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0036 HARRINGTON WAY - Health
L ington Way '. Ji?051 I I a ypF1NE TpN� TOWN OF BARNSTABLE HEALTH INSPECTOR-s Establishment Name: Date: (� l�G Page: of OFFICE HOURS P ° PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ` 200 MAIN STREET 3: FRI.P.M.MON. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. $ HYANNIS, MA 02601 MON.- 9$, +639•p�0 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'EOM FOOD ESTABLISHMENT INSPECTION REPORT Nam Date L ne of section - ` Onerationfs) ff,.utine Address < Risk Food Service n Level Previous Inspection Telephone Residential Kitche Date: log -73 2Pre-operation Owner ^/ HACCP Y/N Temporary Suspect Illness !/W Y Caterer General Complaint Person in Charge(PIC) ig im Bed&Breakfast HACCP43 '2' (-(5 Other Inspector ' Out: . 1 Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities t 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 TIMEfrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures Z77:4 ❑ 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 Gf/ ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) //^^ (!(r ' ❑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 Itemsl Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Non-critical(N)violations must be corrected immediately or Corrective Action Required: ❑ No ❑ Yes within 90 days as determined by the Board of Health. Overall Rating F . I ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled El Emergency Suspension C N Official Order for Correction:Based on an inspection today,t e 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 anon-critical violations. F=3 or more critical violations. n no critical violations observed, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 9 or more non-critical violations=F. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot k 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 4 non-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) violations observed,7 to 8non-critical violations=C. be in writing and submitted to the Board of Health at the above address refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: In ector's Signature Print: 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 ' Signatur Pri j Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N I I Dumpster Screen? Y N a I is ,2.--'�,.++-1„-:� ..ram,-.+�^,..t."--•+..+..-�--'•-•- �--••--r-----'---r----... --.-,-. -..��. ,---�.1,�-.,.--�;.c�-,i'..r^.�w.o+.--.-r'§.--.-^'--�..-'+'s--„ry:s+•Q--''--�..r.�'(r�.- .-mac,w:u., �. -�.-.-•_;,�^;"_.-.�s-*+tirrT'^� ��.-a'�:l`.^�--:-�:*r��:�r•�rt.��-r�:. �-+� "`�� 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 Temperature According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Chazge Duties - 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) - * 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-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 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* - * 7.202.12 Conditions of Use* 590.004(11) Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR s 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 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* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* Eggs 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Egeerwe 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-1 1 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155 155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed 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* in mobile food,temporary and residential Sources 10 Proper,Adequate Handwashing g' PS Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2 301.11 Clean Condition-Hands and Arms* 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail * 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 3-201.17 Game Animals 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* 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 Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 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 ( ) 8 5-205.11 Accessibility,Operation and Maintenance Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 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. A . �-= Falmouth Fresh Lemon Sandwich Cookie White Chocolate Cranberry