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HomeMy WebLinkAboutCUMBERLAND FARMS - FOOD 1CU14BERLAND FARMS ! 375 Barnstable Rd. "Hvannis.—910 Ptq i ^�► s BOARD OF HEALTH Town of Barnstable John T.Norman Board of Health Donald A.Gaudagnoli,M.D. RARNSTAOLL F.P.(Thomas)Lee,. non . Daniel Luczkow, M.D. Alt. 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 129 Issue Date: 01/01/2022 DBA: CUMBERLAND FARMS #2295 OWNER: CUMBERLAND FARMS, INC. Location of Establishment: 375 BARNSTABLE ROAD HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2022 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: C,? , FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I Town of Barnstable For Office Use O Initials. j Q' Date Paid I* Amt Pd$� &MWgr,B,E, : Inspectional Services 9 y c V�_ �a Public Health Division Check# RFD MA'S A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL `y NAME OF FOOD ESTABLISHMENT: CZ�rr►�e�r�ct n� /4�-r-lfts z �� ADDRESS OF FOOD ESTABLISHMENT: 37j5- B to-s na-Lo le- ` d, /7 1/a qw l5 Oo2l/O/ MAILING ADDRESS(IF DIFFERENT FROM ABOVE): LSalvucci@cumberlandfarms.com ��✓r�' E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (W) 75?0- 7//8' TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO Y ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: %-� SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ...(MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application ForinsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT (..,GtMke -/C2`jd Lew/ f� SOLE OWNER: YES/NO J ,OWNER PHONE # ADDRESS_ CORPORATE OWNER: 5rlWe r_2 5 ye- CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: ll'za J 6t List(2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date �,,-ral L Oh I 1. - / / 2. �v© T y0(. serwce—, / SIGNATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/ai)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. t Q\Application FormsTOODAPP REV3-2019.doc C" P`oFr r��o TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 6:00-9:30A.M. • BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MONMASS. .$ HYANNIS,MA 02601 08-8 -4 No Reference R--Red Item PLEASE PRINT CLEARLY �p +a39• . 508-862�644 'ED MP�p FOOD ESTABLISHMENT INSPECTION REPORT i Name Date a of Tynengf3insgection outi ✓ Addre Risk F rvi 'ffe- ection 72 Level Previous Inspection Telephone ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector uJim Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned!Knowledgeable/Duties ❑ 13.Handwash Facilities 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 Q,I FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Wt- ❑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 rr PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control V '# ❑ 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.ProperAdequate 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 1-lea- Critical (C)violations marked must be corrected immediately. (blue&red items) `( Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items Embar o checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ g ❑ Emergency 9 Y 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 andFood Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations ardless 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 6=One critical violation and less than 4non-critical violations re9 ' 2 .Water,Plumbing and Waste (FC-5)(590.00 ) establishment permit and cessation of food establishment operations. 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 C=2 critical violations and less than i non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 violation,4 to 8non-critical violations=C. 29.Special Require ants (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Insp ctor's Signature Print: 31.Dumpst screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' nature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N -_ __ _,--.�.^-.-...-,�.�.��..-,,.,..:-__�._�_�.....+...��....�. �-.,. �.--�.:^.-..,•-.`___.-ter---. __.�_.. ... _-__ _ t...r-�.-�-. -�-._.c --^'...�-..---.... � ..� -�, .� •r_� ..-..- __.�R_.-:-_�-_�-- - - _ :., -. 4yL-....�e.��_ --� ..-'- -`-.. ...- ....-...- -_ -••- __. _ .- s- _ - ,. 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[0 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 - PHF Hot and Cold Holding _ 2-103.11 Person-in-Charge Duties 3-302.14 Protection fronrUnapproved Additives Contamination from Raw Ingredients 7 5 Poisonous or Toxk S66stances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 7-102.11 Common Name-Working Containers* 590.003(C) Responsibility of the Person-in-Charge[0 Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 7-201.11 Separation-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 Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111. Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS _ 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 18 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145° Not Otherwise Processed to Eliminate F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Equipment 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective inrzooi 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 ca[er- 3-201.15 Molluscan Shellfish from NSS_P 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* 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. 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11 A&D PHFs 165°F 15 sec* $ Receiving/Condition ( ) ( ) 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 Commercially 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 * 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 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 705 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F[0 70°F 3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Fonnback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food.Code or 105 CMR 590.000. �FIKE r TOWN OF BARNSTABLE _ HEALTH INSPECTOR'S Establishment Name: Date: Page: of v� Wo OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. • 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified v Masq: `e� More.-FRi. No Reference R-Red Item PLEASE PRINT CLEARLY HYANNIS,MA 02601 �OrEn N�Ax a 508$62 4644 FOOD ESTABLISHMENT INSPECTION REPORT (vim Name ` Date.. Tvne of T s ction O er outine Address Risk F ion Level al Previous Inspection Telephone C esi ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness - Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on a 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) ❑ ` r Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) VII Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ �L FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 1 ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑2.Reporting of Diseases by Food Employees and PIC - ❑ 14.Approved Food or Color Additives ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating L ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding L00 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) a� � Corrective Action Required: ❑ No ❑ Yes Non-critical{N)violations must be corrected immediately or within 90 days as determined b the Board of Health. Overall Rating Voluntary Compliance y y ❑ ry p ® Employee Restriction/Exclusion ❑ Re-inspection Scheduled ® Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ 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 B=One critical violation and less than 4 non-critical violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food 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 C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC 6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8non-critical violations. If 1 critical refrigeration. 2d Poisonous or Toxic Materials (FC-7)(590.0o8) be in writing and submitted to the Board of Health at the above address 590.009 within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 29.Special Requirements ( ) 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dump r screened from public view -11 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: P C's Signature Print: Outside Dining Y N Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1q Food or Color Additives Law Cooled to 41'F/45'F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 15 590.004(F) 7-102.11 Common Name-Working Containers Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41'F/45'F EMPLOYEE HEALTH, _ 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* * 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F * 7-201.11 Separation-Storage* Applicants* 3-302.11(A) Food Protection* 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* 590.003(G) Reporting by Person in Charge* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 17 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) I Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( � Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical) Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. L16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water F* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155' 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145'F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff-ti-11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3 401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) I 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 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) ( )-(D)in cater- Sources Ratites-165°F 15 sec* * ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b)All Other PHFs-145'F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. $ Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial) Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140'F to 70°F 3-202.18 Shellstock Identification g 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 1590.000 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 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45'F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Supplied with Soap and hand Drying Devices Within 4 Hours* 1 26. Water,Plumbing and Waste FC-5 1.006 590.004(J) Labeling of Ingredients' 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements .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. oFIMF r TOWN OF BARNSTABLE_ HEALTH INSPECTOR,s Establishment Name: Date: Page: of h OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BARNSTABLE. ' 200 MAIN STREET - 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �A M63:a m� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY . rE0 MAC 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name Da t of jyoff3ftspection Operation(s) QRoutine Address Risk Food Service e- ction �( t6ew 4nl" - %A 0t, I '11.A- Level .tail Previous Inspection Telephone Resicrential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) f Time Bed&Breakfast HACCP In: Other Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands 1.PIC Assigned/Knowledgeable/Duties ❑ 9 9 ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating - ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7..Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Eood Contact Surfaces Cleaning and Sanitizing ❑ 21.Food,and Food Preparation for HSP ❑ 10.ProperAdequate Haridwashing CONSUMER ADVISORY ❑ 11.:Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations�� 1 Critical(C)violations marked must be corrected immediately. (blue&red items) 1 Corrective Action Required: ❑ No ❑ Yes- Non-critical(N)violations must be corrected immediately or Overall Rating -..� within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today;,the items ❑ Embargo checked indicate violations of 105 CMR 590.000/Federal Food Code. 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 B=One critical violation and less than 4non-critical violations 9 ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC=6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous or Toxic Materials. (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8von-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpst screened from public view Permit Posted? ' Y� N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC' Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 14 Food or Color Additives '" Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 590.004(F) EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* g7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* 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) IExclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources g Food Contact Surfaces 7-206.11 Restricted Use Pesticides.Criteria* 3-801.11(B)- Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIMEITEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* * gg Not Otherwise Processed to Eliminate Equipment ( )( ) Pathogens* 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game g * e-n-utnom 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- Sources* Ratites-165°F 15 sec* ing,mobile'food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004 C Wild Mushrooms* 3-0Ol.11(A)(1)(b)All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requiemnpractices osld be debited under#29-Special 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* M590.004(EE) charges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * venting 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 food6orne * 12vention 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:Shellstock venting Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13ndwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F3-203.12 Shellstock Identification Maintained* nveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item I 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 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures I 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials I FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 30, Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6 2doc 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. oF. r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: (Xitb G1-hoQ Pon Date: 6/o-SIAa Page:_�of OFFICE HOURS B ��E. '• PUB2oo MAN STREET EEVT 3:30 DIVISION - - : 0- :30 A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified -4:30 P.M. HYANNIS,MA 02601 - MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY 508-8624644 'EOM FOOD ESTABLISHMENT INSPECTION REPORT �O Name m 14 �tlaps Date),5/11 Tvoe of Type of Inspection Operation(s) , f Address 3176 8(o6jaw Risk Food Service Retnection 4em eta 60 Level s Previous Inspection Telephone esidential Kitchen Date: m 'r fC&W Mobile Pre-operation (' Owner HACCP YIN Temporary Suspect Illness WMM"6 6VU ' Caterer General Complaint - 11 Person in Charge(PIC) Tim Bed&Bre 1 akfast HACCP ff���K 1/tt R t(i -�, 48 In: 1�.a'� Other jr .