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0070 HIGH STREET - Health
70 . . Igh Street W. Barnstable A = 133 028001 �J 9 u i rr 6 it fi I! ,1 ♦� ..-✓.�:.9=' .-. - � �. L'�-.rw•'-'.r. .. .y�••:>..,. :�.�,,:��u... (�:•.: _. Lie:�+w.:t. ..� �- -."".. .. _��i.-�� � _ ,. �^"`�" A ."_ _ �. � a ..-: t P x ,q } No. 4210 1/3 BLU ESSELTE t 10% o a 0 0 <lwQCAiION 70 SEWAGE PERMIT . NO. - �� YIIIAGE 1 STA 11 'S NAME i ADDRESS U I L D E R OR OWN ER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED r i r • p r , c Commonwealth of Massachusetts 183- Dag -001 _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments }, gO 70 High St. c. Property Address i Howard a;a Owner information Owner's Name ; is reqWest Barnstable MA 02668 8/1/18 p every page.ge.ired �• Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information (S14F a,v 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification 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 based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/1/18 Inspecto gn Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. ****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. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 *W— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 70 High St. Property Address Howard Owner information Owner's Name is required West Barnstable MA 02668 8/1/18 cr every page.. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ''F 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 or the 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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. El The se system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or Y P more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool , ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments { 70 High St. Property Address Howard Owner information Owner's Name is for everypage. West Barnstable MA 02668 8/1/18 p Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 II 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. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins.doc•rev.6M6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N ° 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 Cityrrown State Zip Code Date of Inspection D. System Information Description: New leaching system 2003 per BOH record Number of current residents: 2+ Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped every Sept. per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/86 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Septic tank per age of home, new D-Box and Chambers 2003 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2'6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, inlet and outlet covers raised to 3"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 3" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 High St. Property Address Howard Owner information Owner's Name is required for every page. west Barnstable MA 02668 8/1/18 City(rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured 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 suggested every 3 years to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet 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: Hate t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,.•°� 70 High St. Property Address Howard Owner information Owner's Name is required for every page. west Barnstable MA 02668 8/1/18 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-20 D-box 2' below grade, excellent condition, cover raised to 3"of grade Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6h6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers were video inspected and have about 1"of effluent in them at this time, no indication of past hydraulic failure Cesspools (cesspool must be pumped as part 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 ❑ No t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Soils are compact and dry Privy (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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �Z�qT L >Jif Ar if 3 �l o 156 \A 3 i Nor IVO Sc_�L Q t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 1 t Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12'feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: NGW 144" per 2003 plan Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: 2003 compliance 5+ft to gw ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping site is significantly higher than flood plain at rear of property You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 High St. Property Address Howard Owner information Owner's Name is required for every page. West Barnstable MA 02668 8/1/18 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 NOV-23-2005 09 :09 PM High Pointe Inn 5083624441 P. 02 CERTIFICATE OF ANALYSIS Page Barnstable County Health Laboratory Report Dated: 11/16/2005 Uport PA6 red nor: Order No.: G0533715 Ric'aard Howard High Pointd Inn 70 High Street W,9arn§,.b;e, MA 02668 i Lah Or 0533715-01 Description: Water-Drinking Water �ampleff�: 33713 Sampling Location 70 High St.W.Barnstable,MA Colleted: 11/14/2005 Map 133 Parcel 029-00 1 Received: 11/14/2005 Collected 6j: R.Howard Routine i —ITFM I RESULZ UNITS RL �k �. LAB: Inorganics Nitrate as Nkogen 6.2 mg/L 0.10 10 EPA 300.0 111/14/2005 LAB: Metals 0.31 mg/L 0.10 1.3 SM 3111 B 1 /16/2005 Copper i Bn mg/L 0.10 0.3 SM 31113 11/16/2005 Iron 26 mg/L 110 20 SM 31113 11/16/2005 Sodium LAB: Mlerobibliogy Total.Collfoll n Absent P/A 0 0 309 11/14/2005 LA& Phystedtchemistry ConduretanclE! 250 umohs/cm 1.0 EPA 120.1 1�1/14/2005 6.4 P p1l-units 0 EPA 150.1 I11/14/2005 Sodium leviid is above the maximum contaminant level. Those on a low sodium diet may wish to consult a p siclan. ' r Approved By• (La ire I/wr) 7/f Z I i f I ORIGINAL i Rl. Reporting u1 It MCL-Maximumtkontaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date f ) 1$106— Owner Tenant Address Address Complionce Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities 3. Bathroom Facilities A. Water Supply 1 I 5. Hot Water Facilities 6. Heating Facilities 0 f 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents -- 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary HousingI AM PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s) Interviewed ' y'�` ` Inspecto If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION Date - \ c�0 y1 Y\� t � 1��C. Owner � � � U \ vcm-"�- Tenant y Address Address Complionce Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 1-\ Y-f- i 4. Water Supply 02-0 4-v 5 Hot Water Facilities > 9 6. Heating Facilities O\ 7. Lighting and Electrical Facilities 8. Ventilation 1� 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal b 16. Sewage Disposal 17. Temporary Housing v Yv PART 11 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s)Interviewed Inspector 4',ai4��)--- If Public Building such as Store or Hotel/Motel specify here � �Ll OF BARNSTABLE BOARD OF HEALTH { ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date 's Owner 0554�/VIVfd ?Le - 4/fenant llewwy111� Address �� ` �<'l ✓ �^ Add�re ,0 / Compliance Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities �� 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities �L 6. Heating Facilities 4 7. Lighting and Electrical Facilities 6- 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service v 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents' 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal --;3r Q � zz 17. Temporary Housing PART 11 ® � l 37. Plocarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s) Interviewed Inspect r If Public Building such as Store or Hotel/Motel specify here HOBBS&WARREN,INC. TOWN OF BARNSTABLE 1 � BOARD OF HEALTH i ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION Date � z b � Owner ik§-V L� 9 N Tenant Address 7 Q T J 4"S Address Complionce Remarks or Regulation# Yes No Recommendations �^v =- 2. Kitchen Facilities >S&Q7 SL47 `, 3. Bathroom Facilities ✓ 4, erWY"�"• (�jp �3 S"Gti/t� -k �� 4. Water Supply ?/l lAl 4T � /�R.�✓ v vV'X-_ 5. Hot Water Facilities Olt 6. Heating Facilities F1AA1 Oi / 7. Lighting and Electrical Facilities �cv' t�v' �' ''� 0� 8. Ventilation ✓ 5.f'V,kAA1') G OCR 9. Installation and Maintenance of Facilities S(*,A-U'Qth P A 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural e✓' d,2rj�iS �Gv Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal -..-K>{ r 17. Temporary Housing PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s) Interview d nspector If Public Building such as Store or Hotel/Motel specify here ' HOBBs&WARREN.INC. TOWN OF BARNSTABLE ATION �D SEWAGE # o7G� VII.LAGEQ��1S/< ASSESSOR'S MAP& LOT 0 GU 1 J , Y Y gqu INSTALLER'S NAME&PHONE NO. / Aey z�`j1, CGei,S�.s. � SEPTIC TANK CAPACITY ' LEACHING FACILITY: (type) s'00 (size) 1J �K 3�? 1� ,NO.OF BEDROOM BUILDER OKWNER PERMITDATE: %7 4'1//`�7---COMPLLANCE DATE: 13 v Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility s Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /S—d f Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /0a 1 Feet Furnished by 64 rinty 5 Aq i „�c-�o �- y�, GSJ- yd” % �. o y �� , � �. i ��, O s' � �irMQd`=,� ` � °�! � O � � ' � v y� � � �._J 'No. �y J�? ~"�'""--F-o I '- - CH SE Entered in co: uter* ., TFIE ��MMONWEALTH OF MASSAa.��c,�LTTS p Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for Miopozal *Vqu n Cori.5truction Permit Application for a Permit to Construct( . )Repair(11 )Upgrade( )Abandon( ) O Complete System ►l dividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel va$ W t W- A d le Installer's Name,Address,land Tel.No. Designer's Name,Address and Tel.No. �Qf96/, ca'lt��t - SQL -7/--��3, �yir o7f� Type of Building: f� Dwelling No.of Bedrooms ` Lot Size sq.ft. Garbage Grinder(41t 1 Other Type of Building e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 212 gallons per day. Calculated daily flow gallons. Plan Date 3 Number of sheets l Revision Date Title Ali 5 o rlkre _�,e _5 S Sle_"el Size of Septic Tank %J`WW Type of S.A.S. Description of Soil, 13X 1/Z . ? Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b s Bo =4�_ Signed Date Application Approved by Date 2 /'► Application Disapproved for following reasons Permit No. �t,u 0 01 Date Issued 12 11, -- ------ -- -------- ---- --------------------------- ,- ��TH 9MMONWEALTH OF MASSA' nuE"tTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS , - 3pprication for Migozal *pztem Construction Permit Application for a Permit to Construct( . )Repair(V)Upgrade( )Abandon( ) ❑Complete System R dividual Components r , -t-`ws*cnwW+';s`^R-:.s;^ :d._ r rr Location Address or Lot No. Owner�s�Name;Address and Tel.No: Assessor's Map/Parcel �c J� �a% C50 t Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 617 Type of Building: Dwelling No.of Bedrooms Lot Size b V^19 70sq.ft. Garbage Grinder(4),9 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow S.So gallons. Plan Date elf Z 5112 .3 Number of sheets { Revision Date Title Size of Septic Tank /J�C' I�pe of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board-of Health. Signed �/./ V 4,10 _ _ Date �Z l•�s�/l/'� Application Approved by k'i h4 -,No Date /2 Application Disapproved for the following reasons Permit No. Date Issued ----. `------ ————————————————————————- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site,Sewage-Disposal System Constructed( )Recaired(/' )Upgrades( ) Abandoned( )byGl at ��� / f 4� �,T ',�'�'/95�`�. /t'' has been constructed i 'accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.—)#6 0`I dated Q/l 0 3 Installer Designer ! The issuance of this permit shall not be construed as a guarantee that the system will unction as designed. Date Inspector --------------------------------------- No. ?U U 3 (,0_ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE., MASSACHUSETTS Migool bpgte Construction Permit Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon( ) System located at 7/� / Pd1 3� GU • . �l!'!'f1� ��.li' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this nermi� Date: /! I / (► Approved by TOWN OF BARNSTABLE �. LOCATION S74 SEWAGE# 073 G� VILLAGE_ !� �A��1'l f�f ASSESSOR'S/MAP &LOT 0y AT INSTALLER'S NAME-A PHONE NO. ' . 64', SEPTIC TANK CAPACITY LEACHING FACILITY: (type) s-y0 C4L r��.� (size) NO.OF BEDROOM -BUILDER 0 R PERMIT DATE: / i/ COMPLIANCE DATE: 13 v Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5- Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist d<3 Feet within 300 feet of leaching facility) Furnished by �r�►1 S�� 4 �- 7 0- ye G ` r O 6y ' r r I y O � Sep - 20-01 13 : 52 BARNOBLE HEALTH DEPT 50879404 5/U 01 . NOTICE: This Form Is To Be Used For tLe Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM (1qet-Ne4 , hereby certify that the engineered pian signed b,v ...e uLtec � 4�0.�, concerning the property located at !�_N'.ah 4b'vT �v- W •�o%h� meeis all of the [Cilowin; �:ntena: • This failed system is connected to a residential dwelling only. There are no :omm-trzia! or business uses associated with the dwelling. • -F�e s011 is ciass;f�ed as CLASS I and the percolation rate is less than or equal to 51 rtnutes per inch. The applicant ma,y use historical data to conclude Ns f3c: or ma _onduct Pre!irmnar,' tests at the site without a health agent present • There :s no incre:,se in flow and/or change in use proposed T herc are ;to variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen l fee: aonve the maximum adjusted groundwater table elevation. rAdiust the 1.oundwater table using the Frimptor method when applicablef Please complete the following; Fop oi Ground Surface Elevation (using GIS information) _ 4DiP0 61 t�.W Icvacor, _ adjustment for nigh G.W. a 6D t> R-T.RENCF C.ETWEEN and B S:G.VED DATE: k;a\ �O NOTICE ' Dasec i-on, the above r.formaUon, a repair pen-rut wil! be issued for '-)edr^oms -ra.. rr.uTr +r! ;c�tu^nal bedrooms are authorized to ttie future without engirt erec plans. �.. ._ �cnnn!q:Gu �<�ccxm9 I•. Permit Number: Date: Completed by: HIGH GROUNDWATER BEVEL COMPUTATION Site Location: 1��gh c i n5b�2 Lot No. Owner: r.;�� �� K0. 2�1 Address: ,t.r o 0 n Contractor: f2M:�, i1LINMC)f`��Address:�6 aal t��. �E��f`r�0 (n �'�f4 -51, !votes: STEP 1 Measure depth to water table tonearest 1/10 ft. ....................................:......................................... .Date 1 t9 mont /day Pa, STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: g'pp OA Appropriate index well.................................................... C253 OBWater-level range zone ..................................................... l STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well month year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water level zone (STEP 2B) determine water level adjustment ..............................................:........................................... 3 STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .................................... ................................ i�5l 1; Figure 13.—Reproducible computation form. 15 Department of Environmental Management/Division of Water Resources WELL COMPLETION REPORT • M� WELL LOCATION GEOGRAPHIC DESCRIPTION Address ��•` S r � N S .E f w of (feet) (circle City/Town tA�•C74rNSTA� �z�H� 1A"� V r ST, Well owner � O"J HtQh (road) Address tow.-76 iko,o, '5-fxt -`k N Sf� E W of j r (mi.in tenths) (circle) Board of Health permit obtained: yes no ❑ intersect.,/ eA (road) WELL USE WELL DATA Domestic Vpublic❑ Industrial ❑ Total well depth ft. Monitoring❑ Other I Depth to bedrock ft. Water-bearing rock/unconsolidated material: Method drilled - Q Description Date drilled Water-bearing zones: CASING tt 1) From To Type _&N q6 1pV C 2) From To Length'.d ft. Dia(I.D.)_9�_in. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: dia Screen- Grout �. /�,,�i Grout ElC Other Slot#�length from SQL to STATIC WATER LEVEL(all wells) r Static water level below land surface ft. Date 3 173 WELL TEST (production wells) [ Drawdown 6 ft. fter pumping � hr. 1 min. at IS- How measured�Recovery ft. after_ hr.—min. LOG of FORMATIONS COMMENTS 0 Materials From To J�f1 5c�A/e l a t Driller �I Firm FI Address Pa'&x 1 co S A- 1 City/Town 0Z6 _i Supervising Driller Reg.# Signature of—supervising registered well driller Please print firmly BOARD OF HEALTH COPY yb TOWN OF BARNSTABLEv f 3 BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date Owner �c^ �''"� Tenant AkOW4, , Address O �% S'+ Address Complionce Remarks or Regulation# Yes No p�., Recommendations 2. Kitchen Facilities 3. Bathroom Facilities i/ C � '�O /fZ•�^0'� e.�L(63tv�.tt� 4. Water Supply ✓ we.l Ye,.- 5. Hot Water Facilities ✓ ( � F 6. Heating Facilities 7. Lighting and Electrical Facilities ✓ 8. Ventilation ,� cso�s i� Sriv� cYi ` 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents `� br/l� 6y t S 0"1"d 15. Garbage and Rubbish Storage and Disposal ✓ 6�1 j#6 f &Y Gnu. 16. Sewage Disposal ✓ t 17. Temporary Housing' PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s)Interviewee Lam, Inspector If Public Building such as Store or Hotel/Motel specify here H01389$WARREN.INC. TOWN OF BARNSTABLE Q LOCATION 7�� /�//�G� �� SEWAGE # VILLAGE ) ; -� ASSESSOR'S MAP & LOT @ 04 INSTALLER'S NAME & PHONE NO.lkna wm ey?av ; SEPTIC TANK CAPACITY r e© C 41 'LEACHING FACILITYAtype) ,` ma` s (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER C06 BUILDER OR OWNER j`lt�Gl DATE PERMIT ISSUED: 9r- DATE COMPLIANCE ISSUED: "` ` ... VARIANCE GRANTED: Yes No �y�l� �, ° /' \ � s. �� ,o � Y - , yr t ��' �� � � � � ,� � + _ �� , - No................-....... Fps.........-••--•-•---••--•�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Diupuual Morkii Tomitr r#iu ramit Application is Ihereby 1maade for a Permit to Construct ( ) or Repair ( an Indiviid�ual Sewage Disposal Systemat��j ....°YI. ..6 -----------------------•-•-•---•----•. --•-----------------�.. 1J _�_ -----------•----•-----....---- .. o ation-dress r t � .----•-• ................, r� .. Cam......................... -- W Ow ,/f Addre s / d is taller Address Type of Building Size Lot............................Sq. feet ►� Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ____________________________ No. of persons..........-................. Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _d ------------------------------------------ ---------------------------------------- •-------------------- W Design Flow_....._.._�7.:-______________________gallons per person per day. Total daily flow-----q-qQ........................gallons. WSeptic Tank—Liquid capacity........___gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width____r .....__._......... Total Length.____.........___. Total leaching area....................sq. ft. Seepage Pit No......I.............. Diameter-----1_6-.-______ Depth below inlet.... ............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ ----------------------------- -----•----•----------•-------•-----------------............................................................................... ODescription of Soil.............................................------.....---........------------------------------------....----------...---------------------•--------•••--•-•---•••--. x V ....•-•--------••---------••--••......................•------------•-•-••-••-•--•-•-•-••-••••••-----•-----•-•-----------•••-----•-------•-•-----••----•--•-•••---•---••••-..................•-------•-.. W UNature of Repairs or Alterations—Answer when applicable.__ S'S .,.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the syst in operation ntil a Certificate of Compliance has been iss d of ealth. ����_ Signed --------- Dace Application Approved ..........I......:............... -----.........Dace........... .. Application Disapproved for the following reasons: ............................ ................. ..... ............................• 1 ............... ............................. .............................. . Da Permit No. ��-�---------�-- -------------------- ------ - .........'�...��-.�. Issued Dace No.................--.�fl �� �_ Fus..... - �f`. � THE COMMONWEALTH OF MASSACHUSETTS B(59R' D'�i'OF^'KE;ALTH I TOWN OF BARNSTABLE / , pphration for Bioviiottl illiarkii Tottstrurtio Vrrutit k Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at / t, ' ................'-��}------------�LEI._._`_r:.---------------------....-------------- -------------------------------,-------�------�-�-=---..........--.............................. nation-_ i,dress ,� or Lot Noy -----=N. , ress � LII�*/�F;tE• � � 'i �staller Address UType of Building T___ Size Lot............................Sq. feet Dwelling— No. of Bedrooms._-_-T__ _________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons........:-___-_..___---.-_- Showers ( ) — Cafeteria ( ) Other fixtures d .. -------------------- ---------------------------------------- •-------------------- W Design Flow..........' ......................gallons per person per day. Total daily flow-----g/qU........................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width------.-.------- Diameter---------------- Depth-----_______-.-. x Disposal Trench—No. .................... Width----�-.-------_-_-- Total Length.................... Total leaching area------------........sq. ft. I------------- 1-6...._..__ Depth below inlet___�............. Total leaching area..................sq. ft. Seepage Pit No..__.. Diameter.____ z Other Distribution box ( -) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_---_-----____----_--. --------------------------------------------------------------------------------•-----------•--••---......................................................... ODescription of Soil........................................................................................................................................................................ x c.> •--•-----------•-------••-••--------------••••-••--•-•----------••--•••-•----•----------••--•••--------••••----------------•----••-••--••-------•--••...----•-----------•-.......•--•--•---••••••.....•. W x --- ---------- -----------------------------------------------------------------------•------••---•--------------------------- -----------------------••---•-•----------.....-•--------•-••-•------••-- U' Nature of Repairs or Alterations—Answer when applicable.-. -`�Z_.1PA�\..__\_OCXD...�-�:�_�` -----t') �.......... x •-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by-the_bo d of health. Signed .........-.----- ----- --------1... .----------- Date APPlicationApproved Y . .�............ ........................ - ............................... Date I Application Disapproved for the following reasons: ......................................_................ . .......................... .......................` ---------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- .......................... Permit No. .....7 " .. t �� Issued ------------ `"`-_`——_ Dale THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance .► THIS IS 0-G&R-��Y�,That the Individual SewagelDis osal System constructed ( ) or Repaired ( ) by ....... .. �� le ....... - =...... dvLo_ ' ... at _......_'..L�J......_`+-1'!........ -{ ------- -�'" =="'.' -r-1 ' ` --------------------------------------- has been installed in actor nce with the provisions of TITLEi o e State Environmental Code as described in _ the application for Disposal Works Construction Permit No. f ... .....-f` ' �___.. dated _ .��-"..�., THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIO SATISFACTORY DATE--------/.............. Insp ctor - - �/-..: ....... _.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . � TOWN OF BARNSTABLE N o.................. FEE..._..........�/a'J� Rapooal Workii Tonotrurtion rgmi,tt--�7 `` C Permission is herebyranted _ ` �� r r G�' - 1-----t!1-- �� c-- g ....... ........... ._.. to Construct ( ) or Repairs �� Individual Sewage-Disposal System I ( � ( atNo....................... ............................•1. ------- ---`-------....-.�.. )..7-....-7, ._�_-..............- • Street /'•7 � s � as shown on the application for Disposal Works Construction Permit No � __� - ._ Dated__ --------.. ? .... •••••-------------------- Board of Health / DATE-----•---�----------------!----•i� r/ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS 1 � OESSORS MAP NO- A6 • PARCEL NO: t-�3 ;?,Y" a - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di_ripwial 3Vnrk,i Towitrnrtinn 11amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ` -�S�wy es Location- ess or Lot No. .................._.......................................................................... •-•-------------------------...----........--•-------........----.............................--- _ .-Owner A ress :w o1 r IV.. t QNa-1/�3�1! Off. l�_�e`wN� � �Q•r�.._..��.� Installer Address UType of Building Size Lot............................Sq. feet �., Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria 04 d Other fixtures ---------------------------------------------------------------------- -- ---------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter.................Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-.______----__----sq. ft. Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) •.' Percolation Test Results Performed by.......................................................... •-------------- Date........................................ ,.� Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..._-.______-______---. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R, .....-••--•--------------------------------------••-------------•••-------------•---•---------..---------------...._...........-•---....._....._...-••.----- ODescription of Soil......................................................................................................................------ .......................................... W U x ------------------------------------------------------------------------------------------------------------- ------------ f U Nature of Re airs or Alterations—Answer�when pplicab{e. ! / :,_�2(jn_. ?.��tr3..._.. -. ._. ie�. . �r _... cC�o?1'`O��G � r............ ........... Agreement: 1i The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuedrhe board of health. Signed --- 1 3-fry^ --- ---------------- -----3.�_ q.3 _:...... Dare ApplicationApproved By -----------------__-------------------------------------------------------------------------------------......--------------------------- --......------------------------------- Dace Application Disapproved for the following reasons: ...................................... . . .......... . . -- .................................. ...--- ............................... ........................ .............. Dace PermitNo- ---------------------------------------------------------------- Issued ................... . .............................. Dace --- ------------------------------------------------------------------ --- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�elrtifirate of Q-1-omplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ...................................................................................................................l------------....................................................................................------------------------------ nstal at ----------------------------- -------- ---- -------------------- --- --------_------------------------------------------- ---------.......----------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No- --------------- dated ------------------------.-----------------_- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------...................----........_.._......--------------- -- ---- Inspector --------------------_ --------...- - - ............................................... ------------- ----------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......................... FEE........................ Disposal Workii Tnnntrudinn "erncit Permissionis hereby granted------------------------------------------------------------------------------------=-----••--.....---•-................•--•••----.........--- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.................................................................. - ---------------------•-----------------------------------------------------------------------------------•----------•---- Street as shown on the application for Disposal Works Construction Permit No------------------_ Dated........................................... -------•---...-•--------•--•-•-------------------------------------------•--••-------••--•--------------- `: Board of Health DATE................................................................................ FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS No......................... fs C� l Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiutt for Divi-puiitt1 Wurkii Tinuitrurtiun thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ,- -� . =-= .. ----- --... Location-.Vdd,ess or Lot No. .................................................................................................. --•--•••••-----•---•-••-•-•-••-•-•--..........-------........---•----•-.._....___....____......... Owner rc NC O f /l,/ • ! 1A^dS�es � _._ :.._. !_-`Y/-1 /CIKA....TI/1__:..!y�'!1 ...' Type of Building Size Lot............................Sq. feet ff • j '/Ae.*✓r1,4-Viistaller Address U • Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------•--------------•.....------.--------.........