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OLD VILLAGE STORE - FOOD (2)
. t Old Village Store 2455 Meetinghouse i W. Barnstable`t55-tNT ALSO SEE FROMAGE' A TROTS Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. F.P.(Thomas)Lee, Daniel Luczkow,M:D. Alt. $, +639• 200 Main Street, Hyannis, MA 02601 A 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: 215 Issue Date: 01/01/2022 DBA: OLD VILLAGE STORE OF WEST BARNSTABLE, THE OWNER: D & L DEVLIN, LLC Location of Establishment: 2455 MEETINGHOUSE WAY W. BARNSTABLE„ MA 02668 Type of Business Permit: RETAIL WITH FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $200.00 YEAR. 2022 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2022 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: C,r�A FROZEN DESSERT: Thomas A. McKean, IRS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: f PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Well water must be tested regularly Mad,ow� Town of Barnstable For office Initials: Date Paid Amt Pd$AM BAENSTARM - Inspectional Services 0 a Public Health Division Check# Cas1L Thomas McKean, Director 3 aSal 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: L!`7 If f. ADDRESS OF FOOD ESTABLISHMENT: �14 Lka L2,5CF WAY, 0j. 3��r�37�t MAILING ADDRESS(IF DIFFERENT FROM ABOVE): ''P6 Fox YJ;77 E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: (2-0�3l -q TOTAL NUMBER OF BATHROOMS: RE WELL WATER:YES ( NO ... ANNUAL WATER ANALYSIS S REQUIRED)) ANNUAL: SEASONAL: DATES OF OPERATION: /C / ) TO /Z/ ?I /_4j NUMBER OF SEATS: INSIDE: OUTSIDE: TOTAL: a 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? &10 IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)?k'Q TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING...(CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL.MOBILE &NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc ,s OWNER INFORMATION: FULL NAME OF APPLICANT- .D4 as t t SOLE OWNER: YES ' O $ OWNER PHONE# ADDRESS CORPORATE OWNER:__ � L �NE—�✓[_) tj J;A1 L 1 CORPORATE ADDRESS: 54J I& 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 I Certified Food Protection Manager PER SHIFT. **ATTACH COPIES OF CERTIFICATES** The Health Div. will NOT use past years' records. You must provide new copies and POST THE CERTIFICATES at your food establishment. Certified Food Managers Expiration Date Allergen Awareness Expiration D to D, 0 Z/ 12. /ZOZ_q 1. Cr Q.�_ . _,� 2. Wf-f-)R oIl/0 /;Z6Z3 i22si 20Z1 SIGNAT M 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 508-8624644 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 httv://www.townofbarnstable.us/healthdivision/anplications.asi). OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1 st to Dec. 3 I't each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1 st. Q:\Application FonnsTOODAPP REV3-2019.doc Town of Barnstable BOARD OF HEALTH John T.Norman r , Board of Health Donald A.Gaudagnoli,M.D. +; Paul J.Canniff,D.M.D. 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: 215 Issue Date: 01/01/2021 DBA: OLD VILLAGE STORE OF WEST BARNSTABLE, THE OWNER: D & L DEVLIN, LLC Location of Establishment: 2455 MEETINGHOUSE RD W. BARNSTABLE„ MA 02668 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $200.00 YEAR. 2021 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2021 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Well water must be tested regularly yY�oFn+E,gr Town of Barnstable For Of Initials: BARNSfABLE, Date �1. Inspectional Services AmtPd$��6q 0Public Health Division o`Z �FDMA�s Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE Z U3 .ZDZ® NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: �� �L z.L %O 2e ADDRESS OF FOOD ESTABLISHMENT: J y5 G� �l _ a a)A�j '�E�]P/057; /�( C , �� MAILING ADDRESS(IF DIFFERENT FROM ABOVE): PC) 21:�;,x Z45�2, 6 zc9e S E-MAIL ADDRESS: (: y1/lC ) KA TELEPHONE NUMBER OF FOOD ESTABLISHMENT: TOTAL NUMBER OF BATHROOMS:_=tZQQ PO-B L 1,) WELL WATER: YES V NO_ ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: {/ SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: 0 OUTSIDE: 6 TOTAL: SEATING: MUST OBTAIN A COMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING,MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING,AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING?_ y IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S). 0 TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) V FOOD SERVICE _RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) _BED& BREAKFAST CONTINENTAL BREAKFAST _COTTAGE FOOD INDUSTRY(formerly residential kitchen) _MOBILE FOOD _FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) _CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL, MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV. FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:\Application FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT D/'r,k(r t- L- -� - SOLE OWNER: YES/NO �,� OWNER PHONE # 5_O 8 3 ADDRESS CORPORATE OWNER: CORPORATE ADDRESS: J t9 yt/li= 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. b.AN ? -J , UcvL IJ/ 12 /Za?Ll 1. D1tla)6(- /) / Z J /Z61 2. . 1=�t � z //z /20z 4A� /2 Z© SIGNATU O 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.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 Hearth 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/healthdivisioti/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 I st to Dec.3151 each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC 1st. Q:\Apphcation FormsTOODAPP REV3-2019.doc Friday, November 20,2020 10:23 Massachusetts Department of Environmental Protection - Drinking Water Program BACTERIOLOGICAL REPORT .. ,, '�" .. Y i ,.,.,, ... .... ,. .v,Y'.-,S r• �: „Wad ., r � 1 I. PWS.fINFUIZMATrO efer to oar DEP,Co Iforrn:Sam hn : ,,lal� tolllelcom late the.`;P.;. :S 3nfokm tron ands E, roomed, m le Sipe Informat? a 1Q .isectlo s„b. .....1 -.:. x, ,. .. ..a .... �>'.i.,Yd�,f,..,,,..,..,rw ,..� .,.w.:..>_,>,:;..1,:t3tw.,__w..�..�:,��4 .,.:�3a,,S.!?h.,.��.7�,"<-.....J�V,�,w PWS ID# 4020016 PWS Name: Old Village Store City/Town: FBarnstable, —� CLASS TNC .,.,, ,. ._ F ,1, .,. 1 o.... s.., x... 1. , e,> .-.. .....-.,W N ,ui rc to�t , ...:, .f`m .. .i.. �t I a.. , RV., '{. .� ...,1 : .,v. 4M fT f ....r, i- Y,l_ ,AtU:. -s,.�: ..,�,, k ...,4iF;.. n.ff:. --.Yb i!V � r,. i .. ,. k .. _. >:naNb.t' rat _. a ._.. J', d., f.,_ ..LS '� �,a.. ... ...:. �s J,..,,r w .,l. &. �.. .. Q. 4 :,., , & W,, d, vu F Pl ,. ,. , , $5, `' , > , .. - yygnl �{}:, ,.. ..M t?r , , „r. .F; .