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Home My WebLink About0055 IYANNOUGH ROAD - HAZMAT 1�Gt vs�014 Number Fee 1160 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that GOL SUPERMARKET .-------------------------------------------------------------------------------------------------------------------------------- SS Iyannough Road, HYANNIS, MA .----------------------------------------------------------------------------------------------------------------------------------------------------------------------- Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. Restrictions: .------------------------------------------------------------------------------------------------------------------------------------------------------------------. This license is granted in conformity with the Statutes and ordinances relating there to, and expires 06/30/2021 unless sooner suspended or revoked. ---------------------------------------- JOHN NORMAN DONALD A.GUADAGNOLI,M.D. 07/01/2020 PAUL J.CANNIFF,D.M.D. THOMAS A.MCKEAN,R.S.,CHO Director of Public Health tP Town of Barnstable oF� Inspectional Services BARNSTABLE Public Health Division " nsrae[•an�9-201eu •rrcnxis IM1'.25i0!IS%115. SEMIL"•tRR_B?tNil5&.E 1639-2014 • RAMSTABM Thomas McKean, Director s ; 200 Main Street, Hyannis,MA 02601 hyT Office: 508-862-4644 Fax: 5081790-6304 4-i 00 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st-JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26- 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111�499 Gallons: $125.00 Lsr1 V� ._Pak C�fIA� _ CATEGORY 3 PERMIT-500 or more Gallons: $150.00 ❑ 019 *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL?X_YES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: e, C13QWC A 1\ 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: tF�p ev v �� ") M Iki t2 7. MAILING ADDRESS(IF DIFFERENT FROM ABOVE: 8. TELEPHONE NUMBER OF ESTABLISHMENT: � � 9. ENTAIL ADDRESS: 10. SOLEOWNER: YESX NO IF NO,NAME'OF PARTNER: 1�) 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME U (--�0305 PRESIDENT y\q \-J !0 j V 4 I :V6aO On1UZen L\1tlb� TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT Q: M DATE �Application Forms\Haz Mat Appli Draft Jan2019.do I'na d on�l?� N 009)d � 0o *n I�►oyti Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 BARMAW; . . 200 Main Street• Hyannis, MA 02601 prEOM a`0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: (101 SU l( Date: Location/Mailing Address: 15' U ni 2 Contact Name/Phone: CrOh WVP Inventory Total Amount: `-t 100 [�DS: 4e--S ►"' '14 o I License#: �0 C0a Tier II : N Labelino: re q Spill Plan: t5)/*A, Oil/Water Separator: NO Floor Drains: (-dePa8 Emergency Numbers: Storage Areas/Tanks: callon b f J v Emer enc /Containment i ment: q IV, Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: IY I� Licensed Waste Hauler&Destination: Other Waste Disposal Methods: LIST OF TOXIC AND HAZARDOUS MATERIALS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze -___,,,,Dry cleaning fluids 76 Automatic transmission fluid ther cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil 4Refrigerants Degreasers for engines&garages V Pesticide§J'a6 Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda acquer thinners \/ Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons V Laundry soil &stain removers , (including carbon tetrachloride) (including bleach) O Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: X5 i aiv Inspector: ' f Facility Representative: WHITE COPY- HEALTH DEPARTMENT/CANARY COPY- BUSINESS Number Fee 1160 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that GOL SUPERMARKET SS IYANNO UGH ROAD, HYANNIS, MA Is Hereby Granted a License For: Storing or Handling 111 -499 gallons of Hazardous Materials. ----------------------------- --------------------------------------------------------------------------------------------- ----------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2020 unless sooner suspended or revoked. ---- --------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2019 JUNICHI SAWAYANAGI THOMAS A. MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable KE Inspectional Services BARNSTABLE �t ti WPSic�i4U�, LL TBw�Ya=�:E 1 o� Public Health Division � . 