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Home My WebLink About0436 SOUTH MAIN STREET - Health 436 South Main Street Long DPI!- Inn �o �- eoL' UFONO. 1521/3 ORA 10% I i ,y BOARD OF HEALTH art , Town of Barnstable John T. Norman Board of Health Donald A.Gaudagnoli,M.D. sar�usr,�aae, Paul J.Canniff,D.M.D. °$ i 200 Main Street Hyannis, MA 02601 IF.P. Thomas Lee Alternate tibyq. � Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 455 Issue Date: 01/01/2021 DBA: LONG DELL INN L OWNER: HAPPY TAILS HOSPITALITY LLC Location of Establishment: 436 S. MAIN STREET CENTERVILLE, MA 02632 Type of Business Permit: BED AND BREAKFAST Annual: Seasonal: YES IndoorSeating: 10 OutdoorSeating: 0 Total Seating: 10 FEES ----- - -- - FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: $55.00 CONTINENTAL BREAKFAST: - - - - - ----- MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: opts►q� Town of Barnstable For Office Use Only: Initials: tl Date Paid : .AM ,E : Inspectional Services ASS. 1639. `�� Public Health Division t heck# QED N�+s Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE M40_ 7,01\ NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: PW 'j 1LS H,091'tALwA4 "& L-Dr1&L DELL 11j" ADDRESS OF FOOD ESTABLISHMENT: Li j(® 5 D < P7�� S ( c�N> �2Uiic.� 6''1 © ='�z MAILING ADDRESS(IF DIFFERENT FROM ABOVE)'E-MAIL ADDRESS: �,p 4a 0 VV4 a XJA4 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (�0 6) -7 7 S- TOTAL NUMBER OF BATHROOMS: 0 WELL WATER:YES NO--,/— ..(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: 14 / 1s/2-1 TO I / is/Zl NUMBER OF SEATS: INSIDE: 10 OUTSIDE: TOTAL: D SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT P%4.G <Mr.0 6UeJ SOLE OWNER: YES/60) D.O.B OWNER PHONE# 50 b `71 S ADDRESS H �(, S//off� �i�' s/ ism-ulLt.9 M .. 0Z&3-ZZ CORPORATE OWNER: 110 -TAIL-5 - aG CORPORATE ADDRESS: q S(o S0 e, ( Ce-N-1aPvGLz M'� D PERSON IN CHARGE OF DAILY OPERATIONS: W1AP-C, e-1 - 0656Z $ -OOPA A _WPLE NIJ List (2) Certified Food Protection Managers AND at least (1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration, Date Allergen: Awareness Expiration Date 1. �IA�-G �4��So� 0� i 1 l � ZO"t21. MA4C �I�D PSt�� i� •Z.S � ?-�'z'L 2. W aniO C)I SIGNATURE OF P ICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to oyenine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.ast). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Q:\Apphcation FormsTOODAPP REV3-2019.doc OF IKE,oy TOWN OF BARNSTABLE - HEALTH INSPECTOR s Establishment Name: �� Dater Oage: of q OFFICE HOURS 51P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M. RARNSTABI.E. ' 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified p Me3q.a 0� HYANNIS,MA 02601 08-8MON -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY rfD MA'S 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name Da tea Type of Tyl2e of InsRection 'J OOoeration(s) outine Address N� �.Rlsk Food Service e-inspection 1 C ° ` Level Retail Previous Inspection Telephone v��7 Residential Kitchen Date: P/so Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness VVI C General Complaint Person in Charge(PIC) Time Bed&Ba as HA re In: Other s �-- Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) 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) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling I ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) ��^, Corrective Action Required: No El Yes Non-critical(N)violations must be corrected immediately or Overall Ratingc')`h(nl within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection to- ,the 4items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. B=One critical violation and less than 4non-critical violations 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxic Materials FC-7 590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8non-critical violations. If 1 critical refrigeration. ( )(29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: In ect Itu 31.Dumpster screened from public view _ Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N p s 'gnatu a Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y: Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 6 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Coaling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* 3 590.003(13) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 29 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* I Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg eve 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or _ 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3AD3.1 I(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23.30) 3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A 3-202.18 Shellstock Identification ( ) Cooling Cooked PHFs from 140°F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 1 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. TOWN OF BARNSTABLE HEALTH INSPECTOR•s Establishment Name: -- / Date: ✓ ge: of FT t OFFICE HOURS ' P ° PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MON.-FRI. � MAss. g HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY p ,e79•a m � � � 'FDN1P' FOOD ESTABLISHMENT INSPE TI N REPORT Plype of j1pe of Inspection Name Dat5611 Operation(s) outine- Address c„ o Risk Food Service Re-inspection `-'� Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness tiQ Cate General Complaint Person in Charge(PIC) Time ed 8 Breakfast HACCP In: Other Inspector �� Out: I C'� Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. ^ Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) 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) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 60 LIT _ ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 17114.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating 1716.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling F-1 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP' ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories 16 Violations Related to Good Retail Practices[Blue Items) Total Number of Critical Violations .5 &jPPD Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. Embargo ❑ Emergency Closure Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. B=One critical violation and less than 4non-critical violations 9 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations.and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations obse to 8 non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address iolat• -crit al violations=C. 29.Special Requirements (590.009) within.110 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspect 's ig a4 Print: 31.Dumpster screened from public view Q, Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print:.- , Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y IN / Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41'F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each * 590.004(F) 7-101.11 Identifying Information-Original Containers 2 590.003(C) Responsibility of the Pelson-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140'F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130'F* * 7-201.11 Separation-Storage* Applicants 3-302.11(A) Food Protection* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* * 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 16 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145'17 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 1/1/2001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155'17 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009 A D Violations of Section 590.009 A D m_cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( )-( ) ( )'( ) Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 1Q Proper,Adequate Handwashing C Game and Wild Mushrooms Approved By 3-401.11( )(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail * 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 3-201.17 Game Animals g g Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 2330) 12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70'F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* Temperature Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41'F/45'F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6.2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. oF.HE r TOWN OF BARNSTABLE„, HEALTH INSPECTOR,s Establishment Name: �n Date: /� 4age: of.' OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARN5rABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 MON.-FRi. No Reference R-Red Item PLEASE P INT CLEARLY, �p �679•n e 508-862-4644 'F FOOD ESTABLISHMENT INSPECTION REPORT Name I Date G�/6 l Tvne of T ns ection Operation(s) Routine Address13 Risk Food Service pection Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile re -opera I Owner HACCP Y/N Temporary Sus ss Caterer General Complaint Person in Charge(PIC) Time rea HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) 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) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1:PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS �- ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling �- ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSbo ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Ll I Critical(C)violations marked must be corrected immediately. (blue&red items) I 1 I orrective Action Required: No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection to ay,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo Emergency Closure El Voluntary Disposal El Other 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils 6=One critical violation and less than 4non-critical violations 9 (FC 4)(590:005) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment per and cessation of food establishment operations. If C=2 critical violations and less than non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must i ' 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 n tical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. ation,4 to 8von-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspe to's e P 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining y N IC's Signatu a Print: /�j Self Service Wait Service Provided Grease Trap Size. Variance Letter Posted Y // �/ .•�./. ` E%' 1 Dumpster Screen? Y N / s, .•;-,. _. ,,.. �. .Y-,.; .x _ _. -i-.r' -... .a"}-. �?.c-•. �.��y. ?^._:.. t� _.r-s 4'ir •✓...- �� _.. .� w ,'L-.�'�.-.r .r-. a�._ . 1 F s _ _ Y Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 6 Cross-contamination L 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR. 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3AOI.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Eggs Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg c"9G 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A),(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23-30) 3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 16 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12' Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000- Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 - 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 1 Reduced-Oxygen Packaging Criteria* _ 8-103.12 1 Conformance with Approved Procedures* i S:590Forrnback6-2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000: oFT roy TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name:�-�-� Date: Page:_ of qo OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSfABLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified H ANNIS,MA 02601 M-8 -FRI.62-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD EST 508IS MENT INS C ON REPOR Name to ype of ns a ion Operation(s) Routine. Address Risk Food Service pection Level Retail Prev�ou ti Telephone Residential Kitchen Date, �� Mobile Pre-oper tion Owner HACCP Y/N Temporary Suspe Illness Cater General Complaint Person in Charge(PIC Time ed&Breakfas HACCP p Other Inspecto ' Each violation checked require/an explana ion on the narrativ )ag and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) 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) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands m`-'^i ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating fi ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue'Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating �J within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. Embargo Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils B=One critical violation and less than 4 non-critical violations (FC 4)(590.005) cited in this report may result in suspension or revocation of the food 26.Water,Plumbing and Waste if no critical violations observed,4 to 6von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot g (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must ; 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-cri' al vio lions. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10&�s of receipt of this order. vi 4 to 8 non-critical violati ns 30.Other DATE OF RE-INSPECTION: Ins r' ' na ur Q int: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y 'N P 's ' natu Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives „ Law Cooled to 41'F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12" Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19. - _ PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 590.004(F) Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F * 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Se 3-501.16(A) Roasts Held At or Above 130°F* Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health Control* - Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils ( ) _ 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* _. Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Cl Equipment* Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg cnw ioiaooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 3-201.14 Fish and Recreationally Cough[Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* When 3-401.11 2-301.14 Wh to Wash* A 1 b All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items 23-30) 3-101.11 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 Handwashing Facilities 3-202.18 Shellstock Identification* 13 3-501.14(A) Coolin gCooked PHFs from 140°F to 70°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Supplied with Soap and hand Drying Devices Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-.Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. oFI Er TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: L / CQ_ " . f 11 Date! / / / Page: Of ° OFFICE HOURS l P ° PUBLIC HEALTH DIVISION D 8:00-9:30 A.M. : R" NEE. i 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. e� HYANNIS,MA 02601 MON.-FRI. No Reference R Red Item PLEASE PRINT CLEARLY .a7q. 508-862-4644 p'EON1P"' FOOD ESTABL4SHMENT INSP C ION REPORT Name -in In Date. Tvne of Type of Inspection n I IRA/ �� n s Routine % f Address Y / k*�4'--&/ ;( �tisk k`Food Service Re-inspection W �A / ( � + ^y ILevel /'`Ret.0 Previous Inspection Telephone Residential Kitchen Date�� Mobile (iPre-operatiinJ Owner HACCP Y/N Temporary uspectIllness r _ Caterer General ComplaintIYAR ' Person in ChargeI(PIC) Time Bed&Breakfast HACCP m_ Other Inspector t /22U V F11 _ YV �. Each violation checked requires an explanation on thernarratjve page(s)and a citation of specific provision(s)violated. t ^ t P Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E)- ❑ y jM`� - i Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ j 'f 4 Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ t V - 7 "4P / FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 1// ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities _ EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures -^ ❑ 5.Receiving/Condition ❑ 17.Reheating r / + ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ( � � ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding / PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control � , ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) _ -sue" 9 ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP IV / if t ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY r d ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories . ,v Violations Related to Good Retail Practices Blue Items /e � ) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than non-critical violations if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) g violations observed,7 to anon-critical violations. If 1 critical refrigeration. be in writing and submitted to the Board of Health at the above address � 29.Special Requirements (590.009) within 10 days of receipt of this order. ��ation,4 to 8non-critical violatiol�s=C F( 30.Other DATE OF RE-INSPECTION: I s ecto's Sig,Aurre 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N - #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign ture Print: ( \ Self Service Wait Service Provided Grease Trap Size Variance Letter.Posted Y N � V� Dumpster Screen? Y N /�'1 d � Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* $ Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* - Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in--Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 7-101.11 Identifying Information-Original Containers*Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 - Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY POPULATIONS HSP 1590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and * 4-501.111 Manual Wazewashing-Ho[Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a Hermetically Sealed Container Sanitization Temperatures 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1$ Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meals&Game Pathogens* Effective fiuzoot 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Proper,Adequate Handwashing Ratites-165°F 15 sec* Sources* 10 ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g. g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the $ Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1$ Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41'F/45°F Item Good Retail Practices FC 1590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 1.003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* a Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans i 6-301.12 Hand Drying Provision 129. 1 Special Requirements .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. oF.HE r TOWN OF BARNSTABLE HEALTH INS!ICTOs�ffentName: Date: 5 Page: • of - OFFICE HOURS P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNsrAB,E, : 200 MAIN STREET -3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MAS S.. `0� HYANNIS,MA 02601 MO s2 FRI. No Reference R-Red Item PL SE PRINT CLEARLY 1AP`' FOOD ESTABLISHMENT INSPECTION REPORT - 1 Name Date y �,�Ij, Type of Type of Ins ection _ 0 Operation(s) -Routine Address Risk Food Servic€" e-Re Level Retail Previous Inspection 'CC` Telephone. Residential Kitchen Date: Mobile Pre-operation �, + Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time ('13ed 9 t3rea HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) 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) ❑ ^__1 ` FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands `�-+ ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities '�O i EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives S ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures \ ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling Y� ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories ,r Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) 01 Corrective Action Required: ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 9 ardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than non-critical violations re if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. lion,4 to 8non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspect is i int: , n 31.Du ster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI ignature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y Dumpster Screen? Y N Violations related to Foodborne Illness olations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) ' and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14' Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 - Poisonous or Toxic Substances 3-501'16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3 590.004(F)-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* - ' 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An _ 3-501.19 Time as a Public Health Control* 3-302.15 Washing Fruits and Vegetables * - Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 1] Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System gg Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff°"°e 11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.1](B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 590.009 A - D Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. g Receiving/Condition 2-401.11 Eating.Drinking or UsingTobacco* 3-403.11(A)&(D) PHFs 165°F IS sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23-30) 3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* ( ) g 13 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140°F to 70°F - 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. of J `°F,Ne rok TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Lo,4 De / Date: 2 0 Page:OFFICEHOURS f PUBLIC HEALTH DIVISION 800-9:30A.M. BARNSTABLE. 200 MAIN STREET - 3:30-4:30 P.M. i MASS. g. MON.-FRI. Item Code. C-Critical Itzm DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified A +639•s�0 HYANNIS,MA 02601 508-8szas44 No Reference R-Red Ite;n PLEASE PRINT CLEARLY 'FDN1�` FOOD ESTABLISHMENT INSPECTION REPORT Name n Date L !Moe of ec ion h k Operation(s) Routin' i r f GtT' Address ' Risk Food Service e-inspection C� �r r t Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation i' d Owner (✓��,� HACCP Y/N Temporary Suspect Illness " t l +rd�8` Ca General Complaint Person in Charge(PIC) Time a re fast HACCP In: Other Inspector (rV/� r✓V` Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ O 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) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Non-critical(N)violations must be corrected immediately or Corrective Action Required: No ❑ Yes within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations. If no critical violations observed, 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 9 or more non-critical violations=F. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must water,sewage back-up,infestation of rodents or insects,or lack of C=2 critical vi lations and less than 4non-critical. If no critical. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violation ob 8 non-critilpal violations=C. refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector' ignatu P 31.Dumpster screened from public view �S G V( �4o n Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' Sig ature Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N - * t--...e-✓w.� °,-'..v..-as.i yam. . - _ - ^_..- .-.•.�.yL'✓�°G-,-'.+�� __ ,. - _ Violations related to Foodborne Illness 4 Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003 A Assignment of Responsibility* 8 Cross-contamination Law Cooled to 41°F/45°F Within 4 Hours* ( ) g14 Food or Color Additives 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foc.ds Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 7-101.11 Identifying Information-Original Containers*Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-102.11 Common Name-Working Containers 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* P g * 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 590.003(G) Reporting by Person in Charge Requirements * 3-304.11 Food Contact with Equipment and Utensils* 590.004(11)7-203.11 Toxic Containers-Prohibitions* Variance Re q Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 1 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* gg Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* e��e"tnizom 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-4(Il.l l(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources & P arY 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail practices should be debited under#29-Special 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23.30) 3-202.15 Package Integrity ( ) Commercially Processed Rns Food-Roast Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A 3-202.18 Shellstock Identification ( ) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 Equipment and Utensils FC-4 .005 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equi P 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients` Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. -- - - rd �oF1NE roh� - TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: 1�� Un Date: age:�_of OFFICE HOURS P °e PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:M N.- P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 08-8 -FRI. soa-ss2-asaa No Reference R-Red Item PLEASE PRINT CLEARLY 'FDN1P` FOOD ESTABLISHMENT INSPECTION REPORT Name Dat Tvoe of a of Inspection O07 ueration(s) Routine Address Wsk Food Service e-nspection el Retail Previous Inspection Telephone Residential Kitchen Date: 25 Mobile Pre-operation Owner A W&� HACCP Y/N Temporary Suspect Illness O 1T General Complaint Person in Charge(PIC) Time Bed 8 Break as HACCP In: Other InspectorRA IN) Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ C*e00 Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ yn Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ W vC/ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives I ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals l/1 FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health ContVHSP ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation f❑ 10.ProperAdequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of ConsumerAdvisorViolations Related to Good Retail Practices(Blue Items) Total Number of Critical Violat Critical(C)violations marked must be corrected immediately. (blue&red items) Non-critical(N)violations must be corrected immediately or Corrective Action Required: ❑ No El Yes Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations A=Zero critical violations and no more than anon-critical violations. F=3 or more critical violations. n no critical violations observed, 25.Equipment and Utensils FC-4 590.005 9 or more non-critical violations=F. ( )( ) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address C=2 critical violations and less than 4 non-critical. If no critical refrigeration. violations observed,7 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order.Ej 30.Other DATE OF RE-INSPECTION: Insp'e(c`tor' Signature Print: 1 31.Dumpster screened from public view + 6uolfI AO Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N pIC's Ig re Print: #Seats Observed Frozen Dessert Machines: Outside Dining Y N Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N ILO "(, Dumpster Screen? Y N / V1 o1a tidns-;re1atedtoFod_db orne-Jilness Violations Related to Foodborne Illness Interventions I.Interventicins,'and Risk-Fadtors-(Red.'IteMs 142) and Risk Factors(Red Items 1-22) (Cont.) =170013 PROTECTIOW ANAGEMENT `PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS I M - I 3-501.14(C) PHFs Received at Temperatures Accordmguo 11 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1=4 _Food or Color Additives Law Cooled to 41'F/45'F Within_4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 r Additives* 3-501.15 Cooling Methods for PHFs F-4 a PHF Hot and Cold Holdin 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41 IF/45*F tE M PLDYE1E,HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 590.004(F) 7-101.11 identifying Information-Original Containers* 590.003(C) Responsibility of the'Person--in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140'F* 7-102.11 Common Name-Working Containers* RequireReporting-by Food Employees and Contamination from the Environment 7-201.11 Separation-Storage* 3-501.16(A) Roasts Held At or Above 130*F* Applicants* 3-302.11(A) Food Protection* 2=0 Time as a Public Health control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* �Applicant To.-.Report ToThePerson In Gharge* 3-304.11 Food Contact with Equipment and Utensils* 7.202.12 Conditions of Use* 590.004(11) Variance Requirements .590.003(G) Rcporting�by.Persqn in Charge 7-203.11 Toxic Containers-Prohibitions* !1 1590.003(D) [Exclusions and:Res I Restrictions* Contamination from the Consumer 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS.