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0151 WARWICK WAY - Health
151 Warwick Way Centerville A= 148 — 114 ` I I I I I PERMIT NO: TOWN OF BARNSTABLE ISSUE DAT 903R January 1, 201 PERMI T 11.WEEP ENT �,�� r;:: ; I In accordae itheio e r`i of Chapter 94, Section 395A a Se n ff the Gen ,a it is hereby granted to: JULIE E. BEARSE HAYDEN - � SBA Nr to:< . Whose place of business iy 'WAR x VILLE M2P3 Type of business and any1re6r4,cti4ns: "' HEN EST/'BWSH ANT To operate a food establirTet itthe `� `115'C BLEx RESTRICTIONS IF ANY: y :r ., & ; (� .. v t`a,.5' fB, ,11,J y s ML SEATING: 0 ANNUAL: I r v=— ti e SEASONAL: TEMPORARVOlt � t� _ D OF HEALTH RETAIL FOOD STORE: :fh_ J w FOOD SERVICE ESTABLISHMENT: yne Miller, M.D., Chairperson '`� � '� x, r..�.-�.. �. _ Q- RESIDENTIAL KITCHEN FOR RETAIL SALE: 7 . 4 Paul J.Canniff, D.M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST '�^� '.,e.� Junichi Sawayanaqi MOBILE FOOD UNIT: TOBACCO SALES: December 31 , 2016 FROZEN DESSERT: Thomas A. McKean, RS, CiHO CATERER: Director of Public Health Town of Barnstable 114E 1p Regulatory Services Barnstable o; Richard V. Scali, Interim Director 1AM-Ameiira City MUMS ABLE, ' I lY >� r 1639• Public Health Division 2007 �� A'fO�A°�p 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: I 3 NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT:_ t"01Z4C�j� MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: f] L(S) I.. (w 1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: - NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: TYPICAL HOURS OF OPERATION MON-FRI: TO 4— DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) _4, ))nj& 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 po RETAIL FOOD BED & BREAKFAST ,y 3 CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) ***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: FULL NAME OF APP ICANT �/r' SOLE OWNER: ESVN SOCIAL SEC RITY O. ADDRESS / L�7,� PHONE # - 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. SERVSAFE) EFFECTIVE JANUARY 1, 2004, AND ALLERGEN AWARENESS TRAINED STAFF EFFECTIVE OCTOBER 1, 2010. EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS (i.e. ServSafe) AND ONE ALLERGEN AWARENESS TRAINED STAFF MEMBER. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES"* 1. W EXPIRATION DATE: / I p/ 2. EXPIRATION DATE: / / 3. EXPIRATION DATE: / / 4. EXPIRATIO DATE: SIGNATURE OF#PLICANT AND DATE Q\Health\Application Forms\Foodappl.doc Town of Barnstable Regulatory Services BARN3CABLE ' Richard V. Scali, Interim Directoi y NAM 039. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Fax: 508-790-6304 November 14,2013 JULIE E. BEARSE HAYDEN JULIE's BAKERY 151 WARWICK WAY CENTERVILLE MA 02632 ATTENTION Your food service/retail permit(s)will be invalid after December 31,2013. ESTABLISHMENTS FEE Food Service. . . . . . . . . . . . . . . . . . . . Retail. . . . . . . . . . . . . . . . . . . . . . . . . . FrozenDessert . . . . . . . . . . . . . . . . . . Mobile Food . . . . . . . . . . . . . . . . . . . . . Residential Kitchens . . . . . . . . . . . . . 75.00 Bed & Breakfast. . . . . . . . . . . . . . . . . Tobacco . . . . . . . . . . . . . . . . . . . . . . . . TOTAL DUE $75.00 Food establishment inspections are ongoing by a Health Inspector; therefore,it is n necessary to make an appointment with the Health Division. However,if yo establishment is not open during normal working hours (8:30—4:30p.m.), please call 508-862-4644 during these hours to schedule an inspection. Enclosed is a food permit application form. Please complete and sign the form,and mail it along with the required payment on or before December 18,2013 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 twocurreot Se.rvSafe Certificates.,.you will be sent,via mail,the food/retail permit(s) for calendar year 2014. Important If you are on a Private Well for Drinking Water(not Public Water Service), be sure to have your well test completed prior to our inspection. Reminder to All: 1) Maintain your logs. 2)Establishments with 25+seats are required to have a person trained in anti-choking procedures on premise while food is being served and to have insurance covering person with training. Failure to renew permit on or before January 1,2014,will result in an additional fee of $10.00 late charge. If you should have any questions, please call 508-862-4644. Q:dbftles/inspectn.mdb reports Rest Total Fees Annual letter : k , designation has been confe&4upon :4 JULIE HAYD ivho has met affthe'professionaCrequi..rements for certification ;. mierFaoc�S,a f et in Pre food service safety and sanitation _ www.PremierFoodSafety.com (800)676.3121 exam 8421 Recognized By Conference For-Food Protection Certificate Non 1608551 r^ 118/10 P n Exam;Date 06 ?C , :. Test Code. 62030384 21 i" Ni kl ' She erd E tchel,Vice President,Test Development ..; Certificate expires no later than: 06118/15 •1 •• \ +.'ti{'.'