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HomeMy WebLinkAboutOSTERVILLE VETERANS ASSOC. - FOOD (2) OSTERVILLE VETERANS ASSOC. , 753- OSTERVILLE '®15 iFl Town of Barnstable BOARD OF HEALTHJohnT.Norman Board of Health Donald A.Gaudagnoli,M.D. akjzri rrADLr, F.P.(Thomas)Lee,. Mns9. 200 Main Street, Hyannis, MA 02601 Daniel Luczkow,M.D. Alt. � 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, 305B, 146, 189 and 189A; Chapter 111, Sections 5 and 127A, a permit is hereby granted to: Permit No: 257 Issue Date: 01/01/2022 DBA: OSTERVILLE VETERANS ASSOC. INC. OWNER: OSTERVILLE VETERANS ASSOCIATION INC. Location of Establishment: 753 MAIN STREET OSTERVILLE„ MA 02655 Type of Business Permit: RETAIL Annual: YES Seasonal: IndoorSeating: 35 OutdoorSeating: 0 Total Seating: 35 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: Q. 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: APPROVED 04-20-16 - 1.) There shall be no kitchen or food prep. 2.) If Hall is used, caterers must bring food, dishes, glasses and utensils. 3.) All pots, plates and utensils must be taken off-site for cleaning. i Town of Barnstable For Office • Initials: Date Paid 1 _Amt Pd s� „ Inspectional Services `� Public Health Division' - 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 1a 01I NEW OWNERSHIP RENEWAL J NAME OF FOOD ESTABLISHMENT: JI�J��i�(� (� S wr, C� r ADDRESS OF FOOD ESTABLISHMENT: -75 a Main Hai n St 4ery i��, MA 62655 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): PD Box bO 05koIt`1e MA 62&55 1� E-MAIL ADDRESS: nel an W Q:j g cm(! tj s+, nef— TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 6&t4A Uff TOTAL NUMBER OF BATHROOMS: WELL WATER:YES NO ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/ / TO NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: 35 \X 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? 1�► A IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW)0 FOOD SERVICE TAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) ED&BREAKFAST @/ r1111 CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential Idtchen) \ 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 508-8624644 Q:\Application FormsTOODAPP 2020.doc it OWNER INFORMATION: FULL NAME OF APPLICANT kvis laft 6s6 1 eA5wcrw, SOLE OWNER: YES/NO OWNER PHONE# 67-3130 IBC ADDRESS CORPORATE OWNER: !IC =-kr, CORPORATE ADDRESS: ►'V &x 4g4a PERSON IN CHARGE OF DAILY OPERATIONS: 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. NATURE OF APPLICANT DATE ***FOOD POLICY INFORMATION*** i 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/auptications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January I 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:\Appfication FonnsTOODAPP REV3-2019.doc oF�HE r TOWN OF BARNSTABLE HEALTH IrvsPECTOR's Establishment Name: Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION _. soo 9:30:A.M. BARNSfABLE. • 200 MAIN STREET 3:30 4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified e39.p,0� HYANNIS,MA 02601 soa-asz asaa No Reference; R:-;Red,Item PLEASE PRINT CLEARLY rFD1A�` FOOD EST LI H NT-INSPECTION REPORT- - G;an //0F yea / Name a, Da e o e of:Inspection (( 1/yL Address . Risk I tood Service Re-inspection CX//�1 /, / Level Re tal Previous Inspection V "v Telephone Residential Kitchen Date: Mobile- Pre-operation Owner - HACCP Y/N Temporary Suspect Illness _ Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP Inc Other g Inspector Out: iCcc Each violation checked req res an explanation on the narrative page(s)"and 8 citation of specific provision(s)violated. 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) ❑ 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 r . . - ❑ 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 HSPLP ❑ 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) �J� Corrective Action Required: ❑ No ❑ Yes Non critical(N)violations must be corrected•immediately•or within 90 days as determined by the Board of.Health. Overall.Rating.. Voluntary Compliance ❑ ry p ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled .: ❑ Emergency Suspension C N ' Official-Order for Correction. Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other.. 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent 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: B=One critical violation and less than 4 non-critical violations 9 '25.Equipment and Utensils (FC-4)(590.005) 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. Serious) Critical Violation=F is scored automaticall If no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If y Y. 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you'have aright 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 8non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation;4 to 8 non-critical violations=C. 30.Other "' DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpst creened 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's Signature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted - Y N bumpster Screen Y N ��..�-.-�. -`...'T.-.-..`.. ."-....� •. ,+-+r_y-sl�.r-._...�•--..^r._.'-s'3i�.-»"�'+,.-s mad+^-•^-�v....,, ..`-.-..-r-«s�s•'�=ds'� - .;.C.e-•-.r_^,-�•°---•--- •�-•..'t. --�__--'°-�..�+�,..-.. _ 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 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding 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 * 590.004(F) 7-101.11 Identifying Information-Original Containers 2 590.003(C) Responsibility.of the Person-in-Charge-to Other*;, ., ) Hot PHFs Maintained At or Above 140°F* 7-102.11 Common Name-Working Containers* 3-501.16(A 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 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use** 3-501.19 Time as a Public Health.Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use 590.004 11 Variance Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) 9 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions.and Restrictions g � ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water 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 HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS CONSUMER ADVISORY 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs 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 Eggs 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 1112001 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* * 3-3.02.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 't-;--, 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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs 'SP_ECIAL'REQUIREMENTS.;,,;_. Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g g � 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Sources* Ratites-165°F 10 Proper,Adequate Handwashing 15 sec* ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 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 1 T Reheating for Hot Holding practices should be debited under#29-Special Requirements. 5 Receiving/Condition 2�01.11 Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* li 3-202.11 ReceiPHF' Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.1 I(B) Microwave-1 see 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing ofContamination Co nv 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 I 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 3-101.11 Food Safe and Unadulterated* O g B 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 3-501.1 A CoolingCooked PHFs from 140°F to 70°F 3-202.12 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 r .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 1 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 .009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 5:590Formback6-2doc 8-103.12 Conformance with Approved Procedures* '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. °F114E rok _ { TOWN OF BARNSTABLE:.,, HEALTH INSPECTORS Establishment Name: V�!`� VQi ate: �. L� Page: - r of_! OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-930A.M. BARNSTABLE. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MA& MON.-FRI. HYANNIS,MA 02601 sos-ssz asaa No Reference. R-Red Item. . PLEASE PRINT CLEARLY FOOD ESTABLISHMENT INSPECTION REPORT Name S V�J¢ r(JX� Date' 2 L' Type of Type of Inspection Ooe s Routine Address '"��r� S �',� Risk Food Service Re-inspection C, L2��M2ul Level Previous Inspection Telephone Residential Kitchen rru-s I p Mobile operatio Owner HACCP Y/N Temporary e ness Caterer General Complaint t Person in Charge(PIC)(V e I � �� Time Bed&Breakfast HACCP In: ` Other Inspector , Out:1 1 O k44`OW"a Each violation checked equires an explanation on the narrative page(s)and a citation of specific provision(s)violated. t Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Q T Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ WT Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ JV1�l FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities VV ✓ ! 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 O--t, =�` ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling I ) ❑ 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) ( a � ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP Ir ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY19 ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories t IS c�G Violations Related to Good Retail Practices Blue Items Total Number of Critical Violations - ,� - �S t ( ) Critical(C)violations marked must be corrected immediately. (blue&red items) In �)'I Corrective Action Required: El Yes Non-critical(N)violations must be corrected immediately or Overall Rating lV Q� within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Sche I ❑ 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. El9 -1.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 6von-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 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. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 = 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 to 8non-critical violations C. 30.Other DATE OF RE-INSPECTION: Inspect is Stigriature Print; 31.Dumpster 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 ture Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N /Ijd„d- �i - Dumpster Screen 7 Y N (o"� Voilkions related to Foodborne Illness 1 Violations Related to Foodborne Illness Interventions Inte dons 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 i 1 590.003(A) Assignment of Responsibility* F 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* *- _ 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) 2 590.003(C) Responsibility of the Person-in-Charge to _ Other* 7-102.11 Common Name-Working Containers* 3-501.16(A) Hot PHFs Maintained At or Above 140°F P g 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* 1 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee 7-202.11 Restriction-Presence and Use*.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 Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q _ 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR or Contaminated g - 3-306.14(A)(B)Returned Food and Reservi of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition o/Adulterated or 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 andWater From Regulated Sources y Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(13) Use of Pasteurized Eggs* 590.004 A-B Com liance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P_ _. _ _ _ 4-50d-1-11 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations 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* - 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of Eggs 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effective 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) 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- * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources 10 Proper,Adequate Handwashing - g' P mTY Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under Regulatory Authority 2-301.I l- - Clean Condition-Hands and Arms 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* foodborne 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. $ Receiving/Condition 2-40L.11 Eating,Drinking or Using Tobacco* ! 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3 403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 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 CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) 3-203.12 Shellstock Identification Maintained* Conveniently 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* 3-50.1.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(1) 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 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 Conformance with Approved Procedures* i 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. .i ,A �oF.eE rok TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: - Page: of OFFICE HOURS �p PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MAss.� HYANNIS,MA02601 MON.-FRI. NO Reference R-Red Item PLEASE PRINT CLEARLY, t63q,►�0� 50e-862-4644 'FDN1�` FOOD EST BLI HM NT INSPEOTION REPORT Name Date a of Tyne of Inspection Ooeration(s) Routine Address Risk Food Service Re-inspecti n Level Retail Pre In p o� Telephone Residential Kitchen Date: Mobile Pre-oper ti Owner HACCP Y/N Temporary Suspect I ess Caterer General Complaint vt- Person in Charge(PIC) Time Bed&Breakfast HACCP . Other Inspector uIf V / Each violation checked requires an explanation on the narrative pa e(s)and a citation of specific provision(s)violated. Violations Related tc Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 59Q.009(E) ❑ n 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 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 i ❑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 HSf ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY 1 C M 6 t ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories `J 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 Eo s Non-critical(N)violations must be corrected immediately or within 90 days as determined by the Board of Health. Overall Rating ❑ Voluntary p Volunta Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 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 4 non-critical violations 9 if no critical violations observed,4 to 6von-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 9non-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-cri .al violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8 non-critical violati, s=C 29.Special Requirements (590.009) a t IZ 30.Other DATE OF RE-INSPECTION: Inspe s Sig ture 31.Dumpster screened from public view - Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N / #Seats Observed P s Si nature Print: Frozen Dessert Machines: Outside Dining Y N 9 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 L 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) I Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 590.004(F) 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 * 7-102.11 Common Name-Working Containers* Require Reporting by Food Employees and Contamination from the Environment 7-201.11 Se 3-501.16(A) Roasts Held At or Above 130°F* 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 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations 3-201.12 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. 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* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* Pathogens* Ef rn�e 1112001 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* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 4-702.11 Frequency Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* aces 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 g 590.009 A - D Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( ) ( ) Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 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 9 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practiceses 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 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 Had 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 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 5-20411 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 . 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 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 1.008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Z#eoFwe r� TOWN OF BARNSTABLE " -,,HEALTH INSPECTOR'S Establishment Name 1 ate: Page: of c OFFICE HOURS iAnNsrAe�e. PUBLIC HEALTH DIVISION 8:00-9:30 A.M. ki( 200 MAIN STREET 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTIO OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. o MON.-FRI. �prFD639- �' ' - HYANNIS,MA 02601 . sos-Ss2-asaa No Reference R-Red Item A -P LEA LY :� F FOOD ESTABLISHMENT INSPFICTION REPORT Name IM Date vDe of I s c ion ` - Ooeration(s) Routice, Address `^ Risk t F ervice e-in ctio Level Retai4- Previous I f j f Telephone side 'al Kitchen Date: 1 Mobile Pre-opera i Owner HACCP Y/N Temporary Suspect Illness I'' P Caterer General Complaint Person in Charge(PIC) ( I Time Bed&Breakfast HACCP I --~I I - r9 9 I Other Inspector ( Each violation checked requires an explanation on the narrative eage(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Isk 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 74 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 d PROTECTION FROM CONTAMINATION ❑20.Time Asa Public Health Control r ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) i� ❑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) 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 El Embargo Emergency Closure ❑ Voluntary Disposal ❑ Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. 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 B=One critical violation and less than 4non-critical violations 9 (FC-4)(590.005) 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 9non-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 8 non-c tical iolations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008) 9 violation,4 to 8 non-critical viol ion C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: I s ctor Sign ture int: 31.Dumpster screened from public view / ' Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N I #Seats Observed s i nature Print: Frozen Dessert Machines: Outside Dining Y N g 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 EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each * 590.004(F) * - 7-101.11 Identifying Information-Original Containers 2 590.003(C) -Responsibility of the Person-in-Charge to Other* 7-102.11 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 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 Requirements * 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, 3-30fi.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 i ( ) - - - Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and . ( ) P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations , 3-201.12 Food in a HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wazewashing-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 E s-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* Effective 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* l 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 I 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* ( )- ide in cater- - 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 - $ Receiving/Condition 2-401.11 Eating,Drinking or UsingTobacco* 3-003.11(A)&(D) PHFs 165°F IS sec* Requirements. 3-202.11 PHF's Received at Proper Temperatures* 2A01.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items non-critical 12 Prevention of Contamination from Hands Critical and n non-critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 TagsiRecords: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 Handwashin Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification* 9 ( ) 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 TagsiRecords: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. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision rY g 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 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. IH *E TOWN OF BARNSTABLE. HEALTH INSPECTOR'S Establishment Name: Date: Page: of. OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. " 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified aim .0� HYANNIS,MA 02601 MON.-FRi. No Reference R-Red Item PLEASE PRINT CLEARLY 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name Date' ype of T ns ection Routine Address Ris ection JA Level etas Previous Inspection AM Al-I Telephone ntial Kitchen Date: ALI- 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 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 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 Lo 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 checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ElVoluntary Disposal ElOther: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Flealth 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 4non-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 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 C=2 critical violations and' than 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of Y y (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must ' 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 8non-critical violations. if 1 critical refrigeration. 29.Special Re irements (590.009) within 10 days of receipt of this order. violation,4 to 8 non-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.7�DumPst.r 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's ignature 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* F 8 Cross-contamination l4 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 Tdzic 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-lOLll Identifying Information..,On mal Containers* 590.004(F) - - Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* r 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 . Washing Fruits Restriction-Presence and Use*its 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 Requirements 3-304.11 Food Contact with Equipment and Utensils * ( ) q 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions ' Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Rodent Bait Stations 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. 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 Contact Utensils and Food Contt 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* o Equipment* Not Otherwise Processed to Eliminate . 