Cashew Bark *Contains Eggs* *Contains Nuts* *Made in a facility that processes nuts&peanut butter* White Chocolate(Sugar,Partially Hydrogenated Palm Kernel Oil, Lemon Filiing:Powdered sugar,unsalted butter(cream,natural Whole Milk Solids,Reduced Mineral Whey Powder Nonfat Dry Milk flavorings,milk),vanilla extract,lemon juice,lemon zest Solids,Soya Lecithin(an emulsifier),Salt and Artificial Flavor) Net Weight 6.0 oz per sandwich cookie Cranberries,Cashews. thecapecodcookie.com 508-737-7521 Net Weight 1.5 oz per,piece Best By Best By thecapecodcookie.com 508-737-7521 Dark Chocolate Peppermint Bark Zucchini Bread *Made in a facility that processes nuts&peanut butter* *Contains Eggs* *Made in a facility that processes nuts&peanut butter Dark Chocolate(chocolate,sugar,cocoa powder)peppermint extract, Flour,Zucchini,Sugar,Eggs,Vegetable Oil, Baling Soda,Baking Powder peppermint candy pieces(sugar,corn syrup,peppermint extract) Cinnamon,Baking Powder.Salt,Lemon juice,Lemon Zest,Vanilla Extract, Net Weight 1.5oz per piece Best By thecapecodcookie.com 508-737-7521 www.thecapecodcookie.com 508-737-7521 Butterscotch Bark Mashpee Peppermint Meringues *Contains Nuts* *Made in a facility that processes nuts&peanut butter* *Made in a facility that processes nuts&peanut butter* *Contains Eggs* White Chocolate(Sugar,Partially Hydrogenated Palm Kernel Oil, Sugar,Powdered Sugar,Egg Whites,Peppermint Extract,FD&C Whole Milk Solids,Reduced Mineral Whey Powder,Nonfat Dry Milk Reds 40&3. Solids,Soya Lecithin(an emulsifier),Salt and Artificial Flavor)Sugar Net Weight.1.0 oz per piece Butterscotch Chips(Partially Hydrogenated Palm Kernel Oil,Coconut Best By ; Oil,Lactose,Whey (Milk),Natural Flavors,and Artificial thecapecodcookie.com 508-737-7521 Flavors(Including Barley Protein),Nonfat Milk,Sodium Caseinate (Milk),Buttermilk Solids,Soy Lecithin,Salt,Artificial Colors (Yellow 5 Lake,Yellow 6 Lake,Blue 2 Lake),Butter,Caramel Color)Health Toffee Bits(milk chocolate,sugar,palm oil,dairy butter (milk),almonds,salt,artificial flavor,and soy lecithin) Net Weight 1.5 oz per piece Best By - thecapecodcookie.com 508-737-7521 z;�T_, Dark Chocolate Coconut Bark *Made in a Facility that Processes nuts&peanut butter* Dark Chocolate(chocolate,sugar,cocoa powder)coconut extract, coconut flakes Net Weight 1.5oz per piece Best By thecapecodcookie.com 508-737-7521 Cotuit Cranberry Oatmeal Cookie Orleans Oatmeal Raisin Cookie *Contains Eggs* *Contains Eggs* *Made in a Facility that Processes nuts&peanut butter* *Made in a Facility that Processes nuts&peanut butter* Flour(unbleached hard wheat flour,malted barley flour,niacin, Flour(unbleached laird wheat flour,malted barley flour,niacin, reduced iron,thiamin mononitrate,riboflavin,folic acid)Cranberries, reduced iron,thiamin mononitrate,riboflavin,folic acid)Raisins, Oats,Eggs,Sugar,Brown Sugar,Unsalted Butter(cream,natural Oats,Eggs,Sugar,Brown Sugar,unsalted Butter(cream,natural flavorings,milk),salt,cinnamon,vanilla,milk,baking powder,baking flavorings,milk),salt,cinnamon,vanilla,milk,baking powder,baking soda soda Best By Net Weight_oz per rookie Net Weight_oz per cookie thecapecodcookie.com 508-737-7521 thecapecodcookie.com 508-737-7527 VIP Provincetown PB&J Cookie Hyannis Heath Cookie *Contains Eggs* *Contains Eggs* *Contains Peanut Butter* *Made in a Facility that Processes nuts&peanut butter* Peanut Butter(roasted peanuts,sugar,hydrogenated vegetable oils Flour(unbleached hard wheat flour,malted barley flour,niacin, (cottonseed,soybean,rapeseed)sale),Eggs,Brown Sugar,Sugar, reduced iron,thiamin mononitrate,riboflavin,folic acid), Unsalted Baking Soda,Grape Jelly(Concord grapes,grapes,corn syrup,fruit Butter(cream,natural flavorings,milk),Butterscotch Chips(Partially pectin,citric acid,sodium citrate) Hydrogenated Palm Kernel Oil,Coconut Oil,Lactose,Whey (Milk), NetWeight_oz per cookie Natural Flavors,and Artificial Flavors(Including Barley Protein), thecapecodcookie.com 508-737-7521 Nonfat Milk,Sodium Caseinate (Milk),Buttermilk Solids,Soy Lecithin,Salt,Artificial Colors (Yellow 5 Lake,Yellow 6 Lake,Blue 2 Lake)s,Eggs,vanilla,baking powder,baking soda,salt Net Weight:2.6oz Best By .