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HomeMy WebLinkAbout0135 ROUTE 149 - Health (2) i '"Willi-- U! ' UPC 12534 .2-153Lt� k�r Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that Village Garage Inc. 143 Route 149, Marstons Mills, MA Is, Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2018 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF, D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. i 07/01/2017 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health' 3 � �CJJ awl Towrl�of Bgnstable P � Cd egu story ervlces l Q* Richard V. Scah,Director Public Health Division BARNST o� + BARNSTABLE. * Y41-Vs.ds-153919"1,tasrs .st[ MAss. � Thomas McKean,Director ta,9_z�„ 9�''°TFn rjA�o+s` 200 Main Street,Hyannis,MA 02601 nn/ Office: 508-862-4644 vi �-02��� Fax: 508-790404 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 *A late charge of$10.00 will be assessed if payment is not received by July 1st 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? YES_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES(25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: - VILL G APA�E ' 2 5. NAME OF ESTABLISHMENT: W ZA6E G3AV 2E // 6. ADDRESS OF ESTABLISHMENT: l ` ROUTE7z 7. MAILINGADDRESS(IF DIFFERENT FROM ABOVE: SUE As 1Gic6 8. TELEPHONE NUMBER OF ESTABLISHMENT: M 7 9. EMAIL ADDRESS: 10. SOLEOWNER: ES NO IF NO,NAME OF PARTNER: -A/ 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT T TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICAN ATE C:\Users\Decollik\AppData\Local\Microsoft\Wind efnpirary In ernes iles\Content.Outlook\BMQD49H AZMA APP 2017 VISED.docx Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS $125.00 , Town of Barnstable Board of Health This is to Certify that Village Garage Inc. 143 Route 149, Marstons Mills, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. ------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2017. unless sooner suspended or revoked. ---------------- \_ _ WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 07/01/2016 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO t`S Director of Public Health e mi Town of Barnstable pbgo� d�� • �tti Regulatory Services . Richard V. Scali,Director BARNSTABLK XAS& Public Health Division BWSTABLEi6gq w m ;""en n� •• i.. Thomas McKean, Director 16 -201 ° tr, o 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 N APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN T— ANNUAL PERMIT(RUNS-JULY'l'st—JUNE 30th): APPLICATION FEES CATEGORY 1-PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 V'S CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ A late charge of$10.00 will be assessed if payment is not received by July 1st. ASSESSORS MAP AND PARCEL NO. DATE FULL NAME OF APPLICANT: LLI A CL NAME OF ESTABLISHMENT: -LAQ5 ADDRESS OF ESTABLISHMENT: �� /�/,9 /IBIS /�/�L�S � 1 MAILING ADDRESS(IF DIFFERENT): 5;APIC TELEPHONE NUMBER OF ESTABLISHMENT: EMAIL ADDRESS: SOLE OWNER: S NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME PRESIDENT o t r TREASURER. RITMIC �c CLERK IF PREPARED BY OUTSIDE PARTY: SI TURE P CANT Name: Company Address Telephone#: Email: QAAp ication FormsUiAZZAPP Rev I6.docx Page 1 of 2 f, , CEPITERViLLE-OSTER'YiLLE-MAR5T0NS MILLS FIRE DISTRICT 1875 ROUTE 28 CE14TERVI LLE,MA. 0263- (508) 790-2380\FAX# (508) 790-2385 OIL/HAZARDOUS MATERIAL RELEASE FORM F.A #: 9SF�310 LOCATION: ADDRESS OF RELEASE:_115 Route 149 M""atang X131- MA 02649 DATE OF RELEASE:_4/25195 PRODUCT RELEASED: - df w ESTIMATED QUANTITY: TTntcnn,xn CORRECTIVE ACTION TAKEN BY RESPONSIBLE P ARTY: NOTIFICATIONS: FIRE DEPARTMENT:YES(g) NO( ) DATE: TIME: ?fin NATIONAL RESPONSE CENTER:YES( ) NO( DATE: TIME: DEPT.OF ENVIRONMENTAL PROTECT ION:YES( ) NO I.X) DATE: TIME OIL SPILL COORDINATOR: YES( ) NO( DATE: TIME: TOWN BOARD OF HEALTH: YES(g) NO( ) DATE: 4. o TIME: TOWN HARBORMASTER: YES( ) NO( DATE: �- TIME: OTHER AGENCIES: COMMENTS: .,.,n ,.o,,,,,,, ^,�. -,r.: go� ramc�v�,l oE (21 22-5 £uu�i �i aa�.is. rr i _— __--_ _., §eet- =quare) ----r------- ---' -' t,±t- - ---___. _==_- __- --___... .._ t=+, ------ _- on 0 REPORT FILED BY: tub .���., f���U L a L) DATE: V v — e w w....,.w7., Martin MacNeely, Fire Prevention Officer WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C.O.M.M.FORM #58 � � ��� �� I °p IKE A Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 B"nM�`E 200 Main Street• Hyannis, MA 02601 1639. 6 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: Date: i Location/Mailing Address: 1 a I ark 0 L-6 X Contact Name/Phone:-:5—.