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TOXIC AND HAZARDOUS MAT RIA 'S REGISTRATION FORM
NAME OF BUSINESS: Se%L S. Q�6 e ail To:
BUSINESS LOCATION: oard of Health
n • Town of Barnstable
MAILING ADDRESS: cJ ® P.O. Box 534
TELEPHONE NUMBER: �Y� ,7��'-C3 /L Hyannis, MA 02601
CONTACT PERSON: ,L cLL
EMERGENCY CONTACT TELEPH NE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own.use, in qu tities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
--- Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid —19� oilet cleaners
Engine n g e and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) Disinfectants
Motor oils/waste oils Road Salt (Halite) '�� MFU T—
Gasoline, Jet fuel Refrigerants
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) —Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes -----Jewelry cleaners
Asphalt & roofing tar Leather dyes
� V�Paints, varnishes, stains, dyes -—Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
LJ aint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
(/ Metal polishes (including chloroform, formaldehyde,
9dkS Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners) , ��-►Ti+s F-& o b sly w�SL,BIZ
they cleaning solvents A `�
Bug and tar removers fl, 0
� ousehold cleansers, oven cleaners go '
White Copy-Health Department/ Canary Copy-Business
Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS: (A_554%' l P�'ra/IGli�ii'J/ltrtq
BUSINESS LOCATION: t 5( 6u,Cpj ST H r�.S
MAILING ADDRESS: S' tA en e �� ,SL 6 &,p C Mail To:
TELEPHONE NUMBER: .) ff
y `j '71 r) <5_ Board of Health
Town of Barnstable
CONTACT PERSON: °3�>A,i;'T-�>� wr s4.[o ui P.O. Box 534
EMERGENCY CONTACT TELEPHONE NUMBER: 7 7 / ii k s s' Hyannis, MA 02601
F
TYPEOFBUSINESS: 0 (_oAo4nu
Does your firm store any of the ardous materials listed below, either.for sale or for you own
use? YES (V, _ NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease,, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
r— Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners
(including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers j
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
Date:
i
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAMEOFBUSINESS:
BUSINESS LOCATION: 2"rL.5< h 4,al sT t-�-1 iw,, �s
MAILINGADDRESS: "; A n� e � �� l.a� f ST Mail To:
Board of Health
TELEPHONE NUMBER: �''� y 7 -1 i 0 k Cry` Town of Barnstable
CONTACT PERSON: 'r>,a,d: sa t'o c,J P.O. BOX 534
EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601
TYPEOFBUSINESS:
Does your firm store any of th zardous materials listed below, either for sale or for you own
use? YES _ NO '
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
` ADDRESS:
TELEPHONE:
LISTOF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
i you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(for gasoline or coolant systems) Drain cleaners _
NEW USED "Cesspool cleaners -
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides .
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Deg rea ersjorengines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Gt Car wash detergents Jewelry cleaners
Qihirtr Car waxes and polishes Leather dyes
Asphalt & roofing tar Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW. USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners a
(including chloroform, formaldehyde,
Floor-& furniture strippers hydrochloric acid, other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
may be toxic or hazardous lease list
(including bleach) Y (p ):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents f
F
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
t
i
T , Town of Barnstable
Public Health Division
y MASB. . 200 Main Street,Hyannis MA 02601
s639.
ADD MA'S
Office: 5 08=862-4644. .
Friday April J0, 2020, 5:45 p.iri.
Mr. Adam Bennett
Executive.Director
Champ House, O'Neil Building
82 School Street
Hyannis, MA 02601
EMERGENCY WRITTEN .ORDER REQUIRING ISOLATION AND QUARANTINE
This Order is being.issued to protect.the.publ'ic health and safety where there'is a cluster of
confirmed and suspect COVID-19 cases within the Town of Barnstable., The reason for this
order is due to the fact that three (3) residents within the Champ House O'Neil Building, 82
School Street have tested positive for COVID-19. Also several residents within this building
have failed to.voluntarily follow self-quarantine instructions.