+ = thecapecodcookie.com 508-737-7521 s• - Harwich Hot Chocolate Brownie Cookie *Contains Eggs* qog � k *Made in a Facility that Processes nuts&peanut butter Hot Cocoa mix(sugar,corn syrup,modified whey,cocoa,coconut oil, nonfat milk)Flour(unbleached hard wheat flour malted barley flour, niacin,reduced iron,thiamin mononitrate,riboflavin,folic acid), Plymouth Pumpkin Spice Cookie Unsalted Butter(cream,natural flavorings,milk),Sugar,Eggs,Milk, *Contains Eggs* Vanilla,Baking soda,marshmallows(corn syrup,sugar,dextrose, *Made in a Facility that Processes nuts&peanut butter* 1 water,gelatin) Flour(unbleached hard wheat flour malted barley flour,niacin, Net Weight_oz per cookie reduced iron,thiamin mononitrate,riboflavin,folic acid), pumpkin, Best By baking powder,baking soda,cinnamon,nutmeg,cloves,salt,unsalted thecapecodcookie.com 508-737-7521 butter(cream,natural flavorings,milk),sugar,eggs,vanilla...Icing- / Sugar,milk,butter,vanilla Net Weight_oz per cookie li Best By �. thecapecodcookie.cvm 508-737-7521 Chatham Chocolate Chunk Cookie *Contains Eggs* *Made in a Facility that Processes nuts&peanut butter* Flour(unbleached hard wheat flour,malted barley flour,niacin, -_--N reduced iron,thiamin mononitrate,riboflavin,folic acid)Semi-Sweet Chocolate Chips(Sugar,chocolate,cocoa butter,milkfat,soy lecithin, The Sandwich Double Chocolate Sandwich Cookie natural flavors),Eggs,Unsalted Butter(cream,natural flavorings, *Contains Eggs* milk)vanilla,baking powder,baking soda,salt *Made in a facility that processes nuts&peanut butter* Net Weight:2.8oz per cookie Cookie:Flour(unbleached hard wheat flour,malted barley flour Best By niacin,reduced iron,thiamin mononitrate,riboflavin,folic acid), thecapecodcookie.com 508-737-7521 sugar,unsalted butter(cream,natural flavorings,milk)cocoa powder, eggs,vanilla extract,salt,baking soda Chocolate Coating:Semisweet Chocolate(Sugar,chocolate,cocoa butter,milkfat soy lecithin,natural flavors),unsweetened chocolate, corn oil Peppermint Filling:Powdered sugar,unsalted butter(cream,natural a flavorings,milk),vanilla extract,peppermint extract. Net Weight 6.5oz per sandwich cookie Best By thecapecodeookie,com 508-737-7,521 w �WAI own of Barnstable rJ oFt"ergo R gulatory Services BarristablEff r P� Tho as F. Geiler, Director AM-America city t BARNSTABLE, * , ' F �f buss. �Q Pub c Health Division �A i6;q. homas McKean, D' 200 Main Street, Hyanni . Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: l 1 &/o—,�- NAME OF FOOD ESTABLISHM N ADDRESS OF FOOD ESTABLISHMENT: 3o a c ,Y1 MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: PARCEL(S) e) TELEPHONE NUMBER OF FOOD ESTABLISHMENT: - NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: Pm(Z LnA TYPICAL HOURS OF OPERATION MON-FRI: :_ TO (� DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ES TABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD _ BED & BREAKFAST c O O CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) QAHealth\Application FormsToodapp l.doc ***REMINDER*** IF OUTSIDE DINING, Yr T MUST BE APPROVED BY THE P- ARD OF HEALTH AND \ l \ LICENSING AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? N IS AN AIR CURT .IN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?�J CONTACT INF RMATIO FULL NAME OF APPLICANT Lee SOLE OWNER: YES /NO ADDRESS PHONE # IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** 1. ( T EXPIRATION DATE: 2. EXPIRATION DATE: / / 3. EXPIRATION DATE: / / 4. Pq EXPIRATION DATE: / / 4r SIC TURE OF APPL CANT AND DATE QAHealth\Application Forms\Foodappl.doc McKenzie, Marybeth Jry 60 9U nUll To: carrieleetouhey@gmail.com' Subject: labels Carrie-Lee, I printed out your labels and will put them in your folder. I'll also switch over your permit- from temporary to a regular permit. The labels look good to me, but you probably should put a best buy date on it. This date can be determined by you. I'll email you in about 6 months to set up an inspection time. Have a good summer. Marybeth McKenzie , 1 a ..r Cotuit Cranberry Oatmeal Cookie *Contains Eggs* *Made in a Facility that Processes nuts&peanut butter* Orleans Oatmeal Raisin Cookie Flour(unbleached hard wheat flour,malted barley flour,niacin, *Contains Eggs* reduced iron,thiamin mononitrate,riboflavin,folic acid)Cranberries, *Made in a Facility that Processes nuts&peanut butter* Oats,Eggs,Sugar,Brown Sugar,Unsalted Butter(cream,natural Flour(unbleached hard wheat flour,malted barley