-l. rSS 9-Y 29-101 J o (p cc Inventory Total Amount: ^' 2 0 MSDS: ycS License#: Tier II : t) o Labelina: D Spill Plan: �S Oil/WaterSeparator: IJ`�Dc Floor Drains: v Emergency Numbers: �e•S Storage Areas/Tanks: cl a,l ey 4- o ( - 1 s ° eLt$< Emergency/Containment E ui ment: t<,i rA A%Ve. Waste Generator ID: D 6142 Waste Product: o Date&Amount of Last Shipment/Frequency: Zq I I to 04,9+r- e, 1 _ Licensed Waste Hauler&Destination: Qe&k-A:<v\- (Z7: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS �k5e,'tiovL- NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardou7material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids v1 Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) ✓ Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants .� Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, pp hydrochloric acids, other acids) VIOLATIONS: �� A` q& dc4`l twk-0 C" Jlay' A`Cce' n' • >�M�,'t<� ��\ o�. RDER �C t tatty % c. 15 IV vet. INF RMATION/RECO MEND TIONS: ItG2v� ti. 45 C'e(lZ� , v /C oc CAA—- 1 t Inspector: 1 Facility Representative: `I�l. WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS °p 1HE r Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 &'RM�Le. ' 200 Main Street• Hyannis, MA 02601 039. �prFDMP� � TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: I I it (9ara Date: Location/Mailing Addres Ile. Contact Name/Phone: Z ( - y Z 8- /7. 73'ohi- o ec, (a,.) tAVVkW-- : 68- y2A -►� 5't Inventory Total Amount: /'Llo it'l MSDS: 2g License#: - ex Tier II : 0 V Labeling: DK Spill Plan: Oil/WaterSeparator: Floor Drains: Emergency Numbers: e,5 Storage Areas/Tanks: - ovK -Ced Emergency/Containment Equipment: &O -:!�,/ Waste Generator ID: Ih Ol W ste Product: Ot Date&Amount of Last Shi ment/Fre uen : `j ►S q D qJ r,, 1 X I r 0 &,r I 2 3 woo Licensed Waste Hauler&Destination: ¢ &, Other Waste Disposal Methods: y LIST OF TOXIC AND HAZARDOUS MATERIALS tang -o� �` �ol� Cpevt�CSo�J, NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,V->&X-R4x storage and disposal of 111 gallons or more requires a license from the Public Health Division. A,+fap 4 e. 4 X�b JAntifreeze Dry cleaning fluids I Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers V Hydraulic fluid (including brake fluid) Windshield wash Motor oils - 2 •k, 2 v4y� Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants V Miscellaneous petroleum products: Road salts Jgrease, lubricants, gear oil Refrigerants :Sb W Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives (creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners �— Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, /n hydrochloric acid, other acids) VIOLATIONS: �\k �C VCJ 1 6 Z CA, A- Ct � « � 4S 0K-\ u, t�CIQO< vC� 1�t to ORDERS: a der k Q vK 45 c < < 4C. P INFORMATION/REC MMENDA ONS: W 0 7 a Ct 1 - (JWI W- ok I .p C1L"iR-`i s�C S I lvOuJ Inspector: , L"'id Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY-BUSINESS I *TKE A Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 • BARMASS. .$ 200 Main Street• Hyannis, MA 02601 t639 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rED MAC Business Name: V t Date: Location/Mailing Address: I Contact Name/Phone: C4 �,\ Inventory Total Amount: MSDS: R 5 License#: 20(. Tier II : v Labeling: Spill Plan: ��S Oil/WaterSeparator: Floor Drains: m z, Emergency Numbers: �e-S Storage Areas/Tanks: I 1 JXJA0a te, c l a I 0,l Emergency/Containment Equ oment: e S ; �' Waste Generator ID: D aste Product: D% Date&Amount of Last Shipment/Frequency: $ 1 too ct,J A- I et�Z< D-`{D S Licensed Waste Hauler&Destination: ,4016 of — .0-C) I k I A 063CIL Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS Iv 0 ftk 1 a V, LVIa IV- k Wv�wkoty <kv�.ce- `e s NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws o MA, hazardous materi use, �v15 -'�t off• storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) V Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid!(electrolyte)/batteries Io Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) Any other products with "poison labels" (including chloroform, formaldehyde, ''ll hydrochloric acid, other acids) VIOLATIONS: �IAt.r&v5 fv��_P_la.`5 V5 ORDERS: %4VV �G�v1 S -� ojnan 0JQ A 5 CkA- a p0 lc \bXA_V��5 INFORMATION/R+ECOMMENDATIONS: a o 0 0-il - I> Inspector: Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: /o 13 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: U% ,`�e_ BUSINESS LOCATION: I`f-3 1�d.r�� I� Q( , a.c'��o,ns ,N(,1�s INVENTORY MAILING ADDRESS: SQ,tice_ TOTAL AMOUNT: TELEPHONE NUMBER: 7017 CONTACT PERSON: ---S-o kA. Ca c EMERGENCY CONTACT TELEPHONE NUMBE :',rhn MSDS ON SITE? TYPE OF BUSINESS: J�a C'e i� q,n e� ' II g9 e5 INFORMATION / RECOMMEND TIONS: 9Ket jQ noe 12S a� 3&C ,,­5, Fire District: I, 45t fre- g w�, .Ma►1,�r_5�s on s I+e. 426 «+- leAs-k S,/.e—a<5 1)tip- A410 1) a.b 50 cbe►L�s/Dais a('oyyt�Q W.0 i- 0,5� 0. 