9 BARNSTABLE, Thomas McKean, Director MASi639 ♦0 ArEo�a 200 Main Street, Hyannis,MA 02601 !`o �c c Office: 508-862-4644 Fax: 508-790-6364 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS MY 1st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26- 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 -499 Gallons: $125.00 �9 V:SrH ck-=W CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? YES_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS, INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF • GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? AYES NO. 4. FULL NAME OF APPLICANT: \ 5. NAME OF ESTABLISHMENT: �►V�.. �� ,LU I 6. ADDRESS OF ESTABLISHMENT: 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: c P 8. TELEPHONE NUMBER OF ESTABLISHMENT: �Iz 1�`` �AQp& 9. EMAIL ADDRESS: �" 10. SOLEOWNER: YES�( NO IF NO,NAME OF PARTNER: 11. FULL NAME,HOME ADDRESS,AND TELEPHONE#OF: CORPORATION NAME \)v O�Tj "0 PRESIDENT - TREASURER CLERK 12. IF PREPARED BY OUTSIDE PART NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT A�A� DATE qss aj , Q:\Application Forms\Haz Mat App Revised 09-10-18.docx dF4b�f \ ~ Number Fee 1160 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that GOL SUPERMARKET SS IYANNO UGH ROAD, HYANNIS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. ------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------=------------------------ This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2019 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF, D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2018 JUNICHI SAWAYANAGI THOMAS A.MCKEAN, R.S.,CHO Director of Public Health r t' �toewguMoryVinvlcesf Bs able ��`�'� �' Richard V. Scali, Director ' of t"e 1-1 Public Health Division BARNSTABLE NFNSfAELF.fBREM1YILLF.CDtUR•NYM'NIS BABNSrABLF, = Thomas McKean, Director KQSMRS""LS1°,o;WESSARRR"ILE MAE& g prEo��> 200 Main-Street,-Hyarin> MA 02601- -- - - - - Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE , HAZARDOUS MATERIALS ' IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st-JUNE 3 Oth). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1. ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL? CY YES_NO. IF YES, SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: C-Z��j 5. NAME OF ESTABLISHMENT: (bq\ , 6. ADDRESS OF ESTABLISHMENT: 15f- 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: t� 8. TELEPHONE NUMB yER OF ESTABLISHMENT: �J�� c-&za 9. EMAIL ADDRESS: 10. SOLEOWNER: YES tS NO IF NO,NAME OF PARTNER:V\q�__k)�\A �� %,\(`O Fir 11. FULL NAME,HOME ADDRESS AND TELEPHONE#OF: CORPORATION NAME i PRESIDENT TREASURER CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE#: COMPANY ADDRESS EMAIL: SIGNATURE OF APPLICANT DATE T�Ojdaj)j Q Upplication Forms\I-IAZMAT APP 2017 REVISED.do oF�ME row Town of Barnstable Office:508-862-4644 ~� Public Health Division Fax:508-7s0-6304 ` BARNSTABLE. ` 9 MAC, 200 Main Street• Hyannis, MA 02601 059.MA°�0 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT rF0 y Business Name: &0 1 6,1 -e Date: 42-70 Location/Mailing Address: �71:4AIA&� &V, Contact Name/Phone: o Inventory Total Amount: ^' t SO a� SDS: JAW 1 l Ce01dU- �,a1' License#: k 160 641- Tier II : Labelina: mill Plan: Oil/WaterSeparator: Floor Drains: c01 Emergency Numbers: StorageAreaslTanks: S b-c- �6 a<,c vA&-X -a.ti 4�� Emergency/Containment Equipment: Waste Generator ID: Waste Product: Date&Amount of Last Shipm nt/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: \\ LIST OF TOXIC AND HAZARDOUS MATERIALS lA. �v ew��y NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of A, hazardous material se, tks eex--11 storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid —� Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) �— Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil � Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar . Swimming pool chlorine Paints, varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes —�— Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers / (including carbon tetrachloride) (including bleach) V Any other products with "poison labels" (including chloroform, formaldehyde, \ hydrochloric acid, other acids) VIOLATIONS: 4. Gy0.