flour,niacin, flavorings,milk),salt,cinnamon,vanilla,milk,baking powder, reduced iron,thiamin mononitrate,riboflavin,folic acid)Raisins, baking soda Oats,Eggs,Sugar,Browr.Sugar,unsalted Butter(cream,natural Net Weight_oz per cookie flavorings,milk),salt,cinnamon,vanilla,milk,baking powder,baking thecapecodcookie.com 508-737-7521 soda Net Weight_oz per cookie 1 thecapecodcookie.com 508-737-7521 Provincetown PB&J Cookie *Contains Eggs* c *Contains Peanut Butter* Peanut Butter(roasted peanuts,sugar,hydrogenated vegetable oils Barnstable Butterscotch Cookie (cottonseed,soybean,rapeseed)sale),Eggs,Brown Sugar,Sugar, *Contains Eggs* Baking Soda,Grape Jelly(Concord grapes,grapes,corn syrup,fruit *Made in a Facility that Processes nuts&peanut butter* pectin,citric acid,sodium citrate) Flour(unbleached hard wheat flour,malted barley flour,niacin, Net Weight_oz per cookie reduced iron,thiamin mononitrate,riboflavin,folic acid), Unsalted thecapecodcookie.com 508-737-7521 Butter(cream,natural flavorings,milk),Butterscotch Chips(Partially Hydrogenated Palm Kernel Oil,Coconut Oil,Lactose,Whey (Milk), Natural Flavors,and Artificial Flavors(Including Barley Protein), Nonfat Milk,Sodium Caseinate (Milk),Buttermilk Solids,Soy Lecithin,Salt,Artificial Colors (Yellow 5 Lake,Yellow 6 Lake,Blue 2 Lake)s,Eggs,vanilla,baking powder,baking soda,salt Net Weight:2.6oz. Harwich Hot Chocolate Brownie Cookie thecapeccdcookie.com 508-737-7521 *Contains Eggs* *Made in a Facility that Processes nuts&peanut butter* Hot Cocoa mix(sugar,corn syrup,modified whey,cocoa,coconut oil, nonfat milk)Flour(unbleached hard wheat flour,malted barley flour, niacin,reduced iron,thiamin mononitrate,riboflavin,folic acid), Unsalted Butter(cream,natural flavorings,milk),Sugar,Eggs,Milk, Vanilla,Baking soda,marshmallows(corn syrup,sugar,dextrose, Plymouth Pumpkin Spice Cookie water,gelatin) *Contains Eggs* Net Weight_oz per cookie *Made in a Facility that Processes nuts&peanut butter* thecapecodcookie.com 508-737-7521 Flour(unbleached hard wheat flour,malted barley flour,niacin, reduced iron,thiamin mononitrate,riboflavin,.folic acid), pumpkin, baking powder,baking soda,cinnamon,nutmeg,cloves,salt,unsalted butter(cream,natural flavorings,milk),sugar,eggs,vanilla...Icing- Sugar,milk,butter,vanilla Net Weight_oz per cookie Chatham Chocolate.Chunk Cookie thecapecodcookie.com 508-737-7521 *Contains Eggs* *Made in a Facility that Processes nuts&peanut butter* Flour(unbleached hard wheat flour,malted barley flour,niacin, Ta reduced iron,thiamin mononitrate,riboflavin,folic acid) Semi-Sweet Chocolate Chips(Sugar,chocolate,cocoa butter,milkfat,soy lecithin, natural flavors),Eggs;Unsalted Butter(cream,natural flavorings, milk)vanilla,baking powder,baking soda,salt The Islands Irish Lace Cookies Net Weight:2.8oz per cookie Oats,brown sugar,unsalted butter(cream,natural flavorings,milk), thecapecodcookie.com 508-737-7521 Flour (unbleached hard wheat flour, malted barley flour, niacin, reduced iron, thiamin mononitrate , riboflavin, folic acid), milk, vanilla extract Net Weight_oz per cookie thecapecodcookie.com 508-737-7521 Color)Health Toffee Bits(milk chocolate,sugar,palm oil,dairy butter (milk),almonds,salt,artificial flavor,and soy lecithin) Net Weight_oz per cookie thecapecodcookie.com 508-737-7521 fir The Sandwich Double Chocolate Sandwich Cookie d� i " *Contains Eggs* *Made in a facility that processes nuts&peanut butter* Dark Chocolate Coconut Bark Cookie:Flour(unbleached hard wheat flour,malted barley flour, *Made in a Facility that Processes nuts&peanut butter* niacin,reduced iron,thiamin mononitrate,riboflavin,folic acid), Dark Chocolate(chocolate,sugar,cocoa powder)coconut extract, sugar,unsalted butter(cream,natural flavorings,milk)cocoa powder, coconut flakes eggs,vanilla extract,salt,baking soda Net Weight_oz per cookie Chocolate Coating:Semisweet Chocolate(Sugar,chocolate,cocoa thecapecodcookie.com 508-737-7521 butter,milkfat,soy lecithin,natural flavors),unsweetened chocolate, corn oil Peppermint Filling:Powdered sugar,unsalted butter(cream,natural flavorings,milk),vanilla extract,peppermint extract. Net Weight_ozper cookie thecaperodcookie:com 508-737-7521 White Chocolate Cranberry Cashew Bark *Contains Nuts* White Chocolate(Sugar,Partially Hydrogenated Palm Kernel Oil, Whole Milk Solids,Reduced Mineral