(HSP) 1590.003(E) I Removal ofExelusions andRestrictions Disposition ofAdulterated or Contaminated g Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED-SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* E74- Food.and-Water From'Regulated Sources Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served* 3-201.12 Food in aHermeticallySealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and 3-201.13 F1uid-Mlk1an&Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS CONSUMER ADVISORY 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.IIA(l)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of - 4 Utensils d Food Contact Surfaces of s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from-an Approved System* -601.11(A) Clean an E gg 1Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled'Diinking'Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff-im 11112001 4-602.11 Cleaning Frequency of Utensils and Food .,nimals-155°F 15 sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 590:006(B) Wti�ter�Medts Standards-in 310 CMR 22.-0* Contact Surfaces of Equipment* -and Beef Roast-130*F 121 min* shellfish-hnd-Fhsh#rdrrranAppr6Ved Source 3-401.11(B)(1)(2) Pork Eggs* -4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 see* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.41 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- *Molluscan Shellfish from NSSP Listed Chemical* Ratites Sources* Proper,Adequate Handwashing Rati -165°F 15 sec* ing,mobile food,temporary and residential -Game and Wild'hfush*rooms Approved By 10 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under 2-301.11 Clean Condition-Hands and Arms* Regulai6�y;U;ihoiffy 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202:18 Shellsto6kIdentification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.604(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail F_11--Good Hygienic Practices L_17 Reheating for Hot Holding practices should be debited under#29-Special 3-261.17 Game Animals* Requirements. $ J -Recielving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) --- Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and-Unadulterated* F1 2 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the `6 Tags/Records:,Shellsto6k 590.004(E) Preventing Contamination from Employees* is Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shelistock Identification* 13 Ha6dwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70*F 3-203.12 Shellstock Identification-Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41*F/45'F Item Good' 6tailrPractices �FC A-9Q.1900 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41'F/45'F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,-Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying De vices 27. ys ca acility FC-6 .007 7 Conformance with Approved Procedures I r63 0 1.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCPrplans 16-301.12 1 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 18-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. w 04 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARN rAKIM Paul J.Canniff,D.M.D. a 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 455 Issue Date: 01/01/2020 DBA: LONG DELL INN OWNER: HAPPY TAILS HOSPITALITY LLC Location of Establishment: 436 S. MAIN STREET CENTERVILLE, MA 02632 Type of Business Permit: BED AND BREAKFAST Annual: Seasonal: YES IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: $55.00 CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q.A FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: A i_ Initials: Town of Barnstable For Office Date Paid `7//6 jAmLPSI$ , ABA : Inspectional Services p i639 � s Public Health Division check# � - �ED MAC • ", Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE t �-� NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: d��°� ADDRESS OF FOOD ESTABLISHMENT: '-/3& SO Al+®I'Q MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: S � 110-lu� 'MAI 'eh � TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS: 19 WELL WATER: YES_NO (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: 6711 /M To NUMBER OF SEATS: INSIDE: —� OUTSIDE: ® TOTAL: 9 SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED& BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD � —4 FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL, MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc • 1 OWNER INFORMATION: C- FULL NAME OF APPLICANT SOLE OWNER: YES. NO D;O.B OWNER PHONE # ADDRESS jj� to SO 144JAJ 51 CORPORATE OWNER: /1�»P"P' 1-ZkjS®1 CORPORATE ADDRESS: �� • �"�° S PERSON IN CHARGE OF DAILY OPERATIONS: Cs;; �� ®l��is�— �!'" List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date SIGNATURE O( P LICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at httt)://www.townofbarnstable.us/heaIthdivision/at)plicatiou asfi. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q\Application FormsTOODAPP REV3-2019.doc 4 S Town of Barnstable BOARD OF HEALTH Paul 1 Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. BAnNSTABLE John T. Norman -MASS. F.P. Thomas Lee Alternate $� �sq 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 455 Issue Date: 03/01/2019 DBA: LONG DELL INN OWNER: HAPPY TAILS HOSPITALITY, LLC Location of Establishment: 436 SOUTH MAIN STREET CENTERVILLE, MA 02632 Type of Business Permit: BED AND BREAKFAST Annual: Seasonal: YES IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: $55.00 CONTINENTAL BREAKFAST: MOBILE- FOOD: MOBILE- ICE CREAM: cC � FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: f i �oFZ„ETopti For Office Initials; oT Town of Barnstable • Date aid a(A Amt Ed$ �/✓ �:� +veHA MARS.LE,$ Inspectional Services i7 �SA99. A'1639. A�� . . . Check i EOMA� Public Health Division - Thomas McKean,Director Lo f ' F 200 Main Street, Hyannis,MA 02601s 4 Office: S08-862-4644 Fax .508-790-6304 hw� APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE-3 2S Zi51Q NEW OWNERSHIP RENEWAL X NAME OF FOOD ESTABLISHMENT: Happy Tails Hospitality, LLC dba Long Dell Inn ADDRESS OF FOOD ESTABLISHMENT: 436 S Main Street Centerville, MA 02632 Q MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 4 s E-MAIL ADDRESS: stay@longdellinn.com TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( O8) 775 - 2750 TOTAL NUMBER OF BATHROOMS; 8 WELL WATER: YI1S NO X ... (ANNUAL WATER ANALYSIS RE^ IRE `�� ` 6- -A ANNUAL: `t a X DATE. OF OPERATION: 47'�'T�I 'ro 12115 1 f AnNIJAL: SEASONAL: S NUMBER OF SEATS: INSIDE: 10 OUTSIDE: 0 TOTAL: 10 U SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER.;" OUTSIDE DII\'ING,MUST 13E APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE.DINING REQUJREA1,ENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? NO IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? NA TYPE OF ESTABLISHMENT: (PLEASE CHECK ALI.,THAT APPLY BELOW) f F'. F.. FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) X BED&BREAKFAST CONTINENTAL, BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential 1titchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) _._—CATERING... (CATERING NOTICE REQUIRED BEFORE EVENT(SFE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) �I **>: SEASONAL MOBILE &NEW FOOD ONLY** REQUIRED TO CAIL HEALTH DIV.FOR JNSPI C'T'ION PRIOR TO PERMIT BEING ISSUED i Q:;Application FormsU�00llAPPl2L,.V2018.doc 9 I i t t t PLEASE CALL 508-862-4644 OWNER INFORMATION: , FULL NAME OF APPLICANT Happy Tails Hospitality, LLC SOLE OWNER:XM NO D.O.B NA OWNER PHONE# 508-775-2750 w. 1 e ADDRESS_436 S Main Street, Centerville, MA 02632 CORPORATE OWNER: Happy Tails Hospitality, LLFEDERAL ID NO. : 45-5084691 CORPORATE ADDRESS: 436 S Main Street, Centerville, MA 02632 fi PERSON IN CHARGE OF DAILY OPERATIONS: Marc Jacobson / Donna Wrenn List(2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff . All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. "ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You inust provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. Marc Jacobson 1 / 11 / 22 1. Marc Jacobson / 25 / 22 2. Donna Wrenn 1 / 1 I / 22 � t SI ATU O PPLICANT DATE l ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days hi advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div, Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at httn://www.townofbarnstable.us/healthdivision/applieitiolis.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establislunents must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC: Ist. Q:\Application Porms\I'00DAPPREV2018.doc .PERMIT NO: TOWN OF BARNSTABLE ISSUE DAT 455 BOARD OF HEALTH 04/01/201 PERMIT TOiaABLISHMENT In accordance w!1 tt ga aUtority of Chapter 94,, Nu Section 395A and lip e I'L�_ ect -a_ a ermit is hereby granted to: HAPPY TAILS HOSPITA61 L L QNG DELL '_`4 Whose place of business isr `t.!'SOUTH_ G., f ENTE ,02632 1 . Type of business and anyE t S: _BAST EST` f5 NT To operate a food establijh�e A iq the TABLE V. I RESTRICTIONS IF ANY: y SEATING: ANNUAL, -v NQ •-a SEASONAL: YES TEMPO `-: yF s E E SHAD OF HEALTH RETAIL FOOD STORE: q Wl FOOD SERVICE ESTABLISHMENT: d•Canniff, D.M.D. Chairperson '` J ichi Sawa ana i RESIDENTIAL KITCHEN FOR RETAIL SALE y g RESIDENTIAL KITCHEN FOR BED+BREAKFA onald A.Guadagnoli, M.D MOBILE FOOD UNIT: - e@ TOBACCO SALES: FROZEN DESSERT: `'' Thomas A. McKean, RS, CHO CATERER: Director of Public Health d,THe t� Town of Barnstable # I3(e 3 Regulatory Services loPUP� AB BA MAM A : Richard V. Scali, Director f�j BARNS LE ,� R!:SipBLE•C=YM1vvI1E•C.^TLRT•N'ru1!:li A 1639. � !4F�:Jki Y3'.i5• y5v1:1F•lf•=BAP::SfC Public Health Division C9-2014 Thomas McKean, Director 'XOS1�E 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-2r 90-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: 2& OCI Z c9 k-1 NAME OF FOOD ESTABLISHMENT: Happy Tails Hospitality, LLC dba Long Dell Inn ADDRESS OF FOOD ESTABLISHMENT: 436 S Main St Centerville MA 02632 E-MAIL ADDRESS: stay@longdellinn.com TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( 08 ) 775 - 2750 NUMBER OF SEATS*: INSIDE: 10 OUTSIDE: 0 TOTAL: 10 * Note: If indoor seating provided, see Licensing regarding Common Victuallers License TOTAL NUMBER OF BATHROOMS: 8 ANNUAL OR SEASONAL OPERATION: Seasonal TYPICAL HOURS OF OPERATION MON-FRI: 8 :00 AM TO 10 :00 PM DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) NA IF SEASONAL: APPROXIMATE DATES OF OPERATION: 4 / 1 /%9 TO 12 / 15 / fj3 ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD X BED & BREAKFAST CONTINENTAL BREAKFAST *IF SEATING: ALSO,MUST OBTAIN RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) L1 , ***REMINDER*** IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? No IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? NA CONTACT INFORMATION: FULL NAME OF APPLICANT Happy Tails Hospitality, LLC. SOLE OWNER: XXX NO � ADDRESS 436 S Main St Centeville, MA 02632 PHONE# 5( 08 ) 775 - 2750 IF APPLICANT IS A PARTNERSHIP,FULL_NAME AND HOME ADDRESS OF ALL PARTNERS: Marc Jacobson and Donna Wrenn Same address as above IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 45-5084691 STATE OF INCORPORATION Massachusetts FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) 1. Marc Jacobson EXPIRATION DATE: 1 / 11 / 2022 2. Donna Wrenn EXPIRATION DATE: 1 / 11 / 2022 EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** LIST THE NAME OF YOUR CERTIFED FOOD ALLERGE RENESS TRAINED STAFF. 1. Marc Jacobson E Imo, ON DATA/ 25 / 2022 l© / Z&/ -ZU n Si TURE OF APPLICANT AND DATE Q:\Application Forms\Foodappldoc AVA CEKTIFICATION MARC JACOBSON for successfully completing the standards set forth for the ServSafe®Food Protection Manager;Certification Examination, which is accredited by the American National Standards Institute(ANSI}-Conference for Food Protection(CFP). f '1611074 5208 CERTIFICATES UMBER EXAM FORM NUMBER 1/11/ 17 1/11/2022 ., DATE OF E AMI'NATION DATE OF EXPIRATION. Local laws apply.Chick with your focal regulatory ncy for recertification requirements. t ' I She• nan Brown CtP,National Restaurant A:69o tion Solutions #06� U aooadonce with 1Nar t me 2006,Resokaion ADM N 06913(Rspulatian 3.2,Skmdmd A3,2t• Qi (02015 Nehowlgestovrr qpn End fo a dnfion tNROEEf•Alt r ghh rmerwd..5av5afe and thn e trodamar6 of the Mtl1EF. National Rasl�Tirr4 A+sociatione and th#arc JWW am fiadsmarks off*Notional Raaw rantAsainfiay This document cannot 6e reproduced w o6ned. 14102901 v.1401 Contact us with questions at 175 W Jodwm 8W.Ste 1500,Chicago,IL 606M4 or SemSefe®reslauront.org. / lr. ti a CERTIFICATE OF VWARENESS lit AL L E YkAt.3-4-E N TRAINING J JACOBSON2747460 Certificate Number: h „mil �.n p . • Date of . •n- 1/2-5/2022, Issued By.- `above-namedpersonis herebyissuedthis certificate NATIONAf for co an allergen awareness trainingprogram R Mpleting • , u /g e/ r ,•II r ' / Health • • Massachusetts Restaurant Association 800.765.2122 in accordance with 105 CMR Nm Southborough,MA 01772 yea 508�303-9905 - yy a c�-�� u 3 I �+• 1 i l U V a C" E ' TIFICATION DONNA WRENN - Y for successfully completing the standards set forth for the ServSafe®Food Protection Manager,Certi6cafion Examination, which is accredited by the American National Standards Institute(ANSIkonference for Food Protection(CFP). P . 611087 5208 . . CERTIFICA UMBER EXAM FORM NUMBER 1/11/2fl17 e . 1/11/2022, DATE OF E AMINAT16N DATE OF EXPIRATION, Local laws apply.C k with your 6cal regulatory ncy For recertification requirements. S6SFrn4n Brown Svp,National Restaurant Association Solutions. O'a erg #0655 ; In aaor&"with Maritime Dour _ iet 2006,Resolndon ADM N 06&2013 Pvdafion 3.2,S+andard A3.2). 0201 S N�atm�Ml mhnra to(tupmtioi @ck dioe 6oendation ORAff?:AR n0a reswv d.SwSaFa and t6 b8o are trodenarin of the NRAEF. Natignal.t+.siaunard Auocio6ott and the arc dedgn me trcidem*r6 of the Natioml Regaunant ibis doewwat cannot 6e reproduced eratte . Contort w with wns a 175 W ladoon flhd.Ste 1300,Chicago,IL 60604 or SewScWrastaurant.ong. {41D2901 ytdOF. a , MUMMA f F2 PERMIT NO: TOWN OF B_ARNSTABLE ISSUE DAT 455 B.OAR6.Q�_1�E�CC 12/28/201 PERMIT Tgl QRT _A on L_&TIgLISHMENT In accordance witfi reg'ition � u�gC ate rutoi ity of Chapter 94, Section 395A an&CVapter 1 rt-Sec frtff the Ge-'era�l � a`Pektnit is hereby granted to: _ I HAPPY TAILS HOSPITALITY, LLG _ ': -._.�a�L-.c.-al �_ Eel?1%:_ti•. -`:.`,_,-•. _ Whose lace of business i* - S0UTI-t�All y p °`y_ NTERVIL 1+`fillA '02632 R Type of business and anyestritiohs: BI = AST ESTABLISHMENT = G '.�.• f _ _L..1.-r.=y _. _. ._._� '-..___ ...._ a L. To operate a food establishmea .... the `'Fb' f I ' ] E r RESTRICTIONS IF ANY: =p-__ L. �Yl yr cam_ Ei SEATING: ANNUAL: VE5 SEASONAL: TEMPORARY': •=.:�_-z '� ;��:,�. //}}RD OF HEALTH RETAIL FOOD STORE: `t: �•`4' _;.;,`�-_ '` Foul J. Canniff, D.M.D.,Chairperson FOOD SERVICE ESTABLISHMENT: RESIDENTIAL KITCHEN FOR RETAIL SALE: ti — � '' `4= Junichi Sawayanagi. RESIDENTIAL KITCHEN FOR RED+BREAKFAST $85o0`"`t` ;^.tsa'st ��'' Donald A.Guadagnoli M.D MOBILE FOOD UNIT: TOBACCO SALES: 0 1 7 � FROZEN DESSERT: Thomas A. McKean, IRS, CHO CATERER: Director of Public Health I t R Town of Barnstable o„ Regulatory Services .6 • MANSTABIZ, • Richard V. Scali, Director BARNSTABLE �� eansae•c'.tiTSrri•�nrtKru.:is �. 