��wb ORDERS: evt.(vJ .►w% S �l o•�, vJ v� �� 'O C .Zq,v" C�Lv�,c•a 1 !& v a1, - �2 -t o �c,2 c�v2 ccCL2S 5 INFORMATION/RE MMENDATIONS: Inspector. O`C, Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Number Fee 1160 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that G OLSUPERMARKET SS IYANNOUGH ROAD, HYANNIS, MA Is Hereby Granted a License For: Storing or Handling 111 -499 gallons of Hazardous Materials. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in conformity with the Statutes and ordinances relating there to,and and expires 06/30/2017 unless sooner suspended or revoked. ---------------------------------------- PAUL J.CANNIFF,D.M.D,CHAIRMAN DONALD A.GUADAGNOLI,M.D. 07/01/2017 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health rw of Unstable egulatoervices Richard V. Scah, Director °`Tr°"`"°� Public Health Division BARNSTABLE i BnkUSlAelf.fFNfERViLLE.LONIi• .0511:$ y,_`! BARNSTABLE. ` naxsivas n;tts•osreavLLl1•x4sranpnsrw_E �W 9 MASS. Thomas McKean, Director 16,<,_z�,� ,.� `1'A i639 A`0 200 Main Street' Y H annis' MA 02601S�g TED AIA� Office: 508-862-4644 ��/ '7'0:�Wg Fax: 508-790-6304 `r APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE, CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS JULY 1 st—JUNE 30th). APPLICATION FEES CATEGORY 1 PERMIT 26— 110 Gallons: $ 50.00 El CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ *A late charge of$10.00 will be assessed if payment is not received by July 1st. 1, ASSESSOR'S MAP AND PARCEL NO. 2. IS THIS A PERMIT RENEWAL?�YES_NO. IF YES,SKIP QUESTION 3. 3. FOR ALL NEW PERMIT APPLICATIONS,INDICATE WHETHER BUSINESS HAS ZONING/BUILDING APPROVAL FOR HAZARDOUS MATERIALS STORAGE/USE OF GREATER THAN HOUSEHOLD QUANTITIES (25 GALLONS)? YES NO. 4. FULL NAME OF APPLICANT: 5. NAME OF ESTABLISHMENT: 6. ADDRESS OF ESTABLISHMENT: 7. MAILING ADDRESS (IF DIFFERENT FROM ABOVE: a 8. TELEPHONE NUMBER OF ESTABLISHMENT: C�'V y 6�� 'ODD 9. EMAIL ADDRESS: 10. SOLEOWNER: YES �(NO IF NO,NAME OF PARTNER:y YN C'�(\ I ON 11. FULL NAME,HOME ADDRESS,AND TELEPHONE# OF: CORPORATION NAME y k�* XXC PRESIDENT \ � TREASURER . 1 l �NC1R(' 5.9 CLERK 12. IF PREPARED BY OUTSIDE PARTY: NAME: TELEPHONE #: COMPANY ADDRESS hi k jAW EMAIL: SIGNATURE OF APPLICANT DATE Q:\Application Fonns\HAZMAT APP 2017 REVISED.docx °F IKE r Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 BARN��E. ' 200 Main Street• Hyannis, MA 02601 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT Business Name: &-a j Date: Location/Mailing Address: .S tVX V%O,., Contact Name/Phone: t~ syv�- �s'o,ticc�l v�g Sod - '► I- SRr/ �2 Inventory Total Amount: MSDS la6��l.ov1 ka1�l�o � License#: WoO � Z Tier II : Labelina: L+dL1 A Spill Plan: OK— Oil/Water Separator: P� Floor Drains: 6,1�- C Emergency Numbers: ye,-2 Storage Areas/Tanks: &,&) Emergency/Containment ui ment: koj4i, ca. S 0,0,-- Waste Generator ID: Waste Product: N - Date&Amount of Last Sh pment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: A' LIST OF TOXIC AND HAZARDOUS MATERIALS I o V\0,,0-\"'( CVa"y-5 %V, "��1�� s 5��cc� ��g .Ka �-,e�• NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more requires a license from the Public Health Division. Antifreeze Dry cleaning fluids Automatic transmission fluid Other cleaning solvents&spot removers Engine and radiator flushes Bug and tar removers Hydraulic fluid (including brake fluid) V Windshield wash Motor oils V Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar Swimming pool chlorine Paints,varnishes, stains, dyes Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soil &stain removers (including carbon tetrachloride) (including bleach) J Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOM MEN D�\TIOS: of ow 5 �w- VA v - J ` Inspector: Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Number Fee 1160 THE COMMONWEALTH OF MASSACHUSETTS $125.00 Town of Barnstable Board of Health This is to Certify that GOL SUPERMARKET SSIYANNO UGH ROAD, HYANNIS, MA Is Hereby Granted a License For: Storing or Handling 111 - 499 gallons of Hazardous Materials. -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ This license is granted in conformity with the Statutes and ordinances relating there to, and and expires 06/30/2017 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN -- PAUL J.CANNIFF,D.M.D. 07/01/2016 JUNICHI SAWAYANAGI THOMAS A. MCKEAN,R.S.,CHO Director of Public Health Town of Barnstable Regulatory Services ti Richard V. Scali,Director WAMNSTABM = *:] MAS& Public Health Division a6;9 Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 ( `' a Office: 508-862-4644 zj -1 Fax: 508-790-6304 1 d' APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE HAZARDOUS MATERIALS IN ACCORDANCE WITH THE TOWN OF BARNSTABLE GENERAL ORDINANCE,CHAPTER 108, HAZARDOUS MATERIALS,ALL BUSINESSES THAT HANDLE OR STORE HAZARDOUS MATERIALS GREATER THAN HOUSEHOLD QUANTITIES ARE REQUIRED TO OBTAIN AN ANNUAL PERMIT(RUNS DULY 1st—JUNE 30th). APPLICATION FEES CATEGORY I PERMIT 26—110 Gallons: $ 50.00 ❑ CATEGORY 2 PERMIT 111 —499 Gallons: $125.00 CATEGORY 3 PERMIT 500 or more Gallons: $150.00 ❑ A late charge of$10.00 will be assessed if payment is not received by July 1st. ASSESSORS MAP AND PARCEL NO. DATE FULL NAME OF APPLICANT: NAME OF ESTABLISHMENT:- ADDRESS OF ESTABLISHMENT: �� MAILING ADDRESS(IF DIFFERENT): Q ` TELEPHONE NUMBER OF ESTABLISHMENT: l7 � 1L EMAIL ADDRESS: SOLE OWNER: YES 4 NO IF NO,NAME OF PARTNER: FULL NAME,HOME ADDRESS,AND E EPHONE#OF: CORPORATION NAME ` PRESIDENT TREASURER CLERM IF PREPARED BY OUTSIDE PARTY: SIGN LICANT Name: Company Address Telephone#: Email: Q:Wpplication FormsUiAZZAPP Rev 16.docx Page 1 of 2 °pIME*off Town of Barnstable Office:508-862-4644 Public Health Division Fax:508-790-6304 aARMAN` 200 Main Street• Hyannis, MA 02601 '639 TOXIC AND HAZARDOUS MATERIALS INSPECTION REPORT RFD MAy a Business Name: CTo �v �e. Date: 7 1 Location/Mailing Address: K vto� vt✓1 Contact Name/Phone: F Sov�- 6--0A SOS -7'7 MSDS: �o o xCO1"1- *''Wlle(License#:Inventory Total Amount: �`�' �� A-� ��'t- Wl� DD Tier ll : I,)0 Labelina:1re--"4%\ W04`^� Spill Plan: °K✓S ¢leis Oil/WaterSeparator: Floor Drains: a. Emergency Numbers: �g Storage AreaslTanks: v<M (A Oltw L- V 1 <i� v S Ott Emer enc /Containment E ui ment: mqfi \AJCx,,k1,CCq6 Waste Generator ID: Waste Product: Date&Amount of Last Shipment/Frequency: Licensed Waste Hauler&Destination: Other Waste Disposal Methods: \\ LIST OF TOXIC AND HAZARDOUS MATERIALS No \v 1 c�`-awS t h, 1v��1e�nkv �„1c� laS NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws oiMA, hazardous materi use, (tk'p 160- storage and disposal of 111 gallons or more requires a license from the Public Health Division. 1j Antifreeze Dry cleaning fluids Automatic transmission fluid V Other cleaning solvents&spot removers l . 1457 Engine and radiator flushes Bug and tar removers Hydraulic Hydraulic fluid (including brake fluid) Windshield wash Motor oils Miscellaneous Corrosives Gasoline,jet fuel, aviation gas Cesspool cleaners Diesel fuel, kerosene, #2 heating oil Disinfectants Miscellaneous petroleum products: Road salts grease, lubricants, gear oil Refrigerants Degreasers for engines&garages Pesticides: Caulk/Grout insecticides, herbicides, rodenticides Battery acid (electrolyte)/batteries Photochemicals(Fixers) Rustproofers Photochemicals(Developer) Car wash detergents Printing ink Car waxes and polishes Wood preservatives(creosote) Asphalt&roofing