Pursuant to the authority vested in the Barnstable Board of Health under Massachusetts
General Laws, Chapter 111; Section 95, and 105 CMR 300.00,'and.authority vested in the
Board of Health Agent under Massachusetts General Laws, Section 111, Section 30,'you are.
hereby Ordered as follows:
1) You are required to "Lock Down" the O'Neil Building,Champ.House, 82 School Street
Hyannis MA immediately and until further Notice from the Barnstable.Board of
Health;
2) The Order of"Lock Down requires that no one may enter or leave the facility except
for authorized asymptomatic staff members, health care personnel for urgent
medical needs and testing, and except for residents who need medical care and/ or
are undergoing testing at an off-site testing center as authorized by a physician.
3) All residents are to be confined to the facility, shelter in place, and.isolate from the
general public;
4} You are required to comply forthwith with all of the provisions contained in the
document "Information and Guidance.for Persons in Quarantine.due to .COVID-19..
issued by the Commonwealth of Massachusetts Executive Office of Health and
..Human Services, dated March 11, 2020, a copy of which is attached hereto and
incorporated by reference as"Exhibit A."
5). You are required to comply forthwith with all of the provisions contained in the
document "Information and Guidance for Persons in Isolation due.to COVIp-19.
issued by the Commonwealth of Massachusetts Executive Office of Health and
Human Services, dated March 11, 2020, a.copy of which is attached hereto and
incorporated by reference as "Exhibit B.". ..,
A
6) You are required to comply forthwith with all of the provisions contained in the
document "Health Care Personnel with Potential Exposure to Patients with COVID-19
Guidance issued by the Commonwealth of Massachusetts Executive Office of Health
and Human Services, dated March 19, 2020, a copy of which is attached hereto and
incorporated by reference as "Exhibit C."
7) You are required to comply with directives from the Town of Barnstable Director of
Public Health and/or the Town of Barnstable Public Health Nurse.
8) You are required to observe each and every element of this Order unless advised
otherwise, in writing, by the Barnstable Board of Health.
The duration of the isolation and quarantine period shall be for fourteen days. However an
emergency written isolation and quarantine order may be re-issued in the future if an
additional quarantine time period is needed. This order is subject to change as this is a
rapidly evolving situation and may be sustained or modified by the Board of Health or their
duly authorized Agent.
Should you be aggrieved by this order, you have a right to appeal pursuant to 105 CMR
300.210(F) by contacting the Director of Public Health Thomas A. McKean, at telephone
508 862-4644. An individual or group subject to an order of isolation or quarantine may file
a petition in Superior Court challenging the order at any time. Unless rescinded by order of
the Department or local board of health or a court, the order for isolation or quarantine.shall
remain in force and effect until any appeal is finally determined.
omas A. McKean, R.S., .-H.O.
Director of Public Health and
Board of Health Agent
The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
Bureau of Infectious Disease and Laboratory Sciences
305 South Street, Jamaica Plain, MA 02130
MARYLOU SUDDERS
CHARLES D.BAKER
Information and Guidance for Persons Secretary
Governor in Quarantine due to COVID-19 MONICA B Commissioner
MD,MPH
KARYN E.POLITO
Lieutenant Governor Tel:617-624-6000
www.mass.gov/dph
You are required to quarantine (separate yourself) from other people because you have been
exposed to the 2019 Novel (New) Coronavirus (COVID-19). If you have COVID-19, you could
spread it to people around you and make them sick.
COVID-19 is caused by a virus. It is spread through respiratory secretions (mucous and droplets
from coughs and sneezes) from an infected person and can cause serious illness such as
pneumonia (lung infection), and in some rare cases, death.
This information sheet provides you with information about what to do and not to do while you
are in quarantine. If you have questions after reading this, you can call your local Board of
Health, or the Massachusetts Department of,Public Health which is available 24/7 at 617-983-
6800.
During your quarantine period, you should not have visitors in your home. The other people who
live in your home can continue to do their normal activities as long as they are not in contact
with you, as described further below, and not also under quarantine. If you test positive for
COVID-19 and someone comes into contact with you that person might also then need to be
quarantined.
While you are in quarantine you should follow these instructions:
l. Do not leave your home except for urgent medical care. If you must leave your home for
urgent medical care, wear a mask, such as a surgical mask, if available. Call the
healthcare provider before you go and tell them that you are quarantined due to COVID-
19 exposure. For the protection of others, you should use a personal car or call an
ambulance to travel to your healthcare provider. Do not take public transportation,
ride shares (e.g. Vber or Lyft), or taxis under any circumstance.