Whey Powder,Nonfat Dry Milk Solids,Soya Lecithin(an emulsifier),Salt and Artificial Flavor) Cranberries,Cashews. Net Weight_oz per cookie thecapecodcookie.com 508-737-7521 �d Dark Chocolate Peppermint Bark *Made in a facility that processes nuts&peanut butter* Dark Chocolate(chocolate,sugar,cocoa powder)peppermint extract, " peppermint candies(peppermint extract,sugar,corn syrup) Net Weight_oz per cookie thecapecodcookie.com 508-737-7521 Z Butterscotch Bark *Contains Nuts* *Made in a facility that processes nuts&peanut butter* White Chocolate(Sugar,Partially Hydrogenated Palm Kernel Oil, Whole Milk Solids,Reduced Mineral Whey Powder,Nonfat Dry Milk Solids,Soya Lecithin(an emulsifier),Salt and Artificial Flavor)Sugar Butterscotch Chips(Partially Hydrogenated Palm Kernel Oil, Coconut Oil,Lactose,Whey (Milk),Natural Flavors,and Artificial Flavors(Including Barley Protein),Nonfat Milk,Sodium Caseinate (Milk),Buttermilk Solids,Soy Lecithin,Salt,Artificial Colors (Yellow 5 Lake,Yellow 6 Lake,Blue 2 Lake),Butter,Caramel ECOJECH AP Z-1% Environmental PARCEL, � www.eco-tech.us 'LOT _ THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 36 Harrington Way Hyannis Port Owner's Name: Thomas&Maura Ockerbloom Owner's Address: P.O.Box 594 Hyannis Port,MA 02647 Date of Inspection: May 12,2004 Name of Inspector:(Please Print) David D. CouOianowr,R.S. Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed bas A on my,., training and experience in the proper function and maintenance of on-site sewage disposal systems.I ai a a DEI0 �o approved system inspector pursuant to section 15.340 of Title 5(310 C'MR 15.000).The system: 2 X Passes <+ Conditionally Passes W oo co Needs Further Evaluation By the Local Approving Authority o ;;aa Fails cis -- m I av Inspector's Signature Date: V���Y 1 Z 0 m The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board fiof Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority NOTES AND COMMENTS Inspector's Note=> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 i Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 36 Harrington Way Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12,2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no,or not determined(Y,N,or ND).in the_for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not),is structurally unsound,exhibits substantial infiltration or exfiltration,or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 36 Harrington Way Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12,2004 C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will fail unless the Board of Health(and public water supplier,if any)determines that the system is functioning in a manner that protects the public health,safety,and environment The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3)OTHER 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 36 Harrington Way Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12,2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form) No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore,the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E)Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 1I of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in section D above the large system has failed.The owner or operator of any large system considered a significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 36 Harrington Way Hyannis Port Owner: 'Thomas&Maura Ockerbloom Date of Inspection: May 12,2004 Check if the following have been done'You must indicate either"Yes"or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? including Y _ Were all system components,exeludthg the SAS. located on site? Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y _ Existing information.For example,Plan at the Board of Health. Y _ Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 Harrington Way Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):n/a—No plan on file at Health Dept. Number of current residents 3 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no):no :(If yes, separate inspection required? Laundry system inspected (yes or no): n/a Seasonal use(yes or no):no Water meter readings,if available(last two year's usage(gpd): 154 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sgft/etc.): Grease trap present: (yes or no) Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no). Water meter readings,if available: . Last date of occupancy/use:_ OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System not pumped in recent past(Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternate technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe) APPROXIMATE AGE of all components,date installed(if known)and source of information: Age_22±years Certificate of Compliance issued 9/1/81 (BOH permit#81-325) Were sewage odors detected when arriving at the site:(yes or no) no 6 Page 7 of 1 I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Harrington Way Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12,2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:—cast iron X 40 PVC other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints;venting,evidence of leakage,etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK:Yes (locate on site plan) Depth below grade: 6 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 alg_lon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle: 30 in Scum thickness: I in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 14 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping not required at this time but maintenance pumping is recommended every 2 years Liquid level at outlet invert.Tank and tees appear structurally sound and functioning as intended No evidence of leakage in or out GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Harrin on Way Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12, 2004 TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain) Dimensions: Capacity: gallons Design flow:_gallons/day Alarm present(yes or no):_ Alarm level:_ Alarm in working order(yes or no):_ pumping:Date of last Comments:(condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:Yes (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: at outlet invert Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.) D-box annears structurally sound with no evidence of leakage in or out Effluent level at outlet invert Some solids in tank. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Harrington Way Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12,2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located,explain why: Type: X leaching pits,number 1 _leaching chambers,number _leaching galleries,number _leaching trenches,number,length _leaching fields,number,dimensions _overflow cesspool,number —innovative/alternate system Type/name of Technology Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Soils above leaching pit appeared unsaturated.No evidence of surface ponding breakout,lush vegetation,or other evidence of hydraulic failure was observed Leach pit contained 42 inches of effluent in a 6 foot pit CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY:none (locate on site plan) Materials of construction: Dimensions:_ Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 • Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Harrington Way Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100'(Locate where public water supply enters the building) LEACH LOCATIONS PIT 2 Oa ❑ D-BOX A B 1 25.5 ft 21 ft SEPTIC 2 27 ft 31 f t '° TANK 3 27 ft 44 ft A F1 B EXISTING DWELLING # 36 W Z J W G 3 I HARRINGTON WAY NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Harrington Wav Hyannis Port Owner: Thomas&Maura Ockerbloom Date of Inspection: May 12, 2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 15+ feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked.date of design plan reviewed Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: _ Checked local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Barnstable GIS department records indicate that property is over 15 feet above groundwater table 11 L C TION � SEWAGE PERMIT N0. VILLAGE INSTA ll- R'���/, AME i ADDRESS ri BUILD R 0 r DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED f f E1 R.FR n- rr Fss.. ..........._/ No... .L.. ....... THE COMMONWEALTH OF MASSACHUSETTS 3 BOAR® OF HEALTH I OF....................................................................................... Y V� a Appliratilan for RspoiiFal nrk� C� n rnr inn ernti � f Application is hereby made for a Permit to Construct or Repair ( ) an Individual SewagelkDisposal System at: .................:°T� <sa - � .te1 GTo_ ....V iy Location-Address or Lot ��N///o. 8%4 le Bl o�f. a=97.... ner Installer rT Address pp- ln d Type of Building Size Lot_._.3_Ql-0-_ .