The URL can be used to link to this page

Home My WebLink AboutCAPE REGENCY - FOOD 0(8 9 - oo1 Town "of Barnstable BOARD OF HEALTH John T.Norman Board of Health,1,l Donald A.Gaudagnoli,M.D. HARNSTABU, _ F.P.(Thomas)Lee,. MAS& Daniel Luczkow,M.D. Alt. 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: 135 X Issue Date: 01/01/2022 DBA: CAPE REGENCY NURSING,HOME / BROOKSIDE OWNER: ATHENA HEALTH CARE SYSTEMS g Location of Establishment: 120 S. MAIN STREET CENTERVILLE„ MA 02632 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: .120 OutdoorSeating: Y 0 Total Seating: 120 FEES FOOD SERVICE ESTABLISHMENT. r$300.00 » YEAR. 2022 RETAIL FOOD: -COTTAGE.FOOD OPERATION: '' Permit Expires: 12/31/2022 B&B-•FULL BREAKFAST: CONTINENTAL BREAKFAST:" MOBILE- FOOD: r MOBILE-ICE CREAM: 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: For.Offic 1 - Init IRIS: Town of Barnstable �z2 end : .,,RPMA Inspectional Services, Chrrk D0 - --� Public Health. Division Thomas McKean,Director 200 Mail}Street,Hyatir�s,NIA 026.01 Office: 508-862-4644 Fax: 508-790.630.4 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT. DATE NEW OWNERSHIP RENEWAL, NAME OF FOOD ESTABLISHMENT:�V� y� I rtGV Z. 4 tI LIT1� C � C Cn Lf ADDRESS OF FOOD ESTABLISHMENT: I aO S`014'' MAIA 84 . CC.mi4trYl IIt hg 04.3Z MAILING ADDRESS(IF DIFFERENT FROM ABOVE); Colam , E-MAIL ADDRESS: In / ►Aor /J. S�1_{K.Qsr_thI,:12 9CC,-C 6M TELEPHONE NUMBER OF FOOD ESTABLISHMENT:( TOTAL NUMBER.OF BATHROOMS: �. WELL WATER:YES NO_y_ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL;_ SEASONAL: DATES OF OPERATION:.._1_7_ TO._I NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED B�'THE IIEALTII DIV.AND LICENSING AND MEET OUTSIDE DINING REOUIREMENTSi IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED ATWAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE _RETAIL;FOOD:-ONLY required for TCS foods,foods.requiring refrigerationlfreezer) 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 fIEALTII DIV FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508462-4G44 Q\Application FormsTOODAIT 2620.doc Y, .iy I OWNER INFORMATION: �" t FULL NAME OF APPLICANT SOLE OWNER: YES N OWNER PHONE:# ADDRESS 1 5pc3 �1 a lta F0.Fmtn� br1 G'T' C]b01-1 CORPORATE OWNER- CORPORATE ADDRESS:_135— )"► Rorx�ar W►1 r GT PERSON IN CHARGE OF DAILY OPERATIONS.: e C.I A 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•� Y,r � 01 It -La . �, din aozz, 2. AnarL wrtgh i?D aq / d34. II � i6 IGNATUTt O .APPLIC DATE ***FOOD POLICY INFORMATION*** SEAS.ONAUFOOD SERVICE:All seasonal food establishments„including,mobile'trucks must be inspected by the Health Div prior Woyening!! Please call Health Div.at 508-8.6 4644 to schedule.your inspection. Please call at least(1)days in advance. FROZEN DAIRY.DESSERTS: Frozen desserts must be:tested by a State:.Certified lab prior to opening and monthly thereafter, with.sample:Tesults submitted to the Health Div, Failure:#o do s6 will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone Mid caters within the Town ofBamstable.must noiify'theTown by fax or mail prior to catering event. You must complete a catering notice found.at httn://svww townatbarnstable.us/henithdivision/i�oplicitions.asii. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January lst to Dec.31'each.calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)`AND`REQUIRED FEES BY DEC lst, Q:1Application Form TOODAPP REV3720-19.doc O�SF Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BARNSTABLE, Paul J.Canniff,D.M.D. 14a ' F.P. Thomas Lee Alternate 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, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted,to: Permit No: 135 Issue Date: 01/01/2021 DBA: CAPE REGENCY NURSING HOME / BROOKSIDE OWNER: ATHENA HEALTH CARE SYSTEMS Location of Establishment: 120 S. MAIN STREET CENTERVILLE„ MA 02632 Type of Business Permit: FOOD SERVICE/SENIOR Annual: YES Seasonal: IndoorSeating: 120 OutdoorSeating: 0 Total Seating: 120 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: E For Office Use BIKE►p� Initials: Town of Barnstable Date Paid Amt pd$ MIMSfABLE, : Inspectional Services MAM. Check# 01 i639. Public Health Division pTFO MAy 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 I 10A6 NEW OWNERSHIP RENEWAL-X NAME OF FOOD ESTABLISHMENT: ( gre&e -.6 RtCl(I'� C-0/0; Ckn4cx ADDRESS OF FOOD ESTABLISHMENT:Inc 0 sUIJ+� re, 1 I1 t , m p d 3 a ;a MAILING ADDRESS(IF DIFFERENT FROM ABOVE):, L E-MAIL ADDRESS: F�L�1 4r e C&AP R&Q GV R�IGC.•CAY✓1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 08 $ TOTAL NUMBER OF BATHROOMS: WELL WATER:YES No ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: A20 OUTSIDE: ,fJ' TOTAL: Oda SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. t ***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 SOLE OWNER: YES NO OWNER PHONE# "fps 78 18 ADDRESS )35 O2ca 1 . Feve(err1Y,r,4on . CT D&.32 CORPORATE OWNER: T h enG CORPORATE ADDRESS: I <6t it Il Q( cal PERSON IN CHARGE OF DAILY OPERATIONS: CA r ,1 List(2) Certified.Food Protection Managers AND at least(1)Allergen Awareness Certified Staff E 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. 5a nel G. I�, aZ 2l 0) / It / o q .1.s4hndyxt ' 2.' Anjrt Wr l _ ID L' oZ�j / 30� _ SIGNATURE O APPLICA DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openine!i 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.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.31"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 Si BOARD OF HEALTH Town of Barnstable John T.Norman Board Of Health Donald A.Gaudagnoli,M.D. R BARNSTABLF, + Paul J.Canniff,D.M.D. �o a 200 Main.Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate „ - Plone:(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: 135 Issue Date:, 12/10/2019 `DBA: CAPE REGENCY NURSING HOME / B_ ROOKSIDE OWNER: ATHENA HEALTH CARE SYSTEMS .Location of Establishment: 120 S. MAIN STREET CENTERVILLE, MA 02632 - Type of Business Permit: FOOD SERVICE/SENIOR Annual: YES Seasonal: IndoorSeating: 120 OutdoorSeating: 0 Total-Seating: 120 FEES FOOD SERVICE ESTABLISHMENT: $300.00 YEAR. 2020 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires:' 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: `_ Qn FROZEN DESSERT: Thomas A. McKean;RS,CHO Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: .F cam. ... For Office Use Only: Initials• Town of Barnstable rr11 _ • Date Paid AmtYd$ ��V � : Inspectional Services,' c �� Check � t.. Public Health Division Thomas McKean,Director ' w � 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax 508-790-6304 }..A APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE D I J t -10�0 NEW OWNERSHIP_ RENEWALX ' NAME OF FOOD ESTABLISHMENT: CM. eamh %He-CergN ADDRESS OF FOOD ESTABLISHMENT: 1-2-0 w 5-OUtIT Y1Y,,) V,C�?2 � MAILING ADDRESS(IF DIFFERENT FROM ABOVE): t1 I l�J7V E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: t•-Nu•1 - 1 K3.5 TOTAL NUMBER OF BATHROOMS: _. ++ WELL WATER:YES No ...(ANNUAL;WATER ANALYSIS-REQUIRED) ANNUAL: SEASONAL: + DATES OF OPERATION:_/' / TO ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REOUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? n' IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?Mn TYPE OF ESTABLISHMENT- (PLEASE CHECK ALL THAT APPLY BELOW)- FOOD SERVICEZX— -' _RETAIL FOOD`-ONLY required for TCS foods,(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST 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 j PLEASE CALL 508-862-4644 Q\Application FonmsTOODAPP REV3-2019.doc OWNER INFORMATION: FULL NAME OF APPLICANT r} Q -� SOLE OWNER: YES NO "' OWNER PHONE# " 5�(,� 2179 / 9 ADDRESS 4 Z.. ( GU ' CORPORATE OWNER- -�- M S CORPORATE ADDRESS: al 44,4 PERSON IN CHARGE OF DAILY OPERATIONS: 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 1J a 1-30 o i,- /r aQ / 1. S 2. g . S NATURE OF'APPLICANT DATE ***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 for 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 httV://www.townotbarnstable.us/healthdivision/applications.asp. OUTDOOR COOIQNG: Outdoor cooking, re aration,or display of an food product b a food establishment is prohibited. . �,P P, n, P Y Y P Y r , *NOTICE:.Permits run annually from January Ist to'Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND.REQUIRED FEES BY DEC 1st- t Q Upplication Forrns1FOODAPP REV3-2014.doc � ,....... ,.._...�f-...-,.r--..x..-.-:_..rM.,.. ..«�+�...,...-,-...-+... �-r, _. ram..=,-..- .ram.. ,:...�----•-._-. . . _-...- ...v._.-• TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: ...Page: of 3 OFFICE HOURS P ° PUBLIC HEALTH DIVISION 6:00=9:30'A:M. s @1ARNSTABLE. - 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. g• MON.-FRI. _ 9gA +639• .0 HYANNIS,MA 02601 soa-asz 4s44 No Reference .R:-Red Item PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT- / Date lG L1Tveao Name outin J Address t Risk od servi Re-inspection r ` Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint � Person in Charge(PIC) C (�/� I e Bed&Breakfast HACCP i � � r vil I-s v� Other h Inspector Out: Y C1 Wa f Each violation checked require an explanation on the narrative page(s)and a citation of specific provision(s)violated. CPlt�^ 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) ❑ v Action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands x (�`� ✓ i ^1 - � �� ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash FacilitiesZVI lS ll 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 i / � . FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) !!( l ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures 1 l-4 bJ t7� ❑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 C[/ PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/.Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) �" .ClL 1l 21 (Q ' ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP /J n 4,❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY. _ / //� ❑ 11.Good Hygienic Practices E322.Posting of Consumer Advisories f` `�` `C/ r_L Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations l � Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ o ❑Yes Non-critical(N)violations must be corrected immediately or within 90 days as determined.by the Board of Health. Overall Rating \ . �- Volunta Compliance L-J ❑ ry ❑.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 ❑ 9 ❑ 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 (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 re 9 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 )( ) g9 y y 9 9 q 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 b this order,you have a tight 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: Inspector's Sig ature Print: 31.DumpstPyscreened from public view CJ%"' r� Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: PIC's Signature Print: Outside Dining Y N 9 Self Service Wait Service Provided Grease Trap Size Variance Letter.Posted Y N Dumpster Screen? Y IN 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.* * 19 PHF Hot and Cold Holding 2-103.14 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 7 5 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* ty g3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to 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* P g 7-202.11 Restriction-Presence and Use* 20 Time as a Public Health Control 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* 7-203.11 Toxic Containers-Prohibitions* 590.003(G) Reporting by Person in Charge*. 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 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 1 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 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* TIME/TEMPERATURE CONTROLS 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* CONSUMER ADVISORY Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-001.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-1U1.11 Drinking Water from an Approved System* 4-601.11(A) Clues,ULumi6 mud Fuud Cuulm�t Surfaccs of Eggs-Immediate Service 145'i 15 sec* g PP Y Equipment* Not Othenvise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* effecnwc uinoor 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 rf ces of E ui 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 g, P mTY 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-145'17 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-Q3.11(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 Iterns 23-30) Critical and non-critical violations,which do not relate to the foodbore 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* F 18 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 Cooling Cooked PHFs from 140°F to 70°F (A) g 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* y * 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours 9 * 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 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 1.008 HACCP Plans 6-301.12 HandD 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 1 Conformance with Approved Procedures* S:590Fonnback6-2doc '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. o�INC ror TOWN OF BARNSTABLE7. _u _ HEALTH INSPECTOR'S Establishment Name: Date: _ Page: of v` o OFFICE HOURS ; ye PUBLIC HEALTH DIVISION 6:00=.9:3aA.M. BARN STABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified v Ma3q: �0i HYANNIS,MA MON.-FRI. No Reference.- R.-•Red_Item,, ., - PLEASE PRINT CLEARLY, 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT. '91f Name Date 2 Type of T section G`"s "'� T Routine U Address 1 S Risk Food Service Re-inspec Ion r < Level _ Previous Inspection - W Telephone Residential Kitchen Date: o Mobile Pre-operation ` Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint � ® ` Person in Charge(PIC) Time Bed&Breakfast HACCP 61-1 _ In: Other I Inspector Out: 14 0 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) An 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) ❑ `�iJQ.IJe- 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 T ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) j ❑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 F 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. . c- ❑ 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 t r� within 90 days as determined by the Board of Health. Overall Rating I� ❑ VoluntaryCompliance p ❑.Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ mar 9 ❑ 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 (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 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27:Physical Facility - 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 y ty (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. violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspe o s'sigh e r P 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 Si na a Print: 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* S 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 PHFs19 PHF Hot and Cold Holding 2-103.11 Person-in Charge Duties Cooked and RTE Foods. 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 590.004(F) * 7-102.11 Common Name-Working 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 7-101.11 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* P g 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* * Charge* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or 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 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 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)tB)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(3) 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(3) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served y Pe 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. 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 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That arc Raw,Undercooked or Equipment* gg Not Othenvise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eg cr;�e mnooi 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* - 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 37201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- * Ratites-165°F 15 sec* in mobile food,tem o and residential Sources g� P mTY 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 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 3-202.15 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 foodbome 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$ Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 3-501.14 13 Handwashing Facilities Cooling Cooked PHFs from 140°F to 70°F (A) g 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. 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. ME Tq,. TOWN OF BARNSTABLE.,. -, - oFFICE'PECTORs Establishment Name: - Date: .. Pa;ge Of o`. HEALTH INS HOURS PUBLIC HEALTH DIVISION 8:00 930A.M. BARNSTABLE. 200 MAIN STREET 3:30 a 30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MON.-FRI. HYANNIS,MA 02601 soa-esz�saa No .Reference, .R-Red.item PLEASE PRINT CLEARLY rFD MP'� FOO ESTABLISHMENT INSPECTION REPORT , Name ` ) Datej Zj' Type of Ty Inspection l *ram 0,�4O 1 ine C7 v -Address S a Risk e-Ins c Ion �7 r ` Level Retail Previous Inspection " Telephone Residential Kitchen Date: Mobile Pre-operation 4e n Owner HACCP Y/N Temporary Suspect Illness It) Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP /L� ;( r 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) ❑ 0 /pU' Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ (A�* Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT- ❑ 12.Prevention of Contamination from Hands d f j ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 1 (� 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 ,/ j� r,� FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures V (_ > ❑ 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 �J PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control. ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ' ()_�. T ❑ 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) I�J Corrective Action Required: No Req Yes Non-critical(N)violations must be corrected Immediately or ❑ ❑ within 90 days as determined b the Board of Health.. Overall Rating y y ❑ 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 Personne_I (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 In 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 4 non-critical violations 9 if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=Pis 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 aright to a hearing. Your request must 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 ( )( ) 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. 28.Poisonous or Toxic Materials. FC-7 590.008 9 violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. Print:'tor s Sig r 30.Other DATE OF RE-INSPECTION: Inspec _ 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 PI ur Print: 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 y Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) l; 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* * * 3-501.15 Cooling Methods for PHFs 590.003(B) JDern,nstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202:12 Additives 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 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 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 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 Se aza[ion-Storage* Applicants* 3-302.11(A) Food Protection* P g 20 Tlme 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 7-203.11 Toxic Containers-Prohibitions* 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 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 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 Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(3) Raw or Partially Cooked Animal Food and g Not Served* 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts * 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 Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* PP y Equipment* Not Otherwise Processed fn Fliminate. 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ep"°e uuZo°i 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* 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 temporary and - ide in cater- Sources* Ratites-165°F 15 sec* 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* 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 Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome 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* C y onvenientl Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products P 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. 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. FtsEr TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: 1' Date: 1'r-9,M, Page: Of �$ OFFICE HOURS r PUBLIC HEALTH DIVISION 8:00 200 MAIN STREET -s:3oA.M. BARE. 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date erified MASK.L g, MON.-FRI. v� .e3q• .• HYANNIS,MA 02601 eoa-as2 as4a No Reference. R-•Red Item_ PL SE PRIN LEA Y FOOD kSTABLISHMENT INSP C 4 REPORT s Name Date a of f Inspection _ r O n s Routi Address Risk Food Sery spection r Level et ' Previous,I p Telephone Residential Kitchen Dater VVV /f Mobile Pre-op n Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Bed&Breakfast HACCP Person in Charge(PIC) Time other Inspector i Each violation:checked requires an explanation on the narrativ ' age(s)and a citation of specific provision(s)violated. (�7' 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) ❑ •' 6 Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ v i - / FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands - 1.PIC Assigned/Knowledgeable/Duties ❑ 9 9 ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food-Employeesand PIC - ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMElrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ) ❑ 5.Receiving/Condition ❑ 17.Reheating ` 4.4 n ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with`Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding . d PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control / i ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Ap ❑ 9.Food Contact.Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP. ❑ 10.ProPerAdequate Handwashing CONSUMER �� r hhh ❑ 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: Ji!j'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 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 4 non-critical violations 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 observed,7 to 8.n n-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 within 10 days of receipt of this order. violation;4 to 8 non-critical lolatio s=C. 29.Special Requirements (590.009) y p t 30.Other DATE OF RE-INSPECTION: Ins or ig to Prirtf 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N r J ;�_ f�; #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI�'s Si a Print: l 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 3-202.42 Additives* 1_ 3-501.15 Cooling Methods for PHFs 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.*- �- - 3-30214 Protection from-Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw In redients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F _ 590.004(F) * - EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* Other* I g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge to - - - 7�f172.11 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 Applicants* - - 3-302.11(A) Food Protection* 7-201.11 Separation-Storage*P20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 7-202.11 Restriction-Presence and Use*Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* 3-304.11 Food Contact with Equipment and Utensils Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 I1 Variance Requirements 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)Resumed Food and Retted 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 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations Raw Seed S routs Not Served* 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and p 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* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of A11. ean Utensils and F f f Food Contact Surfaces o * Animal Foods That are Raw;Undercooked or 5-101.11 Drinking Water from an Approved System* 601 (. ) Cl Eggs-Immediate Service 145°1^'15 sec F.rinipmrnt* Not Otherwise Processed to Eliminate. 59UAU6(A) Rattled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef ctNe 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* 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g �' 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 15 sec* 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 Mid Mushrooms Approved By 2-301.11 Cleanon on-Condition d A * Regulatory Authority an 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 3-202.15 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* 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 3-202.18 Shellstock Identification* 3-501.14 13 Handwashing Facilities Cooling Cooked PHFs from 140°F to 70°F (A) g 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 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products P 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFI Made from Ambient * 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 1 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACUP Plans 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. p IME r TOWN OF BARNSTABLE_ _ HEALTH INSPECTOR,s Establishment Name: % l�(/�� ate: Page: of OFFICE HOURS �. H OARNSTARLE.O� PUBLIC 2 0 MAIN STREET - - ' 3:30-s:30 A.M. Item Code C-Critical Item DESCRIPTIO OF VIO TION/PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. MAC, g F'I MON.-FRI. N Reference R-Red m PLEASE PR IN CLEARLY HYANNIS MA 02601 0 �A +a39•a 0 508-862-4644 4/ FOOD ESTA13LISHME,NT INSPECT N REPORT- Name ate of ns ec ion J p s Routine Address Risk od Serve pection Level Previous 1 s c 1 Telephone Residential Kitchen Date: (J Pre-o erat� + Mobile P JA Owner HACCP Y/N Temporary Suspect Illness / ,I Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP Other �� o Inspector u Each violation checked requires an explanation on the narrative ge s a a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Fa tors Red Items Anti-Choking 590.009(E) ❑ IN Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) I J Action as determined by the Board of Health. Allergen Awareness 590.009(G) a . FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands . ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS If V ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or-Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals 01 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 - I ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY f y El 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices Items Blue 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, ems ❑ 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 6=One critical violation and less than 4non-critical violations 9 , ( )( ) 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-cri ical. 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-c itical vi-ations. If 1 critical refrigeration. 29.Special Requirements 1E (590.009) within 10 days of receipt of this order. vi tion,4 to 8 non-critical A bns 30.Other DATE OF RE-INSPECTION: In tor's igna re ( nt: 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 ignature Print: / Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N '� / (� ti ?. 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-contamination14 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 590.004(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* 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* 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 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* 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 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) Clean u 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,Meats&Game Pathogens* Effective rarzom 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 Cough[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- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3401.11(C)(3) • Game and Wild Mushrooms Approved By 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 3-202.15 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* 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 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 Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* 5-204.11 Location and Placement* * 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. 11 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand m Provision Drying 29. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback&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. PoF.Nfrok { TOWN OF BARNSTABLE HEALTHIrsPECTORs Establishment Name: / - Date: % Page Of ti -OFFICE HOURS BARNSTABLE.O` 419' PUBLIC 2 0 MAN STREET 3:30-4:30 P.M. DIVISION : 0- :30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified >�e� HYANNIS,MA 02601 MO8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY rfo MPS 508-862-4644 FOOD E TABLISHMENT INSP CT ON REPORT Name Date voe of Type of Inspection tl Operation(s) Routine Address Risk Food Service Re-inspection ` Level Retail Previous Inspection Telephone Residential Kitchen Date: t e Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint ; Person in Charge(PIC) _ Time Bed&Breakfast HACCP In: Other Inspector Out: / � Each violation checked requ res n explanation on the narrative page(s)and a citation of specific provision(s)violated. J Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ health hazard and require immediate corrective Violations marked may pose an Imminent e q 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 { E , L' ❑ 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- Ej es Non-critical IN)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 Embar o.. Emer enc Closure Voluntary Disposal Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ g y- ❑ ry p ❑ 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 B=One critical violation and less than 4.non-critical 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 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 observed,7 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 violation, on-cr al v' lations=C: 29.Special Requirements (590.009) within 10 days of receipt of this order. / 30.Other DATE OF RE-INSPECTION: Inspector' nature Pri t: 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 S gnature U/ Print: / Self Service Wait Service Provided Grease Trap Size Variance Letter Posted. Y N Dumpster Screen? Y N 0• ' I Violation 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 Law Cooled to 41°F/45°F Within 4 Hours* ( ) gn _ 14 Food or Color Additives 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.* * _ 1.9 PHF Hot and Cold Holding 2-103.11 Person-in-Chazge Duties 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°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* P ty ga to 590.004(F) * 2 590.003(C) Res Responsibility of the Person-in-Char 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 1307-102.11 Common Name-Working Containers* °F* Storage*- Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation20 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* 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 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 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. Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 1 g3-401.11A(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 59U.UU6(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff crave ionoot 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 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 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* 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 sh ( 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirem nos Id be debited under#29-Special 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 foodbome 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* 13 Handwashing Facilities 3-501.14(A) 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* y Within 4 Hours* 23. Management and Personnel FC-2 .003 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* 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 3-402. 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 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. Poisonous or Toxic Materials I 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�NE r TOWN OF BARNSTABLE HEALTH wsPECTOR,s Establishment Name: Date: I Page- of ' OFFICE HOURS I ,I ! 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 erified HYANNIS,MA 02601 MON.-FRI. No Reference R Red Item. - PLEASE PRINT CLEARLY rE0 MPS 508-862-4644 - - FOOD ESTAB ISHMENT INSP CT ON REPORT Name Dat e of Type of Inspection Operations) Routine 1114 Address ' Risk Food Service Re-inspection Level Retail Previous Inspection / Telephone Residential Kitchen Date: / �o U d Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge.(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Q Each violation cked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. j _ 1 Red Items Violations Related to Foodborne Illness Interventions and Risk Factors ( ) Anti-Choking 590.009(E) ❑ ,- � a 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) 2 ift It fo I 44D1- t4 ❑ 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 ❑ 11.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 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 0 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 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 F] 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 B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F. Seriously 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. i. if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If y Critical Violation=F is scored automatically 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 9 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) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8pon-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) y p - 30.Other DATE OF RE-INSPECTION: In e. or's ign e Print: .. 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N 1 #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIG's Signat re 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* 6 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* * s 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.* * 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 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. 590.004(F) 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* 3-302.11(A) Food Protection* 7-201.11 Se azation-Storage*Applicants* 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 3-304.11 Food Contact with Equipment and Utensils* 590.004(I1) Variance Requirements 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* 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 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 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 1 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 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 Equipment* Not Othrrwisr.Prnrrccrd to Fliminnte 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective uuzooi 590.006 B 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* ( ) 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 Surfaces 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 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 ca[er- 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* 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 Tastin * * (Blue Items 23-30) 3-202.15 Package Integrity g g 3 403.11(C) 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* 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. Poisonous or Toxic Materials I 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. p INE T TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: Date: Page- of ° - 'OFFICE HOURS - - °� PUBLIC HEALTH DIVISION :8:00 s:30A.M. srne�e. : 200 MAIN STREET 3:30 4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF"CORRECTION Date Verified BARN STABLE. _ MON.-FRI. _ ,,}9,p0� HYANNIS,MA 02601 soa-as2 asaa No Reference, -R-.Red Item- 4 -f t PLEASE PRINT CLEARLY _ M"' FOOD ESTABLISHMENT INSPECTION REPORT ' - '� Name `p /j ! IC D Typ of T ns tion Opera-flo-nYs-11. Routine Address P .- Risk ood Service - Faction Previous Inspection Retail _ Level , Telephone Residential Kitchen Date: rtmv-0A8= n r Mobile Pre-operation Owner 7 HACCP YIN Temporary Suspect Illness Caterer General Complaint n Person in Charge(PIC) ime Bed 8 Breakfast HACOther f- / ` ` In: I / 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) V " ( Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) V%, 1Ai� Action as determined by the Board of Health. Allergen Awareness 590.009(G) r /� i f FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands j ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS,•'�� f. r � v ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives - - ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals EMPERATURE CONTROLS Potential) Hazardous Foods) - - FOOD F ROVED SOURCE TIMEIT _FROM APPROVED y. (Potentially ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition LL ❑ 17.Reheating _ ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling � V ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding , ,? C 20.Time As a Public Health Control., 1 l PROTECTION FROM CONTAMINATION ❑ ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) �_ S I ❑ 9.Food Contact Surtaces Cleaning and"Sanitizing ❑ 21.Food and Food Preparation for HSP , - /// Y_�_\,X�Ivlr. . ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ) F i c.._'❑ / 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical-Violations 15 Critical(C)violations marked must be corrected immediately. (blue&red items) :. Corrective Action Required: Vj ❑ No r ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating � - ; within 90 days as determined by the Board of Health. A ❑ 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 ormore non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations t 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 4n6n-critical violations if no critical violations observed,4 to 6nnn-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. within 10 days of receipt of this order. violation,4 to 8non-critical violations C. ' 29.Special_Requirements (590.009) y P Inspector's Signature Print: 30.Other DATE OF RE-INSPECTION: 31.Dump ter screened from public view \ Permit Posted? 1 ,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. N Dumpster Screen? Y N -`� v t" °{ �c,� 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 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 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 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590-004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* * Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 590.003(C) Responsibility of the Person-in-Charge to � 7-102.11 Common Name-WorkingContainers* 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 3-302.15 Washing Fruits and Vegetables 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* _ Applicant To Report To The Person In Charge* Food Contact with Equipment and Utensils* 7.202.12 Conditions of Use* 590.004(41) 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 Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g ( ) Disposition of Adulterated or Contaminated - - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and 3-701.11 Discarding or Reconditioning Unsafe Food FOOD FROM APPROVED SOURCE * 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 - * 4-501.111 - Manual Warewashing-Hot 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(rEMPERATURE 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* 3-401.1 IA(I)(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 * Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved S stem* ( ) Eggs-Immediate Service 145°F 15 sec PP Sy stein* (lihrrwrcr Prnceccr l to Fliminptr Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* sff-nve tarzoor 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* faces of Equipment* Shellfish*, 4-703.11 Methods of Sanitization-Ho[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* in mobile food,temporary and residential Sources g• P mrY 10 Proper,Adequate Handwashing ut Clean Condition- ans an Arms* 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and A Mushrooms Approved By 2-301.11 Clnditi Hands A * 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* 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 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasfing* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Critical and non-critical violations,which do not relate to the Foodborne Items 23-30) 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* 13 Handwashin 9 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 * 5-204.11 Location a Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention Accessibility, P 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. Malkus, Karen From: Samantha Farrenkopf <SFarrenkopf@NSUWater.com> Sent: Thursday,August_06, 2020 1:13 PM To: Brian Fortin; David Laasko Cape Regency(physicalplant@CapeRegencyRHCC.com);Joseph Smith; Malkus, Karen Subject: June 2020 Discharge Monitoring Report-Cape Regency Attachments: DMR Filing 06 2020 11240.pdf Please find attached your copy of the June 2020 DMR filing for operation of the wastewater treatment facility servicing Cape Regency. Thank you, Sa*na+U1 U F"r'e v&,op f, ES, WWTO, PWSO Operations and Compliance Coordinator BENNETT ENVIRONMENTAL ASSOCIATES, LLC. A Natural Systems Utilities Company 1573 Main Street/ P.O. Box 17:43 Brewster, MA 02631 S08-896-1706 508-896-5109 fax http://bennett-ea.com � Confidentiality Notice: This electronic mail message and any attached files contain.information intended for the exclusive use of the individual or entity to whom it was addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure under applicable law. If you are not the intended recipient,you are hereby notified that any viewing,copying, disclosure or distribution of this information maybe subject to legal restriction or sanction. Please notify the sender, by electronic mail or telephone,of any unintended recipients and delete the original message without making any copies: Go Green! Consider the environment before printing this email. This message may contain privileged and confidential information. If you are not an intended recipient,please note that any disclosure, dissemination, distribution, or copying of this information is prohibited. CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe! i Inspection report stored ton Q drive: Q:\IA Systems\I=A 1=nspection Reports 2AO Inspection report stored, on Q drive: Q:\IA Systems\I-A Inspection Reports it2-io t--�2 . • 4� r • ,M h s tt Department of Environmental Protection 847 _ i -S of Re source Proteobon-Gro tl 1 rDsch.rg Pogmm; 1 P IN b r Groundwater Permit DAILY LOG SHEET zr id.he bnN be - - 1. 