---------- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area.....................sq. ft. Seepage Pit No...................... Diameter-----------.-------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other.Distribution box ( ) Dosing tank ( ) ►-' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No:,l................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••-----•---•-----------------•--------•-••----•----•------•-••----•----•--•--•--••••........---••--•-----••••-•--•••........................................ 0 Description of Soil........................................................................................................................................................................ x w I r, Nature of Repairs or Alterations—Answer when fapplicarbl{e._... t`�. c./..................` macf --------- !:-�. -••-. ...._._ . fl.�-t - _.._<<tf)M c�c. .....��i..J�c31 n-�ec..Sv,?^^ .(•-G� ±._��[�N . oI� r -I ..._................ Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the systerr. in operation until a Certificate of Compliance has been-issued by, he board of health. Signed ...... f .......... ..... ---------------------------------------- Date ApplicationApproved By ---------------------------------------------------------------------------------------------------------------------------------------------------- ----------------�_e---------- Application Disapproved for the following reasons: ..... . ... ...................................................... ...... .............. . ..... . . ............... ..................................................... .. .. ........................................................ ......... --- .. . .......................... Date PermitNo- ---------------------------------------------------------------- Issued ........................--- ................. . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE QUIertif rate of Complianre 7 HIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by - - w,,r _ ..... It,�tauet at ..--. ......................-----.............----------------------------------------------------------------......--------------------------- ---------------------------------------------. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...__..........._...-------_-------------- dated .............__---------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. --/ DATE J �A - ... _. Inspector .'.�::.:�' ---� - ;'--- ....'"--- .= ---------------- -------------------------------------•---•------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......................... FEi........................ Binpnual Workii Tunntrurtiun "rrntit Permissionis hereby granted---------------------------------•-------------------------------------------------------•----------------•---------•-------•------•-----•--- to Ccnstruct ( ) or Repair ( ) an Individual Sewage Disposal System atNo-------------------------------------------------------------------- ------------•--•---•------ •-••••----•-•- Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated........................................... ............................................ ...................................... ..................... Board of Health DATE................................................................................ FORM 3e.508 HOBBS&WARREN.INC.,PUBLISHERS 1 'Fe ASSECSORaS MAP NO. Q PARCEL 9 "/ ff U C Al S E A G E PERM I T NO. VILLAGE I N S T A L L E R'S N A�II1� K�NEDY TRUCKING 13io �- 02�®0(3) d� 525 lull C 4 SUUT WEST BARNSTABLE, MASS. a U I L D E R OR OWN 16 t, DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � o i 0 Hf° 4e . i ' 'SSESSORS V1 A!O:1�1 No.12T.1 ae_ FEB �...... THE COMMONWEALTH OF MASSACHUSETTS ��-- BOARD OF HEALTH -----��?V..........OF....... ST..�23G ...---•....................•- Appliratinn for Bisp aal lVarkii Tanstrnrtinn ramit Application is hereby made for a Permit to Construct (i.-� or Repair ( ) an Individual Sewage Disposal System at: .�...�_...--T-•---------------------'--�ivs7�sG ..... ........----...--•-...----...---�T---•---------.......---------•--•--.-...------------- Location-Address or Lot No. �� ��zl� -----•-'------- -^----------------- «�__ '�---._...�11�±::...•......--'---.-.._..--------.......-...--- ............ . —..... Owner Address ...... / 't' In:ta,ier Address d Type of Building Size Lot...gt_�_�___�.....Sq. feet Dwelling—No. of Bed. .............3_..__.._____..__.........Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—Type of No. of persons............................ Showers YPBuilding ---------------------------- P ( ) — Cafeteria ( ) Otherfixtu es --------•--•-•--•'----------------'------•-•--•__.-•--............................................................................................... W Design Flow______________............_.._...___.._____.gallons per person per day. Total daily flow........... gallons. WSeptic Tank—Liquid capac=ty.l.:�79�?_gallons Length..C6 Width.. "6...... Diameter______________ Depth-.!;F..��.. x Disposal Trench—No..................... Width.......-.._.._.__... Total Length-__-_______.�.... Total leaching area....................sq. ft. SeepLge Pit No.........�--------- Diameter_-___�.- . ..... Depth below inlet...3�-A......... Total leaching area_t� .e..sq. ft. ZOther Distribution box ( ) Dosing tank L) 4 Percolation Test Results Performed b 47, -'9"12�.A�✓lCS ��`• Date.. ___�� Test Pit No. 1__'`�/�Z---minutes per inch Depth of Test Pit.../_�..-._.. Depth to ground water_--__--'---___----- 44 Test Pit No. 2..ZZ___minutes per inch Depth of Test Pit__i ........ Depth to ground water....... a ...................................- •------------------------------------------------------------------------------------------------------------------- 0 Description of Soil.... r�" ✓ 6° ''�------ 8..r3�' S/G7y.:. `S`� -Softy '31'_Z'--p x ' .o".. / � � 7o _.__a _U .---•- .... . .--'- .... W --_. --- Nature of Repairs or Alterations—Answer when applicable.......................---------- --1GINEER M _______________________________--_ ,r�sr- Agreement: STALLATION AND CER i iY 1'`'__4 v"a:' �s ��� 1 STALLED IN STR►G= The undersigned agrees to install the aforedescri d Individual Sewage—1s 0 stem in accordance with the provisions of TiTrr ' �^ n� F TO�L�wr�• p 5 of the State Sanitary Code The undersigned fiirt�er ag ees not to place the system in operation until a Certificate cf Compliance has been is d by the rd of he th. Signed •-- . ------• -...... -- ----- --------''-- Date Application Approved By....___ ._�_. .................------------------•---.........-- ...................................... Date Application Disapproved for the following red :----------------------------------------------------------•'----------- ..................................... Date Permit No.__677_-:�. ....---•--•----------------------_ Issued.-- -- �---"=3---------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. !✓' ......OF...... 7J9f3G.................................. �rrtif iratie of Tnntplianre TH?.-jeTT IS TO CERTIFY, That the Individual Sewage Disposal System constructed (for Repaired ( } by..----- - ...... ----------------------•---------------------------------__----------------------•-•-•---•-•--•-----------•-•-•------------------------- ----I.....---�t- --------57---- ._._.YY. aLnstall !x[!t� �!S.[!- -------------------------------------------------....... has been installed in accordance with the provisions of Ti T IE 7 of The State Sanitary Code.as described in the application for Disposal Works Construction Permit No... ............ dated..------ ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................................•........--•---------••----. Inspector..............................`..................................................... r No27_19.... Fizs... ,ate. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ 1n/..---. --OF......�� 7 13G- ......................... Appliration for Bi_qpos al Works Tonitrnrtion Frrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: -• --•........... ...•-- ------ ---......------. •---••-- ----------------------------------------------...........------ Locat on- Address or Lot No. � os/c .......... .......... o��^! /'.1 '--•--------•--.......-----............._..--- Owner Address -� ............`............. ----------------------------------...... ..--_.... ••---- ....- ------------•. / Ins'aLer Address �� � Type of Building Size Lot_._---t_____________- Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria WGI Other fixtures ----------------------------------------------------------•-------•---•-••--••---•-•---------------------------------------------••............---•- Design Flow..............� .......................gallons per person per day. Total daily flow............. 0.......................... 1:4 Septic Tank—Liquid ca.pacityt� .gallons Length$`�_........ Width.` "G..___. Diameter________________ Depths. ...... Disposal Trench—N?o. .................... Width.................... Total Length.................... Total leaching area--__-__-----------sq. ft. Seepage Pit No--------/---------- Diameter..../`1...___. Depth below inlet.-!!.- .......... Total leaching area-s .-�...sq. ft. Z Other Distribution box ( ) Dosing tank '-' Percolation Test Results Performed by....E.__-................. sr_.. 'h .......... Date. 7..._ _-��� .�-.: a � Lest Pit No. l:`���....mmutes per mch Depth of Test Pit_/�/4:_._..._. Depth to ground water...... 44 Test Pit No. 2.:`"1?r.•_:`minutes per inch Depth of Test Pit.!'44.......... Depth to ground water........................ W -------------=-=------------•---•-•- ,-..------•-••--...........------........---------------•-----......................................................... p GO r-/ UV -1G� SfGT' sS" �'S/�/t. ._.6 " Zo' � .c}� _.._..._...- Description of Soil - l ........................................................... 