> J1 0, /VL Wig - Inspector tQryf Out: rV\44 J 1 Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. DOd �G( >r� ®p Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ L Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ - O� - r r 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 e �- Wa. dam ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces.Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories 6 Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating - within 90 days as determined by the Board of Health. ❑ Voluntary Compliance Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items Embargo checked indicate violations of 1.05"CMR 590.000/Federal Food Code. ❑ g 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 4non-critical violations g 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 6uon-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 C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of 28.Poisonous violation,4 to 6 non--critical violations C. or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non-critical violations: If 1 critical refrigeration.. 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 . RI Qn rj M Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's n Print" - Self Service wait Service Provided Grease Trap Size Variance Letter Posted Y N ' Dumpster Screen? Y N .0 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 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives ' Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to * 7-102.11 Common Name-Working Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage*7-202.11 Restriction-Presence and Use* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance 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)Resumed Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 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.I IA(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145'F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gg Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef dive utnoot 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)-( )in -165°F 15 sec* D cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Pro ing,mobile food,temporary and residential Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 3-401.11 2-301.14 When to Wash* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail ( )( )ro) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C CommerciallyProcessed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Critical and non-critical violations,which do not relate to the foodbome * 12 Prevention of Contamination from Hands 3-403.11 E 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 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 3-402.1 L Parasite Destruction* 5-204.11 Location and Placement* .3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 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 Supplied with Soap and hand Drying Devices PP P rY 9 Cabello of Ingredients* 27. Physical Facility FC-6 .007 590.004 9 9 s (n v ty 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials I FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 special Requirements 1 .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 1 Reduced-Oxygen Packaging Criteria* 8-103.12 1 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. t BOARD OF HEALTH t�.=r Town of Barnstable John T.Norman s" Board of Health Donald A.Gaudagnoli,M.D. BARNSTAUM Paul J.Canniff,D.M.D. MA. *. F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 129 Issue Date: 01/01/2021 DBA: CUMBERLAND FARMS #2295 OWNER: CUMBERLAND FARMS, INC. Location of Establishment: 375 BARNSTABLE ROAD HYANNIS„ MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: I v For Ofjj nlv: Initials: `m T Town Of Barnstable Date Paid Ant Pd a4mirABLE Inspectional Services I a vn toss.. Check# �A i639. Public Health. Division lE0 µA'i Thomas McKean, Director 200 Main Street,Hyannis;MA 02601 ? Office: 508-862-4644 Fax: 50&790-6304 APPLICATION FOR PERMIT TO OPERATE A✓FOOD ESTABLISHMENT DATE 12���r .. NEWOWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ADDRESS OF FOOD ESTABLISHMENT: � 7 S� IJc�rrtS57cLdl� Ra ATTN: LAW DEPARTMENT MAILING ADDRESS(IF DIFFERENT FROM ABOVE): rr+ n�r'iTatERIG LLC lSawucclQcumberlandfarrns.corn 165 FL:ANDERS ROAD E-MAIL ADDRESS: Ao1581 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: : TOTAL.NUMBER OF BATHROOMS: I WELL WATER:YES NO✓ ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: `� SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. **'*OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING { REQUIREMENTS. i IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?' TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) ]FOOD SERVICE _RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer). _BED& BREAKFAST _CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) _MOBILE FOOD _FROZEN DAIRY DESSERT MACHINES .....(MONTHLY LAB ANALYSIS REQUIRED) _CATER..ING ....(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q 1Application FormsTOODAPP 2020.doc d t I OWNER INFORMATION: FULL NAME OF APPLICANT SOLE OWNER: YES to OWNER PHONE# SOfr'�V-AS S/ ADDRESS 57� CORPORATE OWNER: ;- b CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: Zia- List(2) Certified Food Protection Managers AND at least.(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have I Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES" The Health Div,will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 2. SIGNATURE OF APPLICANT DATE .SIP L'Ge�Se �Or� ***FOOD POLICY INFORMATION"* SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks.must be inspected by the Health Div. prior to opening!! Please call Health Div.at 508-862-4644 to schedule your:inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the.suspension or revocation of your Frozen Dessert 1' Permit until the above terms are.met— CATERING POLICY.: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a,catering notice found at htta://www.town6fbarnstable.us/healthdivision/applicaticins.asr). OUTDOOR COOKING: Outdoor cooking,.preparation,or display of any food product bya food establishment is prohibited.. NOTICE: Permits run annually from January 1 st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO.RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st: Q.Application FormsTOODAPP REVS N I q.doc i ' tME fi BOARD OF HEALTH Town of Barnstable John T.Norman r Board of Health Donald A.Guadagnoli,M.D. BARNVrABM F.P.(Thomas)Lee 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,Alternate +k Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 129 Issue Date: 1/1/2021 DBA: CUMBERLAND FARMS #2295 OWNER: CUMBERLAND FARMS, INC. Location of Establishment: 375 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY i S Town of Barnstable For�if ' ' Initials• . Date c5 _ Amt Pd$- g � A Inspectional Services �� ,was. g C Public Health Division . .. ...... . ;. Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 x TOBACCO ESTABLISHMENT.PERMIT APPLICATION(Non-Flavored); 12/20/2020 DATE NEW BUSINESS OWNERSHIP RENEWAL X 4' NAME OF TOBACCO ESTABLISHMENT: CUMBER LAND FARMS #2295 ADDRESS OF TOBACCO ESTABLISHMENT: 375 Barnstable Road MAILING ADDRESS(IF DIFFERENT FROM ABOVE): 165 Flanders Rd. Westborough,Ma. 01581 E-MAIL ADDRESS: LSalvucci@cumberlandfarms.com TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: 5( 08) 790 7118 OWNER'S NAME:.Cumberland. Farms,.,Inc. OWNER S PH#�O , 270 1504D. OWNER'S ADDRESS: 165 Flanders Rd. Westborough Ma..01581 CORPORATE NAME: CUMBERLAND FARMS INC. _ CORPORATE ADDRESS:165 Flanders Rd. Westborough Ma. 0158.1 CORPORATE FID# ANNUAL:�_ SEASONAL: DATES OF OPERATION:_/_! TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE COMMA GENERAL.LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: httRs://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https://maale.,g slature.eov/Laws/GeneralLaws/PartIV/TitleI/Chapter27O/Section6 t ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT.THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 i SIGNATURE: PRINTED NAME: Laura Salvucci SR.LICENSING COORDINATOR_,._ DATE: 12. A0. /2020 Q:1Application Forms\TOBACCO APP-NonFavor 12-18-19,docx 1tCs96_ ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—&371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Signature "Printed Name Date Sig tuft Printed Na Date T O� Signat r Printed 1 ame �� Dad T Ad-Mzz1L,) ignature Prmted Name Date Si nature Printed Name Date �- 1 rZ 0,Ceq3WII✓ls I2 1211;a0 Signature Printed NameJ Date ISignatur Printed Name Date C \C:sers`decoilik\.appDaUM-dealAAicrosofi.\Windo s\1 NetCache'NConten t.OutloWN70F4.13KrOBACCO APP2019 dob.docx 4S�t"t;r�.� Commonwealth of Massachusetts Lcticr ID:L0317892160 � s Department of Revenue Notice Date:September 4,2020 bi, j 1s'aj Geoffrey E.Snydcr,Commissioner Account ID:CGL-10031037:c48( mass.goVIdor RETAILER LICENSE FOR SALE OF CIGARETTES II„II"l�II'llll'�II�I'�I'll'I'III'I'lllll'lll"'ll��llltll�fl'� COMBCRLAND FARMS INC CUMBERLAND FARMS#0176 CUMBERLAND 165 FLANDERS RD WESTBOROUGH MA 01581-1032 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3). Cut along the dotted line and display at your busing Iocation. At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(611) 88.7-6367 or toll-free in Massachusetts at (800)392-6099, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3 A. Retailer License for Sale of Cigarettes hFhr0� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. CUMBERLAND FARMS INC Account ID: CGL-10031037-486 CUMBERLAND FARMS #2295 Location ID: 10031037-0513 375 BARNSTABLE RD License Number: 1413834752 HYANNIS MA 02601-2933 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2020 Expiration Date: September 30, 2022 400RAP, Commonwealth of Massachusetts Letter ID:L1283362368 � ❑ C;' Department of Revenue Notice Date:September 4,2020 ®. t' ;I Gcoffrcy E.Snyder,Commissioner Account ID:CRL-10031037-489 'R\r am mass.gowdor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO Irlr��lll1111�iIItllililllnitu��lll111111111iI��II11rI�httr�l CUMBERLAND FARMS INC CUMBERLAND FARMS#0176 CBMBERLAND 165 FLANDERS RD WESTBOROUGH MA 01581-1032 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T). Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.govlmasstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617)887-6367-or toll-free in Massachusetts at (800)392-6089, Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ------------------ - .-»- ------------------------------ ------- ----------- ----------------------------------------------------------- Ayti�crltrs,�� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T a F Retailer License for Sale of Cigars and Smoking Tobacco This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. CUMBERLAND FARMS INC Account ID: CRL-10031037-489 CUMBERLAND FARMS 2295 Location ID: 10031037-0711 375 BARNSTABLE RD License Number: 151660544 HYANNIS MA 02601-2933 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations, Effective Date:October 1,2020 Expiration Date:September 30, 2022 10, Commonwealth of ylassaehusetts I Letter ID_Lf1334813760 s Department of Revenue Notice Date,July 21.2020 J, t}eof rcy E.Snyder,Commissioner Account ID;EDL-1 003 1 03 7=534 ` r W �FtiTOt�� mass g&V dor LICENSE FOR SALE OF ELECTRONIC NICOTINE DELIVERY SYSTEMS ICI"11111"I'�I lll�llll�r�lrrl�l�il���llllr�tlul�l�l�l�lttt�l'I .(:UMBERLAND FARMS INC C1.IMBERLAN TARMS#353.1 165 FLANDERS RD WESTBOROUGH MA 01581:-1:04" Attached below is your Retailer License for Sale of Electronic Nicotine Delivery Systems. Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConnect account at mass.go0masstaxcon nect to view and re-print a copy of this license. If you have any questions about your license,call us at(617)887-6367 or toll-free in Massachusetts at (800)392,-6089, Monday through Friday,8:30 a.m. to 4:30 p.m. DETACH HERE ------------------------------------ ---- . .x -..- - -- -- ---- --- ----- --------------------------- -- ------ at:H(i MASSACHUSETTS DEPARTMENT OF REVENUE Retailer License for Sale of Electronic Nicotine Delivery Systems � . This license must be posted and visible at all times. The sale of F``rOY tobacco products to anyone under 21 years of age is prohibited. CUMBERLAND FARMS INC Account ID: EDL-10031037-534 CUMBERLAND FARMS 2295 Location ID: 1 003 103 7-1 240 375 BARNSTABLE RD License Number: 1659480064 HYANNIS MA 02601-2933 This cert hes;that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to:sell electronic nicotine delivery systems at the address shown above. This license is non-trans terable and may be suspended or revoked for failure to comply with state im'vs end regulations. Effective Date:July,21, 2020 Expiration Date: Septcmber 30, 2022 l� - R BOARD OF HEALTH Town of Barnstable John T.Norman Board of Health Donald A.Gaudagnoli,M.D. EIAR ABLK Paul J.Canniff,D.M.D. MAM a 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate DA6 � Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 129 Issue Date: 12/10/2019 DBA: CUMBERLAND FARMS #2295 OWNER: CUMBERLAND FARMS, INC. Location of Establishment: 375 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Cr'� FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: of rti For Office Use Only: Initials: Town of Barnstable 11/1 $ _ Date Paid �C��4�[ly AIIlt�d BARNSPABLE. : Inspectional Services 'AM 9 `� Public Health Division (' t� QED M0�s Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE du`z 7 NEW OWNERSHIP RENEWAL nn��11 NAME OF FOOD ESTABLISHMENT:�G(��»bryy' Zr/Y►S )) ADDRESS OF FOOD ESTABLISHMENT: ,37s &tMS 7'a41e Rj . MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: LsaNuccl@cumberlandtanns.com O/, -_— TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (Eip U � TOTAL NUMBER OF BATHROOMS:I WELL WATER: YES_NO__�_,/.. (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: V SEASONAL: DATES OF OPERATION:_/ / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL, MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 QAApplication FormsTOODAPP 2020.doc r— Cumberland Farms, Inc. Tax Department OWNER INFORMATION: 165 Flanders Road FULL NAME OF APPLICANT �s roug w. MI A 01581 SOLE OWNER: YES/NO OWNER PHONE# a 7j2 ADDRESS_ G d Farms, 111c. CORPORATE OWNER: Tax ntzoartwent Flanders Road 65- CORPORATE ADDRESS: tirt,s,., PERSON IN CHARGE OF DAILY OPERATIONS: G7 2�2h E�j'�j !