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg°'i-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 P 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency r f cesSanitizationquof Utensils and Food 3-0Ol.l 1(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 3-40L11(A)(1)(b)All Other PHFs-145'F 15 sec 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 Commercial] Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) Y Critical and non-critical violations,which do not relate to the foodborne 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* 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[0 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel. FC-2 .003 5-20411 Location and Placement* Temperature Cooling PHFs Made from Ambient 24. Food and Food Prote(;#gn 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,PlumWng and Waste FC-5 .006 Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Ph si 1 Facility FC-6 .007 590.004(J) 9 9 Y �.C� tY 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. P91gonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29, Special Requirements .009 3-502.11 Specialized Processing Methods* �(!. Other E 02.12 Reduced-Oxygen Packaging Criteria* 03.12 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. oFtNe r TOWN OF BARNSTABLE HEALTH IN$PECTOR's Establishment Name:, ® Date: / I Page:, of v` ° o 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 .63c:e�0� HYANNIS, MA 02601 M-8 -FRI. No Reference R Red Item PLEASE PRINT CLEARLY fEo MP'� 508-862-4644 FOOD ESTABLISHMENT INSPEC .ION REPORT Name ,t ! D%ate Tyne of Type of Inspection Operation(s) Routine Address Risk Food Service Re-inspection � i �V Level Retail Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Char a(PIC) ' Time Bed&Breakfast HACCP In: Other Inspector �J 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 ❑ 1.2.Prevention of Contamination from Hands. ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS - ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE 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 - 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: o ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. oluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection oday,t e items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo Emergency Closure El 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. 590.005 B=One critical violation and less than 4 non-critical violations 25.Equipment and Utensils (FC 4 9 )( ) 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 boon-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 violations observed,7 to 8non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials FC-7 590.008) be in writing and submitted to the Board of Health at the above address ( )( iolation,4 to 8 non-critical violations=C. 29.Special Requ' ments (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspe I ig a r In. r-- 31.Dump r 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' Si nature 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 1 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 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* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.00 11 Variance R uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* � ) � 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions g � ) Disposition of Adulterated or Contaminated Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* q Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Warewashing-Hot Water 7.206.12 Rodent Bait Stations 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* TIMEITEMPERATURE CONTROLS 3-202.14 1 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. L16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY * Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water 3-401.11A(1)(2) Eggs- mme is sec Animal Foods That are Raw,Undercooked or 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* 5-101.11 Drinking Water from an Approved System* * gg NotOtherwise Processed to Eliminate Equipment 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Effe�Ye 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 StuffingContaining Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 1 p 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 practiRequices should 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* 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* 1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 13 Handwashing Facilities 3-202.18 Shellstock Identification* 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 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 I 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. oF,NE rp TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of •y"p "Ot- 'OFFIC12 HOURS • BAR- NsrAB�Eo PUB2 0 LIC HEALTH N ST RETDIVISION 8:00-9:30 A.M. - 3:30-a:3o P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified Mass. $ - MON.-FRI. ,a�9,a m HYANNIS,MA 02601 soa-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY . 'EON1P` FOOD ESTABLISHMENT INSPECTION REPORT / ! " - �L �_ J Name /l C Datef I i e of Tvpe�Ftnsnection 1` Operations) ,Rine Address7-5 Risk Food=Service ion Level etail Previous Inspection Telephone 94terglUential Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness 7 Caterer General Complaint Person in Charge(PIC) ° Time Bed&Breakfast HACCP In: Other ., Inspector 1 Out: YV� 1 ,r 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) ❑ � f Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ A0 l Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands -�- ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMErrEMPERATURE 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 � V\ ❑7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP - ��� , ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) ® 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 Embar o checked indicate violations of 105 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 6=One critical violation and less than 4non-critical violations g (FC-4)(590.005) 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 C=2 critical violations and less than 9non-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 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. r within 10 days of receipt of this order. violation,4 to 8non-critical violations=C. 29.Special Requirements (590.009) Y p Print: Signature 30.Other PATE OF RE-INSPECTION: Inspector 31.Dumpster 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's ignature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N �--- Dumpster Screen? Y N 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 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods:* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 1 g 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* 87-102.11 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 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 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ) q Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-30.6.14(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* q 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 HermeticallySealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs,,. - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3 401.11A(1)(2) Eggs-155'F 15 sec dness* 22 3-603.11 Consumer Advisory Posted for Consumption of - -601.11 A Clean Utensils and Food Contact Surfaces of *"= Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System 4 * ( ) Eggs-Immediate Service 145'F 15 sec Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* EJf c6ve 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 3-0Ol.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency r f 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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- Ratites-165°F 15 sec* Sources* 10 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 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 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C * (Blue Items 23.30) - 3-202.15 Package Integrity ( ) Commercially Processed RTE Food-140°F 12 - Prevention of Contamination from Hands Critical and non-critical violations,which do not relate to the fuodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 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 Handwashin Facilities 3-501.14 A g 3-202.18 Shellstock Identification* g ( ) Cooling Cooked PHFs from 140°F to 70°F 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. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °p SHE Tok, TOWN OF BARNSTABLE - - HEALTH INSPECTOR's Establishment Name: "�, � Date: Page: -. of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNSTABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified HYANNIS,MA 02601 - MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY' ' ''Teo MPS� FOOD ESTABLISHMENT INSPECTION REPORT 508-862-4644 Name �. Date Tvne of Ins ec ion g Routine Address �� Risk Food ervic -nspection Level Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation J Owner HACCP Y/N Temporary Suspect Illness O®� Caterer General Complaint HACCP Person in Charge(PIC) \ Time Bed&Breakfast Other In: 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) ❑ 1 l lbw 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 C ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) 1714.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 OPULATIONS( ❑ 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) 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. RVoluntary 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. ❑ g ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health rnember 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 )( ) aggrieved y y g g q 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 Y y (FC-6 590.007 a rieved b this order,you have a right to a hearing. Your request must 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 8non-critical violations. If 1 critical refrigeration. = 29.Special Requirements (590.009) within 10 days of receipt of this order. violation,4 critical violations C. Inspec tor n t Print: 30.Other DATE OF RE-INSPECTION: ` 31.Dumpster screened from public view \V Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's nture 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* L 8 Cross-contamination 14 Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B)IDemonstration 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[0 7-102.11 Common Name-Working Containers* P g * 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* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* - Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q Contamination from the Consumer - 3 590.003(D) Exclusions and Restrictions*590.003(E) Removal of Exclusions and Restrictio 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Re or of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP ns Disposition of Adulterated ted 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 1 Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155'F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of * 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System * gg Not Otherwise Processed to Eliminate Equipment ( )O Pathogens* 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meals&Game g * Effect-1/I12001 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 Sanitization of Utensils and Food 3-401.1](A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surf 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 or590.009(A)-(D) 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g Violations of Section 590.009(A)-(D)in cater- * Ratites-165°F 15 sec* in mobile food,temporary and residential Sources 1p Proper,Adequate Handwashing g' P � Game and Wild Mushrooms Approved By * 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 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* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-4 ( )( )( )01.11 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 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne * 12 Prevention of Contamination from Hands 3-403.11E Remaining Unsliced Portions of Beef Roasts* 3-101.11 Food Safe and Unadulterated ( ) g illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 3-501.14 13 Handwashing Facilities Cooling Cooked PHFs from 140°F to 70°F (A) 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 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 Supplied with Soap and hand Drying Devices Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .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. Poisonous or Toxic Materials FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements .009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. °p INE ram, TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: / age: of ti OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNS'1'ABLE. • 200 MAIN STREET 3:M N.-F30 P.. Item Code. C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. 0g. HYANNIS,MA 02601 M-8 -FRI. '4 +bsq•a. 508-as2 as4a No Reference R-Red Item PLEASE KINT LEARLY 'FDN1P` 'FOOD ESTABLISHMENT INSPECTION REPORT Name Dad Tvoe of T f Inspection Operation(s) Rout1 Address Risk Irl od Servii Re-inspection Level Retal Previous Inspection Telephone Residential 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 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 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 Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Non-critical(N) ons mustimmediately or violations be corrected idiate) Corrective Action Required: ❑ No Yes Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,th items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations A=Zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations. If no critical violations observed, 25.Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food B=One critical violation and less than 4 non-critical violations 9 or more non-critical violations=F. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must water,sewage back-up,infestation of rodents or insects,or lack of C=2 critical violations and less than 4non-critical. If no critical 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address iolations obsery 7 to 8 non-critical violations=C. refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. DATE OF RE-INSPECTION: �Ins�pectoSi a re � Pri 30.OtherS�o 31.Dum ter screened from public view U Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N PI ! ' nature Print. (� Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N �,,,..:,... .a.:,.s _. ,f. . -,---...-..� �-___. -_.. - -_ _._. .,.Y.r � .> ---� ..far �d »w.."+-•'��..'L,J' 1C�'-'.'-'-.-�': " 'r � _ '����t.3.. rr.+, r^.r - 'S� ;.r�-.r`.1'� --.-'`r"'s-+r�'y�- .-'"""--�:s-+.:-r`.�._'sue-.+--w--.,- , 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. 2-103.11 Person-in-Charge Duties Cooked and RTE Foods.* 3-302.14 Protection from Unapproved Additives* 19 PHF Hot and Cold Holding Contamination from Raw Ingredients 15 Poisonous Identifying Information-Original 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 * 590.004(F) 2 590.003(C) Responsibility of the Person-in-Charge to Other* 7-102.11 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* Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation-Storage* 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 3-304.11 Food Contact with Equipment and Utensils* 590.004(11) Variance Requirements 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 7-203.11 Toxic Containers-Prohibitions* 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 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 Hermetically Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs - CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of Eggs-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eg cn"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 r f Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-20L14 Fish and Recreationally Cough[Molluscan Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009 A - D Violations of Section 590.009 A Chemical ( ) ( ) ( )-(D)in cater- Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11 C Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* ( )(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 17 Reheating for Hot Holding 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 practices should be debited under#29-Special 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. $ Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* Blue Items 23-30) 12 Prevention of Contamination from Hands Critical and non critical violations,which do not relate to the foodborne 3-101.11 Food Safe and Unadulterated* 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 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 3-202.18 Shellstock Identification* Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F * Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained Ih Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 I 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. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. y I/ / Date: i Pa � �p THE r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: S fur`/C�. I i�ZfT e: of 9 OFFICE HOURS rl'BA E. PUBLIC 2 0 MAIN DIVISION 3:30-4:30A.M. -. 3:30-a:3o F.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MA55. $ HYANNIS,MA 08-8MON -FBI. 5os-Ssz-asaa No Reference R-Red Item PLEASE PRINT CLEARLY 'F0N1A� FOOD ESTABLISHMENT INSPECTION REPORT Name Q Date Type of Inspection ry , J� p gLQ Boutin AddressRisk ood'Sic nspection ery I V`A 11,101 G S �j� Level Reta' Previous Inspection t Ffive Telephone esidential 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 F �� W, 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 leL 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 SUSCEP IBLE PULAT NS(li ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HS ❑ 10.Proper Adequate Handwashing - CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Non-critical N violations must be corrected immediate) or Corrective Action Required: ❑ No ( ) y 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 todWetems checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=Zero critical violations and no more than anon-critical violations. F=3 or more critical violations. n no critical violations observed, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations 9 or more non-critical violation 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 4 non-critical violations s=F. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 27.Physical Facility (FC-6 590.007 aggrieved by this order,you have a right to a hearing. Your request must water,sewage back-up,infestation of rodents or insects,or lack of )( ) C=2 critical violations and less than 4non-critical. If no critical refri eration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address violatio o ed, o 8 non-critic violations=C. 9 29.Special Requirements (590.009) within 10 days of receipt of this order. Inspector' �ignatur P� 30.Other DATE OF RE-INSPECTION: 31.Dumpster screened from public view �j 0 Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N PIC's Si 're #Seats Observed Frozen Dessert Machines: Outside Dining Y INPrin 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.* Additives* 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Contamination from Raw Ingredients 15 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At orBelow 41°F/45'F 59.0.004(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 g Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F Res onsibilit of the Person-in-Charge to 7-102.11 Common Name-Working Containers* * } Require Reporting by Food Employees and Contamination from the Environment * 3-501.16(A) Roasts Held At or Above 130°F * 7-20L11 Separation-Storage Applicants 3-302.11(A) Food Protection* * 20 Time.as a,Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Use 7-202.11 Restriction-Presence and 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(I1 Variance Requirements 590.003(G) Reporting by Person in Charge * 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ) q 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 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* TIMEITEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of Eggs 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of E s-Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef/"five 11111001 4-602.11 Cleaning Frequency of Utensils and Food ,+nimals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 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 practices 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirem ntts.ld 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* 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* 3-403.11(E) Remaining 12 Prevention of Contamination from Hands Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the g 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 3-203.18 Shellstock Identification g Item Good Retail Practices FC 540.000 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 () 9 9 27. Physical Facility FC-6 .007 7 Conformance with Approved Piocedures/ 6-301.11 Handwashing Cleanser,Availability / 28. Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1 1.009 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. HEALTH INSPECTOR'S Establishment Name: Date: Pag e: of dF � ��✓ ,.TOWN OF BARNSTABLE OFFICE HOURS: 3 � n,PUBLIC HEALTH DIVISION 8:00-9:30 A.M. EGA 200 MAIN STREET • 3:30-4:30 P.M. MON.-FRI. Item Code C=Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dateverified' nMA+��� HYANNIS,MA02601 508-862-4644 N0. Reference R-Red ItemPLEASE PRINT CLEARLY Name ' Datei . Type of T Ins ection o !R ' er outine Address Risk :Service- Re-i ection Level Previous Inspection Telephone Residential Kitchen Date: Mobile Pre-operation oq Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge (PIC) Time Bed & Breakfast HACCP In, Other I pector, Ald 1(2664' Out: i NWI violation hecked 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 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 ❑ 12. Prevention of Contamination from Hands ( ' ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS [12. 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) v ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures oev ❑ 5. Receiving/Condition El17. 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 A&10. Proper Adequate Handwashing i1.Good Hygienic Practices CONSUMER ADVISORY Al _ug ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Items) Critical(C)violations marked must be corrected immediately. Non- critical(N)violations must be corrected immediately or (blue&red items) within 90 days as determined by the Board of Health. Overall Rating Corrective Action Required: ❑ No ❑ Yes C N 23.Management and Personnel (FC-2)(590.003) Official Order for Correction: Based on an inspection today,the items 24.Food and Food Protection checked indicate violations of 105 CMR 590.000/federal Food Code. ❑Voluntary Compliance ❑ Employee Restriction/Exclusion ❑Re-inspection Scheduled El Emergency Suspension (Fc s>(sso.00a) j This report,when signed below by a Board of Health member or its 25.Equipment and Utensils (FC-4)(590.005) agent constitutes an order of the Board of Health. Failure to correct 26.Water, Plumbing and Waste (FC-5)(590.006) violations cited in this report may result in sus-pension or revocation of ❑Embargo ❑ Emergency Closure ❑Voluntary Disposal ❑Other: 27. Physical Facility (FC-6)(590.007) the food establishment permit and ces-sation of food establishment - -^- -- --' operations. If aggrieved by this order,you have a right to a hearing. A= Zero critical violations and no more than 3 non-critical violations. F= 3 or more critical violations. If no critical violations observed,. 28. Poisonous or Toxic Materials (FC-7)(590.008) 9 or more non-critical violations= F. Your request must be in writing and submitted to the Board of Health at B= One critical violation and less than 4von-critical violations. 