2019 SEP DAILY a F 3.sampling Month 8 Frequency - Massachusetts Department of Environmental Protection k eDEP Transaction Copy I Imp rta t wh n a.FaD3utyi°f°rmas°° r ` f sling ut roans on l:F mhty name,address - -the compNer,use CAPE REGENCY HEALTHCARE CENTER - - Here is the file you requested for your records. only-tabkoy m a Nama move ya - 120 SOUTH MAIN STREET To retain a copy of this file you must save and/or print. y a 1 mt�y the ib st-Addreaa- r BARNSTABLE IMA OF2630_ city - tl.SIGN e.21P Code Usernanle: SFARRENKOPF 2.0'tact infotmetion Transaction ID: 1148388 - j OSEPH SMITH - • e.Name of Padlity eontaU Person Document: Groundwater Discharge M hitoring Report Forms 5088961706 s rth&uwater.com Size of File: 1031.14K - b.Teleptme Number - .small ed4resa nn Stalus of Transaction: 1.Pro Samplig iformation Prow:: - � � z - Date and Time Created: 10/28/2019:1:42:16 PM 9/1/2019 NOTAPPLICABLE Co.samgea(mMaay»yf- e.Laeomlary'rvama + .. _ - BEAPERSONNEL " Note:This file only includes forms that were part of your - rwarysla PedPnned sy(rvamel - - _. transaction as of the date and timeindicated above:If you need - - a more current copy of your transaction;return to eDEP and B.Form Selection select to"Download a Copy"from the Current Submittals page. 1.PI see selxt Famt Typo and Sampling Month&Frequency ' - f Daily Lag sheet:2019 Sep Daily Ail forms for submittal have bed completed: - I� 2. This is thelast selection. 4� 3.r Delete the selected form. gdpols 2015-09-15.doc•rev.09/15/15 Groundwater Penult Bally Lag sheet•Page 1 of 1 ..s............i... ,....�«_� ' - Massachusetts Department of Environmental Protection 847 _ Massachusetts Department of Environmental Protection 847 .Sure u of Resou ice Protecton Groundwater Dischame Pog m. 1.Po-N b B uof R...roo Pnotedibn-Gro d -ter Discharge Program Groundwater Permit z.Te.tl T u N b �_ Groundwater Permit 2 T.m hfi b N b DAILY LOG SHEEP l DISCHARGE MONITORING REPORT 2019 3EP DAILV 2019 SEP MONTHLY 3.Sampling on,8 Fequency 3.Sampling Man-8 Frequency C.Daily Readings/Analysis Information - - - A.Facility Information Important:when Oa[e FEE nenl R llon euse - Ir TudliEty tnfluerd pH Eflluerd chlorine Uv filling out forms on r I.Faciltyname,address: Fkvw GPD Row GPD Flow GPD pH Reed- Intensity the computer, ICAPE REGENCY HEALTHCARE CENTER - (m9A) (°A) oNy,e lab key to _ 1 I ffaon t the 20SOUTHMAINSTREET( - y .-b sl-Mdress�j �j ��! fi.3 fi9 BARNSTABLEMA 026304 64c cly E.s�zre e.Zipcaea fi.7 69 - .2.Contact ifomation: 6.6 7.27- OSEPH SMITH • 15MB961706 - 'sm N@nsuwater com 9 18307 6.7 7.1 1 b.-on,- c a-mall address_ ,^ 11 21515 64 7.1 3.Sampling information' 111345 a. - - PHA ANALYTICAL ICAL12 7389 /7 6.2 6.9 0 smde(Myy) b. mlmi176349278 PHAAYATICALPERSONNEL 11729 9 - - aA 1a 6 Pedannetl By(Ne.) i6 20478 E3 6.8 17 20611 s.4 s.9 B.Form Selection - ta 19122 6.4 7.1 1.Please select Form Type and Sampling Month&Frequency Z0 16192 64. 72 Discharge Monitoring Report-2019 Sep Monthly - 17252 7.0 T 21 16248 2z 15901 � r-All[otms for submittal have bee pleted., 23 1531fi 63 6.8 2.r This is the--select,,. ,. 24 22688 6.5 73 . - - 25 21 000 6.5 ].4 3.r Delete the selected form. o 25 22850 67- 7.1 I 27 21372 fi.4 7.3 .. 2a 22579 'a• - 29 20029 - 30 19489 6.4 �7O� 31 gdpolsAoc•rev.09/16/15 Groundwater Permit DailyLog Sheet•Page 1 of 1 r ! gdpola 2015-09-15Aoc•rev.09/15/152 Groundwater Permit Daily Log sheet•Page 10 1 1 _ LL1847 Massachusetts Department of Environmental Protection 847 f B,mauoi Resource PmtecUon-Gmundwater Olscharge Program 1.Permit Number Bureau of Resource Protection-Groundwater Discharge Program 1-tumtNumbeI Groundwater Permit \. Groundwater Permit 2.T..demft.don Numb. z.Ta Iaentlnwnon Number MONITORING WELL DATA REPORT DISCHARGE MONITORING REPORT 2o19SEP MONTHLY f 2019 SEP MONTHLY 3.Sempling�requenry I3.Sampling Month&Frequonry D.Contaminant Analysis Information A.Facility Information •For'o,belowdalecflon ilmlt,leaa than(<)velu,o mudetected,eIbu-ND' Important:m,, •TNTC=too numerous f-L(Feral results only) filling out forms on I.Facility name,address: •NS=Not Sampled + Ute computer,use CAPE REGENCY HEALTHCARE CENTER gMy the Me key W eN e qNe ym,r wreDr- i m 120 SOUTH MAIN STREET tlo not use Na 1.Paramaterl0onfaminanl 2lnfluent 3.EMueM 4.EMuerd Method taco key. b.6beet Pddresa Units DaW-n Irma BARNSTABLE MA 0-0 00D ® ND 2.0 m� c.C'dy d.3bb e.7lp Cade Mrs IYY��Yii T33 ® ND 5.0 t 2.Covlact ulformatiov: MGL rmn OSEPH SMITH TOTAL SOUOS e.N-fFedliy CPnbGPen:,n MGL 5088961706 smith@nsuwaWr.com AMMONIA-N pg0 b.T1.,-Number c.emNl,ddrem MG NmWTEN 3.Smvplmg ivfprmatiov: 4.3 0.10 M6L 9/172019 INOTAPPUCABLE TOTAL NRROGENMONNO3•MN) $.09 0.650 a.Oae Sam,.b-dfyryy) b.Lebwetw Name MGL BEA PERSONNEL OILa0RFA5E ND 4.0 eAlmysb PedmmM ay lNeme) MG B.Form Selection I 1.Please select Form Type avd Sampling Mouth&Frcquenry i Momtodng Well Data Report-2019 Sep M-my r All forms fw submittal have been camplefed. 2.rJ This is the but selecfion. 3.r Delete the selected form. I Infegre-blank.doc•rev.09/1515 Gmumbwaler Plant Olschage MonitOM9 Report-Page 1 of 1 f gdpdis 2015-09-15.dac-rev.09/1915 Groundwoter PemJt Daily Log Sheet•Pa90 1 or 1 1 LL Massachusetts Department of Environmental Protection 847 Massachusetts Department of Environmental Protection IM7 Bureau of Resource Protection-Groundwater Discharge Pro,mm 1.1-1 Num er Bureau of Resource Protection-Groundwater Discharge Program 1.Pemlit Number Groundwater Permit �.- Groundwater Permit 2.T.klentiAratlgn Number 2 Tea NentifiwUon Number MONITORING WELL DATA REPORT 2019SEP MONTHLY 3.Samplire Monty b F-mmW C.Contaminant Analysis Information Facility Information •For•0•,below detection limh,less than(<)value,ornot detected enrer•No' < i lmportant:m,, CAPE REGENCY HEALTHCARE CENTER •TNTC=too numerous to eu-IFecel result,only) Rims out forms on ,Hanle •NS=Not Sample0 Na wmputer.uea •DRY=Not enough water In wall to e,mpl,. Dory Me tab key m 120 SOUTH MAIN STREET { ve your cursor- b.SV„I Atldr>e= i da not use IEARiNTTKE MA 02fi30 return key. c City d.Sbro e.9P Lode PammalaALontaminant MWJ MW-B MW-1 Units Wall PI We11#:2 Well#:3 Well#:4 Wall#:5 WelN:6 Certification 1 Od 'I M,*1-ce 11I.f tar Mat d-menland ell-menb were 1 pePared urtler my dlreGbn draupaMebn In eawdarxewM a system tledgnetl b asure Mel @mIiIIM peracmel yopedy gdarereb a vYrab Ne Infartnafbr wbMtletl. 6.16 5.fi5 5.37 I Bests an myirpuby,f Me permn rcDerarna wlm manego M,ayabm,ordmae persvas&eCdY raponsitle br�Medng M, MlameO'an,Ne b(rvmad,n subMttetl b,b Me heal of my Mnwledge eM be,el,true,ecwmte end mmplete.l emrwan Mffi Me SfATC WATER I£YEL 77.15 17.24 18.56 � ere algni6®nt pereltlasMa$mlltrng talsp hbrmatlon,Lk1W41g Me possidlly of Me arty lmpdsmnbni tw kno�[9ddetl,ru.- sPECI -NOucr O I SMANTM AA FARRENKOPF t0I282019 $26 538 220 ! Any person signing I. slowum b.Dab(-fyyry) 1A4106C f ,document under I (2) Na shall make CMR 5.14(1m Re ortin Package Comments i (3l lollawing 2019MBENNE TENVIRONMENTAL AND EFFLUENT SAMPLING LINGOF THECOMPLETED WASTEWATER SEPTEMBER certi8cadpn TREATMENTS NTHLY STEM.NT MONTHLY WASTEWATER ATER SAMPLING WAS COMPLETED TREATMENTS MONTHLV WASTEWATER SAMPLING WAS COMPLETED ON 9117119. It you are tiling LABORATORY RESULTS REPORTEDAIL PARAMETERS WITHIN DISCHARGE PERMIT electronic-ally antl LIMITATIONS.EFFLUENT PH WAS REPORTED WITHIN THE 6.5-8.5 LIMIT DURING THE MOf TH. i wenttoat M THEMINIMUM,MAXIMUM AND AVERAGE GPO FLOWS REPORTED OVER THE COURSE CF i additional THE MONTH WERE 11,729 GPD,22,888 GPD AND 17,957 GPD,RESPECTIVELY. ' � menLs,select F Ma chetic box f( r I 1 i I 1 mwdgwp-blank.doc•ray.Og/15/15 M,NtdMg Well Data for Gmurdwat,r Permit•Page 1&1 gdpdis 201Ma-15.doc•rev.09/15/15 GrouMwater Pemtll•Page 1 of 1 f { - 1 Serial_No:09251916:37 I. - In E.o ANALYTICAL REPORT Z o E - Lab Number. L1942957 - Client Bennett Environmental Associates - < _ 1573 Main.Street , Browder,MA W631 K.K K ATTN: Joe Smith u° w w w ' Phone: (508)BW1706 E a w w N� U U US Pmjad Name: CAPE REGENCY.• .. • - ProjectNumber: K11240DA-S.WW.700 - - x Report Date: 0925/19 , USin w M. —Mg proles reponldem vaokaee:ndd br apna An&yawl m e repomtl.m padc.ee re pee oared and sno.m be repiodawd onty In na w erNreH.Alpba Anaybwi Hales no msPorum rty far results arMlor Gala Nel are oat wnsLienlvnN me an9 riot - Ce od,ns S Approvals MA(M�Skb),NH NEIAP(2064)CT(PH-0574)IL(200077).ME(MAo0006),MD.(340),NJ(MA9M).NY 11114a), K o - - - NC(25/00,566)S PA(60-0 1),RI(LAOoo065),Tk(T10-76),IT(W-D935),VA(MO195),USDA(PermltfP330.1]-00196j. w . .. uY m 3 33 Eight Walkup Drive,Westborough,MA 01581-1019 - 508-898-9220(Fez)508-898-9193 800-624-9220-www.alphalab.com - E E v�i�1.A a s a E w Page 1 of 17 ¢in - Senal_No:09251916:37 - - - _ Serial_No:09251916:37 Project Name: CAPE REGENCY Lab Number:. L1942957 - ProjectNumber: K11240DA.S.WW.700 Report Data: 09/25/19 - Case Narrative The samptee were ne—N accordance coin,fbe Chin of C-My and w algnifiwmd—don. I.enwo&ered derma Me preparation - qr anatysiz unless alM1erw se notetl.sample Rece'pt,Conminei l&orma00n,and Me CM1aln of Custody are mwbA A Ma badr of Me repo- - Resul6 wnialretl wN4n Mls repoR relate�nlymthe sample submitmd antler Nis NpM1a Lab Number anti meet NELAP requlremenm mr an t - - - NELAP—iced paramem less omerwi5e noted In Me mllbwng nemenve.The data presenmtl n Mile repoR Is or9anaed by Pawmerer � (I.e.VOC,SVOC,etc).Sample apasfin Quality C.—data(.e.Sunag.m Spike Recovery)Is repoRed at Me end of Me laget analyte list fareaMlrMMtlual sample,mllowetl by Ne Laboatory Batdt Quality Canbgl al the end.fe Mparameter Tentatively ltlenlifietl - - , - _ - -„ CompOcnd3(rlGs),Yf requesmtl,are repermtl mrwmpountls ltlentnietl to bepresenl andara not part of ine mallotllpmgwm Target .. ' .4 - " ' Compound Nst,even Hontyasuhsel of Me TCL are being repoded Ifa sample was re-analyzetl brme#raded due toaregWred quality ' - +wnbd wrtective adian antl nboN sets of tlamare repoRed,Ne laboratory lD Dl Nereanatysis or reexbadien is tledgnatetl wlN an"R" - ? - w'RE-.respediveH INORGANICS - ' VJnen muNPle Batd,Quality CarNoi elemema ere repoRetl(e9 more Nan one LCS)Ne d led samPlesm M I [ namdin - � - - McBreY SM1aded M1eader Ana of eats data fate MyLeborelory DatN Sample 5peofic% ry iRPp vat N lls outside Ne lisletl & Aarepten®Cher.le bottled In Me,,pod.In reference m q...t H(CAM)or 41RCP)wken'Ni is el,ecked.Me perrormanw criteria - - y mrCAMandRCPmeNotlsallow(grsemequalty IrtiurealoomramsnucevnmmmeNoawmvranre I then ree,Na � - - MISCELLANEOUS - spedfic failure lS net....bed but noted in Me as sad QC Odle,Summary Report I.-41rec6y—Me Case Nama0va.0C rn-eben is also nce,on l in Me...Usabi%Assess—bell IF.-11)ofoW Dad Memer mot,wTeren can be reNewed In - eenlunctlpnwlNMesurrob, 0,,lleedatetl re I.bry vimria antl any assod&etl data usability lmpliwtons.. L SDigseMments,sorts and iLssuea are reportetl on a tlry ova ghtbasts unless olherw ll n&ed.Deldr.11 of all data qual fill and aaeryma - ♦ • _ , usetl in Nus repoR are Provided n Me Gmssary Igwmd at Me batle of Ne report. - HOLD POLICY-Fw samples submNetl on M1ald,Alpbaspo-q is to MM.amples(wiN Me axceptlon of Plr wnismrs)hea of Uazga mr2l i � ' wleMar tlays from Me tlare Ne prated k wmpletetl.Afler2l calendar days,we will dlapase&all samples wbmtned lnduding Nose pin - onbellunlessyen h.vew&aded your NpM1a Pmjed Manager and made a.ange-malt Alpine to continue m held M,samprei.N, , wnislers will be disposed after 3 business day.fmm the tlate Me purled is wmpleld. Ple.w cored Prated Management a160ee24- cots art quaztiervs. _ l a I,the undersigned attest under the pans and penalties of perjury that,to the best of my knowledge and' - - belief and based upon my personal inquiry of those responsible for providing the information contained' in this analytical report,such information is accurate and complete.This comficate of analysis is not complete unless this page accompanies any and all pages of this report. ` Authored Signawre: •u^ 'Michelle M.Moms Title:Technical Director/Representative - . Date:09/25/19 Page 3 of 17 Page 4'oft Selial_No:09251916:37 Senal No:092519:6:37 i Project Name: CAPE REGENCY Lab Number: L1942957 Project Nama: CAPE REGENCY Lab Number: Li 94'.957 Project Number: K11240DAs,WV.700 Report Data: 0925/19 Project Number: K11240DA.S.WW.700 Report Data: 09425,19 i SAMPLE RESULTS SAMPLE RESULTS Lab ID: L1942957-01 Dale Collected: 0 911 7/1 9 14:42 Lab ID: L1942957-02 Date Collected: 09117 19 1 5:28 Client ID: MW-3 Date Received: 09/18/19 Client ID: MW-6 Data Received: 09118,19 Sample Location: CENTERVILLE,MA Field Prep: Not Specked Sample Location: CENTERVILLE,MA Field Prep: Not S3eclfied Sample Depth: Sample Depth: Matrix: Water Matrix: Water AnalyUael pllutlon Dab Dam Anatyllcal Parematar Result Ovaiiilar units RL F.— Prepared Aneayaad Memotl pnalyat j Penmemr Result oua1i0er U RL MOL Facmr Prepared Anatyaed Msmod Aaalyat 1 G e'Al CO try W_iti_'r"o gh tab =.Cail§:.z:,c: 'k ,t'ti; _..'...} .. ',;,'#y:.,' x�� .�.,. I:Ch€ NlOogen..0. ND mgfl 0.050 1 - OW19119 0710 H3533 MR I Nla9gw,Mmm ND 4m9d 0050 - 1 - 09I19I1907:21 H,3533 MR Nitrogen,Mtram 2.4 mgA 0.10 1 09/1 a—z H,3St2 MR Nitrogw.Mbate ..So non 0.10 1 09I19I190>:21 M,3533 MR Nihegw,TMel l9eldahl 0.a3fi Nlaa9en,Tael N.1-1 io0 mgfl 0 B. 2 0924J1905:36 OM511912:31 121,11-113-H JO _ MOT _ 0.800 - 2 09r24I1B 05:36 092511912:32 121;+SOONH3-H JD I I I I i 1 I H2u$11 Page 5 of 17 Page 6 of 17 I Serial_No:09251916:37 Serial_No:09251913:37 j CAPE REGENCY L1942957 Project Name: CAPE REGENCY Lab Number: L1942357 Project Name: Lab Number: ) Project Number. K11240DA.S.WW.700 Report Data: 0925/19 Project Number: K11240DA.S.WW.700 Report Data: 0925119 SAMPLE RESULTS Method Blank Analysis Batch Quality Control Lab ID: L1942957-03 Data Collected: 0911711913:20 Client ID: MW-7 Dale Received: 09/18/19 Sample Location: CENTERVILLE,MA Field Prep: Not Specified Dilution Dale Data Analytical Sample Depth: Parameter Result Qualifier Units RL MDL Factor Prepared Analyzed Method Analyst Matrix: Water nutmn oam Dem gnalyticel G e'14Ch try W�st8 gh L b f 5s pI(} 01�63 B tch WG1 9 28508-i o � ....., .::... .