.ifr`.,}i.;!..i `1j:�:.i.::\•f:,'i•.i•:W':: RMIT NO: TOWN OF BARNSTABLE BOARD OF HEALTH 903 PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance.with rogulat<©ns pro 149—d under authdrrty of Chapter 94, Section 395A and Chapter a i'1,Sectrnri 5 of th9. e General Lavy ,a permit is hereby granted to: JULIE E. BEARSE HAY.D I�% ;' JULIE'S BAKERY DIB hose place of business Is t511 ►RRV1►ICK CENTEE �f1i.4E MAll 0263 ype of business and any res ri i0fi!EV . ROtIDENT-A KI C K ESTA6t4 4MONt 0 operate a food establishmerft ICT he TOWW O 0AR� ABLE RESTRICTIONS IF ANY: SEATING: 0 ANNUAL: Y SEASONAL: TEMPORARY x 60ARD"Qf HEALTH r FEE-S 1 s RETAIL FOOD STORE: Itgiller, M.D., Chairperson r, Paul J Canniff, D.M.D. FOOD SERVICE ESTABLISHMENT: RESIDENTIAL KITCHEN FOR RETAIL SALE: 9"75 oR : - UP IC hi Sawayanagi RESIDENTIAL KITCHEN FOR BED+BREAKFAST: er1311t EXQIfQS MOBILE FOOD UNIT: >r � TOBACCO SALES: ©ece 2013 Thomas A. McKean, IRS, CHO FROZEN DESSERT: Director of Public Health CATERER: r" r J Town of Barnstable 44 y� oFz"E lti� Regulatory Services Barnstable P� Thomas F. Geiler, Director aa-nmericacity Public Health Division 2007 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: �_- I �' k NAME OF FOOD ESTABLISHMENT: OM Q..S 1 — ADDRESS OF FOOD ESTABLISHMENT: tst wkpw,, MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: PARCEL(S) TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( �_- 11 ►j NUMBER OF SEATS: INSIDE: O OUTSIDE: TOTAL: TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: hy� TYPICAL HOURS OF OPERATION MON-FRI: �I O Q ' TO O DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) i 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 '' ` n FOOD SERVICE RETAIL FOOD BED & BREAKFAST CONTINENTAL BREAKFAST r w RESIDENTIAL KITCHEN U +� MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) oop i ddzpoo j\suuo3 uoijzogddV\LpjwH\a d.LVQ(INV 1,IVDI'Iddv AO a2If1Zdu0IS :d,LVQ NIOIIV21IdXa T r . :211.VQ NOLLVdldX2f '£ :d.LVQ NOIZVHIdXa 'Z :a.LVQ NOI.LVdijxa 'T �=��Sd,LVOI3IZ2ldO aH.l, 3O HOVd NO .LNaWHSI'IUVJSd alll d0 aWVN dHs, lfld :ISVdrld****NOLLVH:IJO d0 SNflOH rIrIV ON111f1Q aJ ISNO (laUlfl all Si ddV LS QdIA111121D NOI.I.VJ INVS QOOd :INN .LSVdrl ZV 2iHUNHN ddV,LS WINIV111 SSdNd21VAAV NHOUHrI'IV 2WO (INV (a3rSluaS 'a't) S21a9VNVw NOI LOdZ021d QOOd Q5IIdIJLH:lD OMJL ZSVdrl .LV 5HAVH O.L aaalfloall SI JLKa IHSIrlaVZS:l dOLAU:lS QOOd HOVd '010Z `T 2I2[gO,LOO dALLOdddd ddV,LS (IU IIV-dL SSaNaUVMV N:j021drI'IV (INV `t�OOZ `T'A-dVflj,�Vf dAI.LDdddd (ddVSA21dS 'd'I) 33V,LS Qdldll-draD NOI,LV,LINVS QOOd Uf OA d0 SaWVN aHs, ZSIrI :(,LSV.Ixvauu rIVJLN'A tIJLNIOO (INV 000d "Vdd21d ,LON OQ ZVH,L S.LI UlkHSI'IffV,LSd (IOOd rIIV.Ld2I Shclfl'IDxa) NOIZV21Vdd21d Q003 ORI LOfI(IROO S.LRawliSI'IffVZSd dOIAllas 0003 NOI,LV210d210OAII d0 :4 LVZS 'ON NOLLVOI3IZAI21QI rIV2ldQdd :NOLLVHOd210O V SI JLNVOI'IddV Al S,HHN L?IVd rIrIV d0 SSJ HQOV db1IOH (INV JWVN rlrlfld `dIHS2laNJL21Vd V SI .LNVOI'IddV'dI - —) # aNOHd SS"(I(IV 'ON 1 lluflOdS rIVIOOS ON/SaA :212IMMO arIOS .LNVDIr1ddV d0 HNVN l Ifld :NOI LVMOANI ZOV,LNOD L(S)2I000 dOIAHUS ddV,LSZIVM ZV QdQ1AOHJ NIV,L21fIO HIV NV SI ZDNINI(I 3QIS,LfIO 2IOd QdQIAONd ddVZS IIVM Si VIHd.LIHD OAIINIQ aQISs.flO fills d0 rIrIV 1:42I i (INV ONISN2DI'I (INV Hl IVdH d0 CIHVOEI :4H,L Aff Q:IA02lddV :lg,LSflW flO ONINIQ dQISJLflO Al PERMIT NO: TOWN OF BARNSTABLE July 10, 2010 903 BOARD OF HEALTH PERMIT TO OPERATE A"FO`O `ESTABLISHMENT In accordance with re ulati. n romulj' edfiw aer-authority of Chapter 94, Section 395A and Chalter 113eetion of t13e Ger is hereby granted to: JULIE E`. BEARSE HAY�DN Jt1LIE SBAKERY Whose place of business Is 151,VYA2 WIC K�111f�AY, 5EN71±RVI,�LE MA," Q632 ; f ' ': qg t g � Type of business and any retrctl0ns R'kSIDENTIALKICHEN ESTABLISfMENT. To operate a food establishment in the TOWN OF ARNSkT BLE RESTRICTIONS IF ANY: 5 � � 71 SEATING: 0 ANNUAL Y " " Jk ` SEASONAL: TEMPORARY, '- pf y ES BOAR D OF.HEALTH RETAIL FOOD STORE: r 'FOOD SERVICE ESTABLISHMENT: a& � P aynelVliller, M.D., Chairperson RESIDENTIAL KITCHEN FOR RETAIL SALE: 750Qw r, UIiJ Caflnlff, D.M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST _ Juriichi Saw.avanaw MOBILE FOOD UNIT: TOBACCO SALES: December 1 "2010e-'. FROZEN DESSERT: "v .., ,�, „�✓ Thomas A. McKean, RS, CHO CATERER: Director of Public Health I Town of Barnstable Regulatory Services Thomas F. Geiler,Director + SAANSTABM s' � T b a�gr Public Health Division 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 NAME OF FOOD ESTABLISHMENT: Q I[! ADDRESS OF FOOD ESTABLISHMENT: ( \4ZC&'puptLK MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP. PARCEL(S) 1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: 11 _ TYPICAL HOURS OF OPERATION MON-FRI: P DA TO I : O DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) Son"o- IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING UJI 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 Q:\I-IealthWpplication FormsToodappl.