/✓!air'-S_e� List (2) Certified Food Protection Managers AND at least(1)Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. 2. Richard Fournier Tax Manager SIGNA URE OF A PL ANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE: All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openine!! Please call Health Div.at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/applications.asy. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:Wpplication FormsTOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. ABLE, Paul J.Canniff,D.M.D. b 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate ° Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 129 Issue Date: 1/1/2020 DBA: CUMBERLAND FARMS #2295 OWNER: CUMBERLAND FARMS, INC. Location of Establishment: 375 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Q Thomas A. McKean, RS, CHO, Health Agent Restrictions: PLEASE POST CONSPICUOUSLY i I , For Office Use Only: Initials: "E' .� Town of Barnstable _ Date Paid BAPNWABLE Inspectional Services '039. Check iOlFpla�� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION on-Flavored DATE !? NEW BUSINESS OWNERSHIP RENEWAL POOOF NAME OF TOBACCO ESTABLISHMENT: /yj�cf�q/j� GL rids ;0_ou�7 ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: LSaM=I@wmberia.ndfwm.com TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: -7-f-0- OWNER'S NAME: 0j1n1hArbind Farms, ItICQWNER'S PH#( 7Q- L52WD. OWNER'S ADDRESS: Tax Department CORPORATE ADDRESS:WeStborough, MA 01581 ANNUAL: SEASONAL: DATES OF OPERATION: / / TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) TOWN OF BARNSTABLE COMMA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https•//malegislature g_ov/Laws/GeneralL a,Ns/PartIV/TitleI/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco ayment of Fee(s) -see page 4 SIGNATURE: PRINTED NAME: Richa"Frnier Tax ManagerDATE: Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc i H4� Commonwealth of Massachusetts Letter ID:L0952746624 DY };'•'' Department of Revenue Notice Date:September 18,2018 s 4. Christopher C,Harding,Commissioner Account ID:CGL-10031037-486 t'rro�� mass.govldor RETAILER LICENSE FOR SALE OF CIGARETTES lh� i111�t� IlrPllrhlrrinyltl�ltllw�lllhnll�i CUMBERLAND FARMS INC CUMBERLAND FARMS#0176 CUMBERLAND 165 FLANDERS RD WESTBOROUGH MA 01581-1032 Attached below is your Retailer License for Sale of Cigarettes(Form CT-3T).Cut along the dotted line and display at your business location. At any time,you can log into your MassTaxConneet account at mass.govfmasstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617) 887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE ---------------------------------------------------------------------------------------------------------------------------------------------- XCt((,SF� MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T Retailer License for Sale of Cigarettes 7 'F-roF�w This license must be posted and visible at all times.The sale of tobacco products to anyone under IS years of age is prohibited. CUMBERLAND FARMS INC Account ID:CGL-10031037-486 CUMBERLAND FARMS#2295 Location ID: 10031037-0513 375 BARNSTABLE RD License Number: 1689999360 HYANNIS MA 02601-2933 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: October 1,2018 Expiration Date: September 30,2020 Commonwealth of Massachusetts Lcttcr ID:LI 122783872 Department of Revenue Notice Date:September 17,2018 q; H Christopher C.Harding,Commissioner Account ID:CRL-10031037-489 F1vi0& mass.gov/dor RETAILER LICENSE FOR SALE OF CIGARS AND SMOKING TOBACCO �IIIIIt11t�nitllln111111111111111111lthl111rinf Il�lnl'i'le CUMBERLAND FARMS tNC CUMBERLAND FARMS#0176 CUMBERLAND 165 FLANDERS RD W8STBOROUGH MA 01581-1032 Attached below is your Retailer License for Sale of Cigars and Smoking Tobacco(Form CT-3T).Cut along the dotted line and display at your business location.At any time,you can log into your MassTaxConnect account at mass.gov/masstaxconnect to view and re-print a copy of this license. If you have any questions about your license,call us at(617)887-6367 or toll-free in Massachusetts at (800)392-6089,Monday through Friday, 8:30 a.m. to 4:30 p.m. DETACH HERE Cl-ftj MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T m Retailer License for Sale of Cigars and Smoking Tobacco Y F,vt OF This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. CUMBERLAND FARMS INC Account ID: CRL-10031037-489 CUMBERLAND FARMS#2295 Location ID: 10031037-0711 375 BARNSTABLE RD License Number: 1854052352 HYANNIS MA 02601-2933 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to .sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:October 1,2018 Expiration Date:September 30,2020 d r AHI Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. t' BARNS AUM . John T. Norman `AS F.P. Thomas Lee Alternate 200 Main Street, Hyannis, MA 02601 Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstablems Permit to Operate a Food Establishment In accordance with regulations promulgated under authority of 105 CMR 590.000 M.G.L. Chapter 94 Sections 305A, 3056, 146, 189 and 189A; Chapter 111,Sections 5 and 127A, a permit is hereby granted to: Permit No: 129 Issue Date: 12/20/18 DBA: CUMBERLAND FARMS #2295 OWNER: CUMBERLAND FARMS, INC. Location of Establishment: 375 BARNSTABLE ROAD HYANNIS, MA 02601 Type of Business Permit: RETAIL FOOD Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: . 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: - -- — -- - - - - MOBILE-FOOD: MOBILE-ICE CREAM: C+�� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: FTHE ropy For Office Use Only: Initials: Town of Barnstable " Date Paid Amt I'd$ t BARNWABLE. ' Inspectional Services 2,9 Public Health Divisio n 1' Thomas McKean, Director ff -r 2 00 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 r' APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: C Q►mob er Ian d Farms 22g5 ADDRESS OF FOOD ESTABLISHMENT: 1 5 b a r n s+Gi b I e, Rd. H ya n 11 i s, MA 02.U01 MAILING ADDRESS (IF DIFFERENT FROM ABOVE): _IU5 Flanders Rd. Westboro uah , MA 015131 E-MAIL ADDRESS: _ LSQ1VUCCI e Cumberland farms. COnm TELEPHONE NUMBER OF FOOD ESTABLISHMENT: jc ()B)19 0 - 1 l 18 TOTAL NUMBER OF BATHROOMS: -1 WELL WATER:YES NO /... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL:_� SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: -ja_ OUTSIDE: TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FormsTOODAPPREV2018.doc I! r _ --------- PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT Cumberland Farrlls, Inc. -TGx Qegalr+Me.n4 SOLE OWNER: YES/NO OWNER PHONE # 508) 7-jo _ 15O+ ADDRESS lub Flanders Rd. (, kAlooroug1 h , MA w58I CORPORATE OWNER )wt of I6 �aeM 1a� CORPORATE ADDRESS: iLPS Fl ande 5 Rd. MS-Eborou_a h, Mfl 015b) PERSON IN CHARGE OF DAILY OPERATIONS: L I u h f-4h ft a rS e List (2) Certified Food Protection Managers AND at least(1) Allergen Awareness Certified Staff All FOOD ESTABLISHMENTS must have 1 Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration Date 1. Imo-' �, - / / 1. 2. SIGNATURE OF CANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to opening!! Please call Health Div. at 508-862-4644 to schedule your inspection. Please call at least(7)days in advance. FROZEN DAIRY DESSERTS: Frozen desserts must be tested by a State Certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Div. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms are met. CATERING POLICY: Anyone who caters within the Town of Barnstable must notify theTown by fax or mail prior to catering event. You must complete a catering notice found at http://www.townofbarnstable.us/healthdivision/api3lications.asy. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. TOBACCO ESTABLISHMENTS: All tobacco establishments must complete an Application for Tobacco Sales Permit and Employee Signature Form. NOTICE: Permits run annually from January 1 st to Dec. 3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FonnsTOODAPPREV2018.doc �114E, Town of Barnstable • - Regulatory Services Department 9'AMSTAB MAS& Public Health Division s639. �0 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION , 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT Z Cuter louland Fwms -Inc. LAST NAME OF APPLICANT FIRST NAME MIDDLE INITIAL CUrnbtri and Furnss 4 22g5 D/B/A 315 Bcirn5 �nble, Rd, NiuGnnis ; MA QU.Poi STREET ADDRESS (50�) Iqo- -ME5 -- TELEPHONE# FID# Do you currently possess a state license to sell tobacco products? Yes J No Each employee who sells tobacco products must receive and understand the Sections VII b. and VII c. of the Board of Health Prohibition of Smoking Regulation, (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided-on the next p Each employee who sells tobacco products must sign the Empl ee Signature Yorm provided herein). G Signature Date Q:\Application Forms\TOBACCO APP2018 dob.docx J Lizabeth Bearse .••�• Store Manager • • Cumberland 375 Barnstable Road F A R M S Hyannis,MA 02601 Our Vision The cresr choice for your ovoryday needs. _ Phone:508-790-7118 store2295@cuinberlandfarms.com I__ i F r ` 1. y, I •Never settle•Tell it li It ales u e s Own it•sucr..eed together Our Mission "' Delivar the friendliest.cieanest and nrost convenient cnstorner erperlence.by first being the host place to worts. o� 0 Cumberland F A R M S i r ,y f YsY :,S sue^ ht 'y Ad N� ! <. e. H.fi+sw,:,�-ry ,,,, r_�bswd✓va: .._ '/.,,.aDsd�'-,r, ms^3i _.' ,a<..< _- a%<....n=t »3 ,- ?w+.< Ate. �.r I.z...w v...1..-s-a..a ESTABLISHMENT'S NAMEyV TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one(21). Below is Section 371-9.of the Town of Barnstable Board of Health Regulation: Sales to Minors—§371-9.Sale and Distribution of Tobacco Products. 1: No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age, 2, Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: Si atfire ted Name Date �0 Q k�ad4j- e ► P ' ted Name Date Signature Printed Name Date i Signature Printed Name Date �. Ckw Sign�Iive "Pruned Name Date Siifnature Printed Name , DateX A0 � 10) Signatur Printed Name Date Q:1Application FormATOBACCO APP2019 dob.docx �:Yru"y YY' �.• 'u. i �S`'� `rk' 3, 9 _.F '. �INE Town of Barnstable For Office Use Only: Initials: Inspectional Services Date Paid Amt Pd$ " Check# Cash 1639.= � Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-790-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO:TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 t APPLICATION FOR A TOBACCO SALES PERMIT 'z ESTABLISHMENT NAME (DB/A) 0/ ADDRESS OF BUSINESS of S MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OWNER'S NAME: LAST FIRST MIDDLE LSaM,"cumberlandfarm&com ;rar- A yv -/soy EMAIL PHONE# FEDERAL ID# Do you curren possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a co . provided on the next page). Each employee who sells tobacco products must sign 11 a Employee Signature Form (provided herein). Signature Date /d' Richard Fournier Tax Manager Q:\Application Forms\TOBACCO APP2019 do . x l r . _ 17714-- Lizabeth Bearse '�•••• Store ManagerOR • xn b&land 375 Barnstable Road Hyannis,MA 02601 i F A R AA €€ ow Ns1on I n cropr cnac•ro.Ma�sryday n«as. Phone:508-790.7118 store2295@cumbertandtarms.com gSTABLISMYMNT'S NAME i TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one(21). Below is Section 371-9.of the Town of Barnstable Board of Health Regulation: t Sales to 1Vlinors—§371-9 Sale and Distribution of Tobacco Products. i. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or Older. Verification is required for any person under the age of 27. N The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: g S- ted Name Date ted Name Date 1 l a rg Signature ^ Printed Name Date ' Signattue Printed Name Date Prin Printed Name Si Gue Date Signature Printed Name . Date i � �2i� Sigma Printed Name Date (IApoicaaeo FartaATOSACCO APP2019 dobAocx t, �LL Scanned with CamScanner >uata (Aart Tor -tank System Tightness Test 22ir TAP ' PLEASE PRINT � TANK TESTER � , ail `�1-0 71 1. OWNER Property /,r r it rr Name /Ador:Ues'J Representative Telephone Tank(s) `xe C-` �Gir1 v 0Q — s —/7G7 Name Address Reoresentative Telephone 2. OPERATOR A �,cys' s 3��'771-�Sfd Name Address Teleohone 3. REASON FOR TEST (Explain Fully) "'.._t.,c+ Wmac^:, ew 4. WHO REQUESTED is 4 rwna TEST AND WHEN Name Title Comoany or MAIM� 4 Address d^: 4•A.PRW",,.,�, - TeleonOne 5. WHO IS PAYING c/l. r✓ -, ��oG r' , 4; v.r/-/-2 Compa y,Agency or Individual Person Authorizing FOR THIS TEST? Title' Telephone Billing Address City State Zip Attention of: Order No. Other Instructions ldpntity by Direction Capacity I Brand/Sup tier Grade Approx.Age Steel/Fiberglass 6. TANK(S) INVOLVED `/ C %D 04C> >� .A v 7 Lie �'- O Op v /s/►,; 7 c 3 i/ Location Cover Fills Vents Siphones Pumps 7. INSTALLATION 4//) ICJ ��� Tclt�ie .