2. Wear a mask, such as a surgical mask, if available, if you must be in contact with other
people. If not available try to maintain a distance of six feet from others;when this is not
possible, limit your time being closer to people to five minutes or less.
3. Do not have visitors in your home.
4. To the extent possible, stay six feet away from other people in your home. If absolutely
necessary, have one person help you and do not have contact with other people in your
home. Wear a mask, such as a surgical mask, if available when in the same room as that
person. If not available try to maintain a distance of six feet from others; when this is not
possible, limit your time being closer to people to five minutes or less.
3/11/20 1 .
5. If possible, use a separate bedroom and bathroom. Do not share towels or bed
sheets/blankets with other people in your home. Wash your laundry separately from the
laundry of other people in your home.
6. Do not share eating or drinking utensils. Wash utensils normally in a dishwasher or by
hand with warm water and soap.
7. Cover your mouth and nose with a tissue when coughing or sneezing and throw tissues
away in a lined waste container. Then wash your hands.
8. Wash your hands frequently using soap and water for at least 20 seconds each time you
wash. If soap and water are not available,use an alcohol-based hand sanitizer that
contains at least 60% alcohol.
Anyone you come in contact with (including anyone in your home) should:
1. Wash their hands with soap and water for at least 20 seconds often. If soap and water are
not available they should use an alcohol-based hand sanitizer that contains at least 60%
alcohol.
2. Wear a mask, if available, when they are in close contact with you if you cannot wear a
mask. They should be careful to only touch the parts of the mask that go around the ears
or behind the head. Do not touch the front of the mask. They should wash their hands
immediately after taking the mask off. If not available try to maintain a distance of six
feet from others; when this is not possible, limit your time being closer to people to five
minutes or less.
3. Wear disposable gloves if they have to have direct contact with your body fluids
(saliva/spit, mucous, urine, feces, vomit) or handle your dirty laundry. Remove the gloves
carefully without touching the outside of the gloves, throw the gloves away, and wash
their hands with soap and water or an alcohol-based hand rub.
Anyone you come in contact with (including anyone in your home) should remain aware of
their health and watch themselves for:
• a fever(temperature over 100.3 degrees).They should take their temperature in
the morning and at night.
• other symptoms such as a cough, difficulty breathing, shortness of breath, chills,
stiff or sore muscles, headache, or diarrhea.
If anyone you come in contact with has any of these symptoms, contact the local health
department or the Massachusetts Department of Public Health at the phone numbers
below.
F If they need to seek medical care, they should call their healthcare provider before they go and
tell them that they may have been exposed to COVID-19.
If they do not have any of the symptoms described above, they do not have to stay home and
instead may continue with their normal activities.
3/11/20 2
Other advice to keep your germs from spreading:
1. Your gloves, tissues, masks and other trash should be put in a bag, tied closed, and put
with other household trash.
2. Your laundry may be done in a standard washing machine using warm water and
detergent. Bleach may be used but is not needed. Do not shake out the dirty laundry and
avoid having the dirty laundry touch anyone's skin or clothing.
3. Surfaces in the home that you touch or that become dirty with your body fluids
(saliva/spit, mucous,urine, feces, vomit) should be cleaned and disinfected with a
household disinfectant according to the label directions. Wear gloves while cleaning.
4. Your bathroom should be cleaned every day using a household disinfectant according to
the directions on the label. Wear gloves while cleaning.
How long must you follow these instructions?
You will need to remain quarantined for at least 14 days.from the date of last exposure. A public
health authority (MDPH or your local board of health) will be in contact with you daily and will
tell you when you can stop quarantining yourself. They will regularly re-assess you and will
determine if you still need to stay quarantined or if the risk of infection to others is low enough
that you can leave your home.
Questions?
Please call your healthcare provider, your local board of health or the Massachusetts Department
of Public Health with any questions.
1. Your healthcare provider
Name:
Phone number: OR
2. Your local board of health (Town/City)
Town or City:
Contact Person:
Phone number: OR
3. The Massachusetts Department of Public Health
On-call Epidemiologist
Phone: (617) 983-6800 (7 days per week/24 hours per day)
Thank you for your active cooperation in keeping ,yourself, your family, and your community
healthy and safe.
Date provided to quarantined individual:
Provided by (name):
3/11/20 3