{, ':,r' , .l .:- . II p II .,. Y,,. )GAL,fiYFU , CI Re,e _to,.oa Mass EP.sta#exlab serif,t r I „ 1 r ctatexfo.r ro, er b tied tneti►ods. . 1 � I _.. r - .,. x.. r. I n ,,i a .w .._.... 4,7. ,.:,.,:,..kl. , ..,.,.., 1 f.. ?..t�.s,.i�_��� d....,�,z:.�,>1,w.>L.cr7��..�x��,tt.Y.x.vtr,�,,.,.:�rtdr,�„x�,rw,,,�t,!�:,ua)~1__.�...,�€.a�,,,,_.,.._..ssa ,�� � +��s�q. Primary Lab MA Cert.# M-MA063 Primary Lab Name: Envirotech Laboratories, Inc. Subcontracted? N Analysis Lab MA Cert.# M-MA063 Analysis Lab: lEnvirotech Laboratories, Inc. Resubmit Indicator: 10riginal Reason For Resubmission: Collection Date of Original Sample: TC Method E.Coli Method Fecal Coliform HPC Method Chlorine Method MF-SM9222B � J' Lab Sample Notes: A-BG=1 ,.. ., t' �q.. ,�tr wN„ - sw a�, - .'u „ _f"l:. ,.�. w ;.: : s.•;,, ..t,.:.1, DEP APPROVED SAMPLE SITE INFORMATION TOTAL� E/CO fZAr Cf1LO EiPG=f•,.. p CbLLEG D.. t iPA+Bt3a +1 '<1 �7, � �� '� _h C (�xr�ION, �r �e,nzhJ,as " •r sar.�a., �.,.,. ,n`� a;, '!` x� s. _.t, ;: , };. 'Y .-„ - •�, <, 4 ,,e . ^»�crJu.._,e.. � ,,, , ,. , ,w ,COLIFORNt3 F.EC�AL _ ,,� .} ,� .. .. ...: . ....�.. .< .._. �i ,a-. ,r• ., � _il .", ,_ I,�<,mri;,, . : , ,K.. p SUI. RESUL`2' ,, . „ ,. �,x�.�.�1$lY , :; � L r•.. ,.;s. ,. 15EPI '1) r .., , :, S;T1L:{" ,���. . #Cm ..-�, ,, �, ,' s . 5, ,,.A , , , „1 , ,, �•�.... 1+.. ..,:...5 t Yl k . .. .�. , .. w v. 1. � .�k ,•,.S. 5, r � .. . >' x f. ,..�u. a .....,., , R. ..:- ., 'G �.� ,.... , r a �r. 14 11, , ai' :.� ��,.. .r.... .,:+ k.w,kY,4�, -P••-1 , _.I ... ,.n,...:._, � „u'In,.ut,.Y�.,..c�.,..at�k,� ,1.,.s.,•1..,n.�tih�._ ,:�4i'fW4wklr��, ,.,.vr-14'x...,rw, ',......>.�!.�mf.. .e��uFL�si,e rt'h �„�'VYt�.�it-n{�,s�'P,,�tti�4'.'e�'+� .+-.w�44.7»� sy,.,,,._�stJfi`: 3..,,�..r•�.».r>!.. RW 01G Raw Water 0 11/18/2020 12:50 11/18/2020 14:45 T Everson DEP-202350A PT 10001 Finished Water 0 11/18/2020 12:55 11/18/2020 14:45 T Everson DEP-202350B RS 001 Kitchen Sink 0 11/18/2020 13:05 11/18/2020 14:45 T Everson DEP-202350C 1 DEP Sample Type,Location code#and DEP approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. 2 SWTR systems:HPC samples shall be taken at the same distribution sites and at the same time as total coliform,whenever chlorine residual is not detected at the sample site. 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/l00mL,P(present),A(absent),or Too Numberous To Count:TNTC-I(invalid)or TNTC-P(present). 5 Collected appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. t8 c i a �'fl'Y la7Ae,� z.k,u a�ns•V Fi'1 a, a a 4/,4.k 1,IP!' P i" jce�rtyxunder p}enaJites of*/awrtliala�3am'11e erson�°auih`orlaelo fl,J�,tii; Laboratory Authorized Signature Ronald Saari i, c }xrt� "a�,4 +ia"� s d� R a�r ltie"'r�lG1P, , d ouChis} nrth,a�t� lie`f tr ormddditcontuned her n " �� `" and Date fp s1 aN »-u { v � x �,;ri��Rk>"�w� kw,}.�,r ri5�� YS{r»Na�S�1 75• ,i rt�� ��ita,y 6ai v �r contpt`�te�,�o�the�rGest�exlentro�d�tryknow�ledg�� '�r1� � 9 �li�'�� ' �1 DATE 11/20/2020 DEP Review Status: ❑Accepted � Disapprove Review Comments: Page I of 1 CHAIN OF CUSTODY FORM S R Client: Bennett Environmental Assoc: PWS: 4020016. Class:TNC 1573 Main Street Project: OLD VILLAGE STORE PO Box 1743 Towns VILEST BARNSTABLE Brewster,MAL 02631 M F Ph.# 508-896-1706 Lab iD# Bottle# Date: Time: Sample Location: Location Sample Analysis Code:.. Type: 120 ml sterile tJ L IL' Raw Water S R. RW-Q1 G RW Total Coliform. 120 ml sterile 1 =5 Finished Water S F 10001 PT Total Coliform 120 misterile I Kitchen Sink S F 001 IRS Total Coliform. ✓ r SAMPLED BY: DEP REPORTS: X Yes No Other Relinquished- Datertime Re'c v w Da4e me Received: Relinquished: DateTrne Received: Datemme Received: Bellaire, Dianna From: Todd Everson <teverson@NSUWater.com> Sent: Tuesday, December 01, 2020 4:29 PM To: Bellaire, Dianna Subject: RE: 2021 Food Permit for Old Village Store Background of 1 in Raw Water only is considered acceptable. All Total Coliform bacteria reported as zero. Todd Todd Everson, PWSO Lead Operator Water Supply—Cape Cod Service Area BENNETT ENVIRONMENTAL ASSOCIATES, LLC. A Natural Systems Utilities Compa-iy 1573 Main Street Brewster, MA 02631 508-737-0113 mobile 508-896-5109 fax http://bennett-ea.com Confidentiality Notice: This electronic mail message and any attached files contain information intended for the exclusive use of the individual or entity to whom it was addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure under applicable law. If you are not the intended recipient,you are hereby notified that any viewing, copying, disclosure or distribution of this information may be subject to legal restriction or sanction. Please notify the sender, by electronic mail or telephone, of any unintended recipients and delete the original message without making any copies. Go Green! Consider the environment before printing this email. This message may contain privileged and confidential information. If you are not an intended recipient, please note that any disclosure, dissemination, distribution, or copying of this information is prohibited From: Bellaire, Dianna [ma ilto:Dianna.Bellaire@town.barnstable.ma.us] Sent: Tuesday, December 01, 2020 4:25 PM To: Todd Everson Cc: Bellaire, Dianna Subject: RE: 2021 Food Permit for Old Village Store Hi, Thank you for the quick response. Could you tell me where on the report from 11/18 does it say the water analysis states it is passing or acceptable?Or if you could just send me an email that states it is acceptable or passing? Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Bellaire, Dianna From: djdevlinl @gmail.com Sent:_ Saturday, December 05, 2020 11:26 AM To: Bellaire, Dianna Cc: Leslie Devlin Subject: Re: 2021 Food and Tobacco Permit- Old Village Store Ms. Bellaire, this email is to certify that The Old Village Store,located at 2455 Meetinghouse Way,West Barnstable, MA 02668,does not sell either cigars or vaping products. We also have no intention of selling these products in the future. Respectfully, Daniel J Devlin and Leslie W Devlin Co-Owners Sent from my iPhone On Nov 30, 2020,at 2:17 PM, Bellaire, Dianna<Dianna.Bellaire @town.barnstable.ma.us>wrote: Hi, As,per oui conversation, here are the copies of the food and tobacco applications from last year. Please complete the applications and provide the following: 1. Two checks-One made out for$200.00 for the food and$85.00 for the tobacco-made out to the town of Barnstable 2. Copy of your Allergen Certificate with 5 year expiration 3. Copy of Eric's Servsafe Food Manager Certificate, I have yours 4. Email that states you don't sell cigars or electronic delivery systems 5. Copy of passing well test. I will try and find my email contact for the well. I will copy you on the email if I find his contact info. Thank you. Be safe. Dianna Bellaire Permit Technician Town of Barnstable Health Division 200 Main Street Hyannis, MA 02601 P:508-862-4643 Fax:508-790-6304 Email:Dianna.Bel laire@town.barnstable.ma.us The information contained in this electronic transmission('e-mail"),including any attachment(the "Information'D,may be confidential or otherwise exempt from disclosure.It is for the addressee only.This Information may be privileged and.confidential work-product or a privileged and confidential communication.The Information may also be deliberative and pre-decisional in nature.As such,it is for internal use only.The Information may not be disclosed without the prior written consent of the Director of Public Health and/or the Town Attorney's Office of the Town of .. 