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 DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: ( FULL NAME OF APPLICANT SOLE OWNER(�YES)N ADDRESS p J PHONE# 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*** 1. �V\� EXPIRATION DATE: 6 / `Q b 2. EXPIRATION DATE: -/ / 3. EXPIRATION DATE: 4. EXPIRATION DATE: / / SIGNATURE OF APPLICANT AND DATE QAHealth\Application FormsToodappLdoc MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include copies of your employees food sanitation training certificates (at least two are required effective January 1, 2004). 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 sanitation training certificates (at least two are required effective January 1, 2004). 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 = $45; Food Service Permit 0-49 seats = $200, 50 or more seats $250; 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; Frozen Dessert License $30; Tobacco Sales Permit=$50, Additional non-refundable Fee for New Establishment or New Ownership = $100,Late Fee.=$10.00 Back to Main Public Health Division Page ME E 0 WIN 44 2-2Z At- .-A r -es' s _ MOM dd 420- 1- PER- — {y fO r.. .. . . r" — _ - D z� - �.r- r� - 1 o cfesignatton has been conferred upon - - -_- - - - = = _-_ - - - _ = -AN ~ = = - E D : z - :_x J MR RIF` A, lis: 0- OR 0 . - — - v wFio bias met aCCthe professarsnaCrequreinents for cei tctioo I n = Prem erFood *ty zn fo©cfseruice safety ancCsaraitation f 01 t F .25 (84t6°3 I _ _ _ Exam 8 1 12 og ed y co enc or-- oa rotecl n n - - lf erbfica N€� �camJ3a� 06/18 '1t� f i' E tc Veer s Depnt _ opt ode' '6203042St Ce ;.cafe expires no Eater than Oti/1813 :rx. r• r {.r ' r•,r_ '` r �4 r {i\{;;s{::•:•:'v+:''`•?;ry'::;:':":�:r'•.:;;?k>>:>}:: ti A. �: +�". •,: - i G..\,. .: 4..':: ...: ..'.•:rr:..f.: {': -v;:+{ :r'rf. ..::-f:: 't,h:.`v .•r:': +✓L '+.+ ---------------- ------- 1 Congratulations You have passed the National Prometric Certified Professional Food Manager examination. Score Report Your name has been added to the National database of Food Managers. Congratulations!You passed the Certified Professional Food Manager examination. Your Score is as follows: Score Status Exam Date 95 06118/2010 PASS ----------------------------------------- This is to cerdff that JU WNW &Ott the nnsary requ r-enaedts r Food Manager Certification: t JULIE HAYDEN -_ - _ == JULIE'S BAKERY Exaff l RecogA-rcetl By%pference r Food ct3ectwn # 1#]tI'12110ff Jxdllate. 1 /1 151 WARWICK WAY CENTERVILLE, MA 02632 Prometric 800.624.2736 ------------------------------ -------- Prometric Inc. E 1260 Energy Lane St-Pan]MN 5510R R00.624.2736 :j Foo-I &A sad Por()p V sl.t 17:� i2 fCl€r pica. lt(�L'"U con l"I�e 11.p- 0-11 JULIE HAYDEN o t . €'�to h_Ea T7E'1 -Zfi tJ`e,urt .4slo1 a� 1'E�J1�7E"1Jt 7ItS�J1?I 1(tG_�ZC(lf C+;'1. 1 z 8 AcF,A€A�+YF• M.S� / EKE .=Y t 1L. �. E Ldcis(1"9L Sa Cty( 1 ..anal - - WFlvrernie, a "Safty cart � }arc 311. Exam 8421 Recognized By Conference For Food Protection r ; Certificate No 1608551 '' .. = Exam Date: 66118/10.' .ila I� 3�c # - t tic�1 �c .ire jd n=4:`i sf D t�Ipi—,0tiE. Test Code: 620303$421 mY Certificate expires no later than: 06/18/15 PERMIT NO: TOWN OF BARNSTABLE 01/23/2008 881 BOARD OF HEALTH PERMIT TO OPERAT-ElA FO'GWESTABLISHMENT OW, �� In.accordance withegulat9 sp�rornulgated underuthviity of Chapter 94., Section 395A and Chap#eISc'tlon�5fh Geieral� �vs;a permit is hereby granted to: JULIE E.BEARSE HA ,� � l�l _ �II;S BAKERY Whose place of business is: j 1 lt RWICF �CEIV FZVf .LE M 4.Q2632 Type of business and any re tcct�s F D EYlETABLISHMEf�T x M AW 1717 � FF� To operate a food establishmet,tin t e TOVI , A�tST LE RESTRICTIONS IF ANY: zr 3 TAIPM &, 1 SEATING: 0 ,' p ANNUAL: l E SEASONAL: TEMPORARI • . x E s /,831 VF HEALTH RETAIL FOOD STORE: �� Chairperson FOOD SERVICE ESTABLISHMENT: , .R: ' C fle:Miller,M.D., Paul d. CanniffRESIDENTIAL KITCHEN FOR RETAIL SALE: .$T5063sz D.M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST: "Junichi Sawayanagi MOBILE FOOD UNIT: � rrnit 14lrs TOBACCO SALES: 21112i3Q8 FROZEN DESSERT: Thomas A. McKean, RS, CHO CATERER: Director of Public Health I� in, 18, 2008 1 : 2'2PM JD Dadda6o 1" )'6 P, 1 TO: DAVII) STANTON TOWN OF BARNSTABLF PUBLIC HEALTH DIVISION FAX 508-790--6304 FROM: JULIE HAYDEN 151 WARWICK WAY CENTERVIs T,E. MA 02632 508-428-1155 MENU FlIL3R JULIE'S BAKERY CAKES AND CUPCAKES FONDANT, I3UTTERCREAM (MADE WAIF' :J. SHORTENING), ROYA _, '.(:L 4 v BREADS, YEAST & (QUICK COFFEE CAKES SCONES, MUFFINS COOKIES BARS ;BROWNIES CANDY FRUIT PIES 01/ b/2008 07:47 FAX — l�001 ObC .............. . ... .... . ..... . ..... ..... ....... , C { ..................... ......... �l I l ...... . ....... .............. .... . .... ...... Fondant From Wikipedia, the free encyclopedia Fondant is a confection used as a filling or coating for cakes, pastries, and candies or sweets. In its simplest form, it is sugar and water cooked to a point, specifically theF soft-ball stage, cooled slightly, and stirred or beaten until it is an opaque mass of �<< creamy consistency. Fondant is commonly used to decorate wedding cakes. This gives the cakes a smooth appearance. Contents f Birthday cake with hard white ■ fondant icing used as trim, 1 How it is used ■ 2 Additives 1 framing its soft,colored butter i cream frosting ■ 3 Chemistry ; _ ... _ .. ...