1 ::r oLfeces +o ar—ya-v4-kr,ns 4--3..C> 11s 1s7roM Sa+.JcA,*,VV-, q'c"*25 Waste T ��n: 7 Last shipment of hazardous waste: �rtada�la�ble Name of Hauler: v+o t o ,�ewtf Recovw_<-V Destination: AcAy S k)44 Of/, ]J,)h,,�,ti Waste Product: $ �t I` ' h} o45+-_ e,, -t Licensed?<f'& No So/ve'N't NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS:-Re,xA..0 b e cyc:�2- 45 A P "` The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive Ca"NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides 38$ dNEW279 3 USED It° (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine /5 Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes J* � Co 1 a a hO� Laundry soil &stain removers (including bleach) �/3o F� _s e, a vQ I I-,b le, Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initials TOWN OF BARNSTABLE BAR-W 1;090 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager Address of Offender MV/MB Reg.# Village/State/Zip Business Name am/pm, on 20_ Business Address Signature of Enforcing Officer Village/State/Zip Location of Offense Enforcing Dept/Division Offense I. �: 4- , ,(;1 ��� t Vl . �: �• - �x , Facts This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT TOWN OF BARNSTABLE BAR-w r rn Ordinance or' Regulation WARNING NOTICE Name of Offender/Manager �� kti . :- Address' of Offender MV/MB Reg.# Village/St"ate/Zip Business Name 17 , . , 11 am/pm,f 1 r 20 1 Business Address 1 Signature of,"Enforcing Officer Village/State/Zip Location of Offenses `' - - Enforcing Dept/Division Offense Facts This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-'ENFORCING DEPT. Number Fee 206 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that Village Garage Inc. 143 Route 149, Marstons Mills, MA Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. ------------------------------------------------------------------------------------ --------------- -------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2016 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 07/01/201 5J JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health P� f r � E r Town of Barnstable office: 508-862-4644 Fax: 508-790-6304 Regulatory Services Department • Public Health Division sn RvgraOLK p Mom. Thomas A. McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt Hazardous Materials Payment received: $100.00 (Check) on 8/25/2015 Check number: 008775 Check amount: $100.00 Name on check: Village Garage, Inc. E :Business: Village Garage Inc. {Address: 135 ROUTE 149, Marstons Mills • Town of Barnstable °FTHE lqy, Regulatory Services Richard V. Scali, Director sA MASS. » Public Health Division �A 1639. lE0 MP'�A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. D7U ^00 DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN III GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT U I f�, Gft"e / y NAME OF ESTABLISHMENT �/ijjR:R.e C2&t Ac� -e l C ADDRESS OF ESTABLISHMENT l 3,5 2t e 14 0A A r Sr0/U S Milk (WA TELEPHONE NUMBER SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 043 -10 'S6k STATE OF INCORPORATION ' FULL NAME AND HOME AD RESS OF: PRESIDENT a�,V1 o.TP_if �o� ©Xf�r� Df • CI UIT- M,4 • 0010-5- TREASURER CLERK IV\ •Yl SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS HOME.TELEPHONE# 50Lf - Ya?0 PU AZAPP.DOC TOWN OF BARNSTABLE BAR—W 4930 Ordinance or Regulation -- WARNING NOTICE Name of Offender/Manager Y) r �'�> -�� Address of Offender MV/MB Reg.# Village/State/Zip Business Name am/pm, on 20_ Business Address { yry `s 1 A ►U ! �,'�`J �•J�.¢�t Signature of En/foorci g Officer Village/State/Zip Location of Offense � � � � -e- 1�•' 1 Enforcing Dept/Division _e Offense Facts c.e. LJ4t y(1' t,11� yl --7 �,' /j . This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN,OF BARNSTABLE BAR-W 4930 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager .t� , ! Address of Offender MV/MB Reg.# Village/State/Zip Business Name 1�• .am/pm, on + ]I q 20 Business Address ! t. — 4 IL,I Signature of Enforcing Officer Village/State/Zip : r Location of Offense s ; , i� r �`-� : r . e.� :� � }X '• 'e Enforcing Dept/Division Offense k-� � .�:, �� ". �1, �� _ , • " ,.t_ Facts t a , J,.� in 4 s c.�? . � ,� i. % '"sr'i ' � 's s.t. "`3 / f This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.