29.Special Requirements (590.009) the above address within 10 days of receipt of this order. If no critical violations observed, 4 to 6 non-critical violations = B. Seriously Critical Violation = F is scored automatically if no hot water, 30. Other C= 2 critical violations and less than 4 non-critical. If no critical violations sewage back-up, infestation of rodents or insects, lack of refrigeration, or DATE OF RE-INSPECTION: observed, 7 to4non-criticalaf s=C. no PIC or alternate PIC present. Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered? Y N I ec rs ig rint: 3'. #Seats Observed Frozen Dessert Machines: Outside Dining Y N e-1'��� - Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y gnature Print: C. r -.�..-.•n. ._ ..._- __�"F\�Y.nas.•-_ _ -e- .tea.r.. -... - --f.. .-�.� _ M1 r-rls'1i�"'-'•4'.�F'.[-�r"i'�w/FJr.�.�-MaS=.i'.-�+.-r-- - .SI_ .'-.'SiKavow: � � _�-._..?Gi _s----s £_ �„ �z�i�- ..r r Violations Related to Foodborr#elness 3-501.14(C) PHFs Received at Temperatures Interventions and Risk Factors(Red Items 1-22) Violations Related to Foodborne Iness Interventions and Risk According to Law Cooled to PROTECTION FROM CONTAMINATION Factors(Red Items 1-22) (Cont) 41°F/45°F Within 4 Hours. FOOD PROTECTION MANAGEMENT 8 Cross-contamination 3-501.15 Cooling Methods for PIiFs 3-302.11 A 1 Raw Animal Foods Separated from PROTECTION FROM CHEMICALS 1 590.003 A Assi eat ofR Responsibility* - ( x ) �'Paza 19 PHF Hot and Cold Holding 590.003 B Demonstration of Knowledge* Cooked and RT Foods• 14 Food or Color Additives 3-501.16(B) Cold P11Fs Maintained at or below Contamination from Raw Ingredients 3-202.12 Additives* 2-103.11 Person in charge-duties g 590.004(F) 410/450 F* 3-302.11(Ax2) Raw Animal Foods Separated from Each 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above EMPLOYEE HEALTH Other' 15 Poisonous or Toxic Substances F.- Contantination from the Environment 7-101.1 1 Identifying Information-Original 140° 2 590.003(C) Responsibility of the person in charge to Containers* 3-501.16(A) Roasttss Held at or above 130°F. require reporting by food employees and ( 3-302.11 A Food Protection* applicants* I 3-302.15 Wash' Fruits and Vegetables 7-102.1 1 Common Name-Working Containers* 20 Time as a Public Health Control 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and 7-201.1 1 Separation-Storage* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Utensils* 7-202.1 1 Restriction-Presence and Use* - 590.004(11) Variance Requirement Charge* Contamination hom the Consumer 7-202.12 Conditions of Use* 590.003 G Reporting b Person in Charge* 3-306.14 A B Returned Food and Resemee of Food* 7-203.1 I Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 3 590.003D Exclusions and Restrictions' Disposition of Adulterated orContarmnated 7-204.11 Sanitizers,Criteria-Chemicals+ POPULATIONS(HSP) 590.003 Removal of Exclusions and Restrictions Food 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 3-701.11 Discarding or Reconditioning Unsafe 7-204.14 Drying Agents,Criteria* Beverages with Warning Labels* FOOD FROM APPROVED SOURCE Fps 3-801.1 1(B) Use of Pasteurized Eggs* 7-205.1 I Incidental Food Contact,Lubricants* d' Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206:1 1 Restricted Use Pesticides,Criteria* 3-801.1 I(D) Raw or Partially Cooked Animal Food and 4-501.111 Manual Warewashing-Hot Water 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served. 590.004 A-B Compliance with Food Law* Sanitization Temperatures* 3-801.11(C) Unopened Food Package Not Re-served. 3-201.12 Food in a Hermetical][ Sealed Container* 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* Sanitization Temperatures* CONSUMER ADVISORY 3-202.14 Eggs and Milk Products,Pasteurized* TIME/TEMPERATURE CONTROLS 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 22 3-603.1 1 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Water* concentration and hardness.* 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or 4-601.11(A) Equipment Food Contact Surfaces and PHFs Not Otherwise Processed to Eliminate 5-101.11 Drinking Water from an Approved S stem' Pathogens.* Enee e,n oo, Utensils Cleans 3-401.I I A(1)(2) Eggs- 155°F 15 Sec. g 590. A Bottled i Water* 4-602.11 CleaningFr of Equipment Food- 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 590. Water Meets Standards in 310 CNIR 22.0* Frequency Eggs-Immediate Service I Ssec* ShetYrsh and Fish From an Approved Source Contact Surfaces and Utensils 3-401.I I(A)(2) Comminuted Fish,Meats&Game ppO 4-702.11 Frequency of Sanitization of Utensils and * SPECIAL REQUIREMENTS 3-201.14 Fish and Recreationall Caught MolluscanEquipment* Animals-155°F 15 sec. Y � Food Contact Surfaces of590.009(A)-(D) Violations of Section 590.009(A)-(D)in Shellfish' 3-401.1l(B)(1)(2) Pork and Beef Roast-130°F 121 min*4-703.11 Methods of Sanitization-Hot Water and catering,mobile food,temporary and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical' 3-401.1 I(A)(2) Ratites,Injected Meats-155°F 15 sec. residential kitchen operations should be Sources' r to .: Proper,Adequate Handwashing debited under the appropriate sections Game and WMd Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms' 3-401.1 1(A)(3) Poultry,Wild Game,Stuffed PHI's, Regulatory A 2-301.12 CI Procedure- Stuffing Containing Fish,Mcat, above if related to foodbome illness 3-202.18 Shellstock Identification Present* = Poultry or Ratites- 15 sec.* interventions and risk factors. Other 590. C Wild Mushrooms' 2-301.14 When to Wash 590.009 violations relating to good retail it Good Hygienic Practices 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks g 3-201.17 Game Animals* 145°F* practices should be debited under#29- ' 5! Receiving/Condition 2-401.11 Ea or UsingTobacco, Special Requirements. 3-202.11 PHFs Received at Pr Temperatures* 2401.12 Discharges From the Eyes,Nose and 3-401.12 Raw Animal Foods Cooked in a P 9 Mouth* Microwave 165°F 3-202.15 Package In 3-301.12 Prevent Contamination When Tasting* 3-401.I I(A)(I)(b) All Other PHFs-145°F 15 sec.* VIOLATIONS RELATED TO GOODRETAIL 3-101.11 Food Safe and Unadulterated* (Blue Items 23-30) 12 .: Prevention of Contamination from Hands 17 Reheating for Hot Holding 6` TagslRecords:Shellstock Critical and non-critical violations,which do not relate to the 590.004(E) Preventing Contamination from 3-403.11(A)&(D) PHFs 165°F 15 sec.* oodborne illness interventions and risk actors listed above,can be 3-202.18 Shellstock Identification' I t Employees* 3-403.11(B) Microwave-165°F 2 Minute Standing found in the following sections o the Food Code and 105 CA4R 3-203.12 Shellstock Identification Maintained Handwash Facilities f f % � Tags/Records:Fish Products 13 Time* 590.000. Conveniently Located and Accessible 3-403.1 1(C) Commercially Processed RTE Food- R26. Good Retail Practices FC 590.000 3402.11 Parasite Destruction' S-203.1] Numbers and Capacities* 3�02.12 Records,Creation and Retention' 140°F* Management and Personnel FC-2 .003 590. J Labeling of Ingredlertts• 5-204.11 Location and Placement* 3-403.1 1(E) Remaining Unsliced Portions of Beef Food and Food Protection FC-3 .004 Conformance with Approved Procedures 5-205.11 Accessibility, lion and Maintenance Roasts* Equipment and Utensils FC-4 .005 7 Supplied with Soap and Hand Drying 18 Proper Cooling of PHFs Water,Plumbing and Waste FC-5 .006 MACCP PWns3-502.11 S alized Proces Methods' Dehces 3-501.14(A) Cooling Cooked PHFs from 140°F to Physical Facility FC-6 .007 6301.11 Handwashin Cleanser,Availabili Poisonous or Toxic Materials FC-7 .008 70°F Within 2 Hours and From 70°F 3-502.12 Reduced oxygen ,criteria* 29. Special Requirements 009 8-103,12 Conformance with Approved Procedures' 6 301.12 Hand Provision to 41°F/451F Within 4 Hours.* 1 30. 1 Other 3-501.14(B) Cooling PHFs Made From Ambient ss'nrcock-:ac Temperature Ingredients to 41°F/45°F Within 4 Hours* *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. �1 �.(HErq TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date: Page: of ' •Y� • OFFICE HOURS: . PUBLIC HEALTH DIVISION 8:00-9:30 A.M. = RARNBresr.e. 200 MAIN STREET 3:30-4:30 P.M. ,� MON.-FRI. Item Code C-Critical:lterh DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified u �� HYANNIS,MA02601 508-862-4644 No. Reference R-Red Item. PLEASE PRINT CLEARLY tov ' Name Date Type of T f Insipection ion s Routine Address Risk F ervic Rein ection Level ious Inspection Telephone Residential Kitchen Date: Owner HACCP Mobile Pre-operation kgm Rim Y/N Temporary Suspect Illness 6Per5on in Charge PIC Time Caterer General Complaint 9 (PIC) Bed & Breakfast HACCP In: Other -12 ector Out: violation checked requir s 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 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 ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEEHEALTH PROTECTION FROM CHEMICALS 112. 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 1120. Time Asa Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 1121. Food and Food Preparation for HSP is10. Proper Adequate Handwashing 11.Good Hygienic Practices CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Items) Critical(C)violations marked must be corrected immediately. Non- Total Number of Critical Violations critical(N)violations must be corrected immediately or (blue&red items) within 90 days as determined by the Board of Health. Overall Rating Corrective Action Required: ❑ No ❑ Yes . C N 23.Management and Personnel (FC-2)(590.003) Official Order for Correction: Based on an inspection today,the items ❑Voluntary Compliance Employee p Emergency p 24.Food and Food Protection (Fc s)(sso.00a) checked indicate violations of 105 CMR 590.000/federal Food Code. ry pliance ❑ Em to ee Restriction/Exclusion ❑Re-inspection Scheduled ❑ Emer enc Suspension This report,when signed below by a Board of Health iiiember or its 25.Equipment and Utensils (FC-4)(590.005) agent constitutes an order of the Board of Health. Failure to correct 26.Water, Plumbing and Waste (FC-5)(590.006) violations cited in this report may result in sus-pension or revocation of ❑Embargo ❑ Emergency Closure ❑Voluntary Disposal ❑Other: j 27. Physical Facility the food establishment permit and ces-sation of food establishment - -- Y y (FC 6)(5s0.o07) 3 or more critical violations. If no critical violations observed, 28. Poisonous or Toxic Materials (Fc-�>(sso.006> A= Zero critical violations and no more than 3 non-critical violations. F=operations. If aggrieved by this order,you have a right to a hearing. s or more non-critical violations= F. Your request must be in writing and submitted to the Board of Health at B= One critical violation and less than 4 non-critical violations. 29.Special Requirements (590.009) the above address within 10 days of receipt of this order. If no critical violations observed, 4 to 6 non-critical violations= B. Seriously Critical Violation = F is scored automatically if no hot water, 30. Other DATE OF RE-INSPECTION: C= 2 critical violations and less than 4 non-critical. If no critical violations sewage back-up, infestation of rodents or insects, lack of refrigeration, or observed, 7 to 8non-critical iolatio -C. no PIC or alternate PIC present. O Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered? Y N Ins S' a rin Seats Observed Frozen Dessert Machines: Outside Dining Y N _ Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y P S nature Print: r - - - -s +�+�-+v v..�:r.s.r.a:.. _.....-:,._,.. ..� �.� �-�-----�-.�,���7�,e,-�a`+cw.,of,.,�,t,.,,.''�.�5'. � �w v't• :.r+- ry,..,yti-�,. - iv- _'•�3'i ..v--+r_ �:.v-=..� +e.. �...H.:�rc,_�'-s�e"ri.s.... . r.._�.� .. ..,r- • i Violations Related to Foodbome Illness 3-501.14(C) em PHFs Received at Tpe'i cores interventions and Risk Factors(Red Rams 1-22) Violations Related to Foodbom0ness Interventions and Risk According to Law Cooled to PROTECTION FROM CONTAMINATION Factors(Red Items 1-22) (Con(.) 41°F/451F Within 4 Hours. FOOD PROTECTION MANAGEMENT 8 Cross-eontaminadon PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 1 590.003 A Assi ent ofR nsibili • 3-302.11(Axl) Raw Animal Foods Separated from 19 PHF Hot and Cold Holding 590.003 Demonstration of Knowledge « Cooked and RTE Foods* 14 Food or Color Additives 3-501.16(B) Cold PHFs Maintained at or below 2-103.11 Person in charge-duties Contarrrnadon from Raw Ingredients 3-202.14 Additives' 590.004(F) 41°/45°F* 3-302.11(Ax2) Raw Animal Foods Separated from Each 3-302.1 Protection from Unapproved Additives* Other* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above EMPLOYEE HEALTH 140°i'.« 2 590.003 C Responsibility of the person in charge to Contarnination from the Environment 7-101.1 1 Identifying Information-Original ( ) g 3-302.11 A Food Protection* Containers* - 3-501.16(A) Roasts Held at or above 130°F. require reporting by food employees and Time as a Public Health Control s 3-302.15 Was Fruits and Vegetables 7-101.11 Common Name-Working Containers* 20 applicants* 3-501.19 Time as a Public Health Control* 590.003(F) Responsibility Of A Food Employee Or An 3-304.I I Food Contact with Equipment and 7-201.1 1 Separation-Storage* 7-202.11 Restriction-Presence and Use* 5>0 0(1. 4(li) m _ -Variance Requiree n t Applicant To Report To The Person In Utensils* Charge* Contamination horn the Consumer 7-202.12 Conditions of Use 590.003 G Reporting b Person in Charge* 3-306.14 A B Returned Food and Reservice of Food. 7-203.1 1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE Da ofAduReratedorContarrrinated 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 3 590.003 D Exclusions and Restrictions` won * 21 3-801.1 1(A) Unpasteurized Pre-packaged Juices and 590.00 Removal of Exclusions and Restrictions Food 7-204.12 Chemicals for Washing Produce,Criteria 3-701.11 Discarding or Reconditioning Unsafe 7-204.14 Drying Agents,Criteria* Beverages with Warning Labels* Food` 7-205.11 Incidental Food Contact,Lubricants' 3-801.1 I(B) Use of Pasteurized Eggs FOOD FROM APPROVED SOURCE Food Contact Surfaces 3-801.11(D) Raw or Partially Cooked Animal Food and .�_.' Food and Water From Regulated Sources 9 7-206.1 1 Restricted Use Pesticides,Criteria* 8 Raw Seed Sprouts Not Served. 590. A-B Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 7-206.12 Rodent Bait Stations* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) I Unopened Food Package Not Re-served. 3-201.12 Food in a Herinetica][ly Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* CONSUMER ADVISORY 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 22 3-603.1 I Consumer Advisory Posted for Consumption of 3-202.14 Eggs and Milk Products,Pasteurized` * TIME/TEMPERATURE CONTROLS concentration and hardness. 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or 3-202.16 Ice Made From Potable Water* 4-601.11 A Equipment Food Contact Surfaces and PHFs Not Otherwise Processed to Eliminate 5-101.11 Water from an Approved System* ( ) Pathogens.*e"e°'°11001 Utensils Cleans 3-401.1 I A(1)(2) Eggs- 155°F 15 Sec. 590. A Bottled Water` 4-602.11 CleaningFrequency of Equipment Food- 1 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* eq y Eq pm Eggs-Immediate Service 145°PlSsec* 590. Water Meets Standards in 310 CUR 22.0* Contact Surfaces and Utensils* 3-401.1 1(A)(2) Comminuted Fish,Meats&Game She9(ish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and SPECIAL REQUIREMENTS 3-201.14 Fish and Recreational] Caught Molluscan Animals-1 of R 15 sec. Y uBh Food Contact Surfaces of Equipment* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in Shellfish* 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* catering,mobile food,temporary and 4-703.11 Methods of Sanitization-Hot Water and 3-401.1 1(A)(2) Ratites,Igjected Meats-155°P I5 sec. p ry 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* residential kitchen operations should be Sources* to Proper,Adequate Handwashing * debited under the appropriate sections Game and W1d Mushrooms Approved by .2-301.11 Clean Condition-Hands and Arms* 3-401.1 1(A)(3) Poultry,Wild Game,Stuffed PHFs, Stuffing Containing Fish,Meat, interventions and risk factors. Other above if related to foodborne illness R u/a Authority2-301.12 Cl Procedure' 3-202.18 Shellstock Identification Present* Poultry or Ratites-165°F 15 sec.* 590. C Wild Mushrooms` 2-301.14 When to Wash` 590.009 violations relating to good retail 11 Good Hygienic Practices 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 3-201.17 Game Animals* 145°p« practices should be debited under#29- 5 ReeeivinglCondition 2�01.1] Ea orUsin Tobacco* S ecial Re uirements. 2401.12 Discharges From the Eyes,Nose and 3-401.12 Raw Animal Foods Cooked in a p q 3-202.11 PHFs Received at Pr Temperatures* Mouth* Microwave 165°F 3-202.15 Package In • * 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-101.11 Safe and Unadulterated` 3-301.12 -Preventing Contamination When Tact (Blue Items 23-30) Food 12 Prevention of Contamination from Hands 17 Reheating for Hot Holding t5 TagslReeords'Shellstoek 3-403.11 A&D Critical and non-critical violations,which do not relate(o the 3-202.18 Shellstock Identification• 590.004(E) Preventing Contamination from ( ) ( ) PHFs 165°F 15 sec.* joodborne illness interventions and risk factors listed above,can be 3-202-18 Shellstoek Identification Maintained* Employees* 3-403.11(B) Microwave-165'F 2 Minute Standing found in the following sections of the Food Code and 105 CA4R Tags/Records:took Identification Fish Products 13 Handwash Facilities Time* 590,000. Conveniently Located and Accessible 3-403.1 1(C) Commercially Processed RTE Food- Item Good Retail Practices FC 590.000 3402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 140°F* 23. Management and Personnel FC-2 .003 3402.12 Records,Creation and Retention* 5-204 11 Location and Placement* 3-403.1 1(E) Remaining Unsliced Portions of Beef 24. Food and Food Protection FC-3 .004 590. J Labeling of ingredients' Roasts* 25. Equipment and Utensils FC-4 .005 Conformmance with Approved Procedures 5-205.11 SupplAccesed wi lion and Maintenance Supplied with Soap and Hand Drying lg Proper Coaling of PHFs 26. Water,Plumbing and Waste FC-5 .006 IHACCP Plans Devices 3-501.14(A) Cooling Cooked PHFs from 140°F to 27. Physical Facility FC-6 .007 3-502.11 S alized ProcessingMethods` 28. Poisonous or Toxic Materials FC-7 .008 * 6-301.11 Handwashin Cleanser,Availabili 70°F Within 2 Hours and From 70°F 2g, Special Requirements .009 3-502.12 Reduced oxygen with criteria 6-301.12 Hand Provision « 8-103.12 Conformance with vet Procedures* to 41°F/45°F Within 4 Hours. 30. 1 Other 3-501.14(B) Cooling PHFs Made From Ambient s:rniramaa k.-zm Temperature Ingredients to 41°F/45°F Within 4 Hours* *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 � i �w �1R. Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gauda noli,M.D. g 0AnNi AeLL :` Paul J.Canniff,D.M.D. MAW 0 � 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate 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: 257 Issue Date: 01/01/2021 DBA: OSTERVILLE VETERANS ASSOC. INC. OWNER: OSTERVILLE VETERANS ASSOCIATION INC. Location of Establishment: 753 MAIN STREET OSTERVILLE„ MA 02655 Type of Business Permit: RETAIL Annual: YES Seasonal: IndoorSeating: 35 OutdoorSeating: 0 Total Seating: 35 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2021 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: GQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: APPROVED 04-20-16 - 1.) There shall be no kitchen or food prep. 2.) If Hall is used, caterers must bring food, dishes, glasses and utensils. 3.) All pots, plates and utensils must be taken off-site for cleaning. Only:For Office Use Initials: Town of Barnstable 6Amt Pd$� 620 Date Pa : . Ae Inspectional Services id MASS' '639. Public Health Division AtFD MA'S A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPL''IICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE W NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: Neville I�Q�( S ADDRESS OF FOOD ESTABLISHMENT: -153 m ai o 6t - 111 Ile. 0 MAILING ADDRESS(IF DIFFERENT FROM ABOVE): P6 E20 lou E-MAIL ADDRESS: e I ! • (,CI ILI I�P,S t! CO N`C�S-�u (1 / TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (5 ) - g TOTAL NUMBER OF BATHROOMS: C WELL WATER:YES NO_X ...(ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO NUMBER OF SEATS: INSIDE: 36- OUTSIDE: 0 TOTAL: 3S 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)9 1"11,1 TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE c•lt fJ,A,,, o4aI j required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFASTCOTTAGE FOOD INDUSTRY(formerly residential kitchen) in,`k J 1 0 1 CO- das& W MOBILE FOOD `FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REOUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc I cf �,e a ,l OWNER INFORMATION: I FULL NAME OF APPLICANT Oxr�io �Yi-n es 5xa Dc�Q.��,11e mus &X-N SOLE OWNER: YES/NO OWNER PHONE# 50$=_3(07-,3130 ADDRESS 33a 2S S � CORPORATE OWNER: I -� e ` • CORPORATE ADDRESS: 63 �Ila,i n 4- PD Panv 1-1., e PERSON IN CHARGE OF DAILY OPERATIONS: 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. r I 2. - --/-/ SI NATU 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/applications.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.3I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Application FormsTOODAPP REV3-2019.doc Bellaire, Dianna From: neil.andres@comcast.net Sent: Tuesday, November 24, 2020 10:11 AM To: Bellaire, Dianna Cc: Scali, Richard Subject: Re: 2021 Retail Food Permit- Osterville Veteran's Association Donna - The Osterville Vets has been closed since March 16, 2020 and will not reopen until Gov. Baker approves phase 4 reopening. Our current food license will be unused for 10.5 months of 2020. We most likely will not open until at least June of 2021. It is my understanding that license fees will be deferred until we are allowed to open. We will be paying our other license fees at that time. Can the food license fee be deferred until opening or can we let the food license lapse and get one when we open? Things are tight and our book keeper has been furloughed. Neil Andres Osterville Vets On 11/23/2020, 4:48 PM Bellaire, Dianna<diaima.bellairegtown.barnstable.ma.us>wrote: Mr. Andres, I received your application and there wasn't a payment. You have a retail food permit with the Town of Barnstable. Please submit a payment of$100.00 for retail food permit. This should be a check made payable to the Town of Barnstable. Your application will remain in pending until I receive payment. Please be aware that your current permit expires at the end of the year. Please send payment to avoid late fees. Thank you. Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 i w p4 Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. BAPN AHM Paul J.Canniff,D.M.D. MAK �+ 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate 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: 257 Issue Date: 12/10/2019 DBA: OSTERVILLE VETERANS ASSOC. INC. OWNER: NEIL ANDRES Location of Establishment: 753 MAIN STREET OSTERVILLE, MA 02655 Type of Business Permit: RETAIL Annual: YES Seasonal: IndoorSeating: 35 OutdoorSeating: 0 Total Seating: 35 FEES FOOD SERVICE ESTABLISHMENT: YEAR. 2020 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: CQ� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: � a For Office Use Onlv: Initials: Town of Barnstable (�g� Q' Date Paid Amt Pd$ &"NSTABLE• Asa. : Inspectional Services _ Public Health Division Check# QED MAC s - Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 *. Office: 508-862-4644 Fax: 508-790-6304 ,j APPLICATION FORFOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL Y NAME OF OOD ESTABLISHMENT: Ds-E`e(Vr!