1 Town of Barnstable John T.NOF o BOARD No HEALTH � rman Board of Health Donald A.Guadagnoli,M.D. BARNSTABLE, : F.P.(Thomas)Lee IMF`' Daniel Luczkow,Alternate 200 Main Street, Hyannis, MA 02601 a+ Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 215 Issue Date: 1/1/2021 DBA: OLD VILLAGE STORE OF WEST BARNSTABLE, THE OWNER: D & L DEVLIN, LLC Location of Establishment: 2455 MEETINGHOUSE RD WEST BARNSTABLE, MA 02668 Type of Business Permit: Non-Flavored Annual Seasonal FEES YEAR: 2021 TOBACCO SALES: $85.00 Permit Expires: 12/31/2021 Thomas A. McKean, RS, CHO, Health Agent Restrictions: Well water must be tested regularly PLEASE POST CONSPICUOUSLY I I Only*For Office Use Initials: Town of Barnstable `. Date Paid 1,01 A1J1LP�$ C)_J Inspectional Services &639. �� . Public Health Division Check# ATE.�y Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 i TOBACCO ESTABLISHMENT...PERMIT APPLICATION (Non Flavored) DATE NEW BUSINESS OWNERSHIP RENEWAL � S � k NAME OF TOBACCO ESTABLISHMENT: /-f,� 6 Lb `� �� ADDRESS OF TOBACCO ESTABLISHMENT: . 7 2 5:c,-Pq e�TC/-YG-/4C)L)54 W � MAILING ADDRESS(IF DIFFERENT FROM ABOVE): _PO 3DX 6--� W r Ba e-ros 1 aLaL,(:!�- oZ(o&b E-MAIL ADDRESS: / 5 TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: ( 5) Z- 3,70.) qq OWNER'S NAME:,�i9XJI L D4Y(/u� OWNER'S PH#(—Q8)Z67- I8/ZD. OWNER'S ADDRESS: CORPORATE NAME: `r CORPORATE ADDRESS: /+K46-7 1a� ANNUAL: SEASONAL: DATES OF OPERATION:_/_/ TO s DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) 5 TOWN OF.BARNSTABLE.CODE/MA GENERAL.LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 t MA GENERAL LAW CHAPTER 270/SECTION 6: https:Hmaleaislature jzov/I,aws/GeneralLaws/PartIV/Titlel/Cha ter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY*** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. E PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT.THE FOLLOWING REQUIRED DOCUMENTS: 4 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 s SIGNATURE: O s PRINTED NAME: Q:\Application Forms\TOBACCO AFP-NonFavor 12-18-19.docx ( The dElla a tors1 of West Bamstabic 508. S AELISHMENT'S NAME } i TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s)of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving Tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: s Sales to Minors— .371-9. Sale and Distribution of Tobacco Products.. 6 1. No person shall sell or provide a tobacco product,as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. i 3 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: p i Xrik 'lie,( Y Sig re Printed Name Date _ ,eyj nc, Z/ . Si e � Printed Name Date I&2�c Si a Printed Name Date t ,r1 �exl�e�n�Q_T\n �� l Ll 1Q,0 e Printed Name Date Signature _ Printed N me Date 1 S Witfre Printed Name Date Signature Printed Name Date Q:\Application Forms\TOBACCO APP-NonFavor 12-18-19.docx f auH Us MASSACHUSETTS DEPARTMENT OF REVENUE Form,CT-3 G j Retailer License for Sale of Cigarettes �T01i This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. D&L DEVLIN INC Account ID: CGL-I 1190557-008 THE OLD VILLAGE STORE License Number: 2131855360 2455 MEETINGHOUSE WAY WEST BARNSTABLE MA 02668-1403 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date: November 12,2020 Expiration Date: September 30,2022 r{ , Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Gaudagnoli,M.D. nAnrtsrxe Paul J.Canniff,D.M.D. 1 200 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: 215 Issue Date: 12/10/2019 DBA: OLD VILLAGE STORE OF WEST BARNSTABLE, THE OWNER: D & L DEVLIN, LLC Location of Establishment: 2455 MEETINGHOUSE RD W. BARNSTABLE, MA 02668 Type of Business Permit: FOOD SERVICE Annual: YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $200.00 YEAR. 2020 RETAIL(FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2020 B&B-PULL BREAKFAST: CONTINENTAL BREAKFAST: MOBILE-FOOD: MOBILE-ICE CREAM: C,d FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Well water must be tested regularly l For Office Use Only. Initials: Town of Barnstable Date Paid I Afq A mt Pd$� � Inspectional Services MAss. ` Public Health Division Check# ,9 Thomas McKean, Director 200 Main Street, Hyannis,N A 02601 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE Ir NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT:�E �LA V d C-4- ' � �'� W667 7—a/i"5 5 42(E ADDRESS OF FOOD ESTABLISHMENT: 2455 `C �� rr��—u�l,J-5c: GPJf4Y k ��j2e(j5T-.q Cj p— MAILING ADDRESS(IF DIFFERENT FROM ABOVE): �O (' `��I (�� G_b= dl�fA E-MAIL ADDRESS: TELEPHONE NUMBER OF FOOD ESTABLISHMENT: D 370 J TOTAL NUMBER OF BATHROOMS:—J--Cuo 1 U WELL WATER: YES V NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION:_/_/_ TO NUMBER OF SEATS: INSIDE: 6 OUTSIDE:- .0 TOTAL: n 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)? NO TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT M_aCHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING ... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) *** SEASONAL,MOBILE & NEW FOOD ONLY*** _REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED PLEASE CALL 508-862-4644 Q:Wpplication FormsTOODAPP 2020.doc OWNER INFORMATION: FULL NAME OF APPLICANT I Aj SOLE OWNER: YE /N OWNER PHONE #�nSd �97 9G / Z ADDRESS_ 2 EEizA-1CraoL-)-5c=: 1-04-`f k). (O,9 CORPORATE OWNER: C_-- CORPORATE ADDRESS: PERSON IN CHARGE OF DAILY OPERATIONS: LJ���V U atJ aJS 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. i Certified Food Managers Expiration Date Allergen Awareness Expiration Date ob has-1ao l Ae4 >O/ d'2 /W2,Z 2. t e W, )16FVL=) O q / 20 20 f/ /2/ SIGNATU O 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/a1)plications.asp. OUTDOOR COOKING: Outdoor cooking,preparation,or display of any food product by a food establishment is prohibited. NOTICE: Permits run annually from January 1st to Dec. 31"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S)AND REQUIRED FEES BY DEC Ist. QAApplication FormsTOODAPP REV3-2019.doc • oFtNr•tqy, Town of Barnstable For Office Use Only: Initials: �. r�¢�� Date Paid1 Amt Pd�/I9 9EAMSwTABrE, 0 Inspectional Services �S p cb " 9. Check# a s63q. Public Health Division HIED�p , Thomas McKean, Director j IN 200 Main Street,Hyannis,MA 02601 �2f-" Y Office: 508-862-4644 Fax: 508-790-6304 TOBACCO ESTABLISHMENT PERMIT APPLICATION (Non-Flavored) DATE 11 Z!o E NEW BUSINESS OWNERSHIP RENEWAL er' NAME OF TOBACCO ESTABLISHMENT: ©e--D ADDRESS OF TOBACCO ESTABLISHMENT: MAILING ADDRESS(IF DIFFERENT FROM ABOVE): a��� E-MAIL ADDRESS: TELEPHONE NUMBER OF TOBACCO ESTABLISHMENT: �aLZ- 3761 OWNER'S NAME: 1J/�aI I EL 1. L LI 1 OWNER'S PH#jL aZD. OWNER'S ADDRESS: )451S3 CORPORATE ADDRESS: S'ftM E- ANNUAL: SEASONAL: DATES OF OPERATION:—/—/— TO DAYS CLOSED EXCLUDING HOLIDAYS(EX.MONDAYS) 6 TOWN OF BARNSTABLE CODE/MA GENERAL LAW INTERNET LINKS: TOWN OF BARNSTABLE TOBACCO CODE LINK FOR CHAPTER 371-9: https://www.ecode360.com/33996392 MA GENERAL LAW CHAPTER 270/SECTION 6: https•//malegislature gov/Laws/GeneralLaws/PartIV/TitleI/Chapter270/Section6 ***NEW BUSINESSES AND NEW OWNERS ONLY *** REQUIRED TO CALL HEALTH DIVISION AGENT FOR AN INSPECTION PRIOR TO PERMIT BEING ISSUED. PLEASE CALL 508-375-6621 ALL APPLICANTS ARE REQUIRED TO SUBMIT THE FOLLOWING REQUIRED DOCUMENTS: 1) MA State License to Sell Cigarettes 3) IRS Federal Tax ID#Document 2) MA State License to Sell Cigars and Smoking Tobacco 4) Payment of Fee(s) -see page 4 SIGNATURE: V PRINTED NAME: V, - t" L DATE: 11 / 26/1 Q:\Application Forms\TOBACCO APP-NonFavor 11-21-19.doc I p ESTABLISHMENT'S NAME TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one (21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—� 371-9. Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products, as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The employee(s)below received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: NtQtEL- EV LIB S i gff 917r Printed Name Date Si Printedgame MPri tDate ��S' ntedK ame 1' 11do Signature Printed Name Date ignatuv Printed Name Date Signature Printed Name Date a7l—�J%P� " / Signature Printed Name Date Q:\Application FormATOBACCO APP-NonFavor 11-21-19.doc c.. `rs'he.HS��T MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T j Retailer License for Sale of Cigarettes fry This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. D&L DEVLIN INC Account ID: CGL-1100557-008 THE OLD VILLAGE STORE License Number:2013065216 2455 MEETINGHOUSE WAY WEST BARNSTABLE MA 02668-1403 ` This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above.This-license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. Effective Date:_ October 1,2018 Expiration Date: September 30,2020 -------------------------- ''cH�SF MASSACHUSETTS DEPARTMENT OF REVENUE Form CT-3T ' Retailer License for Sale of Cigars and Smoking Tobacco ''Fvrox�� This license must be posted and visible at all times.The sale of tobacco products to anyone under 18 years of age is prohibited. D&L DEVLIN'INC Account ID: CRL-11190557-011 THE OLD VILLAGE STORE License Number: 759246848 2455 MEETINGHOUSE WAY WEST BARNSTABLE MA 02668-1403 This certifies that the taxpayer named above is licensed under Chapter 64C of the Massachusetts General Laws to sell at retail at the address shown above. This license is non-transferable and may be suspended or revoked for failure to comply with state laws and regulations. ' rl Effective Date:October 1,2018 Expiration Date:September 30,2020 f Town of Barnstable BOARD OF HEALTH John T.Norman Board of Health Donald A.Guadagnoli,M.D. BARN OM Paul J.Canniff,D.M.D. � a 200 Main Street, Hyannis, MA 02601 F.P. Thomas Lee Alternate '— Phone: (508) 862-4644 Fax: (508)790-6304 www.townofbarnstable.us Permit to Sell Tobacco In accordance with regulations promulgated under authority granted by Sections 5,31 and 127A of the General Laws of the Commonwealth of Massachusetts and Chapter 371 of the Town of Barnstable Code, a permit is hereby granted to: Permit No: 215 Issue Date: 1/1/2020 DBA: OLD VILLAGE STORE OF WEST BARNSTABLE, THE OWNER: D & L DEVLIN, LLC Location of Establishment: 2455 MEETINGHOUSE RD WEST BARNSTABLE, MA 02668 Type of Business Permit: Non-Flavored Annual _�C Seasonal FEES YEAR. 2020 TOBACCO SALES: $85.00 Permit Expires: 12/31/2020 Thomas A. McKean, RS, CHO, Health Agent Restrictions: Well water must be tested regularly PLEASE POST CONSPICUOUSLY V�' 4%0- Thursday,August 22,2019 16:13 Massachusetts Department of Environmental Protection-Drinking Water Program BACTERIOLOGICAL REPORT I r PWS�INRO A�'I�ON. Refer�t :b.ou,aD P.Cal>Eform�Sa: i � plan to hel com Cete�the� �S�Infarmatto��n and�D ' 1:A -o am IeES'�i�e InI��o.��� a oar echons b� PWS ID#: 14020016 1 PWS Name: 101d Village Store I City/Town: JW.Bamstable,MA CLASS: JTNC �: �•c.Fr,S' <a�;� .3p�,x+�,'.s.�'; ii6. z, �.:,xa..�.�... r'^sm��'. � i: �- " :� �' ;4 �'.'.- �°'tR��'..; y. u. :7y: ': "`t '>"n''� '8ir fiI ANAI.YTIC'�AL�'I1YF® �,'yCIO�. �'e a�rto o as� �� a,� � b ,y'��e.•�#�ainclnce. l,i � e. r`� ..s �nfi' M��, 1 '. ,>r, , _:.: _r.-,�».. ,,-�zi�. .__�__�xr.�tw��biew�:�� �..u� �,�.3,,,��*,c7iv.a��,��•n�sa�°,in.w�axinv. >\�r�nrv�us .�c�u:�,��.����,. aaer���C���au�mK,Psez�ires:�;��s�a� r�, :�3t .,_,. .s,�mu.:� :�a: :,N1'� M .�.. z::w �.��-r�. Primary Lab MA Cert.# M-MA063 Primary Lab Name: jEnvirotech Laboratories,Inc. Subcontracted? N Analysis Lab MA Cert.# M-MA063 Analysis Lab: jEnvirotech Laboratories,Inc. Resubmit Indicator: joriginal Reason For Resubmission: I I Collection Date of Original Sample: TC Method E.Coli Method Fecal Coliform HPC Method Chlorine Method ENZ_SUB.SM9223 Lab Sample Notes: ,> 5 :,.,�PY .._.v ✓1,. yrr. ,. ,.,::� . ,,:,,,'1 9(,:.. v� ITE .r*,..rry _j Po tni DEP APPROVED SAMPLE S INFORMATION �3"r.: QTAL7E GOL OKa ORII�I F: 'q99I3P5 �1°I�s/ 'r !x�•':r , fb h Cr i4 COLECe 7 yy' "o nrDA$"ar } GOL�IEOI�M�: EASItSUI T RES7IrL BY t s y o SAMF Ew d .,.... ..,:,:. EP ... ., ..... D .>a .3.,,r. �i a, .., »U_..v,�✓ uw. .n� :. Ar n� w. ., f, z!+.- -_...aal tz.,�.,, � .� .;>,y e : rr t f, � rM1` .:,..,, °,, .... ...,.: -� ,.. ,., ,� ..f e. : r - 3. ,✓ ,,r...�>�t h1,a... a,:.x�'� .,,... .9 .... .. .. ...:..».,, +, r,zi n h u, a-.. C,r, ,7,,..F fi.