9�'AtFp Mpl�`� Public Health Division 16z-2014�� °S '= " 'eF ►-a Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 308-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT .6 DATE: i(v N'-N 2-ok(o Lo ok �� I n'I' t, NAME OF FOOD ESTABLISHMENT: Happy Tails Hospitality, LLC dba Long Dell Inns ADDRESS OF FOOD ESTABLISHMENT: 436 S Main St Centerville MA 02632 E-MAIL ADDRESS: stay@longdellinn.com TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( 08 ) 775 - 2750 NUMBER OF SEATS*: INSIDE: 10 , OUTSIDE: 0 TOTAL: 10 ' * Note: If indoor seating provided, see Licensing regarding Common Victuallers License TOTAL NUMBER OF BATHROOMS: 8 ANNUAL OR SEASONAL OPERATION: Seasonal TYPICAL HOURS OF OPERATION MON-FRI: 8 :00 AM TO 10 :00 PM DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) NA IF SEASONAL: APPROXIMATE DATES OF OPERATION: 4 / 1 / 11 TO 12 115 / l� ' ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD X BED & BREAKFAST CONTINENTAL BREAKFAST *IF SEATING: ALSO,MUST OBTAIN RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) r ***REMINDER*** IF OUTSIDE DINING YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? No IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? NA .CONTACT INFORMATION: FULL NAME OF APPLICANT Happy Tails Hospitality, LLC. SOLE OWNER: XXX NO ADDRESS 436 S Main St Centeville, MA 02632 PHONE# 5( 08 ) 775 - 2750 IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: Marc Jacobson and Donna Wrenn Same address as above IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 45-5084691 STATE OF INCORPORATION Massachusetts FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD •PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) 1, Marc Jacobson EXPIRATION DATE: 3 / 28 / 2017 2, Donna Wrenn EXPIRATION DATE: 3 / 28 / 2017 EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF. 1. Marc Jacobson ON DATE: 4 / 10 / 2017 SIG AT OF APPLICANT AND DATE QA\Application Forms\Foodappldoc i a rServSaf a EXAM FORM N O. 4706 _�� t ,1 CERTIFICATE NO. 8949118 $�: w ServSafeo �yL �W r_ v "� � 1�" �K. YMa!4,CO for successfully completing the standards set forth for the ServSafe®.Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). 03/28/2012 DATE OF EXAMINATION 03/28/2017 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. • • • NATIONAL ACCREDITEDPROGRAM" RESTAURANT American National and the Conference for Food Protection 0 ASSOCIATION® Paul Hineman #0655 Executive Director, National Restaurant Association Solutions ©2010 National Restaurant Association Educational Foundation.All rights reserved.ServSafe and the ServSafe logo are registered trademarks of the National Restaurant Association Educational Foundation, and used under license by National Restaurant Association Solutions,LLC,a wholly owned sdbsidiary of the National Restaurant Association. This document cannot be reproduced or altered. 10070201 v.1202 EXAM FORM NO. 4706 reServSaf e CERTIFICATE, NO. 8949125 t, a,. 5'1 ,ServSafeCertification C'S �." i r,.d<t<? .v kK rT*•wo'^=' 7 m F �f£R.E N r, AC Wd .:w..ntA c.fci vl�+k-......:.s.. .. .,• _... - for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). 03/28/2012 DATE OF EXAMINATION 03 28 2017 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. • NATIONAL ACCREDITED PROGRAM RESTAURANT Americ n National Standards Institute and the'lConference for Food Protection @ ASSOCIATION© Paul Hineman #0655 Executive Director,National Restaurant Association Solutions ©2010 National Restaurant Association Educational Foundation.All rights reserved.ServSafe and the ServSafe logo are registered trademarks of the National Restaurant Association Educational Foundation, and used under license by National Restaurant Association Solutions,LLC,a wholly owned subsidiary of the National Restaurant Association. This document cannot be reproduced or altered. 10070201 ,. 0202 CERTIFICATE OF ALLERGEN AWARENESS TRAINING Name of Recipient: Marc Jacobson Certificate Number: 804'S65 Date of Completion: 4/10/2012 Date of Expiration: 4/10/2017 r Issued By: The above-named person is hereby issued this cert fcate �� or completing an allergen awareness trainin ro ram NATIONAL f g gp g � ■°�•�• RESTAURANT recognized by the Massachusetts Department of Public Health ASSOCIATION ¢, in accordance with 105 CIVIR 590.009(G)(3)(a). Massachusetts Restaurant Association 800.765.2122 333 Turnpike Road,Suite 102 www.restaurant.org Southborough,MA 01772 This cert fcale will be valid for five(5)years f•om date of complelion. 508-303-9905 wwwrnarestaurantassoc.orglie r ` � �"► +"! � /'� +°k � � � +'i 1� +ask /' i I . Alk PERMIT NO: TOWN OF BARNSTABLE ISSUE DAT 455 Y � LbLFAL January 1, 201 PERMI (� ISHMENT In accordaOe h eg t tion to u r of Chapter 94, I Section 395A a I e ` e n f the G n �' �' � � eit is hereby granted to: HAPPY TAILS HOSPITALITY, L _ L; l "' �DELL�NI -F `t Whose place of business i SOUTt x NTERVI J ~ 2632 f Type of business and anyAre&tra;tic ns: e� AST ESTA iLISH E14T y ^ riryX,4 h To operate a food establiS IfIei igthe T LE r RESTRICTIONS IF ANY: F a; aF � 971 SEATING: =- t ANNUAL: E SEASONAL: TEMPORAR\: - . . D OF HEALTH RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT: sa lot yne Miller, M.D., Chairperson RESIDENTIAL KITCHEN FOR RETAIL SALE: �. 4" � , ,`,; �K.�, � Paul J.Canniff,, D.M.D. P .: ,-` RESIDENTIAL KITCHEN FOR BED+BREAKFAST $ z Junichi Sawayanani MOBILE FOOD UNIT: ' TOBACCO SALES: D e e m e 3�1 , 2016 -- FROZEN DESSERT: Thomas A. McKean RS CHO CATERER: e r Director of Public Health PERMIT NO: TOWN OF.BARNSTABLE ISSUE DATE 455 BOARD OF HEALTH December 22, 2010 PERMIT TOEFFOO.DESTABLISHMENT In accordance with ie u on 10- A gated�tnder'a ' ty of Chapter 94, Section 395A and Ch >'1tionr � a=panit is hereby granted to: -44 DENNIS SINGLETARY ,. � B/ LONGDELLIN . . Whose place of business is s 4�6 OUTH I A1fT S�f R T O ITERVI�.�LkVk ,02s32 " R% Type of business and any restrictions. BEI�,A r B�� A T ESTABtIS�-IMENT To operate a food establishtnentin the TOWN Q 815TAI LE ' g RESTRICTIONS IF ANY: .a� SEATING: ANNUAL 1(ES: � t SEASONAL: TEMPORARI A' � GIA 1 AR OF HEALTH RETAIL FOOD STORE: g � .: a neIVliller, M.D.,Chairperson FOOD SERVICE ESTABLISHMENT: fis° RESIDENTIAL KITCHEN FOR RETAIL SALE: ; "� .�i o Pain J.Canniff, D.M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST $45 U M � �x � sue` 11hichi Sawavanaqi MOBILE FOOD UNIT: A orMIt x XOSO TOBACCO SALES: �a C m,b-eT - FROZEN DESSERT: �,. u"� Thomas A. McKean, RS, CHO CATERER: Director of Public Health .� . , Town of Barnstable pft"ET Regulatory Services Barnstable Thomas F. Geiler, Director MAmahr1ly M"STABLE, MAC. a Public Health Division 16 9. Thomas McKean,Director . 2007 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 5087790-6304 5 APPLICATION FOR PERMIT TO.OPERATE°A FOOD ESTABLISHMENT DATE:'. NAME OF FOOD ESTABLISHMENT: 6ti- !'6/� ADDRESS OF FOOD ESTABLISHMENT: �D �� Y`/ G MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: -PARCEL(S) TELEPHONE NUMBER OF FOOD ESTABLISHMENT:%F f/ -�750 NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: / TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: 5�*5wq TYPICAL HOURS OF OPERATION MON-FRI: :em TO/O DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) IF SEASONAL: APPROXIMATE DATES OF OPERATION))/ J l �� T0O *'REMINDER' SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY „ FOOD SERVICE RETAIL FOOD BED & BREAKFAST + "' CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN = ' MOBILE FOOD TOBACCO SALES e.� FROZEN DAIRY DESSERT MACHINES ' CATERING OUTSIDE DINING (OVER) QAHeallh\Application FormsToodappl.doc **UMINDER*** , , IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS'.WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT /�- SOLE O'v ADDRESS �7 ��,W7 /l tom' PHONE # �d IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS . THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): y LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD•SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED'STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*" ej� f 6 l 4 j2A 4 EXPIRATION DATE:A /!I/ D r 2• EXPIRATION DATE: .3. EXPIRATION DATE: / / 4• EXPIRATION DATE: / / IO SIGNATURE OF A IC ND DATE Q:\Health\(Application Forms:Foodappl.doc G jovvn of Barnstabl `101/ °�T"E � T°w Regulatory Services'y rnsta "P Thomas F. Geiler, Director AN-AM—t=City BARNSTABLE, + ` p j ,� . a Public Health Division r.'9 4 - SS i639 �� 2007 ATED MA'S� i Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8 62-4644 Fax: 508-790-6304 APPLICATION FOR PERAUT TO.OPJER.A.TE A•FOOD ESTA.BLISHAMNT t DATE:30 MA/y'20 ; ,� <:.�, • ,� . x., �.�•�t:>�;= �. ffA�y -Tq;ics F • . u\ _. L,oN4 �r-LL NAME OF FOOD ESTABLISHIVLENT: GL _ r ADDRESS OF FOOD ESTABLISHMENT: y3G So, /'Wl� -l Sr, [' �, �//�F� 1-1R ' MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP:'Z PARCEL(S,)f----S -- . .- . '_ .a• � ._. _ _." � :4-:;. .tip•w . TELEPHONE NUMBER OF FOOD ESTABLISHMENT: cs4$ , ��.4r- Z-7$D NUMBER OF SEATS: INSIDE: I O OUTSIDE: NA- TOTAL: /D TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: S900 L)(k TYPICAL HOURS OF OPERATION MON-FRx: '�b :00 (k TO �D P DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) 04 IF.SEASONAL: APPROXIMATE DATES OF OPERATION: / I / TO V� / K/ ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY t !•` 9 ( r�l a r 9 FOOD SERVICE V RETAIL FOOD BED &BREAKFASTS CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN' MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVEN) mHralih\Annlicalinn Fnrmc\Fnnrio 7 rinr ***R.EAffNDER*** IF OUTSIDE DINING, YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING, AND MEET ALL .OF THE OUTSIDE DINING CRITERIA. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT MAC, 59AWoN) SOLE OWNER: YES /0 ADDRESS • -q3P . SO., �(A-r�. =sT- i eEN Q��cc€ �- y Z63 2 wj . PHorrE# " 73� Z?SO IF APPLICANT IS A PARTNERSHIP,,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: ��- "' cEov fbzu r"E- ,Nlg o 2G3 Z IF APPLICANT-IS A CORPORATION: FEDERAL IDENTIFICATION NO.r-_S70 � STATE OF INCORPORATION �� sS <n r FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION {EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED'STAFF IS REQUIRED ONSITE�DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** I. �(i !7 fS6 k) EXPIRATION DATE: S %Z 6/ Z 017 2. o�� J waG EXPIRATION DATE: 3. EXPIRATION DATE: 4. XPI DATE: / 3 ( / ZvtZ SIGNATU O.F PLICANT AND DATE 4. Pown of Barnstable C � SNE Regulatory Services °. Richard V. Scali, Director „, BARNSTABLE w BARNbTABLE. • �" i vawsras •�anuF.cmumirru+wa MA & r Public Health Division , , uso6 wws.os av¢ •wsreaaxs nay t639-20t4 iOlE1 �16 Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 'fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: 12,11 \S NAME OF FOOD ESTABLISHME �6 J ADDRESS OF FOOD ESTABLISHMENT: 3 So. S y: E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (� ) NUMBER OF SEATS*: INSIDE: © OUTSIDE: TOTAL: ( 0 * Note: If indoor seating provided, see Licensing regarding Common Victuallers License TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: S L-7ASOUA-L' TYPICAL HOURS OF OPERATION MON-FRI: b : oy A TO t0 :OO P DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) �j A IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / 116TO I Z l iS- l 1 ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD r/BED & BREAKFAST CONTINENTAL BREAKFAST *IF SEATING: ALSO,MUST OBTAIN RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) ***REMINDER*** IF OUTSIDE DINING, YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? NO , c Ar IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT `ILS SOLE OWNER: YE /NO ADDRESS q3b So f� ST , c0ilm yltCG Al- 6 43 2 PHONE # ) 7?,$- IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: 44t ^/hv6s IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. qS 's®6 q 69 STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) EXPIRATION DATE: / L / :o►'1 2. U� EXPIRATION DATE: 3 / n/ EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF. 1. Mof., TION DATE: L / ►D / 'Loll SI URE OF APPLICANT AND DATE Q:Wpplication Forms\Foodapp2.doc T • • MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include copies of your employees' food protection manager training certificates (at least two) and food allergen awareness training certificate (at least one.) In addition, please include the required fee amount (see fees at bottom of this page). Make check payable to: Town of Barnstable. Allow five to seven (7) working days for in-house processing. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis,MA 02601 FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax copies of your employees' food protection manager training certificates (at least two) and food allergen awareness training certificate (at least one.) In addition, you must mail the required fee amount(see fees at bottom of this page). Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. Allow up to four days for in-house processing. To get a food permit application form, click here. To be able to access this form, your computer must have Acrobat Reader. Most computers have Acrobat Reader, and it, will usually activate itself automatically. If your computer does not have Acrobat Reader, you can download a copy of it by going to the Adobe website. For further assistance on any item above, call (508) 862-4644 FEES: Bed & Breakfast Permit= $55; Food Service Permit 0-49.seats= $250; 50 or more seats $300; Continental Breakfast= $30; Retail Food Store—Less than 8,000 S.F. = $100, more than 8,000 S.F. = $285; less than 1,000 S.F. and Incidental to Business= $20; Residential Kitchen= $75; Frozen Dessert License= $30; Tobacco Sales Permit= $50; Additional non-refundable Fee for New Establishment or New Ownership _ $100, Late Fee= $10 Back to Main Public Health Division Page . Q:\Application Forms\Foodappldoc �Vd oFtNE rok TOWN OF BARNSTABLE ! " FFICE HOURSR s Establishment Name: Date: ge: of o P ° PUBLIC HEALTH DIVISION 1 ! 