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HomeMy WebLinkAboutPlymouth Party LLC - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: FOOD ESTABLISHMENT In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:, MARGE GALLETTA Whose place of business is: PLYMOUTH PARTY LLC 25 LADY SLIPPER DRIVE PERSON(S) IN CHARGE: MARGE GALLETTA Permit Expires: December 31, 2019 Food Fee: $175.00 License Number: FS -5 BOARD OF HEALTH .Michae(Hea(ey, Chairman K FOR BOARD OF HEALTH USE ONLY Permit# Issued FOOD ESTABLISHMENT PERMIT APPLICATION (Application must be submitted at least 30 days before the planned opening date) Establishment Nam__ am Establishment Address: Establishment Mailing Address (if different):NAM 2 i9 Establishment Telephone No: i %/- 7P r ') s Applicant Nime&Title: �uF�e �/1 ���` ate, BJP/" din V/�v��ucrf���CJ z3U Applicant Address: Applicant Telephone No.: / a 2' o� 24 Hour Emergency No.: Applicant Email _�9�nvPc -- Owner Name & Title (If different from applicant): Owner Address: Owner telephone number: Owner email: Establishment Owned By: EJ An Association VA Corporation El An Individual 111 A Partnership If a corporation or partnership, give name, title, and home address of officers or partner. Name Title 19 Other legal Entity 0';� 36 a Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name &Title: Address: { Telephone No: / ./✓ FAX: (y E-mail: Alt E -Mail: District Or Regional Supervisor (if applicable) Name & Title: Address: 24 Hour Emergency No: Telephone No: 24 Hour Emergency No: FAX: E-mail: WATER SOURCE: DEP Public Water Supply No: (If DAYS/HOURS: Food Establishment Information SEWAGE DISPOSAL: No. of Food Employees: Name of Person In Charge Certified in Food Protection Management: If more than 31 Ivlduals are certifie omplete list is on file. X77,6 Person Trained in Anti -Choking Procedures (If 25 Seats or more): 0 Location: l Permanent Location 'Moblie Mobile Start Date: Mobile End Date: Mobile Comments: Length of Permit: t Annual Q Seasonal Seasonal Dates: Temporary Temporary Start Dale: Temporary End Date: Temporary Time: Rain Date: Food Operations: Check all that apply): Establishment Type: Q Retail -NO FOOD PREP ( Sq. Ft) $12E Food Service up to 100 seats INCLUDING FOOD TRUCKS $175.00 Food Service for 101 -200 seats $250.00 lJ Food Service for 201+ seats $300.00 E] Supermarkets $400 0 Caterer $35.00 E] Milk & Cream $10.00 Q Mobile Food Consession NO PHF PREPARED ON SITE $100.00 O Manufacture Frozen Desserts/Ice Cream $25.00/freezer ❑i Pushcart $50.00 If of Pushcarts: 0 Residential Kitchen $100.00 Tobacco Products $150.00 l71 Retail Snack Food $50.00 Definitions: PHF- Potentially hazardous food (timeltemperatum controls required) Non-PHFs - non -potentially hazardous lood(no time/temperature controls required) RTE -ready -to -eat foods (Ex. sandwiches, salads, mums which need no furthermucessing) Q Sale of Commercially Pre -Packaged Non-PHFs LJ1 PHFCooked To Order 0 Hot PHF Cooked and Cooled or Hot Held ! Sale of Commercially Pre PackagH Preparation of PHFs For Hot And for More Thane Single Meal Service -- ------ Cold Holding For Single Meal Service 0 PHF and RTE Foods Prepared For Highly Delivery of Packaged PHFs _-_ _ _____.