( .. . !9. ..1. ! a :: I,,<r. ,mx! v a ..n. 4F ,: ,, r. ,.. ,(. ,-iJ•r. 1 } �.i... ... ...., ....:, .F,,>.,.✓r,y, ..t„t,i��.....Y.�a�.l�.J.t�.,vP, .�—s f�i}a.an.,d�_�54�t,4!�:�rd�.,E, �:.��i�:^k..az,������,.z....��,aw� iilmt�.,..:::�z.�1!�.a��, .>a,N .,' ,�.0.a�' �.n���:..a t�i�,wu,a..Ai�,P{���.��5 r'c,,,,�:.. ,i w.�,.,rtP,.Pin.4�..r�.b�iM.r„.� .:,t•.z, RW 01 G Raw Water A 8/20/2019 12:55 8/20/2019 16:00 D.Meany DEP-191388A PT 10001 Finished Water A 8/20/2019 13:00 8/20/2019 16:00 D.Meany DEP-191388B IRS 001 Kitchen Sink I A 1 8/20/2019 13:15 1 8/20/2019 16:00 D.Meany DEP-191388C 1 DEP Sample Type,Location code#and DEP approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. 2 SWTR systems:HPC samples shall be taken at the same distribution sites and at the same time as total coliform,whenever chlorine residual is not detected at the sample site. 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/100mL,P(present),A(absent),or Too Numberous To Count:TNTC-I(invalid)or TNTC-P(present). 5 Collected appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. cerh under ena! ces'u` law thaty' tarirFY e' erson"aut7i`orizedrto'illr� `s out th�rsfo' rm anpd zth����n foNp r.m5f�`antt"oin(�n�cowrn�liw~aafn:ed���ierem�rsv 3iru e°aceuratf �� Laboratory Authorized Signature nature Ronald Saari 85' ands and Date completerfo therbesteztentto�,my knoi►�le�g��u,���.��r�i'' ,� �,� �r��ria �/ �xti�rli;m '�}rrsn � fyll n�aH,�V 'a1if�sWyi�lfrttfuh`l7"� llfit'4�f }��tix!7 DATE 8/22/2019 DEP Review Status: ❑Accepted ❑ Disapprove Review Comments: Page l of 1 i I , Massachusetts Department of Environmental Protection - Drinking Water Program N Nitrate Report PWS INFORMATI014 Please refer to your DEP;Water Quallty,Samplig Schedule(WQSS)to he n 1p complete this form PWS ID#: 4020016 City/Town: Lest Barnstable PWS Name: Old Viliage Store PWS Class: COM ❑ NTNC ❑ TNC DEP LOCATION t� j rS`arople� DaEe x 5. " LOC iD# DEP Lyocation Name Sample'Information 5� Collected By Acitltfied7 Collected A 10000 WELL#1 Lj (M)ultiple LJ (R)aw © (S)Ingle ❑d (F)Inished Yes ❑ 8/20/2019 D.Meany B (M)ultiple (R)aw Yes ❑ H (S)Ingle (F)inished C ❑multiple ❑ (R)aw Yes ❑ ❑ Sin le ❑ Finished D Ll (M)ultiple El (R)aw Yes ❑ ❑ (S)ingle ❑(F)inished n Routine of �� ' f Original,t esubmitted or a 4� If Rbidbmitf rdtj o orb hsf below ,� $ Sp ci213ample,�� �,� ,�Confirmatfion�Fteport ��s ,;��x� 1, Repsoh,�for'Resubmfsslon�.��:�,_ �R Ori Ipal'Sam le Cdllectetl Date A ❑d RS ❑ SS 0 Original ❑Resubmitted ❑Confirmation Resample❑ Reanalysis ❑Report Correction B ❑ RS ❑ SS ❑Original ❑ Resubmitted ❑Confirmation Resample❑ Reanalysis ❑ Report Correction C ❑ RS ❑SS ❑Original ❑ Resubmitted ❑Confirmation Resample❑ Reanalysis ❑ Report Correction D ❑ RS ❑ SS ❑Original ❑ Resubmitted ❑Confirmation Resample❑ Reanalysis ❑ Report Correction `.::>�s �SAIUIPLE NQTES fir:Such�as,if 8 Malitfold%IV��Iti le aam:Igo ICst the"§ources_�iat�Wefe°an Ilhe during sam le ollectlon ?,�A���`�,� ,_ A B C D lI ANALYTICAL LABORATORY INFORMATION„ ,.�.. �4e.Si: Primary Lab MA Cert#: M-MA063 Primary Lab Name: Envirotech Laboratories,Inc. ---]Subcontracted?(Y/N) N� Analysis Lab MA Cart#: Analysis Lab Name: t �>_ .' � FLabMethod� ? Date an�lyzeds r" A 1.53 0,01 EPA 300.0 8/20/2019 DW-192828A 4,�70�nY B �0 C 90 D `10 Finished water results equal to or exceeding 1/2 of the MCL(5 mg/L)triggers quarterly monitoring. Finished water results exceeding the MCL of 10 mg/L requires confirmation sampling within 24 hours. Notify MassDEP of any MCL exceedances. I,r K�,`Lr4-`BSAMPLENOTES r � , � , A B C D fcerhfy ynde penaltles:gf/aW that+l�m the person Primary Lab Director Signature: au(hortzed to ft/l out this form aritl the rnfortratlon contaln'ed herein is Date: free acc urate and complete ta�he best extent of my knowledge.;; G if not submitting these results electronically,mail TWO copies of this report to your DEP Regional Office no later than 10 days after the end of the month in which you received this report or no later than 10 days after the end of the reporting period,whichever Is sooner. DEP REVIEW STATUS(Initial and Date) Review JE] WQTS 0 Accepted Disapproved Comments I Data Entered .,� Massachusetts Department of Environmental Protection - Drinking Water Program Sec Secondary Contaminant Report t PWS INFORMA_TION Please refer to your;DEP Water QualitySampling Sahedu(e(WQSS)to help complete thls•form ; PWS ID#: 4020016 = City/Town Lest Barnstable PWSName [01:d:=village -� PWS Class: COM ❑ NTNC ❑ TNC 0 1 DEP�=LOCATIOtta N � � R,� �EA 10000 WELL#1 8 (F)toshed8/20/2019 D.Meany B ® (R)aw (S)ingle (F)inished '' R�iutmeor` sOng(naf,Resubmitted or if>ResubmittedR,epp`rt?list belovfl y r j, r a r tii n F x '.4 8ecial Sample Confirmation RepCrt:, (1),R`ea'sdn-fortiesubmission, -(2)Callechon_Date of Original Sample A W RS ❑ SS Q Original❑Resubmitted❑Confirmation❑Resample❑ Reanalysis❑ Report Correction B ❑ RS ❑ SS ❑Original❑Resubmitted❑Confirmation❑Resample❑ Reanalysis❑ Report Correction s,�S1�fUfPLE�N�®TES (Such as if a IVlanifold/Mu(tlRle sample,llst any sotrce�th2E werd on,linertlunng satnpls�colle�ction� ��h„ s A B r al ANILYTICALABO,RATORY INF.,ORMATIbN ., v x w ? Primary Lab MA Cart.#: M-MA063 Primary Lab Name: �Envirotech Laboratories.Inc_ Subcontracted?Y/N 0 Analysis Lab MA Cart.#: Analysis Lab Name: „���ampot�d'"`'�x � ��- Results k SMCL7 MDL�� y- Lab M�t:ho�d� D�e �h � Lab Sample ID#,�• A s B a (mg ) F 2An�l zed::: ,.,��.�,�-��Y�.;<r+ � .�, � .��-.� , ..,, a z.x ,A__.M: ... __ �,8. .�•, IRON(mg/L) 0.84 0 3 0.01 EPA 200.7 8/22/2019 DW-192828A W MANGANESE(mg/L) 0.023 O`05 0.005 EPA 200.7 8/22/2019 DW-192828A ALKALINITY(mg/L as CaCo3) 22 Not e r 1.0 SM 2320E 8/20/2019 DW-192828A CALCIUM(mg1L) 16 f ogle 0.1 EPA 200.7 8/22/2019 DW-192828A MAGNESIUM m IL ( 9 ) 4.1 None 0.1 EPA 200.7 8/22/2019 DW-192828A HARDNESS(mg/L as CaCO3) 57 � ' ,',Node,T 3.0 EPA 200.7 8/22/2019 DW-192828A POTASSIUM(mglL) 3.5 None9 0.1 EPA 200.7 8/22/2019 DW-192828A TURBIDITY(mg/L) 5.7 Ndre 1.0 SM 2130E 8/20/2019 DW-192828A ALUMINUM(mglL) ND 0.21v; 0.010 EPA 200.7 8/22/2019 DW-192828A CHLORIDE(mg/L) 290 6Q„ . 3.0 EPA 300.0 8/22/2019 DW-192828A COLOR(C.U.) ND 15.w 5.0 SM 2120B 8/20/2019 DW-192828A COPPER(mg/L) 0.134 A, 1 0.003 EPA 200.7 8/22/2019 DW-192828A ODOR(T.o.N) ND 3 S 1 SM 2150B 8/20/2019 DW-192828A pH 6.31 6`5 8 5 N/A SM 4500-1-1-13 8/20/2019 DW-192828A SILVER(mg/L) ND „ ,0�1b 0.002 EPA 200.7 8/22/2019 DW-192828A SULFATE(mglL) 3.0 EPA 300.0 8/20/2019 DW-192828A CONDUCTANCE umhos/cm ( ) 893 500 5.0 EPA 120.1 8/22/2019 DW-192828A ZINC(mg1) 0.005 5! 