HomeMy WebLinkAbout0213 OCEAN STREET (12) c26 p
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. f TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Application �wIx
,,)Health Division Date Issued � Z
'Conservation Division J Application Fee
Planning Dept. Permit Fee r
Date Definitive Plan Approved by Planning Board
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Historic - OKH Preservation / Hyannis
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
fi
INSULATION
.v FIREPLACE
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ELECTRICAL: ROUGH
PLUMBING: ROUGH
GAS: ROUGH
FINAL BUILDING
3
' DATE CLOSED OUT
ASSOCIATION PLAN NO.
4.
i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
flap z, Parcel Application #
ealth Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee.
Date Definitive Plan Approved by Planning Board
Historic - OKH _Preservation/Hyannis
Project Street Address Z 117 aG'�AI 97;--
Village
Owner Address
Telephone (R({ S- y'i Qo
Permit Request C)lJ 3r �G Ji ml` v o aD T
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Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 1SW7 Construction Type C�
Lot Size �, l f ITC.',� t S Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing ��� new Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including
7oil
hs): existing new First Floor Room Count
Heat T e and Fuel: Ldi Gas ❑ Electric ❑Other
Central Air: ❑Yes 1d No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 40
'Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
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Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other::=1 0
Zoning Board of Appeals Authorization ❑ .Appeal # Recorded ❑ jv
Commercial ❑Yes ❑ No If yes, site plan review # - ,
Current Use Proposed Use ►
M
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
NameIAOIC�JA/ Telephone Number t� �°a � J� ( `� i^
Address AIL A Q License # D
024 U Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE
.r FOR OFFICIAL USE ONLY
APPLICATION#
'DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
i
DATE CLOSED OUT
1
ASSOCIATION PLAN NO.
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of?"Eto h _ TOWN OF BARNSTABLE HEn�TH INSPECTORS Establishment Name: �2 �_ 1 ( � 1 Date: /(P0*9. of
�P` o OFFICE HOURS .
PUBLIC HEALTH DIVISION e:00-9:30A.M.
aAaMn&Ra E: 200 MAIN STREET 3:MON.-F30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified
v $ MON.-FRI.
�A i639. .0 HYANNIS,MA 02601
rFo MAC� 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY
FOOD ESTABLISHMENT INSPECTION REPORT
ffia' t
Name Q Dat 7 Type of Inspection ri
' Routine (. U
Address Risk Food Service Re-Previous Inspection
(� /
Level ar ` Previous Ins ection
Telephone ^ r � - Residential Kitchen Date: V
Mobile Pre-operation
Owner HACCP Y/N Temporary Suspect Illness
Caterer General Complaint
Person in Charge(PIC) VIAL Time Bed&Breakfast other
r ` n:
Inspector i L.. Out: �/ C� I t
Each violation checked requires an explanation on the narrative page(s).and a citation of specific provisions vi C-f. ol to .
Violations Related to Foodborne illness Interventions'and Risk Factors- Red Items
( ) Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective
Action as determined by the Board of Health. 590.009(E) ❑590.009(F) ❑ �'� t c%l !c <: (i i .i
FOOD.PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands +
❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities VA, e ('
EMPLOYEE HEALTH PROTECTION FROM CHEMICALS
❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 1
❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) / .� Z v1 -'z ✓
❑4.Food and Water from App•roved Source ❑ 16.Cooking Temperatures
❑5.Receiving/Condition ❑ 17.Reheating
❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling
rT
❑ 7.Conformance with Approved Procedures/HACCP Plans_ ❑ 19.Hot and Cold Holding I 'c� ( ( \ .
PROTECTION FROM CONTAMINATION
❑20.Time As a Public Health Control -
❑8.Separation/Segregation./Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑9:Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and food.Preparation for HSP - / -
❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY
❑ 11.Good Hygienic Practices 22.Posting of Consumer Advisories c G r
Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations
Critical(C)violations marked must be corrected immediately. (blue&red items)
Non-critical(N)violations must be corrected immediately or Overall Rating Corrective Action Required: (� ❑ �N ❑ Yes
within 90 days as determined by the Board of Health. ❑ Vplunta ryCompliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension
C N Official Order for Correction:Based"on an inspection today,the items
checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency,Closure ❑ Voluntary Disposal ❑ Other:..
23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent
24.Food and Food Preparation -(FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.. If no critical violations observed,
25.Equipment and Utensils (FCI)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 9 or more non-critical violations=F.