8:00-9:30A.M. BARNSTABLE. • 200 MAIN STREET �3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MONHYANNIS,MA 02601 08-8 -FRI. 5oa-s � sz-asaa No Reference R-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHM T INSP T N RE RT Name Date Type of hype of Inspection 'Operation(s) Routine Al/ Alllr� Address Risk Food Service Re-inspection 6aLevel Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Tempora Suspect Illness / General C taint Person in Charge(PIC) Time Bed&Breakfast HACCP Other n: Inspector_ = ® t: Each violation checked requires an explanation on the narrat' a pages)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) 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) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals a FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONSdems m ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ^e� ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Non-critical(N)violations must be corrected immediately or ctive Action Required: ❑ No ❑ Yes within 90 days as determined by the Board of Health. Overall Rating untary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection tod checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than anon-critical violations. F=3 or more critical violations. n no critical violations observed; 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 9 or more non-critical violation 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations s=F. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 4 non-crical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address o 'ons observed,7 to 8 non-cri cal refrigeration. ations=C. 9 ation. 29.Special Requirements (590.009) within 10 days of receipt of this order. int: 30.Other DATE OF RE-INSPECTION: I p tor' i a e B (a ^C 31.Dumpster screened from public view I& Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI Signature Print:- /�l�^�^/p n r�/�/Jrn/^ Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N s �v V 1 Y a j< V V i LY l�' J Dumpster Screen? Y N x . Vlolati6ns related to Foodborne Illness' Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to I 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives �• Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 1 3-501.15 Cooling Methods for PHFs 2-103.11 - Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* IF19- PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each * 590.004(F) * ' 7-101.11 Identifying Information-Original Containers 2 590.003(C) Responsibilityof the Person-in-Charge to Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* - Applicants*- - 3-302.11(A) Food Protection* 7-201.11. Separation-Storage* 20 _Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 7-202.11 Restriction-Presence and Use* 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 590.004(11) Variance Requirements Contamination from the Consumer and Utensils* 590.003(G) Reporting by Person in Charge* 3-304.11 Food Contact with Equipment 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* •REQUIREMENTS FOR 3-306.14(A)(B)i Returned Food and Reservice of Food* 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g - Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanifization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water I Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 15 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Egg mme Service Utensils and Food Contact Surfaces of s-Immediate Sice 145°F sec* * Animal Foods That are Raw,Undercooked or Equipment 5-101.11 Drinking Water from an Approved System* * Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg cri°e tiuzooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS - 8° 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 15 sec* in mobile food temporary and residential g• P �Y 10 Proper,Adequate Handwashing 3-401.11 C 3 Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* ( )( ) Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165'F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail * 1'Y Good Hygienic Practices practices should be debited under#29-Special 3-201.17 Game Animals 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165'F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel:.. FC 12 - .003 # 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction ✓'�� * f 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3 402.12 Records,Creation and Retention Within 4 Hours 26. Water,Plumbing and Waste: 1, FC=5 L .006 590.004(J) Labeling of Ingredients" Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability pp t 28. Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. PERMIT NO: TOWN OF BA TABLE ISSUE DATE 455 December 28, 2009 PERMIT Alt" } MENT V ter 9 4 In accordant i re l ha P Section 395A and t I cti c e General 'thereby granted to: SINGLETARY DENNIS �, L IN Whose place of business is:. 33 OUTH ERV ILL ► 0 6 2 Type of business and any r t�icnE g. - TABLY KME To operate a food establish elit° t TOW .. TABLE RESTRICTIONS IF ANY: Bllk 4- � 4 AR' MA AL SEATING: ANNUAL: Y . � .•�`" SEASONAL: TEMPORARY: OF HEALTH RETAIL FOOD STORE: -�� rg a e Miller, M.D.,Chairperson FOOD SERVICE ESTABLISHMENT a w RESIDENTIAL KITCHEN FOR RETAIL SALE V ul J.Canniff, D.M.D. � � T RESIDENTIAL KITCHEN FOR BED+BREAKFAST $45.00 _ Junichi Sawavanaqi MOBILE FOOD UNIT: erltYi re. -- Q� TOBACCO SALES: December 31 , 2 010 FROZEN DESSERT: Thomas A. McKean, RS, CHO CATERER: Director of Public Health l( S Town of Barnstable op THE Tp� P •y Regulatory Services Barnstable Zl Thomas F. Geiler, Director 47-AmerlceCity + BARNSPABLE, 9� . a i6 9 Public Health Division i r plF'D MA'1 h 0()7 Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Officer 508-862-4644 Fax: 5087790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: NAME OF FOOD MENT: ESTABLISH M ADDRESS OF FOOD ESTABLISHMENT: MAP AND PARCEL OF FOOD ESTABLISHMENT: MA . b 7 PARCEL(S) TELEPHONE NUMBER OF FOOD ESTABLISHMENT: j77.5_37so NUMBER OF SEATS: INSIDE: / OUTSIDE: TOTAL: TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: TYPICAL HOURS OF.OPERATION MON-FRI: : n TO/ DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS, IF.SEASONAL: APPROXIMATE DATES OF OPERATION: / I / 10 TO/Cl_ ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE a RETAIL FOOD E: y X BED & BREAKFAST CONTINENTAL BREAKFAST a" RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES '' rn CATERING OUTSIDE DINING (OVER) QAHeal(MApplication FormsToodappl.doc r 1 ***REMINDED*** IF OUTSIDE_DINING, YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: n� , FULL NAME OF APPLICANT A L V�✓f �� / 1 SOLE OWN YES / O ADDRESS J� e -� PHONE # 17 a'6 J IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE 'AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE" ** /� '� EXPIRATION DATE: 1171461 2. EXPIRATION DATE: . 3. EXPIRATION.DATE: / / 4• EXP/IRATION DATE: G SIGNA; U OF PPLICANT A ATE QAHeaIO Application formsToodappl.doc Town of Barnstable aFZME� y" / Regulatory Services Barnstable o�' P II vi Thomas F. Geiler, Director ■11g-^n1e�ca City + BARNSfABLE, • 1lilt Public Health Division L/ Al�D 9�6 007 Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 5087790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: il�5/ zi �' - q �/ NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: �(0 <55 � MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: PARCEL(S) TELEPHONE NUMBER OF FOOD ESTABLISHMENT: "V NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: / TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: =< TYPICAL HOURS OF OPERATION MON-FRI:, 1 / J�`l TO , t DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) ' V IF SEASONAL: APPROXIMATE DATES OF OPERATION:/ ` P: TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE ' RETAIL FOOD BED & BREAKFAST CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) QAHealthWpplication FormsToodappl.doc a ,e aFa .,rye a ,. .. Aa > > .+. . .y.s, .. .. - .. 4r ..-,.w sa•i: . , . . ,, a - -r er. • ... l.: _ _... _ ***REMINDER*** IF OUTSIDE DINING, YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: _ 61�1_57 FULL NAME OF APPLICANT '! C iV `L ilwz SOLE OWNEP9 EE ADDRESS U PHONE # @�- � 0 IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): LIST THE NAMES OF YOUR FOOD SANITATION. CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITA?I�?N CERTIFIED STA`FI IS PiL'IP.ED Ol`.SITL DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** 9 1. EXPIRATION DATE. / 1/ 2. EXPIRATION DATE: / / 3. EXPIRATION DATE: 4. EXPIRATION DATE: / / / 44 SIGN O A PL CANT AND DATE QAHeaIMApplication Forms%Foodappl.doc EXAM FORM NO. 1933 CERTIFICATE N O. 5588265; �y 7.. O r Certificzs:di'on - TF __DEN.NIkS"P SINGLETARY- for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafeo Food Protection Manager Certification Examination,which is accredited by the American National Standards'lnstitute (ANSI)-Conference for Food Protection (CFP). Presented by the National Restaurant Association Educational Foundation 10/19/2007 DATE OF EXAMINATION 10/19/20 1 2 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. • ACCREDITEDAnneri PROGRAM National Restaurant Association Conferenceand th ,,,Protection dards ® Mary M.Adolf EDUCATIONAL FOUNDATION-7 can National President and Chief Operating Officer #0655 National Restaurant Association Educational Foundation www:nraef.org This document cannot be reproduced or aftered. ©2001The National Restaurant Association Educational Foundation 07060701 v.0708 i PERMIT 455 BOARD OF HEALTH PERMIT TO OPERATE.,A.FO.OD ESTABLISHMENT In.accordance with reglrhat�ons:promulg, d,ender aikthority of Chapter 94, Section 395A and Chapter.1, Slvrtion 5 oftlte Ger eras La'ivs,a Kermit is hereby granted to: o HAPPY TAILS HOSPITALITY,:Lk, Df&kA L3N .DELL INN Whose place of business is: -y tt46CC7TH MAI�kY� ST� 7 , C;ENTER�(LLE; VIA 'Q2632 nKJ Type of business and any restr f cti `IUD OD BR1=A T ESTA$t#W!VN ENT Tl To operate a food establishment In tote TOZtf BLE s 52 RESTRICTIONS IF ANY: s r SEATING: u. 3 , Xx x ANNUALS K r� ,� rY r, �F , SEASONAL: TEMPORARY Y �'u. _" Y r � E E s � CARDOF HEALTH RETAIL FOOD STORE: w b ` e.=�Vliller, M.D., Chairperson FOOD SERVICE ESTABLISHMENT: s,, x F _ F: .� `Paul.��. Canniff, D.M.D. RESIDENTIAL KITCHEN FOR RETAIL SALE: * a Ty a w �, r 1� RESIDENTIAL KITCHEN FOR BED+BREAKFAST S�tOD �<*Jutiichi Sawayanagi MOBILE FOOD UNIT: 4.>. PJCTII `�XplS x TOBACCO SALES: h ceka� er ; 'Z FROZEN DESSERT: Thomas A. McKean, RS, CHO CATERER: " Director of Public Health . ?- Town of Barnstable .' p 1HE r ,o a,~ti Regulatory Services Barnstable , r o'; Thomas F. Geiler,Director ; - MAn ' ' r Public Health Division 1639 ,� �EOMA'tA Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT^TO'OPERATE A FOOD ESTABLISHMENT DATE: NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP.�PARCEL(S) 006 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 7_ - 7w NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: d 0- TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: � �� 'q L—• TYPICAL HOURS OF OPERATION MON-FRI: TO` " m DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) IF SEASONAL: APPROXIMATE DATES OF OPERATION:/ 151 TOIA //� ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE t . `= RETAIL FOOD > BED & BREAKFAST h ?:9 CONTINENTAL BREAKFAST ' RESIDENTIAL KITCHEN1 MOBILE FOODrn TOBACCO SALES ; FROZEN DAIRY DESSERT MACHINES. CATERING OUTSIDE DINING (OVER) Q:\Health\ApplicationForms\Foodappl.doc ***REMINDER*** IF OUTSIDE DINING, YOU MUST BE APPROVED BY THE BOARD OF HEALTH ANDS.,, LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? l IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT s �Z SOLE OWNE NO - ADDRESS PHONE # S 75"A75U . IF APPLICANT IS.A PARTNERSHIP; FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD .ESTABLISHMENTS. THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): LIST THE NAMES.OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO-HAVE AT LEAST._TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** 1. ]��AjiVl S 7901 EXPIRATION DATE:!� / / 40 2. EXPIRATION DATE: 3, EXPIRATION DATE: 4. XPIRATION DATE: ' f 1 qoIl SIGNATURE APPLIC AND DATE Q\HealtRApplication FormsToodappl.doc PERMIT NO *OWN OF BARNSTABLE • 2003 455 BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, 0 Section 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby gran O /� CHARLOTTE DORNICH D/B/A: LONG DELL INN V Whose place of business is: 436 SOUTH MAIN STREET , CENTERVILLE, MA 02632 Type of business and any restrictions: CONTINENTAL BREAKFAST ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY SEATING: ANNUAL: YES SEASONAL: TEMPORARY: FEES BOARD OF HEALTH RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT Susan G. Rask, R.$.,Chairperson RESIDENTIAL KITCHEN FOR RETAIL SALE Ralph A. Murphy, M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST $30.00 Sumner Kaufman, M.S.P.H. MOBILE FOOD UNIT: Permit expires: �/n TOBACCO SALES: December 31, 2003 FROZEN DESSERT: Thomas A. McKean, RS, CHO MILK: CATERER: ^� Director of Public Health Town of Barnstable p tHE Tp� Regulatory Services t Thomas F.Geiler,Director * BARNMBLE, MASS. 9. Public Health Division �rFD 1iA°�s Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 November 1, 2002 LONG DELL INN 436 SOUTH MAIN STREET CENTERVILLE,MA 02632 ATTENTION: SERA-N IF r-ZGERA1JB Your food service/retail permit(s) will be invalid after December 31,2002. ESTABLISHMENTS FEE Number of Seats: FOOD SERVICE RETAIL FROZEN DESSERT MOBILE FOOD BED&BREAKFAST 30.00 TOTAL DUE iNIL0 Food establishment inspections are ongoing by a Health Inspector; therefore, it is not necessary to make an appointment with the Health Division. However, if your establishment is not open during normal working hours (8:00 - 4:30 p.m.), please call 862-4644 between (8:00-9:30 a.m. or 1:00-2:00 p.m.) to schedule an inspection. Enclosed is a food permit application form. Please complete the form and mail it along with the required payment on or before December 15,2002 to the Town of Barnstable, addressed to the Public Health Division, 200 Main Street, Hyannis,MA 02601. Upon satisfactory compliance and receipt of your payment and copies of current Servsafe Certificate, you will be sent, via mail, the food/retail permits)for calendar year 2003. Failure to renew permit on or before January 1, 2003 will result in an additional fee of $10.00 late charge. If you should have any questions,please feel free to call the Public Health Division office at 862-4644. QJhealthMpfiles/allrest 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owners Name information is required for every Centerville Ma 02632 2/25/2012 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use key.the return Name of Inspector --I Capewide Enterprises Company Name q M 153 Commercial St. I J. ' -n �I Company Address ,u Mashpee Ma. 102649 City/Town State 3 Zip Code 508477-8877 S14522 r • Telephone Number License Number J - .», 8"i7 B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2/25/2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. U t5ins•11/10 Tide 5 Official Inspection Form:Vac.ee Disposal System•Page 1 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM , 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El Have large volumes of water been introduced to the system recently or as part of �® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 8 Number of bedrooms (actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 882.45 gpd provided t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M W 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2010 = 250,000 total =685 gpd 2011 =202,000 total = 553 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owners Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2000 gallons How was quantity pumped determined? size of tank Reason for pumping: routine maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 2005 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gallons Sludge depth: --- t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012, every page. City/Town I State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? tank was cleaned as part of inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is H-20 and was found to be structurally sound. Inlet and outlet tees were intact and in good condition. Tank should be cleaned yearly as routine maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert oil Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found to be functioning as intended, the water level was even with the outlets with no sign of past hydraulic overloading. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 26.5'x45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil and stone was probed in various locations with no sign of present or past saturation. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 436 South Main St . Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 8.5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/17/2005 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Design plan dated 6/17/2005 indicates that groundwater was encountered at 102". System was designed and installed to have a seperation of 5.3'between bottom of s.a.s and the adjusted high groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 436 South Main St Long Dell Inn Property Address Kate Singletary Owner Owner's Name information is required for Centerville Ma 02632 2/25/2012 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 436 South Main St Long Dell Inn M Property Address Kate Singletary Owner Owner's Name information is required for every Centerville Ma 02632 2/25/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately c e 1 A 1 A A • 1 O I y t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 N6. 0 5 Fee$1 0 0 , 0 0 THE c6hdA0N%U EALTH OF MASSACHUSETT8 Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS 0(pplication for M.5po l 6pztem Zon5truction i9ermit Application for a Permit to Construct( , )Repair( X)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 7 7 5—2 7 5 0 43M6 S. Main St, Centerville Dornich/Singletary Assessor's ap/Parcel 207/6 436 S. Main St, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 7 9 0—9 2 7 0 Wm E Robinson Sr Septic Lisa Lyons PO Box 1089, Centerville Hyannis Type of Building: Dwelling No. of Bedrooms 8 Lot Size sq. ft. Garbage Grinder(no) Other TI pe of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow --gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) We will install a new Title 5 heavy duty septic system to plans of Lisa Lyons. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not t.o place the system in operation until a Certifi- cate of Compliance has been issued by this and"of Health. Sign Date d"'` '-6 S� Application Approved by NDate 10 Z/ Application Disapproved for the following reasons Permit No. 5 cJG Date Issued .No. t n-�Cfr v.Jr :`4 + Fee $1 0 0.0 0, `".,1 ra = r i ' f -THE C MONWEATH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION - TOWN OP"BARNSTABLE., MASSACHUSETTS ZIppYication-for Zigpozal bpkem Conotruction Permit Application for a Permit to Construct( . )Repair rade Abandon p (a }�4Jpg ( ) ( ) El Complete System ❑Individual Components 'r �n ,Location Address or Lot No. Ownee�s Name,Address and Tel.No. 0 436 S. Main St Centerville Dornich/Singletary Assessor'sMap/Parcel 207/6/ x`* -436 S. Main St, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 7 9 0—9 2 7 0 Wm E Robinson Sr,. Septic Lisa Lyons PO box 1089, Centerville Hyannis Type of Building: ` ` Dwelling No.of Bedrooms 8 Lot Size t sq.ft. Garbage Grinder( n)o Other Type of Building No:of Persons Showers( )` Cafeteria Other Fixtures Design Flow gallons per day. Calculated daily flow --gallons. Plan Date Number of sheets Revision Date Title <K Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) We will install a- new Title 5 heavy duty septic system to pans of Lisa Lyons. Date last inspected: Agreement: -- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi dar f'f Health. Signed( Date 1 ��D Application Approved by ( Date Application Disapproved for the following reasons i Permit No. U. Date Issued / 5 THE COMMONWEALTH OF MASSACHUSETTS Dornich/ BARNSTABLE, MASSACHUSETTS Singletary Certificate of (Compliance THIS ISbT�O CERTIIF n, tkat�hobinsonw� D* opstlpS stsnervnitruected( ) Repaired ( J Upgraded( ) Abandoned 4(3 6) 5. main- street, at has been constructed in accordance with the provisio of itle 5 and the for Disposal System Construction Permit No. �J ated /p�I1 1S Installer i Y`3 y'a'\ Designer �� S The issuance of this a tishall of be construed as a guarantee that the sys e m wll c'o as designed. Date Inspector i Dornich/ THE COMMONWEALTH OF MASSACHUSETTS Singlf�t,) 3 AC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ' Di5po.5al *pgtem Construction Permit Permission is hereby gra to to Construct( ))Repair( Upgrade( )Abandon( ) System located at 4 S. Main S"treet, Centerville_ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Povided: Construction m st be completed within three years of the date f this per Date: /0��` Approved by Town of Barnstable Regalatory Services Thomas F. Geiler, Director BARNSTABLE, 9q� MASS. � Public Health Division ATED ,�A Thomas McKean,Director 200 Main.5treet,Hyannis,NIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: C�, b5 Designer: Lisa Lyons Installer: Wm E. Robinson Sr Septic Address: Address: PO Box 1089 Hyannis � � Centerville On16 `'111- 4__" Wm E Robinson Sr Septir-vas issued a permit to install a (date) (installer) septic system at 436 South Main St, Centerville based on a design drawn by (address) Lisa Lyons dated 06-17-05 (designer) l/ 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. tN OF Af4s A •%Gam' (Installer's Signature) t i 0 C. 11143 : • (Designer's Sign re) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form I Adi PERMIT NO: TOWN OF-BARNSTA$LE, ISSUE DATE 455 OAR ,� F HEALTH 12/2812006 PERMIT�O OPERATE 1 OD;ESTABLISF�I�IVIENT � � In accordance-#tt,4 regulations proTulgated iiirier atiflip� y orChapter 94, Section 395A and Cha ter11;Sect i#W45, ot�the General Laws a eritis hereby granted to: p� DENNIS SINGLETARY r 3 � �' t 'N x r©/R/ALONG[}ELL INN. x Whose place of business Is 436 SOUTH MAIN=STREET, a✓ENTERVILLE, MA 02fi32 Type of business and any restrictions: E3E[�hAND BREAfCFST„ STABLISH;IIIENTp. k To operate a food establishmentin the TOWN CP1RNS LE 3 RESTRICTIONS IF ANY: _ a pT k. SEATING: ANNUAL: YES " M11 " SEASONAL: TEMPORARY: �4 B6ARD OF HEALTH RETAIL FOOD STORE: . FOOD SERVICE ESTABLISHMENT: " .v g Wayne Miller, M.D., Chairperson RESIDENTIAL KITCHEN FOR RETAIL SALE: �� - Sumner Kaufman, M.S.P.H. RESIDENTIAL KITCHEN FOR BED+BREAKFAST: $45.00 Paul J. Canniff, D.M.D. MOBILE FOOD UNIT: Fe7iT1 tt eXp"1 reS TOBACCO SALES: 1 2 / 3 1 /2 0 0 7 � FROZEN DESSERT: Thomas A. McKean RS CHO CATERER: � e Director of Public Health PERMIT NO: TOWN OF BARNSTABLE ISSUE DATE 455 BOARD OF HEALTH December 20, 2007 PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: DENNIS SINGLETARY D/B/A: LONG DELL INN Whose place of business is: 436 SOUTH MAIN STREET , CENTERVILLE, MA 02632 Type of business and any restrictions: BED AND BREAKFAST ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY: SEATING: ANNUAL: YES SEASONAL: TEMPORARY: F E E S BOARD OF HEALTH RETAIL FOOD STORE: Wayne Miller,M.D., Chairperson FOOD SERVICE ESTABLISHMENT: RESIDENTIAL KITCHEN FOR RETAIL SALE: Paul J.CannifF, D.M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST: $45.00 Junichi Sawayanagl MOBILE FOOD UNIT: Permit expires TOBACCO SALES: December 31 , 2008 FROZEN DESSERT: Thomas A. McKean, RS, CHO CATERER: Director of Public Health 1 V Ty 11 V1 7.7Q,1 1 ►76c1u11G o�tHe ,, Oulatory Services Thomas F. Geiler,DirectorBAMSTABIA 9� tip. r 'Public Health Division ATED"`0�A Thomas McKean,Director 200 Main Street; Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: 1/ ga O G - NAME OF FOOD ESTABLISHMENT: ADDRESS OF'FOOD ESTABLISHMENT: ' MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: PARCEL(S) 00 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: �`'� - NUMBER OF SEATS: INSIDE: A� OUTSIDE: TOTAL:. �CA L; - TOTAL NUMBER OF BATHROOMS: (J a ANNUAL OR SEASONAL OPERATION: a TYPICAL HOURS OF OPERATION MON-FRI: :JD 0w TO �' F5 N DAYS CLOSED EXCLUDING HOLIDAYS (I.E.MONDAYS) �'' `"' . M IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO / ! ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD BED &BREAKFAST CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER—+), Q:\Healdi\�kpplication Foans\Foodappl.doc ***REMINDER*** IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED.FOR OUTSIDE DININGT IS AN AIR CURTAIN.-PROVIDED AT WAITSTAFF SERVICE DOOR(Sr -� CONTACT INFORMATION: FULL NAME OF APPLICANT l SOLE OWNER YES O C Y N . = '67AADDRESS /rCIAL �Gl 6 0 / l ��, ,, �3 PHONE#Qf5b 775 A 7.0 IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DON'T PREPARE FOOD AND CONTINENTAL BREAKFAST): , LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION'CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** 5 ' i l el_ L v EXPIRATION DATE: 2. EXPIRATION DATE: 3. EXPIRATION DATE: / / 4. EXPIRATION DATE: / / I SIGNA OF LI ANT AND DATE Q:\HealthWpplication Forms\Foodappl.doc PERMIT NO: TOWN OF BARNSTABLE 6/21/05 455 BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 Section 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: DENNIS SINGLETARY D/B/A: LONG DELL INN Whose place of business is: 436 SOUTH MAIN STREET , CENTERVILLE, MA 02632 Type of business and any restrictions: BED AND BREAKFAST ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY: SEATING: ANNUAL: YES SEASONAL: TEMPORARY: F E E S BOARD OF HEALTH RETAIL FOOD STORE: ' Wayne Miller,M.D.,Chairperson FOOD SERVICE ESTABLISHMENT: RESIDENTIAL KITCHEN FOR RETAIL SALE: Sumner Kaufman, M.S.P.H. RESIDENTIAL KITCHEN FOR BED+BREAKFAST $45.00 Susan Rask, R.S. . MOBILE FOOD UNIT: Permit expires: TOBACCO SALES: 12/31/05 � FROZEN DESSERT: Thomas A. McKean, RS, CHO CATERER: Director of Public Health - ` Town ot- Narnstable Regulatory SeMces Thomas F.Ceder,Di rector v C. , �—e- 3 NAM ' 'Public Health Division /� ' C> Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508- 304 ,P -66 APPLICATION FOR PERMIT'T DATE: NAME OF FOOD ESTABLISHMENT: ADDREss OF FOOD ESTABLISIMENT: 43 G SOcJ-F+-1 /-w t J S�"Z 1�w �Wrrev i LIU MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: ,PARCELS) TELEPHONE MMSER.OF FOOD ESTAMSMVIENT: 5( uU ) N'C MER OF SEATS: INSIDE; OUTSIDE: TOTAL,: TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: 4M V0.4 L-- TYPICAL HOURS OF OPERATION MON-FW: :L TO 2 D© P/�( DAYS CLOSET)EXCLEDING HOLIDAYS(LE.MONDA.YS) IF SEASONAL: APPROXIMATE DATES OF OPERATION: TO J S A.SONAL EST CALL FOR INSPECTION,PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD " BED&BREA0AST CONTDMNTAL BREAKFAST 017RESIDENTIAI,IMC. YEN � MOaxLE FOOD TOBACCO SALES MOZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER—+) Q:1Ftoa1�lAp�ifcatio�P,amavPccaoppl.aoe IF OUTSIDE DINING,YOU MUST BE APPROVED DY I+BOARD OR MALTS STD LIQNSM,AND MMET ALL F THEMUTSME 094ING OWRIA IS WAIT STAFF PROVIDED FOR OUTSIDE DVMG? IS AN AM CURTAIN PROVIDED AT WAITSTAFF SERVICE D00R(9)? o / FULL NANM OF SCANT �P- 1.S S/lrl `L' SOLE OWNEL,, !NO SOCIAL ' NO. 3 , ADDRESS 10 a 1 vl 1t-o llip 14A. L4�P—IVI-7 PI[ONE#(!L�) CQ�C/Q CP 30 J-13© IF A"LICANT IS A PART1 ERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: w IF APPLICANT IS A CORPORATION: FEDERAL IDENTMCA'MON NO. STATE OF INCORPORATION WOOD UWWCE HMG+NTS 0MUCTING EQQjD TIO (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DON'T PREPARE FOOD AND CONTINENTAL SPMAXPAST): , LIST THE NA VM OF YOUR FOOD SANITATION STAFF (LE■ SEKV-�AFE) DIVE JANUARY 1.2M,EACH FOOD SERVICE FSTABI Ea*ffbNT IS REQUMD TO HAVE AT',LEAST x�o FOOD SA,NTTAT'IoN,CERTIFIED 8.TAFF. AT LEAST ONE O CERTMIND STAFF UIitED NS DURING ALL HOURS OF + ON.**+PI,jAM- PUT THX NANM Of THE ESTABLISMAENT ON TM CXW MCATE*** I. L(utulsS��h;/aa F.XY"IRMON DATE-.—!I , O r l 08 2• EX RATION DATE: I I 3. EMRATION DATE: I I 4: EXPIRATION DATE: / 4 t a SxG1v OFt AID DA= Q'+��APA FemasVlbodppi.eee i i i Ry r 4 II i THE ERSON,'FIRM OR CORPORATION WHOSE NAME APPEARS. ON THIS CERTIFICATE.HAS COMPLIED WITH THE PROVISIONS OP . THE ILLINOIS STATUTES AND/OR RU ES AND REGULATIONS AND- IS HEREBY AUTHORIZED TO ENGAGE IN THE ACTIVITY INDICATED ON THE FACE OF THIS CARD. ISSUED UNDER THE AUTHORITY OF STATE OF ILLINOIS DEPARTMENT OF PUBLIC HEALTH � r SI N URE O LICENS A TO ALA. E ' BUSINESS OWNERS DATE 5 _ Fri in pl as ��.5 ✓� 12y APPUCANTS ::`<:;:: YOUR NAME- / IjSINESS R R E A l � -n . TELEPHONE Telephone Number me D • 11WME OF NEW BUNNESS TYPE OF BUSINESS -S IS THIS A HOW OCCUPATION? YES =N113Aig0A0DPESS0FBUSINESS6r Have you been given approval fromfront b ilding dlvI ' n?6 MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Etarnstab!e. This form is intended to assist you in obtaining the infotma on you may need. Once you have obtained the required signatures,listed be'o%v,you may apply for a business certificate at the Town Clerk's Office fist flaor-Town Han). You MAST go to the following office to make sure you have all the required permits and licenses.. GO TO 200 Main St. - (corner of Yarmouth Rd.