101 Smoke Shop Establishment # in Boynton Beach

Comments: A copy of this report has been provided to the person in charge of the food establishment and will he available online at re KAUSHIK PATEL, OWNER FREDA HADID, ENVIRONMENTAL SPECIALIST It Name and Tite of Whom This Report was Issued Print Date. 8/4/2025 Page 1 of 1 (8 CamScanner Florida Department of Agriculture and Consumer Service: Division of Food Safety FOOD SAFETY SAMPLE COLLECTION REPORT WILTON SIMPSON Chapter 500, Florida Statutes COMMISSIONER, Name: 101 Smoke Shop Owner. 101 Federal 44 FI Lic Type: Minor Outlet/Prepackaged/No PHF Address: 100 S Federal Hwy Boynton Beach, FI 33435 - 4926 SAMPLE INFORMATION Sample Number: 99963883216241 Product: Malaysian Kraton Brand: Remarkable Herbs Variety: NIA Lot RGMAS 16023 Origin Country: COLLECTION INFORMATION Date of Collection: 08/04/2025 12:47 PM Laboratory: Food Laboratory Reason for Collection: Survey sample Additional Comments: SAMPLE DETAILS Type of Container at Time of Collection Plastic bag zip lock Type of Storage at Time of Collection: Chilled Size of Container: 30z # of Container In Sample: 4 Collected From: Retail area Size of Lot: 12 Ounces Stop Sale Issued? N SHIPPING INFORMATION Date of Shipment: 08/04/2025 Shipped By: FedEx Tracking Number: 8832 8248 1340 Psa -aall (850) 245-5: Inspected By: Visit #: 9999-7182-3000-44 Bureau of Food Inspection Attention: Business Center 3125 Conner Boulevard, C-26 Tallahassee, FL. 32399-1650 SDAA T AANA AA TN Establishment #: 413549 ‘August 04, 2025 FREDA HADID FREDA HADID, EN MENTAL SPECIALIST Il

Comments: All requests for a new food permit submitted January 1 through June 30, shall be assessed a permit fee per F.S. Chapter 500 and Rule 5K-4. All requests for a new food permit submitted July 1 through December 31, shall be assessed permit fees of fifty percent (50%) of the applicable fee per F.S. Chapter 500 and Rule 5K-4. Payments can be made online at https://foodpermit.fdacs.gov or can be mailed to Florida Department of Agriculture and Consumer Services, P.O. Box 6720, Tallahassee FL 32314-6720. Checks and money orders are to be payable to Florida Department of Agriculture and Consumer Services. All payments must include the Food Establishment number and reason of payment type in the memo section of the check or money order. Thank you for submitting your food establishment permit application. To complete the application process, you must remit payment in full. To expedite the processing of your food permit application, electronic online payment is available at https://foodpermit.fdacs.gov. Follow the instructions on the portal page for payment processing. Payment by check or money order is also accepted, but must be made payable to FDACS and remitted to Florida Department of Agriculture and Consumer Services, PO Box 6720, Tallahassee, FL 32314-6720. Please note that payment by check or money order may delay the processing of your food permit application. Permit fees must be paid in full before your application can be processed further. Failure to pay any permit fees in full will result in the denial of your permit and you may be subject to administrative penalties if you are found operating without a valid food permit, which is a violation of Section 500.12(1)(a), Florida Statutes. If you are found to be in violation of this provision, the Department may impose up to a $5,000.00 fine against you and/or seek administrative action to close your business. The Minimum Construction Standards checklist has been used in accordance with 500.12(2)(a) Florida Statutes by the food safety inspector to determine compliance before obtaining a food permit. The food establishment is operating without a valid food permit. An application for a food permit has been submitted. The Food Establishment shall remit payment of the appropriate fee within 10 days. Electronic online payment by credit card or e-check is available at https://foodpermit.fdacs.gov. Payment by check or money order is also accepted but must be made payable to FDACS and remitted to Florida Department of Agriculture and Consumer Services, PO Box 6720, Tallahassee, FL 32314-6720. Please note that payment by check or money order may delay the processing of your food permit application. Contact the Business Center by email at [email protected] or by calling 850-245-5520 for further assistance. Norovirus clean up and disinfection handout provided.