__. ■ 4 Similar confections ■ 5 See also How it is used The finished product solidifies and may be stored until needed, at which point it is -" reheated. As a liquid it may be poured into molds, or over cakes and pastries as a form of icing. The word fondant comes from the French fondre and Latin fundere, meaning w � to melt". It literally translates as melting or melty in current French. ti In its softer state, fondant may be rolled or molded. It is often used as a filling for chocolates and a topping for elaborate cakes. Fondant can also be used to smooth the sides of cakes, making them easier to decorate and more professional-looking. Fondant may be used as a substitute for chocolate in coatings for candies, either as A fondant-covered cake mock white chocolate, or with cocoa added to the fondant, as a chocolate-like depicting a sewing kit. covering. _.. .................................___ _... _......... _ Typically, glucose is added to prevent the syrup from graining while cooking. Corn syrup is the most common form of glucose used in North America. In the rest of the world glucose sugar is used exclusively. Cherries or other fruits preserved in liqueurs or syrups can be dipped in liquid fondant laced with the enzyme invertase, which is then allowed to solidify. When the fruits are subsequently dipped in chocolate to form a hard outer shell, the fondant liquefies again inside the chocolate after the enzyme has had time to change the fondant into a syrup. This creates a candy with a hard chocolate shell and a syrupy, fruit-filled center. Additives Some fondant adds hydrogenated vegetable oils to the recipe to give the fondant a creamier texture and longer shelf life. Chemistry Fondant is formed by supersaturating sucrose in water. Less sugar will dissolve in water with a cooler temperature. Then, after the sucrose is dissolved, the solution is left to cool and the sugar will remain dissolved in the supersaturated solution until nucleation occurs. I -1'L, while the solution is supersaturated, a seed crystal (undissolved sucrose) falls into the mix, or the solution is agitated the dissolved sucrose will crystallize to form large, crunchy crystals. ■ If,however, the solution is allowed to cool and then stirred furiously, violently mixing the entire mixture, it will form many tiny crystals and result in a smooth texture. Similar confections Fondant can be confused with sugar paste which is similar but contains arabic gum. See also ■ Inverted sugar Retrieved from "http://en.wikipedia.org/wiki/Fondant" Categories: Articles lacking sources from December 2007 1 All articles lacking sources I All articles with unsourced statements I Articles with unsourced statements since December 2007 1 Confectionery I French words and phrases ■ This page was last modified 23:19, 28 December 2007. ■ All text is available under the terms of the GNU Free Documentation License. (See Copyrights for details.) Wikipedia® is a registered trademark of the Wikimedia Foundation, Inc., a U.S. registered 501(c)(3) tax-deductible nonprofit charity. Town of Barnstable v/ S Regulatory Services ` Thomas F.Geiler,Director BAR Public Health Division . 039•a� Thomas McKean,Director I 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: 6 NAME OF FOOD ESTABLISHMENT: - ADDRESS OF FOOD ESTABLISHMENT: k1( 'r,��., MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: /V'KPARCEL(S) TELEPHONE NUMBER OF FOOD ESTABLISHMENT: U�f a4`- ►5� NUMBER OF SEATS: INSIDE: (. OUTSIDE: d TOTAL: 0 TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: f)j(- TYPICAL HOURS OF OPERATION MON-FRI: : C�®�6*0 C)C 7 M DAYS CLOSED EXCLUDING HOLIDAYS(I.E.MONDAYS) £: IF SEASONAL: APPROXIMATE DATES OF OPERATION: ***REMINDER*** " r =J SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO QP' NING= ca r co rn TYPE OF ESTABLISHMENT. PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD BED&BREAKFAST CONTINENTAL BREAKFAST_ tESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING I - - J a 1 OUTSIDE DINING Q:\Health\Application Form s\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 DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: _ FULL NAME OF APPLICANT I - � SOLE OWNER/NO SOCW SECURITY NO. CAI b 1� ADDRESS (� t 0 1 (! a PHONE# 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* I. u- f OW Y e EXPIRATION DATE:/ 1 -7/ aDaq 2. EXPIRATION DATE: / / 3. EXPIRATION DATE: / / 4. EXPIRATION DATE: / / T SIGNATURE OF APPLICANT AND DATE Q:\11calthUppli6ation Form sToodappl.doc MAIL-IN REQUESTS Please mail Ithe completed application form to the address below. Also include copies of your employees food sanitation training certificates (at least two are required effective January 1, 2004). 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 sanitation training certificates (at least two are required effective January 1, 2004). 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 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 = $45; Food Service Permit 0-49 seats = $200, 50 or more seats $250; 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; Frozen Dessert License$30; Tobacco Sales Permit=$50, Additional non-refundable Fee for New Establishment or New Ownership= $100,Late Fee.