185 (Haymarket Cafe) Complaint 2016 Geo Tracking 4:G but& Entered Es
Date Entered: AS k�
BODYART
NUTS CE
SMOKE
FOOD
ODOR
WATER/SEWER
FOOD ILLNESS
PESTS
HOARDING
HOUSING
POOLS
NAIL SALONS
SEPTIC
OTHER
CGMPL 4I TANE'S ;INFORMATION:
Call Taker initials: a,
Dare of Compiaint: R /0.g / to,
Complainant's Name:
Occupant's Name:
Cammpian®t Locathin:
NATURE OF
COMPLAINT:
Crv1 LiQL4 ti-. el-
125 lOW, St-
af C
Animals: Wil#1 Child Under 6: Y/N
,nn — a„ gll c, —7 r4-
Telephone# ( ) -
Telephone#
)
rJ 1 / • I 1 4".i/L-A4
•
tau .& % It::' 'S
st3cl
rt Vo r, oath) , atuvue 6n c..
OWNER'S INFORMATION:
Owner's Name: � rcien ca,t Address:
Property Mgr./
Land Lord:
Address:
Scheduled ��
Scheduled on:
Complaint ��
Unfounded: 7 !//D%/o s td .dG
Conditions ///tie-5,51
Found:
Telephone#( )
Alternate # ( )
Scree/
ACTION TAKEN: ,q/on.P
% l7/ /6
Signature of Inspecting Officer Date/Time of Inspection
02.56:34 a m. 08-29-2016 2/3
Massachusetts Department of Public Health
FOODBORNE ILLNESS COMPLAINT WORKSHEET
Date. 08/29/2016
MAVEN IDff' 102593311
Please complete and fax to
MDAH Food Protection Program
905 South Street
Jamaica Rain,MA 02130
Fax: (617 983-6770
Questions?
Food Protection Program
Division of Epidemiology:
Enteric Laboratory:
(617)983-6712
(617)983-6800
(617)983-6609
PERSON COMPLETING INFORMATION
Affiliation:
❑ Local 6011
® State
0 Other
Name: Brandi Hopkins
Town or DRr division: Mpasachussos Deootmcot of Public Health
Other, specify:
REPORTER I.COMPLAINANT
..:_ _ .-_ __ ;; ' . .. :_ ILL PERSONS._
Nam. Adds b&Town Age Caput Lion Me�IPlevidv Mod Diagnosis
Name a Rens Spx4iren
pp,,brene
NoM!tingstowm,RI 51 r"
Yeas)
ID No
OYes
ONo
It
0 Yes
0 N
I
O Ym
0 Yes
7 No
Mxv" Min
I_-_ MI Mu
B c ereue(shod) YN In Cyclosoora 2 days 14 Jevs So/Allah poisoning at nr can
L.__ '� .._ to f Stia.th - arv3
atm o„6
�I I I "I p ' !' !1 111 1111 �� �� �I .11 !�'I!d! 1111 11 '� 11
'.: 1 1 i I' e I 1: I I organism ices ifiod, obrai-, hutcry for Mime period 13e'Arnan minimum and -ra,in rim In a 'h r e n<. I o
E 'i'. ]I II L C' : 1 i r I Et-wean meals('fool s)only. Alwalrs'E ccd time ccnw rid if pa libla:ethery'FN'CE to Be= Ire id a _- s s' 1
. I., ;J s (I ,r P x I AI t U Lscrrfjcn Consulted Location ation aurehesed 3n'ra1 Oi Ii :f II
t
u II s ; h s u I I F I II li] Home [Flame' kityrilaitet Cafe_ _ 9 ii t
1 r. i a Where purchared Abscess: 155.fsin St ] II .
.. -. .. 1:1 Other. specify: City: Nttnarnroa a II o I:
I: t 1 .: State: big Zip de: 1
I. I. ri t-lollle Name _ t 31 It ,
n - f1 Whore pure'au°d Add re s: _ , _ __ _ ___ ]
❑ Other specify: City:: ___—._. .—._.__._ 3 ut :a .
I I 1 State: _______ Zip code; __-_.__ _ :] i.
I. I. I:] Paine Name: _.__ t ,m It 1
_. .. _. . ❑Where purchased Address:._______.___._______.___. ] r.
.. .. 0 Other, specify: City ._._.._._ 3 'a s is
I I" I Stare: 19p code:
I I C] Horne Narre: _ — ___ _ —.—.._____. e is t.
- . . ❑Whore purchased Address: ] r : 1
.. - - ❑ Other, specify: City: _._ _ 3 it t 1
t: I'. I :: ] ______ _ state: Zip code: _._.____ '3 i.
I b ❑ Horne Nam Ie: _- ___ _ A It is
.. LI Where pulrehaf ed Adth e's. _ _____ _ . ] E
.. - I7 Other, s{pecifY'. City: 3 'il r 1
I" E .__.._._.___._._ Stele: i:ip code '.] 'i : I
t ti CI Horne Name: _- _ _____—._______ A ui I. 1 I
.. _. _ 17 U'here purchased Address: I 'I 1
.. .. I (Aber, specify City I 3 'f ) 1
I'. fa ___._. _._.__—__
__._ _.—_— state. imp code: :] 'e 1