— _ _- Susceptible Population Facility - ----- -- -- - 0 Sale of Raw Animal Foods Intended E] Reheating of Commercially- - Processed Foods for Service Within 4 Hours to be Prepared by Consumer Vacuum Packaging /Cook Chill Customer Self -Service of Perishable Foods Only Preparation of Non-PHFs Other Food Operations /�," '1. 1, y -- ---- -- ------------ 0 Use of Process Requiring A Variance iF and Non- l� Customer Self -Service and/or HACCP Plan (including bare hand Q Ice Manufactured and Packaged for contact alternative, time as a public health Retail Sale control) E] Juice Manufactured and Packaged for E] Offers Raw Or Undercooked Food Of Retail Sale Animal Origin 0—offers RTE PHF in Bulk Quantities ❑' Prepares Food/Single Meals for —_ Catered Events or Institutional Food Service Q Retail Sale of Salvage, Out -Of -Date — _ - -:: or Reconditioned Food To be completed by the Board of Health - ---' Total Permit Fee: Payment is due with application F] waived. I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food establishment operation will comply with 105 CM 590.000,,aa��d all other applicable law. I have been instructed by the board of health on how to obtain copies of a 05 MR 59q�00`a d-jDq:.federal Food Code. Signature of Applicant: `'1% P - Pursuant to MGL Ch.62C, sec. 49A, I ce 4 ify unde"Il the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid state taxes required under law. Social Security Number or Federal ID: Signature of Individual or Corporate Name: TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Sig ature of Ind/Vidy`�br Corporate Name By: orporat Officer (Mandatory, if Applicable) "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Usem\sleite\Desktop\Scott's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc �� .uw .............. rr.,...... j... w........,....o..u.. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IV wrvw.ntass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses DDlicant Information _ _ Please Business/Organization Address: �r 3 � e Phone ht: " i _l/ 7 F11 Are you an employer? Check the appropriate box: Business Type (required): I. ❑ I am a employer with employees (full and/ 5. ❑ Retail or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7, ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 1 [No workers' comp. insurance required] 8 ❑ Non-profit 3. © We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, 1 L❑ Health with no employees. [No workers' comp. insurance req.] 12.Q/OthePi 4� Ci C *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers compensation policy is required and such an organization should check box #L 7 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Insurer's City/State/Zip: Policy # or Self -ins. Lie. Expiration Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the�r ns and ei /illi ofperjury that the information provided above is true and correct. Qi nnafi.r<• /� / /l/�/ DAiE' "/ 3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia X w ti x THE COMMONWEALTH OF MASSACHUSETTS I6P0 '� TOWN OF PLYMOUTH PUBLIC HEALTH DEPARTMENT „ 6 2019 BUSINESS LICENSE PLYMOUTH PARTY LLC 25 LADY SLIPPER DRIVE PLYMOUTH, MA 02360 DBA: PLYMOUTH PARTY LLC CID #:312422 BL ID #: 102234 LICENSE #: 4967 Your 2019 Business License for A LICENSE TO OPERATE A CATERING ESTABLISHMENT is printed below. Please retain a copy for your records. If you have any questions, please call the Public Health Department at 508-747-1620 ext. 10118. Doing Business In: Has been granted: THE COMMONWEALTH OF MASSACHUSETTS TOWN OF PLYMOUTH PUBLIC HEALTH DEPARTMENT 2019 PLYMOUTH PARTY LLC PLYMOUTH, MA 02360 A LICENSE TO OPERATE A CATERING ESTABLISHMENT FEE PAID $ 150 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws and 105 CMR 590.000 Expiration date: December 31, 2019 Signature /4 A4" "'^ DRN LICENSES ARE NOT TRANSFERABLE / R A C4 2./ q 2 - ED CJ:49 0 g; � § - � k -ƒ..