tar 1 Swimming pool chlorine 1 Paints, varnishes, stains, dyes 4cy- Lye or caustic soda Lacquer thinners Miscellaneous Combustible Paint&varnish removers, deglossers Leather dyes Miscellaneous Flammables Fertilizers Floor&furniture strippers PCB's Metal polishes Other chlorinated hydrocarbons Laundry soiill�vemovers (including carbon tetrachloride) (inc ludin bleach Any other products with "poison labels" (including chloroform, formaldehyde, hydrochloric acid, other acids) VIOLATIONS: ORDERS: INFORMATION/RECOMMENDATIONS: w -f o alp 5 Inspector: Q�l Facility Representative: WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Fee Number 1160 THE COMMONWEALTH OF MASSACHUSETTS 1oo.00 Town of Barnstable Board of Health This is to Certify that GOL SUPERMARKET SS IYANNO UGH ROAD, HYANNIS, MA Is Hereby Granted a License FOR: STORING OR HANDLING 111 GALLONS OR MORE OF HAZARDOUS MATERIALS. ------------------------------------------------------------------------------------------------------------------------------------------------------------------- This license is granted in with the Statutes and ordinances relating there to, and and expires 06/30/2016 unless sooner suspended or revoked. ---------------------------------------- WAYNE MILLER,M.D.,CHAIRMAN PAUL J.CANNIFF, D.M.D. 07/01/2015 JUNICHI SAWAYANAGI THOMAS A.MCKEAN,R.S.,CHO Director of Public Health F� -� Town of Barnstable °FTFIE� Regulatory Services Richard V. Scali, Director 9� LE, Public Health Division �F1639. A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $100.00 ASSESSORS MAP AND PARCEL NO. DATE APPLICATION FOR PERMIT TO STORE AND/OR UTILIZE MORE THAN Ill GALLONS OF HAZARDOUS MATERIALS FULL NAME OF APPLICANTV NAME OF ESTABLISHMENT • ADDRESS OF ESTABLISHMENT RVR'Q �A 1l`��\� TELEPHONE NUMBER SOLE OWNER: YES_'�__NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL y\Qon,T 0\yk ovo IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT 1Si vo �. TREASURER CLERK • ANT y�� RESTRICTIONS: HOME ADDRESS VQ a5 '0V0 HOME TELEPHONE# CAcache\Temporary Intemet Files\0LKD3\HAZAPP ReQ015.DOC Date: Y/,�5 TOWN OF BARNSTABLE .`hi,p I 10&-,- TOXIC AND HAZARDOUS MATERIALS FORM NAME OF BUSINESS: C9ry 16,Qeci Ae,<�2e..k BUSINESS LOCATION: 55 1-yay Ao.,!jV, VU �Gytdl15 INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: S06-771 -Sp6jZ ----N � CONTACT PERSON: E150-,�. &o,lc�lveg EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: � d4 � �� k��5�� WitI n,LOAA,r•.- INFORMATION / RECOMMENDATIONS: �� J��sk �.^�w�nc� r�vs Flre District ew 4APAU,'A5 �2�C�M �.�1�S�7tDy�� 50'II 0—MS `t'pp�Q ItV11\NW-t� Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive Zfi ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants jy-1 Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible (� Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables 3 Other products not listed which you feel Floor&furniture strippers 0pmay be toxic or hazardous (please list): Metal polishes �— 3S�a +toff �I Laundry soil &stain removers l (including bleach)$ �-L +t Spot removers&cleaning fluids (dry cleaners) ft0 l Other cleaning solvents 1 Bug and tar removers (p Windshield wash Z,+` WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials } hid. kaa.. . 0_*1HE)p Town of Barnstable p- +,et{ '.�' U.S.POSTAGE>>PITtVEY BOWES 7, L `'^�f,!t jJ'{`�'+;'-, • • BARN LE. 1�UblIC Health DIVISIOn h a .y...-p..a 51•Q r / �0 g 200 Main Streeter `+:y: i . �e �fED MP�AO Hyannis,MA 02601 - •• 5 ZIP 02601 $ 000.46 02 41N 0000.336455 DEC. 16. 