&Main Street)and you will find the following offices: 1. BUILDING COMMISSIONER'S OFFICE This indvidual has been informed of any permit requirements that pertain to this type of business. A:,thorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual has bee formed of the p it requI nts that pertain to this type of business. th rized Signature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORRY) • This individual has been informed of the licensing requirements that pertain to this type of business. Authorizer)Signature* COMMENTS: Business certificates tcost$30.00 for 4 years), A business certificate ONLY REGISTERS YOUR NAME In the town(which you must do by M.G.L. -it does not give you permission to operate-you must get that through completion of the processes from the varies departments involved. **SIGYVIFIESAPPI70114AL FOR A SUS#VESS 0ZRTlFICATE O N1.Y Z 348 659 767 Receipt for Certified Mail No Insurance Coverage Prdrolded o UMTED STATESDo not use for International Mail MSTAL SEWICE (See Reverse) 03 Sent o t St t 2 P �M tat nd ZIP Code co C P sta e E Certified Fee O � Special Delivery Fee R6st'rkted'Delivei/Fee t f 1Rei6fn'Re6e1pttSliov$in6t to Whom&Date Delivered Return Receipt Showing to Whom, Date,and Addressee's Address TOTAL Postage &Fees is Postmark or Date �/9/9 STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see Lrrovff.--•' t 1. If you want this receipt postmarked,stick the gummed stub to the 9ight,of the return address 0 leaving the receipt attached and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return cv) address of the article,date,detach and retain the receipt,and mail the article. rn 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed 0 ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT 2 REQUESTED adjacent to the number. C 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, endorse RESTRICTED DELIVERY on the front of the article. E `o 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If LL return receipt is requested,check the applicable blocks in item 1 of Form 3811. 6. Sae this receipt and,piPsgo-it-if you make inquiry. 105603-93-B-0218 ai SENDER:'0 I also wish to receive the ■Complete items 1 and/or 2 for additional services. rn ■Complete items 3,4a,and 4b. following services(for an ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ■Attach this forth to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address d permit. d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N ■The Return Receipt will show to whom the article was delivered and the date .. Consult e delivered. postmaster for fee. a 3.Article Addressed to: 4a.Article Number 0 CL E // 4b.Service Type E l//t/-E?il /'� d 0 ❑ Registered Certified of ❑ Express Mail ❑ Insured S .IX ❑ Return Receipt for Merchandise ❑ COD o Zo ,�� ; p a 7.Date of Delivery APtt 9 2 pp w '� 1999 5.Received By:'�(Pl Na 8.Addressee's Address(Only if requests C W pi and fee is paid) t t� F. g 6.Signature:(Addressee or ger. E P o v *(}I!TP!-.A:,T RFGION w X ii i =•:•1— tti I fit 01 11 ' i iii PS Form 3811, December 1994 102595-97-B-0179 Domestic Return Receipt �q VNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 e Print your name, address, and ZIP Code in this box • PGblic Health Division Town of Barnstable PO Box 534 Hyannis, Massachusetts 02601 Fax(508)775-3344 Phone(508)790-6265 lei Ill 11i Ill 11 Ill till till Illlll1111111411111111111 lilt Itlilllllll Town of Barnstable Department of Health, Safety, and Environmental Services RAMSTABM "'9 1659. Public Health Division �� P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health �. April 5, 1999 John Viveiros _ Department of Environmental Protection 20 Riverside Drive Lakeville, MA 02347 r RE: Septic Inspection complaint at 436 South Main Street, Centerville, MA. Owners: Joy& Leroy Swayze. Dear Mr. Viveiros, This letter was prepared to make you aware of potential illegal activities and misrepresentation on an inspection report. A detailed description of the violations are listed below. On December 10, 1998, John Graci, Septic Inspector, performed a Title 5 transfer inspection at 436 South Main Street, Centerville, MA. The inspection report indicates that the Distribution Box is"structurally sound." • 310 CMR 15.109: Disposal System Installers Permit On December 11, 1998, Hickey Construction of Falmouth, MA visited the site to pump and repair the septic system. According to the owner, who was present for the repair, the distribution box was replaced. Hickey Construction did not obtain a disposal works construction permit from the Board of Health to perform the repair work. Also, Hickey Construction is not licensed to perform repairs or installations. • 310 CMR 15.340 6) Misrepresentation on an Inspection Report The distribution box was not"sound" until the replacement, which occurred after the date of inspection. The date of repair was verified by the date of the issuance of the check paid to Hickey Construction by the owner. r The violations stated herein were encountered during a Bed& Breakfast inspection. The inspection was performed by Donna Miorandi and Glen Harrington, R.S., Health Inspectors. Enclosed for your review is the inspection report filed by John Graci. I request that you hold.a hearing in regards to the alleged violations by both parties and take appropriate action. Sincerely yours, Th e Director of Public Health enclosure cc: John Graci Hickey Construction Susan G. Rask Commonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection One winter Street' Septic Boston Ma. 02108 John Septi ` D.L.P. Title V c Inspector P.O. Box 2119 Teaticket, MA 02536 f5 - WILLIAM F.WELD (5 008 -q' Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM go �F PART A CERTIFICATION 4 Property Address: 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 6 Address of Owner: v 49YR Date of Inspection: 12/10/98 (if different) OFp�q ;V Name of Inspector: JOHN GRACI JOY SWAY2E I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: i CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x 'Passes Thla Inspection le based on criteria defined InTitte V _ COndlti0 ally Passes code 310CMR16.303.My findings are of how the system is performing at the time of the inspection.My inspection does _ Needs u her Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fails septic system and any of Its components useful life. Inspector's Signature; t! Date: 1211o19a The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/27197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-5500 r I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 0 Owner: JOY SWAYZE Date of Inspection:12110/99 — Sewage backup or.breakout.or. h1oh.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND'THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering,vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersuppiy well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. _ — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged Cesspool. SAS is in hydraulic failure. (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 6 Owner: JOY SWAYZE Date of Inspection:12110199 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from.a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10.000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)87) • • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 0 Owner: JOY SWAYZE Date of Inspection:12110199 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection.'i x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of•sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. -x— — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)) (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 6 Owner: JOY SWAYZE Date of Inspection:12r1e199 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 7T9 9 P Number of bedrooms: T Number of current residents: 3 Garbage grinder(yes or no): No Laundry connected to system(yes or no):-Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nIa Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nra Last date of occupancy: nla OTHER:(Describe) Ns Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS LAST PUMPED IN THE SPRING BY McCOMBER System pumped as part of inspection:(yes or no)ves If yes,volume pumped:2000 gallons Reason for pumping: MAINTENANCE TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system,(yes or no) ( if yes,attach previous inspection records,if any) x I/A Technology etc.Copy of up to date contract? Other: WITH AN ADDITION CESSPOOL WITH LEACH PIT APPROXIMATE AGE of all components,date Installed(if known)and source information: CESSPOOLS ARE 30•WITH NEW SAS INSTALLED APPROXIMATELY 6 YEARS AGO Sewage odors detected when arriving at the site:(yes or no) No ( revleed 04127I97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 6 Owner: JOY SWAYZE Date of Inspection:12110108 SEPTIC TANK: x (locate on site plan) Depth below grade: SOTTV Material of construction:x concreate metal FRP Polyethylene—other(explain) If tank is metal, list age i pia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: BOTH CESSPOOLS ARE 6'X6'FUNCTIONING AS SEPTIC TANKS-NOT TIGHT Sludge depth:2":3" , Distance from top of sludge to bottom of outlet tee or baffle: 32",31" Scum thickness:2"A" Distance from top of scum to top of outlet tee or baffle:BOTH6" Distance form bottom of scum to bottom of outlet tee or baffle: 16":1T" How dimensions were determined: MEASURED Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) MAIN CESSPOOLS AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERYYEAR GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rva Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: ria Date of last pumping;d. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: ONE I";ONE2" Material of construction: cast iron_40 PVC_other(explain) Distance from private water supply well or suction Iine:TOWN Diameter: nIa Qmments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04127)97) • 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 6 Owner: JOY SWAYZE Date of Inspection:12110199 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: teaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number:Na leaching galleries,number: rya leaching trenches,number,length: rva leaching fields,number,dimensions:ONE 20'x1e'FIELDI.6"THICK overflow cesspool, number:n1a Alternate system: rda Name of Technology:_nra Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PR IS STRUCTURALLY SOUND,IT HAS 16-OF LEACHING LEFT.THE LEACH FIELD IS FUNCTIONING PROPERLY AND SHOWS NO SIGNS OF FAILURE. i CESSPOOLS: (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: rva Depth of solids layer: rva Depth of scum layer: rda Dimensions of cesspool: rda Materials of construction: rya Indication of groundwater; rya inflow(cesspool must be pumped as part of inspection) nla Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda PRIVY: (locate on site plan) Materials of construction: rva Dimensions: rva Depth of solids: rva Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda �i (revised 04l27)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address: 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 5 Owner: JOY SWAYZE Date of Inspection:12110199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nfa Capacity: r9a gallons Design flow: rda gallons/day Alarm level:_nfa Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: LIQUID LEVELVM BOTTOM OF PIPE. Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)_I o Alarms in working order(yes or no)_Ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda I (revised O4127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 6 JOY SWAYZE 12110199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) i � Y ' U S (reyfeed04)27197) Page t of 10 ; h �• RUBSURFACE SEWAGE DISPOSAL SYSTEM 1 � ECTION FORM PART C SYSTEM INFORMATION(continued) 436 SOUTH MAIN ST.CENTERVILLE MAP 207 LOT 6 JOY SWAYZE 12110199 Depth of groundwater 10 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your,own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revlaedOWT197) Page 10 of 10 0.' y . cIg1 0 20 COUNTDOWN I Grain of salt One thing to remember when anyone TO THE announces a forecast for the coming century or millennium: COO Most are wrong. According to 26 sociologist Seymour Martin Lipset, more than 65 percent of FRIDAY all forecasts issued by social sci- entists from 1945 to 1980 were faulty. And that didn't include predictions made by public opin- ion polls or those revealed by psychics. op. �s- Z 7sO 7,-o7 - 6v6 /J ` P J'7 t t s l0 ds 74v,/ %J-cll t kn 4ZI _ _ ✓�o��r — .,�/o /'��o�c1s .°7 S�� 6.e�-i c��.�-��.� r�a.,.�-�04.-�(c wG e - v .i -�-41 _ �_ kli 11 i {�It • �-. -��.... ram.._.�� _ r...�--.-.- __.� ��_�.._.T�-- -__._--.. __.-.�.�-s �_.�. _ �-.. _�-�t�_-}3��i-_ ,_ -_._.__.�--_..r._-. �S i r t F ,k ,i Town of Barnstable . '. Department of Health, Safety, and Environmental Services Health Division 367 Main Street, Hyannis MA 02601 Thomas A.McKean oillo.. 501-790.6265 Director of PuMle Health PAX: 301-773-3344 INSTRUCTIONS FOR APPLICANTS FOR DISPOSAL WORKS PERMIT 1. Complete Disposal Works installer's Permit application* 2. Complete application must be approved by the Health Inspector assigned to on-site sewage disposal and the Health Director. 3. Applicant must make an appointment to take examination; given on Wednesdays only. After 9:30 a.m. and after 2:00 p.m. 4. Examination will be graded by the health inspector assigned to on-site sewage disposal. 5. Applicants who fail examination must wait three(3) months prior to retaking examination. 6. Application and test results must be submitted to the Board of Health for final approval before issuance of the permit at least ten days prior to the regularly scheduled Board Meeting. 7. If approved, applicant must obtain instructions and permit from the health inspector assigned to on-site sewage disposal between 8:30 a.m. and 9:30 a.m. or between 1:00 p.m. and 2:00 p.m. daily Monday through Friday. *EFFECTIVE JANUARY 1, 1996, THERE IS A CHARGE OF 400W.00 TO TAKE THE TEST. TOWN OF BARNSTABLE ocef't ht iiJ t o '. o `� LOCATION �7�v S Q �S SEWAG'E # ,D 5 S' S VILLAGE l OC4 2f e r 1 i A-�, e ASSESSOR'S MAP & LOTy107- o a INSTALLER'S NAME&PHONE NO.6t)i L 1-1 Q rk 67 Z b 4S 4 C5e/ -e1(:!' SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUIf:DER OR OWNER J PERMITDATE: � /�S� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 2000 GALLON TANK-H2O DISTRIBUTION BOX LEACHING FIELD 26.5'X 45' SCALE NOT TO SCALE NOT TO SCALE 77 N.9B roBna118Pi 6.OP DaI4ID\ i .•emarve Pemm11ID1�3 eerawr�vs MDJ 7COVHlf I q• AP 90. rIT +3. ;4" 05 rSs F ac+-, "c.L 1 $f'.%:.sh*,.f'G ( '...-,:—zr rr - , 4.01 94.5 :':'.. .... ... ........ ... ....... \. 