-,. Panmomr Re-It Dua11fl9r Units ftL MOL Facmr Preparetl Anayxod Method gnalyst N9m9en,Nloam No m94 c H,-.z MR Nla'an,we ND mgfl 0,050 1 09/lwl90]23 H,353.2 MR NihOpen,Mm. Nocole - H,35a2 MR' .a,.,NlVam 0.32 mgfl 010 1 - p9I18119 m:23 H,353.2 MR Mlro9w,TomllQeltlaN e430 myl 0300 1 0-9 o5:35 o92511812:33 121,4500NHYH JO G','I,Ch try'WeslbO ghL h:f f P��(),01.B3 B ldl WG1287670.1 Taalp ngil _- M4119- ___ 4300NNSH JO- f I l i l 1 i i Page 8 of 17 Page 7 0117 j I i Serial No:09251916:37 Serial No:09251916:37 Lab Duplicate Analysis Lab Control Sample Analysis - Project Name: CAPE REGENCY Batch Quality Control Lab Number. L1942957 Project Name: CAPE REGENCY Batch Quality Control Lab Number. L1942967 Project Number: Kl1240DA.S.WW.700 Report Data: 09/25/19 Project Number: K11240DA.S.WW700 Report Date: 09/25/19 1. Pammeto Native Sample Duplleate Sample Units RPD oust RPD Limits - Genere(Ch mstry W tb ro gh Lab A, oa teOfsa�_pl(s)�011-08'yQC Batcht�D WG1265906-3fK qCS mple,1.194295703-Ci nt ID bMW 7j Ca yk.R' LCS LCSD %Recovery .. .-w ,-.. -,_.._ ..,.. Parameter /oR ry Dust %Recovery Qu.1 Limits RPD Dust RPD Limits Nlmgen NlOv 032 031 mgA lbp.'-gALab'IAssoUhtetl a FI 037 GeneratChem try Westborough LebFAsso ated'mple(s)ROi-03 -qC B`t h ID WG1265908 3?'QC S rtip`Ie jL'7942957 03�Ilent ID MW 7.kY, � 1,� "' �' - - "'r' N Nibete h' aB NI0o98n.Nhme ND ND gB ......... :. ... -� -?-*. a• : -+ +- n.:.- Generei, hemist VL�estbprou ry.L bA9 Gated am le(s)09:-03�BetchWG12859092`: �� :t5 Gr+ 'N - t :=West rou h?Lah�Ass ateds :Pl(j 01 03,-qC B tch.i[)"M1WG1287670 35 oC Semple:Lt942969 01.Cllent ._ �. ._....,..,.t...._,....3.,, ... ... Nllmgen,TDW K.W.hl 1.46 1.60 mg/1 f R4 ,Nilr00en,Ni41b - ".f BB „,i�i - 80.110 - - Gene I Ch m stry.W stb ugh''L b`'/A socletetllsampl(s)Ot;03�Batch VJG1267670 2 1-"'^r 1, 'G ,y, (+S -y �' +0 xi,'.,�0 `- . N en Tole,pelaenl A Page 11 of 17 '. Page 9 of 17 Seria1_No:09251916:37 Project Name: CAPE REGENCY Lab Number:-1942957 Serial_No:09251916:37 Project Number, K112400A.S.WW.700 Report Date:09/25/19 4 Matrix Spike Analysis Sample Receipt and Container/ntormadon _ Batch Quality Control Project Name: CAPE REGENCY Lab Number: L1942957 Were project specific reporting limits specified? YES Project Number. K11240DA.S.VWV.700 Report Date: 09/25/19 - Cooler/n7ormaflen - - Cooler Custody Sea/ Native MS MS MS -MSD MSD Recovery RPD .. A Absent Parameter Sample Added Found %Recovery oust.Found %Recovery Qual Limits RPD oust Limits Contalnerintormatlon initial Final Tamp - Frozen Gen rat Chemistry W 3tbo�oughL bAs oc;t dsampMe(s)0103 QC BatiA ID WGf2659084 qC Sempl 1�7942957u03 G cat lD sMW7 _ Confainer/D Container Type Cooler PH PH de C Date/rime ype 9 Pres Seal Analysis(') NUDgen,NiL31e 0.32 4 LIM295741A Paalk120Munprexrveb A 1 7 2A Y Ae,em - NO-3(2),NOsa1s(2) Ge Chemtsfry Wesfb m gli LablA sec at Csernpl().01A3'sgCB t-KID WG4265909.4 qC Sample iLA 942957031 Cl enllD MW7vY al c_rt% ` - L1B43B47.01B P-.2-25paM— A 2.4 Y Abxnl TKN .(20) i .• - ^`'• ... ., _ _. .... ._ N g ,NndIs _ No 4 4.0 ;.q`M1 - - Nez-353(2),Nosa53(n .--.-- ,--�a- -_us4zena2A Paese l2D e a 7 z4 Y swam — ---- -- L-2ena2B Plame zsam Hzsw P143Bn<e A a a 2.4 Y am.m TNN�sso(ze) General Chem try We tb bgh L b As oc ated sample(s)•-07'037 oC BatdF.ID WG?287630.4,j oC S mete Lt942g69:.01 Cl e t ID;.MS S mpl l „5 v L1a201— 1-12am unpreserve0 - A 7 7 2A Y At.. NO2-3v(2).NOsa53(2) Nllm9en T-I KIe1d3M11 J - B 1a 10.7 A _ - - 77-111 - • 24 L10420-039 Pu01250m1 H2504 P1e5— A zA Y Ab— —4500(21) ''-- "--_—"---- _---- Page 10 of 17 Page 12 of 17 -Values in parentheses indicate holding time In days yrrVia?.A ti�, Seria1_No:09251916:37 Serial_No:09251�IZ:37 f Project Name: CAPE REGENCY Lab Number: L1942957 Project Name: CAPE REGENCY Lab Number. Lt 942957 i Project Number: K11240DA.S.WW.700 Report Date: 09/25/19 Project Number: K11240DA.S.WW.700 Report Date: 09/25/19 GLOSSARY I 1 -TFs rtf rcefor dtis arWym shoWtlhepmidetW madNM tpce tlds aaslYa is ehw[Immthe urge maMelbt ofpe Acronyms i angiw em— ➢L ➢ cM rib Nvc T,c which mrIm-V cananb(LOQ),rtWraduestimetN VJues,whin te ins ea mget emly3ia wvwvmuoweme qumtifiW below Xa Iimil Orqumtimdov ry0Q).The OL iocludm myadjmmmv AnelytiW MMOd:Bop Ne tlocum<m hem wM1ic1h[h<m<pad Pngineae aM Ne amlyGcel ref<rtna mMotl.(Eumple:EPA 82608 is fmm Nludam,conanmtiom ormoismte commS where eppli¢ble.(DOD repartfamsb.viy) ahawvu 1,82608.)The codes forth reference vapod donmwv are Warded N Ne Refvenw saeov ofNe Atltlmdmv. EDL Fvvwad De¢ctivv Limie ibis valuercpresmblhe levelm which mgelmJS'Ie comcaWimu arzrtWrro]azeslimn-0 DiRer<nce:WiN nsWc[to Toml Ortidinble Prxuraor(TOP)Assay erulysis,Ne NR<rtviceudefinedu Ne Pest-Trtetmemvalve mmm Ne vJuev,whey Nose mgamJym covcevhadow u<qumtlfi<tl below the reWrtinglimit(RL).lM EDL mcludw any PZTreewml value. adjwm<nb Oom diludom,conamlrenom ormoismecamm�t what eppliable.Thc w<Ot'FD[s aspaif mrM mJysis MMpll:AsitpeMinsmfm,klt ,e Conminerinlonnadon satlm ofpe rtWM1 Final pH rtllav Pn ofconmmerd<lmnioM aflm "A wing SOlW Phaa Mictacxvncdov(SPMC). " edjw da pba mry,dappewble Nov ed mryveQ aloe reflecb loihJ OH EN@C EstimetM Maximmv PosaNeCmvmmnon The wnano-edav Nmmulb Gam tMsgml prt.atat pe ram4ontbae ofm 1 - - mpeato Volatile Organ ak/I'imercflecv N<tlea/[ wh'M1 'atlReegemWW.- wMntheivwmeetall Dfpe demfiwnan criteria eueW the ion ebwOm«mdo cnlem.MEMYCuawommu pmm'<d vials wne nidJly fmzen.No[<'If fmzm daWtimebbryond46 Mun fmmsample 0llttban,rota.will6e re0enrotl n'bold'. off Pncm g<vry.walredon. i I.u.IID:M it petmim to Sample Receipt&C.-mr lnfar—section oftM report lnitiJ TH nfl.e pHolwnmivadetermined upon F.YA tin n on A LCS Labommry Control Sample:A samplem,I,lreefmm 11111m of in ,spgtedwiNvm<M kmwo meawv of aS ifepplirehle .Jyaa oramatmJ wmainivg knosm mdv<ri(led amounts OfmJyaa. 1 PFAS TPnLFOS.[ffa Tomi'resWtuequc�PFAS,iaml(SyrnWtia daf etlwNe amnmativn afrtaWv for PFNPA,PFH�LS,PPOA, sad,tM mWv ufib individml comWnmb m1 also h reWtad LCSD -Leboramry Comol Sample Dupliram:Ref<rm LCS. T..wnh,P,emm OrgaJcewyses,eToml'rzmlt;adef din Ne summation o(mWvlor individwlisomers orAmclon.Ifa'Taml' LFa -eborcmry Famhed 8lmt Asampletwtrixf fmmtM.".xm.ofinramt miketl wipv edkvoxm amomv of mWtvM u<sad,per<sWlsofi6mNvidvalwmWvwbwill,bs PpmW TNs is ePPliwblem Tolel'nsulm for meWod56160,8081 meyka or mnJ wnminittg known and aNiW amours ofmJyas. and 80 LO➢ -Limi[OfD<twpan TNsvaluc rtWesmvtlm levelmwhichemtge[mJSd<tan relbblyhdemcad Coraspaifm amlym pe spccJ mebix byesWCNc mepod.Th<LODinclutles arty atljwmmv hour diludam,covmttratiow ormoislure cmtevt Date ouelipen h.eeppliceble.(Da0 r<Pon(Omaa on1YJ -Sptttn idmtiCrcd m'Aldal Candewws"x byWoducu aflM exba<tiaNconcenvatton Prxedurn whin acetone is introducedin LOQ LOQrldumtiacm:ThevJmu dil. ivsvmevtwn valumely masurtmmJyl<.aspttific wnunmtion The A pe Preceas LOQ Jcludn my edjwunenb fmm deudow,comenvatiom of moismrt anan4 wherzapPliwble.(DaD repod(artmb I -The erafya,yas saecyl ehov<Om rtpot[mg limit in Ne avacasei m<Nod blurt Flag.my Vpliw m associated SeM smpl.Nat amy.) B Moe deacmble wvcwtretiom.1.—lym al teen 0av tin lira u.).conmw—faradm.blink For MCP-mlaad LmdtofQumtitatio.:The Net I hichminMvnemmn agummy measurem mJyhe I specific wmev c..Tha 'p,ps ony eppliaromwci—red_IP that bone det 1.wv txiowaf.<...lyre et less Use.Dour uou LOQ include.ury edjwmenb fmm dcuhors,concenmmivm ormaiNue cmavt wMre eppEa3k.(DOD report format: U.e commbadon found in the blurt For Do—D.projem,.....y aWliw[o eamciead field samples N.Mve dearmble aJY.) anwtrow orthe.alya.less IMn tin Ii—(IN)It,c .Pum—I in Ne blink AND dmmelya waz deemed stove mehalfP rzWttinglimit(m ebov<Nc repotvg Ivoi[forcommon lab conlaminmb)inNewonaadtnMadblink.FarNl- v-re1W Wojecb,Ong Doty applies b avaie[ed Eeld samDln IMt Mve dcxmble rovanitmiom ofNe anJya above Ne M➢L -Mepod O<acdan L'unit:Thbvalucrtpmmv the level tv wfiich mrgamalyte conammtiam are rcWrmtlwmitraad report limit For Nl-related pmjcts(euludivg M).Oag oJY appliamaxocimai field samples that Mve dekcmble values,wfim gaze mrgttuWyl«onavvatiota ue qumofied below Ne repa2n81imit(ItLJ The MOL imludes my comsr tiov ofd�eavaya,wtiuY ussdetecmi above the aparting limit in p<eswcivedmnMd Mmkor.Eove fins tlmc pe adjosmenv Cram Nlutiow,wmenvaliew ormoismts canko4 wherz apPliwble. rtportm6limit forcommonlab mtmmiomv(PMhalms.Acaone.Mepyime CNontle,2-Buvvav<). MS -Minixspxk.S.mpl<.AumPle Prwa>l by edtlinge Mown mesa a(mget mmlymmazPaifiW amoral a(matrixsunpl<far C -e«lutiom The mtpAtenelya c«loos wipaknown hb stumuN(i.e.smmgak,inmmistmtivtlz,ea.)(or co-utractW whicM1m Wtl<p.devratimea ormthretmWya conavmtioo ua table F0r Mepod 3330,the spLLerecovery u<aleWerctl nos' using lM Dative camemetiom—ding esimaatl.dues. D -ofCPncentryx,alamlya wss quentNetl fmm tliNatl analysis.Flag onlyeWliamfcM temple dot Mve ticmcmblc wmmo-anom MSD tru Spike Semple Duplicate R<Rrm MS. . - Me -Cm—.cmtradon afawya eu<eN the range P(the mlibtadw<urve mNar linurrmg<ofN<insmavem NA -NatAWlicable. z G -Thecavicemadan may h bi.M high duel.matrix w[<R w(L.P-h-h)wip mm.ga compouM(a).The malt should NO -Not Calculead:Rtmbut".,.t whom.ormore ofpe result/uNved iv the WculatiovxmmG.tec[mtM pvwarfa he rowWae]esumapy mv8 ph -Theanalysis ofpH was peRotmetl beyond Ne regulaory-requirtd Mldingtime of IS minuets(ramthenme oMample wlleLvon. NDPA/DPA-N-NimaONpM.YlemiveNiphevYlmdne. _ - lorpe two calumms Ms hen rzWtatl duem obviow invert<rtna. M --to—, -Evtimate4 valve.Thu rtPreunb m<m"vnmW—unnivn kr Tmm 1,ldemiftM Com .-IT.) NP -Non-PI—T.-h;.ilvrl fore Pollb ofAtmrberg lima p 1.1. l M RL -RapomvgLimit:The ssluemwhichm iwmmem emeccuremly m.ruremewMea[aspaife cananveum The RL -Repamng Unit(RL)ua<tls pe MCP CAM hipping Limit for Nis analyze. Nclutlw mY adjuxmevb from d'Jutiaw,canaomtions Ormais[urc wnzwt wM1crtapPliwble. ND -No[deacvslmtla rtportm6limi[(RL7 for Ne wnPle. RPD -RJvme Pemevt DiRerevice:Th<mWu fivm trspu mNm metro spike dupliam as pmmrcy deigned to azsesstM NJ -Nmumptivecvideace of mmWtmd Phis repmmbmmYvstedcoocwtredov far Tenm[iv<ly ltl<n19iW ComWmds(TIG),when precisim o(wydW rmWb megrvev rrebuW meacprtmMwrelativepemmt NRerence(RPD).VaNn wbicM1 art lug paid rhi.iovbbasetlassamwsapxtral binarysearch. Wanfve draw Nc rzpomnglMit for evY mdivitluJ p.ememram evJuetedtyutilrsing Neebsoluze dieemna between Ne P .The RPD between peresuly forth.two wlumm excee6s 0a meNod-spoil mitena values;Jthough pe IUD vela<willhprovidedmtM rePorl ! Q -The li Isampl.eueeis pe essociaad eaeplmce man..For DOD-1-1 proje ,LCS mNm CvrdiIng CWibratian SNhI -Smndmd Reamme nPiel Artkrevice mmple afa Mown orcmiftctl value Us[borpe sazn<meivW.metrkw pe qm ryconaO I W1,Noa:Thueegianot p ssmeigW field smn Iw. Smna.tl'_PlevwmeJmquetifiMovaU azmcimedswp applimblefm mnnxsxh..vaues MP -Set),mi.Tmkl.mching Pmadureper EMMe.dlJl5, NetSxtlmRL.(M<vls oJY)nFmm Nm4x pe spike eddedar for Mtch tlupliwh RPD when Na sample comevtreliomxlev T. -Tmx Equmlmry Feman:The—assignedm hNoxin and hPs me Wma pairtvuciry relative m Z,7,8-TCDD. R - ly[imlrt P«frv—e rle mmalyse. TEQ oxic Pgvivalene TM messure PfasamDle§mxiciry derived bymultiptyine eacM1 Naxm mid rumn by ibearzaPontling TEF -Aoelytiwl rzsWv ere from c-ri.rtumctiov. mtl NmslmmingiherazWtiugvalw. SK -Aoalytialrzmin ere from nmdibetl xeeaJvgevaysu. TIC kevo<ed ComW APr pa thm W ban idemi mbc PPax evd Gnat pan orlhe vrgel wmpv—I It,(TCL)for IM—dmNor pmgtw.All TICS art quWivdvely Wmd—andtepattetlazesthmadcommvaeom. Footnotes ' Rgncd Formaf: D1x Uaacxty Repoli Repot Formal: O.UsehdVRepot Page 13 of 17 l Page 14 of 17 Serial_No:09251916:37 Serial_No:09251913:37 Alpha Analytical,Inc. ID No.:17873 Project Name: CAPE REGENCY Lab Number: L1942957 Facility:Company-wide Revision 15 Project Number: K11240DA.S.WW100 Report Data: 09/25/19 Department:Quality Assurance Published Date:8/15/2015 9:53:42 AM Title:Certlflemj Approval Program Summary Pau.1 of 1 j Certification Information REFERENCES 1 The 1o11owln9 analyzes ere not Included In our PNmary NELAP Scope of Accmdlzatlon: 44 Methods for the Determination of Inorganic Substances in Environmental Samples, westboroaaM1 Fadnry EPA/6 00/R-93/100,August 1993. EPA 62u624.1:M,xy.n.,-lam 121 Standard Methods for the Examination of Water and Wastewater.APHA-AWWA-WEF. EPA826OC:�l2A'5-TehAm 0ber¢ene;4- r,hduens.Aaobetvene; rg y:IvtlOmeN (meNylmdide),1,2,4,5-T....ylbaraene;4- Standard Methods Online. EPA 82MD:NPW:DI.OhylwphM1.I.ne,1,4-Diphenythyd2a'ne;SCM:Dtmethylnaphh alem,l.4-Dlph.nylhydra m. SM4500:NPW:fun—noble C. Ide;3Ch:-.1 Plmsphows,TIW,N0NO2,NO3. Manatlald Facility sin 26E0D:Ts. EPA 8011—NPW:PCB:1.5,31,07.101,110.141,151,153,180,153,187, EPA T045:H.I.M.re,2,4,4-TmnelhyF2penane,2,4,4-Tn d,p l-panlene,Thlopheno,2-MMV-phene, 3-Meth-ph—,2-ENy1lhlophene,I.x. .nylbenzene,[We,,I—,1.2,4,.ffiylbs..ro,Be—hiophene,t-MBNyIn.phs—re. Blolo9ical Tsaue M.W.;EPA 3050B The following analyes are Included in our Massachusetts DEP Scope of Aco-hatlon Weatbowugh Facilly: odnkma Wafer EPA 300s:Chicide,Npam-N,Flu M..SUlfam;EPA 3M2:Nihele4q,Nibit,N:SM45001,10—NltretaN,NIImeN:SM4500FC,albux CNCE, EPA 180.1,SM—El,SM—In-D,SM2320B,SM2WC,SM4500H-B,s 00NO2-B EPA 332:—lomte;EPA 524.2:THMS and VOCs;EPA 504.1:EDE,DBOR MlcmbloI.W..SM921513;SM9223-PIA SM92238-Ca11lert-0T,SM9222D. SW50ufable Wafer ' Am—niH,B,EPA-ACHAT.1,S107,06 ,SM2540C,SM2PA3,1.1,S CL£,0-,EA353.M4-11,-eH:0OP-E,Sia--,C.shl-PA350.1: Ammonia-,,LACHAT SM521m.SM: 110C,SM,1 EPA Z,E A I—,EPA 4 EPA hl"0:NNam-N,M2MO,E,A 300: bl.,Id, W,rllt E. EPA 6 .1 Willh eha SMrb—i SM5.h.,M450oCL-0,EPA 1684,EPA 420.1,SM4400CNCE,SM25400,EPA J00:CM1IDrlde,SWfaN,Nltmte. EPA 608.3;Volape ,T,,.ph,g rw m,lip EPA Ira,C Taha E.,r.,Bxim Akan,,HainBHC,,H.Pc Ngamaxid,P tleXa-BHC,Dieldr'vI,DOD,ODE.DDT,Endosulfan I,Enoasullan II, ErdIPA 62l5.1 salfete,Aculs Endnn Aldehyde, bles),hpr,HePlarhlor Epoxide,PCBs EPA 625.1:y: M(AdtllBaseMeubal Eamadables),EPA 8221E-01-045'.PCB-OII. MlcwbloloBY:SM9223BCOXleg-0T;Enterolet-0T,SM9221 E,EPA 1600.EPA 1603. Mansfield Facilly: —Mg wales EPA 200.7:AI,as,U.Cr,Cu,Fe,Mr,NI,N.,A®.Ca,Zn.EPA 200.8:N.Sir,M.8,He.CA.Cr,Cu,Pb,Mr,NI,Se,As.TL,Zn.EPA 243.1 HII. EPA 522. EPA21teble Wafm j EPA 2c0.7;AI,Sb,Aa,Be.Cd,Cr,Cr,Co,Cu,Al,Ni,K.S. ,Na,Me K,3e,Ali,Ne,Sr,TL,Ti,V,Zn. EPA USA AI,Sb,As,Be,CA,Cr,Cu,Fe,Ph, Ni,K.Se,Ag,Na,Th,Zn. :PA USA H9, SM23400 For a complete listing of analytes and methods,please contact your Alpha Project Manager. LIMITATION OF LIABILITIES i Alpha Analytical Paul—services with reasonable care and diligence normal to the analytical testing laboratory Industry.In the event of an error,the sole and exclusive responsibility of Alpha Analytical shall be to re-perform the work at its own expense.In no event shall Alpha Analytical be held liable i for any incidental,consequential or speoal damages,including but not limited to,damages in any way connected with the use of,interpretation of,Information or analysis provided by Alpha Analytical. I We strongly urge out clients to comply with EPA pret...I regarding sample volume,preservation,cooling, containers,sampling procedures,holding time and splitting of samples In the field. I Document Type:Form Pre-Qualtrax Document ID:08-113 Page 15 of 17 j Page 16 of 17 ( Seral.No:09251916:35 I fi 89 a } 8`s s € $$p€pas �l,LFiA 4O1a aoIi Rs 3Enz Ja - z ANALYTICAL REPORT i Lab Numbe. 