2016. Victoria's gaen /0' Iyannough Road o SS Hyannis, MA 02601 _ NI ^X1Z 01.E :,E. 1 _ T-0 -Se i�czz _a.0 6 i�I`t ER t v z l\T�—'r am ilJ F'�6i \.L UNABLE TO FORWARD UTF sC. 0Zboa. p4013azao 1 { " 15Z -015513�_s,17 -{03 4i11111 . r•• i i 1iii 1i i i i1i 11;di 111111 li I4 - i� ill �e r " I I I II , II I it I! H II 111 1 I`' II 11111 1 i I II I °ft"Er°w Town of Barnstable BARIVSIABLE, : Regulatory Services . v� 1639, q Richard V. Scali, Director M BARNSTABLE RFD A'1 a Public Health Division 4ARSiCNS 4i15•OSIES4Ilit•AcS!LS.RNSTnEi[ Sb39-203a Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 December 5, 2016 NOTICE TO ALL BUSINESS OPERATORS WITH HAZARDOUS MATERIALS IN THE TOV`N-OOF BARN"- ABLE' - In accordance with Town Code, Chapter 108, all businesses that handle or store Hazardous Materials greater than household quantities are required to obtain an annual license with the Public Health Division. Effective January 1, 2016, the Barnstable Board of Health enacted a new fee schedule for hazardous materials stored on site. The fees are codified in Chapter 318 of the Town Code and are outlined below based on storage category: i Category 1 License 26— 110 Gallons: $ 50.00 Category 2 License I I I 499 Gallons: $125.00 Category 3 License 500 or more Gallons: $150.00 If you should have any questions or concerns, please feel free to view the Town Code which is located under the E-Code section on the Town Website, www.town.bamstable.ma.us. Based on Public Health Division records, your business is not currently licensed to store/use hazardous materials. Please consider this letter an order notice to schedule an appointment for a hazardous materials inspection with the Health Division. Please contact Timothy Lavelle, Hazardous Materials Specialist, at 508-862-4645 or tim.lavellegtown.barnstable.ma.us to schedule this inspection within the next 14 days. Your continued cooperation is greatly appreciated. If you have any questions or need further information, please call the Public Health Division at 508-862-4644. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S. Director of Public Health Town of Barnstable Q:\Hazmat\Hazmat new inspection order 2016.doc THE DNIAEALTH OF MASSACHUSETTS BOARD 9F HE PT .J............. .. ... --- ......................................... Appliratiou for Diipnsaal Workii Tomitrurtiurt ramit Application is hereby made for a Permit to Construct ( ) or Repair ( lel"'an Individual Sewage Disposal System at: .... _. _. . �.� . ... _`_:.............. ........•---•----------•--....-----•-•--............-----......•-•.........._......-----........_. / •.�^� or Lot No. Y.o n-Add ....... . .. ,� . . ..... ..._...--��1--�� -----------------•--------------..._....-----.....----.....-•----...--------...................... Owne Address a . F .......... .... ..•• -- -•- Address---•---•---- Installer ype of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a+ Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Al ---------- ODescription of Soil.........--- (...................................•---•-•-•--•-•-----------•---....-----------------------•----------------....----...•----------•• V .. -------•.........................................•--------------...--------•--------------..................................................... -•••----••---------•--------•--•---•-------•----•••---------------------•-•-•-----------•..._----••----•------------- -- ••••-•--•--•......--•-----_�- r-�-..�....-----••--...._. VNature of Repairs or Alterations—Answer when applicable...................... Dae......64W&4=:----`�`* ---•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—.The undersign d further agrees not to place the system in operation until a Certificate of Compliance has been sued by t boar Aheia��lthe Signed = ....... . . -......•. D / Application Approved By.... -••_--•---`.! "`�.. -.......-•------- - 2 ,C- (ate Application Disapproved for the following reasons-----------------------------------------------------------------•-.-•--------•---•--------...----•...........-- --_--•••-•.....••------•......................•----------------------.............---------._..........-----•--•--------•--•••--------......-•-----•-•••--•------.....••----------------------....---••- Date Permit No. �� .... Issued-------------•...