=$1.0.00 Back to Main Public Health Division Page FEE: V, rD Name of Est blis went: Address: I�) � WQ�i.1 �►I�Y ��� " "'.� Owner: I RESIDENTIAL KITCHENS FOR RETAIL SALE APPROVED NOT APPROVED Plans -Received and Approved Water Supply-Approved Source Sewage Upgraded or Town Sewer Grease Trap (At the discretion of the B.O.H.) Thermometers (in Refrigerator&Freezer) Dishwasher with a maximum registering thermometer(final rinse at least 150 degrees F) Kitchen Sink Facilities A) Sufficient Area B) Soap Dispenser C) Disposable Towels Bathroom A) Sufficient Area B) Soap Dispenser C)Disposable Towels Floors,Walls, Ceilings Lighting Sufficient Refuse Containers (Sufficient Number Durable, Easily Cleanable Insect and Rodent Resistant) Pets kept out of food preparation areas Launder Facilities, if located in kitchen, shall not be used during food preparation. Poisonous or Toxic Materials (labeled, stand properly) *Notice:-Only immediate family members residing in the household may prepare food for retail sale in a residential kitchen. *Notice: Only non-potentially hazardous foods shall be prepared in a residential kitchen for retail sale per Section 590.028 (B). (See definition of Potentially Hazardous Food within Article X Section 105 CMR 590.001) residkit/wp/q .ServSa TM EXAMINATION FORM NO : 4208 CERTIFICATION NO : 4117412 Norm ServSafeo Cerrincati'mon TO , JULIE E`:HAYDEN for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafe® Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). Presented by the National Restaurant Association Educational Foundation 11/17/2004 DATE OF EXAMINATION 11/17/2009 DATE OF EXPIRATION Local laws apply. Check with your local regulatory agency for recertification requirements. • •�.�• Mary M.Adolf President and Chief Operating Officer National Restaurant Association Educational Foundation ACCREDITED PROGRAM National Restaurant Association American National Standards Institute and the Conference for Food ProtectionEDUCATIONAL FOUNDATION ©2004 National Restaurant Association Educational Foundation www.nraef.org 03102301 v.0410 HEALTH INSPECTOR'S dFTME TOWN OF BARNSTABLE OFFICE HOURS: Establishment Name: Date: ? Page: of� r) PUBLIC HEALTH DIVISION 8:00-9:30 A.M. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item tical It KAM _ MON.-FRI. DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 26J9,',ye' HYANNIS,MA 02601 508-862-4644 No. Reference R-Red Item PLEASE PRINT CLEARLY Date ✓ , `�. Name v�,` / 0 Type of Type of Inspection Operation(s) Routine Address Lj Cl / Risk Food Service Re-inspectionll_ / Level ai Previous Inspection Telephone Residential Kitchen D Pre-operati Owner HACCP Y/N Temporary mess ) 7v .e Person in Charge (PIC) Time Caterer HACCp General Complaint 1 In: Bed&Breakfast Other Inspector v `l W; S 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 Tobacco �+ Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ a' 5� �� `� �Ilk r Action as determined by the Board of Health. r- °FOOD PROTECTIONPROTECTION MANAGEMENT I ❑ 12. Prevention of Contamination from Hands � 'N ❑ 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 115. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/RecordstAccuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time Asa 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 Violations Related to Good Retail Practices (Blue Items) ❑ 22• Posting of Consumer Advisories Critical(C)violations marked must be corrected immediately. Non- Total Number of Critical Violations critical(N)violations must be corrected immediately or (blue&red items) within 90 days as determined by the Board of Health. C N Overall Rating 23.Management and Personnel (FC-2)(590.003) Official Order for Correction: Based on an inspection today, he items Corrective Action Required: No ❑ Yes 24.Food and Food Protection (FC--3)(590.004) checked indicate violations of 105 CMR 590.000/federal Food Code. This report,when signed below by a Board of Health member or its ❑Voluntary Compliance [IEmployee Restriction/Exclusion Re-inspection Scheduled ❑ Emergency Suspension 25.Equipment and Utensils (FC-4)(590.005) agent constitutes an order of the Board of Health. Failure to correct 26.Water,Plumbing and Waste (FC-5)(590.006) violations cited in this report may result in sus-pension or revocation of ❑Embargo ❑ Emergency Closure ❑Voluntary Disposal ❑Other: 27. Physical Facility (FC-6)(590.007) the food establishment permit and ces-sation of food establishment 28. Poisonous or Toxic Materials (FC-7)(590.008) operations. If aggrieved by this order,you have a right to a hearing. A= Zero critical violations and no more than 3 non-critical violations. F= 3 or more critical violations. If no critical violations observed, 29.Special Requirements (590.009) Your request must be in writing and submitted to the Board of Health at 9 or more non-critical violations=F. q the above address within 10 days of receipt of this order. l3= One critical violation and less than Orion-critical violations. 