1 L1942958 _ a > N111 F Client: Bennett E mental Associates i A I 1573 Main Street S' Q - alli!Y'ate11M — Brewster,MA02631 I I ATTN: Joe Smith r _ 4� � S 1� Phone: (508)896-1706 � I IS m } P 1 t Name: CAPE REGENCY - 3 P 1 tNumber: K11240DA.S.WW.700 j EI E - { .Report Date: 09/25/19 (n II v 5 a n a ¢ ® v l - LL O _ ' I The dgiral�pmlaG reppNdala package Is held by Plpl,a Anaytlrai ThIs repoNdala package k pagNated and sM1oold pe repmduced pnry In Its Z 5 ! enmety.Plpha—A.,holds no lesponsib011,W lesubs andlur data lh—Mt—slsterdwlM the pru,s. F g ggg N Q o E E NC(25 tlbns 6 Approval MA( (LA NH N l(T(2064),GT(PH-05]4),IL),g (]),ME(MA000fi6),MD(34a),NJ(MASQS),NV(1114a), NC(25]0p166fi)PA(fi5-03fi]i)RIMOD]gfi5)T%(T104]g44]6)l?(VF-09]5),VA(4fi0195),USDA(Pertni[IXP]30.1]-00196). U d s e v Eight Walkup Onve,Westborough,MA 01581-1019 :' r( ( 508 898-9220(Fax)508-898-9193 800-624-9220-1w.vtl.alphalab.com Page 1 of 16 " Serial No:09251916:35 Project Name: CAPE REGENCY Lab Number: L1942958 41 Project N mber: K11240DA.S.WW.700 - - Report Data: 09/25/19 C N.,.*tibc a The pl Ned in Nance wiM h CLstody rd g m d.' re en t retld'ng the prepa—n . o K o o or analysts unless pthelvsa noted Sample Rece pt Conte nv lnfomat on and Ma Chl fCusbtly arel taa a tihebarkofth—lMn N 21 - Results runts netl vnthnM report relate only th emotes submlXed underdds Npha Lab Number and mee[NElaP requlremen6 brali - .. NEtAPaaredited pammebs unless ptherwa opted in Me bllpvnng narreave.Thatl p nted in Nis report is oigah¢etl by peremeter N E Op - fa.VOC,SVOC,etcJ.Sample specific Oualiry Coniml data(.e.s nogare Spike Recovery)ureportetl al heend GMe rarget analyle list z c o E mde W...Indiwd al sample,bilh-ed by the tabomtory eaten ouaiiry Control at the end pr ead,P rrlienT ntaavery ld-t.d - e at Compounds(TICS)Irreq ed po tlf p dsW riff dl b y t nd are lwt part hf ih th Nprog -Tergel �� —" � � - Compound List evengonryasubset p(Ne TCL are being reported ttasampla was.reanayzed dr re extracted duebarequiretl qualiy UO o o + - wn4ol mrective aGlpn aM dboN sets of tlapare reportetl,the Laborerdry lDaf be rcanalyss orreex9ac5an is tleslgwted v"iM an'R' - - - - or•RE',IrsPecVvely. .-- - • When mul5ple 9atN Oualiy Control�elemanm are repprted(eg.more than one LCS),Me aewdated samples far each elemehtare notetl in ' Me grey shaded heaEerllne Gearh dath bhle.Any tabarabry Batch,Sample Spedfic krecevery ar RPD value Natk huLsitle Meli51M - Acceptance Cdteda is boltletl in the tepart.lnrelerence to quesdonsH(CAM)or4(RCP)whan'NO'Is checked,Me padoimanre criteria ' br CAM and RGP methods allow far some qualiy cdn0al failures b occur and stlil be wlMln meNotl wmplWnce.b drew instances,the - � specigc hilure is npl nanated but noted In Meesspciatetl OC OWier Summary Report,IawteA tlireciry eRertM Cau NanaWe.00 � - Inbrmatlon is aLw 1—M d!In tha Data Usablty Assessmentl.bla IF—if)ai our Date Merger tool h e it can he mbewed In W mnluncpon with the—pe as.ft,assodMM regulatory CtanP antl any associated data usablly lmpl mt ce - Sa'Vsed men6 sot ds antl tl —d n a dry—mill basis unless o.—s noted Definibhla of a II tlata qualifiers and acronyms F -d in thi.ftre ore d tl nthe Glossary 1—nad at the bark of the report.• - - - E u w NJ U U HOLD POLICY-For samples submitted on Mld,Alphas policy N b Mid samples(with die exrupdon&M,canisters)flee of Gorge for 21. - calendar tleyafrem Hie tlab Me pmjaG is comple4.M.After 2lnlentlar days,we will dispose Gall samples submittetl lndutllrg those put' ' on hold unless you have centnted your Alpha Prej-Malager and made ararg—ls br Npha to continue bold the samples.AR' —[a—will M disposed after 3 W,I ass days Iron Me date Me P epct is compbted. - WPlease cenbG Pre7ed Management at gag-624-9220 wiM airyques0ons. -. W - n U Q W Z❑ Z G I the uhders grid,attest under the pans and penalties of perjury that to the best of my knowledge and c - ` - belief and based upon my personal Inquiry of those responsible for proud ng the information contained w In this analytical report,such information Is accurate and complete.This cert�cate of analysis is not _ _ - complete unless this page accompanies any and all pages of this report. E E Michelle M.Moms z i Authorized Signature: - - - Tide:Technical Drector/Representative Date:09/25/19 - a Qrn -:Page 3 of 16 Serial_No:09251916:35 Serial_No:092A1i:3$ t r Project Name: CAPE REGENCY Lab Number: L1942358 Project Number: K11240DA.S.WW.700 Report Date: 09/2519 SAMPLE RESULTS Lab ID: L1942958-01 Date Collected: 09/17/1912:25 Client ID: INFLUENT Date Received: 09/18M9 Sample Location: CENTERVILLE,MA Field Prep: Not SF ecified Sample Depth: i Miami Water 011utian Data pab Anatyllcal Parameter Result Ou.1— Unib RL MOL Factor Prcparctl Analyzed Mrthod Analyst OR INORGANICS S d Tmd 400 mg1 10 NA 09191191215 11 406 Id DR S TdaIS zpentletl 38. ifi NA 33 - 09 1 133 9193 1 1 26400 l mg4_....... ._.. ..._. N g n,Am on 20.0 m94 0.150 - 2 119/191 5 09231922:36121 piOONHIBH AT BOD,5tlay 9]. mg9 30 NA _ 15 09I18I190 5 09(23I1923:10 1e1,52106 TE MISCELLANEOUS i i Page 4 of 16 Page 5 of 16 Sorial_No:09251916:35 SerialNo:09251915:35 Project Name: CAPE REGENCY Lab Number: L1942958 Project Name: CAPE REGENCY Lab Number_ L1942958 Project Number: K11240DA.S.WW.700 Report Data: 09/25/19 Project Number: K11240DA.S.WW.700 Report Data: 09/25119 SAMPLE RESULTS Method Blank Analysis Batch Quality Control Lab ID: L1942958-02 Date Collected: 09/1711912:30 Client ID: EFFLUENT Date Received: 09/18/19 Sample Location: CENTERVILLE,MA Field Prep: Not Specified Dilution Data Data Anzlytical Sample Depth: Parameter Result Qualifier.Units RL MDL Factor Prepared Analyzed Mrthod Analyst Matnz. Water DIU- Date Date A-lyfi.lCh, i try W ttio �h L b f sA pl(� D2;B tcl3 WG7295908 Parameter Result Gualitler Unib RL MDL Factor Prepared ysetl a od Aaalynt - - -'NO 1 2 MR N Bs9en Npeb nlg4 010 - 09I19I190840 G H IaCti m W_tb,.�' Lab ..+�.. 9 r ,-_.2`3,.... A,.-\}»',a 1 �-._ y.f d. '. G Q.Tel Clf aY y W stbo 9h L b f..., ➢I()S 02:,6 tch WG7 85909 1 .. ._€ d�h,. i Sdtl T ISuspe..Mad NO ND mg4 5.0 NA 1 - 091191191323 121,25d00 DR .itr cn,NiMte NO moll 0.050 - 1 - OW1911907:18 44,353.2 MR .1-, No f - 443532 R Nlrcon,Nitrate 43 m911 0.10 - i - 01t911907:18 44,353.2 MR G IQriM try W th' ,ghL bfi Ple(),01.92 iB tch<WG�2859681 NNoo Total K4eldahl 0793 08 0.300 1 0924I190536 0925/1912331214500NH}H JO BOD.5 6,Y NO moll 20 NA 1 0&9 0 5 0RL9 :1 BOD Sday NO 9/l 2.0 NA 1 09119119 64 25 09T13I923.10 1215210a TE - Oil BG.a HemGrav NO mg0 4.0 - 1 6117 M 0911911918:00 ]416fi4A ML G ICti tryaW stb' ghL b f 7. pl() D1A2 Bateh11 WG12860111 pe O mg4 8O 1 0-191313 212WD � Iql Ch ,-try W $t;,,,9h L b}f '- <�I(� ➢2 B t h WG1286281 1 J �� 0118 MLL Grease.HemGmy NO rage 4.0 1 09119119 t]:30 09I19I1918:00 884A G n I.Ch m try W tba ou9t�L b t mPl(] 01-;pit h WG77vefi263 mg4 tragan,NmmonM ND 005 t91t9]5 Y192 148O AT i G n f.Ctietn<try,y�est6 gh.L,sb f f;s PI()D1s0 1 h WG12854381Ce eclNe,TOtal mall. - G rat Gfi Stry_Wy(boryu9hL b(or OmPle(s} O2'9afch tW�12876701x r,<_r�,A r,�a5 a T»�`ra;c I Nhagen,-1 peuenl ND !� m9A.w O 0 1 o9@u19— W-912s1 1 4 f i i 4ydvHA Page 6 of 16 Page 7 of 16 i 0 i X �' a kR .. .. .. E pq IU.y: 95 1 j z 2k 'y E it d d E E: �E22 I m e t wra'; Q u h 4 Y 6 U .,.F 1✓ F 3 l.T 0,�, f .i , N n F d y O ctr, c9-, S q :1 o i NE 7 2,96 o �3 i -•m" a. 3 .� 1 m 3,• 3 3i r - t '' U t i% 4 "� cis .ai y I r a ..; Wpix m3 O t m J m . i E +L• E tE �' E 3E iE E SmF �s ES, E E. E E{ EA Jrc F 63 ,+D 'i y Ega ? _ S k j 0 a a: a 3 U U W t p ko Q � j Q d 1�. ��1 U Y a i 1 I� U Y S n m� E E tE' i E 'E E;.' xEt E ry a z z' E e. qE i E` E t@ @s a �Et 3'. 'd4 m E. E { 1 U,:.: z Y z C9 •Sj`�.m I ce3 2' k. m �f 'W In i r t a m �E E' m _m E E {E, yE. , I a a': to a a a ar i E o — 0 0, oy m IK m F t-' 5, 5E 5 2 as m j s E ES E :N E E E f E E 4 0 E m;F w E E Ei 6xi - �._ rn ar p vy y� I 5 0 U E 4 YU; Q O. U € m e ,ry� eqq E e app eyp Epp U 0 m m 3 .i, o of 3' 3 3 3 a a a" m m m ; U I& u " U O m E Ai 2 ° E w ! j P fn > t m t O j 2 U a a a a a a m m }E E4 {E. 4m .E, F E� E, 1 f.. i. .ai I k S NE" �y c�d E a `e U Y # j i a Eu a sass E- E� E E+ E': 4 9 4 9 4 a g A i c�S�A!d��'®s5.1i s''Sc 6 x 2 6cC gcc 6' 1!�9SEWw1w 3 q NnF m; .. ° P4 �11 6"r2'c4.1 @: 'Rg C.�R��.E�e W ,PZ83.��.�.�4��5�.��.�@a@' ��a Re .. E6 RI £o a ?E. �'2 gx 'Sa _�'&5 '� 8 s'° Qy �o,� 6 66 e1, BE Rol o �� s @.� �F fig' s . 1'1 a �.a s�[a. �� o�a s e�6 k'°sgr,rg-, Ao om 3 �1 $ pa�oe "d 'e .�eK° sc ,�c ".$ �g ,$as°.e i � a€"s� ad o f m m gg Jig as..a. ea g sCC § ak p8p °a WHOM- ion �s55 3��'S� � < m'_ 'm 3 o mo z _ o _E 33 E 6EE6gBgkQ' d pE 6.5'06.�? •`l• m pp g °3 D o - a � F�5'"31 1110 S' B .�1. o yea;Ig 1-1 Mal - Nd0 r e� ,s�€4. .6x' 1 1 s3 � � e�`S �� Hill, .' �. � �� s �� I inWIN N m `ate . 3a: &. p¢ � zEe� n N oil .3 a Ulu �R m elm m m e s "�. ¢ S a 8: R¢ 6 a°. lea a PIK a ' z e �s. n ��'° 5 W ee �p s x .y p gm 2 a L i_y"v �H1 N!N e omj�3m �S�vn 20 TD k9 'E illwin�_ m&,','G�_'og _ u''S e _ e u6_mm- _ "Nam i " 3m a 8 'pill LL¢ ELF HIM; 9^ 'F $ ��u"g° n10 g ie ND o i g m�19 0, - s 7R� "p@ �R�t'sR^fig d� s g$>�Oat9 cR z ma m -aa; ng, a B"I ��° �` pas m @ N okd R� S 5'R �1gp&q 'E,�z_ 3 �� s � oo°c` m .2 an°o 3m� n m ws'. m " ¢ nJ ' a m �"d� I @.Rg R it '9 R u a ocu �" Q"E'='F '" 9g. E .°'E�g gS c .M ii �a o N's ;� i $um a s ne' � 1 1211 p g3.=�1 11 Rye' � � R. 9gsk k° �"BUSEc az S '°in;s� `�a=°=d� ;uo= - QaPN aim' `s HIM�`�$ HE � Se��111w z =_�� psIN c�� d nn 9 2 g9 5 I q�� d..`•a. R ff t 3p @.Pd a�c"ps s@ � yak � F � EY�.a �So '$ g ^'S u'6 �} � @ R R Ce_ o C 8� USI 6 " Ga'4'�"''6s aN a9G PHI a °as �9 a �a� R 93 � R�R��° a$ H1,411 flu 5 ^i Ilk rw •, z� m � - '�_ga �.Aq � g,F sPs. �HUI s Ea � �.59 '�' r �. tag s«o g1 ° �xg n S 9i a � ''sR��ssFgd,A s�d'�, lip! t. g 6@ �g6g cR ma' a e § `�._ gc as 'k��e � 5� Z mgoi e8 9 t 4 U � os oo 5 �a ��sEI g I a �=�a �a'�Gz s F E a 8 I F� s> ° 'RP ohs �aa �"'� I anaEl- Hita m r m H, � all a� e y c � %W f.'HE 1 z � mn.3i Ni �D I E�q � �. � B �^as�c�� $• ' �a£ � 3 la Serial No:09261916:36 CHAIN OF CUSTODY Pro;etl N-1 Cep,R,Bersy 13"x ❑Aan G,wntlu P :L,cObn:C,nIeMIN;IAA A1.ie'FH Pimnm CUM,BemurLLEmlmmnenl,l Psc,cl,les Pe,kc1 P:N112AOOA.6.KW.]W ` A„re1e:15]J Mnln 6treel _ Proecl tA,M an Jau h6m2F '^• 6�aweter�fAA 03B]t (ALPHA pu,la tl: — Ph—:60be0F,>OB ANALYSIS c ee6-00&e100 __®SlanemA ❑Pah i,eeraw2wm - - �a Email aknenkv rp�NSWJvI,r.cmm o�� ❑Tnu mnP:.wewnvahNgAMe Oue Oeb: T,na: a6,er Projod SPetlf,Reg0lremenle/COmmeM910eteMion U,IW: �eni N P.L.ID 9.vnPie 10 —'.-�ru J mro 6unelw'. �n i. p _' LLel ue,onhl I wmb 4 `1LS'-' mn,eM v ur '1[:7' ��- EMM1t T„ a VJN 4 Id01 0101 1 Li I u I Li l Li II i11 0 0 U U ululu ululuU El C,ntelneeT ' rb�w PmeeveWe fir:,wow PeewenaaM eHe,« mnnan Page 16 of 16 i Massachusetts Department of Environmental Protection IM7 f B -uof Resoure P tecbon-Gm tl t r Discharge Program 1.-It Number \t, Groundwater Permit DAILY LOG SHEET 2 Taa Wensrtabon N mbar _ _ 2019 OCT DAILY Sampi ng Month B Frequenc,.. Massachusetts Department of Environmental Protection }'. - i,. A.Facility Information FLIAeDEP'Transaction Copy Imp rta two filling out forme on 1.Fanbty vame,address the computer,U- ICAPE REGENCY HEALTHCARE CENTER Here is the file you requested for your records. only Ina lab keym maveydurwrsor i 120 SOUTH STREET"n - ' To retain a copy of this f do It use the file you must save and/or print. rewm key. <b slrem Adores: BARNSTABLE- MA 10200 .. CIY a5tate e.ZIPCode Usemame: SFARRENKOPF Transaction ID' tl64920 IJOSEPH SMITH - - .N Fadlay Dondct Person _ Document: Groundwater Discharge Monitoring Raport Forms ' 5088961]O6 - - ism NQNSW✓akr.dom Size of File: 1034.60K -b.rakPnar�Neir� mdl eaareaa- Status of Transaction: Submitted - 31 Sampiivg information: - 10/112019 NOTAPPLICABLE - Date and TmeCreated: 11/22/2019:8:69:53 AM 4 a.Date Samded(mmadhyy). b.tnbmarory Name { BEA PERSONNEL -- - " Note:This file only includes forms that were part of your �,Malyah Pedtmraa ay an fNariwl - - transaction as of the date d time indicated above.If you need - a more current copy of your transaction,return to eDEP and., _ B.Form Selection - - select to"Download a Copy'from the Current Submittals page: i I.Please,dart Fomn Type and sa,npling Month&Ftegnmcy - Dairy Log Sheet-20190ct Daily - .r All forrvs for sub.it'w have been completed . 2:C This"s the last section. i - 3. Delete the selected fmtn. . s r - gdpdis 201 So9-1 Sdm•rev.0911WIS Groundwater Permit Daily log Shea!-Page 1 of 1 1 [LI Massachusetts Department of Environmental Protection gq7 i L Massachusetts Department of Environmental Protection13-u of ResourceP t t0on Groundwater DI,,harg,P g 1.Pe 111 b iB uof ResourcePmteceon-Gro d [,,DischargePogram.� 1 P I N b rGroundwater Permit GroundwaterPermit .. z.rax a tie b ry b ( .DISCHARGE MONITORING REPORT - z T la b6 d n N bar DAILY LOG SHEET 2019 OCT DAILY - `i 20190CT MONTHLY a% Sampling Monty 8 Frequenry 3.Sampling Monty 8 Frequenry C.Daily Readings/Analysis Information - - - - A.Facility Information Importantwhen. , Oak Effluent Rouse Irrigation Tmbidry Irdluerd pH EMuerd eModne W nllmgoutfannson 1.Facility name,address: Flow GPD How GPO Flow GPD PH Reeldual Int-Ity - - the computer,use 'CAPE REGENCY HEALTHCARE CENTER (mall) N only Ne lab key It J t move y torso 120 SOUTH MAIN STREET 1 20700 6.4 6.6 d�r�tky Na,r b.Sbeel Andreae 2 21600 6.5 7.2 I - , 3 21600 6.7 7.2: BARNSTABLLE M fi30 A 02 tali _ _ a.Sda. e.2$- 18700 5 Mon l 2.Contact information s 18700 .> - - - { nam OSEPHSMITH ] 16700 - 6.1 7.0 6 i a Nameof Fadlityc. ct Person 20300 62 6.8- 5088961706 smithQNSUwater.com 9 23500 6.3 ]A t b.TelepForeNumhar • c mail eddrass' 10 mco 11 15300 - fi2 - ].1 E 3.S piing infbmotioc 11 15300 - 10/70/2019 LPHA ANALYTICAL. 13 75300 r tali 14 f -. e.Date 3amded ldlRYddhWV1 ,. .. oratory Nama - 169M 6.2 7.0 1 'PHA ANALYTICAL PERSONNEL ' 15 '21400 fi.t 7.0 I cArahsis Pedortned eY(rvama). , 1s MOO 6.4 7.1" - t] 1200 - sa zt B.Form Selection is 20033 6:3 7.1 ' _ 1.Please select Foim Type and Samplivg Month&Frequency 19 20033 xo D harge Monhanng Repo1-2019 Oct Monthly 2WM - - 21 19800 6.4 22 15200 6.3 e':7.0.. I -All£corn.,for bminl have been comptekd. 