�P, Y Pi�Q/rQiI�S �` Dn / ADDRESS OF FOOD ESTABLISHMENT: Main c5f Dif anI(16,�M�} MAILING ADDRESS(IF DIFFERENT FROM ABOVE): E-MAIL ADDRESS: Deg 1,afi r&5@ XM04 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 61—)W- TOTAL NUMBER OF BATHROOMS: _ WELL WATER: YES NOY— ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: OUTSIDE:Q 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. j� Q IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)9 TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) 4EBED& BREAKFAST CONTINENTAL BREAKFAST :COTTAGE FOOD INDUSTRY(formerly residential kitchen) M ` V INC' MOBILE FOOD III I FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) j 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 ty. / OWNER INFORMATION: FULL NAME OF APPLICANT I DA SOLE OWNER: YES/NO OWNER PHONE # I ADDRESS r CORPORATE OWNER: CORPORATE ADDRESS: �Sr� Mail) PERSON IN CHARGE OF DAILY OPERATIONS: 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 Manners Expiration Date Allergen Awareness Expiration Date "J(Z j� 2. 1 1 SIGNA 6RE 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 openine!! Please call Health Div.a: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 Civ. 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.asp. OUTDOOR COOKING: Outdoor cooking.preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec.31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:Wpplication Forms\=00DAPP REV3-2019.doc I w Town of Barnstable BOARD OF HEALTH } � Paul J Canniff,D.M.D. A.Ga Board of Health Donald A.Gaudagnoli,M.D. uwnh:rraOLL '+` John T.Norman 6 4 t 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate la��ato 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: 257 Issue Date: 12/20/18 DBA: OSTERVILLE VETERANS ASSOC. INC. OWNER: NEIL ANDRES Location of Establishment: 753 MAIN STREET OSTERVILLE MA 02655 Type of Business Permit: RETAIL Annual: YES Seasonal: IndoorSeating: 35 OutdoorSeating: 0 Total Seating: 35 FEES_ FOOD SERVICE ESTABLISHMENT: YEAR: 2019 RETAIL FOOD: $100.00 COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B- FULL BREAKFAST: CONTINENTAL BREAKFAST: -- --— MOBILE-FOOD: MOBILE-ICE CREAM: G'� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: 1 FOR ESTABLISHMENTS WITH SEATING: i f i PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: w FtHE ruy� For Office Use Initials: * o� Town of Barnstable Date Paid Amt Pd$ / l � MAIM Inspectional Services 1 `0 Check — 6 Public Health Division Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 w (l O Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE 7 NEW OWNERSHIP RENEWAL NAME d FOOD ESTABLISHMENT: G�1/lIA ADDRESS OF FOOD ESTABLISHMENT:�S� Mal n C*ppj- Z641, pf MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �� X0 A t ,.,,� E-MAIL ADDRESS: I I eI I • oj) �e5 cp tomca71• TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 6& -_OaO TOTAL NUMBER OF BATHROOMS: WELL WATER:YES N04 ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: 3,� OUTSIDE: TOTAL: 3 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) / Uhl BED&BREAKFASTS CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) �1�� JV�CQ G6t cz e, 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 y PLEASE CALL 508-8624644 OWNER INFORMATION:FULL NAME OF APPLICANT Om 9[[(�ad�5 0s6vaI66wks Pa&r SOLE OWNER:: YES L NO OWNER PHONE# 56- 30-3130 ADDRESS 33a 'r CORPORATE OWNER: U1ll2 FEDERAL ID NO. 04-901?3a4p CORPORATE AI)DRESS: -753 Main 51- Pb ftX (06 34erAle- PERSON IN CHARGE OF DAILY OPERATIONS: C�rne�LU� f1t �S 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 _SIGNATURE'_OF_APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks.must be inspected by the Health Div. Ono r to opening!! Please call Health Div.at 508-8624644 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.t6wnofbarnstable.us/hesithdivision/appiications.asi). 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 1st to Dec.31a each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1st. QAApplication FohnsTOODAPPREV2018.doc PERMIT NO: TOWN OF BARNSTABLE 01/01/2018 257 BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: NEIL ANDRES, PRESIDENT D/B/A: OSTERVILLE VETERANS ASSOC., INC - FOX HOLE Whose place of business is: PO BOX 661753 MAIN STREET, OSTERVILLE, MA 02655 Type of business and any restrictions: FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY: SEATING: 178 ANNUAL: YES SEASONAL: TEMPORARY: FEES BOARD OF HEALTH RETAIL FOOD STORE: $100.00 Paul J. Canniff, D.M.D, Chairperson FOOD SERVICE ESTABLISHMENT: Junichi Sawayanagi RESIDENTIAL KITCHEN FOR RETAIL SALE: Donald A. Guadagnoli, M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST MOBILE FOOD UNIT: Permit expires: <: TOBACCO: 12/31/2018 FROZEN DESSERT: Thomas A. McKean, IRS, CHO CATERER: Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE oTHE �R/`'Town of Barnstable Lkl FI 2 Regulatory Services ✓ �Sr,�M Richard V. Scah, Director s. BARNSTABLE � BA4HSfRBIF•C-00 VILLP•O]NR•MflJIH15 o +°`�� Public Health Division ��K�1639�4158ARNSaEE Thomas McKean,Director 575 b 200 Main Street, Hyannis,MA 02601 :;0 Office: 508-862-4644 J�, Fax: 508-790-6304 AS APPLICATION FOR PERMIT TO OPERATE A FOOD ESTbABLISHMENT DATE: NAME OF FOOD ESTABLISHMENT: 05+ Wlie 6M'5 A5WCIAnn �rAC,- ADDRESS OF FOOD ESTABLISHMENT: �53 Ina11n �3110GI �'s¢�1'lI{I,l� '1'I�� QZ(vS15 MAILING ADDRESS (IF DIFFERENT FROM ABOVE): PO -3O)( i!le., M A" 02lD.45,5' E-MAIL ADDRESS: n and yes c e -� a. o� TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( 05 ) - � NUMBER OF SEATS*: INSIDE: J D OUTSIDE: TOTAL: *Note: If indoor seating provided, see Licensing regarding common Victuallers License TOTAL NUMBER OF BATHROOMS: _ ANNUAL OR SEASONAL OPERATION: Gl' V TYPICAL HOURS OF OPERATION MON-FRI: :pD Pm TO OD Aft) DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) qDfle r IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD,SERVICE 30,h R n 4 0 n Oalt- _.�_RETAIL FOOD ao I` U I owocJ ED & BREAKFAST � CONTIN *IF BREAKFAST IF SEATING: ALSO,MUST OBTAIN RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) Q:W.pplication Forms\Foodappldoc >1 ***RENlMER*** IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANTnndre5 '-p.5p, psiai SOLE OWNER: YES/NO ADDRESS I�Q, �r 11 �� u'�S . rn PHONE # Q-7 BUJ IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PAR R irim 3;R 1A L.-h M6 a` &I 55 IF APPLICANT IS A ORPORATION: FEDERAL IDENTIFICATION NO.Q23a STATE OF INCORPORATION: I rt A FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) J- �`1• l ".IM.S STPJI)(�Y EXPIRATION DATE: —o, 2. EXPIRATION DATE: EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF. 1. IRATION DATE:1- k," it / lo/ 11 SIGNATURE OF APPLICANT AND DATE Q:\Application Forms\Foodapp3.doc Pr l PERMIT NO: TOWN OF BARNSTABLE ISSUE DAE 257 BOARD OF HEALTH 12/22/20, 6 III PERMIT TO OPSRATTV 0&-.ESTABLISHMENT In accordance wit11�'reg�� `s gat ,Tdhder�uxhority of Chapter 94, Section 395A and Chu pteY ctiwr-;5' he�aRe aws, permit is hereby granted to: "' D1fA�'-TT-6STEl - t Whose place of business is:` '_ Q=BOX 66/t5t - 1 05TILL , MA 02655 Type of business and any r-esfrfft-m: =t{OW,6Ei / STABLISF AI I�rty - �- . �-& T , To operate a food establisF�rt�ent intfie T �. _ �:�,� _ ABLE _- __• _: ..<�_'��=�i=_�-�ors= " �_; 1 f I RESTRICTIONS IF ANY: F e ti'= -' = =<: s- '�� csa -•: E J:: E SEATING: 178 ANNUALS �-ES�= SEASONAL: TEMPORARY; `t= - ,E E S �E-Z� �r4 zti' QARD OF HEALTH RETAIL FOOD STORE: 1 S F@o.00 l J.Canniff, D.M.D Chairperson FOOD SERVICE ESTABLISHMENT: f RESIDENTIAL KITCHEN FOR RETAIL SALE �.� - f�'- �, c i4' f' vrc J 111CI71 Sawayanagi RESIDENTIAL KITCHEN FOR BED+BREAKFA E " ' jG- _ � =` a i Donald A.Guadaqnoli M.D. MOBILE FOOD UNIT: - L 2 r'CrE1is_ e TOBACCO SALES: FROZEN DESSERT: Thomas A. McKean, RS, CHO CATERER: Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE I de ``�\ • ``�zz r .4 *wn of Barnstable t° t�r Regulatory Services �� AST �xx�A . = Richard V. Scali, Director BARNSTABI,E CC#3iQ 1639. 0. Public Health Division 16� � � cr xs3s-aoxa Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 s APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENTLq DATE: NAME OF FOOD ESTABLISHMENT: C61wi lle �e4tms AScoClaffl,sic, ADDRESS OF FOOD ESTABLISHMENT: 753 main c+ Po &X 6 pwll(��M� E-MAIL ADDRESS: nal dresLD ea.sfham-- M, 40V TELEPHONE NUMBER OF FOOD ESTABLISHMENT: NUMBER OF SEATS*: INSIDE: .3s OUTSIDE: TOTAL: 35 * Note: If indoor seating provided, see Licensing regarding Common Victuallers License TOTAL NUMBER OF BATHROOMS: _ ANNUAL OR SEASONAL OPERATION: 6WUkUA)-11 TYPICAL HOURS OF OPERATION MON-FRI: TO �_: DO AM DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD __II ED & BREAKFAST 5 a D l K,Jug C:�ee5� CONTINENTAL BREAKFAST *IF SEATING: ALSO MUST OBTAIN RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICENSE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) ***REMINDER*** IF OUTSIDE_DINING,YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT�m���(] ��m bkik Le�06klw' Tic. SOLE OWNER: YE''`�S/NO II__ W �- ADDRESS ,I-3Q ma%Ai Dr PHONE # (0)q,53_- LII'357 IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL PARTNERS: r 5 , c�kilfo' 66 L C-)eavnr �� q 13 gff 't! 2J. C'dCTi►�e �d -I�e� -�Py irt 55 fnfec Ral, IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. (7 - b T7 3,� STATE OF INCORPORATION InA FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LI T T[HE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) .- riinz EXPIRATION DATE:/jD-/-ls— 2. EXPIRATION DATE: EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** LIST THE NAME OF YOUR CERTIFED FOOD ALLERG AWARENESS TRAINED STAFF. 1. E I TIrZ;4 / SIGNATURE URE OF APPLICANPAND DATE Q:Wpplication Forms\Foodapp2.doc PERMIT NO: TOWN OF BARNSTABLE ISSUE DATA: i 257 BOARD OF HEALTH January 1, 201 PERMIT TO O *FE-firF' STABLISHMENT In accordance wr ytigatur arhority of Chapter 94, Section 395A and C fi5 'cti5 e e '- a = ermit is herebyranted to: �_ A. SOUZA PRESIDENT/N d :r DI", STER ANS ASSOC. INC -FOX HOLE �f'D �_ Whose place of business is OX 66/ - U�� E MA 02655 Type of business and anyik rr"s: EIfI� TABLISF , To operate a food establishr�ient inhhe T r ABLE Y. RESTRICTIONS IF ANY: Mf"`E S _ SEATING: 178 Y .F�- �,s .�_ € c t ANNUAL: S— t, � ._- SEASONAL: TEMPORARY; k € t k E E S -q- OF HEALTH RETAIL FOOD STORE: 0.00 lr �� FOOD SERVICE ESTABLISHMENT: "� �' ( Miller, M.D., Chairperson �.-. a , � ri. f� C .-3` t'� '-t Ew"wwe� RESIDENTIAL KITCHEN FOR RETAIL SALE: !ss J.Canniff, D.M.D. "4! - r RESIDENTIAL KITCHENFOR BED+BREAKFA � '�' nichi SawaVanagi r } MOBILE FOOD UNIT: • errl " S �/ I TOBACCO SALES: `' . !AC ` �€ O FROZEN DESSERT: Thomas A. McKean, RS, CHO CATERER: Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE #wn of Barnstable , �l Regulatory Services Richard V. Scali, Director j� j BAMS ABLE. $Alit�j�j 3 9LE K"S. Public Health Division �p059. 64-'.4 ► " Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: If 1 Z 15 NAME OF FOOD ESTABLISHMENT: &fe,0116 V06&R5 A wc� � fi n - ADDRESS OF FOOD ESTABLISHMENT: 353 N?Q,in 5f� PL)OO ( P Vi'!le E-MAIL ADDRESS: n a. )dj-e5 re eaA —w a., qpq TELEPHONE NUMBER OF FOOD ESTABLISHMENT: `� _ �5D$ )7Z$ �l8'D!D NUMBER OF SEATS*: INSIDE: 3,,S- OUTSIDE: TOT AL: * Note: If indoor seating provided, see Licensing regarding Common Victuall re ardin C �— TOTAL NUMBER OF BATHROOMS: rA ers License ANNUAL OR SEASONAL OPERATION: a4U4_LA0J, TYPICAL HOURS OF OPERATION MON-FRI: L4 : OO PM TO l : OD AVM DAYS CLOSED EXCLUDING HOLIDAYS (I.E.MONDAYS) n01-a— IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO / / 'REMINDER " SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE FOOD a/;7, VLG�l11'l 4a�L— RETAIL BED&BREA KFAST 4� W M f I k S01 Ce CONTINENTAL BREAKFAST *IF SEANG: AL t nSO,MUST OBTAIN RESIDENTIAL KITCHEN A COMMON VICTUALLER'S LICEN SE MOBILE FOOD FROM LICENSING DIVISION. TOBACCO SALES FROZEN DAIRY DESSERT MACHINES _ CATERING OUTSIDE DINING (OVER) ***REMINDER*** IF OUTSIDE DINING YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING.AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: I '(' r FULL NAME OF APPLICANT_ j� A re j)a,4 �s4 ,�f t ile Up�'i-Pl t,S �55�,J tc, SOLE OWNER: YES/NO ADDRESS 3 3a OnrjAsik PHONE#lffj q68'- d7S 5 IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS . ►�1�y5 �_nGk25 3aa 0-tyJ54-Ir u , yicQ es l rnrrh 134� iki 1 Z�ryj" (e_ wY�i -1,reasure� IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO.04-oZO-J,3,ilj STATE OF INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) I - �1c5 1�ns 1 ew J EXPIRATION DATE: 2. EXPIRATION DATE: / / EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT.THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF. 1. EXPIRATION DATE: / / SIGNATURE OF-APPLICANT-AND.DATE- Q:\Application Forms\Foodapp2.doc I OWN OF BARNS I ABLE ISSUE DAIIJ. 177 257 BOARD OF HEALTH January 1, 201 PERMIT TO OPE =ESTABLISHMENT In accordance wit u W�- e ippthority of Chapter 94, Section 395A and C t ct s, .permit is hereby granted to: , 3 A. SOUZA PRESIDENT/ Neil , s OSTER S ASSOC. INC -FOX HOLE 7$1;xWhose place of business is 66 I sTFUT , O .,MA 02655 Type of business and any s#r;: fABLIS . To operate a food establi ent in he _ ABLE . RESTRICTIONS IF ANY: �y MIMPR J > : SEATING: 178 ANNUAL S = SEASONAL: TEMPO E E s � ARV OF HEALTH RETAIL FOOD STORE: 00.00 rMlller, M.D., Chairperson ai FOOD SERVICE ESTABLISHMENT: - 00 +' RESIDENTIAL KITCHEN FOR RETAIL SALE. J. Canniff, D.M.D. RESIDENTIAL KITCHEN FOR BED+BREAKF T rt r J ichi Sawavanagi `. MOBILE FOOD UNIT: r S � TOBACCO SALES:" FROZEN DESSERT: _ Thomas A. McKean, IRS, CHO CATERER: Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE 12.Town of Barnstable Regulatory Services Richard V. Scali,Director �" BAMSTABLE A Public Health Divisional .r 1659. .� 16T9-29ta ► +" 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: I( 1. 4 NAME OF FOOD ESTABLISHMENT: D(SifTi Ie �1"Gt.kS a550CIQ�1D11 �in�' ADDRESS OF FOOD ESTABLISHMENT: -75?j "A s E-MAIL ADDRESS: I)CMd reS LP ea&[ha m-ma., q c q TELEPHONE NUMBER OF FOOD ESTABLISHMENT: NUMBER OF SEATS*: INSIDE: 35 OUTSIDE: TOTAL: * Note: If indoor seating provided,see Licensing regarding tommon.Victuallers License TOTAL NUMBER OF BATHROOMS:_A ANNUAL OR SEASONAL OPERATION: 6U'1A Wd TYPICAL HOURS OF OPERATION MON-FRI: 00 TO I :_Ott AM DAYS CLOSED EXCLUDING HOLIDAYS (I.E.MONDAYS) Y1 PtL IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO 'REMINDER " SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE _�&BED&BREAKFAST RETAIL FOOD CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES DESSERT MACHINES _ ,,FROZEEAIRY CATEOUTSDINING (OVER) • ***REMINDER*** IF OLhSIDE DINING,YOU MUST BE APPROVED BY THE HEALTH DIVISION AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT CV0611US res 1>86t as6yille Ut'T2.1m+sASSEzr htc SOLE OWNER: YES/NO ADDRESS J I,l 3P ) 5de_ Or ), j�2• !'1,Sf&b rnPf PHONE# 9 5cF- b"j$ IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNE 5:10s A, 1 L t r- 7 C115 I ff_-� v(,lle IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. - STATE OF 'INCORPORATION MPf FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD AND CONTINENTAL BREAKFAST): EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO CERTIFIED FOOD PROTECTION MANAGERS. AT LEAST ONE CERTIFIED FOOD PROTECTION MANAGER IS REQUIRED TO BE ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON EACH OF THE CERTIFICATES*** LIST THE NAMES OF YOUR CERTIFIED FOOD PROTECTION MANAGERS (I.E. SERVSAFE.) 1• A A n shecU j, ?,- EXPIRATION DATE:/ (b / 201-a 2• EXPIRATION DATE: / / EFFECTIVE FEBRUARY 1, 2011 EACH FOOD ESTABLISHMENT THAT COOKS, PREPARES, OR SERVES FOOD INTENDED FOR IMMEDIATE CONSUMPTION EITHER ON OR OFF THE PREMISES SHALL HAVE AT LEAST ONE CERTIFIED FOOD ALLERGEN AWARENESS TRAINED STAFF MEMBER. *** PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** LIST THE NAME OF YOUR CERTIFED FOOD ALLERGEN AWARENESS TRAINED STAFF. 1• XPIRATION DATE: l�� aOl SIGNATURE OF APPLICANT AND DATE n Q:\Applicacion Forms\Foodapp2.doc �� , 257 BOARD OF HEALTH January 1, 2014 PERMIT TO OPERAT-;A::F.OQD,,ESTABLISHMENT In accordance with regtdtipps proiulgatemtilrrdex at�tltprity of Chapter 94, 1. Section 395A and Chapt�r4lll $ECfQnene# �Tav§,axmit is hereby granted to: A. SOUZA, PRESIDENT/Neil ArridKsE ,�.QSTERVI t-,Lft & RAOS.ASSOC., INC - FOX HOLE Whose place of business is: /753_ ►►45I-RE€T,,. OSrtERVLLI,E,�114 02655 v E Type of business and any restIridIb `r Fd@tVE !$LISHNtF1fi' , To operate a food establishn erft in the' TOV{ LE RESTRICTIONS IF ANY: • SEATING: 178 ANNUAL: SEASONAL: TEMPORARI OF HEALTH RETAIL FOOD STORE: MYIler, M.D., Chairperson FOOD SERVICE ESTABLISHMENT: F ,_.fiailG�B� - x ;.x' Canniff, D.M.D. RESIDENTIAL KITCHEN FOR RETAIL SALE: J£ RESIDENTIAL KITCHEN FOR BED+BREAKFAST � i5richl SaWaVarlagl MOBILE FOOD UNIT: TOBACCO SALES: + it l e:il21� ai " FROZEN DESSERT: _ .. "' `" Thomas A. McKean, IRS, CHO CATERER: Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE Town of Barnstable 0411iE'°h Regulatory Services Barnstable P� Thomas F. Geiler, Director MAmedca City * BARNSTA�BLE, q MAC. Public Health Division Ile � �AlFi)39 2007 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: d1 i NAME OF FOOD ESTABLISHMENT: ( UdksociAon ADDRESS OF FOOD ESTABLISHMENT:-757j Mo ��' P��IjX � �-P,rVt��P l►L�►_ MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP:APARCEL(S) TELEPHONE NUMBER OF FOOD ESTABLISHMENT: Sg) qAgSOIL NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: 17Y. TOTAL NUMBER OF BATHROOMS: 7/ ANNUAL OR SEASONAL OPERATION: TYPICAL HOURS OF OPERATION MON-FRI: : DD Pm TO DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY l � FOOD SERVICE ' RETAIL FOOD BED & BREAKFAST CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER) QAHealth\Application Forms\Foodappl.doc *** **� REMINDER IF OUTSIDE DINING, YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS.AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: FULL NAME OF APPLICANT (/S e SOLE OWNER: YES / 1 �0U a�l�' ADDRESS PHONE # - � IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION rn� FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DO NOT PREPARE FOOD ' AND CONTINENTAL BREAKFAST): LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. -AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS R QUI_RED ONSITE DURING ALL POURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** 1• EXPIRATION DATE: / / 2• EXPIRATION DATE: 3 EXPIRATION DATE: / / 4. IRATION DATE: / / -SIGNATURE OF APPLICANT AND DATE Q:\Health\Application Forms\Foodappl.doc Akwn of Barnstable �oF +e t°j+ti Regulatory Services Barnstable Thomas F. Geiler,Director snxxseABM `" 9$ MASS. �r Public Health Division 2007- 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: 1 1 oZ 7 NAME OF FOOD ESTABLISHMENT: ©5feal'1 e �cfipwaA5 A5eoc;t*on mac_ ADDRESS OF FOOD ESTABLISHMENT: 753 N)a r) 5f- 015 ef- , e. MA MAP AND PARCEL,OF FOOD ESTABLISHMENT: MAP: '1.4/ PARCEL(S) hI S TELEPHONE NUMBER OF FOOD ESTABLISHMENT: Lon 7a8- g g0(o NUMBER OF SEATS: INSIDE: 1-7a OUTSIDE: D TOTAL: 17 F TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: Anoo&L, TYPICAL HOURS OF OPERATION MON-FRI: 4:0D PM TO I:DD RnY) DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) I16YtQ-., IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE - prt p4c6tFA6nack -mods, m i Ik,J �- RETAIL FOOD BED & BREAKFAST CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY-DESSERT MACHINES CATERING OUTSIDE DINING (®AVER) Q:\Health\P.pplication Forms\Foodappl.doc -' ^" ***REMINDER*** IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: n fVC a/h M 1 VJ6— FULL NAME OF APPLICANT Co�nel n, �fey ee5iJe C)Aery ll 1 US � P � � �,4eraAs .4 N J z a03- ssocj on, r'Kc. SOLE OWNER: YES /NO ADDRESS a i - Pp A?53 ft11 h �o �Co OS vac /t� PHONE.# IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF L PARTNERS: , . Roz ele 1 ,'C) t.c.Sot -- .t r ` rieta ` i AM.3. �o� its �I .res -Prc i�n�- 33� "side U. W � Abird_ a wad 5- ice Presj,, W IsqI Maih sf Lofu►+ R ba *rw-u - TreAsy�e zso �Iaa�bwn Rd. N1a -1>�s Mi As IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. 014-Ao7734(p STATE OF INCORPORATION IY)A FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DON'T PREPARE FOOD AND CONTINENTAL BREAKFAST): t� LIST THE NAMES OF YOURYOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** o k)Df r awe. 1. EXPIRATION DATE: / / 2. i EXPIRATION DATE: / / 3. EXPIRATION DATE: 4. EXPIRATION DATE: / / 0633NA OF ICANT AND DATE Q:\HealtRApplication Forms\Foodappl.doc • — S'v kS A. 1 V r�11 V1 17Q1 lil{,�iL11G 19 ulatory Services sue. `mamas F. Geiler,Director ector " STABIZ, Public Health Division Thomas McKean,Director d� 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: NAME OF FOOD ESTABLISHMENT: OSTe(V1�'e ],�e .rancS Y1 SS�C% �tG ADDRESS OF FOOD ESTABLISHMENT:153 ro ain POBoX (06p D ill MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP: PARCELS) J TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ✓vo ► - gO�P { NUMBER OF SEATS: INSIDE: V OUTSIDE: TOTAL: 118 7� TOTAL NUMBER OF BATHROOMS: . , , At Fiff ANNUAL OR SEASONAL OPERATION: Ctfin TYPICAL HOURS OF OPERATION MON-FRI: bD TO DAYS CLOSED EXCLUDING HOLIDAYS (I.E.MONDAYS) ,AptA— IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO / 1 ***REMINDER*** _ SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TOI OPENttGC - TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY Un FOOD SERVICE RETAIL FOOD ' BED &BREAKFAST co � CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING (OVER=-+) QAHealtWLpplicadon Forms\Foodappl.doc - r RENHNDER IF OUTSIDE DINING,YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED.FOR OUTSIDE DINING?" IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: " ( [ C FULL NAME OF ICANT��et�i Ile �f4e /,A5 SOLE OWNER: YE /NO ADDRESS M &C IIke, PHONE# - _ IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PAR RS•' &g U% 1 66trest �A .�� - iga �- IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. Oq OlNb STATE OF,INCORPORATION FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DON'T PREPARE FOOD AND CONTINENTAL BREAKFAST):. � Gee LIST THE NAMES OF YOUR FOOD SANITATION CER STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 20049 EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION 'CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** 1. EXPIRATION DATE: 2. EXPIRATION DATE: 3, EXPIRATION DATE: / I 4. EXPIRATION DATE: SIGNATURE OF APPLICANT AND DATE QAHealdAApplication FormsToodapp I-doe PERMIT-NO OWN OF BARNSTABLE 12/28/2005 257 BOARD OF HEALTH A, PERMIT TOO � BLISHMENT In accordance W. r t o �< R to tt gut pity of Chapter 94, Section 395A and ,e 0 ctioyaws el mit is hereby granted to: ROBERT A. SOUZA,P S f OSTERF ,.»ET NS ASSOC. INC FOX HOLE Whose place of business i 66/ ill O 4 A 02655 Type of business and any res:rr t10 ABLISH . Pa To operate a food establis er4in he T( il sz, & ABLE RESTRICTIONS IF ANY AONRT SEATING: 178 ANNUAL. A S ,� x • a, 1A. Rr SEASONAL: TEMPORAR F E S McK y D_OF HEALTH RETAIL FOOD STORE: a�i Miller,M.D., Chairperson FOOD SERVICE ESTABLISHMENT 150 016 RESIDENTIAL KITCHEN FOR RETAIL SALE or Kaufman, M.S.P.H. RESIDENTIAL KITCHEN FOR BED+BREAKFAST' e MOBILE FOOD UNIT: jAs x� san Rask, R.S. . TOBACCO SALES: ,� Q/>, FROZEN DESSERT: CATERER: ° Thomas A. McKean, RS,CHO Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE � I own of Barnstable q 02-9 Regulatory Services _ ;YAO co ` Thomas F. Geiler,Director • BARNSTABLE, • Public Health Division 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: NAME OF FOOD ESTABLISHMENT: pSTPiyI e. lLajl.S IT�SIi�:IG� DIl, G• ADDRESS OF FOOD ESTABLISHMENT: 2 53 Mari, 5t PO Box lol0 C6 arvdle MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP:J_4 _PARCEL(S) D I5' TELEPHONE NUMBER OF FOOD ESTABLISHMENT: c5o� - ggOl� NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:.94A�A 17F TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: 6Lx A LIAL, TYPICAL HOURS OF OPERATION MON-FRI: :00 Pm TO _:AM DAYS CLOSED EXCLUDING HOLIDAYS (I.E.MONDAY5) IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR T C) OPRAIING C; -c C - TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY < in > FOOD SERVICE RETAIL FOOD BED &BREAKFAST , CONTINENTAL BREAKFAST j rn RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING OUTSIDE DINING Q:\HealthlApplication Fo=\Foodappl.doc IF OUTSIDE DINING YOU MUST BE APPROVED BY THE BO* F HEALTH AND O LICENSING, AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DININGT IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: ��L �1 . FULL NAME OF APPLICANT (�-AerVi lle ��PrG.vbs t'C�S50G1`Gt-�O� -T-KC. SOLE OWNER: ®/NO ADDRESS Main J+- Po Sox (P& Ds4-arville m A� PHONE# 9 90(O IF APPLICANT IS A ,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: �eJv��. D IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. o?o72.3:R O STATE OF INCORPORATION rn FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENT$ THAT DON'T PREP Y,FOOD AND CONTINENTAL BREAKFAST): Cflryl �eretc�. �PS Gtre oneOG�� � Vim- y LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 20049 EACH FOOD SERVICE.ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE- NAME OF THE ESTABLISHMENT ON. THE CERTIFICATE*** 1. EXPIRATION DATE: / 2. EXPIRATION DATE: / / 3. EXPIRATION DATE: 4. EXPIRATION DATE: SIGNATURE OF APPLICANT AND DATE QAHcalth\4plicadon Fmrms\Foodappl.doc i PERMIT NO: TOWN OF BARNSTABLE JANUARY 1, 2005 257 BOARD OF HEALTH 4� PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter 111,Section 5 of the General Laws, a permit is hereby granted to: ROBERT A. SOUZA, PRESIDENT D/B/A: OSTERVILLE VETERANS ASSOCIATION, INC FOX HO Whose place of business is: 753 MAIN STREET, P.O. BOX 66 , OSTERVILLE, MA 02655 Type of business and any restrictions: FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY: SEATING: 178 ANNUAL: YES SEASONAL: TEMPORARY: F E E S BOARD OF HEALTH RETAIL sr : Wayne Miller, M.D., Chairperson FOOD SERVICE ESTABLISHMENT: $250.00 RESIDENTIAL KITCHEN FOR RETAIL SALE: Sumner Kaufman, M.S.P.H. RESIDENTIAL KITCHEN FOR BED+BREAKFAST Susan Rask, R.S. MOBILE FOOD UNIT: Permit expires: TOBACCO SALES: December 31, 2005 FROZEN DESSERT: Thomas A. McKean, IRS, CHO CATERER: Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE I 'own of Barnstable • oFn+e rows Regulatory Services pcb), ,A o; Thomas F. Geiler,Director RECE -D �'"M MASS. Public Health Division 0 9• ♦0 Thomas McKean, Director 1,- ' 4 2004 200 Main Street, Hyannis,MA 02601 TOWN Ur ihitil._ Office: 508-862-4644 FakFAN 79 -b3U_ w APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: a D NAME OF FOOD ESTABLISHMENT: OS-�er�c`[le 'LTQ r15 t'[SSOCI(,PSI l D11, 'tC . ADDRESS OF FOOD ESTABLISHMENT: -7,5 3 Ma 60 P© J ox (p(p DS-I e- V I de— MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP:A I PARCELS) d� TELEPHONE NUMBER OF FOOD ESTABLISHMENT: NUMBER OF SEATS: WIS11 OUTSIDE: TOTAL: I'75 TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: A W kt, TYPICAL HOURS OF OPERATION MON-FRI: 60 Pm TO DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE _; ; RETAIL FOOD ' BED &BREAKFAST CONTINENTAL BREAKFAST > r; RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES ! ' FROZEN DAIRY DESSERT MACHINES f ry CATERING OUTSIDE DINING (OVER—+) QAHealth\Application FormsToodappl.doc • ***REMINDER*** • I OUTSIM'DINING YOU MUST BE APPROVED BY THE BOARD OF HEALTH AND LICENSING AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? CONTACT INFORMATION: ii FULL NAME OF Ar?LICANT �S ,I'Ut�l e �fGI'Gtl')sS�L'I GIfM, SOLE OWNER: 00 Oq_c)b7 ? 0 ADDRESS PHONE #(29 4& - q gDlo IF APPLICANT IS A PARTNERSHIP, FULL NAME AND HOME ADDRESS OF ALL PAR HERS: `�� _Lr "V,' Pre-5'tdof 6l1 Pres a 5 S� & v��' IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. Ao773a� STATE •F INCORPORATION S FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DON'T PREPARE FOODAND CONTINENTAL BREAKFAST): csr LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE . FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** 1. EXPIRATION DATE: / / 2. EXPIRATION DATE: 3. EXPIRATION DATE: / / 4. lei EXPIRATION DATE:— AA / p / 7-SIG-NATURE OF APPLICANT;AND DATE Q:\HealthWpplication Forms\Foodappl.doc PERMIT NO TOWN OF BARNSTABLE • JANUARY 1 2004 257 BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: ROBERT A. SOUZA, PRESIDENT D/B/A: OSTERVILLE VETERANS ASSOCIATION, INC FOX HO Whose place of business is: 753 MAIN STREET, P.O. BOX 66 , OSTERVILLE, MA 02655 Type of business and any restrictions: FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY SEATING: 178 ANNUAL: YES SEASONAL: TEMPORARY: FEES BOARD OF HEALTH RETAIL FOOD STORE: Wayne Miller, M.D.,Chairperson FOOD SERVICE ESTABLISHMENT $170.00 RESIDENTIAL KITCHEN FOR RETAIL SALE Sumner Kaufman, M.S.P.H. RESIDENTIAL KITCHEN FOR BED+BREAKFAST Susan Rask, R.S. MOBILE FOOD UNIT: Permit expires: TOBACCO SALES: December 31, 2004 FROZEN DESSERT: Thomas A. McKean, RS, CHO MILK: CATERER: Director of Public Health NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE ��1 i *Town of Barnstable oFt r Regulatory Services Thomas F. eiler, 1 t Rrz G ,Director � BA"SrnsM . a`�� Public Health Division \� DEC 1 5 2603 Ea'AP� Thomas McKean,Director TOwry of�r, 200 Main Street, Hyannis,MA 02601 HEALTH DEP T"`�`E Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE: tf W03 NAME OF FOOD ESTABLISHMENT: ©,5tervdle VeTefm-s 4550Ci'A' '00, -Tk-C: ADDRESS OF FOOD ESTABLISHMENT: -7,63 M a M 5 t- pb a X o& 05+erV1'11 e. MAP AND PARCEL OF FOOD ESTABLISHMENT: MAP:I�PARCEL(S) TELEPHONE NUMBER OF FOOD ESTABLISHMENT: 5( 0g) o��" - Foo NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL:�� TOTAL NUMBER OF BATHROOMS: ANNUAL OR SEASONAL OPERATION: 6LK-- VAL TYPICAL HOURS OF OPERATION MON-FRI: `l : 00 PM TO I : 00 AM DAYS CLOSED EXCLUDING HOLIDAYS (I.E. MONDAYS) nor e L IF SEASONAL: APPROXIMATE DATES OF OPERATION: / / TO / / ***REMINDER*** SEASONAL ESTABLISHMENTS MUST CALL FOR INSPECTION PRIOR TO OPENING TYPE OF ESTABLISHMENT: PLEASE CHECK ALL THAT APPLY FOOD SERVICE RETAIL FOOD ° BED & BREAKFAST CONTINENTAL BREAKFAST RESIDENTIAL KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DAIRY DESSERT MACHINES CATERING (OVER---4 ) OUTSIDE DINING QMealth\Application Forms\Foodappl.doc w ***REMINDER*** IF OUTSIDE DININ&OU MUST BE APPROVED BY TOARD OF HEALTH AND LICENSING,AND MEET ALL OF THE OUTSIDE DINING CRITERIA IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? r Y CONTACT INFORMATION: k!8cu4sA6socj'Aon,:(A—c f�FULL NAME OF APPLICANT o5��141e RD A SOLE OWNER: YE f NO ADDRESS2 00 666AKL19 'fZr 9 27�—x PHONE#C__) - IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PAR IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. a6773d(p STATE OF INCORPORATION M FOOD SERVICE ESTABLISHMENTS CONDUCTING FOOD PREPARATION (EXCLUDES RETAIL FOOD ESTABLISHMENTS THAT DON'T PREPARE FOOD AND CONTINENTAL BREAKFAST): a LIST THE NAMES OF YOUR FOOD SANITATION CERTIFIED STAFF (I.E. SERV-SAFE) EFFECTIVE JANUARY 1, 2004, EACH FOOD SERVICE ESTABLISHMENT IS REQUIRED TO HAVE AT LEAST TWO FOOD SANITATION CERTIFIED STAFF. AT LEAST ONE FOOD SANITATION CERTIFIED STAFF IS REQUIRED ONSITE DURING ALL HOURS OF OPERATION.***PLEASE PUT THE NAME OF THE ESTABLISHMENT ON THE CERTIFICATE*** 1. EXPIRATION DATE: / / 2. EXPIRATION DATE: 3. EXPIRATIOl�. DATE: 4. EXPIRATION DATE: / / SIGNATURE OF APPLICANT AND DATE :�HealthW lication FormslFooda l.doc Q PP PP FBERA N OF BARNSTABLE 0 JANUARY 1,2003 BOARD OF HEALTH PERMIT TO OPERATE,AFOOD ESTABLISHMENT r In accordance with re.gulat►ons promulgated nnderauthority of Chapter ermit is her Q tQ� ection 395A and Chapter n" Section 5 of the General Laws,a p Y g U ,PRESIDENT a r 3: D/B/A; f�$TEVItLE'�/ETERANS ASSOCIATI N C f' usiness is: 753 MAIN STRO P OX 66 , OSTERVILLE, MA 02655 s and any restrrctwrsRVICE ESTABLISHIV[ENTTo operaeaod establlshrnent In the TOlt1FN OF=SARNSTABLE RESTRICTIONS IF ANY SEATING: 178 ANNUAL YES 61, SEASONAL: TEMPORARY P3E E s .... BOARD OF HEALTH RETAIL FOOD STORE: Susan G. Rask, R.S.,Chairperson FOOD SERVICE ESTABLISHMENT �DOt� R*h A. Murphy,M.D. RESIDENTIAL KITCHEN FOR RETAIL SALE ,: Sumner Kaufman,M.S.P.H. RESIDENTIAL KITCHEN FOR BED+BREAKFAST r Peml#eX[ fCeS MOBILE FOOD UNIT: TOBACCO SALES: mber31, 2003' omas A. McKean, RS, CHO FROZEN DESSERT: Th MILK: Director of Public Health CATERER: NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE Own of Barnstable F E Regulatory Services ° g Thomas F. Geiler, Director '^ MASS. " Public Health Division 'q i63 ♦0 PIED N A Thomas McKean,Director 367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Renewal: No Fee 7 Z SEATING �O ��4 ANNUAL_ SEASONAL ASSESSORS MAP AND PARCEL NO. DATE /Ir .`;?- APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT FULL NAME OF APPLICANT 5" :i �¢. t in NAME OF FOOD ESTABLISHMENT� �E ADDRESS OF FOOD ESTABLISHMENT E A Z- � GZGS�l TELEPHONE NUMBER (L-0446- 9966 TYPE OF ESTABLISHMENT: FOOD SERVICE_RETAIL FOOD MILK BED AND BREAKFAST CONT.BR. RES.KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DESSERT CATERING SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO.4-2.622-IL6a STATE OF INCORPORATION M4S5. FULL NAME ND H M ADDRESS OF: PRESIDENT E R EkId-4UZI-S TREASU R CAA- 0 2M SEL P, 04 11 CLERK E2 ( , L i SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS dga/�& 6�6 Q w 0swdl'v HOME TELEPHONE# "996b Foodest/wp/q i S Own of Barnstable LA °� oFt►+E T Regulatory Services Thomas F. Geiler,Director ''' MIAS B Public Health Division 9� 163�q. ,0� �1 ArED 39. 0. Thomas McKean,Director 367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Application Fee: $50.00 ' SEATING_ ANNUAL V SEASONAL ASSESSORS MAP AND PARCEL NO._I ! �DI S DATE // 7 O/ APPLICATION FOR PER//--MIT TO OPERATE A FOOD ,OD ESIT�ABLISHMENT FULL NAME OF?PPLICANT NAME OF FOOD ESTABLISHMENT S e. ADDRESS OF FOOD ESTABLISHMENT -7 r-3 Main Sf Po Box (off O�r GI.e, TELEPHONE NUMBER TYPE OF ESTABLISHMENT: FOOD SERVICE / RETAIL FOOD MILK BED AND BREAKFAST CONT.BR. RES.KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DESSERT CATERING SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. o qa STATE OF INCORPORATION NA FULL NAME YHC�ME ADDRESS OF: PRESIDENTA sDt c er�i 1 0 05feriji'l le TREASURER ef&W . " 6 I,1 S CLERKly SIGNATURE OF PPLICANT RESTRICTIONS: HOME ADDRESS ' E0U! HOME TELEPHONE# 66 2 99 8 Foodest/wp/q I PERMIT NO OWN OF BARNSTABLE • JANUARY 1, 2001 257 BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: ROBERT A.SOUZA,PRESIDENT D/B/A: OSTERVILLE VETERANS ASSOCIATION, INC. Whose place of business is: 753 MAIN STREET , OSTERVILLE, MA 02655 Type of business and any restrictions: FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY: SEATING: 125 ANNUAL: YES SEASONAL: TEMPORARY: F E E S BOARD OF HEALTH RETAIL FOOD STORE: Susan G. Rask, R.S.,Chairperson FOOD SERVICE ESTABLISHMENT: $170.00 RESIDENTIAL KITCHEN FOR RETAIL SALE: Ralph A. Murphy, M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST: Sumner Kaufman, M.S.P.H. MOBILE FOOD UNIT: Permit expires: TOBACCO SALES: December 31, 2001 � FROZEN DESSERT: Thomas A. McKean, RS, CHO MILK: Director of Public Health CATERER: NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE PERMIT NO TOWN OF BARNSTABLE JANUARY 1, 2000 257 BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter 111,Section 5 of the General Laws,a permit is hereby granted to: ROBERT A.SOUZA,PRESIDENT D/B/A: OSTERVILLE VETERANS ASSOCIATION,INC. Whose place of business is: 753 MAIN STREET, OSTERVILLE, MA 02665 Type of business and any restrictions: FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY: SEATING: 125 ANNUAL: YES SEASONAL: TEMPORARY: FEES BOARD OF HEALTH RETAIL FOOD STORE: Susan G. Rask, R.S.,Chairperson FOOD SERVICE ESTABLISHMENT: $170.00 RESIDENTIAL KITCHEN FOR RETAIL SALE: Ralph A. Murphy, M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST: Sumner Kaufman, M.S.P.H. MOBILE FOOD UNIT: Permit expires: TOBACCO SALES: December 31, 2000 � FROZEN DESSERT: Thomas A. McKean, RS, CHO MILK: Director of Public Health CATERER: NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE ' CF 1NE Tp� - Town of Barnstable O Department of Health, Safety, and Environmental Services ► BAMSfABLE. t"A� s639. ,fi Public Health Division 9� g A'FD1A0rA P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health SEATING ANNUAL 1,1" SEASONAL ASSESSORS MAP AND PARCEL NO. /yL-,QI DATE jj aS APPLICATION FOR PERMIT TJ)O�� OPERATE A FOOD ESTABLISHMENT FULL NAME OF APPLICANT OSf P- 16`(.>ce V e7e any ral 00�G�,/l NAME OF FOOD ESTABLISHMENT Ater✓��l.e Wtera s iqs as �eLi i1 c, ADDRESS OF FOOD ESTABLISHMENT 753 main Sf- PUA &X (P& WknItt � TELEPHONE NUMBER 5cfS' q7 (S- I TYPE OF ESTABLISHMENT: y' FOOD SERVICE RETAIL FOOD BED AND BREAKFAST CONT.BR. RES.KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DESSERT CATERING SOLE OWNER: YES_J/ NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARTNERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO.OV-a0773Xo STATE OF INCORPORATION ffiasSackw-A FULL NAME AND H ADDRESS O PRESIDENT 0 Uf 65k(wle UJ,Bic► s°fad Os�Mtllp- TREASURER cS 2ad v?So AJe.w-16wn iU &Y( CLERK ,(,e &-&eAdd Z7,1 T N - - A kP (� SIGNAT RE OF APPLICA a) RESTRICTIONS: HOME ADDRESS ® ��C G, HOME TELEPHONE# foodest/db/q FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT $170.00 NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE RESIDENTIAL KITCHEN FOR RETAIL SALE SEATING: 125 RESIDENTIAL KITCHEN FOR BED+BREAKFAST MOBILE FOOD UNIT: ANNUAL: YES TOBACCO SALES: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: _ MILK: �IeOv TOWN0. O��ARNSABLE�, 7 3 i011 y f BOARD OF�HEALTH PERMIT,TU PIERATEIA FOOD 1=5 i BL.ISHMENT PERMIT NO: 257 JANUARY 1 1999 In accordance w>Gtf regulatjo s prom IgatM under authority,of Chapter 94, Section 396A and Chapter 1'! '; ent noV "d'the General Lavis a permit is hereby granted to: ROBERT A. SOUZA, PRESWENT 4 .. D/B/A: OSTERVILLE VETERANS NC 3. 4., °k Whose place of business is,4q 753�MAIN STREET r, OSTS RVILLE,,„M Of 2655 Type of business and anyrestr,cwe"gtions: FOO :SERVIE ESTABL�IISIMENT To operate a food establishme t i N' I !AB r TOiNI 'OFF B�►RNStABLE Permit expires: December 31 1999 2� BOARD OF HEALTH Susan G. Rask, R.S., Chairperson Ralph'A. Murphy, M.D. RESTRICTIONS IF ANY: Sumner Kaufman, M.S.P. . Thomas A. McKean, RS, CHO Director of Public Health � I l FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT S770.00 NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE RESIDENTIAL KITCHEN FOR RETAIL SALE SEATING: 125 RESIDENTIAL KITCHEN FOR BED+BREAKFAST MOBILE FOOD UNIT: ANNUAL: YES TOBACCO SALES: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: MILK: m= ' TQWT OFBARNSTABLE� k3 BOARD�OF HEALTR PERMIT�TO OPERATE A FOOD ESTABLISHMENT 'k PERMIT NO: 257 f £4 -' 3 JANUARY 1, 1998 xi�ljll � x In accordanch' regulatwns proj"Nmulgated:und ewtt er authority of Chapter 94, Section 395A and:'Chapter 1 Section 5�of the General Laws, a permit is hereby granted to: ROBERT A. SOUZA PRESWENT 4AS . D/B/A: OSTERVILLE VETERANS SSOCtA`1ON INC. g ilo Whose place of business is:- 753,MAIN STREET C3S�ERVILLE, MA 02655 Type of business and any�rrestrl�cUons• FOOD�S,ERVICE ESTABLISHMENT 7 "' -4 r To operate a food establish rhen TOWN OF BARNSTABLF Permit expires: December 31199$, � � BOARD OF HEALTH Susan G.Rask, R.S., Chairperson Ralph A.Murphy, M.D. RESTRICTIONS IF ANY: Sumner Kaufman, M.S.P.H. Thomas A. McKean, RS,CHO Director of Public Health FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT $170.00 NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE RESIDENTIAL KITCHEN FOR RETAIL SALE SEATING: 125 RESIDENTIAL KITCHEN FOR BED+BREAKFAST MOBILE FOOD UNIT: ANNUAL: YES " TOBACCO SALES: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: �. MILK: TOWq Q 1 AFk, BLE,a BO R OE HEAV7 37 PERMIT; T PE RATE A FOCSD EST`JBLISHMENT 77 PERMIT NO: 257 p JANUARY 1, 1997 41 g. wn In accordance with regulaons pro mulga id under authority of Chapter 94, Section 396A and Chapter �c ae�, tthe General Laws, a permit is hereby granted to: g ROBERT A. SOUZA, PRESIDENT j .: : D/B/A: OSTERVILLE VETERANS- S &kf64" c w Y _ Whose place of busine .`n skis 53 MAIN S� , , TERVILLE,40OZ6§6 Type of business•and.an res ions: FOO[KS g#V CE ESTBk SENT To operate a food establish .A N BC r Permit expires: •'December3 97 - �":• BOARD OF HEALTH Susan G. Rask, R.S.,,Chairperson t _ - Brian R.Grady, R.S. RESTRICTIONS IF ANY: .�- Ralph A. Murphy, M.D` M. • _y T' - S W 't _ .w �,�.;,53-G.r�wv �r�.Y:Y`.a�..:,... .s.4..• s.:a.. F� .»..+ �a`2 � .. "�' ...w'"s'SS� ''.,x,,";.y,z.y •._,,,, � i �� Thomas A.McKean;, ` CHO RM S` ♦ f O ..��.. .0 . D i njcto of Public Health . - .: ,..- •4r':<.s: - a a- ,., c.- ..x _"'4.'«;•`.i'{e• yzS... i:G FM. k_'".,_ rt'i• ;.�+ `' TY- 'q.! : do._�r'`i-:` i, :%.;' -i ,>.,;_,.,:. rf:!-.°,a,.�' r-..: ,.�,_.. rS"?�.• �,c�..;..�.[. ?•.,.�,c... ..a•vww.-. ti+.:_.;,..,S ss `. ,. ." .k.:•.u... .. �... c....._�; -.-a:.,,. w._.�..,.i_.......�.. ...,. _.-:.w� +- -Y. .. •....- �2:.+��L7.:,7Yt,. _v.':�';�f.+.�"", .x..'•: .�,s'e• _ys,ysy��<.aa.�-. .y._..e. i .r .-.;_: ,`^^�; �` �" # _� ^:.•e•'�.c s�,�f- h..+�, '.z'x 1"'.,:;�wf+3a`:r^:r.:` *�,. sk - ' ' s` x`•,i;.., :M- "s*.>s .:.rye �.", '�„�,,•a. ;, `","? '.`" �-:�" -_ . .. -. - .. ' s - .� - -. FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT: $125.00 NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE RESIDENTIAL KITCHEN FOR RETAIL SALE: SEATING: 125 RESIDENTIAL KITCHEN FOR BED+BREAKFAST: MOBILE FOOD UNIT: ANNUAL: Yes TEMPORARY FOOD ESTABLISHMENT: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: MILK: TOWN OF BARNSTABLE BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NO: 257 JANUARY 1, 1996 In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter 111, Section 5 of the General Laws, a permit is hereby granted to: ROBERT A. SOUZA, PRESIDENT D/B/A: OSTERVILLE VETERANS ASSOCIATION, INC. Whose place of business is: 753 MAIN STREET , OSTERVILLE, MA 02655 Type of business and any restrictions: FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE Permit expires: December 31, 1996 BOARD OF HEALTH Susan G. Rask, R.S., Chairperson Brian R. Grady, R.S. RESTRICTIONS IF ANY: Ralph A. Murphy, M.D. Thomas A. McKean, R.S., CHO r Director of Public Health SEATING: 125 FEE SEASONAL: NO RETAIL: FOOD: $200.00 MILK: DESSERT: TOWN OF BARNSTABLE BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NO. 257 JANUARY 1, 1995 In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General laws, a Permit is hereby granted to: ROBERT A. SOUZA, PRESIDENT D/B/A: OSTERVILLE VETERANS ASSOCIATION, INC. Whose place of business is: 753 MAIN STREET , OSTERVILLE, MA 02655 Type of business and any restrictions: FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE Permit Expires: December 31, 1995. BOARD OF HEALTH Brian R. Grady, RS, Chairman Susan G. Rask, RS Joseph C. Snow, MD Thomas A. McKean Director of Public Health io d a - SEATING: 125 FEE RETAIL: FOOD: $200.00 MILK• 0. TOWN OF BARNSTABLE BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NO. 261 JANUARY 1, 1994 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: ROBERT A. SOUZA, PRESIDENT D/B/A OSTERVILLE VETERANS ASSOCIATION, INC. Whose place of business is at 753 MAIN STREET, OSTERVILLE, MA r Type of business and any restrictions FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE Permit Expires DECEMBER 31, 1994 BOARD OF HEALTH Brian R. Grady, RS, Chairman Susan G. Rask, RS Joseph C. Snow, M.D. Thomas A. McRean Director of Public Health r SEATING: 125 FEE RETAIL: FOOD: $187 .50 MILK TOWN OF BARNSTABLE BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NO. 283 JANUARY 1, 1993 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: JAMES DOWNEY,PRE. D/B/A OSTERVILLE VETERANS-FOX HOLE Whose place of business is at 753 MAIN STREET, OSTERVILLE, MA Type of business and any restrictions FOOD SERVICE ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE Permit Expires DECEMBER 31, 1993 BOARD OF HEALTH Susan G. Rask, Chairman Joseph C. Snow, M.D.. Brian R. Grady Thomas A. McKean Director of Public Health "V SNATI:CG: 125 ANNUAL NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 129 $1II7.50 . . . .. . .. 7.0h11. . . . . of . . A.I.:FST t: .. .. .. . . .. . . .. .. ..... Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. .. . .129. ... . .. .. .jANIUARY. 1, . 19. .�?. In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: OSi RVILLE, VETF1it;�NS ASSOCIATION, INC. N)%B/A FOX HOLE.., , , , , .„ . . .. .„. . Whose place of business is . . . . .75A �NIN STREET, OSTERVILLE Type of business and any restrictions . . . . . .Vgglq .S RVICF. FSTA LZSHMEl�1T ,, ,, ,, ,, , , ,, , , TOW To operate a food establishment in . . . . . . . . .. . .. OF BAR�;STAB... . .. .. (City or Town) Permit Expires . ,N71 CFMBEP. 31,, , , , ,.19.. .. . . . . .. . . .. . . . . . . .. .. .. .. .. ....... .. ... Copy Board This Copy To Be Retained By Local Of Board of Health. Health . . .. . . . . . . . . . . . . . . .. .. . . . . .. .. .. . ... .. . FORM 738 HOBBS&WARREN,INC.-1986 r. SF>NTING: 125 , NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 238 MITI B MNS E —_�DL7.50 . . .. . .. .. . . . . I . . . . of . . . . . . . . . . .. . . . . . . . . . . .. .. .. .. .. .. . Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. .. . .. .. .. 238 Januaxn�. 1., . . 19. 91 . . . . . .. .. . . . In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: Cas v LT>E TFOMANS AASX.T, SIC, d/b/a FOX 110T,E . . . . . . .. .. . . . . . . . . . . .. .. . . . . . . .. . . .. . . . . . . . . . . .. .. .. .. . . . . . . . . . . . . .. .. .. . . . . . . . . . . . . . . . 753 Main Street, Oster ll Whose place of business is . . . . . . . . . . . . . . . .. .. . . . . . . . . . . . . . . .. .. .. . . . . .. .. .. .. .. .. .. . .. FOOD M.VICE ESTABLIST t Type of business and any restrictions . . . . . . . . . . .. .. . . . . . . . . . . . . .. .. .. .. .. .. .. . . . . . . . . . . ... To operate a food establishment in . . .. .. .. .. . . .. . . . . . . . . . . . . .�.PJ OF � (City or Town) Permit Expires . . . . . � 31 4 . . 19.31. . ATT14 JANE ESHRAUG1, OiAIR.?WN Copy �t1gkf 1t i . . . . . . . . Board This Copy To Be Retained By Local ,. . . . . . . . . .0, ..` �. !, ,,,,, ,, ,, ,, , , , , ,, , Of Board of Health. { Health FORM 738 HOBBS&WARREN,INC.-1986 �nt 125 Now NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS ?97 $187.50 Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. .. .19.7.. .. . . January lr 19.g .. In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: .. . . . .0=7! T. -8. . E713'MANS. ROM�. .. .. .. .. .. .. .. .. . . . . . Whose place of business is . . . . . . .. . . . . . . . . . . . . . . .. . . . . .. .75. Main .Street �stexville BISSTAMISSIDIENTI Type of business and any restrictions . . . . . . . . . . . . . . . . . . .. I.�. ...�� `"'. . . . . To operate a food establishment in . . . . . . . . . . . . . . . . . . . . .. r'".... .I. . .. f�At. .... .?3I+E (City or Town) Permit Expires .. .. . . '"Eli .31#. . 19.90 . Grover C.FZ. rarrish, xi.O. Chairman. .. . . . . . . . . . . . . .. . . .. . . .. .. . . . . . Copy ;?ttie. � Board This Copy To Be Retained By Local e itl u ? t +a�'1 of Board of Health. Health FORM 738 HOBBS&WARREN,INC.-1986 Agent L 1 101 NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS �g 9125.00 ... ... . ..Tt*:71-4.. . .. of . .. . . .. .. .. . .. . .... .. . Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. . .q7 ... . .. . In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: !;c,rFvt►T?,T:.r �1E.TFPA FOX )ii?LE.. ... . . ... .. .. .. .. . ... ... Whose place of business is . .. . ... . .. .. .. ... . . ..... .. . .?t?{n, t);P.P Qs erville., ,.,,. Type of business and any restrictions . . .. . . .. .. ... . . . ..kQQD. S.UVjetE0'.17MARLT,S?TSENT To operate a food establishment in . . .. .. .. .. . ... .. .. . . 1Q N. .0.I,:.DAVI STAUZ,, ,, ,, , ,, ,,,, (City or Town) Permit Expires . . .1)eeeatber.$1, . . . . 19.$9. . F:-,.-rris :,M.D... . lai?Arman COPY :..T.^r..� .R rb.:.: ... .... .. ... . . . . Board This Copy To Be Retained By Local .1•amer>•H.- Crocker,. Sr. of Board of Health. Health FORM 738 HOBBS&WARREN,INC.-1986 Agent f/. • se-t lrLg 12� NOW NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS 62 $125.00 ... .. ......Town .. of ...Ba.rnstrble. ... .. . .. .. .. .. .. ... Board of Health of I PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. .. .. .... ... . November.2?. . . . In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: Oaterville Veterans Assoc. ,Inc. d�b�a Fox hole / Whose place of business is !1`in Street, Ostervilie Type of business and any restrictions Food Service Establishment To operate a food establishment in .. .. .. .. .. .. .. . .. .. ... .Toxm, of.Barnstable.. ,. . .. . ... (City or Town) December 31 B13 � Permit Expires . . .. .. . ... .. .. ... ... .. 19.. .. . Grover C.M. 1':'arrish, M.D. Chairman Copy Ann Jane Eshbaugh .. .. .. .. .. .. . Board This Copy To Be Retained By Local 3afiie; Cr©Cher of Board of Health. Health FORM 738 HOBBS&WARREN,INC.-1986 A 4 I 6'� v+caa al7v• iLJ NUMBER FEE ` 56 THE COMMONWEALTH OF MASSACHUSETTS $125.00 TOWN 0 BARNSTABLE Of Board. of Health of PERMIT TO OPERATE A FOOD SERVICE ESTABLISHMENT Se tember 12 86 P Permit No. -•-------•------------------ .......... -- i IIn accordance with Regulations promulgated under authority of Chapter 94, Section 305A j and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: OSHERVILLE VETMWS ASSOC. INC., d/b/a FOX HOLE ------------------------------------------------------------------------------------------------------------------- -------------------- ................................... Whose place of business is ....................................................MAIN STREET, OSTERVILLE....-•...... Type of business end..any..xutrictxans...................................Food... er#icP...Eskabliahment-_.-- To operate a food service establishment in......................... own of Barnstable.........___..._..._._... -•-- ---- -- ----------- - (City or Town) Permit Expires .................DECEMBER 11, 19..87.. Robert L.--Childs, Chairman ----- ----------•----- Ann Jane Eshba.. . ............... Board Copy Grover C,.M. Farrish. tM.D. _ of Ik . --f. --..._ This Copy To Be Retained By Local _-,-_------ Health Boardof Health. ................................................................. i ......................... •--•--------.......-•'--............................ FORM 73'B HOBBS&WARREN, INC. AGENT ' I I SEATING• 125 NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS i v � �— m ofnRTicmAT'T 15 _..._.__... .__•__.......... .�:::.i�.'.]�2......................... Board. of Health of PERMIT TO OPERATE A FOOD SERVICE ESTABLISHMENT Permit No- ............................ ---*��-v �m_..a_g319• ;5 In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: ._©CT'G'A ��7.--�s•• •u-u 'TC A�t+r?�n rr?� ._.�"�f'_ /;....-. T'n�F�._'''�T 3`.................................... ............. •-.---•.--. �- a.3...ca:�'�:crvr..-�.a�sy c.. t}7-� ..._...-•._-,.;... ir:,:a�, Whose place of business is ----..............................................'Spa-s't. S??'ET s ��TEg�VILI<E--•--.-.----.- Type of business ....................................... ............................... nn uF TrrCl;•- ?n ;vT•5?'�' ?T .... To operate a food service establishment in.................. .......................... (City or Town) Permit Expires ..................1-Z,i�..'j-"�"r -.11 v...19..-0& ..................................•-------•-----•..............•-•.-------•-... Copy ................----.......................................................... Board This Copy To Be Retained By Local .........-•--•-•.............•--•---........-----••-••-•............--••--.... of Board of Health. .................... Health FORM 73B HOBBS&WARREN, INC. / AGENT i i c�'c�" 1 V 1 ' No. N �, L� - �- Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade 00 Abandon( ) ❑Complete System '`Individual Components Location Address or Lot No. 3 3 N1ai t $}��5frr Vi�� Owner's Name,Address,and Tel.No. GS /Gc ✓,-,{cv-eah S +5 SoL,c hz" Assessor's Map/Parcel 4-j sr /y/ Ge%0/5' Ro 64 . p kry,1 _ . nio_ s 0 Z ASS Installer's Name,Address,and Tel.No. s'C{Qp 3d-6 Designer's Name,Address,and Tel.No.C�o�s-77/`7S6Z bt`VGe l'lQ1.00.l�,�S I6 f II 3Cj�' 3e c/%,- �tiG �AJ'licLGr/wf � Jn..UYlILY/kf IeW�I` [ E' Noe- G ht ►►14`' ✓azo-'-Ql Type of Building: Dwelling No.of Bedrooms Lot Size /Z,.353/t sq.ft. Garbage Grinder(�) Other Type of Building 6 tu_A^ a/( No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) %6 Z 9pef y 24, `?Zc/gpd Design flow provided gpd Plan Date y//3�/� Number of sheets Revision Date Title S_ A.S 12L p4j, Size of Septic Tank 15D0 1(0ns Type of S.A.S. 4z a-r-h,LS G ta-m hcr>i J�anG Description of Soil Q e (,y 0'1 l Loin &W1 v,Icer Nature of Repairs or Alterations(Answer when applicable) /Ze h/ems •-koc-, JC?CX> /Orf5 ev,r4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board af Health. Signed Date / Application Approved by Date Application Disapproved by / Date for the following reasons �y v td Permit No. Date Issued � II In f *F � Fee s. THE COMMONWALTH OF MASSbCHUSETTS 1 Entered in computer: ' �� r r 1,.at_ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLk;i4MASSACHUSETTS _ application for Disposal 6pstem Consti•urtiarr VermI :it, Application for a Permit to Construct( ) Repair( ) Upgrade(* Abandon( ) ❑Complete System 5&dividual Components Location Address or Lot No. '75 3 M14(H 5�,(��(zrui(�� Owner's Name,Address and Tel.No. f1 i i5 So a Assessor's Map/Parcel /y/ Q�/O/$ D 64 f3 hw iI k O Z�.`S Installer's Name,Address,and Tel.No. ;Ce• 3. 6 Designer's Name,Address,and Tel.No. Sc?S—WI—756Z -ZfvCe- �-A cc-C 1�551<� II 3c165 r /�yG �~f/,zLlrlh� S $Vr&,cy,hf ! 1c3111ti ST 72 No +44 c r,i uc 6Zev0 Type of Building: y Dwelling No.of Bedrooms Lot Size /Z.39/t sq.ft. Garbage Grinder(I1f Other Type of Building r „�,F� a// No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ylo 2 qp f y Z4= 9Zy gpd Design flow provided &.8' gpd Plan Date Number of sheets Revision Date S/T//4, Title Size of Septic Tank 15eo ca.l(otis Type of S.A.S. �c e clt,k4 G/i a m ht � S/A0iyG f Description of Soil Nature of Repairs or Alterations(Answer when applicable) -k e, iogo yk//a /each p,f s cut 14 /LGt ,n6 --k am h-ers 15/i," a S/o' )c /2'X Z rhr 4yard /2 1D/6 i i Date last inspected: Agreement: j The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board IHealth. / Signed Date 9,4�, �, f Application Approved by Date C�— IC1, 6 O Application Disapproved by Date for the following reasons d o N Permit No. Date Issued -------------------------------------------------------------------------- --- -------------------------------------- -------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by S�1�i`r 1 �� c Co c\S/Sirr". . t I U it at �G,,1 ,� C�.SiP�v r f{e has been constructed in accordance - with the provisions of Title 5 and the forDisposal System Construction Permit No. 6 dated Installer —grvcc / /G.CC�_�/i s 1(I, Designer &Y #bedrooms /v1h Approved design flow L/>98.�5_ gpd The issuance o this pe` it shall not be construed as a guarantee that the system will functi' fa's designeld. Date Inspector ----------------------------------- ---- No. G� — ' Fee THE COMMONWEALTH OF MASSACHUSETTS j PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS bisposal 6pstetn Construction 3oPrmit Permission is hereby granted to Construct( ) Repair( 1/) Upgrade( ) Abandon( ) System located at /S.3 ;:l s i t)5 l e,P,I Ile and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mustbe completed within three years of the date of this permit. "1 I v Date � 1 � Approved by I _ i u 3 ,. Y Town of Barnstable Regulatory Services Richard V. Scah,Interim Director * * anw i639•vsrasLe. M^ Public Health Division ♦� '�FDrrA Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: � 25 /6 Sewage Permit# Z O/4,- 12J Assessor's Map\Parcel Designer: Installer: 5n 4.rjl,,Ax Ce Ks fv%jcA vv� Address: 7* Q.,.44 Si Address: JR7 f_:6,1Q _c} k4 .a,�o. ts O 24.o f I I toO Z kys On 4/-12-/6 Slccro%ac s/,�yafia� was issued a permit to install a (date) (installer) septic system at 753 MhwS.�, based on a design drawn by (ad dressy dated `/-/3 - /6 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box ". Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the I\A approval letters (if applicable) OF S STEPHEN yG (Installer's Signature) ALLYN m MLSON r No.30216 STI ( signer's Signature) (Affix D �ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc 2 0/6- 00 W C1 I , r GRANTED WITH CONDITIONS. The Board voted to grant the variances on the revised plan dated 4/11/16 with the following conditions: 1) a two-bedroom deed restriction will be recorded at the Barnstable County Registry of Deeds, and 2) an official copy of the deed restriction will be submitted to the Health Division. C. Stephen Wilson, Baxter"Nye Engineering, representing Osterville Veteran's Association, owner— 753 Main Street, Osterville, M/P 141- 015, 12,381 square feet parcel, multiple variance request, repair of failed septT sys em. GRANTED WITH CONDITIONS. The Board voted to grant the variances listed on the proposed plan along with an additional one (variance from using a double chamber tank which allows them to use the existing septic tank). This is granted with the following conditions: 1) the plan will be revised changing the design from flow diffusers to 500-gallon chambers, 2) plan will list all variances granted and 3) plan will list the number of chambers to be used (the engineer will determine whether 5 or 6). III. Septic Installer's License: Kenneth Kline, Orleans, MA GRANTED. The Board granted Kenneth Kline an installer's license. IV. Variance — Food: A. Mr. Kieran Stone, Trader Joe's — 655 lyannough Road, Hyannis, Map/Parcel 311-008, requesting a grease trap variance for new location for sampling foods. GRANTED. The Board voted to grant the grease trap variance. (Roger Parsons was in agreement.) B. Keith Steiding, KKatie's Burger Bar— 334 Main Street, Hyannis, Map/Parcel 327-090, requesting a grease trap variance. GRANTED WITH CONDITIONS. The restaurant owner said the space will be reduced from the size the previous owner used —the seating will be reduced from 300 seats to 100 seats. The Board voted to grant the grease trap variance with the following conditions: 1) there will be a grease recovery device (GRD) (The Big Dipper will be repaired or replaced with another GRD.), 2) pending approval by the plumbing inspector, the "Atlantic Metalwork's" equipment will be installed right after the 3-bay sinks, Page 2 of 5 BOH 4/12/16 Message Page 1 of 1 STERVILLE VETERANS No SS required per TM. Tina 774 36-0266 OSTERVILL F XH LE ret 753 AIN STREET 11/12/2013 11/9/201 O O does have S.S. Needs Allergy ��. Un VA pa i Tfrl d '� mid:e7605e416fdfb64b8c6294c5378634bb 9/19/2018 Commonwealth of Massachusetts �. Executive Office of Energy &Environmental Affairs Department of Environmental Pr tection I One Winter Street Boston, MA 02108.617-292-5500 �1 Charles D.Baker Matthew A.Beaton Governor Secretary Karyn E.Polito Martin Suuberg Lieutenant Governor Commissioner April 20, 2016 Neil Andres 753 Main Street(P.O. Box 66) Osterville, MA 02655 Re:Title 5_ BRP WP70 Alternative Design Flow for Title 5 Systemj --_oc6R-.a. Osterville Veterans Association-Osterville Transmittal Number X269924 Dear Mr.Andres: The Department of Environmental Protection (MassDEP) has reviewed your application,received on March 18,2016 requesting the use of alternative Title 5 design flows for an'upgrade of a failing subsurface sewage disposal system to serve an existing Osterville Veterans Association building at 753 Main Street,Osterville. The application contains a three years water use data from this same facility. After review of the application and input from the Town of Barnstable, Mass DEP approves an alternative Title 5 design flow of 924 gallons per day for the Osterville Veterans building with the following provisions: 1. There shall be no kitchen or food preparation in the building .2. If the hall is used, caterers must bring in food,dishes,glasses and cutlery into the building 3. All pots, plates and other utensils used in the building must be taken off-site for cleaning. Should you have any questions regarding this matter please contact Olusegun Onatunde of my staff at 617-556-1168. Sincerely Marybeth Chubb,Acting Section Chief-., Groundwater/Title 5/Reuse Bureau of Water Resources This information is available in alternate format.Call Michelle'VUaters-Ekalieft Diversity Director,at 617-292-5751.TTY#,MassRelay Service 1-800-439.2370 MassDEP Website:www.mass.gov/dep Printed on Recycled Paper t` THE l Town of Barnstable • BARNSPABLB. 9� MASS,: ,.� Board of Health �fp�,lA 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D, Junichi Sawayanagi. May 12, 2016 Mr. Stephen Wilson, P.E. Baxter Nye Engineering and Surveying 78 North Street Hyannis, MA 02601 RE: Osterville Veteran's Association, 753 Main Street, Osterville A= 141-015 Dear Mr. Wilson, You are granted variances on behalf of your client, the Osterville Veteran's Association, to construct an onsite sewage disposal system at 753 Main Street, . Osterville. The variances granted are as follows: 310 CMR 15.211: To place the soil absorption system two (2) feet away from the property line, in lieu of the ten (10) feet minimum setback required 310 CMR 15.211: To place the soil absorption system nineteen (19) feet away from a catch basin, in lieu of the twenty—five (25) feet P minimum setback required 310 CMR 15.223: To use the existing single compartment septic tank in lieu of the requirement to install a double compartment tank. 310 CMR 15.203(6): To allow the system to be designed based upon water meter readings. 310 CMR 15.405(2): To allow a 25% reduction in the size of the leaching area. 944 square feet is provided in lieu of 1260 square feet required. Q:WP//WilsonOstervilleVeteransAssoc2016.docx These variances are granted with the following conditions: (1) No additional seats are authorized at the downstairs club/bar area, where 32 seats maximum are allowed. (2) No additional seats are authorized at the upstairs lounge. (3) The plans were revised to include 500 gallon chambers instead of flow diffusers, as discussed. The septic system shall be installed in substantial conformance with the revised engineered plans dated April 13, 2016. (4) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the plans dated revised April 13, 2016. These variances are granted because the physical constraints at the site severely restrict the location of the septic tank and soil absorption system due to the small size of the lot which severely restricts the possible locations of septic components. Sin erely you , Wayne iller, M.D. Chairm n Q:WP//WilsonOstervilleVeteransAssoc2016.docx r r ate' DATE: �J r FtHE>•p� P 44 FEE 's BARNSfABLE + 9 REC. BY � nr �p 1639• ♦® I.A f RFD MAr A Oil �`_; O V1. 0 Barnstable SCHED. DATE: �� Board of Health 200 Main Street,Hyatuiis.VIA.0260.1 Office: 508-8624644 p. Wayne A.Mil'Icr,M:D FAR: 508-790-6304 Junichi Sawayanagi Paull.Canniff,D,,\Yt.D. VARIANCE REQUEST FORINI LOCATION Property Address: 753 M41N S'fi'ia¢ lg lrryi// Assessor's klap and Parcel Number: (Y j Ld I S Size of Lot: l 7 3 8►T Wetlands Within 300 Ft. Yes Business Name: No Subdivision Name: APPLICANT'S:NAiVIEiU�kraats A_S_5yc, Phone Did the owner of the property authorize you to represent hint or her? Yes X No PROPERTY OWNER'S NAME CONTACT PERSON 1 Name: 6 sit e itic t) kegjgs A5564ltdh'on Name: 5fthye.+A "lldy . l•? _ _ i Address; Erb 113oK. 66 01htr^tttlie aZ,"j Address:: 13aY/rs-: /UHF 79 "P ONn4S Phone: Phone: SOS'- 77 7502 VARIANCE FROM REGULATION(List Reg) : REASON FOR VARIANCE(May attach if more space needed) NATURE OF WORK: House Addition ❑ House Renovation .171 Repair of Failed Septic Systetir Checklist (to he completed by office sla#person receiving variance request application) Please srrtimit copies its 4 seprr to completer!sets. ' Four(4)copies of the completed variance requesrfotm Four(4)copies of engineered plan submitted(e.g.septic system plans) Completed seven(7)page checklist continning review of engineered septic system plan.by submitting engineer or registered sanitarian Four(4).copies of labeled dimensional.tloor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property Owner authorize.dyou to represent hinviaer for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date.,t applicant s expense (for Tnlc.: V and/or local sewage regulation variances only) Full menu submitted.(forgrease trap variance requests only) Variance request application fee collected(no.lee.for lifeguard modification renewals,grease trap variance renewals(same owner/lessee only], outside d'nin variance renewals s uncowner/lessee only), pair failed sewage disposal s•stems[only.if no ex ausion to the b.a.a [.' _. Y];and variances to re 6 P ) ( ) P building proposed]) Variance request submitted at least 15 days prior-to meeting dale VARIANCE APPROVED \Vayne\Miller,Chainuan NOT APPROVED -::: _ _ away uaagi Junichi S REASON FOR DISAPPROVAL Paul J.Canniff;D.M.D. C:\Users\decollik\AppData\Local\b+ic'rosoft\Windows\Temporary Internet :Files\Content.outlook\BAJ9P9B7\VARIREQ..DCC . .2 t OJ 9 :OZ. Variances Requested-Title 310 CIV1R 15.211(1) To allow setbacks from the property of 3.P. and 4 0' in lieu of the required 10'. To allow a catch basin to be located 22.8' from a SAS in lieu of the required 25'. i 310 CNtR 15.203(6) To allow a system design flow to be based on water meter readings. 310 CMR 15.405(2) To allow a 19.3%reduction in the required subsurface disposal area design; 752 s.f. in lieu of the.required 932 s.f . 2016-:0.07:02 VarienceRegwst.doc BAXTER NYE ENGINEERING & SURVEYING Registered Professional Engineers and Land Surveyors 78 North Street,3`d Floor,Hyannis,MA 02601 Tel: (508)771-7502 Fax: (508)771-7622 March 16th, 2016 Board of Health 200 Main Street Hyannis, Massachusetts 02601 RE: Variance Request, Osterville Veterans Association Members of the Board, On behalf of our client,The Osterville Veterans.Association, we have filed variance requests for the replacement of the existing leach pits (2) with a new soil absorption system. The Osterville Veterans building was constructed in 1898. It consists of a walkout basement with a lounge area for the members and a first floor that is a function hall. The bathrooms are located adjacent to the lounge. The lounge is utilized by members of the Veterans Association. It has a licensed maximum capacity of 74 people. The hours of operation are 4:OOpm to closing (11:OOpm —winter; 1:OOam —summer). The first floor hall is used, on the average, 2-3 times per month. It has a licensed maximum capacity of 103 people. There is no kitchen in the building so no food preparation occurs on-site. If the hall is used for a function caterers bring in the food, dishes, glasses and cutlery. Everything is taken off- site when the function is over. The present soil absorption system consists of two 1,000 gallon leach pits (with 3'of stone) and rovides 654 s.f. of leaching area. They were installed in April, 1984. The proposed soil absorption system will consist of 5 Flowdiffusors with 4' of stone on the sides, 2' of stone on the ends and 1' of stone below the chambers. This provides 752 s.f. of leaching area. The variances being requested are as follows; 310 CMR 15.211(1) To allow setbacks from the property of 3.1' and 4.0' in lieu of the required 10'. To allow a catch basin to be located 22.8' from a SAS in lieu of the required 25'. 310 CMR 15.203(6) To allow a system design flow to be based on water meter readings. Land Surveys • Site Design • Subdivisions • Septic Design • Wetland Filings • Planning 310 CMR 15.405(2) To allow a 19.3% reduction in the required subsurface disposal area design; 752 s.f. in lieu of the required 932 s.f I hope that the proposed repair will meet with the Board of Health's approval and that this work can proceed in a timely manner. If you have any questions or comments please call me directly at 508-771-7502, ext. 13 or via e-mail at swilson@baxter-nve.com. Sincerely, /een A. Wilson, PE cc: N.Andres,OVA #2016-007:02 0:\2016\2016-0071\ADMIN\LETTERS\Varience Request-BoH.doc Land Surveys • Site Design • Subdivisions • Septic Design • Wetland Filings • Planning 2 Vf TRANSMITTAL ` BAXTER NYE ENGINEERING & SURVEYING Registered Professional Engineers and Land Surveyors 78 North Street,3`d Floor,Hyannis,MA 02601 Tel:(508)771-7502 Fax:(508)771-7622 Date: April 8th,2016 TO: Board of Health Total No.Pages: 200 Main Street v BN Job No.: 2016-007:02 Hyannis,Mass. 02601 Subject: BOH Variance—Revised Plan Osterville Veterans Association Phone: 753 Main Street,Osterville cc: files We are sending you ®Attached ❑Under Separate Cover �l ❑ Via Fax(No. of pages including Transmittal Sheet) ElFirst Class Mail/Registered#: ;El Overnight ❑Pick up ®Hand Delivery The following documents: ®Prints/Plans ❑ Specifications ❑Estimates/Proposal ❑ Change Order❑ Shop Drawings 81 ❑Reports/Calculations F1 Other DATE COPIES NO. PAGES DESCRIPTION 4-8-16 4 2 S.A.S.Repair Plan-Plan Sheets- C1.0& C2.0 (24x36)REVISED These items are transmitted as checked below: ❑ For Your Use ❑As Requested ❑ Returned For Corrections ® For Review And Comment ®For Approval ❑As Required Remarks: Attached please find the revised plans for the proposed soil absorption system. The proposed design flow has been increased from 690 gpd to 924 gpd. This represents using the highest 6 month flow period (July to December) instead of taking the average of two years of flow information. Please note that there is an irrigation system at this site that is used during the summer. The proposed leaching area has been increased from 752 s.f. to 944 s.f. Please contact me with any questions or comments as necessary. t— Stephen A. Wilson, P.E. 0:\2016\2016-007\ADMIN\TRANSMITTALS\BoH trans-variance-revised plan.doc Note: This transmittal contains privileged information.Please contact the sender immediately if this transmittal is illegible, incomplete or not intended for your use. Thank you. BAXTER NYE ENGINEERING & SURVEYING Registered.Professional Engineers and Land Surveyors 78 Noiih Sheet,YJ Floor,Hyannis, MA 02601 Tel:(508)_771-7502 Fax: (508)771-7622 Mardi 14`I',2016 Dept. of Env:iroinnental Protection Title 5 Program 1 Winter Street, 5 '.Floor Boston, Massachusetts 02108 Dear Sirs, . On behalf of our client, The Osterville Veterans Association, we are submitting BRP WP 70 and supporting documents for your-review and.approval. I The existing soil absorption system(leach pits) is failing and the Veterans Association has been pumping with increasing frequency..We would appreciate if approval of the proposed design flow could be expedited. The Centetville-Osterville-Marstons Mills Water Department statement for water usage is enclosed. Please note that water quantities on the statement are per 1,000 gallons, hence 35 equals 35,000 1 gallons. Variances be requested from the Barnstable Board of Health in accordance with 310 CNIR 15.405, :. Contents of Local Upgrade Approval.No increase in flow is proposed. If you have any questions or continents please call ine directly at 508-771-7502, ext. 13 or via e-mail at swilson@baiter-nye.coni f Sincerely 0 SteplAWilson, PE C&I/RR enc :.: cc: N. Andres, OVA #2016-007 02. . . 