0 ...�o_.../4SL� C`Le'�u--_...� :z> � Gi....ivEc. �✓ 7^r/ -ey S/vr/A-G 1 ,. �5 ' _ Sim%-•---- - - ----•---•-•------ ••---•------••------ ---------------- ---------.. W ----- -------------------------------- ------------------------------------••----------------------------------------•--- :-•-------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable--___--__-_•----------------------------------------------------------------------------------- ---------------------------------------------------------------•--------------------...............----•---....---------------------•--•-------•------------------------------------------------••------ Agreement: The undersigned agrees to install the aforedescr' ed Individual Sewage Disposal System in accordance with the provisions of TITLE, of the State Sanitary Cod The undersigned fur4�e ,toees not place the system in operation until a Certificate of Compliance has been i d by the rd^o-f�h l Signed•. ...... • ------. -----•. --cam- ...-- Date Application Approved By........ ...-"'=- .................................. -------------------------------------- Date Application Disapproved for the following re ---------------------------•-----•--............----------••......---- ----•------------- ---------••••...... ............................................................................................................................................................................ ............................ Date 3- Permit No.. ...7'..../..,. ------------------------------ Issued.- �--• � '=�---•------- DateTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH >tN.c/........OF....ld'taLrrT .�3 � ................................... (9rrtif iratr of Toutplittnrr THI IS TO CERTIFY, That the Individual Sewage Disposal System constructed il-) or Repaired ( } by... ... k� -•-�- --------------•- -----------Installer------------------------ ---•-------•------------ .-P L---- ----- has been insmiled in accordance with the provisions of TiT E j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..k7_... _j-..7............. dated...----3.-. e-__�_2-_----._-__-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector...................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ��W N' OF.....8! !ST ��' `77 .......... ... .................-----.................................... �'O._ .:�.....�.1...... FEE.�...7...--•---..... Bioposal Vorkg Tonstrttrtiott amit Permission is hereby granted•••• ------- -----•-------•------- -----.---•-----•------•--------•--- to Construct (/') or Repair ( ) an Individual Sewa�e Disposal System -t No. f k._(................................................................----- _ Street .�_f as shown on the application for Disposal Works Construction Permit No _:AVF... Dated...... _�L.. . ?.......... ..... ....------•--.. Board of Health DATE—I.._.(.. -- 5 ?_................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Department of'Enunonmental anagemiint/Dwision of Water Resources _ R i VIIAT R��V1IELb,'0OIVIVL�ETION' REPO!RTi 777 777777 aV11,ELL LOCATION Address �s '1rr fi� i f jT ' t City/Town' A�fYP��C r' =. �? % TjL 1 G.S Quadrangle Map _ 'goo 5- �'Addr'ess°° ��� "f"mr rj'c�r, 3�f '� �s�dh _�Q► � l!6 r9 , WELL USE CONSOLIDATED WELL R+ j.iDorfiesiic®ool,Publ9c❑ ,Industrial❑ Type,of Water-bearing Rock Other- -- Water-bearing Zones 31 ti 1) From To Method Drilled 4e.r - i 2) From To e 5 Date Drilled /'��S/ �' 3) From To T. 4) From_ To cr' CASING Depth to Bedrock - ' Type -_'{CL�1�A1{t� UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing'Materials r Feetbelow land surface -/A Sande fine❑ medium❑, coarse;0 ' Date measured .L/15/ Z, Gravel: fine❑ medium❑' coarse•❑ GIRVYE'L.PACK WELL, Screen A _ I Slot# �. length � ,-from to Split$cree.n(or 2nd screen) d. WATER QUAt1:TY TESTS MADE" Slof lengtFi from to ' chemical ❑1/o Biological 'Q' Depth To Bedrock `- PUMP TEST Drawdow.n feet after pumping days Y hours at '�t� GPM .How measured, Recovery--,-- - feet.after hou►s: y LOG'of FORMATIONS COMMENTS::"(On well or water) Materials From To cb 1 DRILLER,6 3A o Firm j ,At, PI/M� .{Qt J ; _ f L IC�t oT _ C a Address aE- �R .' - cify 0Iv Mg, a J Registration No,__' Aerator ignature, ?r a ttl � � ease pant rrm y` � � '� �;, �?'1 :• r3,Pd;rya.�'�F�;•��ti�.�i.��'DwQ,t� �rf.Q� �f��L,�n .��+i �•51Mlsn��`Z �t OFFICE LABORATORY 1498 HIGH STREET 176 PLYMOUTH STREET } �RIDGEW.ATER, MA 02324 BRIDGEWATER, MA 02324 OLIVEIRA ENVIRONMENTAL LABORATORIES, INC. FOOD- DAIRY PRODUCTS-WATER-WASTEWATER CHEMICAL& BACTERIOLOGICAL ANALYSES 697-2650 January 21, 1987 Pilgrim Pump Co. 26 Camelot Drive Plymouth, Maass. 02360 Source: Well Water - Bored Well with well point - 36 feet deep - producing 20 gals/min. Located on the High Street property - Barnstable, Mass. p/l/ep S i7C Coliform Count /100 ml @ 35 C Membrane Filter 0 S.P.C./ml @35C 12 Color (APC units) 0 Sediment slight Turbidity (NTU) 0.64 Odor none Taste satisfactory pH 5.9 Specific Conductance micromhos;cm 100. mg /liter Total Alkalinity (CaCO,) 10.0 Free CO, 24.5 Total Hardness (CACO,) 28.0 Calcium (Cal 7.20 Magnesium (Mg) 2.44 Sodium (Na) 9.20 Potassium (K) 1.66 Total Iron ,'Fe) 0.09 Manganese (Mn) L 0.01 Silica (Si0,) 10.0 Sulfate (SO,) 7.50 Chloride (CI) 20.5 Nitrogen - Ammonia 0.11 Nitrogen - Nitrite 0,002 Nitrogen - Nitrate 2.60 Copper (Cu) L = less than On site collection made by Mr. Bruce Bishop - 1/17/87 at 10:00 A.M. Sample delivered to laboratory by Mr. Bruce Bishop - 1/18/87 at 8:30 A.M. Bacteriologically, this well water is of a satisfactory sanitary standard and is suitable for drinking and domestic purposes. Chemically, this well water is acidic and will be corrosive. All other chemicals tested meet the standards. Director S . Yh�Standard Plate Count indicated the general bacterial population of the well at the time of collection. 0 Coliform Group Bacteria: Significance The coliform group bacteria includes organisms found in the intestinal tracts of warm blooded animals, birds, decaying organic matter(hay, leaves, wood, etc.), the top 2 to 3 feet of the soil, lakes, ponds, brooks, rivers, drainage.and types of vegetation. Because the organisms can cause some illness; because the presence of coliform organisms in the water suggests that other more harmful organisms may be present, water containing one or more coliform group bacteria per 100 ml of sample should not be used for drinking or cooking purposes unless boiled 5 minutes or disinfected by other means. This bacteria is of animal origin(intestinal tract)and may be considered as closely associated with disease causing organisms.On this factor, none should be present. Color — APC Units - Ground water ought to be practically free from color. For attractive water - color should not exceed 15 units. Turbidity — NT Units - Recommended limit not to exceed 5 units. Odor& Taste — For water to be of high quality, the water should be odor free and taste good. pH — The pH value defines the concentration of free hydrogen ions in solution. Expressed on a scale extending from 0 or very acid to 14 or very alkaline with 7.0 being neutral. Specific Conductance — Conductivity is a good criterion for measuring the degree of mineralization and assessing the affect of diverse ions on chemical equilibria. Total Alkalinity — The alkalinity of this water represents its content of carbonates and bicarbonates. Free Carbon Dioxide — Well water having a low pH and a Free CO? level in excess of 50. mg/I will be corrosive to iron, bronze, brass and copper tubing and fittings. Total Hardness — Standard not to exceed 50. mg/l. Waters having a hardness level of 50 to 100 are in the medium hardness range, over 100 very hard. Calcium -- Calcium contributes to the total hardness of water.Appreciable amounts of calcium salts break down on heating and form scale in boilers, pipes and cooking utensils. Magnesium — Magnesium is a common constituent of natural water. Magnesium and calcium ions are principal contributors to water hard- ness. Concentrations in excess of 125 mg/I can exert a cathartic and diuretic action. Sodium — Recommended limit not to exceed 20 mg/l. Potassium — Potassium concentrations in drinking water seldom exceed 20. mg/I. Total Iron — Standard not to exceed 0.3 mg/l. Manganese — Standard not to exceed 0.05 mg/l.The principal reason for limiting the concentration of manganese is to reduce esthetic and economic problems. Silica — Silica content of natural water is most commonly in the 1 to 30 mg/I. Silica in water is undesirable because it forms difficult to remove silica scales. Sulfates — Standard not to exceed 250 mg/I. Chloride — Standard not to exceed 250 mg/l. Nitrogen — Ammonia is present in variable concentrations in many surface and ground waters. Its occurrence in ground water is generally a result of natural reduction processes. Nitrogen - Nitrite — Nitrite in water poses a health hazard, but fortunately seldom occurs in high concentrations. Waters with a nitrogen - nitrite concentration over 1 mg/I should not be used for infant feeding. Nitrogen - Nitrate — Standard not to exceed 10. mg/I. Nitrate, in high concentrations can and do cause methemoglobinemia or so-called nitrate poisoning in infants. Water with 10 or more mg/I of nitrate is unsatisfactory and is not considered safe for drinking or cook- ing. It is especially dangerous to children and should never be used in infant formulas. Copper — Standard not to exceed 1.0 mg/I. t' �_ `►-�__,�,�..__, SNP-�T- /. nj ? s'f/G�d LOCATION r ... SCALE DATE ,h?y Z lyac � I PLAN REFERENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p -o --- C \ --- - /a � • �'�:'L7=7 cF sWA^;�= G,Flo HG..t %3Of mac',',. �� •�� ~ � `�^3�` �.__ — Zai lw 1 0 ' •I n (F�ray`% ,Z;7 4-4 : zyr► z o,� Z -SHE-E rs 4Z.O D TOP OF FOUNDATION e CONCRETE COVER CONCRETE COVERS �69' e e 4, CAST IRON 12"MAX. 12"MAX. OP. SCHEDULE 40 P.'