23 13700 6.3 7.0 l 2. This is the las selection. 24 15fi00 fi.b 25 16933 6.8 7.3 3.r Delek the seleckd form. 26 16933 ( } ! 38 18100 - 6.1 7.2 v. a - 39 22100 - fi.2 :6.9: - .. - •.. 31 13700 a!6.8 6.5 . gdpols.doc•mv.0911WIS Groundwater Permit Dolly Log Shee!•Page i of 1 J - - gdpols 201SOS15d c•rev.09115/15 Groundwater PemIH Daily lag Sheet•Page i of 1 ) r f I '""•'"'"'�""'"" Massachusetts Department of Environmental Protection 847 Massachusetts Department of Environmental Protection 847 et Bureauof Resource Protection-Groundwater Discharge Program 1.Pern,,..in r j Bureau of Resource Protection-Groundwater Discharge Program 1.Pertnit Groundwater Permit ' \ Groundwater Permit m er DISCHARGE MONITORING REPORT 2.Tax laenunwuon Number i I \�, MONITORING WELL DATA REPORT 2.Tax ltlantiAwtion Npme4r 'V 2019 0CT MONTHLY 2019 OCT MONTHLY 3..a P,lr on4f�i1 8�roquancy + .9amp Ing M N d Frequenq D.Contaminant Analysis Information A.Facility Information •For'0',below tlemmon llmlL lass Nan(<)vyue.or not tlemdetl,enter'ND' Important:When •TNTC=too numerous to woof.(-I results only) filling out farms on 1.Facility name,address: •NS=Nat Sampled an.wmpumr,use ICAPE REGENCY HEALTHCARE CENTER a*Tatabkoy. e.Noma move ywr armor- 120 SOUTH MAIN STREET do w1 use But 1.Parameter/Canmmina,t 2.1 B...1 a.EBluent 4.Efluom Mefh.d { rotom key. b.Strool Pddmv Units Oemctlon Ilmtt BARNSTABLE MA M00 ® ND 2.0 pal c.CV d.Stam a.21FCade Tss ND SA 1 2.C.vmct_rmaa.n: 1• f OSEPH SMITH MTAL SOIJOS y10 � ma al FadllyCwOtl Pemw NrL C 5088961706 smith@NSUWatenwm AMMONIA41 1g 1 b.Talepbc o N VMer c.email eddmse AM xnRATEN 2.1 0.10 3.Sampling infirmfltioa: bIG,L 10/12019 NOTAPPLICABLE TOTAL NnaadEN(NO3•NONTKN) 2.55 0.4 00 I e.Date semged(mmmd,,,n b.-oncry Name MGL BEA PERSONNEL OIL40REASE ND 4.0 c.MarysU Pedormed By(Neme) MG - B.Form Selection I.Plesse select Fean Type sad Sampling Month&Fregoency Mpnitoring Well Data Report-2019 Oct M.nNly r AU foam for submittal have km completed. 2.F This is the last selection. ! 3.f-DO-the slimed form. fi E InfeBrp-blank.dw-rev.09/15/15 Groundwater Permit Disco.,,.Monimdng Report•Page 1 of 1 I gdpols 20150315.dac•rev.09/15/15 Groundwater Pemllt Dolly Lop Sheet•Page 1 of 1 k� t Massachusetts Department of Environmental Protection B17 i m Massachusetts Department oT Environmental Protecton 847 Bureauof Res.uroe PmtecUon-Gmundw ,Dis ,rge Pmgmm 1.Permit .roar i _ Bureau of Resourw Pmtaction-Groundwater Dis@ame Pngmm 1.Pmmil Num er Groundwater Permit 2.Tax Mentifics-Number j \. Groundwater Permit 2Tax MentlAwtmn Number MONITORING WELL DATA REPORT 20IS OCT MONTHLY V• 3.SomP nag oM nnN 8 Frequency t C.Contaminant Analysis Information Facility Information •FOr"B".bolow detecil.ngmlt,less than(<),due,.r oat detected,ads,-ND' < i Important:When CAPE REGENCY HEALTHCARE CENTER •TNTC=too numerous to count.(Fewl insults only) i filing out forms on I.Name •NS=Not Sampmd the computer,use •CRY-Not enough water in moll m sample. only the lab key to 12050UTH MAIN STREET ova your cure.,- b.91ree1 Pdtlresa do not use the BARNSTABLE MA 02630 realm R.Y. c.City d.Sam I.LP Cod. Pammomr/Canmminant MWS W. MW-> UnI1s Won ft:I Wellk:2 Wel1#.3 Won#:4 WeIIH:5 We Certification 'I certNl underwwly of law Cat unit dmmantaM all atlaNmentswere prepareduMar my drerllon areuPorvlslpnN e-1-111"Its,dealgned 1.assure tlalqualifietl IdIc lFmpaM gaNeraM aealuala Nelnlmnollw aubmlCeJ. fi.34 850 6.25 BosnianWIm.11 of NI wmon or pereoru wba manegoN,,Inuem,or-powm diudd,mdsouto for end-g Cre 9.D. Nl-on.Ins InfpmaLbnaubMlmd b,to NM heal of M knaNad9e no cdcf,eu,eovmmend complete.I ere a Nat Ne STATIC WATER I£VEL 18.31 17.51 18.80 - ere eynlAwnapeialtlea for wGNtlNp kbe Nmmatlon,LWud�tla posslMliry olflna entl Mptlawunwl mr Mo.NrpNdetlo�a.- �T AMANTHA FARRENKOPF 1121-19 9PECm000NeuCfANCE 134.9 232.9 2192 Any pars.,s1gnln9 e.Slpalue b.Oam(mM41sAyl uMglosc j a coconut uad., 3 W CMR 5. r (2)shall make One Re ortin Package Comments Ne lollowing 019 M EN NETT INFLUENT N LUEN AND EFFLUENT SAMPLING (OF n1E S COMPUTETED THE OCTOBERTREATMENT T ceNfiwtion MONTHLY INFLUENT AND EFFLUENT SAMPLING OF THE MBR WASTEWATER TREATMENT SYSTEM.MONTHLY WASTEWATER SAMPLING WAS COMPLETED ON 10110119. B you am filling LABORATORY RESULTS REPORTED ALL PARAMETERS WITHIN DISCHARGE PERMIT elecbonlcally and LIMITATIONS.EFFLUENT PH WAS REPORTED WITHIN THE 6.5-8.5 LIMIT DURING THE MONTH. wantm etmrn DAILY FLOW EXCEEDED THE M,350 GPD LIMITATION TWICE DURING THE MONTH.THIS OVERAGE OF FLOW WAS CAUSED BY SEVERAL FACTORS,INCLUDING A FAULTY VALVE ON adtlitlonal jAN INDUSTRIAL WASHING MACHINE NOT CLOSING FULLY,DRAINING ANDCAUSING WATER manor,select TO BE CONSTANTLY ADDED.ADDITIONALLY,6 TOILETS WERE FOUND TO BE LEAKING BY the check tax THE FLAPPER IN THE TANK OVER A PERIOD OF I0-15 MINUTES EMPTYING THE TANK AND CAUSING THEM TO REFILL.THIS WAS NOT CAUGHT RIGHT AWAY AND TOOK TIME TO F DIAGNOSE.FINALLY,2 TOILETS WERE STUCK OPEN CONSTANTLY RUNNING.THIS CONDITION WAS FOUND AND REPAIRED QUICKLY. ROBERT B.OUR(SEPTIC HAULERS LICENSE#15-2019)WAS CALLED IN MULTIPLE TIME TO PUMP OUT THE ED TANK WHEN IN HIGH ALARM DURING THIS MONTH.A TOTAL OF 76,000 GALLONS WERE PUMPED DURING HE MONTH.THE MINIMUM,MAXIMUM AND AVERAGE GPD FLOWS REPORTED OVER THE COURSE OF THE MONTH WERE 10,800 GPD,25,200 GPD AND 17,884 GPO,RESPECTIVELY. I I ) mwtlgw 1n,.1,doc-rev.09/15/15 Monlmdng Web Date I.r Groundwater Permit•Page 1 of t gdptlls 201509-15.dac-rev.09I15115 GrouMwater PemJt•page 1 q11 fi t Selial_No:10171914:30 c Of z m E o ANALYTICAL REPORT z o °EE m A Lab Number. L1947537 I client: Bennett Environmental Associates C 1573 Main Street _ 2 Brewster,MA 02631 Ld I o K ATTN: Joe Smithu, —— Phone: (508)896-1706 Era - ProjectName: CAPE REGENCY Project Numbe, K11240DA-S.WW.700 Report Date: 10/17/19 - - ro ro ¢ ¢ E 3 3 i The ad9lwlpmfeprepaVdam p.dm9em MB by apho An iylcel.itch repoNdab peWp 1,p pirated aM aMuld orepnid.—n.—Nlts Z? mWery.NpM AnaNWal MMs m rmmmlbON formsWm andlordam Nat are Cot mmismniwM Na otigNal. W.16 w a LadifimMm BAppmrds:MA(Me(LACt,NHNELIP(2060-6),PHd5Td1. ),VA(45019(MA000961,M0(349),NJ(MMA915),NY(tttae), K o m Z Z NC Fe MOUaafi.S).Tx(r10d]044]9),VrM-0935).VF(d6p195).USOA(Pwmlt pP3l0-1]UOt96} Eight Walkup Drive,Westborough,MA 01581-1019 1 508-898-9220(Fax)508-898-9193 800-624-9220-waw.alphalab.com w E E z z' c 4 4 Page 1 of 17 �.l:.:u.^::• - a s a vmi a Serial_No:10171914:30 - Serial No:10171914:30 Project Name: CAPE REGENCY Lab Number: L1947537 - -Project Name: CAPE REGENCY Lab Number. L1947537 Project Number: K11240DA.S.WW.700 Report Dale: 10/17/19 Project Number: K11240DA.S.WW.700 Report Date: 10/1719 Lase Narrative Case Narrative(cantlnued) ` Thaeamplav were—Iv1d lnac nd—with the Chain of—dy end no signifimm dev a-s were enmunbred—no Ne prepaali.n orembsb .iharwbe n.bd.sample Remip4 Container inf.rmmmn,and the Chin of C-elyare lombd at t;e bech.l Nerep.d. Nitrogen,Nitrate . - WG1294934:A Matrix Spike and Laboratory Duplicate were prepared with the sample batch,however,the Results Contained whhln this repon releb only m Ne samplm sub.fttW under Nle Npha Lab N-n—rd meet—requirements tar all native sample was not available for reporting;therefore,the Matrix Spike and Laboratory Duplicate moults NBIAPam I.d pammebm unless.menNm noted In Na fallowing n.nadva.Thedata prsi..d In Misreport Is.ry.n¢ed by,narn r (I.e.—.taOC,emJ.ii—pleapedflc Quality Conlmldab(Ia.Surmpate Spike Ramvery)Coreported et Ne endol Ne largetenatyle list could not be reported. lormchlndhddualmmDle,blkwed hYNS Labombry Bamh Quality Centel atthee;dofeach parameter.TeNatively ldentifietl - ' Commurds(TIC,),If requmted,ere mp.dcN formmp.unda Idali fled to be present and ere Cot pad of the methadlpru9ram Teryet Comp.-Lbl,even no*amnow.f the TCLere Ming-rue.ka sample was re-anaty ed or re-oxtacled du.m a required quality on I mnecove achon end tt th Cob of ce.ere rep.dM,fro Laboratory ID of the—riuty is or re-axtr-n is dmignated wIN an'R' or'P.respservaN. When multlpb Batch DueuN Canbvl elements ore rep.ded(ea.mom Nan.ne LCS),the maocl—sampim for each sknu, ere;.Cots N the greyehaded header line of inch data Coble.Arty—naory Ba A,Ssmplo SVedflc%recovery or RPD value Nat is.-id.Nelbted Acmldanm Ldmrm Is Mload N Ne report In rebrenm to pumtlons H(CAM)or4(RCP)whan'NO'L'chackM,the mdomnanm flit¢;. for—and RCP man-.'lmu(n Come pushy Control fail—.occu-n-In be wlNin method mmp..nm.Inlhoo Nsmncas,tha 1 apedflc figure ts Cot minted but n.bd N IM1a emadatetl OC Oulder Summary Rapon,tomcod directly spec Ne Laze Namativa OC Nmmmtmn m elm Nmmomted In Ne Oam Usahllly Auessmmt Cows(Format 11).lour Data Meryar mat,where it inn ba reviewed b mnlumm�w;N dw aempb rmW4 essodabd repummry uileM OM¢try amatlabd dam umblliry lmplim4ons. SOWs.dMenm,sands eM gswes ere reported one drywalghl bab unlaw aNerM,e mind.Da.—of all data quagfiers and mmnyrm u,etl In Nis report era p—d In the Gk-or,IomiM et the beck of Ne report 1 • HOLD POLICY-For samples su arieud on hold,Npha',..cy a to MH mmpW(w1M Na exmptmn of AP fanmters)frte of-,b.mr 2l WeMvdays Mmthe deb Na projedk mmplebd.Aper21 m1eMar days,we w9l dupese.l all sampim submMNinrdslN9Nmeput - on re.unlem you Mve mnlaCed-1NDM Poi..—treraM matla erangemmb for Nona tocorft.te how the mmpies.Air - mrbstue wlA M dbpmed alter 3 bmbras days lmm tbe dote evi project e,omnputed. i .... .. . y Mease ranted Protect Mamgemem M e00e2—ut catty any queen— - f f i r -- 1,the undersigned,allest under the pains and penalties of perjury that,to the best of my knowledge and I belief and based upon my personal Inquiry of those responsible for providing the information Contained _ In this Y analytical report,such Information is accurate and complete.This car8fcate of analysts Is not Complete unless this page accompanies any and all pages of this report. CatEn W4Uvnrh Authorized Signature: Too:Technical Director/Representative Date:10/17/19 Page 3 of 17 e`3`.y3.^ Page 4 of 17 r r , Serial_No:10171914:30 Serial_No:1017191 A:30 Project Name: CAPE REGENCY Lab Number. L1947537 Project Number: K112400A.S.WW.700 Report Data: 10/17/'9 SAMPLE RESULTS I Lab ID: L1947537-W Date Collected: 1011011910:55 Client ID: INFLUENT. Date Received: 10/10/19 Sample Location: CENTERVILLE,MA Field Prep: Not Specified I Sample Depth: Matrix: Water DIIWon Data Date Analytical Parameter Result Du 11- UnIM RL MDL Factor Prepared Analysed M—d! Analyst I G ICh ml try W''tboro 9h Labs' Solitls,Total 410 m911 A 20 DNA 2 10/15/1909:30 �121,2S40B OW INORGANICS Soid Tolzla apmdeE. 1z rel 0NA - 10 - _ 1-11911.07 1212—_..Da N trog ,Ammonia 10., mg1 0150 - 2 10111119 15 48 10I1111921:231214500-71 AT i BOD 5eay _ . 78. m911 30 NA 15 N.119lo 0 101IW916:00 121,5210B TE MISCELLANEOUS i i i i Page 5of 17 j Page 6 of 17 i i Serwl_No:10171914:30 Serial_No:1017191:30 Project Name: CAPE REGENCY Lab Number: L1947537 Project Name: CAPE REGENCY Lab Number: L1947537 Project Number. K11240DA.S.WW.700 Report Date: 10/17/19 Project Number. K11240DA.S.WW.700 Report Data: 10/171-9 SAMPLE RESULTS Method Blank Analysis Batch quality Control Lab ID: L1947537-02 Date Collected: 10/10/1911:05 Client ID: EFFLUENT Date Received: 10/10/19 i Sample Location: CENTERVILLE,MA Field Prep: Not Specified Dilution Date Data Ana:y[Ical Sample Depth: i Parameter R It Qualifier U It RL MDL Factor Prepared A lye d Method Analyst Matrix: Water ouu6on Date Data Anaytical G rat Ch 1 try W �bpFo„9h Lab f pl()r02;9 t h WG7294934 7 Parameter Result Clua Ger Units RL MDL Facor Prepared Analyzed Method nalyst i N"Eo9 n,Nltrals NO mat 0.10 - 1 - fo/i1I1908:68 M,3532 MR s rea,Total suspeoeaa ND men 5.0 NA 1 lonan9 n:m 12l,zsdoD oa I �o-o9en,Nmik rvo m9n Dow - t - Ion 1n9afi.a9 a4,3wz MR Ni9 Fd die ND mcA 0.050 1 - 10111/190]:29 06353.2 - - -- ---R -- --- --- G Cdk' fry W sfb`oo ghI h f sampl(s) 01112 B t h WGt285113f 4 N tro9e,N'imM 2.1 m9ll 0.10 - 1 loll/1B 0]7e 46363.2 MR -,--. -- - m 4 0.300 - -- 1 1WI1119 I&M a11/192241 121p50—H AT BOO Sday No m9A 2.0 NA i loll 11t810. TE N tro9en,Total lGetlaM1l O.dde 9 /ta19160 3152106 300 Stl y ND Ae 2.0 NA 1 1a 1I181 'zo lW1u1191coo 121521o8 TE G n ICh lryvW tboro gh Lab fF.. ,pl� 01._(3 t h WG1 9512fi 1 d /" ?•. { 3 018 Grease,Hem-Grev ND mg 4.0 - 1 fatt11917:35 1a1111923:00 74,1fifi4A NPo9en Ammona ND a 0075 t 101111191 I11/t92058 121.SOON113BM AT G IChe try W:tbh ghL b t,,r;mP�f() 02-�B tGt WG�2951331� > y '+'• � ) ,_�•, ��, N o-aaan TOW Nemanl rvo m0oaoo 1 �1: r 2 HaH AT G I;Che try W r ghi Lab f,;@ r pl()s 02.Q I h WG1295295 1 j OYaGreaae,Heml3rav No m94 4.0 1 1a11/1917:M -4,1564A YML I .i G n I C11e 1 try W jb,rAnU„-_ pf() 01-02 B i h WG7295831 , n �,�,�!1i., S.lid Top-S.p d No m911 5.0 NA 1411911:0 1 540D DR G I Ch fry W,tti 9h I.ab fo pt(s) 01;B tch WG„}29fi17S1 F '' "� T i~ _ ._ ._ .. ..ta Ss TOMI No 1-Y 10 NA 1 1a1a11909:w' OB DW i A, I e:3 Page 7 of 17 Page 8 of 17 Serial No:10171914:30 - Serial-No-1 0171914:30 Lab Duplicate Analysis - Lab Control Sample Analysis ., Project Name: -CAPE REGENCY Batch,Quality Control Lab Number:" L1947537 Project Name: CAPE REGENCY Batch Quality Control Lab Number: L1947537 Project Number: K11240DA.S.WW.700 Report Date: 10/17/19 Project Number: K11240DA.S.WW.700 Report Data: 10/17/19 Parameter Native Sample Duplicate Sample Units RPD Qua[. RPD Limits - Gene_ral Cti mistry W s[fi ugh Labs Ass�wated sa pl.(s),02} qG F3;,t h ID WVGQ294937 3L QC S-mpl L71900010 82 CII t,ID DUP Semple'-,�r,w"4A±v LCS LCSD %Recovery " w rp9an,wvla LL _ ND _ No _ an N - za Parameter /Rvery Qua[ /Re ry Q 1 Limit. RPD Dust RPD Limit. Ge_ne r lCmtry W 'Lbos cial dsetple(s)'0102 gC'B'tci1 ID WG'12051133' QG Saml h.94 5-3 0C 11eDFFWENT ' ,--_. G Netrmal Chemb day is try'�jW tb J911'Lab.As oclatetl:sam...p.l{e'^()02'."t!S_B t h�WG12949342- l.F 9r0,,1.1.0 NO ND � ,mg0 ]5 „,.. l.. .':_:. -� ;. ".a Gen ral:Chemist. W tb rou h=L'zb.Assbcleted;5 Ids 02 sr.Batc:"WG�'.94937.2 G.t r- e .... $Wssiborou h Leb•'Associatedr G n rei'Ch try 9.,.��..... „Ptels)A01 qC.B t h ID WG`1295y26 3 tQC^S mpl U_ Nilro ,,Ammonlo 0.777 O.r08 m9ll F 7' 20 Nltrepan,NlMte ri100 .� -110, - YO + t : le =:�: C=Bdtch:l0',. 1 1 3,3.,�_gGSem le.;1947.60602"Cl entlD:.DUPSam le: I -'<" -" '1 General,Chemis.,-,WestD r h,Lab.Asso I led;s m I .01.02 sate IYJG,2951132.<_y;,a,z -:, h ;- ,�.,.....,_,. .t!?I.:. .9,x.,,.,,.,.,.._._P ()1 .,, _....,...�,. ..t.: .t..'�-, .,�.-e:..s ,,."..,........ rc. .. .,.. Nftgen,Total KleldaN ND ND mtll ae ....... ... .._. .. _ ... it.. .,..,.��............. 