--7 DATA �J, If North inside OrivewaY. Concrete.Black Top, Size,7itefill make.Drop Suction,!em��� ote/,^^�� Rear of station,etc. Earth,etc. tubes,Remote Fills Size.Manifolded Which tanks? Make i1 8. UNDERGROUND ,Q Is the water over the tank? WATER Depth to the Water table /' Yes � No q $ 1 - Tanks to be filled��hr. 3 ate .A + 9. FILL-UP Arranged by Name Teleohone ARRANGEMENTS Extra product to**top off"and run TSTT. How and who to provide? Consider NO Lead. Terminal or other contact J/,� nI 7 / ( w) 7 7-5 f +• /30 Q for notice or inquiry / (/ Company' Name TEIGDrtOne 10. CONTRACTOR, MECHANICS, S G r1 any other contractor involved f 11. OTHER '� 000 INFORMATION OR REMARKS Additional information on any items above.Officials or others to be advised when testing is in progress or completed.Visitors or observers present during test etc. Tests were made on the above tank systems in accordance with test procedures prescribed for PPtTO jetP .12. TEST RESULTS as detailed on attached test charts with results as follows: t"M WER Tank Identification Tight Leakage Indicated Date Tested 11PJ721 Q =--, -3 I -, 0-3 PV 7 Z 3 This is to certify that these tank systems were tested on the date(s)shown.Those indicated as"Tight"meet the 't. es bli 1, 13. CERTIFICATION the National Fire Prot tion As cia y'on Pamphlet 329. _ Data Testing Co Iracfbf or Co any. BY. tufe ,�`Serial No.of Thermal Technicians Address Sensor -91115 S ✓/� ��1_3 f /6 Z7 ,�vts �- T i�. Name Address No.and Slreel fat of tuppllef.Owner or Dealer Cl CItY Stale Dele of Te• • _ From T s,15a. BRIEF DIAGRAM OF TANK FIELD 16. CAPACITY ❑ ,k,n char, 57 15. TANK TO TES .yiis 1 Nominal Capacity /� - gg Tank Manufacturer'.Chart 'T / Gallons' Ld.. c entity by position • ❑ Company Engineering DataG� A�` ❑ supplied with Tank Tesler By most accurate Other Brand and Onds capacity chart avallsbl6 �— ❑ Other Gallo^s Total Gallons 17. FILL-UP FOR TEST Reading O �l/C/� S �2� - Inventory In Tank Slick Walar eotlm o - _ In. before Fill-up In. _ to'A" O.IIo^. Tank Diameter Water Bottom Top off equipment + 18. SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS TANK ❑Water In lank Llnels)being tested with LVLLT ❑ In tank excavation Total Ousnlllybl table water Sea mama Bsctlona applicable.Check below and record procedure In log(27). High - Use maximum.IIdw.Dle teal vre.sure ror all le.la. 19. TANK MEASUREMENTS FOR _ Four pond rule does not apply to doublswalled lsnks. TSTT ASSEMBLY 21. VAPOR RECOVERY SYSTEM ❑Siege 1 Stage II Complete section below: In. Bottom of lank to grade' ............ ............ Add 30"for"T'pro 30 In. 24b. COEFFICIENT OF EXPANSION t. Is lour pound rule requlred7 Ye. ❑ No Total g to assemble—apDroximele............. In. RECIPROCAL METHOD .. _ Type of Product ........................................ �' � 20. EXTENSION HOSE SETTING_in. 2. Haight to 12'merle from grads .. In Flydromsler Employed .................................. Tank top to grade'................... - C Temperature In Tank Extend hose on suction tube 6" 'F P.S.1 After Circulation........................................ F 3, pressure at bottom of lank below tank lob •• In. .................. D Temperature of Sample . /e ill pipe extends above grade.me IoD of Ifll. _ .i + .F a pressure at top of tank P.S.1. USE WITH THERMAL SENSOR Difference(•/)...................... .. PN5039 (Blue Box)C�� Observed A.P.I.Gravity ....................... Depth of burial m. -----------`. r ZZ. TnermatSensor reading she(circulation G Page a d-gils Reciprocal�— g //�' r�1� `` Tank Blain. ____ .—__—'F ��, •ter I t,y' 7Qp/� I / Between —`—�—`-- ,—.all(' Total quantity in Reciprocal Volume change m N d Z3. Digits Fin range of expected change lull lank(17) this lank per'F /7 drgds Transfer to Line 26a Water table to tank bottom In. NOTES: �/ 24a. I USING THERMAL SENSOR DTS 2000 24c, FOR TESTING WITH WATER s.a Table c d �� OR OC-2000 WHICH READ 1000 DIGITS PER °F TRANSFER 1000 TO LINE 26, WslerTempereluraeflerCirculetion F /� DIGITS PER °F IN TEST RANGE. Tablechom Thermal Sensor...... ...-"" CoefrlcIonl of Wal - Table O .. ........................................... The above calculations are to be used for dry Boil conditions to I. establish a positive pressure advantage•orwhen using the lour pound rule to compensate for the presence of subsurface water In the tank Added Surfeclent7 ❑Yes ❑No Tra^seer COE to Llne iSO. .re. . '',, . 25. (�L % (b) = (�) _ gallons Refer to N.F P.A. 30. Sections 2•J.2 end 2-7.4 and the lank Volume change in this lank msnufaclursr regarding allowable System Intl pressures. Total lank it Ify.A Coefficient Prof expansion for 9 lull lank it If Involved product per'F � 00(o c/ T�00 Thl,la 26. (`��_ "7r �� —— — Vauma cne^ga Per digit —�— tell Volume change par•F 175 or 7an, 111.A.r v�e�•nr r7r.•alst (;mm�u1.to s deramal place■ factor pl Address NO.end Sltnet(sl City Slsla Dete of Tee 1 Name of SUPPIIer.Owner or Deelef / From 15a. BRIEF DIAGRAM OF TANK FIELD 16. CAPACITY lotion Cher, 15. TANK TO TEST 5/ C ❑Nominal Capacity O'O 1-J rook Manulaclurer's Chart Gallons El Company Engineering Oela Identity by position / ,^ ❑ Charts supplied with Tank Tester v By ,most aocurale y 0 0c) ElOther Brand and Grads capacity chart avellabls /� LL Gallons Total Gallons ea.Reeding 17. FILL-UP FOR TEST /'•� Inventory in Tank / Stick Water Bottom V /t��l In. I C before Fill-up In. Gallons Tank Diameter-- Water Bottom - to�' may/ Top off equipment + 18. SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS TANK ❑Water In tank lJ Llnefs)Deing tested wish LVLLT • - ❑ - Sao manual!actions applicable.Check below and record procedure In lop(27). High water table In tank excavation Total Quantity Lee maximum allowable test pressure lot all teat.. 19. TANK MEASUREMENTS FOR Four pound rule dose not apply to°°°°'°"'°"ed tanks. TSTT ASSEMBLY 21. VAPOR RECOVERY SYSTEM ❑Slags t Stage 11 Complete section below: Bottom of".,I, n to grade. In. .................Add90"fo 'T' my..............• ••--••-• •• 30In. 24b. COEFFICIENT OF EXPANSION 1. is lour pound rule required? Ve• No using o assemble—approximate............. f^. RECIPROCAL METHOD Typeof Product ........................................ A . �O in 20. EXTENSION HOSE SETTING 6 pr —H -.. Height to 12'mark from prude in. Employed .................................. Tank top to grade'.................................. In. V -� Temperature In Tank Extend hose on'uCII.h tube 6"or mor F _P.S.I. lter Circulation........................................ F r 3. Pressure at bottom or lank below lank lop...... ...... In. , 34( ............ ................... g Temperature of Sample / rryy� ./ p pe extends shove grade.use top of fill. 7 1 e / •F 4 Pressure el lop of lank PS''' USE WITH THERMAL SENSOR Din rents(4r-)......................................... G�Q PN5039 (Blue Box) Observed A.P.I.Gravity ................................. Depth of burial r^� • �� �r ZZ. Thermal-Sensor reeding after urculeupn — .--_its L11 L�- Page° `� / !y^, digits Reciprocal g Tank die. —f—in. --___ -- •F Q,cr p . l]�• -- ' / 6 �� f Between fv/ Total quantity in Reciprocal Volume change in N 23. Digits per' range of expected change lull Ienk(17) this lank per F digits Transfer to Line 26e. Water table to tank bottom in. NOTES: �. 24a. i USING TH�ER�ALENSOR DTS 2000> FWater TESTING WITH WATER see Table C S �G OR OC-2000AD-1-000-�r�rTS PER °F TRANSFER 1000 TO LINE 26, ruure soar CirculationDIGITS PER °F IN TEST RANGE. ThermalSensor........ F f Water. ........................................The above calculations are to be used for dry soil conditions to asteblishapositivepressureadvantage.orwhenusingthefourpound tan1, ❑Yea ❑No TransferCOEtoLine25 . rule to compensate lot the presence of subsurface water In the lank area a) >< (b) _ (C) gallons Rater to N.F P.A. JD. Sections 2•3.2.4 end 2.7.2 and the lank 25. ( ------- Volume change In this lank • manufacturer regarding allowable system g felt pressures. Total quantity iA Coefficient of expansion for lull lank(17) involved product per L This 1. ; r 26. 01_ �n�`'' -4 -� --- — - Volume change per dlgls tea for al fir Volume change par•_F 175 or 24h) Dig�b per'F r teat la rlan.tn t7l nr)oat mMda 10 4 deumat pteres c 1 1 1 supplier.Owner or Deals, Address No.and Street U) City Slate Dels of Supp of Too,ems From / 15./T-ANK TO TEST .15a. BRIEF DIAGRAM OF TANK FIELD 16. CAPACITY / �❑, _glatIon chart 7-3 �j Nominal Capacity ( O� V Tank Manufacturer's Chart Gallons Identity by position / ... Company Engineering Data — ❑ Charts auDDlled with Tank Tester By most accurate El Other n. � e, and Grads capacity chart available Gallons Total Gallons 17. FILL-UP FOR TEST as.Reading - Inventory In Tank Slick Wale Bottom J c before Fltl-up t^' In Tank Diameter to'A"A- ... Gallons Walar Bottom • / O 18. SPECIAL CONDITIONS AND PROCEDURES TO TEST THIS TANK ❑Water In lank Lin Top oil equipment +sfs)being tested with LVLLT See manual sections applicable.Check below and record procedure In log 1271. ❑High water table In tank excavation Total Ouanlity / o0/ Use maximum allowable lest Pressure for all toots. 19. TANK MEASUREMENTS FOR Four pound rule does not apply to doublowalled looks. TSTT ASSEMBLY 21. VAPOR RECOVERY SYSTEM Stage I Slope II Complete section below: tiom of look to grade' ....... In. Add 30"for'?' assy........................... �301n 24b. COEFFICIENT OF EXPANSION 1. l,Idurpoundrulerequued? yn ❑ No Td Ingid.eeemble—approximate•...•-.-..••' 1^. RECIPROCAL METHOD S Typeof Product ........................................ 11� C 20. EXT7nub. OSE SETTING 6 . 2.Height to 12'mark from grade n' .... In. Hydrometer Employed ..................................7(/�' �/-1'Tank top 10 ............... .........................< `�' v-F ..... Extend hose 6" ore Temperature In Tank �—P.S.1. After Circulation............... �, Pressure el bottom of lank below lank l I^' ........................... 30 r 0 / � � � Temperature of Sample ................................. —'F [ •� P.S 1 ,/ Fill pipe extends above grade.use lop of hu. e Pressure at lop of lank < USE WITH THERMAL SENSOR Difference 1.7-)...........:............................. < I L� PN5039 (Blue Box) Observed A.P 1.Gravity ... S '_(;I .Depth of burial rn. Y 22. 7nermel-Sensor reading alter(yrclrle __—___—__--- ,r�� 60 drgifs Reciprocal� ,Pa/g7a 7 (x'� C/ Tank die. �L--in. .—__— �F Cl 7 e �• �4��J / Between __ Total quantity in Reciprocal Volume change in A 23. �U per'F in range of expected change lull lank(17) this lank per IF d,g its Water table 10 tank bottom in ?rooster to Line tfie. / NOTES: 7i 24a. I SING THERMAL SENSOR DTS-2000 24c. FOR TESTING WITH WATER see Table C A O 9l OR OC-2000 WHICH READ 1000 DIGITS PER OF TRANSFER 1000 TO LINE 26, Water Temperature after Circulation DIGITS PER OF IN TEST RANGE. TableC from ThermalSensor.........- ............... F i Coefficient of Water Table0 ..... ........................................ The above calculations are to be used for dry soil conditions to establish a positive pressure advantage,or when using the four pound rule to compensate for the presence of subsurface water In the tank dad Surfactant? ❑Yes ❑No Transfer COE to Line M. area Rafe, to N.F P.A. 30. Sections 2-3.2.4 and 2-1.2 and the lank 25. (a) >< (b) = Vo) _ gallons msnulacturer regarding allowable system lest pressures. Total quantity iti Coefficient of expansion for Volume change in this lank lull tan4 1,71 Involved product per•F Digits e,•F m loll Volume change per dlgll lest Volume change par'f I?5^r 2ah1 11,:le pi7]nr?x.•1 GnmMile In 4 doicimol plar:ee lector(a) a DATA CHART . %/� a 073 For Use With petre Tite LINE TESTER UJI CERTIFIC TE# iw N z C/F GULF STA.# 7 7S /�. /S z 3 1. LOCATION: State Telephone No. Q p Street No.and/or Corner City P U. = Z 2. OWNER: C/F GULF 777 DEDHAM STREET -�jC Gv�2QI �1�11�:r�� ZJ000--,2,2 4?C-D W0 Name Address Representative Position Telephone No. O Z C/F GULF 777 DEDHAM STREET CANTON;MA 1-800-225-9702 LL r 3. OPERATOR: V V Name Dealer,Mgr.or Other Address(If Different than Location) Telephone No. . 4..REASON FOR TEST: STATE REQUIREMENTS • z a 2° 5. TEST REQUIRED BY: C/F GULF 348 ALLENS AVE. PROW.,RI (� U 2 V Name Position Order No. BillingZAdress p6. SPECIAL INSTRUCTIONS: le C� G� LJ 7. CONTRACTOR OR COMPANY MAKING TEST C/F GULF MAINT. 348 ALLENS AVE. PROV.,RI MECHANIC(S)NAME 8. IS A TANK TEST TO BE 03111YES 9. MAKE AND TYPE OF l _ CI ` � m� MADE WITH THIS LINE TEST? ❑ NO PUMP OR DISPENSER��/ /V wW d p C�NC/J�l e a aF COVER APPROXIMATE 10. WEATHERI_Ll1 TEMPERATURE IN TANKS °F °C OVER LINES BURIAL DEPTH 3� Concrete,Black op,etc. 11.IDENTIFY 13 LOG OF TEST PROCEDURES, 14. PRESSURE 15. VOLUME 15 TEST RESULTS EACH LINE 12.TIME AMBIENT TEMPERATURE, psi OR kPa READING NET AS TESTED (MILITARY) WEATHER,ETC. BEFORE AFTER BEFORE AFTER CHANGE CONCLUSIONS,REPAIRS AND COMMENTS #1 e �� START LINE TEST Q CONTINUE LINE TEST 61 SQ G'ello `txzI6 i` CONTINUE LINE TEST So 06110 . (.p hOOC3 ODOR q°�'1 01 CONTINUE LINE TEST sQ �j ,� p ,Oy/ 7.0C(� �l CONTINUE LINE TEST .S -5Q p (j .Cf O 00 p2- BLEED BACK TEST Q -O 'a .0 %$/� ����� CX" #2 START LINE TEST G037 Id = CONTINUE LINE TEST S Q SO O SO -OqS (� CONTINUE LINE TEST 'O'Kso �Qe ' CONTINUE LINE TEST L� 7 •S Q ,03 O © CONTINUE LINE TEST �� T S-O ,G '!QM fx7o / BLEED BACK TEST �G� �.._ �03 0- _�'`��LO >� 0_. �91i� U1110eIr 61 wor Qa #3 START LINE TEST S p el`�576 CONTINUE LINE TEST ,R �G ,c 0L2'+ CONTINUE LINE TEST 0 , -OG-' CONTINUE LINE TEST ooa�" ,off CONTINUE LINE TEST SoZ SO ,!� .Q BLEED BACK TEST ^� p # S RT LINE TEST CON UE LINE T T CONTIN LI TEST CONTINU NE TEST CON UE LIN EST PLIED BACK TEST .. .. fill! . .;...; _ LUG OF ILSI I'IIULLUUIILS r iILJ.:UhF RECORD TO.yOo!fAl y,^. K •r ty-�.rO�L,ieLIUH let kALII Hb1UING ! 7 J 7 CONTROL. ` J ! Temperature III High Level record 2�. 28. 29. ,.• Standpipe Level 32. Product In r Product' 35` CMnpa 'Computation Adjustment iolil End Deflection In Inches Graduate r Repbedd T�I�tm�l Hi her+ (c) ■(a) volume Minus DATE Record details of setting up Reading I 4 p. 111 Low Level compute 11�• 4. "mill. lower�L.� };.Expansion+ Expansion(+)or P and running test.