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TOWN OF YARMOUTH BOARD OF HEALTH
1146 ROUTE 28
FOOD ESTABLISHMENT INSPECTION REPORT SOUTH YARMOUTH, MA 02664
Name t
Date
Type of Operation(s)
Type of Inspection
,k( Food Service
,, Routine
11-i
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
Address �t jai Z
`"J
�r
U Retail
U Residential Kitchen
-Re-inspection
Inspection
PreviTelephone
❑ 17. Reheating
❑ 18. Cooling
U Mobile
U Temporary
Date
U Pre-operation
Owner
HACCPY/N
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
U Caterer
U Bed &Breakfast
U Suspect Illness
U General Complaint
U HACCP
Person in Charge (PIC) �? GIS
In. Time
❑ 22. Posting of Consumer Advisories
Inspector `; - '? _ C
Out:
Permit No.
U Other
Each violation checked'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) U
corrective action as determined by the Board of Health.
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
❑ 4. Food and Water from Approved Source
Cl 5. Receiving/Condition
❑ 6. Tags/Records/Accuracy of Ingredient Statements
❑ 7. Conformance with Approved Procedures/FIACCP Plans
PROTECTION FROM CONTAMINATION
❑ 8. Separation/Segregation/Protection
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 10. Proper Adequate Handwashing
LJ 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;
?4. 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
❑ 12. Prevention of Contamination from Hands
Print
t
❑ 13. Handwash Facilities
PIC's gnat re
Si
PROTECTION FROM CHEMICALS
Prim
❑ 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
TIME/TEMPERATURE CONTROLS (Potentially Hazardous Foods)
❑ 16. Cooking Temperatures
❑ 17. Reheating
❑ 18. Cooling
❑ 19. Hot and Cold Holding
r
❑ 20. Time as a Public Health Control
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP)
❑ 21. Food and Food Preparation for HSP
CONSUMER ADVISORY
❑ 22. Posting of Consumer Advisories
Number of Violated Provisions Related to
Foodborne Illnesses Interventions and Risk
Factors (Red Items 1-22):
Official Order for 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:
Inspe tti .A S' nature ,
A
Print
t
C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
R - Red Item PLEASE PRINT CLEARLY
PIC's gnat re
Si
Prim
Page e, of ' t Pages
Item
No.
Code
Reference
C - Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
R - Red Item PLEASE PRINT CLEARLY
Date
Verified
Disposal
❑ Other
r
W
`i- I l>- ,S
i C
C:,G 5 G
n
UL
r J
DisctlsSfoft-w: ers ,jIL.CI]aige:
�i F✓'i
Correction Action Required:
❑ No
❑Yes
A, A (..
❑ Voluntary Compliance ❑ ExcPusyon Restriction/
❑ Re -inspection Scheduled ❑ Emergency Suspension
❑ Embargo ❑ Emergency Closure
❑ Voluntary
Disposal
❑ Other