�1. m 5 (] , 4 0 l Q Q �. U : ] ; 2 I E o A : U. ! mak\ / � � o @: j7 7 2 } / : _ / | ' \i$ 0 % 00. co w 2 \ \ o E[ LU = # o: � %. # O| | ƒ %: ƒ} ƒ; \ t - .- .. ;¥E©-/- w- a); 0{ )^ \ _ 2 Q ¥� <. f § co \ o; PLYMOUTH PARTY MENU Fresh Spun Cotton Candy Snow Cones Frozen Desserts Popcorn Soda Bottled Water BRAINTREE HEALTH DEPARTMENT One JFK Memorial Drive, Braintree, MA 02184 Phone: 781-794-8090 Fax: 781-794-8022 www.TownofBraintreegov.org NAME _-- DATE. -,. TYPE OF OPERATION (W TYPE OF INSPECTION ( 1 ADDR�E�S ` RISK LEVEL f✓�. ❑ ❑FOOD SERVICE TEMPORARY ❑RETAIL ❑CATERER �''t W ROUTINE TELEPHONE _� ❑RESIDENTIAL KITCHEN EIB &B ❑ RE -INSPECTION ❑ PRE-oPERATION OWNER I\ _' HACCP require u^l-/ - - El ❑MOBILE []NURSING SUSPECT PIC TIME IN - HOME❑ ❑OTHER ILLNESS ❑ GENERAL COMPLAINT INSPECT01` :i - ' \,' '- \ \ :' 1 g,_ or PERMIT VO: ❑OTHER .Von-cnmplian with: Ah'f1-GHGKING 5WDO9(E) ❑ TOIi:.cYO i"9 ❑ CF\, -; LP:P:::!:'. A':I2i:�::Sp 590. F1 -u r e u0_n t. ❑ i9SDr;9 G, Official Order for Correction: Based on an inspection this day, the items marked below identify the Violations in operation or facilities which must be corrected by the date specified below. This report, when signed by a Board of Health (BOH) member or its agent constitutes ao order of the BOH to correct violations. Failure to comply with this notice may result in immediate suspension of your permit. tf aggrieved by this directive. you have a right to a hearing. Your request must be in writing and submitted to BOB at the above ITEM CODE address within 10 days ofreceipt ofthis order. TEM CODE EMPLOYEE HEALTH 590.003(A)5-101-03.11590.003(8) WATER IMANAGEMENTAND - 2s 5 -103.11 -.II iI, ND PRESSURE2_103.11 591T00326 HIGHLY SUSCEPTIBLE POPULATIONS ' 3-801.11 590.003(0 E) L I- : i-_ FROM AP FOODPROVEDSOURCE CONSUMERADVISORY 20 C 3fiO3-.II �c , c1t0L113601.12 -,,.. ..,<,.... -., __ E UIPMENTAND UTENSILS c 3 -202.11 -.IS t ::';:. '.�'"•. 28 a-202.11 FOOD CONTACT SURFACES DESIGNED INSTALLED 59 3) r 29 4-20216`6z.13 NON CCNFACFSURFACES DESIGNED INSIALLD MAAWAQD oz cC= 3.202.18 30 4-501.1/.5 DISHWASHING/E UIPNENT DESIGNED INSTALLED OPERATED ,,TC J_ 3 , 4-301.12-.13 THREE COMPARTMENT SINK PROVIDED DRAINBOARDS203.12 -- 4-20e.1lv.l15 E UIPMENT THERMOMETERS AND PRESSURE GAUGE 8-103.12 ` ?:d s r a . >-. .- C - 3-302.12 FOOD CONTAINERS PROPERLY LABELED 4-302.14KIT- 31' TE T .1 PROVIDED 4-603.12 PRE -FLUSHED SCRAPED SOAKED 03 D4 C 3-201411F SAFE FOOD4IANDLING INSTRUCTIONS 050110.-.uo WASH. RINSE WATER CLEAN. PROPER TEMPERATURE PROTECTION FROM CON A NATION i21 3-304.14 WIP N( 0 OTHS �. AN cANIT 2F 05 C 3.302&304.11 ti c - 'IS - p _ 33 4-9011 CLEAN IPM ANDUTENSILS PR 1' C aF01.D(Ay4'A211 c i'„'\ J - - 4-904.11 y ARTICI )4ES S1QRFD- DISPENSED 06 4-502.13 < 4-602.11 i ?\'.\4 \ - 07C 3-306.14 KILT'c _ SEWAGE oe c 3-302.15 R ,Sn,\C r:,,,.,. 