(Use full N0 Oepinhinp Laval la: Change per Hour length of line if need of which Before ;': r AIUrt 3 -y I'-7- Ittll (e�,ur ;:.Contraction— Contracllon(—) TIME // Reeding Restored Reeding Raadinp. { Reeoraied M A33(V)—A37(T) INFPNcrilerta) (N hr.) 0 , Jr JC - npp U ) o `fin /� ff /I 'LiJ 1d� t _ 4��L.� 7^ ©D -•c ..J.,�- � `Y — ,, U a Cno o O t C Q /730 � -- 90 Y r�oc �o .2t7`:` c pof Q_ If r r QO 1�( . a�0 3 6 17 f'OY cc)3 0�1 If _ CAS �/ �, �'0VO d-_0/0 Je S� It bs� V . 7 o f- S 3 3 f {, of/ 7�c?, r froSo 3 Za 7 -c-17 t`00_3 .o�� n `� fr ��S 1 f�`l3 � J? �t� /`�S It )4-0`l7 1 Oc �c 0,1 .0 '1 '� d P p :! I � v (' c I I i S �/� '/ wU Ut 101 11.U11UUIILJ CONTROL RECORD lyfil 6AL U��1n��"111 b1Ult iicrwiaU I/7- aC( � , , n y 5..:: r r AI-a,L �5 is -.36 K ti 37 Temperature At High Level record 27 28 29. ,•• Standpipe level 32. Prod+el inttia t Pr+dueth fT1 'L�Change •--ComputationAdjustment Tolil End Dellection In Inchesl3ndn+tti It ' 'Repl+ud '�DATE Record details of setting up Neading - �.;r ,),ir{t (• •7hlrm gher+. (e)>, p)- volume Minusn t ' y r' : Al toe leref eetnpufe and running left.(Use full No. Be innln Level to t Int . w+r ,,, Eapansion+ Expansion(+)or I rap of li if eeded.) D ol, g wAirh Belora AIUt !: ir's"f'rod+l� H1181 (e) J� Contraction- Contraction(-) Chal per Hour TIME Restered fleedinp BhdlnO , NRonrad ) } ,e33(h—N37(T) (NF Acrilerial (11 hr.) �- 3G LZ 1061 Cc t lam: ,!y l�� ;03 Y 3 �S �`0.3 fr 0e `Oc?S �,ot�� C 3 t f.0- {-per f Q • r — 3367 it Ir �.SG c6 15 /,03 a o16 Q (-/0,� 'Its �-o t! f f`e off_. /3y� Ir If �ls-o Q 1 C`lo (4- 1 rc If ll (j ...( _ J 4 � 4' � 7 t f Q3y i35 II 1' r � 0 03 ;cry.. � '7 f G �-�/3 q�3 GG .;boa .oaf �i f F Ir r ( U ,.4 ��O�tom . -'033 ` f` it 03 �� 07 V -1-02 _OCR o c ¢. rr r 1 -- T. J. ;'- r 1 l 26. 30. HTanosmic 31. . 34 38.NET VOLUME 39. a LOG F TEST PROCEOURES PFIESSURE VOLUME MEASUREMENTS M TEMPERATURE COMPENSATION ' CHANGES ACCUMULATED �� CONTROL RECORD TO.001 GAL. ` )-:"' USE FACTOR Isl t I EACII READING CHANGE 27. 28. 29. Standpipe level 32. 35. 36. 37. Temperature At High Level record product In Product Chen '-Adjustment In Inches Change Computation ' I Total End Deflection DATE Record details of setting up Reading Graduate Replaced(—) Thermal Higher+ (c) x 1e)- Volume Minus and running test.(()se full No. Beginning Laval to Senior Lower— Ex ansion.+ At Low level compute. lengt f line if nee e ° ° p Expansion(+)or tIME C of whit Before Alter Product finding (c) Contraction Contraction(—) Chenle per Nour (II hr.) _f- Reading Restored Reading Reeding Recovered(+) A33(V)_#3T'(L) (MFPA crllerla)'- 1` qq t•1 S- C O 6211 t l 1 27 r7/0 1- 00 ass '/77 1' 313 If �► 7 V,2 , �d� ,cCo �• 3S(:531 7 t O f�17.G n 3- 17 oo P 7l e /�� _ /;� a o.� 7� f`3�S �� q age c7 3 0A, • osy- " %S/ �[� .q a . 5&_5 f e Z t V /•o coo ff, coo 1'c90 r .5 fl� Y°o Ci/S { O 12 7 Y d o /330 r' rr (C- ,Goo ]<S �1 �•/o 017 O 7 r` r' 2- 7,5 110 bl 1 Q A 0 -Y' 013 3 f,c �� 4• o9S f coo - r F /y 11 Ir .6 — 'O 90 f0 Q 071 f Q e`06JQ 1► I /`/�G 1► II �1 Z2_ ,LS F p -' J f.0 7S5 097 }/3 4 .©( 'o o /•o - l t/a % 3p ` 3 / 83-0 , -/ Z 12- a5 0 9,9c .cT- G' Ya 12- t/ -/10.0� ' a :caSG it 1 D 7Zf i ' 7 rl F 3 A CU BERLAND FARMS, INC. 777 DEDHAM STREET,CANTON,MASSACHUSETTS 02021-9118 . CumbeiAnd Farms PHONE:617-828-4900 TELEX:710-348-0130 (CUMBFARMS-CTON) July 22, 1993 Town of Barnstable t Health Department P.O. Box 534 Hyannis, Mass. 02601 RE: Cumberland Farms #2073 375 Barnstable Rd. Hyannis, Mass. Dear Sir / Madam, Please find enclosed the results of recent underground storage tank testing at the above referenced location. If you require anything further, please do not hesitate to contact me at the letterhead address above, or call (617) 828 4900; ext. 03322. Sincerely, CUMBERLAND FARMS, INC. Patricia A. Dugas UST Coordinator cc: CFI File Health Complaints 02-May-05 Time: 1:10:00 PM Date: 5/2/2005 Complaint Number: 18068 Referred To: DAVID STANTON Taken By: ALISHA PARKER Complaint Type: ARTICLE XXXIX HAZARDOUS WASTE Article X Detail: Business Name: Cumberland Farms Gas Station Number: 375 Street: Barnstable Road Village: HYANNIS Assessors Map_Parcel: 310-119 Complainant's Name: A.P. Address: Telephone Number: Complaint Description: gasoline spill at cumberland farms Actions Taken/Results: DS WENT TO SAID LOCATION AND SPOKE WITH CAPTAIN FARENKOPF. STILL NOT SURE OF CAUSE, BUT A PUMP WAS LEAKING, ABOUT 2 GALLONS ONTO THE CONCRETE PAD. CONTAINED AND CLEANED UP BY HYANNIS FIRE WITH AN ABSORBANT. CUMBERLAND FARMS IS HAVING SOMEONE COME SERVICE THE PUMP WHERE IT IS LEAKING. EVERYTHING CLEANED UP BY HYANNIS FIRE, NO FURTHER ACTION REQUIRED. Investigation Date: 5/2/2005 Investigation Time: 1:15:00 PM 1 town of Barnstable is VE'O�ti Regulatory Services Thomas F.Geiler,Director { snarrsrnsr.E, + �. $ Public Health Division i639' �� iOlEo.39 Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO COMPLIANCE CHECK FORM SECTION I: Establishment Survey Participants Name: Cumberland Farms#2295 Name of purchaser: Age: 12 ❑ Male XFemale Address. 375 Barnstable Rd. �xx � /,, Hyannis,MA 02601 Name of Adult Escort/Data Collector: i1J`L 70 City: ,i Time of Check: 37' 2' ❑ AM '_PM Type of Establishment: X Chain ❑ Independent ❑ Not Known Date of Check: Q 2- Style of Establishment(Check Only One): Convenience Store ❑ Pharmacy/Drug Store 0 Gas Mini-Mart 0 Gas Station Only ❑ Grocery Store ❑ Liquor Store 0 Department Store 0 Bar ❑ Private Club(VFW,Legion,etc.) ❑ Restaurant(Bar Area) ❑ Restaurant(Other Area) ❑ Other(Tobacco Shop,Pro Shop,etc.) SECTION II: Did the youth enter the premises and attempt to purchase a tobacco product? kyes ❑ No Ifyes, continue on to the next question, if no,please skip this section and go to Section X. H w was tobacco marketed? Over-the-counter:youth asks the clerk for the product. ❑ Over-the-counter:youth selects the product from a self-service display. ❑ From a vending machine with a lockout device. 0 From a vending machine without a lockout device. Was the purchaser asked for ID? Yes ❑ No Was ID accurately checked? ❑ Yes ❑ No k/A Was the purchaser asked his/her age? 0 Yes XNo Sex of Clerk: Male 'Female Approximate age of clerk: 2� Did the Clerk say anything to you when the purchase attempt was made? Type of tobacco asked for: Cigarettes ❑ Chew/Dip i 0 Other Was the sale made? ❑ Yes ANo (if yes,how mud I ) SECTION III: If the youth did not enter the premises or did not attempt to p) +heck here: 0 and indicate why below: ❑ closed for the day ❑ couldn't locate business p �� �zerchant 0 admission charge 0 closed for the season 0 no longer in business S ropriate for youth ❑ other 0 closed to the public ❑ doesn't sell tobacco tt G unsafe area 0 denied admission at door Token orown of Barnstable °FtT ° ]Regulatory Services Thomas F.Geiler,Director * WWSMBLE, 7 MASS.0 9. � Public Health Division Thomas McKean,Director 367 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 TOBACCO COMPLIANCE CHECK FORM Establis Survey Participants Name: Cumberland Farms#2295 Name of Purchaser: or ID# Address; 375 Barnstable Rd: Age: Sex: ❑ Male Female Hyannis, NIA 02601 Did a second person go into the es ishment? Yes ❑ No�� If Yes,what was the second person's: City: Time of Check:. Z.2 am Age: - : Sex: Male ❑ Female Date of Check: 2 )-Z pm Name of Adult Driver/Escort: e of Establishment Check Only One Convenience Store. . - T. O Pharmac /Dru Store ❑ Gas Mini-Mart Gas Station Only Groce Store ❑ Liquor Store ❑ D artment Store ❑ Bar ❑. Private Club VFW,Legion etc. ❑ Restaurant(Bar Area ❑ Restaurant Other.Area ❑ Other(bowling alley,golf club,etc.): Is this establishment within%2 mile of a school? Yes ❑ No ❑ Don't Know. Is this establishment between'/2 mile and 1 mile of a school? Yes ❑ No ❑ Don't Know Is this establishment between'/2 mile of a youth center(Boy's/Girl's Club)? Yes ❑ No ❑ Don't Know Is this establishment between''/z mile and 1 mile of a youth center(Boy's/Girl's Club)? Yes ❑ No ❑ Don't Know Is this establishment-within'/z mile of an outdoor recreational site(park,ball field, etc.)? Yes ❑ No ❑ Don't Know Is this establishment between'/2 mile and 1 mile of an outdoor rec.site(park,ball field)? Yes ❑ No ❑ _ ]don't Know Tobacco Purchase.Attempt: Was the purchase of tobacco attempted: Yes `No❑ If No,please explain why not: Was the sale made? Yes ❑ NoX Brand Purchased: Price: $ Type of Tobacco purchased attempted. Cigarette Chew/Dip ❑ How was tobacco sold? .�Clerk was required to select tobacco Purchaser requested. ❑ Purchaser was able to place tobacco on the counter. Was the Purchaser asked for ID? Yes b(No ❑ Was the Purchaser asked his/her age? Yes ❑No;1y_1 Was there any tobacco advertising(logos,posters or other promotional displays?) Yes ❑ N< Were any loose(single)cigarettes for.sale? Yes ❑ No Don't Know❑ Sex of Clerk: Male ❑ Female� Approximate Age of Clerk: Did-the Clerk say anything to you when the purchase attempt was made? Other Comments: How was the merchant-informed of the results of the compliance check? ❑ By an adult supervisor immediately after youth has/have left the premises. ❑ Notified after all compliance checks were complete. ❑ Merchant was,not notified 0 Other=please specify OpTHETp�O Tobacco Sales Permit Inspection Report Form " Regulatory Services * BMMSrnBLE. 9$ MASS.: ,m� Public Health Division HIED �A 367 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Business Name i Date .wvl''tt�r� ►M s Z-��1� � r�I G�. Business Telephone Q // Location 3�� � � Time: In Out, � ��.J1�A.J Person in Complaint -Initial ..,... m ...,,111" „..., Yves Noecommen a 031 �REGIILATTON COMPLIANCE i2emaks flr- � s l t: M Signs Posted [MGL 270/61 reCO� JJ� o .Si rl S ^1 otrY S Permit Posted [VIIa) YQCOrtsL� yty(,pet Tobacco Permit n^6V.e (Q�rm�4- &._0 R. License P'Ld1�e VISI IobGce0 Employee Signed Forms no 4orm dyk ` Kept On File [VIIb] e i Self-service Displays On Counter and Within 5 Ft. of a Clerk [VIId) No Floor Displays [VIId] MAW"Ple 51W&Ljo11S No �Tobacco Products Free of Charge [VIIc) Q t Vim'► Inspector: Person Interviewed: 1 i QAHEALTH\TOBACCO\WP Files\Tobacco Forms\TobSalesPermit.doc � LJCW{1�r1,2 Employee Signed Forms /// 116 4-Dy"`s cNA Z IA, Kept On File [VIIb] Self-service Displays On Counter and Within / 5 Ft. of a Clerk [VIId] AA f i No Floor Displays [VIId] / No Tobacco Products J Free of Charge [VIIc] V/ Inspector: ) Person Interviewees '416 q:health:tobinsp Establishment Name: Cu—Ahl.^1 eL -�r Date: - �' Page: of l � Cf,,,ode' G4� ni cad ltel bmim MOM* f�PL�t 331 RefefBi C- - It/ 3—30j' �! ® o v O c� e✓ -e t -� o yr r ',S O o � ✓� �o.�.vv i�. � o� W a �i �o L ti 1 o f / - V. r liG�- GG 07 sAL d u V t,CIF vp t O� ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Inspector's Si ur Print: ,IeMC PIC's Sig at r Print: .,+...�1#z.-�. t3.-k;;.: :-.t'"4'C'K"�-s�ck.,�':.""�.�i'�:'s T'�_...j3-*"�s. :�� �1,v".'�k."�'T�.r+..".:y �Y' ..._.�..dt __.,.f"'C'e`"'`y..",•.•..,...,.+.. .�.w-wy-�;.•.r. Violations Related to Foodbome Illness Interventions and Risk Factors(Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Cross-contamination 1 1 590.003 A Assi ent of Responsibility* 3-302.11(AX 1) Raw Animal Foods Separated from 590.003 B Demonstration of Knowl e' Cooked and RTE Foods' 2-103.11 1 Person in charge-duties Contamination from Raw Ingredients 3-302.11(Ax2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11 A Food Protection' applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils' Charge* Contamination from the Consumer 590.003 G Reporting by Person in Charge* 3-306.14 A II Returned Food and Reservice of Food' 3.1 590.003 D Exclusions and Restrictions' Disposition of Adulterated or Contaminated 590.00 Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes' 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590. A-B Compliance with Food Law' 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container; Sanitization Temperatures* 3-201.13 Fluid Milk and MilkProducts* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized' 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness.' 5-101.11 3- 02.1 Ice Made From Potable Water' 4-601.11(A) Equipment Food Contact Surfaces and Water from an A o ved System- 590. A Bottled Drinking Water' Utensils Clean* 590.0 4-602.11 Cleaning Frequency of Equipment Food- Water Meets Standards in 310 CMR 22.0' Contact Surfaces and Utensils' SheOish and Fish From an Approved Source 4-702 11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish' 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical' Sources' 10 Proper,Adequate Handwashing Game and W id Mushrooms Approved by Rula A 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present' 2-301.12 Cleaning Procedure' 590. C Wild Mushrooms* 2-301.14 When to Wash' 3-201.17 Game Animals* 11 Good Hygienic Practices 5 RecelvinglCondMfon 2-401.11 Eating, or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated• 3-301.12 Preventing Contamination When T • 6 TagslRecords:Shellstock 12 :: Prevention of Contamnation from Hands 3-202.18 Shellstock Identification' 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained' Em to ees' TagslRecords:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3402.12 Records,Creation and Retention* 5-203.11 Numbers andCapacities* 590. J Labeling of I grediente 5-204.11 Location and Placement* 7 Contormance with Approved Procedures 5-205.11 Accessibility, lion and Maintenance IHACCP Plans Suppied with Soap and Hand Drying 3-502.11 Specialized Processing Methods' Devices 3-502.12 Reduced oxygen ,criteria* 6-301.11 Handwas " Cleanser,Availability 8-103.12 Conformance with Approved Procedures• 6 301.12 Hand Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. • 3-501.14(C) PHFs Received at Temperatures Violations Related to FoodHOme Illness Interventions and Risk According to Law Cooled to Factors(Red Items 1-22) (Cont) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 4l°/45°F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at of above 15 Poisonous or Toxic Substances 7-101.11 Identifying Information-Original 140°F. Containers* 3-501.16(A) Roasts Held at or above 130°F. 