30. Other If no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if no hot water, 31. Dumpster screened from public view DATE OF RE-INSPECTION: C= 2 criti io,ation rid less than 4 non-critical. If no critical violations sewage back-up, infestation of rodents or insects,lack of refrigeration, or Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered. Y N obse ed, 8 critical viol t ns=C. no PIC or alternate PIC present. #Seats Observed Frozen Dessert Machines: Outside Dining Y N Inspector: igna r Print:ID 1 t- , Self Service Grease Trap Size Variance Letter Posted Y N 4 p Vv Waft Service Provided p. PIC's t Print: Dumpster Screen? Y N �✓� ,. _y.J _-.r•�•�-.� `.r si - ...� +�,t.'i '✓ - r . . r• .* • !.'Cf��. 1 �1r•""'"��/ :�.r--':.. .c. �Y:..�- ---- w•-.•.y, j�•t�...-w---"+�. ��--�:� 1Yoladons Related to Foodbome Illness IntervenSons and Risk Factors(Red Items 1-22) 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodbome Illness Interventions and Risk According to Law Cooled to PROTECTION FROM CONTAMINATION Factors(Red Items 1-22) (Cont.) 41°F/451F Within 4 Hours. FOOD PROTECTION MANAGEMENT 8 Cross-contamination PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 1 590.003 A Assi ent of Responsibility* 3-302.11(Axl) Raw Animal Foods Separated from 14 Food or Color Additives 19 PHF Hot and Cold Holding 590.003 B Demonstration of Knowledge* Cooked and RT17 Foods 2-103.1 l 1 Person in charge-duties Contamination from Raw Ingredients 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-302-11(Ax2) Raw Animal Foods Separated from Each 3-302.14 Protection from Unapproved Additives* 590.004(F) 41°/43°F* EMPLOYEE HEALTH Other* 15 Poisonous or Toxic Substances 3-501.16(A) I lot PHFs Maintained at or above Contanrnation from the Environment 7-101.1 1 Identifying Information-Original coal 140°F.* 2 590.003(C) Responsibility of the person m charge to y� g g' require reporting by food employees and 3-302.11 A Food Protection* Containers* 3-501.16(A) Roasts Held at or above 130°F. applicants* 3-302.15 Washing Fruits and Vegetables 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and 7-201.1 1 Separation-Storage* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Utensils* 7-202.1 1 Restriction-Presence and Use* 590.004(11) Variance Requirement Charge* Contamnabon from the Consumer 7-202.12 Conditions of Use* 590.003 G R rtin b Person in Charge* 3-306.14 A B Returned Food and Reservice of Food* 7-203.1 1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 3. 590.003 D Exclusions and Restrictions* I Disposition of Adulterated or Contaminated 7-204.1 1 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 590.00 Removal of Exclusions and Restrictions Food 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.1 I(A) Unpasteurized Pre-packaged Juices and 3-701.11 Discarding or Reconditioning Unsafe 7-204.14 Drying Agents,Criteria* Beverages with Warning Labels* FOOD FROM APPROVED SOURCE Food` 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs* d Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.1 I Restricted Use Pesticides,Criteria* 3-801.1 1(D) Raw or Partially Cooked Animal Food and 590. A-B Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-served. 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-202.13 Shell Eggs* Sanitization Temperatures* CONSUMER ADVISORY * 4-501.114 Chemical Sanitization-temp.,pH 22 3-603.1 1 Consumer Advisory Posted for Consumption of 3-202.14 Eggs and Milk Products,Pasteurized TIME/TEMPERATURE CONTROLS '�' P * concentration and hardness.` Animal Foods That are Raw,Undercooked or 3-202.16 Ice Made From Potable � Water 16 Proper Cooking Temperatures for 5-101.11 Drinking Water from an Approved System* 4-601-11(A) Equipment Food Contact Surfaces and PHFs Not Otherwise Processed to Eliminate * Utensils Clean* 3-401.11 A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*"aI vrn n' 590. A Bottled Water gg- 4-602-11 Cleaning Frequency of Equipment Food- 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 590. Water Meets Standards in 310 CMR 22.0 Eggs-Immediate Service 145°F I Ssec• gg She/frsh and Fish From an Approved Source Contact Surfaces and Utensils* 3-401.1 1(A)(2) Comminuted Fish,Meats&Game 4-702.11 Frequency of Sanitization of Utensils and * SPECIAL REQUIREMENTS 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Animals-I55°F 15 sec. Shellfish* 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 4-703.11 Methods oCSanitization-Hot Water and catering,mobile food,temporary and 3-201.1 S Molluscan Shellfish from NSSP Listed Chemical* 3-401.1 I(A)(2) Ratites,Injected Meats-I55°P 15 sec. P ry Sources* 10 Proper.Adequate Handwashing * residential kitchen operations should be Game and WSd Mushrooms Approved by : 3-401.I I A 3 Poultry, debited under the appropriate sections R u/at A 2-301.11 Clean Condition-Hands and Arms ( )O ry,Wild Game,Stuffed PHI's, 2-301.12 CI Procedure' Stuffing Containing Fish,Meat, above if related to foodborne illness 3-202.18 Shellslock Identification Present Poultry or Ratites-165°F 15 sec.