0:1201012016 00711i1DMIN�I ETTERSWEP BRP WP 70 tlows:doc Land Surveys: @ .Site Design ® Subdivisions m Septic Design: ® Wetland Filings. 9 Planning Massachusetts Department of Environmental Protection Bureau of Resource Protection— Title 5 Permitting X269924 Transmittal Number (1 BRP WP 70 Alternative Design Flow for Title 5 Systems - BRP W 70a ikon-Sanitary Wastewater Discharges to Title 5 Systems Facility ID#(if.known) Please read the Instructions and Supporting Materials before filling out this form: A. General Information 1. Which permit category are you applying for?Check:one box: ® BRP WP 70—Alternative Design Flow for Title 5 System ❑ BRP WP 70a—Non-Sanitary Wastewater Discharge to Title 5 System Important:When filling out forms 2• Applicant: on the computer, use only the tab Osterville Veterans Association key to move your Name - cursor-do not use the return i key. . Doing Business as(dba) 753 Main Street:(P.O. Box 66) Ostervll.le ILA Street Address Cityrrown K±-A i Mass. 2655:.. State .... Zip Code Telephone 3. Facility Address/.Location(If different from Applicant): Address City/Town State Zip Code 4. Professional Consultant(Registered.Sanitarian [RS]or Professional Engineer(PE]) Baxter Nye Engineering &Surveying Name/Name of Company:: 78 North Street Address Hyannis - Mass.. 0 City::: State::.: 02601 508-771-7502 Zip :. Telephone 5.: Registrat;ion: Stephen A.Wilson P.E. Sanitarian 30216 Registration Number W wp70.doc i rev:1/14 Design F 5 Systems BRP WP 70-:Alternative D low for Title ms BRP WP 70a-Non-Sanitary Wastewater Discharges to Title 5 Systems Page 1 of 2 Massachusetts Department of.Environmental Protectton . Bureau of Resource Protection =Title 5 Permitting X269924 (1 BRP WP 70 Alternative Desigri'Flow for Title 5 Systems Transmittal Number BRP WP 70a Uon-Sanitary Wastewater:Discharges to Title..5 Systems Facility ID#(if known) A. General Information (continued) 6. Type of facility seeking alternative Title 5 design flow or approval to discharge non-sanitary wastewater to:a Title 5 system: i a. Business type/description: i See attached narrative b: See attached narrative . Size(Sq.ft.; seats,units,fixtures,etc.) 7. The legal entity which owns or will own this facility is: ❑ Individual ❑ Federal ❑ Municipality ❑State/County i ❑ Private Partnership. ❑Corporation ® Other(specif Y): Non-profit Oganization 8. . For WP 70, two copies of studies or similar type facility flow/loadings data, or for WP 70a, a . . report/description:of the non-sanitary wastewater quantity and:constituents and loading evaluation, properly stamped and signed by a Massachusetts Registered Professional Engineer or Massachusetts Registered Sanitarian,.must accompany the application. Are:studies/data/report enclosed? :❑ Yes ❑No PaoHave the data been revised? El Yes El No If yes,date of revision 9. In accordance with 310 CMR 15.203(6), the applicant for WP 70 must provide actual water meter readings from similar institutions for alternative Title 5 design flow applications. Design flows will be based upon 200%of a MassDEP accepted average metered similar design flow or on other methods determined to:be appropriate by the Department._ Is documentation in support of meeting this 1equirement attached? ® Yes ❑ No B. Certification I certify under:penalty of law that this document and all attachments,:to the best of my knowledge . and belief, arearue, accurate, and complete. I am aware that thereare significant penalties:for submitting false information, including the possibility of fine and imprisonment for knowing violations." Stephen_A Wion - — ,� Is , P.E. PPlica _:signature ::::.. Name of Preparer Shen A.Wilson March 141h, 2016 Print Name Date wp70.doc•.rev 1/14 BRP WP 70-Alternative Design Flow for Title 5 Systems P N Discharges Tit BR WP 70a= on=Sanitary Wastewater D' harges to Title 5 Systems Page 2 of 2 . .. . . . .. . . Project Narrative Osterville Veterans Association The Osterville Veterans Association building was constructed in 1898. It consists of a walkout basement with a lounge area for members and a first floor that is a hall. The only } bathroom: n the building islocated downstairs adjacent to the lounge area. The lounge is utilized only by members of the Veterans Association. It has a licensed maximum capacity of 74 people. The hours.of operation are 4:00pm until closing (1 l:OOpm—winter; l:00am—summer). The upstairs hall is utilized, on the average, 2=3 times per month. It has a licensed maximum capacity:of 103 people. Theme;is no kitchen in the building so no food ! preparation occurs on-site. If the hall is used, caterers bring in food,dishes, glasses and: cutlery. Everything is taken off.-site when the function is over. i The present septic system was constructed in April, 1984 and is over 30 years old. o t12016=007:02 TJarralive.doc C-0-MjV1 WATER DEFT CUS'romER STATEMENT: .... ACG'f Np 367.: �1/12/2016 OSTERVILLE VETERANS ASSOC LOCATION- 5 WEST BAY RD: _:: .:.: _:.: OST LOT: NIAP&PARCEL: 116086 : l Consumption Histoiy DATE READ:. CONS 12/31/15 :. . 189 85 : + 06/30/15. 104 47 .12/31/.1.4 57 7.1. 07/10/14 0 0 ! 07/10/14 2902 :. 14 _ . . .. . . . .. . . 06/30/14 2888.: 35 12/31/13 : :. :.: 2853 . 85 ..: 06/30/13 2768 48 TRANSACTION.HISTORY DATE DESCRIPTION 0 to 30 31 to 60 61 to 90 Ovcr 90 08/01/2000 STARTING BALANCE 0.00 0.00 0.00. 110.70 1 I 08/14/2000 PAYMENT 0:00. . 0.00 0.00. 110.70 10/02/2000 "NITMINIUM BILL 0.00. 0.00 0.00: 15.00 11/14/2000 PAYINIENT 0.00 0.00 0.00 -15.00 01/01/2001 '1 1N EX 0.00 0.00 0.00 232.50 01/31/2001 PAYMENT 0.00 0.00 :: 0.00 .-232.50 1 .MIN 0,00 0.00 0.00 15.00::: O 04/18/2001 PAYMENT 0.00 0.00 0.00 15:00 O 07/02/2001 1vIN EX 0.00 0.00 0.00 A 16.50 V . 07/24/2001 PAYMENT 0.00 0.00 0.00 116.50 10/01/2001 MIN 0.00 0.00 0.00 1.5.00 W/18/2001 PAYMENT,::: 0.00: 0.00 0.00 15.00 01/01/2002 MIN EX 0.00 0.00 0.00 247.00 24700 02/01/2002 PAYNIENT 0.00 0.00 0.00 - 04/OI/2002 NUN, 0.00 .:: ::: 0.00 : : 0.00 I:5.00 04/26/2002 PAYMENT 0.00 d 0.00 0,00 -15.00 07/01/2002 MIN EX : :0:00. 0.00 0.00 101;70 . 0alance Due: 238.50 C-&MM WATER DEPT 1 CUSTOMER STATEMENT 08l12/2002 PfU:i\fENT 0.00 0.00 01/01/2003 MIN EX 0.00 0.00 0.00 240.90 01/28,12003 PAYMENT 0.00. 000 0.00 240.90 07/01/2003 MIN EX 0.00 0.00 0.00 101.70 08/18/2003 PAYMENT 0.00 0.00 0.00 -101.70 01/01/2004 MN EX 0.00 0.00.::: .0.00 I88.70 02/17/2004 PAYMENT 0.00 0.00 0.00 -188.70 07/01/2004 MIN EX 0.00 0.00 0.00 168.40 . 1 -01/27/2004 PAYMENT 0.00:: 0.00 0.00 168.40 01/01/2005 iVIN EX 0.00. 0.00 0.00 258.30 02/03/2005 PAYMENT 0.00 0.00 0.00 258.30 07/01/2005 MN EX 0.00 0.00 0.00 127.80 07/18l2005 PAYMENT0.00 :. 0.00 _ . 0.00 127.30 OI/01/2006 MN EX 0.06 . 0.00 0.00 455.50 01/30/2006 PAYMENT 0.00 0.00 0.00 455.50 z 07/01/2006 MN EX 0.00 0.00, . . . 0.00 168.40 08/14/2006 PAYMENT :0.00 0.00 0.00 -168.40 01/01/2007 MN EX 0.00 0.00 0.00 400.40 01/16/2007 PAYMENT 0.00 0.00 0.00: 400.40.: 07/01/2007 MIN EX 0.00 0.00 0.00 139.40 f 08l13/2007 PAYNtEN"C 0.00 0.00 0.00 139.40 01/01/2008 MN EX .0.00 0.00 0.00 223.50 02/04/2008 PAYMENT 0.00 0.00 b 0.00 -223.50 07/01/2008 NIIN EX 0.00 :. 0.00 .. 0.00 174.20. 08/05/2008 PAYMENT 0.00 .0.00 0.00 174.20 01/01/2009 MN EX 0.00_ 0.00 0.00 252.50 :. Q 02/02/2009 PAYMENT 0.00 0.00 0100 .-252.50 \\ 1 v 07/01/2009 MIN EX 0.00 0.00 0.00 171.30 07/14l2009 1'AYINYIENT 0.00 0.00 0.00 171.30 Oi701/2010::N1IN EX 0..00,. :0.00 0.00 345.30 02/01l2016 PAY-IVIENT 0.00 0.00 0.00 345.30 OVO112010 MIN EX 0.00 0.00 :. 0,00 159.70 07/26/2010 PAYiNIEN"1' 0.00 0.00 0.60 159.70 01/01/20.11 MIN EX 0.00 : 0.00 0.00 365.60 - 02/44/2011.PAYMENT ::: 0.00: 0.00 0.00 -365.60 Balance Due: 238.50 C-0-MM WATER DEPT - - . CUSTOMER STATEMENT 07/01/2011 MIN EX 0.00 0.001 0.00 107.50 08/01/2011 PAYMENT 0.00 0.00 0.00 107.50 01/01/2012 ?vIIN EX .0.00. 0.00 0.00 _. . 159.70 01/17/2012 PAYMENT 0.00 0.00 0.00 -159.711 07/0112012 MIN EX 0.00 :0.00 0.00. 84.30 07/31/2012 PAYMENT 0.00 : 0.00 . 0.00 -84.30 _. 01/16/2013 lvfIN EX 0.00 0.00 0.00 197.40 01/30/2013 PAYMENT 0.00 0.00 0.00 -197.40 07/01/2013 _1LIfN EX 0.00. 0.00 0.00 116.20 . 07/31/2013 PAYMENT 0,00 0.00 0.00: -116.20 01/01/2014 M N 223.50IX _ 0.00 . .. 0.00 0.00 , 01/22/2614 PAYMENT 0.00 0.00 0.00 223.50 07/01/2014 MIN EX 0.00 0.00 0.00 73.50 07/30/2014 PAYMENT,: 0.00 0.00 0.00. -73,50. 01/01/2015 SERV EX 0.00 0.00 0.00: 197090 02/18/2015 PAYMENT 0.00 0.00 0.00 197.90 i 07/01/2015 SERV ER _ 0.00 0.00 0.00 12$.30 _.. 08/18/2015 PAYMENT 0.00 0.00 0.00 128.30 I 01/01/2016 SERV EX 238.50 0:00 0.00 0.00 0 Balance Due; 238.50 Enter your transmittal number x2699z4 _ : : Transmittal Number (, Your unique Transmittal Number can be accessed online:http://mass aov/deli/service/online/trasmfrm.shtml Massachusetts Department.of Enviro.nmenta( Protection Transmittal Fora for Permit Application and Payment 1. Please type or A. Permit Information print.A separate Transmittal Form BRP WP 79 Alternative Design Flow for.Title 5 Systems must be completed 1.Permit Code:7 or 8 character code from.permit instructions 2.Name of Permit Category for each permit Soil.Absorption System Repair/Replacement application. 3.Type of Project or Activity 2. Make your Q r check payable to _ i tion - Firm or Individual the Commonwealth B. Applicant Informa I of Massachusetts Osterville Veterans Association and mail it with a 1:Name of Firm-Or,if party needing this approval is an individual enter name below:. copy of this form to: DEP,P.O.Box 4062,Boston,MA 2.Last Name of Individual 3.First Name of Individual 4.MI j 02211. 753 Main Street(P.O.Box 66) 5.Street Address 3. Three copies of Osterville MA 02655 this form will be 6.City(fown 7.State 8.Zip Code 9 Telephone#.. . 10.Ext.# needed. Neil Andres Copy 1-the 11.Contact Person 12,e-mail address(optional) I original must accompany your permit application. C. Facility, Site or Individual:Requiring Approval Copy 2 must accompany your Osterville Veterans Association fee payment. 1.Name of Facility,Site Or Individual . . Copy should be 753 Main Street retained for our Y 2,Street Address � records Osterville MA 02655 508-428-6088 4..Both fee-paying 3 City/Town 4.State 5.Zip Code: 6.Telephone# : 7.Ext.# and exempt applicants must 8.DEP Facility Number(if Known) 9:Federal I.D.Number(if Known) 10.BWSC Tracking#(if Known). mail a copy of this transmittal form to: D. Application Prepared by (if different from Section B)* i MassDEP Baxter Nye Engineering&Surveying P.O.Box 4062 Boston,MA 1.Name of Firm Or Individual 02211 78 North Street 2.Address . •Note: Hyannis MA 02655 508=771-7502 _ For BWSC Permits, 3.CityfTown 4:State 5:Zip Code 6.Telephone# :7.Ext.It enter the LSP. Stephen A:Wilson, RE. 8.Contact Person 9.LSP Number(BWSC Permits only) SA. . E. Permit- Project Coordination 0 1. Is this:project subject to MEPA review? [I yes ® no If yes,enter.the.project's EOEA file number-assigned when an Environmental Notification.Form is submitted to the:MEPA unit: ... ..... . EOEA File Number _ F. Amount Due DEP:Use On! y Special Provisions a 1. E]Fee Exempt(city,town or municipal housing:authorily)(state agency if fee is$100 or less). Permit No: There are no fee exemptions for BWSC permits;regardless of applicant status. 2. ❑Hardship Request-payment extensions according to 310 CMR 4.04(3)(c). RecV Date:: 3. E7 Alternative Schedule Project(according 10 310 CMR 4.05 and 4.. 4. El Homeowner(according to 310 CMR 4.02).: Reviewer: : #1020 $700.00 3/8/2016 Check.Number Dollar Amount: Date Page 1 of 1 Fee Transmittal•rev.::1/07 _. ABUTTOR NOTIFICATION LETTER Date: March 21", 2016 Re: Variance Request As an abutter, please be advised that a Variance Request has been filed with the Barnstable Board of Health. Additional details are below: Applicant: Osterville Veterans Association Address: P.O. Box 66 Osterville, Mass. 02655 Project Location: 753 Main Street, Osterville; aka"Foxhole" Assessor's Map & Parcel: Map 141; Parcel 015 Project Description: Replace existing leaching system. Variances Requested: Please refer to attached list. Applicant's Agent: Stephen A. Wilson, P.E. Baxter Nye Engineering & Surveying 78 North Street Hyannis, Massachusetts 02601 Public Hearing: Town Hall; 2nd Floor Selectman's Conference Room 367 Main Street Hyannis, Massachusetts 02601 April 121h, 2016 at 3:00pm #2016-007:20 Variance-Abuttor.doc J i TRANSMITTAL BAXTER NYE ENGINEERING & SURVEYING Registered Professional Engineers and Land Surveyors 78 North Street,3rd Floor,Hyannis,MA 02601 Tel:(508)771-7502 Fax:(508)771-7622 Date: March 17 , 2016 TO: Board of Health Total No.Pages: 200 Main Street BN Job No.: 2016-007:02 Hyannis,Mass. 02601 Subject: BOH Variance Application Osterville Veterans Association Phone: 753 Main Street,Osterville cc: files We are sending you ® Attached ❑Under Separate Cover ❑ Via Fax(No. of pages including Transmittal Sheet) ❑First Class Mail/Registered#: ; ❑ Overnight ❑Pick up ®Hand Delivery The following documents: ® Prints/Plans ❑ Specifications ❑Estimates/Proposal ❑ Change Order❑ Shop Drawings ❑ Reports/Calculations M Other DATE COPIES NO. PAGES DESCRIPTION 3/16/16 4 2 Letter to BOH—Variance Request 3/16/16 4 2 S.A.S.Repair Plan-Plan Sheets- C1.0& C2.0 (24x36) 3/16/16 1 7 Barnstable Septic Checklist 3/16/16 1 1 Authorization letter 3/16/16 4 2 Variance Request Form 3/16/16 4 2 Floor plans 3/16/16 1 9 Copy of BRP WP 70 Application to DEP 3/8/16 Check#1021 —Variance Fee These items are transmitted as checked below: ❑ For Your Use ❑As Requested ❑Returned For Corrections ❑ For Review And Comment ® For Approval ®As Required Remarks: Attached please find the information in support of the Variance Application for the above noted project. Please contact me with any questions or comments as necessary. Step en A. Wilson, P.E. ON IN 91 `LT Sam 0:\2016\2016-007\ADMIN\TRANSMITTALS\BoH trans-variance 3-17-16.doc Note: This transmittal contains privileged information.Please contact the sender immediately if this transmittal is illegible, incomplete or not intended for your use.Thank you. Osterville Veteran's Association March 16`h,2016 P.O.Box 66 Osterville MA 02655 Established 1947 Board of Health 200:Mam.Street Hyannis,Mass. 02601 Members of the_Board, This iletter,isl to.confum that the Osterville Veterans Association has.authorized Baxter Nye Engineering& Surveying to represent them regarding the repair of the septic system at our building. for the Osterville Veterans Association,. , r t i c�c 1`1 r—T1 JA) ✓ L—�-- T)A Al ii 9 i r I ' x -.✓......................................... oef: Trff f C� sS�12t1rLL� LA P�4R7 t A.� BASC^1) E ti i - 11 V -- - - s W _ .LA �- iU-5 iti1 i Osterville Veterans' Association, Inc. ❑STERVILLE, MASS. February 21, 1984 Town of Barnstable Board of Health Q Town Hall O Hyannis, MA. 02601 Ref: Proposed Septic System/Osterville Veterans' Association. Dear Sir: The Osterville Veterans' Association, Inc. Main Street and West Bay Road, Osterville ask the Town of Barnstable Board of Health to allow a variance for the proposed septic 'system repairs as drawn by Baxter and Nye, Registered Land Surveyors, excluding a grease trap. The Osterville Veterans have no intention of cooking or ever installing kitchen facilities on the premise. Thank you for your consideration. For the Osterville Veterans' Association Board of Directors 4ZJ T s Carlton B. Crocker i i Osterville Veterans' Association, Inc. OSTERVILLE, MASS. March 16, 1984 Town of Barnstable Board of Health Town Hall, Hyannis, Mass. 02601 Ref: Osterville Veteran's proposed septic system To whom it may concern: The Osterville Veteran's Association, Inc West Bay Road and Main Street, Osterville petition the Director of Public Health, John M. Kelly and Barnstable Board of Health members, for special consider- ation to allow the construction and/or installation of a new septic system, without a so-called "grease-trap", as described in a re- vised plan drawn by Baxter and Nye, Land Surveyors, Osterville, dated February 21, 1984. The following is offered as explanation: The facility in question does not prepare, process or serve food to the public, nor does it wash or clean food containers, pots, pans or dishes, etc. There are no kitchen facilities to perform these functions. Furthermore, and more importantly, the Osterville Veteran's Association has no intention of performing any of these food service functions now or in future years and will agree, if necessary, to sign a letter of intent stating that there will be no changes .from current established policies. The premise is sometimes .used for club., as well as private," functions and during these times food is often served by outside catering com- panies. However, the preparation, serving and cleaning has always been performed off-premise by the catering service, as mentioned above. The association is proud. of its facility, as can be witnessed by viewing its building and grounds. The association has a planned maintenance program for grounds and building upkeep, including the septic system. This is priority maintenance to us. Pat i. I i i i y Osterville Veterans' Association, Inc. 05TERVILLE, MASS. The record shows that it has been nearly 25 years since the current system was installed. In 1960/1961 a delivery truck caused a por- tion of the existing cesspool to cave in. At that time a 6' x 8' cesspool (with two extra coarses of block) was constructed as an overflow for the damaged cesspool which was originally built about 1948. This 1948 built cesspool and the 1960/1961 overflow cesspool could not possibly have accommodated us, if over the past 25 years, we had served food other than described in -this letter. We ask this special consideration be granted in view of our intent for the future and our exemplary record. For the Osterville Veteran's Association Board of Directors Carlton B. Crocker, Treasurer 0 O F ti ; O O March 21, 1984 Mr. Carlton B. Crocker, Treasurer , Osterville Veteran's Association Box 66 Osterville, Ma. 02655 Dear Mr. Crocker: You are granted a variance from Regulation 10, of the Town of Barnstable Health Regulations, requiring an outside grease inter- ceptor at all food and drinking establishments, with .the following conditions: (1) No cooking or the serving of any type foods including sand- wiches, will be allowed at your facility. This does not apply to packaged items such as potato chips, peanuts, etc. The exception is complete service by an outside cate- ring company under the conditions outlined in your request. It should be clearly understood that any deviation from the above listed condition will necessitate the immediate installation of an outside grease interceptor. Very��t 'uly you s, 1� ert L. Chi s;Chairman Ann Jane Es augh H. F. Inge, M. D. BOARD OF HEALTH TOWN OF BARNSTABLE JMK/mm ° r:� `�Y fry y,.� � + • ` '.#'V .. e_ e t y+i. r � fit '1e •+ �' + .. C�..� 1 -• Iy�Yr•, S i ,rT r �.'� 4 !� ,k f ii `I 4'r.. ' ` x •.!. .. ., � �:i ,2. f�..l Yr - r tq e- ,.,�{�' � er,''a 4•r � . - q r.+ a txY b, . 4: �a. -r:T '.S' 3. 7y,i r •':� � c '� r t _ �r' t: v 4.,+•• a Y' R 3 }r 'r~ ' } Cy �' i..x� �.^:� r .. . "•i y.. rt yr 1 T ,, v , Y' + e; . b ^;�' r `a a*1'a 1 r t y ti ,. • T p'" r ' y ��f� �? + �.` �5..5-r � •• �r Y, ;, - T r � 'y,;ti' �I�, ���a1 �`•;� r*�h�U a i March 21.; '1984' k ; '�.. f '-"' .� 1 v k^ S n }`F ',- 'rl r �4 � .Ii � •••'fie 7 !, j i , � - f.; r t v'� '� 1 M r. "_r r,•,r •a S r s �' `� .r;,� '' � !�y.ci � - a. •+:: {, is x� + '"+". �j 'Ye• d' .;, ,r_: ...tiro L _ ' r '+ '} ` ,Mr. Carlton B: Crocker , Treasure • � ` `' } r t s�Y �• � '`yj Ostervflle Veteran's Association BOX 66 � ._ r ' •y. T+"_ !� ; /'{•.y q '» a y t i •- 'i t M. C # ' r r ✓ � >!ti 7.. 'OsterviI1e, eta. .+ ,. + e _ r •� •� � #• .Y•{J{ r _ fi dy � ,. .r T �"r`{,y` 4i t •' � w..+�1 �' f Dear Mr. ..Crocker • _ .. _ . {T Y'�* .1 �6 T�'e1 x - �'..A•r. 1 r1 .x.'+� f r , 'You are granted is variance ,from Regulation 10 ' of 'the Town of Barnstable Rdalth�Regulatfons:, requiring ail:csutside grease.inter ceptor-.,At all' food` an'd drinking establishments, ;w 'th, Lh'e` following r� condition"s�: t ter. s s hcoo ,tsrg ofa `type f(1 No ods. including;tsand; . •P ��• wiches, wi11-• be allowed ii­youf-Jar11ity 'This does'not,t'.; apply to ,packagedF itemsr`such>,as potato`chips,' peanuts;, etc: .The exception is: complete service by an out cafe , •Jring company,;under the=-cb ditioms outlinedr in -your re.que`st: , x' ,, yr, s ;. - r ... .•,- ,+ ..` ".f' tir •.' � ^`'"�'>{ y',. A ,^ , +,A. r=,�: z• ,• x t :.is �-r• It,:shouldr bee clearly understood that any derr "ation 'from '.the above �x ' ?` ` ,` _ listed condition will'necessitate the+Aimmedi"ate,'installation''of % 1._ _ r ail outside grease i,nterceptoi. sa ,� •..�, `w'-,, , i '7x>r - �'e, r� .i r ; '°<r rry "+i�w f 'ay„ :..I � •�" • L. - t '•.f� 3r i �. 0� �+i y r : i r " +r. ,s ''. } y 'Y�C �,T'; ,yX } ,, t �_ Very Uly y1()u s, { _ � °. lt�+.'. �;3Y�a��. r€7�s r'��d t✓1� N'^,�`.���` Bit •t c"�. x ""r .' { f' y �cx` +<'; vA �J't*y + '� t_;a',_`��t.', ert L. .Chi ds,r'Chairman is n ••s 4 c' f *� T 7 •r a �.+' .t .4 r _ is •.`„7. y x tr s"E.l,- {.• 5 ` ° "1"Dy ? r< Y'Ann Jane Es augh f' t r+��3��c�r1 � �+.� !<�' �r � r,� ..� r � � s a f3.3 i ; r`•.} fi* H. F Inge, M., D BOARD OF HRALTH TOWN OF,'-BARNSTABI. .. r s;y', % r f`ri�} i4. ♦ "� �'z'.'.n .L �' ., •` T +i Z"j ,Y>,�h �4. �-- '��. '.r S r• � ,1.+ . +! +c^�R` ar t, '� 0 n-`�r a 1 �I ejf, C �'. s'�'at 1.7 �i a"' r - tis`•+ y { '1 • � 't � r. c•t 's 2'�t�.r�"` rt, PT .;f>,- t ' 5+' r - ' '}- +_ .} } tr61 "` �t vy ,�•. t¢ '+, .i Gig +�C ' 'r": - s . r,.r. � �, . . � _.R '�. r , ,a S q4 r Fs..- CA el"Im Q. CfeockeSZ Tf10 U dZ o?// DATE ��� ' _. FEE �FTHE TO� TOWN OF BARNSTABLE OFFICE OF 13AHE4TSBL = , Yksd BOARD OF HEALTH.. . . - ��� i639 367 MAIN STREET HYANNIS, MASS. o26o1 VARIANCE REQUEST FORM All variance requests must be submitted five (5) days prior to the scheduled Board of Health meeting. NAME OF APPLICANT (),k ZUtil4. Ua 4f?gkt S 6SSoc I TELEPHONE NO. ADDRESS OF APPLICANT d AI s,YQf q-005i 19,4V Ad. j6 ,k.CVj11je, NAME OF OWNER OF PROPERTY _08 __k9Utt(,Q P2 yPAw's' k6e, LOCATION OF REQUEST 1k.� ALO(,tQ VARIANCE `FROM REGULATION (List regulation) VARIANCE REQUESTED (Specific request) No4 k5411 / o d REASON FOR VARIANCE (May attach letter if more space needed) \to rjQ Q� PLANS - Two copies of plan must be submitted clearly outlining variance requested. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPPROVAL Robert L. Childs, Chairman Ann Jane Eshbaugh H. F. Inge, M. D. BOARD OF HEALTH TOWN OF BARNSTABLE Osterville Veterans' Association, Inc. ❑STERVILLE, MASS. March 16, 1984 Town of Barnstable Board of Health Town Hall, Hyannis, Mass. 02601 Ref: Osterville Veteran's proposed septic system To whom it may concern: The Osterville Veteran's Association, Inc. West Bay Road and Main . Street, Osterville petition the Director of Public Health, John M. Kelly and Barnstable Board of Health members, for special consider- ation to allow the construction and/or installation of a new septic system, without a so-called "grease-trap", as described in a re- vised plan drawn by Baxter and Nye, Land Surveyors, Osterville, dated February 21, 1984. The following is offered as explanation: The facility in question does not prepare, process or serve food to the public, nor does it wash or clean food containers, pots, pans or dishes, etc. There are no kitchen facilities to perform these functions. Furthermore, and more importantly, the Osterville Veteran's Association has no intention of performing any of these food service functions now or in future years and will agree, if necessary, to sign a letter of intent stating that there will be no changes from current established policies. The premise is sometimes used for clubq as well as private, functions and during these times food is often served by outside catering com- panies. However, the preparation, serving and cleaning has always been performed off-premise by the catering service, as mentioned above. The association is proud of its facility, as can be witnessed by viewing its building and grounds. The association has a planned maintenance program for grounds and building upkeep, including the septic system. This is priority maintenance to us. I Osterville Veterans' Association, Inc. OSTERVILLE, MASS. The record shows that it has been nearly 25 years since the current system was installed. In 1960/1961 a delivery truck caused a por- tion of the existing cesspool to cave in. At that time a 6' x 8' cesspool (with two extra coarses of block) was constructed as an overflow for the damaged cesspool which was originally built about 1948. This 1948 built cesspool and the 1960/1961 overflow cesspool could not possibly have accommodated us, if over the past 25 years, we had served food other than described in this letter. We ask this special consideration be granted in view of our intent for the future and our exemplary record. - For the Osterville Veteran's Association Board of Directors Carlton B. Crocker, Treasurer Osterville Veterans' Association, Inc. OSTERVILLE, MASS. February 21, 1984 Town of Barnstable Board of Health Town Hall Hyannis, MA. 02601 Ref: Proposed Septic System/Osterville Veterans' Association Dear Sir: The Osterville Veterans' Association, Inc. Main Street and West Bay Road, Osterville gsk the Town of Barnstable Board of Health to allow a variance for the proposed septic system repairs as drawn by Baxter and Nye, Registered Land Surveyors, excluding a grease trap. The Osterville Veterans have no intention of cooking or ever installing kitchen facilities on the premise. Thank you for your consideration. For the Osterville Veterans' Association Board of Directors Carlton B. Crocker kW> � I Tel A-'> f _ I;L ,- q a j A I 5 m C:,�� i✓� S '"�' C q o qo �.� Tom:cf - ;- J i FBz..l S ......... THE COMMONWEALTH OF MASSACHUSETTS S�aC BOAR® E HEALTH ....................oF........-.... ..J. 4.1 F Appliration for Biopos ai Works Tonotrnrtion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: .....� / ./ +. .. ................................... . ........................................... ��rV 6// 1.ion-Addres or Lot No. /x& ...------ .._..0 .. .............. _ '... ....... Ow er Address a .. .w�..S---------------------- -•-... -ted 11 e 14 Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms............................................Ex ansion Attic� g— p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures -----------------•------------------------------...---.•••-•---•-••-------••••-----•-•-•-----•-•--•••-••••_•-••--•-----•--•-••-••-•••--•••-•---••..... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by..--------' ----------------•--------- -................................. Date........................................ _1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Grq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M . .-•-••-------••-••••----••-•••-•...................•-•-••--•••......•-••••--........------••----.............-•-•--•-•-----••-•--•••••----------------------- 0 Description of Soil....................................................................................................................................................................... "W V -•----------------------------------------- ----------------------------------- ---------------- ------------------------------------------------ ..--------------- -------- � ••-••-•----•---------.•--------•-•-•----••-•--•.....•--•-•----••--•-•-------••------•••-......•.......................................I....•-----..$,c...._ e tom. V Nature of Repairs or Alteration —j Answer when appli le.. _._______...1__ •___________________�....__.__... ��.1_ .._.___._. ------ :1l- s ............... ......-•-. Agreement: / The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.i� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been i d by the bo rd of health. igned- ��'!�- ! `t!`L``� y/ ..... �� Application Approve ---- ------------------------- l •• .•.... Date Application Disapprove or a following reasons-------------------------------------------------------•-------------------------------------------......_..._._ .......................................... ...........................:.--........--........------........----•------------------•-•--------••............-••••-.................Date -••••....--- Permit No..47i ..:__.___ .�1.__..._ ----.... Issued....................................................... Permit �....�..�.���W..._. ------------------------ Noy,- Fzm............_............ _ i THE COMMONWEALTH OF MASSACHUSETTS ,. BOARD OF HEALTH .; fly....................OF.... -. .d.` 'l !=b r .......................................... Appliratiun for Disposal Works Tonstrurtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair (4Pran Individual Sewage Disposal System at: .. „i� ,lS.. � .... Lot No. -•-^----•.......................... ... ... A - t cation-A dre`s - or ---------------------- W apq nswt ale r Ass +.-S---------------------- •------•-----...........-------- ? O . r Address VType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow...............___________...................gallons per person per day. Total daily flow.........................._.................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth x Disposal Trench—No_____________________ Width.................... Total Length.................... Total,leaching area_•_ ................ Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--•--••------_._.--•••---••-•-----•-••--•••----__-•••••--•--••---••-••-_. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 .-•-------•-----------------------------------------------------------••----•--...---•....------•••.•--•-••----•---••-•-••••-•---••---- --- -___----------- 0 Description of Soil..................................................................................................................................................••-•...................... x U ----------------------- --------------------------------------------------------------- ------------------------- ----------- •----------------- ------------ ------- --------------------- --------------- -------------------------- .......... ---------------------------------------------------------------------------------------------•-•---j----------- -••-•-• = •---•• _}---•-••••-••- e, At7 G t { J,�1 7 1 U Nature of Repairs or Alterations—Answerwhen applica le___,�'_�______________A...__........... .__._ .. . `�....._____. � I 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 Compliancekas been issued by the bo-rdof health. - r Application Approve Iy....: ........................................- ' Date Application Disapprove or a following reasons:................................................................................................................ ........................................... -........................................................................................................................................................... -•--•----•--- Permit No.---.....1....... . ... �-�-------------- Issued----------------- ------•---•--•----•----••---------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......,,. j(-4?�.�.................OF....I�,�`-.'�v-,P.7..s. k1( ................................. Tatifiratr of Tomplitturr THIS IS T CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired l< , , A Instal er 05h.........Z has been installed in accordance with the provisions of TI LW r of Th State am r o p > S toy C�e �descr,b 13 the application for Disposal Works Construction Permit No.... __ � __ _____________ dated_-_..-`_/___ ---------- ____ .................. THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE/CONSTRE S A GUARANTEE THAT THE SYSTEM WI U TION SATISFACTORY. DATE---•--... zQ -----------•--•--••----....-----•-------•-•--- Inspecto ----------••--•----•---------.....---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N ..' ! ........�1` ;l.l#................OF.... ,? `--�..........._...............----•--•• FEE...f1 4..-......... Disposal Vorkv Tuntr ion anti# Permission is hereby granted.••-- to Construct ) orFRe air ( an Individual ewage Dis s Systems j t.:-� ) I at No.... ..�.. -_1 - ..--------------- � _. ._..._. ....... ----------------------------- Streetf'w.................................................. <oard � r as shown on the application for Disposal Works Construction Permit Nated.._,' --._... -------- Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON I ti ' TOWN OF BARNSTABLE LOCATION '�53 l`1A/ cS/. SEWAGE#Q VILLAGE Cry e ASSESSOR'S MAP&PARCEL I Lit 0 !r INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY .�X/ LEACHING FACILITY: (type) SOD G�4�. C s (size) NO.OF BEDROOMS Jll �J OWNER ��S U�� T�S �SSOC, PERMIT DATE: `��t (� COMPLIANCE DATE: Lf �b Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 4-7 5-3 11A JA,n (73r r w d r co U 6' - % , ac ' b " A a6( 8r - 3 c �� i as � t - l{ - r f LOCAT 0 ,mom EWAGE PERMIT NO. W VILLA lvf V / C INSTA LLER'S NAME i ADDRESS F w If S BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ®, ; C t O M rwM+w�l'�•IMw+.ti�+.s+r- s---.w ..... Yys1/i�wAy...c.+n.MvYr.+�fs:....rw..+n^'..r�..,.+,...+..�n•....sonu +•+��.rnrwwrwrrwra...w.�w..r-...+e.rs..e�..�.-�a+��.vr.i..w-�.....-...•w+.•.�.e..._..�..'+ ar��s.�� �v•`T>>:;.,� PTl,CV Irt�� i��A�•/`! T�'1"'y Fi'?ll�/1�46 514o4/1.1 . F` i 4` Utyf•_Il�o�y `-- 4 SGdo �1:...ej �AC.L boo 1Z.E M O V e 'GFx t STT W . U IJ�y L71 rl TANIL Stir `�3C K L.6A4ll 4� MA.s F ,� pRr srv 'J>> �3A61L�t fL Wi 1"�4 Ct.�A 4 t t 1 i 41 , ell -3l ,- S '/ \ / - 17 3 OQ M # f ` PRELIMINARY Y � -,� , �" ,* � "�1tf'f��G. � sue!•{�. 1�•!�. M A-54 - 04 1-7 r , 'S+T% Gc�NG, , Przo�/��e ��a•/��f �r �z�ruL3 --T.-- �+ w r. :.o /LIJ Go�/t Vla A-s S 14C 04 , 41 4 k 4� P+AiT-04E 14 Zp 1e,/i4&6L. ivAUS tZEArcoVe IEF)(ISTtw� Qxr oac . ,�� SAS e� ,e t> A4Y uw�ut T-A 1 �u MAN F4�tE roo ilk °.t; Ps I- I tJ P3A L FI L .. v(/!1"� C.l.��•r s21 WPA�j t C3J Za A "o SAME rIMe /70 t s 0 i E �� `►� c4, _ i /1- a Of 3s s Q I 7 7-0 i r / r s � 7 Y r - i y�rr�,4 �2�A; zS 14 , qAXilll t\fi 4CSUSf� 5x :ten,. BAXTER NYE ,r ENGINEERING & I�ri,t 1 SURVEYING ; Y - }}; Registered Professional Engineers and Land Surveyors ►mac ` ; �' '' 78 North Street - 3rd Floor Hyannis, Massachusetts 02601 \ - - Phone (508) 771 7502 �N p Fax - (508) 771-7622 c�, o•, �; www.baxter-nye.com Locus Map Scale. 1 -1000 BENCHMARK: A CATCH BASIN RIM \ \ S T A M ESN OF P S T A �t10 OF BACK CENTER, ELEV=27.74 O O z �P� �` NAVD88 O� \ G �`� ( SHAME STELYN �G o.4f3687 (; WFLSON N / , AAALLON � AL , _ O� _ GENERAL NOTES: ��aF-SS,��Q �o �F s���° I M GG t O 0 SU �FSS/ONAL I 1. THE INTENT OF THIS PLAN-IS TO DETAIL PROPOSED WORK AT 753 MAN STREET a / �_ LOCUS AREA IS COMPRISED OF. z I G '- - s 2. PER CURRENT 'S`R GOG 29. G ` O c� r RRENT ASSESSOR RECORDS. \ / < G ` x 4 O OWNER. OSTERVIL.LE VETWNS ASSOCIATION, INC. CONSULTANT -- 30 / \9� G ' LAND COURT DOCUMENT Wi. 121725-1 a / RECORD PLAN: LANC COUR'' PLAN 31591-A / 30.8 28 PARCEL MAP 1415O 31 X30 , x G + . 1.1 CHAMBER SYSTEM O \ 3. PROJECT BENCHMARK; AS SHOWN ON THIS PLAN C O N S U L T A N T TP x .3 S "•_� 4. ZONING INFORMATION: Ql 2.1 Ra2 OS O \ '-x27. 33 AREA 68 `. \ ZONING DISTRICT : BA G 40" O CURRENT MINIMUM ZONING;'REQUIREMENTS: O \� 4 _VEN F \ MIN. LOT AREA - N/A i 33 0 , $ / " MIN. LOT FRONTAGE = 20 O N 3 0" FRONT YARD = N/A SIDE .k REAR YARD = N/A ANN. LOT WIDTH -- NIA P R E P A F2 E D FOR : P rs / 4 - �P< E -�,� - - - , p 4 s . OVERLAY DISTRICM.: NONE ' I Veterans Association, In/ �► ,/ .3 , _ POL , �4 / , s /CAI Ostervil e ete ans c. X ? 5. X y / P 29 5. A TITLE SEARCH HIS NOT BEEN PERFORMED FOR THIS SITE THERE MAY / / Fo\ °° - / F�` \ BE RIGHTS BY OTHERS, EASEMENT, TAKINGS, MORTGAGES, RIGHT OF WAYS P. O. Box 66 �'/ 36 \� \` �� t, H- i P \ I MI SEARCH OSterville, MA 02655 y>�' / \ \ ETC. NOT DEPICTED. IF DETERMINED TO BE NECESSARY A TITLE // �' - _ -• // / �e �� PAN O D-B P / / SHALL BE PERFORMED BY OTHERS MID SUPPLIED TO BAXTER NYE •: PARCEL 141 -015 �o `�s `� \ -8� �o ENGINEERING & SURVEYING. 3 Q / / \ / � 6.0 GP r O0- .26� I 6. THE PROPERTY LINE INFORMIATION SHOWN IS BASED ON CURRENT AVAILABLE 12,381 f S.F. \ � RECORD INFORMATION CON:MING OF PLANS AND DEEDS. THE EXISTING FEATURES 1 J I / _ / SHOWN HEREON WERE OBTAINED FROM AN ON THE GROUND FIELD SURVEY X-34.7 `' Q�' � �- � �, PERFORM BY• NEE ENgNIEEF'ING do FEBRUARY 17 � 4 PERFORMED BARTER SURVEYING ON 2 , 201& 7. COMMUNITY PANEL NUMBS. 250001 0544 J, EFFECTIVE DATE 07-16-14 THE FLOOD NNSURMTCE RAX MAFF DEFINES THIS AREA AS ZONE X (UN-SHADED) \/ C EXISTING LE,*H PITS AND D0 G; {G G� \ � BE PUMPED AND REMOVED ( �� \\ 8' ENVIRONMENTAL IN Z. PER MASS GIS OLIVER AS OF 0103/16: SITE IS NOT WITHIN AN /s C. (AREA OF CRITICAL ENVIRONMENTAL GOtrERN). ► O X S \ 0 SITE DOES NOT APPEAR {r.10 AN AREA OF ESTIMATED HABITAT OF RARE WY.DLIFE AS MAPPED ON , BENCHMARK MASS GIS OLIVER PER NH'SP °ESTIMATED HABITATS OF RARE WILDLIFE* FOR USE WITH THE MA CONCRETE BOUND ,36.7 / oo �G �s WETLANDS PROTECTION ACT REGULATIONS (310 CUR 10).- JF, �O � '�� � ELEV-36.84 \ // • SITE DOES NOT APPEAR TO CONTAIN A-CERTIFIEDVERNAL POOL AS MAPPED ON MASS GIS WAR (NAVD88) PG O PER NHESP 'CERTFIED VERNAL POOLS." • SITE DOES NOT APPEAR 17 BE WITHIN A PRIORITY HABITAT AS MAPPED ON MASS GIS OLIVER PER NHESP 'PRIORITY MWATS OF RARE_SPECIES FOR SPECIES UNDER THE MkSSACHUSETTS / 35.6 ��'��, x36. ENDANGERED SPECIES ACT, REGULATIONS (321 CMR 10). SITE DOES NOT APPEAR T.1 BE WITHIN A STATE APPROVED ZONE II GROUNDWATER RECHARGE PROTECTION AREA 4 \ 41 ^� p • A PORTION OF SITE APPO& TO BE WITHIN A ZONE OF CONTRIBUTION A SALTWATER ESTUARY W N (BARNSTABLE B.O.H. REG. 360-45). N ccQ F- �°) y>v � \� ~ Q� 7 � ' 9. UTIUTY INFORMATION SHOWN HEREIN: F- 'cu �� �y j " �'� • THE CONTRACTOR SHALL f,'ONTACT DIG SAFE (AT 1-888-DIG-SAFE) AND UTILITY COMPANIES TO LOCATE w 3 THE LOCATION OF ALL EX`"TING UTILITIES, AT LUST 72 HOURS PRIOR TO THE START OF / 9 q ✓ CONSTRUCTION. EXISTING:UNDERGROUND INFRASTRUCTURE; UTILITIES, CONDUITS AND LINES ARE SHOWN O M �� v � IN AN APPROXIMATE WAY ONLY,,MAY NOT BE LIMITED TO THOSE SHOWN HEREIN AND HAVE BEEN a L 37.0 9,1,, RESEARCHED BASED ON INE AVAILABLE UTILITY RECORDS NOTED HEREON. THE CONTRACTOR AGREES TO O BE FULLY RESPONSIBLE FOR ANY AND ALL DAMAGES WHICH MIGHT BE OCCASIONED BY THE C' CONTRACTOR'S FAILURE To LOCATE SAID INFRASTRUCTURE AND UTILITIES EXACTLY. IF FIELD CONDITIONS \ t OG \ 3,5. N/F 749 MAIN STREET CONDOMINIUM DIFFERS FROM PLAN INFORMATION, THE CONTRACTOR SHALL NOTIFY THE ENGINEER IMMEDtrATRY FOR DEED BK 4251 PG 322 PARCEL 141-014--CND POSSIBLE REDESIGN. j z O \ 2 SOURCE INFORMATION FR IM PLANS HAS BEEN COMBINED WITH OBSERVED EVIDENCE OF UTILITIES TO - DEVELOP A VIEW OF I TT•HO:,E UNDERGROUND UTILITIES. HOWEVER, LACKING EXCAVATION, THE EXACT a 4.G LOCATION OF UNDERGROUND FEATURES CANNOT BE ACCURATELY. COMPLETELY AND RELIABLY DEM1ED. - / WHERE ADDITIONAL OR MIRE DETAILED INFORMATION IS REQUIRED, THE CLIENT IS ADVISED THAT / N/F PRISCILLA M. HOSTETTER, TRUSTEE x36.9 EXCAVATION MAY BE NECESSARY. f WEST BAY ROAD REALTY TRUST rn o DEED BK 23197 PG 253 0 o W PARCEL 141-016 _ �3j EXISTING SEPTIC SYSTEM INFORMATION OBTAINED FROM SEPTIC SYSTEM IINSTALLATON TIE-CARD � Q BY WALTER LEWIS, PMA i 84-279, ON FILE AT BOARD OF HEALTH, & MANHOLES WERE FIELD w W x33.9 LOCATED. cc �s�FAq� to to � TOWN WATER Saw %O N ON THIS PLAN FROM FIELD LOCATED SHUT OFF VALVE dr DIG-SAFE a s � C, A �q� \ MARKINGS. o GAS SERVICE SHOWN ON PLAN PER FIELD LOCATED METER, GATES & DIG-SAFE MARKINGS. m DUMPSTER\ ` ELECTRIC LINE SHOWN 94 THIS PLAN WAS HELD LOCATED INDICATING OVERHEAD SERVICE FROM ® Q o V ENCLOSURE , UTILITY POLE 39-278, 0'4 02-24-2016. z c \ SHEET TITLE S.A.S. Repair Plan 0 SHEET NO D \ C1 so 8 o D A T E : MARCH 16, 2016 0 10 0 10 20 J a SCALE IN FEET SCALE : 1'= 10' g ko DRAWN/DESIGN BY: JKL CHECKED BY: MWE 6 JOB NO: 2016-007 C A D D FILE: 2016-007ULdw 0 N 0 CONSTRUCTION NOTES: BAXTE R NYE 1. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN TYPICAL SYSTEM PROFILE ACCORDANCE WITH TITLE V OF THE STATE SANITARY CODE DATED NdT APRIL 21, 2006, AS AMENDED THROUGH THE DATE OF THIS PLAN, ENGINEERING & 70 BO " o LE & ANY LOCAL RULES & REGULATIONS APPLICABLE. 2. ANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING BY SURVEYING - THE ENGINEER. ELEVATION INFORMATION MUST NOT BE CHANGED WITHOUT WRITTEN PRIOR APPROVAL BY THE ENGINEER. 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILUNG, Registered Professional Engineers SET MANHOLE FRAME AND COVER TO GRADE NOTIFY THE BOARD OF HEALTH AGENT AND ENGINEER FOR and Land Surveyors RISER & COVER SHALL BE WATERTIGHT INSPECTION. SET MANHOLE FRAME AND COVER TO GRADE. 4. ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 4" SCHED 40 78 North Street - 3rd Floor GRADE a 30.0f ENSURE PROPER PIPE PVC. UNLESS OTHERWISE NOTED HEREIN. Hyannis, Massachusetts 02601 FINISHED GRADE OVER TANK : 30.3t CONNECTION BETWEEN 5. IF NEEDED, EXCAVATE UNSUITABLE MATERIAL TO THE "C irlALL CHAMBERS (4' VENT HORIZON", FOR A HORIZ. DISTANCE OF 5' SURROUNDING THE Phone - (508) 771-7502 7,Gr�AOE o�R �' ' �� SCH ) LEACHING FIELD, AND REPLACE WITH CLEAN SAND PER 310 CMR 4" SCH 40 PVC 2 OF -� DOUBLE 9' (min) Cover 15.255 TO THE TOP ELEVATION OF THE SAS. Fax - (508) 771-7622 3 LF O 2% FIRST 2' (TO WASHED PEASTONE REPLACE EXISTING o BE LEVEL) OR FILTER FABRIC 36" (max) Cover � TEES NEEDED - 4" s�i PVC 6. INSULATE ALL PIPES AGAINST FREEZING AS REQUIRED WHEN www.baXter-nye.com ' OUT=27.64 2' 24 LF, 6 LF, 17 LF 2% 1CONCRETE ' LESS THAN 3' OF COVER. • �- 4• ow 7. THE SEPTIC SYSTEM DESIGN DOES NOT INCLUDE GARBAGE S T A P�-�N OFM STAMP ;. INSTALL GAS INV IN-27.58 8� ' . W OUT=27.41 T o 0 0 0 o ca o o o o GRINDER DISPOSALS. • . = = = = = = = _ _ = 4� STEPHEN cti . -. . MN M�27 ra•. :• r - ,.:. .. `• .•,.. _ _ _ _ _ = o = ti 8. CAUTION: THE CONTRACTOR SHALL CONTACT DIG SAFE (AT 24 ALLYNCP • 1-888-DIG-SAFE) AND UTILITY COMPANIES TO LOCATE ALL WFLSON �' r •;;..; EXISTING UTILITIES, AT LEAST 72 HOURS BEFORE THE START OF No,-S `" ' .. � UNSURABLE SOILS. BELOW THE PEASTONE ELEV (TOP 6 CRUSHED STONE 'Y'- 11!' ELEV-25.00 CONSTRUCTION. THE CONTRACTOR SHALL DETERMINE THE EXACT 10 OF SAS), SHALL BE REMOVED TO THE 'C HORIZON' iy D STONE LOCATION, BOTH HORIZONTALLY AND VERTICALLY, OF ALL EXISTING �,c FG/STER�� EpBTNQ t500 C�ALt_ON 8Ff'i1C TANG BASE s MIN - SEE CONSTRUCTION NOTE /s HEREON. � �RdL � NO OBSERVED GROUNDWATER AT a 20.1 w►voas UTILITIES BEFORE THE START OF ANY WORK. THE LOCATION OF Fss/ONAL T ENG D61FB M BOX EXISTING UNDERGROUND UTIU71ES ARE SHOWN IN AN APPROXIMATE WAY ONLY, MAY NOT BE LIMITED TO THOSE SHOWN HEREON AND %MY DB-6 H-20 OR EQUAL HAVE NOT BEEN INDEPENDENTLY VERIFIED BY THE OWNER OR ITS TO BE INSTALLED ON A LEVEL STABLE BASE LEACHM CHALM REPRESENTATIVE. THE CONTRACTOR AGREES TO BE FULLY H-20 RESPONSIBLE FOR ANY AND ALL DAMAGES WHICH MIGHT BE OCCASIONED BY THE CONTRACTOR'S FAILURE TO LOCATE THE SEPTIC SYSTEM NOTES: UTILITIES EXACTLY. IF ELEVATION INFORMATION DIFFERS FROM PLAN CONSULTANT INFORMATION, THE CONTRACTOR SHALL NOTIFY THE ENGINEER IMMEDIATELY FOR POSSIBLE REDESIGN. AT UTILITY CROSSINGS, 1. ALL MATERIALS SHALL MEET H-20 LOADING REQUIREMENTS. VERIFY IN FIELD THE LOCATION / INVERTS OF ELECTRIC, GAS, TELEPHONE & DATA COMM AND RELOCATE IF CONFLICTING WITH 2. TEES IN SEPTIC TANK SHALL BE REPLACED AS NEEDED. PROPOSED INVERTS PER THE ENGINEERS DIRECTION. THE 3. EXISTING D-BOX AND LEACH PITS TO BE PUMPED AND REMOVED. CONTRACTOR SHALL PRESERVE ALL UNDERGROUND UTILITIES AS REQUIRED. CONSULTANT 9. THE PROPOSED UTILITY CONNECTIONS SHOWN HEREON ARE SCHEMATIC. FINAL LAYOUT SHALL BE AS DETERMINED BY THE APPROPRIATE UTILITY COMPANY. 4' SCH. 40 PVC 4* SCH. 40 PVC a SCH. 40 PVC PREPARED FOR : FROM D-BOX FROM D-BOX FROM D-BOX MANHOLE FRAME AND •. COVER TO GRADE - � -- Osterville Veterans Association, Inc. 43 4 ;. 9• MIAL-38 MAX. COVER P. O. Box 66 TT 2 OR Osterville, MA 02655 • •' ' • GEOTEXiILE FABRIC 1 ' 83' •:w i ••rt ., \ / 24' Y L 0 _ ,•'�'. :a•i•4 f. .. WASHED STONE • .' ..• EFFE DEPTH '• 4. r 0 �T� T� iY._. .• .. .! •.. ,,. :•-• ..� - " •.'" •� .. i.-• _ ..-.• �''.. at•• •••''1• i" �'�. aY• •a •'!• a• • • . • i;.' �.. �r'.;;;• ,• s.a . 43 4.83 43 48.5' 45' 56' PROVIDE 9'STONE BASE FOR CIW RS 500 GALLON CHAMBER DETAIL ' - SOIL ABSORPTION SYSTElL PLAN VIEW N°�t char TO MAE) LEACHING AREA REQUIREMENTS TOTAL DESIGN FLOW = 462 GPD* x 200% = 924 GPD GARBAGE GRINDER (NOT INCLUDED) = N/A PERC RATE = <5 MIN. ,/ INCH (CLASS 1) LTAR = 0.74 GPD/SF SIN. LEACHING AREA OF SAS, REQUIRED: (NOTE VARIANCE REQUESTED FOR 25% AREA REDUCTION) w 0)N 924 GPD / 0.74 GPD/SF = 1249 SF (1249 SF MINUS 25% = 937 SF.) PROPOSED SYSTEM: (5) 500 GALLON CHAMBERS, 9" STONE BASE, 43" STONE ON SIDES AND 45" STONE AT ENDS }' em LOGS P-14M DATE 2/23/16 I- ,C Q) SIDEWALL AREA: (12' + 56) x 2'(2) = 272 SF co BOTTOM AREA: (12' x 56) = 672 SF BARNSTABLE w SOIL EVALUATOR: -1) Q� TOTAL EFFECTIVE LEACHING AREA: 944 SF BOARD OF HEALTH AGENT: o SIEVE WILSON, M *-• to SYSTEM DESIGN CAPACITY = 944 SF x 0.74 GPD/SF = 698.5 GPD P.E. DAVID STANTON, R.S. a Lr) O *DESIGN FLOW FROM WATER USE RECORDS TEST PIT 1 o" G.S.E. = 31.1 f "0" Ap; LOAMY SAND z 5" 10 YR 2/2 - o 3 t- B; 1OYR 4/5; LOAMY SAND z a Jj Z 14" W VARIANCES REQUESTED - TITLE V: C; ]OYR 6/6 ; MED-COARSE SAND W I 5 S 132" (PERC A 60' ELEV=20.1 co w 10 CUR 15.203 (6) NO WATER OBSERVED o TO ALLOW A SYSTEM DESIGN FLOW TO BE BASED ON WATER DETER READINGS. DESIGN SCHEDULE ELEVATION 310 CMR t5.2tt (t) TO ALLOW SETBACKS TO THE PROPERTY LINE OF 2.0 FEET AND 2.0 FEET IA LIEU OF REQUIRED 10 FEET. ® Q FINISH FLOOR-FOXHOLE 31.64 z SEWER INVERT OUT OF 1,000 GALLON SEPTIC TANK 27.64t TO ALLOW A CATCH BASIN TO BE LOCATED 19 FEET FROM AN S.A.S. IN LIEU OF REQUIRED 25 FEEL SHEET TITLE SEWER INVERT INTO DISTRIBUTION BOX 27.58 1 CERTIFY THA1T IN APRIL 1995, 1 PASSED THE SOIL EVALUATOR EXAMINATION APPROVED a 310 CUR 15,223 (1)(b) SEWER INVERT OUT OF DISTRIBUTION BOX 27.41 BY THE DEPARZTMENT OF ENVIRONMENTAL PROTECTION AND THAT THE ABOVE ANALYSIS S.A.S. Profile and SEWER INVERT INTO LEACHING CHAMBER 27.15 TO ALLOW EXISTING UNaAMAGEO SEPTIC TANK (1,500 GALLONS) TO RaWN IN LIEU OF WAS PERFORMIED BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE AND W COMPARTTiIEN' SEPTIC TANK. EXPERIENCE DIESCRIBED IN 310 CMR 15.017: BOTTOM OF 25.15 Detail Plan N ESTIMATED GROUNDWATER* DWATER* <20.10 1 310 CM405 (2)R 15. M TO ALLOW A 25% REDUCTION IN REQUIRED SUBSURFACE DISPOSAL AREA DESKIN - 944 SF IN LIEU OF SIGNATURE REQUIRED 1260 SF DATE 5t-/Y-zoI6 SHEET NO m a (SE-2 22) VARIANCES APPROVED: APRIL 12, 2016 C2w0 CD DATE : MARCH 16, 2016 o i a J i S SCALE : N.T.S. � o DRAWN/DESIGN BY: JKL CHECKED BY: SAW ry o JOB NO: 2016-007 C A R D FILE: 2016-07 PP.dw ry I �