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.1 1 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 990.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents,Criteria* Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) I Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.*E1ed6°"2101 Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 3-401.11(A)(2) Comminuted Fish,Meats&Game Animals-155°F 15 sec.* SPECIAL REQUIREMENTS 3-401.1 l(B)(1)(2) Pork and Beef Roast-130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Ratites-165°F 15 sec.* interventions and risk factors. Other 3-401.I 1(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F 3-401.1 l(A)(1)(b) All Other PHFs-145°F 15 sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 sec.* Critical and non-critical violations,which do not relate to the 3403.11(B) Microwave-165°F 2 Minute Standing foodbore illness interventions and riskjactors listed above,can be found in the following sections of the Food Code and 105 CMR Time* 590.000. 3403.11(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000 140°F* 23. Management and Personnel FC-2 .003 3-403.11(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004 Roasts* 25. Equipment and Utensils FC-4 .005 18 Proper Cooling of PHFs 26. Water,Plumbing and Waste FC-5 .006 3-501.14(A) Cooling Cooked PHFs from 140°F to 27. Physical Facility FC-6 .007 28. Poisonous or Toxic Materials FC-7 .008 70°F Within 2 Hours and From 70°F 29. Special Requirements .009 to 41*F/450F Within 4 Hours.* 30. Other 3-501.14(B) Cooling PHFs Made From Ambient s:ssao.aaun.m. Temperature Ingredients to 41°F/45°F Within 4 Hours* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. taE TOWN OF BARNSTABLE HEALTH INSPECTOR'S OF � OFFICE HOURS: Sl , PUBLIC HEALTH DIVISION 8:00-9:30 A.M. 367 MAIN STREET t ON- P.M. ON.-FRI. R&PJsa�'s M HYANNIS,MA 02601 862-4644 6fNAy&� FOOD ESTABLISHMENT INSPECTION REPORT Name �a.,� Date A_ _Q/ Type of Operations) T e of Ine6ection ❑ Foo Service tine Address Risk etail ❑ Re ❑ inspection Telephone Level 'Q - / Residential Kitchen Date: Inspection El Mobile Owner Hn - HACCP Y/N ❑ Temporary ❑ Pre-operation ❑Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ General Complaint ❑ Bed&Breakfast Info.(s-fj�y ❑ HACCP Inspector M(,, Out Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s)and a cilation of specific provision(s)viobted. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F)❑ Action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT -Er 12. Prevention of Contamination from Hands 0 ❑ 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 113.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4.Food and Water from Approved Source ❑ 5.Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7.Conformance with Approved ProcedureSMACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑ 20. Time As a Public Health Control ❑ 9.Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 10.Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP ❑ 11.Good Hygienic Practices CONSUMER ADVISORY Violations Related to Good Retail Practices(Blue Items) ❑ 22• Posting of Consumer Advisories Critical(C)violations marked must be corrected immediately. Number of Violated Provisions Related Non-critical(N)violations must be corrected immediately or To Foodborne Illnesses Interventions within 90 days as determined by the Board of Health. and Risk Factors(Red Items 1-22): C `' Official Order for Correction: Based on an inspection today, 23. Management and Personnel (FC-2)(590.003) the items checked indicate violations of 105 CMR 590.000/federal 24. Food and Food Protection (FC-3)(590.004) Food Code.This report,when signed below by a Board of Health 25. Equipment and Utensils (FC-4)(590.005) member or its agent constitutes an order of the Board of Health. 26. Water,Plumbing and Waste (FC-5)(590.006) Failure to correct violations cited in this report may result in sus- pension or revocation of the food establishment permit and ces- 27. Physical Facility (FC-6)(590.007) sation of food establishment operations. If aggrieved by this or- 28. Poisonous or Toxic Materials (FC-7)(590.008) der,you have a right to a hearing. Your request must be in writ- 29. Special Requirements (590.009) ing and submitted to the Board of Health at the above address fr i f i order. within 10 days o receipt o this o d 30. Other Y P DATE OF RE-INSPECTION: Permit Posted? y Y N Grease Trap Previous Pumping Date Grease Rendered? Y N If Seats Observed Frozen Dessert Machines: Outside Dining Y N Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N OK For*Permit? Tobacco Sales Permit Inspection Report Form TOWN OF BARNSTABLE BOARD OF HEALTH Business Name Date / Business Telephone Location � Time: In Out ✓14 I U Person in Charge Purpose Recommendations Signs Posted [MGL 270/61 Permit Posted [VIIa] D.O.R. License � 06,?- L/ Employee Signed Forms Kept On File [VIIb]. L7� Self-service Displays On Counter and Within / 5 Ft. of a Clerk [VIId] No Floor Displays [VIId] / No Tobacco Products c/Free of Charge [VIIc] Inspector: Person Interviewed: q:health:tobinsp Wadlington, Ellen From: McKenzie, Marybeth Sent: Tuesday, September 02, 2014 4:07 PM To: Wadlington, Ellen Subject: Cumberland Farms 375 Barnstable Rd. FYI Ellen- Please issue a temp 2Jpermit in December to Cumberl'and-'Farm375? Barnstable Rd. until Feb. 3, 2015 due`to the walk in floor needing to be refinirished. 1 ' e Cumberland F A R M S W V fi 1 L .1 A TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 MAIN STREET HYANNIS,MA 02601 October 24, 2016 Dear Valued Supplier: We are moving! Please note that, effective as of December 1, 2016,the corporate headquarters of Cumberland Farms, Inc. will be: 165 Flanders Road Westborough,MA 01581 Our fax and telephone numbers will remain unchanged. Kindly update your records accordingly. Cumberland Farms, Inc. 100 Crossing Boulevard, Framingham, MA 01702 508-270-1400 www.cumberlandfarms.com • li I Number Fee 1129 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that CUMBERLAND FARMS #2073 375 BARNSTABLE ROAD, HYANNIS, MA Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. --------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- ----------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 6/30/2015 unless sooner suspended or revoked. --------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF,D.M.D. 6/30/2014 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health j y Town of Barnstable oF1HE r Regulatory Services P� O Richard V. Scali, Director 9BARNMA .. Public Health Division 1639. ,0 fo►�'�°` Thomas McKean, Director 200 Main Street, Hyannis,MA'02601 Office: 508-862-4644 Fax: 508=790-6304 Application Fee: $100'00 ASSESSORS MAP AND PARCEL.NO. 310 - 119 DATE 06/17/2014 APPLICATION FOR ]PERMIT TO STORE AND/OR UTILIZE MORE THAN 1II GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANT . Cumberland Farms Inc. NAME OF ESTABLISHMENT Cumberland Farms #2073 ADDRESS OF ESTABLISHMENT 375 Barnstable Rd & Lewis St, Hyannis, MA TELEPHONE NUMBER 508-790-7118 SOLE OWNER: X YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME.ADDRESS OF ALL PARTNERS: N/A IF APPLICANT"IS A CORPORATION: FEDERAL IDENTIFICATION NO. 04-2843586 STATE OF INCORPORATION DE FULL NAME AND DOME ADDRESS OE Please see.Attached PRESIDENT TREASURER CLERK - (Authorized Rep) TURE OF APPLICANT RESTRICTIONS: HOME ADDRESS ECS Eclipse, 588 Silver St., Agawam, MA HOME TELEPHONE#, N/A 01001 Q:AppGcanon FormslHAZAPP,D0.0 I r 0 C erI nd G tee¢ F A R AAS Date of Incorporation: September 14, 1984 State of Incorporation: Delaware Principal Address: 100 Crossing Boulevard, Framingham, MA 01702 Office Telephone: 508-270-1400 PRINCIPAL OFFICERS: Ari N. Haseotes President& Group Chief Operating Officer Howard S. Rosenstein Treasurer Mark G. Howard, Esq. Secretary John T. Daly Assistant Treasurer Diane M. Boissonneault Assistant Secretary Cumberland Gulf Group of Companies 100 Crossing Boulevard,Framingham,Mid 01702 508-270-1400 Town of Barnstable �QF'THE r, � Regulatory Ser4ces Kee � Richard V.'Seah, Director ,BARNETABLE 4 Public Health Division iOTen Thomas McKean, Director 200 Main Street,Hyannis,.MA 02601 Office: 508-862-464-4 Wayne Miller,M.D. Fax: 508-790-6304 Paul J. Canniff,D.M.D. Junichi Sawayanagi NOTICE TO ALL BUSINESS OPERATORS WITH HAZARDOUS MATERIALS IN BARNSTABLE The Town of Barnstable Town Council adopted, Chapter 108: Hazardous Materials, a requirement for each business operator to obtain an annual permit and to remit a fee of$100.00 if one-hundred and eleven (111) gallons or more of hazardous materials are stored, transported, utilized, and/or disposed of at a particular site. STEPS 1 —2 - 3: 1. Please complete the attached application form 2. Include a copy of your contingency plan (to handle hazardous waste spills, etc.) 3. Submit the fee of$100.00 payable to the: Town of Barnstable. MAIL all of the above to this office on or before June 30, 2014. A_late charge of$10.00 will be assessed if payment is not received by July 30, 2014, Please feel free to view the above Code, Chapter 108: Hazardous Materials on the Town Website, www.town.bamstable.ma.us , which is located under the E-Code. section if you should have any questions or concerns. QAHazmat\Haz Mat Permit Letter.DOC i I MAIL-IN REQUESTS Please mail the completed application form to the address below. Also include a copy of your contingency plan (to handle hazardous waste spills, etc). In addition, please include the required fee of$100. Make check payable to: Town of Barnstable. Allow five to seven (7) working days for in- house processing. Our mailing address is: Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601. FOR FAXED REQUESTS Our fax number is (508) 790-6304. Please fax a completed application form. Also, please fax us a copy of your contingency plan (to handle hazardous waste spills, etc). In addition, please mail the required fee amount of$100.00. Please make the check payable to: Town of Barnstable. The check must be mailed to the address listed above. Allow up to four days for in-house processing. For further assistance on any item above, call (508) 862-4644 Back to Main Public Health Division Page Q\Application Forms\ AZAPP.DOC Emergency Response Plan Table of Contents Section Pages) 1.0 Purpose 1 2.0 Responsibilities 2 3.0 Emergency Action Procedures 39495 4.0 Emergency Response Plan 697 5.0 Training 7 6.0 Potential Hazards Of Substances In An 8 Emergency Emergency Pump Valves Appendix A 1.0 Purpose: The Retail Emergency Response Plan provides information necessary to respond correctly in case of an emergency, such as a fire or fuel spill. OSHA (Occupational Safety and Health Administration) standard 1910.120 requires that every working establishment maintain a copy of the Emergency Response Plan on the premises at all times. 2.0 Responsibilities: The Store Manager is the Emergency Coordinator for the store. In the absence of the Store Manager, the head employee on duty will be the Emergency Coordinator. Emergency Coordinators are responsible for first response to emergencies, steps following under section 3.0 of these procedures. Store management is also responsible for training employees as defined in section 5.0 of these procedures. 3.0 Emergency Action Procedures: Guidelines for emergency response are outlined on the "Yellow Emergency Response Card", which is to be posted near the telephone. This provides the details of this plan. 3.1 Incase of an emergency involving a fuel spill, fire, propane or natural gas leak: 3.1.1 Follow immediate response procedures in the event of a: Gasoline Leak at Pumps 3.91 Fire at Gas Pumps 3.92 Fire at Other Location 3.93 CO2 Alarm sounds 3.94 5/13 1 of 8 r Emergency Response Plan 3.2 Evacuate the property for a fire or serious fuel spill (25 gallons or more), propane or natural gas leak. 3.2.1 Customers are to be evacuated from the property. 3.2.2 Send fellow employees to the Safe Meeting area. 3.2.3 For smaller spills, the area of the spill is to be restricted from.customers. 3.3 Call for Help 3.3.1 Use the numbers listed on the "Yellow Emergency Response Card" 3.3.2 Call the Fire Department for all fires, regardless of the size, for all p gasoline spills, and g propane or natural gas leaks. 3.3.3 Call for an ambulance when outside medical help is needed. 3.3.4 Use the Calling Procedures on the "Yellow Emergency Response Card"to ensure that the correct information is provided. 3.4 Secure the facility 3.4.1 If safe to do so, lock the store during the evacuation. 3.4.2 If local authorities need entrance, provide assistance or guidance to unlock the facility. 3.5 Restrict pedestrian and vehicular traffic 3.5.1 Restrict all pedestrian and vehicular traffic from the entire area in the event of spills or fires. 3.5.2 For smaller spills,traffic must be restricted from the area of the spill. 3.5.3 For smaller fires that can be handled by a fire extinguisher, customers must be restricted from the store, or if outside, from the area of the fire. 3.5.4 Use yellow caution tape, or use any type of barricade to prevent pedestrian and vehicular traffic from entering the property. 3.6 Do not to attempt to clean up any major blood spill or gasoline spill too large for you to handle! 3.6.1 Do not risk your health to contain, control or clean up a spill. Your safety is of the utmost concern. 3.6.2 Trained professionals will take care of this. They have the proper equipment to handle these situations. 3.7 Go to the Safe Meeting Area Identified for your Store on the "Yellow Emergency Response Card" 3.7.1 If the situation is beyond your control, go to the pre-determined safe location for your store. 5/13 Z of 8 Emergency Response Plan 3.7.2 When local authorities arrive identify yourself to let them know that the store employees are safe. You can also assist them with information about the situation. 3.7.3 All store employees are required to go to this safe location in an evacuation situation. 