✓.C. PIPE 4 SCHEDULE 40 PV.C.(ONLY) '► PITCH 1/4"PER. PIPE- MIN.PITCH I/4"PER.FL LEACH PIT PRECAST o' INVERT a a LEACHING E�- •3� INVERT INVERT. n . Q•� PIT OR � o INVERT . SEPTIC TANK EL �SgS DIST. EL 3SSo - >_ : EQUIV. BOX ... 3G ro .... �.••. GAL. INVERT 3,5 �' o '•► o; EL.....r.-:.., EL3SG7 INVERT :: ww o: ::i: 3/4"TO IV ' . � EL3S./-.4. e' w� \J WASHED e W STONE 0 ► . T •, �o�6'DIA. . N°NE /¢ —+-�' DIA. cC�.�r��eEsn PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM 4'44ye74 '/-- P"Viow.S HAT=M%. NO SCALE QeZOw gorra P�l of •Sy.57Z-7.7 7a Bf liAViA;ev <rr 771-y r GL /NS'TIYk A"GAJ 3'V•&,eiGiE'A V Ii7W SOIL LOG WITNESSED BY : '-�1arAloc.r'w7 DATE �GT /�/5BS TIME.//;ov�4!> -it`s �o�iLo.v EA 9 `ArciF/� . . . . . . . . BOARD OF HEALTH yet��8 TEST HOLE TEST HOLE `?7 ENGINEER ELEV . . 77,77, -`��.So. . ELEV. ..�Q•.G�. . sic7y Nz.4/.B¢.e„ sicnc.35 5¢ S DESIGN DATA : &Z,3, 'p ` NUMBER OF BEDROOMS . . . . . . 3. . . . . . . . . . �. TOTAL ESTIMATED FLOW . . 3 3o GALLONS/DAY Z-Z.3S.:u /53. . . BOTTOM LEACHING AREA �/. SQ.FT. /PIT/,,.I 6.P,D, sD SIDE LEACHING AREA . . .�✓�3./. SQ.FT./ PIT�ZS4 C.P.D, sg„iD r1 G•/I.Avb'Z wl;rw GARBAGE DISPOSAL ./Vb"�L-- (50% AREA INCREASE) o[1/a5�o,19 C. w,1ry/ Bwos TOTAL LEACHING AREA . .'3�7: s. SQ.FT ACcASio�A.L of PERCOLATION RATE �Zr .h./N//./�/ MIN/INCH LEACHING AREA PER PERCOLATION RATE .`3GS. SQ.FT.IG,P.D ,!�,?.. .WATER ENCOUNTERED DNGs P/r W/� NUMBER OF LEACHING PITS . . . . . . . . . . . . . . . . APPROVED . .. . . . . . . . . . . BOARD OF HEALTH F6�2 Fc 7 OF.SJ7�N� oA1 DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AGENT OR INSPECTOR 8 OF .Yv��/ V�//G-/VSTf�I�G�� t•art, i,.S 4 1 ^'. SgMRARIA� PETITIONER .,,,,.._�:'..-?r �n^g^ ��-•-...�.-..'...-.-.... ...-.,�-rn'*Y�i"S'T^ F ,.. 4 Rv.§?f''wl ram'-r'�1NYx eRF"T,3 ! ..+.. v . �PypfTHE t TOWN OF BARNSTABLE 6 OFFICE OF DAH7lTABLL f6sq. BOARD OF HEALTH t639 �p !� �01111Y 367 MAIN STREET HYANNIS, MASS. o2soi Sewage Permit # Applicant : r..►'r,� Proposed Installer: The plan for the on-site sewage disposal system at Gar H_ s r has been approved with the condition that the design engineer must be on-site and supervise installation as well as certify in writing that the system was installed in strict accordance to the approved plan. Aftrovn By Date C-o r VM.:Ce d 1 sue, J4,t L( CUMMAQUID SURVEY, INC. Box 51 Cummaquid, MA. 02637 Edward E. Kelley, President October 19, 1989 Town of Barnstable Board of Health Hyannis , Mass. Ref: 8 1 8 7. .- 3 I Lot # 1 High Street West Barnstable The sewage system was installed in the approximate area and elevation of the approved plans and the system meets all the requirements of Title V and the Town of Barnstable health egulations. OF DWARD O V' � R y Saari Reg,.�Pr;g�fessio?nai No 52' o �� , 9 Lanc1��S�urv.,- �ety�Q �, S4NITAM0 1 Fee--- BOARD OF HEALTH TOWN OF BARNSTABLE Zippiicat ion ArMelt Con!5truct ion Permit Application is hereby made for a permit to Construct ('P , Alter ( ), or Repair ( )an individual Well at: ----- ----- Location — Address Assessors Map and Parcel G 6�_I'� i• — --- -AeAf /- �' — - 6'-�',e� _9_F c,) , /.for nn Owner / Address! -- ,0 l I�C A•vH.e l�_(, e_�� 001 _ _ l�b 13ox 96 o Yt't a s I� /u o - ---- --------- - - — — --- - ----------------- Installer — Driller } Address Type of Building ASSESSORS MAP NO,-I-.'3 -37 .�,..._ Dwelling-------------------------------------------------------- 0 2 9 PARCEL No: Other - Type of Building-------------------------- No. of Persons------------------------- Type of Well y ((Pu e- -------- Purpose of Well_DoA"as 7,1c Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certific I a .of Compliance has been issued by the Board of Health. Signed - ---——------------- i Aft------ date Application Approved By —� date Application Disapproved for the following reasons:— ---- --------- — - --- ------------------------------------------------------------ date Permit No. � ` --- Issued-- - �-�- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f (Compliance THIS IS TO CERTIFY, That. the Individual Well Constructed (tij, Altered ( ), or Repaired ( ) scu V..'ell /�--------- ---- - --- - -- - ---- Installer p has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No/'- —��f-ZDated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- - Inspector--------------_— -_ -�o. =-' _--- ��� V Fee---�-_ '---9v BOARD�F HEALTH TOWN OF BAR N STAB LE Tippl cation-,forMelt Con5truft ton Vermit Application is`hereby made for a permit to Construct Alter ( ); or Repair,( )a individual Well at: , Location Address Assessors Ma and:Parcel P Address - - -- - - -- ------ ------- - -- - ------ Installer — Driller Address Type of Building iDwelling--------------------------------------- -------------- Joe Other - Type of Bui ---=--t------- No.'of Persons---= --------------------=------- f Type of Well—�� V G _ - - ---- Capacity-- -----—=-- -=-— Purpose of Well_Dom c 1 °-�� ----- r Agreement: The undersigned agrees to install the aforedescribed individual'well in accordance with the provisions of The Town cf Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place tl:e`well in operation until a .Certifica le of Compliance has been issued by the Board`of Health. Signed ---- -- - -_ date Application Approved By —eVC,�----- - date Application Disapproved for.the following reasons:-----=---------------- ------------ — --- �; -W------ date--- Permit No. .. - 10 Issued---- -- ---- - date. - ',r,e:Baer.:arar.+.= eaa:e,:e+.+ay:z:�+eawro+a�:ea�:2ae.6!oases+as•al.:easa�a�»easaee�:�ra�avare�ebasaae4aeeaaz►eaves*n4aras��ew�seaaeeacavanreea s.ste�aeaxra�sesswrosa+.tc��ec.a�, BOARD OF HEALTH TOWN OF BARNSTAB•LE C. ertif icatt Of compliance THIS IS TO CERTIFY, That the Individual Well. Constructed ( Altered ( .),'or Repaired ( ) bSt_u w.:. lL- ----- ---- -- -- - -- - — --- --==-- Installer 6 - �� r� r pn, has been installed in accordance with the provisions of the Town of Barnstable B�o�ar/d'of Health Private Well Protection Regulation as.described in the application for Well Construction Permit No./'A""'- '`-AkDated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- -----—- -- = Inspector,---------- - --- - — �ti.l3��G?�!ae�ti4.ieLeasW4eBa4eTi{taf�lBw�Sie-�litxisd!a_Ytiel�Tl..sJDiai9aca9'rtib►�?iSM1!rea9Leiliea4e0.r:1Pik?:$ioc9�'fa4 il�_Y..a�b!w�Yi�?a..i� �'ir Sotih34a:+i!8f•?ltiSi�6.a+u�i���3!Y BOARD.OF HEALTH _ TOWN OF BA.RNSTABLE feCY �on�truftionermt Vf�_11 91�No. - �. ti ti Fee f Permission is hereby granted to Construct ( -1), Alter,( ), o Repair ( ) I'd'vid al W street. E as shown on the a lica ion'for anWell Construction Permit I� /as f No.-- '�= / Dated !� Board of Health E DAT i p _ �I i i l °F.KKE► TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name �l�`�/ o( / Date: th Page: of HOURS PUBLIC HEALTH DIVISION 600ICE-9:30A.M. BARNsrAsLE. ) 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified FRI ;6�; m� HYANNIS,MA 02601 M-8 -464* No Reference R-Red Item PLEASE PRINT CLEARLY �A 79 a' � 506-862-4644 'FDN1P` POD EST B,LI LAMENT INSPjA4CTj1ON REPORT Name n Date Type of a u. inspection Operations) outine Address Risk Food Service -8-e--insp6ction "� A- Level Retail Previous Inspection L Y Residential Kitchen Date: Telephone Pre-o Pre-operation Mobile P Owner HACCP YIN Temporary Suspect Illness 'Caterer General Complaint Person in Charge(PIC) Time � Bed 8 Breakfas HACCP As OtheInspector 11/1 ` Each violation checked requires an explanation on the narrativ'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) ❑ l Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ y FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 1.PIC Assigned/Knowledgeable/Duties (3 1 ❑ 9 9 ❑ 13.Handwash Facilities ) Y EMPLOYEE HEALTH PROTECTION FROM CHEMICALS / 1/- 1 R Q Y W c ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives � " ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals ) / FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) t C J ODXV ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling /� y ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding ! PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP CW 1 ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY IV 5❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories e Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical N violations must be corrected immediate) ( ) y or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. F[:] Embargo r ❑ Emergency Closure ❑ Voluntary Disposal ❑ other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B-One critical violation and less than o 6 non-critical violations 9 if no critical violations observed,4 to 6von-critical violations=B. Serious) Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Y y C=2 critical violations and less than non-critical. . f critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations obsery ed,7 to anon-cri 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address non-critical violations. If 1 critical refrigeration. 29.Special Rerluimments. (590.009) within 10 days of receipt of this order. viol ti 4 to S non critical violatio�is 30.Other DATE OF RE-INSPECTION: Ins p rs Signature f .�f'it 31.Dumpster screened from public view v / I 1 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance.Letter Posted Y Dumpster Screen? Y N ' 6-� Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge* 3-302.11(A)(I) Raw Animal Foods Separated from 3-202.12_ Additives* i g Cooked and RTE Foods.