EXHIBIT A STATE OF FLORIDA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES, Petitioner, HUDSON FOOD STORES, INC. DBA JIFFY 1559 Agency Clerk Number.: B28177 24252 W NEWBERRY ROAD Food Entity Number.: 359346 NEWBERRY, FL 32699 Respondent. ADMINISTRATIVE COMPLAINT Petitioner, the Department of Agriculture and Consumer Services, Division of Food Safety (‘Department’), pursuant to Chapter 500, Florida Statutes, and Rule Chapter 5K-4, Florida Administrative Code, states that it is the licensing and regulatory authority as defined therein; that it has statutory jurisdiction over Respondent and this matter; and alleges: 1. On October 20, 2020, The Department visited Respondent's permitted facility to conduct a food inspection pursuant to section 500.147(1), Florida Statutes. 2. The inspector was denied entry to the food establishment which is a violation of Section 500.004(6), Florida Statutes. 3. Acopy of the Department's inspection report(s) detailing the specific findings are attached as Exhibit 1 and incorporated herein by reference. Wherefore, Petitioner intends to take action pursuant to its authority in section 500.121, Florida Statutes, including, but not limited to, suspension of Respondent’s food permit 359346 and the imposition of an administrative fine not to exceed $5,000.00. Failure to respond to this administrative complaint will result in the Department imposing the maximum fine allowed by law. EXHIBIT A All correspondences regarding this matter shall be directed to the Division of Food Safety, Enforcement section, by telephone at (850) 245-5540 or by email at FSAdministration@FEDACS.gov Send all facsimiles to Compliance at (850) 488-7946. Dated on December 22, 2020 Melissa Sam Division of Food Safety Enforcement Section EXHIBIT A NOTICE OF RIGHTS In accordance with sections 120.569 and 120.57, Florida Statutes, you have the right to request a formal or informal hearing and to be represented by counsel or other qualified representative. To request a hearing, you must complete the enclosed Election of Rights form and file it with the Division of Food Safety within twenty-one (21) days of receipt of this complaint. For an informal hearing, you have the option of having the hearing) conducted by appearing in person, via a telephone conference call, or via review of a written statement. NOTE: If you request a formal hearing, you must also provide a statement of the material facts alleged in this complaint that you dispute. Alternatively, you may waive your right to a hearing and settle this matter by signing and returning the attached Stipulation and Settlement Agreement along with the required payment. Failure to timely file the Election of Rights form with the Division of Food Safety within twenty-one (21) days of receipt of this complaint shall be considered a waiver of your right to a hearing and may result in the issuance of a Final Order without any further notice that may impose up to the maximum penalties as authorized by law. CERTIFICATE OF SERVICE | hereby certify that a copy of this Administrative Complaint with Stipulation and Settlement Agreement and Notice of Rights has been furnished by United Parcel Service on December 22, 2020, to Respondent. Melissa Sam Division of Food Safety Enforcement Section Department of Agriculture and Consumer Services 3125 Conner Boulevard, C-18 Tallahassee, Florida 32399-1650 (850)245-5540 EXHIBIT A Florida Department of Agriculture and Consumer Services Division of Food Safety AA Visit # 3442-0023-60 FOOD SAFETY INSPECTION REPORT Bureau of Food Inspection Attention: Business Center NICOLE "NIKKI" FRIED Chapter 500, Florida Statutes 3125 Conner Boulevard, C-26 COMMISSIONER (850) 245-5520 Tallahassee, FL 32399-1650 Print Date: October 20, 2020 Food Entity Number: 359346 Food Entity Name: Jiffy 1559 Date of Visit: October 20, 2020 Food Entity Address: 24252 W Newberry RD Newberry, FL 32669-2211 Food Entity Mailing Address: 109 NW 3rd Ave Chiefland, FL 32626-0843 Food Entitv Tvpe/Descriptio 124/Convenience Store Significant FS AND/OR Packaged Ice Food Entity Owner: HUDSON FOOD STORES Owner Code: INSPECTION SUMMARY - Focused Inspection On October 20, 2020, Jiffy 1559 was inspected by DAVID CANO, a representative of the Florida Department of Agriculture and Consumer Services. A Focused Inspection is a visit focused on a specific task that does not constitute an inspection and will not result in an inspection summary. PERMIT APPLICATION INFORMATION The permit application information was verified with management or a qualified representative. COMPLIANCE KEY IN = In Compliance OUT = Not In Compliance N/O = Not Observed N/A = Not Applicable GOOD RETAIL PRACTICES Violation Compliance Number Status Violation Description 99 OUT CHAPTER 5K-4: Food Permit OBSERVATIONS AND CORRECTIVE ACTIONS COS = Corrected on Site P = Priority Citation Pf = Priority Foundation Citation (Directly Associated with Foodborne Illnesses) | (Supports or Leads to a Priority Citation) INSPECTION: GRP Violation Number Citation Description COS Observation 99 An agent of the Florida Department of Agriculture and O INSPECTION REFUSAL. Consumer Services was denied access to the MANAGER STATED INSPECTION establishment or vehicle for the purpose of COULD NOT COMMENCE determining regulatory compliance, collecting a UNLESS SPECIFIC FOOD sample or specimen, or tracing of food products in the ESTABLISHMENT event of a foodborne illness outbreak or identification ADMINISTRATION WAS CALLED of an adulterated or misbranded food item. INTO LOCATION AND WAS ON §00.147(1) F.S. P THE PREMISES. PLEASE SEE COMMENTS FDACS 14205 Rev. 07/13 Page 1 of 2 EXHIBIT A Florida Department of Agriculture and Consumer Services Duision et Fond 2a MAM 0MNA Visit # 3442-0023-60 FOOD SAFETY INSPECTION REPORT Bureau of Food Inspection Attention: Business Center NICOLE "NIKKI" FRIED Chapter 500, Florida Statutes 3125 Conner Boulevard, C-26 COMMISSIONER (850) 245-5520 Tallahassee, FL 32399-1650 Print Date: October 20, 2020 COMMENTS INSPECTION REFUSAL. MANAGER STATED THAT THE FOOD ESTABLISHMENT HAS A NEW POLICY AND THAT THE INSPECTION COULD NOT COMMENCE UNLESS SPECIFIC FOOD ESTABLISHMENT ADMINISTRATION WAS CALLED INTO THE ESTABLISHMENT AND WAS ON THE PREMISES. INSPECTOR STEPPED OUT FOR MANAGER TO NOTIFY ADMINISTRATION. WHEN INSPECTOR RETURNED, INSPECTION WAS AGAIN REFUSED BY MANAGEMENT. ACKNOWLEDGMENT | acknowledge receipt of a copy of this document, and | further acknowledge that | have verified the location and mailing addresses on the first page of this document are correct, or | have written the correct information on the first page of this document. NA (Signature of FDACS Representative) (Signature of Representative) DAVID CANO, SANITATION AND SAFETY SPECIALIST ROBERT RICHARDSON, MANAGER Print Name and Title FDACS 14205 Rev. 07/13 Page 2 of 2

Docket for Case No: 21-000634