---------------•••----....._..._--•--- ------•- Date __ _ cralol }•.. THEL ONWEALTH OF MASSACHUSETTS _�. . BOARD PF HH ................OF. .......', a o .! .................................................. A"ptiratinn for 00pasal - nrkS Tonstrudiun rrrtnit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at ,m- ,, i d...............'�.................. ..----..d. .... -------_________ ....----•__-__ .._..........-........................... L46tion-AddcEss,a � C � or Lot No. ... il./ .. /«� .:.:,..c� ./� '�. { .'' •:,P �'r. f>,{/� . . ................................................................................................ Owner f` Address Installer o` Address Type of Building Size Lot...........................Sq. feet aDwelling—No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( ) p•I Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ----------------------------------------------- Design Flow........................:...................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid-capacity______._____gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length Total leaching area...................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water._.__..._.........__._... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ----------------•-----------.......•................ ........................------------------- ------•------ D Description of Soil.........:,.. W-'....................... V ---------------------------------- --------------------------------------- ...---•....... •--------------- •----------------- ---.--------•------ -------------- •----------- . ••..-••• -----------------------------•--••••• •-•----••-•••-•••-------.........••....•----••-• :.. .......... :.. ....................-- :.... U Nature of Repairs or Alterations—Answer when applicable..................... _________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE. 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssued by the board Hof health. may[ ,tgged.e .�............................................ ........................D' / Application Approved By.. e •�'� �••-:-• � c �..... ---- --------• - - ~! " "Date Application Disapproved for the following reasons:..........................................................................................................___ ..---------•----•-•--••--------••--------------••--•--............-----•-•-•---•--------..................__.........._....---------•-------.._._....._......_........._..••••--................•_---•-- Date Permit No........ . �� ....._ Issued..................•---------------•-•---•---•------..... -------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH /, s- /....... ........ ......... ......... ......... ................................ (Irr#if irate of Tautplittnrr J TH S T0) /ERTIFY, Tlat the Individ al Sewage Disposal System constructed or Repaired .._. y. n st�ller / y has been installed in accordance with the provisions of TITLE 5 of,fie State Sanitary Code as describ4 in the application for Disposal Works Construction Permit NTo••-•-�........... .�•�_'........ dated------ ) THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GLiAlA TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... ...a Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, �. .(:...:.`��6................O F.. ,.... .......�.ii�`?<. •�1'r.��......�' No' WW... +// .......... ............................................. Fzz........................ Dispood Works Tunutrurt' in Writ Permission is hereby granted..; ............................................yr to Construct ( ) or Repair ( )-in Individual Se age Disposal System at No....._,�' ....... .. -�.tnO S` -►�...------..` ........... ---•- Q := --.......---•.............................•---__ ...._- .................... iJ Street . a - as shown on the applicat> n for Disposal Works Con ti0, P, aid — IPated. . �£--7._. 0............... " ...r°.,�..11 Board of Health DATE.......... ..__ . 2_- ... 'C .................................. F'OR�M• 1255 A. M, SULKIN, INC., BOSTON rf � i