0.004 EPA 200.7 8/22/2019 DW-192828A EPA has established a lifetime health advisory(HA)for manganese at 0.3 mg/L and an acute at 1.0 mgtL. ;� LAB SAMPLE NOTES Asterisk(*)next to compountl Wards Indicates(tWas subcontracted , - A B I certifyunderpenalties of law that I am the Primary Lab Director Signature: person authorized to rill out this form and the Information 7 contained herein is true,accurate and complete to the Date: L J best extent of my knowledge. If not submitting these results electronically,mail TWO copies of this reportto your DEP Regional Office no later than 10 days after the end of the month in which you received this report or no later than 10 days after the end of the reporting period,whichever/s sooner. DEP REVIEW STATUS(Initial Date) Review ❑WQTS Data Accepted ❑ Disapproved Comments Entered CHAIN OF CUSTODY FORM S R Client Bennett Environmental Assoc: PWS: b LOD, Class: 'T V'— 1573 Main Street Project: `" 1 r�J ii.-� 4�s t'='��.� G�i•--4.._. PO Box 1743 Town: s�c�?c4 �`- Brewster,MA 02631 M F Ph.# 508-896-1706 Lab ID# Bottle# Date: Time: Sample Location: Location Sample Analysis: Code: Type: 12 �1J 1 q 20 22 IL ,r SAMPLED BY: DEP REPORTS: I'� Yes No Other Relin wished: Date/Time Rece' ed: DateTme Received: 2V�q 1 Relinquished: DateTme Received: DateTme Received: Monday,April 15,2019 10:52 Massachusetts Department of Environmental Protection-Drinking Water Program BACTERIOLOGICAL REPORT - 3t1�r+t�.:.aLa ... 1y7..:: � _ T«$IO..N�.,.: ,R YR4 �<e'1�Uer_ arx.Y�oL2SuE:Aw,,"u'k$�..s.R :wt:.h:�U.`iqtfk�C in,�tw rt'aN.Fa iir!.S.3'{,�lr@%•,eL 1 onP`{aWt..,r,oe?_z €sIt;-xoz,:t:db n"iG,e Evi( saa'�p"i.4 R]i,_.'x1i.c}t!71et 1tai,>J,i c9?:....�'�V,+..`w1'st}`33:.',.,.�.:`W sI..X:#a'mC^�'�wk"'+Po!+z1:�6:zNtt"lrvi~';SC'zFakt�'yuad�a"4,ai�,a.>o-:r.".".u9,':'....L: ��Yi-:$(5v�?. Y, ..a.rC.x� k:.5a. �gS Tt AR'�oyed�8�p�a p �- �:f�A- ffiM^„ "tOh� ,. � t,�I.Y. 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Resubmit Indicator: 10riginal Reason For Resubmission: ICollection Date of Original Sample: TC Method E.Coli Method Fecal Coliforml IIPC Method Chlorine Method. MF-SM9222B Lab Sample Notes: �- DEP APPROVED SAMPLE SITE INFORMATION :?`.; >R Mry1n��ix�tf,ksx. 1 �.r�.... t '::.., r,a, k. w:,.�, A Mr, -. 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Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. ,V9Naexar,r, 7',dd U i f b }br7P' p'SR4 qw }by �e�r� '�Ir��derrenott �►�'� ,� +fit her �� is Laboratory Authorized Signature Ronald Saari and Date av Pr4y�y DATE 4/15/2019 DEP Review Status: ❑Accepted l?rsapprove Review Comments: Page I of I CHAIN OF CUSTODY FORM S R Client Bennett Environmental Assoc: PWS: :c., Cuss: 1573 Main street Project: v"Ra"-, - PO Box 1743 Town: r Brewster,MA 02631 M F Ph.# 508-896-1706 Lab ID# Bottle# Date: Ti rn e: Sarnp.le Location: Location Sample Analysis: A' Code: Type: tZ J -1 1-k JV SAMPLED BY: DEP REPORTS: Yes No Other h. Relinquished_ Dar me R!t 62,; DateMme Received: Relinquished: Darerrime Received: Daterr-ime Received: Monday,September 23,2019 12:06 Massachusetts Department of Environmental Protection-Drinking Water Program BACTERIOLOGICAL REPORT „ .,,.. rt"u u?..,•r,R,D r,inlE:aryw.ip�,�C.„¢.}�fnxwoxP �,nw,, a:l l�g.�Iw �r�i�sa�nAsr�`M: �P.a�Ye�net cTN n \ . s. s ,,fo .4.nh ect oua...si- br ° !. 6 eP t R, � � o ,.:sal- PWS ID#: 14020016 1 PWS Name: Old Village Store 1 City/Town: JW.Barnstable,MA CLASS: JTNC '+„� '��:,?*A lw..��• �. d a1,h 7� °��+W':'ir'v'1�"�i ttl�'u� '�:; a.�. - .' ,G3.�'�tr1.S5."'1sK. � � ..��t.`+ II ..A1�TAT. ,:�+CAL,LNFU 'f „ ., ...,r,: �.� �- .. � .�. �. a r,:: v `'�,�,+k ��r��'�r .� S�rr ,� S�• . YTS RMA IO,..,.Refe Ito,your.�YiasDEP-state,lab�certl€iratefa� :r er.:. •ab - Ce••#.a d�ce�Ied'rme � ��: � ��.,.r, :,. .{,:.� , ..�,}.� � -�� • F�Mt� .� . . y,.,.;,� �.,:. :. : ... .,I .;: ,... p: ,.1t. MA,. ,-.. .. .,4 � .... . � ,thoryds ;�,�r s ,i ��� l� � �� r., >, ,. _..._, ,n,:�.v��,a..,..�„a:a�a�r. �ns�r,.�#•.mmic.>d�larar'wJ,A,.w::�.mm .�rin�a�n�.�:�wesse?�a:4��u,ar!��,�.,,�r��aa!�'�: sw.,afru�u^a��{aw�,v r�,�a:srs.�xa.�ztx,;Mtn,�sr�,cr,.7�$�,aa:�,.>�,.�a�,r�thr�.�k�..._,..r_. � .k,.,::�:� .sr,._::: ;:.:<„�,,.�; Primary Lab MA Cert.# M-MA063 Primary Lab Name: lEnvirotech Laboratories,Inc. Subcontracted? N Analysis Lab MA Cert.# M-MA063 Analysis Lab: lEnvirotech Laboratories,Inc. Resubmit Indicator: joriginal Reason For Resubmission: I - Collection Date of Original Sample: TC Method E.Coli Method Fecal Coliform HPC Method Chlorine Method MF-SM9222B Lab Sample Notes: DEP APPROVED SAMPLE SITE INFORMATION TQT.`'i` ?C EI`* CI.ORIbIE, �IPG' F '`a' Yid /^<� "" 'x t + y"td s s ° `CO)6 ECoIED `� 'e� W ' yi@ }+:O a�Ta. J. •.,k r ` mtkF�' ®iL�li i4IO r ANrALYSIS: r ;1s :r r t ,i�a($„'L,AB w w �. $ .'F: vt s» �> �w,r: fir r S r' LILT ORES s, k ?'� .........w w., ,r ., ,.--: 3' t vrers .. .3 .,, , ,t.. ,� cW. :. I `� r�: a D TE "a „ $$� �. ,. 1". ..r._„. . . 1 ..d.,.,. .11 t.. 1 :,, .. .& ...7:..._nYr �s�,, ..4..,p :J ,� k.„."nA 4,.,f, I � wv 1 _..,, a ,°�¶ .-. h n m _, :, ..x $ _ ............. :. . .A., � i?h rnd ,. p,.. r, }� o....> ti�4s�L..:.,•.,.�7� �,s,7,:�1�1..I�d^�Jt,c�..�net "Y�",e�1'��,�r,..:,.. ,:���:,.,liR:..'& t.,_u,.,.,t�,1�,rr c>�.a .?..:,,.�,�.,,,«.� ,u�:.,,u,:...✓;�._,_....rr.s, «1r+:_,_.,.,4.. .,..�d. .:: .......... ..... RW 01G Raw Water 0 9/18/2019 12:10 9/18/2019 1320 DPM DEP-191569A PT 10001 Finished Water 0 9/18/2019 12:15 9/18/2019 1320 DPM DEP-191569E RS 001 Kitchen Sink TNTGI 9/18/2019 12:20 9/18/2019 13:20 JDPM DEP-191569C 1 DEP Sample Type,Location code#and DEP approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. 2 SWTR systems:HPC samples shall be taken at the same distribution sites and at the same time as total coliforrn,whenever chlorine residual is not detected at the sample site. 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/100mL,P(present),A(absent),or Too Numberous To Count:TNTC-I(invalid)or TNTC-P(present). 5 Collected appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. T cerh under' enal '' "°fi`wftlia 'a»i 1 e ' ' ttior �d o���i. %i Laboratory Authorized Signature Ronald Saari fIY P t�es,v�f a t k�" ,heap rsonsa�i" ze f r,e� rY 9 a4fmW, C� ul outt/iuform�andthe,,enformaitaon,c ntacnedl�h"ereinRrs+itrue,�a�et�rat anc�ail and Date ¢2r CO1n Iele tO'lhexbeSt' en 1O" At �knoiu�'�ed��e,.�'�p ��ar ,t��l'+��rt�+ne��b7��aF Jt xJr rJyy� DATE 9/23/2019 r3 .,1.?�:, :_�Y_.1Aer,��.•4��. ��sr�`.'`.s�'�6 �;. rl�W,�.��b..,�- �?Jl'P��`'. � � �l/�l/ DEP Review Status: ❑Accepted ❑ Disapprove Review Comm Page I of I CHAIN OF CUSTODY FORM S R Client Sennett Environmental Assoc: PWS: Class: -T U 1 1573 Main Street Project. 