* interventions and risk factors- Other 590. �TReceivinglCondttlon ild Mushrooms* 2-301.14 When to Wash* n 3-201.17ame Anunals* 11 Good Hygienk Practices 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail $ 2 401.11 Ea' or U Tobacco` 145°Fpractices should be debited under#29- 3-202.11HFs Received at Pr Temperatures* 2 401.12 Discharges From the Eyes,Nose and 3-401.12 Raw Animal Foods Cooked in a Special Requirements. 3-202.15 Package Integrity* Mouth` Microwave 165°F 3-101.11 Food Safe and Unadulterated• 3-301.12 Preventing Contamination When T * 3-401.1 1(A)(1)(b) All Other PHFs-145°F 15 sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES )? Prevention of Contarnination from Hands 17 Reheating for Hot Holding (Blue Items 23-30) 6 Tagsstock Ids:Sheastoek g g Critical and non-critical violations,which do not relate to the 3-202.18 Shellstock Identification• 590.004(E) Preventing Contamination from 3-403.I I(A)&(D) PHFs 165°F 15 sec.* Employees* joodborne illness interventions and risk factors listed above,can be 3-203.12 Tags/lock Identification Maintained* 3-403.11(B) Microwave-165°F 2 Minute Standing found in the ollowin sections o the Food Code and 105 CA4R l3 Handwash Facilities I I g I Tags/Records:Fish Products Time* Conveniently Located and Accessible 590.000. 3A02.11 Parasite Destruction` 3-403.1 I(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000 3A02.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 140°F* 23. Management and Personnel FC_-2 .003 590. J Labeling of Ingredients* 5-204.11 Location and Placement* 3-403.1 1(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance Roasts* 25. Equipment and Utensils FC-4 .005 MACCP Plans Supplied with Soap and Hand Drying 18 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 .006 3-502.11 Specialized Processing Methods` Devices 3-501.14(A) Cooling Cooked PIiPs from 140°F to 27. Physical Facility FC-6 .007 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 * 6-301.12 Hand Provision 70°P Within 2 Hours and From 70°F 29. Special Requirements 009 8-103.12 Conformance with Approved Procedures to 41°F/45°F Within 4 Hours. 30. Other 3-501.14(B) Cooling PHFs Made From Ambient sswrc°mwu,.-,.a Temperature Ingredients to 41°F/45°F Within 4 Hours* •Denotes aitiral 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. LOCUTION 5EW&6tE PERMIT VJO. VILLAGE Z L2 1zvvr ( l - - - IMST LLER ME �`6 ADDRESS / BUILDERS Q& ADDRESS DNTE PER"IT ISSUED •— L'I° DATE COMPLI LI KIcE: ISSUED : 4 6 =7 fro°� s �. � � �p�- f € 1 _! �No.•-•1`'3.. ...��.. THE COMMONWEALTH OF MASSACHUSETTS Y-4 BOARD O H EW= ��- �� _ .... .. _.... OF......... ..........:� ... ............................................................. 5� Nv x Appliratiun -fur Uiapviiat 10orkii Tvntrurtiun Prrui t Application is hereb made for a Permit to Construct ( or Repair ( ) an Individual Se age Disposal System at: L a'on-Addre �or Lot No. ---• •• Owner Address Installer AddressLot... v i S feet Q Type of Building Size Lot... I�/G"_��'_'_.... q. U Dwelling—No. of Bedrooms........�...................... .. -Expansion Attic ( ) Garbage Grinder ( ) aq Other—Type of Building ---------------------------- No. of persons.--______---_-----.__-_-__ Showers ( ) — Cafeteria ( ) w Other fixLures ...................................................... w Design Flow........... ..............................gallons per person per day. Total daily flow.___.______ �.._ .._.._._gallons. W Septic Tank—Liquid capaF gallons Length Width lliameter_.. Depth x Disposal Trench—No. ............. ..... Wi -. -_-___ otal Len th_----_ ....... .. Total leaching area....Ssi__�__sq. ft. Seepage Pit No........._.. a o toe ................... Total leaching ttre:t._.._.___-..__.___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) •-' Percolation Test Results Performed by------- ---------------•-•---•--................----....._--••-••--...... Date----.-----------------••-------•-•----- a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water............--.--.-.-... f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.--.-.--_---_----.---. P4 ------------------------- ---------------•--•••---.._...--•-•-•-••-•.............---•••------•-----.-•--•-------••-------................................... 0 Description of Soil: --------- ----- ----- ----------- ----- ------------------------ U ........................ dSh -- _.sera /a-/.�......------------------ .................................................. I! VNature of Repairs or Alterations—Answer when applicable----------------------------------------.-----------------------..--.----.-_---_-..---..--.-... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the boa f health. Sign ................. ---------------- l `C � Date ApplicationApproved By....... ---- ---- '----------•--------••-•--•--•--•-•••-••---•.........••-•-------•--•---•-- ........................................ Date Application Disapproved for the following reasons:-------•------------------------------------------------------------------------------------------------------•- -----------------------------------------------------------------------------------------------------••--•-...-----•------------------ --------------------------------.............------...... Permit No.. / 2 Issued-------- �..:_... --•-•- ---------------------------••--• `" Date No. if( Fes$.. 0... .. THECOMMONWEALTH OF �MASSACHUSETTS BOP'1IZD �/� ,�, �. ...........0 F......... ................................................. ....-............. AVV iratinn -for UhiVnuttl Workii Towitrurtinn Vrrutit Application is hereb made for a Permit to Construct ( or Repair ( ) an Individual Sevxge Disposal System at: La.._•-----------�--Y.•---- ............. ..........••••-• �-� Lot No.or a ---..re s..... ........ W � Owner Address •....................................................•-----_..-_...._.._........ • ......•..... --••-..._......-•---•---_.....___..............•.................- ............- .. _.__.__...... Installer Address U Type of Building Size Lot ...f �..Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other�res --------------------------------------------------------------------------------------------------------------------- W Design Flow----------------------------------------ff_--gallons per person per day. Total daily flow...........44_.�.r__------__---gallons. WSeptic Tcutk—Liquid capa t w_--gallons Length---------------- Width........-------- Diameter--...-.,......-- D pth------.--------. x Disposal Trench—No. ......----- Wi A��,) Ot-,, l en, Total leaching area.....S- ---rsq. ft. Seepage Pit No.........._{C/ l�ia ._. e'fo-inlet.................... Total leaching area-----.- ----------sq. tt. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date------------- ----------------------_-- Test Pit No. 1________________minutes per inch Depth of Test Pit-.------------------ Depth to ground water..------------------_- 1:14 Test Pit No. 2_--------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ -------------------------- •----•--•-----_--------------•-•-•-•--------- --•-•-•--------......---.........................................................Description of Soil--------------- ----- --- V ---------------------------- ---------------- ---------------------------------------. W U Nature of Repairs or Alterations—Answer when applicable....-------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------•---•------------------------.------.---------------- •-.------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the bo of health Signed •• •-- ----- ------ ' Date ApplicationApproved By---...-- -----_......----•-------••---------------•••-•------•-----•---.......----•-------•-- --•-....-•--•---------- ---------------- Date Application Disapproved for the following reasons:---•-•--------------------------••-----•----•--•-----••--••-----------•--•-•-••-•-------------•----------------- ------•-•-----------------•-----•-------------------•-----------------------_--••-•-------•-------------- _----•---------------- --•-•-----------------.•-------•----------------- Date PermitNo........ 3----------------•-------------•--'---- Issued........................................................ Date TH COMMONWEALTH OF MASSACHUSETTS BOARD F HEA T �•�� y� y ............ ..............OF..._ ........................................................ Trrtif iratr of Toutplinnrr THIS IS TO CERTIFY,,,T�1iat' t'he Individua wa Disposal System constructed (_ r Repaired ( ) by •-••-----•- -------_--------- .'�'`...... "'---•-••- - - ---- ---- -------- --- - ---- - / aInstalle at. ----------•- ------ ---•- --._..._. ---•--- ----- -- ...••------ . ...--•--•---•--•-•----------------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..................:...................... dated----------- .----__-_-__-_----------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S-ATTIISSFACTORY. DATE ._ tl__(p..................•........ Inspector.....-- --•-••-----------•---...------•--•--...-•---•-----------------•-•---•----- THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEAL /yff'—py I..... .....OF....... G!f ? .-- No. FEE__-/0............... i� n�tt1 nrk T litr -rtinn Vantit Permission is eby granted...... -------- ------- ------------------------------------------ --------------------- to Construct ( or Re. air ) an Individual S7eage Dis oral yst1 at No----------------- • ... 2 f Street as shown on the application for Disposal Works Construction Permit No--------�`„ _... Dated-........ '` r'_....__ _:_._ -------------------------------------------------- ................................................... Board of Health DATE---------------•- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 17 e` P �� "SR ��' r t.., r, "�L r i•F �tF h }. i O 'W�� i AL•x }�� 'S.ki L �c A d'� to }• f5 0. 1 a ��. �� IN ,46 14 k �s ,� � �.'• �3 eEZ� k g, f 'T i L• J yiF RIZ Y 4 " ow { 7 NO _.'gfi �Ys ,���� r �bn.. /�. 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