600.lfty "` '""'' "Assoc atetl sar'n le-s 02,*QC'.6etch lD 1NG12'952953t QCrSem I L19M1-B0001 CpentlD:' Sam le"{ - - ,. .. - ...., - - w� 7:. �. R 011 a G. H—rav ND ND Gerieml Ch mistry,4r/ ibo 0 9h L"sb Ass clot d;_, General Cfieml trylyWe I7%r 9h L 6 A be t d ample(s)a01 o -g9`19tch ID WG1295B31 2 "Q S",pl.L7947537 01 CllentSD -B2 00.120 h20 k smms rotal suspenaaa 7z s7 m9n l"'z, 7 _ z9 Gane�a(-Ch m try:1W stb u<q'fi 1;9b Assa t d'sr9lple(s)02.:batch iWG12A513312 y"1 M1 r t? '4 mr 6, *xr k�3,,,y?�Yu, I ,. G 1 Chem slryv W13slti_rou9 wLab A,s .lilted s mpl�() Otrs(]C_Batch ID 7WGf2961753° QC Sample L1946816-01 Cllent7D DUP SamPf.- ;LL; V N°'°9"Tota Klawan .......... S,.>,.ias._..a•_.... ...__.. _ .... _ ...".... ...._....... ......._. _.. _. Solids,rmai _ 360 360 lryl "rrp, h_ is Gari6rul Chamystry,:Westbo Hugh Lab Asso 1 fed-samples)OT Belch�WG1495295 2 r x, ;._;�+{, v ,f_ "„S-,:�,�,I ` �' "- - Oil&O HemGrev _-. P;fy J.£"1'. - 70-114 1a as-120 - i' :PH.. _ Page 11 of 17� .. .. - Page 9of 17 Serial_No:10171914:30 Project Name: CAPE REGENCY Lab Number.L1947537 Serial_Np:10171914:30 Project Number K11240DA.S.WW.700 - Report Date:10/17/19 - Matrix Spike Analysis Sample R-alpt and Container Information Batch Quality Control - ' Project Name: CAPE REGENCY � Lab Number. L1947537 , Were project specific reporting limits specified? YES Project Number: K11240DA.S.W W.700 - Report Date: 10/17/19 Coo/erinformation Cooler Custody Seal - - .Native MS MS MB MSD 'MSD Recovery RPD A e Absent l - Parameter" Sample Added Found %Recovery Qual Found /Recovery Qual Limits RPD Quill Limits Conta/ner/nffrmaton - „., In(dal Finalr.Temp' Froien ,+ 'y G n"erel ChemistryjTWn th µ 9h L b A t_li_s mple(s)f02 y1QC B t 1t1tD V✓G72949`37sA`QC 5ampl L7�h0010 82 Cliont ID 5MS 5 mple, r Container/D Container Type -": Cooler pH .PH_ deg C,Pms Seal Dif,1171— a Analysis(') Niwgen Nitrite NO 4 42 "]9 7,' 80.120 - .2n t947537a1A Pasic 2.2 Y HY4500(201 b - ? <2 - G'ener Ch ml tryl,.We tbd ough Lbb Ass r tlsamp7e�)01,02 qC BatctflD'13�G12951134 qC S"empl,"`U1949537 02:Cll nr Iq EFFt,UEN7 - L a A <z _ m Lt94>697nie Pleauc , i A 7 7. .2.z, nt zs4ppl, D 5210121 "" 4 L194753iL1C Plamc unpmearvee 1 7 2:1 - Y A-11 TSB- 0(71 .aOD,5tlay 100 110. f 7 it 'k - - A F so-14s 35 . •` 'ail`. L194>537A2A Plaatc2 m Hzs04 preaerved.. A <z a, 7KNs599(ze) H. mpl�s)_ ,0'2.z -Y -n"—t Bat h ID WG1295{26-4 g1C5 mpl Ly 947335�0] Cli nt ID h(SrSamPl 4y`' }Geferal Chem stry W stb gh LabA ted's� 1:QC 37a Peslc a _ > - era - NO2a5](2)NOaaa912j aOD5210(2) �Nllmg n.Ammonia 011 4 5 2e a 2.z. 753ra2c Piratic p A +) 2.2 Y —11 ` TBB264 M a 1-1947s3 c Amsar o9om H(lpreaa-,veu A uA 2.2 v Asaem - odnse4(2e) - Gerem!Ch mistry•;W tb rdugh.Fah A ociat it samD (s)r 02 YQC Bad h ID}N/G1295133-4:.QC B mpie 1947606 02 CI t ID MS Sample ), ' `• L114159702E Amaer 1000m HClpreaerwd. .A NA 2.2^ Y Apaent. OG1064(20) Nilro9en Total Kleldahl ` NO ""a 1 .60 - ` - t - t - Gl:ljhral Chem try..We th s u h L b As o I t w7p d-a le(s 02.QC Batch ID 1NG1295295-4,+QC Sam le Li'947301 01 Client ID MSS'm I ` .-- g Oil a GreeSe Hm-G2v e -NO 49 90 90 - - 7a-114 - Page 12 of 17 - 'Values in parentheses 1 nd cate holding time in days - Page 10 of 17 `' s�;�,,!':'•. . y" :.A 1 • , e 1 Sedal_No:10171914:30 Serial_No:10171954:30 Project Name: Project Name: CAPE REGENCY Lab Number: L1947537 1 CAPE REGENCY Lab Number: L1947537 I 1 Project Number: K11240DA.S.WW.700 Report Data: 10/17/19 Project Number: K11240DA.S.VV/.700 Report Data: 10/17/19 I GLOSSARY 1 .Th<n[u<OmterNia amlynah<ale bemmitluetl mvWfied Wore Nb mWynuaba¢e Gom N<wgm m.ryd<Gst°ftlm Acm— °n °nNOd DL -DeteeBan Dmie Thu wlm¢m•4mzs Ne kwlmwticb lara<tuulYn mmmeativv uempmtN ueabvW VJm,whin Terms 6.v.8ae el wmmuatiom H gmOrG<dbelaw Net®itofgmntitatiov(LO%Ibe➢L'nct-wY<dJv+®<vv Aulytiul Mrilmd:H°1M1 Ae dmmrcnr hom whicM1 N<metladmiginvu mIlthe u,aly6W rtremccmMvd(Example:EPA g360Hu Gvm NluSay wmv5etivm armouaue wvrmt.u4me apDGvabl<.(Do0 r.pwt fomab gJY3 shwnm I,B2dOBJ lbe calm(Orth<reGrww muhod dammmu x pwvidetl w Ne Retertsrsa mctivv ofNCAddmMm EDL -Patimucd 0<u<tiwL'mie TEuvaluerepwmvdrt Gwlmwhicb wgu mJy2 mvevmtivm ue npvrtduutwmd pig:Wilk wpmtmi°ml Oddiuhle Pumm(TOP1 AuaY avJYsu.the di%vmaeudefiveEa W<Pwt-Trmmtem calm minva We vJue;whin thm<urgct wlYm mmmuadov�4mvtiGedb:bw Je npotNM Iwia(RL).Thv FJ3L'welutln mY PmTnatmmawmc a4jmwmv 60mdDutivm,mmntra30me emntm,w6ne appluabic.Theumo(EDlabrp cmthe malyJe Fi IPH:Aabp5 or PAW mbe SOIidtAue Mivveanaetim(SPME). emivmample Rmeiprd Cmminu Infometimawianof d.e repOti PmilpH rtamb pH Ormvuuudemm:..,t Wu beute' itivwd Mu®tin Poabl<Cammeuim The mvcmetivv tbu fivm Ae aigml pnssnturoe ntmuvv time vfm edln'meoru the laboNory,JapPlieable Hm Wlmm<or t<gwrtd,valucrtOxnlvitialPH wlyte aim theim men Jl ofNe MmHfisHw mimie mwDt We'woa Wmdaocr ntioaita'm.MFNPC uaawrnute Fmno Dam:Wivnapstm VOMtiIe PSanirewm'J.Fmzm pao-/Iime n9vu the date/dmeetwhicLumciuedReagmrWnm- __ preauvrd viola were ivitiJlYfimuL Nme:lffivmv dau/timeubOmtl48 bums Gom awtple wllwtiery vJm w81 bert0raNin bOld'. .A .Evn't°nvmmal Pwtmde Aeem,. IvitiJ PN:,Ubpuubam Sample Rer<iprACavvimlvfmmatim audvvafttr rgnifnwal PH rNuu DH vfwvuimdrtrmutd vpoo LCS lebvwry-1 Smmle:A mmpkmmia,Gee fiom the mJy m of tv- 1.Mi w S.Frown umwu of nxaK ifVPGcabk. eadyw ma vu'.ed31 mWJngkmxn and wnfidmmmnafmilyna. PEAS TaW:Web rrapeuro PEAS evatyw,the PEAS TDW(Sy wWt u detivedu tlnsmwtiov ormxul¢fro PFHPA,PFHxS,PFOA, PFl:A W PF0.S.ifa Tenr wulturwmuq Ne wulu efin mdiviNW wmpwrn¢w11.Gobc teporbi LCS➢ Lbvnmry Gvtivl Sumlc DUPI"van:R<fmm LCS. TOW:With rtstasnmOrBudc evJyam,aTemP nmlt is defitdmNe amvmauvv ofwW¢fvrwdividmlisovm orAmWm.Ha TaW' LFH inbvnmry FOt3fiNakvk:Ammpk meaix,6a 6vm We aml3+m vfinnmiapikMuiNwnfiW known umwna[ rmvlturegaeamgtbe wuly olio ivdividuil mmpvvmv will aLn be npmte6 TbubeppliWlem TOW'rmWuf rmeNON 83d0,808E wI mawmhlmtaNbgkmwn and wnfird umimu OfnWytea. eM gOB2 LOD Limit °r➢etmtivv:IWawl.e O.mvthe Duxb lirLautgnamly¢wn«IWlybedeucu,...vifiewtyuina pmlfcmavu bya.Dm mMM.ThcLODivclvdu evyedjmimevv fivm dilmivm,wmmvetivmmmounm mnoi DaG OveNGers when appliabk.(poD rcpen!ammo Ovly.) LOQ Limit of Qvnv itWan:The vJm etwNchmbraumevtcm e<evntetymeavmemmJyu usryui0e cvvmnvdev The A �pecva identified u'Aldvl Cvvdmwec'uebypmtlmn of Neawemlmmmvativvpmeelmm whevecemmuwmMueed iv LOP ivclWmany adjmmwb BOm dJuSam,wvmvaHamwmoicvve wntmi when applimbl<.(DOD repo.Sbr- B mmr. -JY) emJyn mstleuetrd abov<tb<npoNn6lmirbthe e.S- ex)a,bWk Flog my GmmusaMtW GeM aury+lm Nora M1aw d4,ftg a yPPE.0ona ofthe d Uld at Im Nm¢n tivua(IDr)the wncmtndon(wwnd w the blavk.Pm MCP-(i iQof Qumtiuoom The wlmuwhichmbrmmwntmn munnlymmnvemwJynunxpenGewmmoauva The rojwu,Deg oNywpsmme bl-Ifi<Idmmpin 0whave dcuctabk mmmoetivm ofNe amtyn almset nv rim•-(k LOQ Ncludm my a4jmvwbitom ddunam,wmm�vatiov or mOimm wntmt when epplicabk.(DOD nwnramw the conmeaGon loved Nthe blink FarDORreuudpmjecq Oae vvlymplinmauvciand Gehlawplm Net haw d<ncnble nnlY) i amnmfivmo dymnlna Otev nn Bmea(I mncmmdvv tvuvdb Neblaok Wyk win tlet a bow n-JNrt ,krgvlo t<ryrtb6m sxmmv abmNrx-i- MbkF.,N- irrtlnted Pmjecu,flag only mplim mzumiand field<amPlu thuheve dencuble wn<envetiev O(Ne milyN vhove Ne ML MMa Limit Thu vdm.prow N<IewlmwhichtugnvvJyu wvwmvtim me nponed a mt 1d { ex remni:krill Far NJ-wland P.Jwu(exJtduB Au),DnB OWY aPPEm mamcuW MM a ampl<1 th<thavcdeuetffiIe whey Nine Wge[wyN mom u�gmvnfiN bebwtbe rtpmtiv%Gvtit(RL).TheMDL'wcludm aoY 11 wvun boa oI.e am M which wvr dc¢cted b above Ne npmtw8limicw Nemsaiued methM lmkmvb°w Gve timm etljusmem fivm Wl ivna,wnwvwtiam m°mOk <vmrnt,whore apPiwable. rtparnn8limk rwwmmon 1.muvwwb(Pbdmuva,Awmw,MMykw CMvntl<,LBuwvm). MS -Mvvu SPG<SOmpl<:Aumple frepu l byetldivealmowv msss vftmgtt wily.ins apmified emmmtefmavixmmple[m - C -Coeluum:Th<WBetmWyu co-elwm wiN uOwwv tub stmdurtl(i.e.smrogn,,.. .etmdmda,an)mrw>ltmw whichmindweMmtmtimann tugm mJym wvcmmtiev is avtiablc.Far McNad]110,Ne epOmrmwrybmkWued 0 .G Ywtstmti°nof<oa (bi Svm dilwA_,iz.Fme OJY uswe Ne mtivc rovmnuadom aclvd'wg eztimamdvdws. i tym wu 9umti mptimmG<M umpim that have d<ncuble cpviceouvuvm MSD -M_SDSe Sample Dt SB Referm MS. ' vrthe malym. C .Comwwtipo plainly,m<eed the mMe yr Ne wlibruivOcmv<avNmGmrrmMofNeimevmmt NA -Nat Appliwbl<. 1 O nud.Tbc wvmuvauov mrybe bihigh dwmmvtry iutmfamw 0.e,welunpv)uiN mmmrgu wmppwaG).The-vu nbauW NO NOCGkvla¢d:Tmmutttitized wM1wwmmon vfNe rmuluv tved'm Ne mlmntim art mv-0etmeuNe pvametefa be cam-mbmand PA N-Nivmod'ryhmykminelDD,hmYl®ive. R .The av uofpli wu p< eexi lxyp Ne ng qnq d bvldiv8 time of 15 rM fio,the Gene ofmmplewlkc4Om MPS Nvt lgnim6le Tbebwxr wluv fin ttr inn wlvmw hen bemmp°rt<ddwm°bviom ututvevx NP NamPlanie Temt uutiliaed lm the wlym IA-1L'miu dml 'Fetimaud vekn Tlda nprtmvmeniwtd wvmvatim forTmvlrvety ltle dCwynmds(11G} RL at L"mde The aWmuNichmmmvmunm a amavJYmmsmem-Y.al RLaryeeifiewmmwiov The ll<PmdW limn(RLl mudr NeMW GMIIepatJv6 Limb rOr Nu emly¢. 11-rive bchtGa mY NPumwvu bvm dJutiov;cvmvtntivm mmvumrt mien,uEne appliableNptdummTn th nportiy;..a(u1 Por Ne mmple RPD .q<Iatlw Penm DiHerzam:Tk nrWnG®mvnrzavNarmmfxry8¢dvpli®tuvePnm°Ny dmiemEmuam Ne Nd .Ptmi®pthx evidm.-eafmvpowd lLla rrptrmnmmumaW mmtntim f°rTmntivJY ldwtifrtd Comp°wda(DG}whoa wv vfamlytiml rtmlu in agivw mavu ommc ezpresedm rtWive pmmtdiR(RPD).VJm which uelm the idm5fice5mubavdwnmavaPrcmll3nry amnh ohm five time Ne npar4n81imi1 fin nvY Ndivi4tW lammett+aR mM1mdbymilvivg NeabmNm dillermaberwnn Ne i P .The RPDbctwm tbermWvfmN<twwl�smuWtthemMad-apmified nitma velum;JNOuBM1 th<RPD vabn wiDbemvvMd bN<repmL QTbcquaary wvwl®picmp<cdt th<eamcutM emPamab,^,Fup06rt.«a pmlmu.LfS mtllm CwenWvg GGMeGan SRN -SnvdWRefinevm MarmiJ:Anf mumple O(ekvoam or mtifiM calve NmuofNe.•m•prs®lamatdxuthe SuvdM aco-4mrs me elm qualifiMmJl aavcumlrmPlewWv.Non:This pagumtapp5mble 6rmaub apOn mmvtm avmund fnb mmpim, whin Nc aampkmumwtimuenanr Nm 4z We aPDcaddMarfa��e¢b dvpli<Le RPD whin Ne aamPlewvmvadvv an leu SRP -SemilymmieTmk l.melive PmruhvewFPA MCNod 1315. thin Sx the RL(M<vu mty) IEF and rwm mevilwvth<u mztiry r<Wive I;.],8- m. R AmlytidwWu ve fivmumpie nav,m TEQ TaleP'wlmt tbemmurt ofnawple'a mxicirydemxd by mWuplywgmch diOzivautl fivmbymwrwpmtlbg TFP RE -Amlytiml wuluue fivmamplemeayss5ov. aM thin<uvmdv6 Ne rtvultivg vJm. I S .A Ybou mWumc 1-madifird amwvue mJY<u. TL Teuativ<ly--a-Cpmpoupd:Ammppuvtl Wthuhm i-S.bhepnsm veil is mt pay OtNewgn mmpmmd i tut(TCL)for the-Svx!a vpm8mm At TIG en quJita dyidmtifid aMrwvttduutlmud mmtntivm. Foabotm Raper Fortner pate Uan501y Report i Report Portnet Oete Dmbiliy Repod Page 13 of 17 Page 14 of 17 ) Sedal_No:10171914:30 Sedal_No:10171913:30 Alpha Analytical,Inc. ID N0.:17873 Project Name: CAPE REGENCY Lab Number. L1947537 Facility:Company-wide Revision 15 Project Number: K112400A.S.W W.700 Report Date: 10/17/19 Department:Quality Assurance Published Date:6/15Y20199:53:42 AM Title:CertifeatefADeroyal Proamm Summary Pane 1 of 1 Certification Information REFERENCES The 10110wln8 analytm ere Wort Inclutletl In ear Primary NELAP awpe Ot Acuetlita8pn: 44 Methods for the Determination of Inorganic Substances in Environmental Samples, wou,ereaeh Fadnty EPA/600/R'93/100,August 1993. EPA e241624.1:MP-xylene,o-xytene EPA 0260L:NPY:1,2,d,STCOemethylbempm;4-ENylroluene,grnbervene;SCZA:IodometM1ane(meNyl btlltle).1,2,4,STaDemeMNOeszam 0. 74 Method 1664,Revision A:N-Hexane Extractable Material(HEM;Oil B Grease)end Dhyttolvpne. Silica Gel Treated N-Hexane Extractable Material(SGT-HEM;Non-polar Material)by EPA 82700:New.DlmolhylnapMM1WOno,1,0.Dlyherohydm2lna;S§W:DImeNNnaphMalene,l,<DlphenyAytlrerina. Extraction and Gravimetry,EPA-821-R-98-002,February 1999. S-00. PtL_W;Amenable Cyanitla;§2M:Tobl Phaephome,TKN,NO2,NO3. 121 Standard Methods for the Examination of Water and Wastewater.APHA-AWWA-WEF. nftldF 111ty 54 Standard Methods Online. SM2 Go:TssEPA 80BU:NM PCH:i,5,31,8),101,110,141,151,153.180,103,187. EPA TO IS:HabNane,2p,4Tdl yl2-pentana,2,4,0.Tdmenyl penlene,-ph-,2-MelhNNloph.ra, ZMeh;_phena,2-Ethy-phene.1,2,3-T ,ue dbenzene,b-,IMana,1,2,4,S xtbamethobenxene.E-elpph-S,l-MaNylnaptNelane. Blvlvaiml TL zue McWz:EPA 3050E Thpfollowing analylvz em In4utletl In our Mwe3chueella DEP Scope of Ante bK1.n i Wexlb-gh F-IlSp. ' Odnkrnp Wafer EPA 300.0:CNodda,Nitrate-N,R-S.Sdrue;EPA 35 Nibate-N,Nibite-N;SM4500NO3 :Nibet<N,NiNbJI;SMlSOBF{,SM-OCN{E, EPA 180.1,SM31MB,s 00CP0,SW320B,SM354OC,SM4S00H41,SM450pNO2Z EPA 332:Petchbrab;EPA 5241:THMz aril Wea;EPA 504.1:EDB,DBCP. Mlwblol.W..SMUISIS;SMSM-P/A,SMg323B{1lSft-0T,SM3223D. Nan-Pubble Wafer SM4500 .EPA120.1,1M2310a,:ArveeL,SM2PAaSM450OLL4:,SM4500E-BC,SM4500NN.SM SP-E.-N eM IGeWE. EPA 350.1: Ammonia,,IACXAT 1.1 SM5210B-1d;31 OC, ,,EPA-D,E S ISK EPA 42EPA 3532:Nitrate,,M-OD,E,A 30S: he E.6M4'a00,bn SM5220D,EPA OA,SMS31D8,SM S.SM4500LLO,EPA 1664,EPA 42D.1,SN4500.CN{E,SM2540o,EPA 300:LNlodtlO,Su'tp1e,Nlwtn. EPA 528A.Vale,d Hxlomebona g AmrMOm, EPAcubun-1.Fe,Toxaphma,PJdM,elpha,HC,b,M.BHC.on r EebA,HC,tlelb-BHC,DleMdn,DpO,ODE,DDT,Entlosulfan I,Etdosuttan II, EPA 62Sn SVOC,Etddn,F3ddn Ntlehytle,HepleMP 600444br Epodtle,PC6a EPA 623.1:SVOM(-IS-all-Tl Ent.reb ml,EPA60014,E-0d5:PCBOiI. ' MlcrvbiOlvlry:SM9333B4;olilert-0T;Enterebrtal.SM9331 f,EPA 1600,EPA 1601. I Manzfleltl Fetllity: , odrtklnp Wamr EPA SCSI:A.Ba,Ce.a,Cu,Fa,Mn,NI,N.,Ao Ga.A EPA 200.8:AJ,Su,M,Be,Be.ed,Or,Cu,Pb,Mn,NI,Se,Ap,T.,ran.EPA W.1 Hg. EPA 522. Non-Peb3fe Water EPA 200.7:Al,sb,As,Be,Cd,Cx,cr.Co,C.Fe.Ple.Mg,Mn,Mo,Nt,K.Se,Ag,Na,sr,TL,T,V,Zn. EPA 300.8:of ne,AS,Be,Ctl,Cr,Cu,Fa,Pb,Mn,NI,K.Se,Ag,Na,TL,Zn. EPA-.1 lit. For a complete listing of analytes and methods,please contact your Alpha Pmject Manager. LIMITATION OF LIABILITIES Alpha Analytical performs Services with reasonable care and diligence normal to the analytical testing laboratory Industry.In the event of an error,the sole and exclusive responsibility of Alpha Analytical shall be to re-perform the work at it's own expense.In no event shall Alpha Analytical be held liable for any Incidental,consequential or special damages,including but not limited to,damages in anyway connected with the use of,interpretation of,information or analysis provided by Alpha Analytical. i We strongly urge our clients to comply with EPA protocol regarding sample volume,preservation,cooling, contalnem,sampling procedures.holding time and splitting of samples in the field. Document Type:Form Pre Qualtrax Document ID:OB-113 Page 15 of 17 Page 16 of 17 5,- -DZDPPPPPP 1-1- ƒ . , ! 2 | « | 3 o • | ! - j � � � \. . % §/\ > : » : :§\` � � i ) � ` !k � . : ; . : • ; . . Inspection report stored on Q drive: Q:\IA Systems\I-A Inspection Reports cz ur