6 4 PO Box1743 Town ti� -- Brewster,MA 02631 M F Ph.# 508-896-1706 Lab lD# Bottle# Date: Time: Sample Location: Location Sample Analysis: Cade: Type: W 4 �Z, JD �—'%Af 9 D 20 tU CGcnJ 5 r— Twin �T --------------- Ya7 SAMPLED BY: T �Al DEP REPORTS: Yes No Other r r Relinquished: Datemme- ecei �me Received: , ,1J 2 � Relinquished: DateTme Recei DateTme Received: 77 Friday,July 12,2019 14:26 Massachusetts Department of Environmental Protection-Drinking Water Program BACTERIOLOGICAL REPORT ,.r:..1.a:raM, , - •t .} � �; : ,R dz: :1� a,, ..�E1 �r�,��tlE�"11� �!nk ` �� $�Fdk �k�� ., ��7c,�i.k:.t�,�t.�v ,xla+�� �Rr., . :.�. ,,� tld�in,3i,l,�ra�. .,,�,,z+".,�� a. ... _ � . .. a our, �,Callfo;. RSa�m lIn iPlanto�� el co �-le{ � e PWS hnfo � at on d. P` � oved Sa a Slte.°Infa.m an sec Iobs<l"i. PWS ID#: 14020016 PWS Name: 101d Village Store City/Town: 1W.Barnstable,MA -----]CLASS: JTNC _. , .�., v,e:a ..�;K �x,. d'd.'. ?A[f!�t ;. ,:�dme .n. „' a-.. �,�± riiryk-' ..a y a , 9>' .U3r'�,^ :._.`. P M Su'_ ij"*�' l�w+R!iY„ .. "i' w.q 1'� "'�' J , R 7gfSpX L..,7lyi tr r7_ 'y.. lI, ANALYTICAL INR.ORMATION " efer-kta our"M'assD P stated ce, te, or a era e., '. , . ram , d4Ni R E. 1..,, lab ca : f , rL b; A G rband certifthodscw - `,R .,.._+.;:rN.r:.!nt.+,�w�^�g_:sod,.rt±,±�Wtf•:yiturpGi-: .p)Fs7F�s: 1o:a735i'*•`�Y.�l. .wum,3.wkm43;1`G :K3ke�:ymm r,.nntrollt).�' ..U;P*�;.� Primary Lab MA Cert.# M-MA063 Primary Lab Name: lEnvirotech Laboratories,Inc. Subcontracted? N Analysis Lab MA Cert.# M-MA063 Analysis Lab: lEnvirotech Laboratories,Inc. Resubmit Indicator: 10riginal Reason For Resubmission: Collection Date of Original Sample: TC Method E.Coli Method Fecal Coliform BFC Method Chlorine Method MF-SM92226 Lab Sample Notes: B BG=s1 DEP APPROVED SAMPLE SITE INFORMATION ;TOT r E°C4LI or j� ;CHLORINE COLT ECO�l„ , �t� YSIrS i�, r 2 ... .. _ RM .. ... .....,. .:L. L....,...,.,..,c..,�.... ? TYP4 ,i.,.Rk..E,r..<..$..,b•,.,l,1,.,..7nL,,-,..._.t,,..t«,fi...r.5.c.,s,a rW>�.3".,,y,�?lu„h�e,?r. 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RW 01 G Raw Water 0 7/10/2019 12:15 7110/ n, 2019 16:55 G Brehn DEP-191110A PT 10001 Finished Water 0 7/10/2019 12:25 7/10/2019 16:55 G Brehn DEP-191110E RS 001 Kitchen Sink 0 7/10/2019 I 20 7/10/2019 16:55 G Brehn DEP-191110C 1 DEP Sample Type,Location code#and DEP approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. 2 S WTR systems:HPC samples shall be taken at the same distribution sites and at the same time as total coliform,whenever chlorine residual is not detected at the sample site- 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as 4/100mL,P(present),A(absent),or Too Numberous To Count:TNTC-I(invalid)or TNTC-P(present). 5 Collected appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. cerhfiy`under penahtres of!aw tha!I dm the personaulho`iizearyio ll[lfi Laboratory Authorized Signature Ronald Saari and Date out thrs form and the iuformahon coniacned hereto is"hue,accurat ands - complete.lo the best extent of my knowledge,, � + �Y X�^���� 17F'r Ff��S+rP n DATE 7/12/2019 DEP Review Status: ❑Accepted ❑ Disapprove Review Commen : Page I of I CHAIN OF CUSTODY FORM S R client: Bennett Environmental Assoc: PWS: /& Class: TA-.I(::— 1573 Main Street Project 0 6 �r'U -?�q 0 PO Box 1743 Town: Brewster,MA 02631 M F Ph.# 508-896-1706 Lab ID# Bottle# Date: Time: Sample Location: Location Sample Analysis: Code: Type: `� 2`•l W-f71 ��i. l CG �I rz F.,,. �,�„�� F Lq°c r i 7 i SAMPLED BY: DEP REPORTS: _1� Yes No Other Relinquished: i Daterrime R ive DateTme Received: Relinquished: DateTcme Received: Datemme Received: Friday,July 12,2019 14:26 Massachusetts Department of Environmental Protection-Drinking Water Program BACTERIOLOGICAL REPORT S.. F ._._.. R r to .our..A I'Col for Satin 1 aggP an to co e e e�PWS, fo on and A rowed. am SI _W q _. .. .. .,.:.,:. ,: -- ..,,,,.,::.. �.:..:,.X aP,.:U�+��,.o-.. .�. .._.a...:,a. .4..cs,x..t.�w�^,,dr�,Ya,ttlk�.w✓.�:tna,ul�l�.1.y„I u�.'vL*'�'�1,.�,dW1!" Wv'iti,NfFti:: ,:L�11N1�Ss�.aul.Y�,�Yd;W��.cl4N,AlRNl:,w�[MIN:W,UtL�h.1dU^>�d{5> 6A1VR(��.����`?m"Se�:ad1t7:91k�'fN..CS`.:Pirv?+..w0(lW,..�Y'�.._f''.l.v.k'Y,�..,..,"2.-+u:«f:@VPe::n.,71..yG.�k...�f._..\_.:3 PWS ID#: 14020016 1 PWS Name: 101d Village Store City/Town: JW.Barnstable,MA I CLASS- '1NC .. .:-:.a:—, :�-" i -,. ,-:,..: r -' .3r •ar -;a- .;.0 .-r, r .»at .-?-�'t r�. rr^.r-xi>r.:mr• ^T =P"r,' „G L7 .1> .:. S fit ?, „ v .., �•?= kT 4 F w- ate+ II. ANALYTICAL INF.ORMAT.ION.� et'erito� o r�MassDEPstatefla certdi te, ar, o e:Lali � ,Cert_and:cert><fed�' ethoc`ls'��� ��-� Primary Lab MA Cert_# M-MA063 Primary Lab Name: lEnvirotech Laboratories,Inc. Subcontracted? N Analysis Lab MA Cert.# M-MA063 Analysis Lab: lEnvirotech Laboratories,Inc. Resubmit Indicator: joriginal Reason For Resubmission: I I Collection Date of Original Sample: TC Method E.Coli Method Fecal Coliform HPC Method Chlorine Method MF-SM92226 Lab Sample Notes: B BG-61 DEP SAMPLE SITE APPR VED INFORMATION O .TOTAL;. E QQl}I{ors x;C�4rO�a�rxl ,5,,tIP ,�1;� :t -�Q�`T�E '�Q �r :r ,�i � LYSZS ,¢�•�E�T,ED �f l,�P,B , -. .... - ... - ....COO , ,.... CAS,. „�. SU:L, „ S ,a�Yd VJ. 1J :::.. .. :...... ,.^ ..,..,,.. pp -: F.G �. ....,.. :{: t- 't"er. C ., i ,.,,.. sr,i H ,e: x l DEP... .. DEP :......., :::< .. :, , „.,,t, a':1 7 4 J ,N��.. ,:.uxl .. DEP A roved �•• � ,.fi:. ,.. ." I w"k Y' /kTE ,�•G'FTME n i ATE,"{ �FIlvIE, t �$: I' ,� „ R�r.i.�., ,��{{ 1 t� IP✓k\ 'ES� i..�}.., �. 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U- nn .:a� ..�,�` -s±,� ,. e �a,,. .,,� ,ri .Sr :>F' A� ``..:w :�t. 4 a ... �:: ::.:..:... _,. .. .... ... :..:.t,.,?ts� :_• ,:,:�..,.T.ax• .,.:s;t _..k"s, )�t., vfishm. 1:AA.,�vi 3'��f.icrw`nt.s.,.+�'r�s��+ ...hYrcE;C+.t'A.� �, s�3�,.au ..�.t'�T��w.� -'.'�.�*�m.3.. .�, ':s�,.2.�ii, r.r,54si ua::5.w�' _ RW 01 G Raw Water 0 7/10/2019 12:15 7/10/2019 16:55 G Brehn DEP-191110A PT 10001 Finished Water 0 7/10/2019 12:25 7/10/2019 16:55 G Brehn DEP-191110E RS 001 Kitchen Sink 0 7/10/2019 12:20 7/10/2019 16:55 G Brehn DEP-191110C 1 DEP Sample Type,Location code#and DEP approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. 2 S WTR systems:HPC samples shall be taken at the same distribution sites and at the same time as total coliform,whenever chlorine residual is not detected at the sample site. 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/100m1,P(present),A(absent),or Too Numberous To Count:TNTC-I(invalid)or TNTC-P(present). 