3.8 Call Cumberland Farms Management 3.8.1 When you are out of danger, you must call the Store Manager(if not present) or the Area Sales Manager. 3.8.2 You must also call the Risk Management Department#provided on the "Yellow Emergency Response Card". 3.9 Immediate Emergency Action Procedures g Y 3.9.1 Leak at the Gas Island Problem Emereency Action 1. Leak from the A) Depress the hose number and then the PUMP STOP button. hose/nozzle NOTE: This will only stop the one problem hose/nozzle. B) If the flow of gasoline doesn't stop depress the RED EMERGENCY STOP button. 2. Leak at pump A) Depress the RED EMERGENCY STOP button. NOTE: This will stop ALL pumps. B) If the problem continues, shut off the breaker for the problem produ in the Electrical Breaker Box(s) marked "Emergency Gas Breakers Inside ". This will shut off the submersible turbine pump (STP) for tha product. C) If the problem continues shut off ALL of the breakers in the box(s). Call Facility Support Services. 3. Leak within the 1. Remove the front lower panel on the dispenser. pump. NOTE: In 2. Trip the Crash/shear valve (refer to Appendix A). this situation, the 3. Depress any of the hose number buttons to turn the console back leak is between the on. crash/shear valve 4. Re-check for leak; if OK, replace panel. and the totalizer. 5. Call Facility Support Services. 5/13 3 of 8 r Emergency Response Plan 3.9.2 Fire at the Gas Island Problem Emergega Action 1. Fire at Pump A) Pull FIRE PULL once, and push EMERGENCY BUTTON. (s) NOTE: This will empty the fire suppression bottles completely. This will also stop all of the gas pumps. B) After fire suppression system has stopped completely, shut off all power (ALL breakers within the breaker box marked"Emergency Gas Breakers Inside ". C) Call the Fire Department. D) Call your Supervisor and Facility Support Services. 3.9.2 Fire at Other Locations Problem Emergency Action 1. Fire located other than Call the fire department. If the fire is small and controllable, Gas Island. use a fire extinguisher. 3.9.3 CO2 Alarm Problem Emergency Action 1. CO2 Alarm 1 Indicator Alarm 1 (low level) light is on and alarm sounds Do Not enter flashes and buzzer the syrup pumping area and any employees in this area are to sounds immediately leave area. Proceed to the bulk CO2 tank and turn supply valve identified with brass tag counter clockwise to the off position. Immediately contact facility support services. Do Not enter syrup pumping area until alarm stops. 2. CO2 Red Alarm 2 Alarm 1 and 2 lights are on and the alarm is sounding faster Indicator flashes and (high level) employees are to Evacuate as a high level of alarm buzzer sounds could indicate a catastrophic leak that can generate extremely hazardous CO2 levels. Secure the store. Go to the Safe Meeting Location. Do Not enter the Syrup Pumping area. Immediately contact Fire Department, and then contact Store Maintenance. 5/13 4 of 8 Emergency Response Plan 4.0 Emergency Response Plan: The following are the company guidelines,which parallel OSHA requirements. They are placed in the same sequence and headed in the same wording as they appear in OSHA Standard 1910.120. 4.1 Pre-Emergency Planning: States, along with designated districts within the states, have developed their own plans. The Store Manager should contact the local fire department for review of your plan to ensure that it is compatible with theirs. The fire department will also advise and record the safe location for your store in the event that store personnel must be evacuated. By doing this,they will know where to go to account for missing store personnel. They can also advise you concerning emergency medical supplies and methods. 4.2 Personnel Roles,Lines of Authority and Communication: The Store Manager is the Emergency Coordinator for the store. In the absence of the Store Manager, the lead employee on duty will be the Emergency Coordinator. Emergency Coordinators are responsible for the implementation of the Emergency Response Plan, and must perform all duties described within it. Emergency Coordinators are responsible for contacting the local Fire Department,the Store Manager if necessary, the Area Sales Manager, the originating Gulf fuel terminal (in the event of a spill by a tanker),the Environmental and Risk Management Departments per directions on"Yellow Emergency Response Card". 4.3 Emergency Recognition and Prevention: The Store Manager(or designee) must inspect(daily or weekly)the gasoline hoses for defects such as cracks or slices to prevent rupture. If a defect is found contact Facility Support Services. If needed,the gasoline pump will be placed out of service until the.problem is repaired. When a gasoline delivery is being made,the delivery driver is responsible for the hazards that are inherent with that type of operation. If an emergency does occur, the Emergency Coordinator will follow the responsibilities as outlined in the Emergency Response Plan. [Gasoline.is identified as clear to orange tinted in color, and having a strong hydrocarbon odor]. 4.4 Safe Distances and Places of Refuge: If a fire or spill is of a serious nature and endangers human life, you are to evacuate the location, directing all occupants to your designated "safe location". The local Fire Department can assist you in determining the most appropriate safe location for your store. In general, it will be a location away from the building, possibly where a telephone is available. It should be in sight of the premises, so that you can readily identify yourself to authorities responding to the scene. The location for this store is 5/13 5 of 8 I Emergency Response Plan 4.5 Site Security and Control: In the event of a serious fire or spill,pedestrian and vehicular traffic must be restricted from the entire area. For smaller spills that pose no danger, traffic should be restricted from the area of the spill until clean up has occurred. For smaller fires that can be handled by a hand-held fire extinguisher, customers must be restricted from the store or area of the fire. Yellow tape, ropes, barrels, etc. are to be used to restrict traffic. 4.6 Evacuation Routes and Procedures: The local Fire Department can assist you in determining the preferred evacuation route to your safe location in the event of a fire or spill. In general, our stores offer immediate access to the outside of our buildings through the emergency exit doors. The most direct route to your safe place should then be followed. Each store manager is responsible for establishing a Safe Meeting Place,training all employees on its location and notifying local authorities of its location. 4.7 Decontamination: This is the process of removing or neutralizing contaminants that have accumulated on personnel and equipment. It is critical to the health and safety of those involved in one of these incidences. Decontamination will be implemented by trained personnel (the company that cleans up and disposes of spills). 4.8 Emergency Medical Treatment and First Aid: If a serious injury is involved, appropriate medical personnel should be summoned immediately. This can be done via your telephone call to the local Fire Department. Otherwise, in the event of a minor injury,the store first aid kit is available Call your area Sales Manager and then Risk Management for major blood spills. 4.9 Emergency alerting and response procedures: Follow the Emergency Action Procedures as outlined in this Plan. 4.9.1 Critique and follow up: When the emergency is over,all information regarding the occurrence should be retained. This will be used to determine if the emergency was avoidable,and if so,how. A determination will also be made regarding whether appropriate steps were taken to minimize the loss.If necessary,the program will be reviewed for any changes required. 4.10 Personal protective equipment and emergency equipment: When applicable you will be handling, containing, controlling and cleaning up small gasoline spills. While conducting these actions please make sure to wear latex or rubber gloves to limit 5/13 6 of 8 Emergency Response Plan your exposure and follow proper disposal requirements (Yellow Spill Bucket). In the event of a fire, an extinguisher should only be used on small, controllable fires. Otherwise,the Fire Department will handle a fire. 5.0 Training: Store management is responsible for training store employee on this plan upon initial assignment and annually thereafter. Retail employees of Cumberland Farms, Inc. must be trained at the first responder awareness level and as a Class C UST Operator. First responders at the awareness level are individuals who are likely to witness or discover a hazardous substance release, and must be trained to: 5.1 Understand what hazardous substances are and the risks associated with them. 5.2 Understand the potential outcomes associated with an emergency created when hazardous substances are present. 5.3 Recognize the presence of hazardous substances in an emergency. 5.4 Identify the hazardous substances, if possible. 5.5 Understand the role of the first responder awareness individual. 5.6 Recognize the need for additional resources, and to make appropriate notifications as outlined in this Plan. 6.0 Potential Hazards of Substances in an Emergency: 6.1 Fires or Explosion 6.1.1 Gasoline is a Flammable liquid. Propane and natural gas are flammable gases. Heat sparks or flames may ignite these 6.1.2 Vapors from these substances may travel to a source of ignition and flash back. 6.1.3 Containers may explode in the heat of a fire. 6.1.4 Runoff to sewer may create fire or explosion hazard. 6.2 Health Hazards 6.2.1 May be poisonous if inhaled or absorbed through skin. 5/13 7 of 8 M • Emergency Response Plan 6.2.2 Vapors may cause dizziness or suffocation. 6.2.3 Contact may irritate or burn skin and eyes. 6.2.4 Fire may produce irritating or poisonous gases. 6.2.5 Runoff from fire control or dilution water may cause pollution. 6.3 Emergency Action (D.O.T. Department of Transportation Guidelines) Spills 6.3.1 Keep unnecessary people away; isolate hazard area and deny entry. 6.3.2 Stay upwind; keep out of low areas. 6.3.3 (Emergency authorities only) Self-contained breathing apparatus (SCBA) and structural firefighter's protective clothing will provide limited protection. 6.3.4. Isolate area for 1/2 mile in all directions if tank car or truck is involved in fire. 6.3.5 (Environmental personnel only) Call Chemtrec at 1-800-424-9300 for emergency assistance. If water pollution occurs, notify the proper authorities. 6.4 Fire Fighting Guidelines (for fire departments) 6.4.1 Small fires: dry chemical, CO2, Halon, water spray or standard foam. 6.4.2 Large fires: water spray, fog or standard foam is recommended. 6.4.3 Move containers from fire area if you can do so without risk. For cooling containers that are exposed to flames with water from the side until well after ire is out. 6.4.4 STAY AWAY FROM ENDS OF TANKS, AS THEY CAN BLOW OUTWARDS. For massive fire in a cargo area, use unmanned hose holder or monitor nozzles; if this is impossible, withdraw from area and let fire burn. Withdraw immediately in case of rising sound from venting safety device or any discoloration of tank. 5/13 8 of 8 198Z0 IN lash AN Iau•xo)@w}alhso) OAV ulo)url 911 F LLV9-VZL-IOVxoj ZL9S-S W[OV �oa�aQal� `3�uua@� •Iu, aau>3ua�ulgl&� d�l�iau�G o `Freezer Kote FK-1310, High Gloss Page '1. of 2 I - Home I MSDS(rDS Search I Contact Us I Dealer Locator ENGLIS Enter Keyword Search PRIMERS SPECIALTY COATINGS FLOOR & MASONRY COATINGS POOL PAINTS HOME)) FREEZER KOTE» Recommend $+1 wswc Freezer Kote ' FK-1310 i Freezer Kote is a high-gloss,rust inhibiting coating designed for application in sub-freezing temperatures. Freezer Kote is an alcohol-based formula that dries quickly and delivers a high-gloss finish.Available in white and safety yellow. • Designed for application in extremely low temperatures(-40°F) • Eliminates cold storage shut down while painting • Alcohol-based formula dries quickly • Suitable for USDA-inspected facilities • High-gloss finish O Available Sheens: High glossGO Available Colors: White and safety yellow _ Cleanup: Ethanol or denatured alcohol Resin Type: Synthetic and natural resins Recommended Use: Interior r: MPI Rating: N/ACD t9• t� VOC Level: <340 g/L Check with your local INSL-X DEALER for product availability. DOWNLOADS TDS FK-13XX(English) MSDS FK-13XX(English) MSDS FK-13XX(Espatlol) `. http://www.insl-x.com/product-detail/insix-products/freezer-kote 10/29/2014 eFreezer Kote FK-1310, High Gloss Page 2 of 2 6 Insl-x Home Primers MSDSITDS Search Specialty Coatings Contact Us Floor& Masonry Coatings Dealer Locator Pool Paints Coronado Interior&Exterior Architectural Paints Maxum Value-Engineered Exterior Stains Corotech High Performance Coatings Lenmar Wood Finishing Systems and Floor Coatings Insl-x®Manufactured by Benjamin Moore&Co.Montvale, NJ©2014. http://www.insl-x.com/product-detail/inslx-products/freezer-kote 10/29/2014 Cumberland F A R M S October 8, 2019 To whom it may concern, We are respectfully notifying your jurisdiction of a change that will occur regarding the ownership of Cumberland Farms, Inc. ("CFI") that may impact CFI's current licenses in this jurisdiction. These changes are outlined below and will become effective October 22, 2019. Current State EG America, LLC ("EG America") is a convenience store retailer based in Cincinnati, Ohio. The company was formed under the laws of the State of Delaware as a limited liability company. CFI is a convenience store retailer based in Westborough,MA and a privately-held Delaware corporation.CFI's Federal Employment Identification Number ("FEIN")is 04-2843586. Post-Closing State—Effective October 22,2019 After the transaction EG America will own 100% of CFI's stock. The transaction will close on October 22,2019.As part of the agreement, CFI will retain its name,maintain the same FEIN, and continue to operate under the existing CFI banner. It is our intention that this letter serves