26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4.to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if no hot
27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must water,sewage back-up,.infestation of rodents or insects,lack of
C= critical violations and less than 4 non-critical. If no critical
28.Poisonous or Toxic Materials )( ) be in writing and submitted to the Board of Health at the above address refrigeration,or no PIC or alternate PIC present.,
(FC=7 590.008 9 violations observed,7 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 or's Signat re Print:
31.Dumpster screened from public view
Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N i �
#Seats Observed Frozen Dessert Machines: Outside Dining. Y N t 's ignature j Print:
Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N
Dumpster Screen?- Y N 1
Oct 23 09 11:47a Adrienne Morosini 508.432 S p.1
FAx so it 432
Town of Barnstable
Regulatory, Services
The g F.Geller,Director
wilding Division
Tom Perry,Buu'ldiet Commiwioper
200 Main Sumn,Hy6z"MA 02601
www.torrn.berttsUbtr�ea.ae
Office: 508-B62.4038 Fax: 508.790.6230
Pmpetty Owcrncr Must
Complete and Sign This Section
-If_h rA A Builder
Y, U G(�1�S C 0 (�/hI ,as Owner of the subject prnpeny
bereby wnhorize �AU tL�..�l r ��A21 il in to act on my behalf,
k all n ua rn relative to work authorized by this buZ&g perrea application for,
24.3 UcCaP\ seer j�frahn /1
(Addttss of job
siguatwe o r ]date
Print Name
If Prope!U Qm=r is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORrrss:awN>rnrF.al,u�srarl
l d Z9Z£Z90089 '0N/W 0 '1S/9 l ;0 600Z 9Z 100(NnS) W081
Massachusetts- Department of Public.S,.
Bom A of Buildin(;Regulations and.Standards
Construction Supervisor License
,} License: CS 59182
Restricted to: 00 r
LAUREN F STAPLETON
1 LAUREL CIR
FORESTDALE, MA 02644
Expiration: 6/3/2010
('unmissiuner Tr#: 27639 _
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10/23/09 9 : 37 : 06 AM 4170 ® 04/04
ACORD. CERTIFICATE OF INSURANCE DATE(MM\DMYY) 10-23-09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
MURRAY&MACDONALD INS S HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
550 MACARTHUR BLVD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIESAFFORDING COVERAGE
BOURNE,MA 02532
COMPANY
75NHN A TRAVELERS DIRECT ASSIGNMENT
INSURED COMPANY
B
STAPLETON LAUREN
COMPANY 9
1 LAUREL CIRCLE '
FORESTDALE,MA 02644 COMPANY -''
;? 1-73
D '1
COVERAGE E N ~r'
W
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, f*�
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE M-AY BE ISSUEMOR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF S'CH POLICIES;"--
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFF POLICY EXP 03
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM\DD\YY) DATE LIMITS ;-- 1---
GENERAL LIABILITY GENERAL AGGREGATE cp �1
COMMERCIAL GENERAL PRODUCTS-COMP/OPAGG. $
CLAIMS MADE OCCUR. PERSONAL&&ADV.INJURY $
OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE(Anyone fire) $
MED.EXPENSE(Any one person) $
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT $
ALL OWNED AUTOS BODILY INJURY(Per Person) $
SCHEDULE AUTOS BODILY INJURY(Per Accident) $
HIRED AUTOS PROPERTY DAMAGE $
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTOS AUTO ONLY-EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGREGATE $
EXCESS LIABILITY
UMBRELLA FORM EACH OCCURRENCE $
OTHER THAN UMBRELLA FORM AGGREGATE $
WORKER'S COMPENSATION AND
A EMPOLYER'S LIABILITY UB-0475NO19-09 05-09-09 05-09-10 STATUTORY LIMITS X
THE PROPRIETOR/ EACH ACCIDENT $ 100,000
PARTNERS/EXECUTIVE INCL DISEASE-POLICY LIMIT $ 500,000
OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE " $ 100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
MS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE
THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR STAPLETON LAUREN.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
TOWN OF BARNSTABLE BUILDING DEPT. EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 -
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
200 MAIN STREET FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
HYANNIS,MA 02601 AUTHORIZED REPRESENTATIVE
ACORD 25-5(3/93) Charles J Clark
The Commonwealth of Massach usetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
t Boston, MA 02111
Psi www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual):
Address: LA-tI
City/State/Zip: , Phone #: So$ 'q 3 �t—
Are you an employer? Check the appropriate bow, Type of project(required):
1.❑ I am a employer with 4. Eff<arn a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ N construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
workingfor me in an capacity. employees and have workers'
y9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t C. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. xt-RA.!
Insurance Company Name: TAA ve-L z�rz 5'Sd M&e ,Q 14 V/2 4 V 0'
Policy#or Self-ins. Lic. #: '7 ftV 6 l` r� � d Explratton Date: b �
Job Site Address: 04!r9 5f 'X—Gity/State/Zip: ,M,5
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cer ify der the ins d ena re -of perjury that the information provided bove.is true and correct.
Si nature: Date:
a!t 2
Phone#: � 3 S-7 60
Official itse only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
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