•..Sq. feet aDwelling—No. of Bedrooms....•.................................Expansion Attic (� Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons...._..2�. ................. Showers (1) — Cafeteria ( ) Other fixtures . ---•-------------------------- = W Design Flow.........��........................gallons per person per day. Total daily flow.........��.�Q._..................._gallons�. WSeptic Tank—Liquid capacityll0DQgallons Length.....-&... Width.�.._10__ Diameter--------------- Depth.S_..`,6 x Disposal Trench—No..................... Width.................... Total Length......._..........i_Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..4?. "&...... Depth.below inlet--- Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) `" Percolation Test Results Performed by._.��Q. 1.G..... Test Pit No. .....minutes per inch Depth of Test Pit,.... .2._...... Depth to ground water....................... Test Pit No. 2._J_..a'--.minutes per inch Depth of Test Pit-..../--.0....... Depth to ground water........................ - ,o i ••--•• o . ;------------------------f-------- Descriptionof Soil..•. .-• 7.—. sS........----•----�----A. ?"�. _s�� c� ------•1_---` -----70 /-U-----7 v ..�!'11 _i.�! Tom..c o f �S C _!� 1��------vj--c-% ---.C.a.tp H_Y.( ...................................... 8 a -•-••-•-•--•..._._..---•----•--•-----------•----••-------------•-•--•-••-•--•-•-............•...............................:......................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----••-•••••--•-•••....•--•.._.......•-•••••••--•-•---•--•-•-•.............•••••--•-••..............-•••-...••••-••................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with • the provisions of iIHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be ssued th oar of health. Sign e l�l/1 �j ................... �/ T r �. to Application Approved B ..••. •- ------------------------•----•-............• �� (�......--•--- • Date Application Disapp ve r t following reasons-------------•------------------------------------------•------------------------..._....._.....•••••........---- ---•••...-•-••------••••-•-•••--••--•......_..--•.................... .......................................... Date PermitNo....................................................... Issued....................................................... Date No.... Fics.......................... THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH ....................... ...... .:...OF............... ..................... Appliration for Biiipos al Workii Tonstrnrtiun amit Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal System at: ............. _...P... ........ .. N...... ._._.. ..M.........------ --.....----.--•---------•..........�................................... ............ �H� s Locationw-n e�d�d�ress� or No--r GO i Wa� 1!rl P lInstalle r Cp S Addre�ss� SSTf�44��F� .. Type of Building Size Lot..... ------Sq. feet Dwelling—No. of Bedrooms...... ................................Expansion Attic (1/1- Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.......C'2................. Showers (-I-) — Cafeteria ( ) dOther fixtures ------------------------------------------------------.•--•--•--•-------•-•-------•--•••----•-••••••--••••.....•--•......-•••---•'•••-•-•-•------••--- W Design Flow.......•.56........................gallons per person per day. Total d�ily flow......._���..___.._.._.__.__..._._gal}ons. WSeptic _Tank—Liquid capacityAQ!2..gallons Length-g.�-6" Width.`/.'/-? . Diameter................ Depth, -0'�( x Disposal Trench—No..................... Width.........7T........ Total Length..........I---•---,- Total leaching area....................sq. ft. Seepage Pit No...�............ Diameter... ..... Depth below inlet----S9.``D._..... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ) aPercolation Test Results Performed by..C&_W O(.A-�-r�?__YX, .R....kg_e_...... Date.. U Ca:..��-__,�. P Test Pit No. 1-_4.s1-...minutes per inch Depth of Test Pit.....10.7_._.__ Depth to groundwater....................... rZo Test Pit No. 2.. _ _....minutes per inch Depth of Test Pit-----/_1?......... Depth to ground water........................ 