* 19 - PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - � 3-302.14 Protection from Unapproved Additive*s -- Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F l _EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers*Other* 590.004(F) * - _ - 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 Se azation-Storage* Applicants* 3-302.11(A) Food Protection* p g 20 Time as a Public Health Control 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* - Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* -, -REQUIREMENTS FOR 3-306,14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-80111(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 Warewashin Hot Water 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Pe 7-206.13 Tracking Powders,Pest Control and * 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate Equipment ( )O Pathogens* 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * e nw rnnooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* - 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By _ 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 2-301.14 When to Wash* Other 590.009 violations relating to good retail 590.004 C Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* 3-201.17 Game Animals* 11 Gobd Hygienic Practices 77 Reheating for Hot Holding practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g, g g 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 * 12 Prevention of Contamination from Hands 3-403.11E Remainin Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-002.11' Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 EO8HACCP Plans 6-301.12 Hand Drying Provision r 29. Special Requirements 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. C �.x n��� � r� � ��� s�.---- °p tHE 1p� TOWN OF BARNSTABLE -HEALTH INSPECTORS Establishment Name: : �' Date: J Page:�_of q "OFFICE HOURS 1�1 PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE, ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 9gA .61g.a�0� HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'FOM FOOD ESTABLISHMENT INSPECTION REPORT Name Date Type of Type of Inspection " - ' ` Operationfsl Routine Address isk Food Service Re-inspection t r-Level Retail Previous Inspection Telephone Residential Kitchen Date: I I / CJ Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP O In: Other , Inspector O Out: ias Eachr 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) ❑ ` MIR Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) C CA ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time Asa Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories FoViolations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations 14/1 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 Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items 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 (FC-4 590.005 9 or more non-critical violations=F. )( ) cited in this report may result in suspension or revocation of the food. B=One critical violation and less than 4non-critical violations 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 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,or lack of be in writing and submitted to the Board of Health at the above address C=2 critical violations and less than 4 non-critical. If no critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violations observed,7 to 8non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view l/ r� C�t�f Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sig to Print: t� Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N i` �flo/afions related;to`'Fpodbornea/lness Wolations'Related to Foodborne Illness Interventions 'Mtecven,tions,and Risk Factors(Reddtems 1.42) and Risk Factors(Red Items-1-22) (Cont.) -- -:F,OQD PROTECTIONINANAGE_MENT PROTECTION FROM CONTAMINATION ;OTECTION FROM,CHEMICALS 3=501•:14(C) PHFs Received.atTemperaturesAecordingso _ - _u __ _ g Law Cooled to 41 E/45°F Within 4,Hours* 1 .590,003(A) Assignment of-Responstbtlity* 8 Cross-contamination 1'4 r+Food,or+GolorAdditives''' 590.003(B) 'Dentonstra[on of'Knowledge* 3-362.11(A)(1') Raw Animal Foods Separated from - - 3-202.12:- Additives* Cooling Meth Cooked and RTE Foods.* * 19 .3 PHF Hot and Cold,H, dHi gs 501.15',,.. 2 103.11 Person-in-Charge-Duties 3-302:14 Protection from Unapproved Additives Contamination from Raw Ingredients 3-501.16(B) Cold PHFs"Maintained At or Below 41°F/45'.F 15 Poisonous or Toxic Substances :EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each * 590.004(F) a 7-101.11 Identifying Information-Original Containers 2 590.003(C) Respons*bltty of.the_Person in-Charge io Other* 3-501.16(A) Hot PHFs Maintained At Above<140 F 7 102.11 °- Common Name-Working Containers* a ':Require Repo ing by food�mployees and Contamination.f .-the Environment 3-501.16(A) Roasts Held At or Above 130°•F* 7-201.11 Se oration-Storage* Applicants* 3'302.11.(A) Food Protection* P ' g 20 Time as a PublicNgatth�Gontrol 7-202.11 Restriction-Presence and Use* - 590.003(F) Responsib lity of A Food Employee or An 3-30115 Washing Fruits and Vegetables * 3-501.19 Time as a Public Health:Control* ApplicantTo Report To The Person In_Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 59.0.003(G) Repotvng by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer �, - {. 3 590.003(D) Exclusionsand Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* '. MENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* � REQUIRE ` 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Ike Oval 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 Fmm Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590:004(A-B) .Com Hance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and P 4-501:111 Manual Warewashing-Hot Water 7.206.12' Rodent Bait Stations 3 201A2 Food ip a Ilermeticall Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y * P 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-Served* 3 201.13 Fluid Milk and-Milk.Products* 4=501'.112 Mechanical Warewashing-Hot Water Monitoring 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH: 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY * Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice'Made From-Potable Drinking Water 3-401.11A(1)(2) Eggs-155°F 15 sec 4-601.l l(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking-Water from,an Approved;System* gg _ Equipment* Not Otherwise Processed to Eliminate. 590.006(.A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game- Pathogens* Ef/cnve uu2oot 4-602.11 Cleaning Frequency of Utensils and Food ,animals-155°F 15 sec* 590.006(B) Water Meets Standards in 3.10:CMR 210* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally CaughtIvlolluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4.703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)_(D)in eater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential' Game and WiId Mushrooms Approved By " 10 Proper,Adequate Handwashing2-301.11 Clean Condition-Hands and Arms* 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* M240131 Cleaning Procedure* 165°F* foodborne illness interventions and risk factors. When to Wash* * Other 590.009 violations relating to good retail 59.0.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec 1� Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special 3-201.17 Game Animals* Requirements. 5 Receiving/Condition Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec*3-202.11 PHF's ReceivedatProper Temperatures* Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 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 foodborne �2 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated* ( ) g illness interventions and risk factors listed above;can be found in the 6 Tags/Records:,SWistoek 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105,CMR 590.000 13 Handwa 3-501.14A shing Facilities Cooling Cooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification* ( ) g Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°Fi45°F Item Good ReiailfPractices F,C *90:000 3-203.12 Shellstock Identification Maintained* Tags/Records:Fish Products 5-203.11 Numbers and Capacities*, Within 4 Hours* 23. Management and Personnel FC-2 003 . 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 0041 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005, * 5-205.11 Accessibility,Operation and Maintenance 3-402.12 Records,Creation and'Retention Within 4 Hours 26. Water,Plumbing and Waste FC-5 .006 Labeling Supplied with Soap and hand Drying Devices 590.004(J) g of - / 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 r a - 29. Special Requirements .009 3-502.11 Specialized Processing Methods* y 30. 1 Other 3-502.12. Reduced-,Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °p THE Tpk, YTOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: iu P "" " Date: I / -Page:-/ of / ti OFFICE HOURS T PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. MASS. $ MON.-FRI. Item Code. C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 508-862-4644 No . Reference R-Red Item PLEASE PRINT CLEARLY 'FDN1A� FOOD ESTABLISHMENT INSPECTION REPORT Name 0 n�r� ��n Date i e of Inspection 4°V- SF I C Operation(s) Qouti A (C _ Risk Food Service Re-inspectionAddress N LevelRetail Previous Inspection ection � % �p Telephone Residential Kitchen Date: v� Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness C General Complaint 0 d Person in Charge(PIC) Time Bed&Breakfast HACCP Other In: Inspector S Out: r \ C) 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) ❑ O Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ t FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) 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 ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent 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, FC-4 590.005 F. 25.Equipment and Utensils ( )( ) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4non-critical violations 9 or more non-critical violations= 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 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,or lack of C=2 criti 1 violations a less than 4 non-critical. If no critical. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address viol ions observed,7 t 8non-critical violations=C. refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspe t 's Signature Prin) 31.Dumpster screened from public view � r Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y IN #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign re Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N -'-� Dumpster Screen? Y N , \ Violations related to Foodborne Illness Violations Rrelated to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* F 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-Charge Duties 3-302.14 ` Protection from Unapproved Contamination from Raw Ingredients 15 590.004(F) 7-102.11 Common Name Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* -Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Separation-Storage** 3-501.16(A) Roasts Held At or Above 130°F* 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 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE' 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 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) I Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 163-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Eggs Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Equipment Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * - Not Otherwise Processed to Eliminate 590.006(A) Bottled Prinking Water* - 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* eff cn"innooi 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and lM/d Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. * 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 590.004(C) Wild Mushrooms ( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) gty 12 Prevention of Contamination from Hands * Critical and non-critical violations,which do not relate to the foodbore 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts illness interventions and risk factors listed above,can be found in the 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13 Handwashing Facilities 3-501.14 A Cooling Cooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification* ( ) S 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. 1 Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 1116-301.12 -301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. r' R 537 BOARD OF HEALTH 11/06/2017 PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with reg ns _ urr authority of Chapter 94, �E.� Section 395A and Chaptel ti Gr F w ; permit is hereby granted to: 1 � �'= 1 RICHARD HOWARD = '�� �41aOINTE INN lkllk vaij - t l' �. ARNSTABL I 0 6�3� Whose place of business is: �` - REE�� _ ,a y gT N. EST IT Type of business and any resit �_ y{ s t LE « To operate a food establishrpe�itTti - " � c` az?�.�"''��''�L.-c-.:.�- r?• ..:}ems y €� RESTRICTIONS IF ANY. I, a SEATING: 6 ANNUAL: E6x SEASONAL:' TEMPORAR.Y.1 � IR I-, Y ' ` RFC dF HEALTH F r SEES : QN-1 S t a2'Z `. r RETAIL FOOD STORE: ` `# nniff.D.M.D,Chair persona y , FOOD SERVICE ESTABLISHMENT: urchr°Sawayanagi RESIDENTIAL KITCHEN FOR RETAIL SALE: t f - c . r � n d A.Guadaqnoli M.D RESIDENTIAL KITCHEN FOR BED+BREAKFA 14P' P MOBILE FOOD UNIT: _ •F TOBACCO SALES: `°- �' Al 4 _ FROZEN DESSERT: Thomas A. McKean RS CHO c s �'�' ,� � CATERER: � ��' Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE IME Town of Barnstable �A.La AA ywh GV fir' ail Regulatory Services n�T A�T V�r�I E i Richard V. Scali, Director w' 1'T BARN STABLE Public Health Division BAPHSfPBtF-CBRBMLLE-mTVIf•tfrpXxlS 1639 39-201oia �377g r,,i Thomas McKean,Director D ..200 Main Street,Hyannis,MA 02601 ..- - N . Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: is 05- 117 rya NAME OF FOOD ESTABLISHMENT: g i 6 ip -r!E j OAS ADDRESS OF FOOD ESTABLISHMENT: 76 N%14.4 S-r�' �, �:15"i'► LE- tWk a�(v<� MAILING ADDRESS (IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ?1v2- i4i4L41 NUMBER OF SEATS*: INSIDE: Co OUTSIDE: b TOTAL: * Note: If indoor seating provided, see Licensing regarding Common Victuallers License TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: 4Nd60q L_ TYPICAL HOURS OF OPERATION MON-FRI: A-1440 DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) XQAIEL IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD BED & BREAKFAST CONTINENTAL BREAKFAST *IF SEATING: ALSO,MUST OBTAIN RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) Q.Apph.cation Forms\Foodappldoc ***REMINDER*** IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT_ SOLE OWNER: YES As ADDRESS 70 VAkr4�4 ST. , t.�. ��}�I�T�t�C.�. �l ©2L6e PHONE# (Ad_) 36?_ --qNq I_ IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: 'Rw-Nogo 7A N►4N S-r. , _ /9 626(o$ IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 52 I5' STATE OF INCORPORATION: (Y�1ASSt'-ICI �� T�S FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** IST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) .& �11. EXPIRATION DATE: 12. 2. EXPIRATION DATE: / / EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** IST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF. EXPIRATION DATE: / ''7 A5 SIGNATURE OF APPLICANT AND DATE Q:\Application Forms\Foodapp3.doc -- Now I'I PERMIT I\'0: TOWN OF BARNSTABLE ISSUE DA11 ,i IJill 537 BOARD OF HEALTH 12/22/201 ' PERMIT TO OPER,T,A 0 17--ES-TABLISHMENT In accordance IVY UP-Cis c+ r`f at s Tlairthority of Chapter 94, I�I l Section 395A and Chapter7 �cti �a Ge _ a_s3�armit is hereby granted to: RICHARD HOWARp -- _~_ D/I � =._ Illi'POINTE INN Whose place of business is: _39 L1GH STREW;= (S ABLE-;4-M z02669 h Type business and any rosXriefid-9s: Ea *, ' FAST ESTAB1sISW'ENT To operate a food establishrrient.in the T �1t - TABLE RESTRICTIONS IF ANY: SEATING: 6 ANNUAL:�YeS j SEASONAL: TEMPORAkY'- F_ _° r= - F ' -_> z -;=f F E Sb�11D OF HEALTH RETAIL FOOD STORE: T. Gam} u.1 J.Canniff, D.M.D Chairperson FOOD SERV CE ESTABLISHMENT: 1 p =�' Jh RESIDENTIAL KITCHEN FOR RETAIL SALE: `-F. t.,�=-�`�:-.�_ � �'" ichi Sawayanagi RESIDENTIAL KITCHEN FOR BED+BREAKFAST, '-W.00 F.= — ___> : _r'Donald A. Guadaqnoli M.D. MOBILE FOOD UNIT: '��, �t�;- �� r TOBACCO SALES: `p- FROZEN DESSERT: Thomas A.McKean, RS, CHO CATERER: Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE I it , Ilk* ` *ownt of Barnstable P� r�� o„ Regulatory Services l�sA MAS = Richard V. Scali, Director BARNSTABLE Hues Fo; p`0� Public Health Division �MA� 9- 1639- Thomas McKean, Director �� 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-79304 , APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMVNT 1. DATE: ///22 NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: 76 (��. �'� �. egg N 3� 60� E-MAIL ADDRESS: INF® a TH4 H16HP©iA➢TFI,ur4 , e_olK TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 508 a, - ►� y i NUMBER OF SEATS*: INSIDE: OUTSIDE: ® TOTAL:_ * Note: If indoor seating provided, see Licensing regarding Common Victuallers License TOTAL NUMBER OF BATHROOMS: 2 ANNUAL OR SEASONAL OPERATION: (�N�►u��.- TYPICAL HOURS OF OPERATION MON-FRI: a �O DAYS.CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS)_ &Alf_ IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD BED & BREAKFAST CONTINENTAL BREAKFAST *IF SEATING: ALSO,MUST OBTAIN RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) r ***REMINDER*** IF OUTSIDE_DINING, YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT �,,Ztj g gip -J� _ ����,q,e 1) SOLE OWNER: YES/ T�O ADDRESS 76 ���W S-r, Gl). � ST �t£. (h,� aaj,44* PHONE# IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: Rin �q D H&-yg V 76 N j 6gz4 6 r W. 3�9R0.J v 7-►A L �I'l4 Z��CaG ' IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION ( }gs f �-►1.55�`�'�S FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) 1. EXPIRATION DATE: /2 /6-7 / /e 2• EXPIRATION DATE: EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF. 1• AAA 2 1�c 1&L�45-990 EXPIRATION DATE:/ 2IOl /:r It /22 / 4 SIGNATURE OF APPLICANT AND DATE QAApplication Forms\Foodapp2.doc r q , �r7 6 *�a''t 1.X.n. �-... �;. � w:1f..v.ld��s: „a,=...L •�..,.. o �`;_.:.� ':3 �i 'r.�R'C a( 51�,;a ra_7.a-... �.'>. < _ m pu� o •, EXAM FORM NO: 4892 1T58;T I FC ATE NO. 059 j: 5 - ,. „ yx4 rre J ' ' 41 , .'S '� ,a:.°n '.�4,;., ',a. ,..�,Fr•�r A ':t r e^r r , s.` p, r �:. 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Y§���-•: F.E ✓\ ,.:171n �lv 1 s:�,;,.ct t�` ✓$ n � �4 Ear �u;:fi �•� t ro 1 r �I S .y' 1" 1 .k: L d 'N,{:.:� 1 j�.:1{R". W Y v b� p .: r : ,f 1. AlJERGENNAW � A l YJ 1 r Il 't l l I 1 E # t a+ g Pb; o R. Name of Recipients Richtrd B� I� 'war 'Q a � Date of C:omtile#ion 26�2o' 2 t ,. ���,: /, sue* .� Date of E TV HF a ' It 3 The above-named person is.hereby'assuedahis.certi cafe <Issued By 1. for completing an allergen awareness training pro ram' }..; reco , . gyz,:> $ by he Massachusetts Department:o Public Health f 1 :.Berkshire ' in accordance with 105 CMR 590 009. G 3 a ' t � AHEC 1 Area Health Education Center z{ This certXcate will be valid or ve S ears rom date of completion.. Pittsfield,Massachusetts f ( �y f w�•vw oodaUergytraimng org .maf' raw wftao ��jj 1 Mt 4 t„ fi i Js c t1E Tom," Town of Barnstable Office: 508-862-4644 Fax: 508-790=6304 o,. Regulatory Services Department Public Health Division v� M&63 ASS, ` Thomas A.McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt (Food Service Permits Payment received: $55.00 (Check) on 11/29/2016 Permit number: 537 Check number: 10282 Check amount: $55.00 Name on check: HIGH POINTE INN i IBusiness: HIGH POINTE INN Owner: RICHARD B&DEBRA M RICHARD HOWARD Address: 70 HIGH STREET, West Barnstable ;Note: $55 - B&B Full Bkft —� _ ___._— ------------------ ---- ----------- --..... _. _ ._._ � F o m m IT a o i 101.8 Vr 93a 6- HIN �.A]H0^I S I � I � I I a �� � T � 4 u - - - � � ,.j II N Ng b Y I � ®J �. LA aye lit �0 alo" wi� II High Pointe Date: 11-25-08 j C,, A z Debbie & Rich Howard Scale: 1 Designer: Paul Savage 70 High St, Sales Team: Mike Hurly & I3m oe I : prov�mcnt West Barnstable, Ma. 02668 Marty Halverson 1645 Newtown Road Cotuit, MasszLchusctts 02635 1