as the proper notification for the transaction outlined above and may result in changes to the information on CFI's existing licenses. While CFI's ultimate ownership will change as a result of the transaction, the company will retain its name and FEIN as identified on the current business licenses and related periodic filings. Additionally, all current business operations at the local store level will. continue unchanged. Finally, all officers of the company, except for the President, will remain consistent. An updated officer listing and diagram of transaction are attached for your records. As a result of the transaction outlined above,we respectfully request that you update CFI's current, active licenses and accounts, effective October 22,2019. We are working with our tax advisors at Ernst & Young, LLP ("EY") for this transaction. An EY representative will be reaching out to your jurisdiction directly, if they have not made contact already. We sincerely appreciate.your consideration in this matter and look forward to your reply. Yours sincerely, f' i � Howard S. Rosenstein, SVP, Chief Financial Officer and Treasurer Attachment: Officer Listing Cumberland Farms, Inc. 165 Flanders Road, Westborough, MA 01581 508-270-1400 www.cumberlandfarms.com Cumberland Farms,Inc. Officer Listing as of October 22,2019 Officer Name s' Title Mohsin Issa President Howard S. Rosenstein SVP,Chief Financial Officer and Treasurer Brian E. Glennon,II Secretary John T.Daly Assistant Treasurer Lyn M.Lustig Assistant Secretary Laura S. Sherman Assistant Secretary Transaction Structure lx �, r CFI will remain the license holder CFI will maintain ownership of all local stores � a� CFI operations are not changing 3/9/2021 Counter Tools-Education visits Visit ID: 906967 Detail Page EDIT (education/edit/906967) Retailer Info Retailer ID:380538(/retailer/380538) Cumberland Farms 375 Barnstable Rd Barnstable, MA 02601 Submission Info Survey Submitted Date: Mar 8, 2021 Survey Submitted Time: 10:22 AM EST(UTC-0500) Visit Completed By: 821 (/user/821) Education Info Can you visit the store? Yes Does the actual store name match the assigned store name? Yes Enter actual store name,then continue: No Response Does the actual store address match the assigned store address? Yes Enter actual store street address (do not include city, state, or zip code), then continue: No Response Purpose of the visit: Routine inspection visit Please specify other visit purpose: No Response Was inspection completed? Yes If no please indicate why: No Response Is the local board of health license posted?Yes Is the state DOR tax license posted?Yes Is required state law signage (MGL ch 270, G and 6A) posted? No Is a `No smoking'sign posted? Yes Is a minimum legal sale age sign posted? Yes Is a cessation sign(s) posted? No Is a vaping health warning sign(s) posted? No Is a cigar health warning sign(s) posted? Yes Is a sale of flavored tobacco prohibited warning sign(s) posted? No Is a "Must be 21+to enter" exterior sign posted? No Response If smoking or tobacco use is allowed inside, Is there an exterior warning sign that smoking/vaping allowed inside? No Response If smoking or tobacco use is allowed inside, is there an interior warning sign that smoking/vaping allowed inside? No Response Itttps://mass.countertools.org/education/906967 1/2 3/9/2021 Counter Tools-Education Visits N floes the establishment have a doorbell, buzzer, or locking mechanism for preventing minors from Jr entering the store? No Response Is any tobacco In a self-service location? No Response Do all tobacco self-service locations meet legal standards? No Response Are any tobacco vending machines present? No Response Do tobacco vending machines meet all regulation standards? No Response Were any violations found?Yes If violations were found, check all that apply: Flavored products or flavor enhancers (including mint/menthol flavors)sold, Missing signage Specify other violation: What action was taken? Check all that apply Referral given to another agency(e.g. Department of Revenue, Attorney General's office, local Board of Health) Specify other fine: Employee/merchant name: No Response Employee/merchant title: Clerk Which of the following topics were discussed with the employee/merchant? Check all that apply Checked local BOH and DOR permits, Reviewed regulations/tobacco sales laws, Retailers' responsibilities, Required slgnage and placement Which of the following materials were given? Check all that apply State signage (MGL ch 270, G and 6A) Specify other materials: If state or local signage was provided to retailers, specify which signs: Flavored cessation ma law Enter field notes Black and Mild Casino for sale (flavored product) ©2016-2021 University of North Carolina and Counter Tools.All rights reserved.Terms of Use&Privacy Policy_(/terms-and- privacy) i littps://mass.countertools.org/educallon/906967 2/2 i - v��rr l -- 2° �� ' 3' --�� ! err+��rY �,►vK '� - •'"•(of'C) "'l `� J C�L�'�', j � ; � � ✓�.�r , C. �i..., �G�t 7�'1-1�'] ;l`7 IST ��.'�r� {� '�'� AOR F<JTURC 05L t VIE- �� __l_. _ � >� •---------- --�_�____,__.. 3 ' ��� sr+ 1��TE� ram, ��c.�I.�r=a..��S !J��:- 3 L�IC� GU t`" k- I K)St' ' � i3�-r—�,��+�tit z' K 3' �✓�)c>,"� ��"t��S 5,��,c�.,� �-` ,z '��" ( — -- _ Y ►��--��� \✓&u— ry- � �,, t vn is � �� : —4 ' i , , � , � � ✓' r ; ems v , s t , j t .__ 3 �j F-�tL✓t�V C� I r76 -�I S }7G..I�.�% A��- i►/'� I _t 0. r, 40 0 SCALK DRAWN 9Y REVISEU DATE APPROVED BY DRAWING NUMBER l p M�(!R 1N U S A- p` ALBANl.NE'd tOS464 w `_- _ • . - t y t .: •h 1H r s ' f � 1 F 9� 19, _ aw`i FRA/AG7 GRAB 1 O i PRECAST coNC � � LEl�CL1►►.�G P►T r p� -Z7 P i 0 C `j o 0 . 4 ' �r(d►.t-t'O�E Ca��� ✓�2 x 1 n�C FTC,, LE LCIA to G 5 LOTS Atq c PIT uo SCdLLo U Lol I ZZ ! _- t1Kzl ViA , 1 r \j J I �J" L _ QEove I ' RE Cam. L 2"T 22' Gas 15 � v - � - -- -- - �'�" � !C>>• Ali kul Lr $F ✓, ��p � a ds�>•4-ELT 13 ►2�� 39JQ. E xis GL,tb _ . ._,. _ 2� ,. ✓LET�.�2 art t �p .Yy APPROVED DRAWN Sr SCALE: �� �7 �/ DATA: - /(� REVtS[D G b Iasi -7 77 � l rl[IN V4 N/i .Z(pro?� I1�1 SUL ��. i 1t�� ►�C)t�� 3 �i 2 . „_.�+._ 1�> '56_ 4:'2, iClO'C�J H-(� ! �..(.��✓ C�l„Zi� 12ona, 1 ��-- _'= �' — — .�/'✓�� �r' �'� '` 1-G�G.y '--+�- Il��,, � �r-lr (��iJ� '�r��- rri. �� . (c--; 17 1 1 3/4- — �� --� -� 1,G,/� �-• .��, c>��T J_� �,C7� I-� �` �I"' , �i y.. rLlf�2 el 05 � V � 1 } 0 ITOc f, t>r I ! 1 I i I s 3, tE _ SCALE DRAWN BY ra- - -' _ .,.__.._._.,._» __^....-.._.__. ..........,._. -.... �..._ - ----_ .-.-._..........._-..:.�.,- -. ._...__�-.._ ..-•---- -__^_'_'-_. � !_"' �„�3��'r2 i���..�� .:: � '(1 REVISED - 1 777 Y ATE ROV o• DRAWING NUMBER O A E ,,�.c pit.r•_ s!�"F � y+tl�ce.Yf� .. .'•..s .r x f .... ... � ! - -.B ...'S},... ,...,T..,..- ._ >„ �`-: .:-.1 g t. 3 r�Pilo zl�ill a PARKING CALCULATIONS LEGAL DESCIRIPTION T A N K D E T A I L S PLANT ING SCHEDULE . RETAIL SALF5 -PROPOSED 34' X 37' CONCRETE PAD one (1) per 200 sq. ft. of gross SYMBOL NAME (SPECIES) No. SIZE With quitclaim covenants the land In Hyannis. Barnstable, Barnstable County. Massa chuset PROPOSED 3" EXTRACTOR TUBE W/ 233-MSD-2422 VALVE floor area I separate enterprise together with the buildings thereon situated on the Corner ASS.. OPW 233-VM W/ 53-M FLOAT OVERFILL PREVENTION of Barnstable Road and Lewis Street In said village consisting of two NA-- Youngstown Juniper VALVE AND STAGE 11 VAPOR RECOVERY (2) (2) lots, bounded and described as follows: 11 SPACFS FEQUIRED (Junipers horiz. plumosa) 9 1X,-' 2' mature height PROPOSED 4" FILL RISER W/ OPW 61-T-4* 4�% DROP TUBE W/ VAPOR SEAL, 633-T TIGHT FILL CAP (2) Pfitzer's Juniper 11 18" 24" high --PROPOSED SPILL CONTAIWENT MANHOLE, MF G. TOTAL SPACES REQUIRED 11 SPACES (Juniperus chinensis pfitzeriana) PARCEL 1. On the North by said Lewis Street BW INC., MODEL 705-BG (25 GALLON) OR EOUIV. (2) -nine and 80/100 (59.80)feet SED RED JACKET ST-1801 TANK LEVEL A .8 PARKING SPACES PROVIDED 7 SPACES On the East by said Barnstable Road, fifty NOTE, On the South by Lot No. 10 on said plan, one tmdred forty and 32/100 (140.32)feet 1' ' 0 PROBE #RE400-333-5 (2) o Mix 2 shovelfuls of peat moss or other organic material In each tree pit i i PARKING SPACES PROVIDED 8 SPACES Being Lot No. 11 on a plan of building lots of Cape,, Cod Development Co., mix 1 shovelful of peat moss or other organic material In each shrub pit. PROPOSED RED JACKET ST-1801 INTERSTITAL TAW, AT GAS ISLANDS surveyed by H.L.Croker on March 21, 1922 and recorrded with Barnstable 1 0 4 1 0 1 1 G-4- Throughly mix In peat moss Into roots (If wintercreeper ground cover. 1 �_L 'l MONITOR. PROBE #RE400-333--5 (2) County Registry of Deeds, Plan Book 11, Page, 103. --------- It PR TAL SPACES PROVIDED 15 SPACES OPOSED SUBMERSIBLE PUMP w/ LEAK DETECTOR TO If sub-soll Is very sandy. add "SOIL KIST" po water retention gel I PARCEL 2 1Y crystals per manufacturers recommendaticis. REDJACKET 2 HORSEPOWER (2) Lot No. 10 shown on a plan of subdivision entitled "Plan of Land in Hyannis of the Cape Cod Development Company. dated March 21. 1922, by PROPOSED FIBERGLASS SM, MFG. BY FLUID CONTA14AENT Henry L. Crocker, Surveyor' referred to hereiribefore and said lot being MODEL TE42-3 (2) situated on the Westerly side of Barnstable-Hyannis, Road, said Lot PROPOSED 2* IN PROPOSED 4* DIA. SLOTTED OBSERVATION WELL (4) having a frontage on said road of sixty (601 feet iand a depth of 3" SYP" BAR approximately One Hundred Forty (1401 feet. PROPOSED 3 - 10,000 GALLON (96' DIA. x '30'-91 AND FIBERGLASS DOL93LE-WALL GASOLINE STORAGE TAW. For title see deed from Alma E. Alberghini to us dilated May 29, 1969, (TOP OF TAW IS 3'-0" BELOW GRADE AND LOT 58 recorded in Barnstable County Registry of Deeds in lBook 1438. Page 509. BOTTOM OF TAW IS 11'-0" GRADE) NOT TO SCALE 44.3 44.4 44. 442 0 v P H 0 T 0 M E TR IC L I G H T I N G P L A N ------ TANK INSTALLATION NOTES 0 44.5 44.3 NOTE: LEVEUS AFE S40M N FWTCANUS- N/F GRAVEL DRIVE 1. The underground gasoline storage tanks were installed in the K. PORKKA 44.1 month of 19 -walled fiberglass. 2. All underground tanks to be double FN 39* 53- 18' E 9.05 3. TAW# CONTENT CAPACITY LOT 50 44.0 A gasdine 8,000 gallons N N 04* 19' 00* E 50.11' \I,- 44,2 gasoline 8,000 gallons 448 1101 43.9 B existing chain link fence gasoline 8.000 gallons C 43.7 ------------ ------------------------- ------------ 4.'The Interstitial space of a clouble-walled tank shall be continuous L-01 itored (RED JACKET ST-1801 dry annulus space probe *RE400- 03-5) 0 0 0 mon and be equipped with an audio and visual alarm system .(RED JACKET ST-1801) sphalt berm 43.6 prop. a see "CURB DETAIL" prcposed 3 10,000 gallon (96" dia. x 30'-91 underground 171 0 171 5. All sup Tly lines are double-walled fiberglass, all vapor recovery and co fibm,-rglass double-wall gasoline storage tanks vent lines are single-walled fiberglass below grade and galvanized [3 0 OD (too of tanks are 3'-0* below grade and schedule 40 above grade. 661 /1,930 SQUARE FEET bo�torn of tanks are 11'-0" Wow grade) (see "TANK NOTESI 6. Piping shall be designed and installed to allow for testing without excessive excavation. V existing 3 - 10,000 gal. u/g ------------- ------------------ steel gasoline storage tanks 7. Provide a float vent valve at the vent line In an extractable tee (installed February 19, 1976) assembly (OPW parts 233-MSD with a 53VNt or equal) and an overfill 0'. 0 CY) to be removed container on the fill pipe (EBW model" 705-BG, 25 gallon) -------- proposed double-wall k LOT 9 detector shall be provided on the discharge of a remote fiberglass fuel lines 8. A line leak 5' conc. walk 1700 0 00 -1801 double-walled piping and manway sunp pump. (RED JACKET ST ----------- -1------- -proposed-stage ]I probe "RE 400-203-5.) vapor recovery Ilne 1 .2 3 4 A Tho'�� 4 A" ;1r�ftPd,r-1Vr ob­rv?4-1�-r. If LO Ln 414.7 ­9� ;ton Ci -------r 7---3) the tank installation.) ----------I island w/ 1 (2-hose) BLENDER N/F C-0 - 11.3"DI- V-0, CY) ;OA & 1 service maid (2) 10. OWNER/OPERATOR: (day or night) 01, K.' PORKKA 43 Lo 9 91 proposed 46' x 46' conc. pad Curnberland Farms, Inc. co (hps) 53.00' 777 Dedham Street (typ) Z: -proposed 28' x 46' canopy Canton, Massachusetts 02021 9 Wing concrete ga (617) 828-4900 x\- 43., 'X Islands to be removsed SCALE: N.T.S. EXISTING BUILDING 42.8 [03 co i exist. leaching pits (3) C.B. existing area lamp 7 existing 6' x 8' pole sign 12 15] 4 . . .... CURB DETAIL LOCUS MAP istiN asphalt paviT- ex 442 88' 46- 34"� -119.98' proposed 3' x 10' concrete gas Island with 1 43-7 UPA9 43.2 F.H. 4 3.0 17 43.7 (2-hose) BLENDER (2) 42.4 OT . 10 & 11 ate 43 4 - - A, .!r 43.2 - CB. Gr 4) 43.0 asphalt curbing existing asphalt berm (typ.Y---- 43.1 7 atim 43.6 42.7 H14AWIS U ale goo= 42.9 00 $4 IR at maM- u� %, 4,00' 24,00' INV. ELEV. 35.96 rd RIM ELEV. 44.66 CLrb opent 24-00' e r xisting conc. curb (typ.) wb 003`i�59) /, 7 81 A.C. sanitary sewet PiPe 12�1i� 10 I jNM WOO -A TAB L sphait pavement IW, ELEV. 3428 RIM ELEV. 42.28 WIDTH VARIES) B A (1905 LAYOUT F 0 UP. 0 U.P.-37 DRAINAGE CALCULATIONS T­7, THE DRAINAGE PATTERNS AND SYSTEMS ARE TO REMAIN S THEY CURRENTLY EXIST. THE SITE CURRENTLY CONTAINS FEB 1 4 A 1996 APPROX. 10,799.88 SO. FT. (80%) OF IMPERVIOUS LOT AREA. THE REAR OF, THE LOT DRAINS IN A NORTHEASTERLY DIRECTION r TO AN EXISTING LEACHING PIT ON THE NORTHWEST SIDE OF THE LOT. Tl­IE FRONT PORTION OF THE LOT DRAINS TO TWO EXISTING LEACHING PITS LOCATED IN THE NORTHEASTERLY 375 BARNSTABLE ROAD LEWIS STREET REVISIONS 13.397.20 SQUARE FEE AND SOUTHEASTERLY CORNERS OF THE LOT. UNDER THE NEW PROPOSAL, THE IWERVIOUS AREA WILL BE HYANNIS , MASSACHUSETTS 2-6-M UPDATE PER CHECKLIST DECREASED BY APPROX. 513.50 SO. FT. (4) AND THEREFORE 0.31 ACRES THERE WILL BE LESS OF A DRAINAGE IMPACT THAN OWNER/OPERATOR Busine5s Phone (800)255-9702 14 - 20.00' THAT WHICH CURRENTLY EXISTS TODAY. V# 742 February 2, M6 Store# 2295 Lzr2/linda/db.V742 44.5 0 EXISTING SPOT GRADES 777 Dedham Street Canton. Massachusetts 02021 L.A.K. DRA INACE FLOW Gas Station* 852073 S I T E P L A N 15964133 ----------........ ----------