9 /---------------- ---••------ f f,�--.............J.----.---------------.----- Description of Soil....�---T 0.3.... _O A_Yl!1........ v_ sF� (1 �� --'�1� Vc 1�_ .J. .I .__`c2._...!©f-!�RR_5.c......... 1/✓1..7`If.._ �I� ......... W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------------------------------------------------------------------------'-----------------------------•-----•-•--••----•-----••••-••--••-••---------.._.......••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT12 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued the r he Al. \ �r 1 igned /� Application Approved By. _%:................." .�. . r Date .. .------r-•---- Application Disapprove or lie following reasons----------------------------------------------------------------------------•••. ••---------•---•••......----••. Date Permit No.................•...••-•................ -- '-- Issued-•----....--------- ..--------•-- ---- ---• --------- ...-•-•-- Date ^---------------- THE COMMONWEALTH OF MASSACH SE T +, BOARD F HEA ..............................O F.......................... ........................................................... �"> w TrtifirFa#r of ToVD .&�/S l an FS'# Individual Sewage Di Mons ruc ed or Re airedg y ( ) P ( ) by ._ 4..... .........................................................X Ins, - _ /1 at..----------•--•........ ......•-•-......•--- ••-• -------•--....-•-- .... �( '`'^" F p `" 3 S t Sanitary ( d �s�e od in the has been installed in accordance with the &isions of I application for Disposal Works Construction Permit No......................................... dated---------_._-_------ .... _.: ._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. - I-.l..l Inspector " .......................................... E`COMMONW OF MASSACH SET S BQAREA F HEA No......................... FEE........................ Permission is ereby granted......... --- ----•-•----•.. ..:�.. ...._ ....- • t.................................................. to Constr et ( or ezpair ( ) a dividual Sew e Dis qs System t --------- ---I.................A at No O ?T � � d�+..� fie t r as shown on the ap lication for Disposal Works �onstruction Per No._�f............. Dated.._...._._._�._i.... _._.... DATE................ --.----•-•-----------------•--.------------------------•-•--- Board of Health t FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 85.07 SOI L LOG , DATE : 8`7/1980 x 8 LEACH PIT W/2`o1= STONE AILLARND• WITNESSED BY: "PAU�_ /C.C. l SERVE REA �l? RAY 10.0 DIST. BOX # #2 } o 0 1000 GAL. q^ �Z SEPTIC T'NK. 2Z 5S1 95.7 10 (` N I ELEv^ � L0Tw ((, .0 CS' ��9 �4 144.24+ - L(� `i2.? 93. N07 ESP N IN LEND 3�SA+ � � E a IN CONC. BND. AT a 2s r+ O #z ! 4 I #' S.W. PRoP coR, �---� - w TEST � � 13 J � � o� g y HOLE 5 U ELEV. = 100.00 (ASSUMED) �° — 85.00 S_ �' i ��P��,� I 9 EDGE OF 9c•a9PAVEMENT 9i,> ; C9 I ' t AARP/NG TON WAY I 1 7( LOT • 5 9 2 LOT • 5' �20 120 r, 1 PROFILE OF SANITARY DISPOSAL SYSTEM 100.20 '! (N-O T T•O .SCALE) .� r TOP OF FOUr4.DPTION MKNH01_ES covE-PS To 'i3E .BUILT TO W 1T HIN 12" OE FIt�t15HEI?:C, A3�E`� FINISHE1 GRAI?E 2.384 -- .¢,. N"CA$T IRON A oR PVC.-SGH.to" y,"PER FT, -Sctt. yQ —MIN, 2 LAYER OF,off 11 n PER Fl. , ; 10 �1�: rr WASHED 97.8 y ,Fr 10{fl0 GAL. 9'1'26. 09 STONE. T. INVERT 97.l01 INVERT INVERT BOX R �'� I VERT °;i SEPTIC TAN p�, tN�E 'T , , ►'�° INVERT �':` r WASHED STON E © i • a a;4 ipr NO GART# AGE =CG ALL kPOUND.. z A � M i N GR i N.D E R 5 ` -`-- -- i o' CI a O ;f4.'.;;' I i i N. „ 41- 2� --�`-6 DIA ELEV. BOTTOM OF IOr �r� PIT SEPTIC S�YSTE M CONSTRUC TION ` SHALL PROPOSE D: 3 BEDROOM CONFORM. TO MASS. ENVIRONMENTAL DESIGN FLOW' 330 GAL./DAY. LEACH CODE - TITLE , Y AND TO TOWN OF RATE: L2 MIN./INCH. PROPOSED LEACH I3ARNSTABL E HEALTH REGULATIONS. CAPACITY: 2:5 n 10.5) �-- 1.0 (TT :5.2 5 2) ---> .5 8 I GAL./DAY. I _ ( NOT INCLUDING RESERVE AREA I SITE PLAN * SHOWING PROPOSED CONSTRUCTION . LOCATION": HYANNISPORT-BNRN5TAI3LE MA. FOR: ROGER V. STENING. APPROVED 19 $ SCALE : I// = 30 [SATE : _ DUNE 11 19RI BOARD OF HEALTH REFERENCE : ;BEING LOT GO AS SHOWN ON PLANsRECORDED AT THE BkRNSTitl BL REGISTRY OF DEEDS IN PLAN BK. II0 -PG.29. DATE AGENT DATE :z _,imp DAT REG. LAND S4 V EAVOR G � R G. PR.QFESSIO AL NGINEER a r.