3517C 5402.13 5SIVAGEAND WASTE WATER DISPOSAL - _ 3-305-OZII FOOD PROTECTION STORAGE, DISPLAY, TRANSPORTATION PLUMBING 36IC 5-201.u/05.15 )0_.3-301.11(c) HANDLING OF FOOD & ICE MINIMIZED IN STALLED AND MAINTAINED 11 3-304.12 3i C 5-203.10 $:?CK S)PHONAGE. BACKFLOW r' N TOILET PERSONNELAND HANDWASH FACILITIES 38 C 2-301.12 Pili)PER.ADEQC?.T: .3 `..<: ,�..: Hi,;G x¢la wtS TOILET ENCLOSED, SELF-CLOSING DOORS, GOOD REPAIR, lzc 2.401.t1-.Iz GC'o'„i;G,E�'Ic ?=:_�.: ���:: INSECT, RODENT,ANtMAL CONTROL C 509,004(E) dot \:'; _ 39iC-&SOLIII;.I15 TNS TS N. C 5-203.11 \ c' S. ^ - PHYSICAL FACILITIES 13 C 5-204/05.11 ti \ 'O� c - :,:...,� _ 40 6.201.11 FL00RS, WALLS, CEILINGS, CONSTRUCTED, CLEANABLE 6-501.11-.13 GOOD REPAIR, CLEAN, DUSTLESS CLEANING METHODS &3m.0-oz.0 HAND CLEANSER, HAND DRYINQ TOILET TISSUE, SIGNAGE 4t: &2011&201.17 WALLS & CEILINGS, ATTACHED EQUIP., CONSTRUCTED la 2-304&402.11 CLEAN CLOTHFS,SHNR RESTRAINT PROTECTION FROM CHEMICALS 421 6-303-202.11 ADEQUATE LIGHTINQ(FIXTURES SHIELDED f. 3-202'12 ` I O ': �- 6.304.1 ROOMS AND E UNMENZv�N-'Fg[f C 7-101.11 IJ\ i t In; r r 43 b-305.17 DRESSING ROOMS CLEAN, LOCKERS PROVIDED r 7-102.11 �:3' I ' t � 1 '- 15 \ ( REFUSE DISPOSAL ' .` 5-501,15-.16 ADEQUATE NUMBER, FREQUENCY, COVERED c 7.201-04. Yl a �.-\1 i .:\ �, ( E,✓,- 44 5-501.116 OUTSIDE STORAGE AREA CLEAN <� 7-206.II-.13 PF.S.';❑D!i)''.: �:; d.e F:1f i'r'': 5-501.11-.13 OUTSIDE STORAGE PROPERLY CONSTRUCTED, VERMIN PROOF C 7.207.09.11 MEDICINES, FIRST AID STORAGE RESTRICTED OTHER OPERATIONS FOOD PROTECI70N TPAE(rEMPERA'R)RE CONTROLS 55,C 6-501.15 3401.11-.12 COUR!•. �;':.I',=Ea,,:_;"' CLEAN MAINTENANCE TOOLS PREVFA' \' MIN ATnN 1-n 7 c 3-003.11 R°lir:,?,-i,: ^ 4 &501.!13/.N4 STORING MAINTENANCE TOOLS, UNNECESSARY ARTICLES IS r. 3-SOi.l4 CnOi_:N(i &263.13'&501.16 MOP SINK PROVIDED, DRYING MOPS 19 C 3-501.16 HOT COLii ""iC;i,^;:".:� 47 -202.11 U.12 SEPARATION FROM LIVING/SLEEPING DARTERS, LAUNDRY :t 20 C 590.004(n)i 9r 41l a-aov03.11 CLEAN, SOILED LINEN PROPERLY STORED ASA T _ 4 ' OTHER T, C 3402.11-.12 22 4-301.11 FACILITIES TO MAINTAIN PRODUCT TEMPERATURE 234-302.12 FOOD THERMOMETERS PROVIDED - 2a 3-501.13 1 PHF'S PROPERLY THAWED - _ - T HER'CRIT'C:?L \ i0! AT['DNS: ❑ DATE OF RE -INSPECTION `. -- f N ' NON-CRITICAL PI 'S V IOLAT(ONS: ❑ SIGNATURE;' INSPECTOR'S SIGN(sT.URE:. - a City/Town of FOOD ESTABLISHMENT INSPECTION REPORT Address: Tel. - Name'I, ^� LFood Date, ' Tvoa of 0oeration(s) Type of Insoection Service ❑ Retail ❑ Residential Kitchen `Mobile El Temporary ❑ Caterer ❑ Bed &Breakfast No. (2outine ❑ Re -inspection p ction Previous Inspection Date: ❑ Pre-operation El Suspect Illness ❑ General Complaint ❑ HACCP ❑Other Address �� — v _ - G ? -.` T .. Risk Level Telephone -- Owner / - • — - ; , / /, <<: , _ ; HACCP Y/N Person in Charge PIC 9 (PIC) Time ; !s in: Out:Permit Inspector ? -� i , ,, i,- :: -, i -��13 •1., o.,., 11WIVU iayupes an eApianation on the narrative page(s) and a citation of specific provision(s) violated. nZIA :; �-:,_3 ::a-`-- 1 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) ❑ Mark items below as IN / OUT / N.O. / N.A. (IN compliance, OUT of compliance, Not Observed during inspection, or Not To the right of each item mark with an "X° for Corrected on Site COS) or Repeat Violntinns (R) OOF1P11lE�"itO6Yl(tfANAtsEMENL �' (COS) R IN OUT 1. PIC Assigned / Knowledgeable r Duties ❑ ❑ PROTECTION FROM CHEMICALS IN OUT -_,. Apprccad Fcpd or Co!cr.4ddit,. es ❑ ❑ tri OUT 2. Reporting of Diseases by Food Employee. PIC ❑ ❑ IN OUT 