400 I 45.01 )UNDWATER SI'ES£.000CNDIS9 Qi.e�ali4LPLDliOIIiGCbATAPBeaEa� ! ' evmc com c ro sma sxaram ro�a®nusam ro eaaa u+r�wEna�vawocnuactvro�ec,wBerP� �• 'Tmva+n.B4aanmroaaDawunA9®owr, MAP 207 PARCEL 6 Pow.eisvenoNB ro aE es saowLa ClBL`Dn cov�n�er GaeDa VWUIDH6EapuD38P - . oxe�ncieamPear rceaee m�nPAvaD o.81 ACRES Dancr>eaxesrascw�a4 eovnsestoaro - eBCDxaxc oe4oammorrmua»nms ' i I 5'REMOVAL TO CP AROUND SAS 45 'X BB.!'HELD 4 NIL VINYL BARRIER TO B£I—ALLED AS SWO CESSPOOLS TO BE I PUKED AND CROSS SECTION LOCUS PLAN NOT TO SCALE, NOT TO SCALE EEun+� Y VS'-1/S"WASHED STONE i ./ DESIGN CAI.CIJIATIONS GENERALNOTES FLOOR PLAN NOT TO SCALE EE443II1GEEDROOMS E eROP09®BEDR0OMS 0MG.PD.=RBO G.PD.yAa®gPp m�,wpaR¢�jp®Z SECOND FLOOR p°°PB1IIPP1OR1OR°C1Of''' FIRST FLOOR ,Po OPnaenoeo�7axmawmm• 6A9 DIDffilSIONS BROWN. IENGT 4S ARCNOINOWNPOUMEWe1lS WGHDI iPFGflI wti m'OPIRe PeOPOEBOIBA[fRiGPAmDY. BOTIOM AREA n9t-69P �ttHE�PISeD�AILB.V]ID.'GnON�WI'It¢ rtYGLSOUAREPCef u9AS 8P I'wu IPPGP802.ODRBNOfPN1WIlIRNA t DIIie OPAWBIIHOADPROIDDIIONdeBd CAPAQREOIIOM® a.>I SBf.�SGPD. I00PPRBYW89NMPALLwP11@Id CAPACifYt01'AL BBA-15 G.PD. ADODIIBOEA96BOWNONPOIMMAP CARRGGS HOU9C 28ID�gBBIGRO®Ntrt RPRaD<BVARWiCPB OR'NFAB - SOmC�n7�0ABAemwB�B uvwcaaOp TEIS SEPTIC SYSTEM IS NOTDPSIGNED savn AA eucovPiRvrnox BBeu.BEBcdaoeou+a REOROOM ACOOMODAIEAGARBAGE DISPOSAL��dNDR�R�stARtyEOPP�ffivr Bv.7DrsEwvwTwNs moeosEn Asec¢T SURVEY INFORMATION °^ w¢aRPe PAyPROPEM LINE DATA TAIMN FROM TEEEWAWAHNESGRVSPN•G 6Alft DNDGOtAN6 Iry INiDD,Bdc W.� PLW IO6119rD FOR DlRGL1AllON T m®� DrvOOI OPO.00a P� OP9�IICSVRIWtl ONLY r l l WYDSN P®D PPn NO BENCH MroDEI®10aP.TROIWOYID�® BINARK- �eBAnoRPtotu® Ao ZOCATION JFWAGE PERMIT N0. VILLAGE A. & 'B CESSPOOL SERVICE 128'BISHOP TERRACE, HYANNIS, MA 0260.1 BUILDER OR OWNER DATE PERMIT ISSUED 41, DATE COMPLIANCE ISSUED d9 ' " 1L�sI 2 bt� " e6L-1 `lat I LOCATION_ SEWAGE PERMIT NO,.Sr , VILLAGE A '& B CESSPOOL SERVICE M2 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED. .,, 12 bL' TOWN OF BARNSTABLE LOCATION SEWAGE#� O VILLAGE ASSESSOR'S MAP & LOT ©C�� INSTALLER'S NAME&PHONE NO. /�� .sG ?S 77 2 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L s �� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE:/f) COMPLIANCE DATE:/!S''� "0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �® Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .10 Aa-3 �`3 I IVA 0 Gr0 elz ��c9 r No.-_84- .. Fzs ...15-.QQ........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .............T.otm---------..OF........Bam.s+a..bl.e....--................................................ Appliration for Disposal Works Tnnstrnrtion Valuit Application is hereby made for a Permit to Construct ( ) or Repair (x ) 'an Individual Sewage Disposal System at: .A26.32.................................................................................... Location-Address or Lot No. ........ ...................................................... .....Q2632 Owner Address a -A & B Cesspool-- 5e ge..................................... I2 ..Bishops..Tex_mee.,..EYanni_s.,..-MA-----026.Q1...... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.........3................ Showers ( ) — Cafeteria ( ) PaOther fixtures .----••--•-------•--•--•--•---------•----------------------•--------..........--•---------....-•-•---•------------------....----.........------------ d w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter-----------.-_- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No...---..-_-........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by.......................................................................... Date.............................=.......... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..--.................... Gi, Test Pit No. 2................minutes per inch Depth of Test Pit..--.--.....--...... Depth to ground water.-...................... a ....................................................--••----------.......------•----•-------•-•----........................................................ ODescription of Soil............ .and............................................................................................................-....................-................. x U --------------- -•-•--...........--•---......---•••-•--•-------............------•--------•••-•-•-------•---------------------------•-------------------•-------•---------.....----...._..-------------- w UNature of Repairs or Alterations—Answer when applicable-----installation...of._a._t,.QDQ.-gallen..hea..v7..duty stomg Q ._jei ch (QYexf7.oW •-------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code The undersigned er agrees not to place the system in operation until a Certificate of Compliance has b 'ss d by th o d the _. (1' Da e ApplicationApproved By------------ -•--•---- ------------•--...--•----------•••--......-------•-•--•--••------------- ••--•----- 6��5 84........... Date Application Disapproved for e f l wing reasons-----------------------------•--•------------------------------------------------•---------------...----..------ ...................................................... ...............•-•----...--•--------•-----................................................................... / Date Permit No.-:8'- ............ Issued 61_P51 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------- -----------Tno ...........OF.......Ram.s'IAt?le.....-.------------.....-•----.................._....... Appliratiun for 11ispuuttl Works Tonstrurtiun rrmit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: ....._.4 d.soma xBLin.-Stneat_,..ILe.nLercille_,_.:ZA JQ263?. Location-Address or Lot No. ....... ....................................................... �3 Q ctuth__l�'n i n. tx�eet_,_..Cprxte? r�.1a e �'='- -•--0263 2 Owner Address a A& •_ccssoo]--se `ica i? lQs..T ?:: . e.¢..N�ra�an�. dA._..0?�0� .... ` Installer Address Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons__..___.�_.........._.___. Showers ( ) — Cafeteria ( ) 04 Other fixtures ................................ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width.................Diameter................. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fsl Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ------------------------------------- •-------------- . 0 Description of Soil-•••-•---15s'3�151------------------------•-•-----------.......-----------••----------•------------•-------------•-----------------------------------....------------ x U -----•--•----•----•--•-•-------••-••------•••--•.....•-----•--------•------•---•••---------•--•---•-•--••-------••••---•----••••----•••------•--•-•-•---•-----------•------•--••----•-•------•---••---•- W UNature of Repairs or Alterations—Answer when applicable....1-n 1rat on-_af_-a__1•,.Q00--- an.Qn..ptgayy_.duty stork. packed__leach..plt-• �overflo?^1�.�.. -------------.................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned her agrees not to place the system in operation until a Certificate of Compliance haAbDe/n is d by th lth.Signe L /l . • CGS-�...�/ �.......... ApplicationApproved By............................................................................... `<; 6 !........_..• Date wry Application Disapproved for the following reasons----------------------------------------- ------------------------------------------....................... --------------------•-----.........-•-•--••------------------------------------------•-••----•-•---••-- Date Permit No. ..................................•--••-------_.... Issued_....... . c.. Date r �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... .own.........OF.......Barnstable.............................................•••••• (9rrtifiratr of Tontp iunrr TINS I TO CERTIFY Thai the Individual Sewage Dis osal System constr t d ( ) or Repaired (X ) A 9 B Yespool Service, 128 Bishops Terrace, lPiyanni'ss, 1,14 02�0� by.................................................................................................. ........... 436 South. Main Street, Centerville, Vista"f1T2632 - Richard Carroll at _..------•------•-•-••----•••••.........---•---•--------•--•----•--••-------•---•--•---•-••-••---------•-•--•---•••----------------•--•---••------ has been installed in accordance with the provisions of T�,�MI / ��??f The State Sanitary �y3e ,tlescribed in the application for Disposal Works Construction Permit No......................................... dated....____.-(_.-__.__ ..__.._..................... '_1' THE ISSUANCE. OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.----...!/Ml.&---------•...................................................... Inspector..................--------........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 84_ ..............Town.................OF.......Barnstable .........•••....._..----•-•••--•.............................. $ 15.00 No......................... FEE........................ Dislinsal Workii Tunstrnrtiun rrmit Permission is hereby granted........A _3: R Cesspool Service . --•--.-•----•-••-•--••••••-----•-•-.....---•-••••-••-•---•-••--....-••--•••...............•-•••-•---- to Co t uct (( ll or; ep�air ( ) an In ivid 1 Sew a D's System 459 5 a�t1S i�la S t-et, Cen ery le, A — Rie haxd Carroll at No.•-•----•'•---------•••••----•.....--•---•-•-••---•---•-•••---•................•--------•--•••--....... Street as shown on the p 1 tion for Disposal Works Construction Perm' . ....................• Dated.6�05��'4 Board of Health DATE. ..... a FORM 1255 A. M. SULKIN, INC., BOSTON , 2000 GALLON TANK H2O DISTRIBUTION BOX LEACHING FIELD 26.5' X 45' CROSS SECTION LOCUS PLAN NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE 99.12 MIN 2% SLOPE--- 95.35 f COVERS TO BE WITHIN 6"OF GRADE 4•SCH.4o P.V.C. 3'MINIMUM ^ MIN.9 COVERT 4°CAP GVI BEACH RD " 2" 1/8" 1/2" WASHED TONE , � \ 4"SCH.40 P.V.0 S .S' - 2MIN r 3 S=0.01MIN. ,�., - oIMIN. 2" 1/8" 1/2" W 94.6 5. 7 13" ,t WASHED" 95.05 n. 95.3 94 98 910 \ 4.0' 94.81 94.5 rt r. \/ / 3 4 -1-1•/2 I3003LYE-WASIiEb TONE' 1 . 10.0 \\ \ 3i4 iz.Iiovai2,51IEDSTorr \ MIN % / 93.6 40.0' 3.25' S' t 3.25' 11' 45.0' ALII UNDWATER 88.3' 26.5' SITE SPECIFIC NOTES DESIGN CALCULATIONS GENERAL NOTES INTERNAL PLUMBING CHANGES AM REQUIRED FLOOR PLAN PIPING TO BE SCHEDUI 40 . PIPING GOING TO SIDE SYSTEM TO BE REDIRECTED TO REAR ALL NOT TO SCALE EXISTING BEDROOMS 8 ALL LOCATIONS OF UTILITIES SHOWN ARE AS _. INTERNAL PLUMBING CHANGES TO BE MADE BY PLUMBER C PROPOSED BEDROOMS @ 130 G.P.D.= 88o G.P.D. MARKED BY DIG-SAFE AND ARE TO BE VERIFIED 4 MIL VINYL BARRIER TO BE INSTALLED AS SHOWN e p SECOND FLOOR BY INSTALLER PRIOR TO CONSTRUCTION. FINAL ELEVATIONS TO BE AS SHOWN MA 207 PARCEL 6 FIRST FLOOR ��STHEO�OWN WETLANDS WITHIN � SAS DIMENSIONS Ioo'OF THE PROPOSED LEACHING FACILITY WIDTH 26.5' THERE ARE NO KNOWN POTABLE WELLS WITHIN CAST IRON COVERS AT GRADE WOULD BE REQUIRED 0•Q ACRES C D L'RE S C BATH BATH 45' 100'OF THE PROPOSED LEACHING FACILITY. ON SEPTIC TANK IF PARKING AREA WILL BE PAVED Q BATH IRRIGATION BOTTOM AREA 1192.5 SF T o'OF THE PROPOSED LEACHING A LITY. H { DESIGNER MUST BE CALLED 24 HOURS PRIOR TO GUEST TOTAL SQUARE FEET 1192.5 SF THIS PROPERTY DOES NOT FALL WITHIN A BEGINNING OF JOB TO COORDINATE INSPECTIONS DINING GUEST GUEST, AREA ROOM ROOM ROOM ZONE I I OF A WELLHEAD PROTECTION AREA CAPACITY BOTTOM @ 0.74 882.45 G.P.D. THIS PROPERTY DOES NOT FALL WITHIN A CAPACITY TOTAL 882.45 G.P.D. FLOOD ZONE AS SHOWN ON FIRM MAP CARRIAGE HOUSE THIS DESIGN DOES NOT REQUIRE VARIANCES OWNER'S TO TITLE 5(310 C.M.R.15.00)OR BARNSTABLE LIVING ROOM SUPPLEMENTAL REGULATIONS. THIS SEPTIC SYSTEM IS NOT DESIGNED ALL CONSTRUCTION SHALL BE IN ACCORDANCE BEDROOM TO ACCOMODATE A GARBAGE DISPOSAL WITH I=5 AND BARNSTABLE SUPPLEMENTAL REGULATIONS. IN-LINE ELEVATIONS PROPOSED AS-BUILT SURVEY INFORMATION LAUNDRY BATH INV.@ HSE 95.67 PROPERTY LINE DATA TAKEN FROM TERRY A WARNER SURVEYING 6/17/o5 INV INTO TANK 95.3 INV OUT OF TANK 95.05 5' REMOVAL TO C2 AROUND SAS INV O 8 PLAN TO BE USED FOR INSTALLATION 45' X 26.5' FIELD KITCHEN INV OUT OFD-OX g48 OF SEPTIC SYSTEM ONLY 4 MIL VINYL BARRIER TO BE INSTALLED AS SHOWN CESSPOOLS TO BE �'INTO FIELD 94.77 BATH BATH NOT TO BE USED TO DETERMINE PROPERTY LINES PUMPED AND FILLED I - BOTTOM OF STONE 93.37 BENCH MARK- BATH SEPARATION PROVIDED 5.0 Benchmark set GUEST GUEST on Sono tube ROOM ROOM BOTTOM OF OBS HOLE 85.12 EL=98,83 (Assumed) SUN DINING GUEST - APPROXIMATE PROPERTY LINE ROOM ROOM ROOM DATFl OBSERVED BY: WITNESSED BY: SOIL LOGS JUNE 7/05 LISA C.LYONS UNWITNESSED GUEST BATH GUEST SOIL EVALUATOR FORM ATTACHED -_--=-- - ~\ Room PARLOR OB S. HOLE #1 OB S. HOLE #2 ELEV. DEPTH ELEV. DEPTH ~.tnwnd �3.73 ", lkt �6� ,_` 95.7 A LOAMY SAND Off96.2 A LOAMY SAND 0"of SEPTIC/MCTCOV-GD ' w 10YR 3/4 e lOYR 3/3 94.8 LOAMY SAND 0 95.87 LOAMY SAND 4'# B l OYR 4/6 22" B 10YR 516 t ---93.5 C1 MS/LOAMY SAND 94.6 MS/LOAMY SAND , �-.--- ., 93.$7 r 19 t 1` 96,80 99. 1 2.5Y 5/4 2.5Y 5/6 SEPTIC/COV 5 loam sand is fine 77tt Cl 11 �,. --- �-^ loam sand is firm 59 0 95,35 93,20 J ®" _, 1 102. vl 89.3 C2 91.3 C2 70" MED/COARSE SAND I 1,81N7 r,IN ,,-r` o a ---1---- 2.5Y 6/6 MED/COARSE SAND 82" F r :` 9S' 1p 2.5Y 6/6 � 95.3 �� 1FT-CHERRY ter__ a� �� 101,8;3 87.9 ADJ. GROUNDWATER 94" 87.6 f S ADJ.GROUNDWATER 104" !f 2.98 }� 85.7 120" 85.2 GROUNDWATER AT 112" 2n 4 Shed µ ti ® 093.00 f 1 „^a � ' / UP/39/165 GROUNDWATER AT1o2" c CHERRY ' f Deck � � � rr,,,. /�-r _. L TOF=102.51 MIW-29 ZONEA ADJ 0.7 95.3 94,63 n MIW-29 ZONEA ADJ 0.7 1 �I••.") o,` _ _.. --- -- ,_._,_(LIB cAssunea) 4 1 �'' I 1/ \ .,.___.__ � • 100.00 OB S HOLE # PFRC RATE<2 MINS./INCH 96:05 ��' f T #436 �,. PK/SET iN _s - d � I ELEV. 3DEPTH 2FT-OAK ---_. 4 94 Ott Deck _,- Deck A LOAMY SAND 1 OYR 4/4 96. TOF=99,12 1 + 93.1 tt 0 9,�,19 (Assumed) ; 1 9/14/05 WITNESSED ' LOAMY SAND s000� 0 ver CRAWL ® f'; F B 10YR5/6 BY DON DESMARAIS y,, a 39tt 90.75 SIM3 ',+ O SPACE 100" 4 Cl SILT LOAM GROUNDWATER AT go" m - - - _ 1pYR 5/4 " MIW-29 ZONEA ADJ 1.8 N , Stone Parking; i 4 yy O Stone Drive VVYY 88.3 68 n 9�F 6 y SEPT /G a j zrn 88.2 MEDIUM SAND 70 } Fence W 1201' -- '''.PROPERTY APPROXIMATE __ ♦��`ZN OFS`s,,� CESSPOOL T =O: 1, A C• e.�� PLAN SHOWING: BE REMOVED 'Pit. - PROPOSED SEPTIC SYSTEM REPAIR IN BARNSTABLE PIT TO BE PUMPED lr +,,'3� FOR: DRAWN BY: LISAC.LYONS AND FILLED :�MI6• ��Z` DICK&CHARLOTTE DORNICH DESIGNEDS3AC LYONS • Q�ir�` LOCATION: REVISIONS: DESCRIPTION: DATE' LOT#M207 PO436 So. RN ST, ATEENJZ NE 17,2 OS OU1SAC.LYONS, .S. LE WITNESSED PER( TEST 9/30/O it SCALE 1:30 �6 I CERTIFY THAT THIS PLAN CONFORMS TO LISA C. LYONS, R.S. (774)4$7-1638 I=5 AND BARNSTABLE B.O.H.REGULATIONS (EXCLUDING WAIVERS SPECIFIED) HYANIVIS, MASSACHUSETTS (508) 790-9270