infections 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
Cl 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)
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)(590.007)
28. Poisonous or Toxic Materials (FC -7)(590.008)
29. Special Requirements (590.009)
30. Other
Number of Violated Provisions Related to
Foodborne Illnesses Interventions and Risk
Factors (Red Items 1-22):
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:
Inspector'7'S19natbre �` -
PrintNic AMA
❑ No
PIC' , ignature
Print -
Page �_ of Pages
Item Code C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date
No. Reference R - Red Item PLEASE PRINT CLEARLY Verified
L401
Discussion with Person in Charge:
Correction Action Required:
❑ No
❑ Yes
❑ Compliance Ll Employee Restriction
Voluntary /
rY Com P Exclusion
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary Disposal ❑ Other