3. Personnel with Infections RestrictediExcluded ❑ ❑ � Nib 4N OUT ,-, ceyea5n�, 11 Elr m OUT 4. Food and Water from Approved Sou. ca ❑ ❑ IN OUT 5. Receiving/Condition ❑ ❑ A OUT 6. Tags/Records/Accuracy of Ingredient Statements❑ ❑ IN OUT 7. conforms with Approved Procedures/HACCP Pan ❑ ❑ I�TitM(NARaN ,., IN OUT 8. Separation/ Segregation/ Protection ❑ ❑ QQ�oUT 9. Food Contact Surfaces Cleaning and Saniiizina N/A El ❑ IN OUT 10. Proper and Adequate Handwashing ❑ ❑ WS Nro 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. Mark items below as [Nor OUT �/ I 123. Management and Personnel (FC -2)(590.003) L_ t_ I 1 1 25. Equipment and Utensils tFc-4)aggo nnel (FC -5)(590.006) or Inspector's Signature: /If 441 i ri i¢t: PIC's Signature: {xx; OUT ?.:� - .,. ��"... ;,aipn ...,.. `ianjs ❑ ❑ N/A PUO IN OUT 1�' Har,.d•.ag.. , a iiitioc ❑ ❑ PROTECTION FROM CHEMICALS IN OUT -_,. Apprccad Fcpd or Co!cr.4ddit,. es ❑ ❑ ,/U,("'�OUT 15. Tcxm Caricas--„ TIMSITSMPERATURE CONTROLS (Potahthdly Hazard rfciod- r'.: -: IN Our 1, Cx, i,- 7e-, =- ❑ o � Nib 4N OUT ,-, ceyea5n�, 11 Elr Y r_ N/O TAOUT8. „ooune ❑ ❑ N(O _JROUT .,;era i �, Irl-�iC;^'c ❑ ❑ N/A N/O EN O T 20' ,ne as a Public Health ContrO ❑ El M-1N REQUIREMENTS FOR HIGHLY' SUSCEPTIBLE POPUL.4 —_(HSP) IN OUT _,. Food and Food Preparation for HSP ❑ ❑ CONSUMER ADVISORY. IN OUT _2,2. Post :^^ ^, Cons,.mer Advisories ❑ ❑-: Number of Vio;atad Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1.22): urricial uraer Tor correction: based on an inspection today, the items marked "OUT" indicate violations of 105 CMR 590.000/federal Food Cade. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have aright 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: 11 7 Page_ of '—Pages THE COMMON/W/E�t-T'H/ OF MASSACHUSETTS FOOD ESTABLISHMENT INSPECTION REPORT Board of Health i► W_ 50 5 .. Name / Date ,TItpe of Operationfsl ❑ Food Service ❑ Retail ❑ Residential Kitchen ❑ Mobile 07femporary ❑ Caterer ❑ Bed & Breakfast Permit No. Type of Inspection ❑ Routine ElRe-inspection Previous Inspection Date: -ire-operation ❑ Suspect Illness ❑ General Complaint ❑ HACCP ❑ Other Address-Risk r Level Telephone /-:7(f^erV7 Owner��// /�' /7 C r HACCP YIN Person In Charge (PIC) Time In: Out: Inspector Each violation cheeWd requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Iciness Interventions and Risk Facturs (fled items Anti -Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009 (E) ❑ 590.009 (F) ❑ action as determined by the Board of Health. Local Law ❑ Allergen Awareness 590.009 (G) G FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned I Knowledgeable I Duties ❑ 13. Handwash Facilities" 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 ❑ 5. Receiving / Condition ❑ 6. Tags / Records / Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures I I-IACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation / Segregation 1 Protection ❑ 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)(590.007) 28. Poisonous or Toxic Materials (FC -7)(590.008) 29. Special Requirements (590.009) 30. Other PROTECTION FROM CHEMICALS 14. Appmaed Food or Color Additives ❑ 15. Toxic Chemicals TIMElrEMPERATURE CONTROLS (Potentially Hazardous Foods) 16. Cooking Temperalures j 17. Reheating 18. cooling 13. Hot and Cold Holding ❑ 20. Time as a Public Health Control REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY 7�1 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Ilnesses Interventions and Risk Factors (Reel 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. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. 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's Signs or • Print: / J_o PIC's Signature: / Print: �k- ^ (�7r.- V� Pege _Pages FORM 734A IREV. 9/20101 HOBBS @ WARREN -BOSTON This Form Approved by the Massachusetts Department of Public Health SPECIAL STATE LICENSE Hawker or Pedler No 126636 A Licensee: Marjorie Galletta 25 Lady Slipper Drive Plymouth, MA 02360 ExExpires: 4-24-20 p.......................................................... 8-18-58 Date of Birth: Above portion must be worn in a visible and conspicuous manner on outer clothing. Take care of your license. Lost license will not be replaced. Fee: $60.00 Display $2.00 The (9mumanwra][14 of filaagasqunfto DIVISION OF STANDARDS ONE ASHBURTON PLACE, BOSTON Date ..........4-25-1 9 Wr i1 kuawn unto all to whom these presents come, that the above-named person is hereby licensed to go about as a HAWKER or PEDLER in all the Cities and Towns in this Common- wealth, and to sell or expose for sale or barter any meats, butter, cheese, fish, fruits, vegetables, or other goods, wares or merchandise; except jewelry, furs, wines, spirituous liquors, small arti- ficial flowers or miniature flags. This license is not valid until after the licensee has endorsed his usual signature in the space provided in the margin hereof, and the license is dated and stamped with the official stamp or signature of the Director. The portion of the license indicating the license number, licensee's name and the date of expiration must be worn in a visible and conspicuous manner on outer clothing, otherwise he will be liable to the same penalty as if he ]yid no license. woo W THIS LICENSE IS NOT TRANSFERABLE SPECIAL STATE LICENSE Hawker or Pedler No 125464 A Licensee: Marjorie Galletta 1 25 Lady Slipper Dr Plymouth, MA 02360 Expires: AP.ft.`L.4.ZQ19............... .._.. .......................... Date of Birth:...OS/18/58........................... I........ Above portion must be worn in a visible and conspicuous manner on outer clothing. Take care of your license. Lost license will not be replaced. Fee: $60.00 Display $2.00 (Diu Unninumralill of 11290 amus DIVISION OF STANDARDS ONE ASHBURTON PLACE, BOSTON Date ................... AP4.2.54418..... $s t1 kumn unto all to whom these presents come, that the above-named person is hereby licensed to go about as a ]3AWiiER or PEDLER in all the Cities and Towns in this Common- wealth, and to sell or expose for We or barter any meats, butter, cheese, fish, fruits, vegetables, or other goods, wares or merchandise; except jewelry, furs, wines, spirituous liquors, small arti- ficial flowers or miniature flags. This license is not valid until after the licensee has endorsed his usual signature in the space provided in the margin hereof, and the license is dated' and stamped with the official stamp or signature of the Director. The portion of the license indicating the license number, licensee's name and the date of expiration must be worn in a visible and conspicuous manner on outer clothing, otherwise he will be liable to the same penalty %.iif he had no li jense. Director THIS LICENSE IS NOT TRANSFERABLE