5 Collected appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. I certy'under penalmes of law that I am t(seerson authoiiedito��a�If aj Laboratory Authorized Signature Ronald Saari 1 �s ; out thrs form and the rnformatron`cont6cnedhereen rs�>!rue,�tdccurate�andS� and Date completeto tree ties!extent of my knowledge,,� >� � � � x �,���' ;M; DATE 7/12/2019 .pry 4,. , § Fta,u�,r �.r�..'rv',1, rve' �'• Dfl.(,,�e_�.'("+N'.)iw�U DEP Review Status: ❑Accepted Disapprove Review•Commen Page 1 of I CHAIN OF CUSTODY FORM S R. Client: Bennett Environmental Assoc: PWS: L10 Zool& Class: Tti c:_. 1673 Main Street Project: -76ec�- PO Box1743 Town: Brewster,MAC 02M M F Ph.# 50"96-1706 Lab ID# Bottle# Date: Time: Sample Location: Location Sample Analysis: Code: Type: she -�o t2` t5 „� Lower l� YLw-�I�a lac v � l Cr'/k"—" 2 Z F,,.9 cam©o f F o 0 / /S SAMPLED BY: DEP REPORTS: Yes No Other Relinquished: l Dzterrlme RdUv. Datelrime Received: Relinquished: DateTme Received: DaWrIme Received: Friday,January 18,2019 16:23 Massachusetts Department of Environmental Protection-Drinking Water Program BACTERIOLOGICAL REPORT i a:nr,,2f t�w�}t.�L�.1au.:i rt.�S.nM1mttql aC 5��. H ar5 ,,YX tta'1X. !'ti"8vx n4,� �SYCe.�.rna...g uF ,r pG, rR;C 7„L 3v b. ..t:..m . b•. a , PWS ID# 4020016��pWS Name t)Id Village Store City/Town: 1W.Barnstable,MA CLASS: TNC — n Q, „�, i � >� .a►�'ON. Ret'er tm� r ,.� r���,. '� � r�� r �_ -, �:t-.,.: .,,:..w mii .,sr , �ls, .�, .w.�, .. ,.. -,.. . .. .. .. '�St�:$ ,�i�v � -..:, �:. � ._ � ,,. ,. ,y.: ..., .•.'. �S, .�t: '#��"d; ...n:.,d�iZvi�.k✓�:7 `'", �... "fir,,.,rCthO�S t,ua�� A sa: �hA `MA—A Primary Lab MA Cert.# M-MA063 Primary I.ab Name: Envirotech Laboratories,Inc. Subcontracted? N Analysis Lab MA Cert.# M-MA063 Analysis Lab: Envirotech Laboratories,Inc. Resubmit Indicator: Original Reason F'or resubmission: -�Collection Date of Original Sample: TC Method E_Coli Method Fecal Coliform f HPC Method Chlorine Method MF-SM92226 Lab Sample Notes: DEP APPROVED SAMPLE SITE INFORMATIONOTAi," lilt a,aiiP v '.. r ,� ECT%D ,h R N .$ „ ., -/t,: ,. n ,,:e,.-.x *v, -.:-.,, .. ,� x r `uw,�x aseu,�..x�.mr_s , ks > '„-• a4}�..r t �_ 1.,,} DEP, ,V f wh::a„ o J VlAL_, , $Us IkT T}L•3 k 1' a ,s .s w,,.. w,.b- .t,. .. �;, ., . $ed.., ,`.. . ,lamp.,. ,.t n $ �� r?apl Y9� ,e.., w`.�5 .. N ..d..,,�ab ern,�c, ��; � .G�. . . . z ,.�t�..,, , , _. .:.., ,r.. a .,.. 9. . .�,1, . ., .s, 4 ,.,.r4 .,w x4.uz- ,, u a..d...g ,.. e wt ..d .�>u � .. ,� .. ., ,. . �- �' _�.s. :�-- h.. ,. �, h _ et"x. t+. :;,. ....._ 11...,.v - .. h'i„ .... r ,r . n,i3. a,.dx�G:,...., n „- sal.,,,, r:.e 1.�.-e :.,.. .d .�?. .. .,�, :Y7�A,f:iy � S�F I ,� 2#� tt�om'' � rJ xv . � ._r ... .. tiV%.{n7 /v,Pat �, M illi!?" RW 01G Raw Water 0 1/17/2019 12:30 1/17/2019 16:30 DPM DEP-190104A PT 10001 Finished Water 0 1/17/2019 12:35 1/17/2019 16:30 DPM DEP-190104B RS 001 Kitchen Sink 0 1/17/2019 12:40 1/17/2019 16:30 DPM DEP-190104C I DEP Sample Type,Location code#and DEP approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Sampling Plan. 2 SWTR systems:HPC samples shall be taken at the same distribution sites and at the same time as total colifomL whenever chlorine residual is not detected at the sample site. 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as#/I00ml. P(present),A(absent),or Too Numberous To Count:TNTC-1(invalid)or TNTC-P(present). 5 Collected appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. ' er1� yYl!!� r ?na1rk�es,°° nl tJlr ( aye'rle'i' t$"��° r �Je ,lil�ksS Laboratory 9 Authorized Signature Ronald Saari out iYirs formeandh�inormarl�on conla�yredliei� as" rite,�acesrra a [;p; and Date con:ple1e41g�llfe b�si�en[,�of�{�ey krrawledgeF �` � �� �< '' e "� F .isd'si� _ — :;�. DATE 1/18/2019 DEP Review Status: ❑Accepted ® Disapprove Review Comments• Page I of I CHAIN OF CUSTODY POB=',Aq S BZ Crent Bennett Environmental Assoc: PWS: ct�/C0 Class: - Es r. 1673 Main Street Project; Town: PO Box 1743 � -��, Brewster,MA 02631 M F Ph.# 508-896-1706 Lab ID# Bottle# Date: Time: Sample Location: Location Sample Analysis: Code: Type: @(�� ! Cam' IAV U SAMPLED BY: � DEP REPORTS: V Yes No Other Relinquished �/ Date/Time / JR ce ed: DateTme Received Relinquished: d Date�me eeeived DateTime Received: Town of Barnstable BOARD OF HEALTH Paul J Canniff,D.M.D. Board of Health Donald A.Gaudagnoli,M.D. UARNnABM John T. Norman 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: 215 Issue Date: 12/20/18 DBA: OLD VILLAGE STORE OF WEST BARNSTABLE, THE OWNER: D & L DEVLIN, LLC Location of Establishment: 2455 MEETINGHOUSE RD W. BARNSTABLE, MA 02668 Type of Business Permit: FOOD SERVICE Annual': YES Seasonal: IndoorSeating: 0 OutdoorSeating: 0 Total Seating: 0 FEES FOOD SERVICE ESTABLISHMENT: $200.00 YEAR: 2019 RETAIL FOOD: COTTAGE FOOD OPERATION: Permit Expires: 12/31/2019 B&B-FULL BREAKFAST: CONTINENTAL BREAKFAST: --------------- ,--- - - MOBILE-FOOD: MOBILE-ICE CREAM: Q� FROZEN DESSERT: Thomas A. McKean, RS, CHO, Health Agent TOBACCO SALES: $85.00 FOR ESTABLISHMENTS WITH SEATING: PERMIT IS NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALER LICENSE Restrictions: Well water must be tested regularly >�r cFt►+E>� Initials: � Town of Barnstable , 1 Date Paid Amt Pd$QC 9AS&MA89. Inspectional Services g� cow Eo 9. 6. Public Health Division �� L Thomas McKean,Director L� I� S f fq 200 Maui Y Street,Hyannis,MA 02601 (6/- 1 j5 Office: 508-862-4644 Fax: 508-790-6304 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT DATE i L z NEW OWNERSHIP RENEWAL NAME OF FOOD ESTABLISHMENT: ��� �� V 1 Cr�'� Ti9 GF W. ADDRESS OF FOOD ESTABLISHMENT: 'a�}�SM �1 lei�`�C�L3�!_ LPMI, fN;MAILING ADDRESS(IF DIFFERENT FROM ABOVE): PD J30 K /--5% W. <0 ZC.(O E-MAIL ADDRESS: . 1 TELEPHONE NUMBER OF FOOD ESTABLISHMENT: ( C-1 3G2, 370! TOTAL NUMBER OF BATHROOMS:--Q—f v AL 1,C— WELL WATER: YES NO ... (ANNUAL WATER ANALYSIS REQUIRED) ANNUAL: SEASONAL: DATES OF OPERATION: / / TO NUMBER OF SEATS: INSIDE: OUTSIDE: SL TOTAL: SEATING: MUST OBTAIN XCOMMON VICTUALLER'S LICENSE FROM LICENSING DIV. ***OUTSIDE DINING REMINDER*** OUTSIDE DINING MUST BE APPROVED BY THE HEALTH DIV.AND LICENSING AND MEET OUTSIDE DINING REQUIREMENTS. IS WAIT STAFF PROVIDED FOR OUTSIDE DINING? IS AN AIR CURTAIN PROVIDED AT WAITSTAFF SERVICE DOOR(S)? TYPE OF ESTABLISHMENT: (PLEASE CHECK ALL THAT APPLY BELOW) FOOD SERVICE RETAIL FOOD-ONLY required for TCS foods(foods requiring refrigeration/freezer) BED&BREAKFAST CONTINENTAL BREAKFAST COTTAGE FOOD INDUSTRY(formerly residential kitchen) MOBILE FOOD FROZEN DAIRY DESSERT MACHINES ... (MONTHLY LAB ANALYSIS REQUIRED) CATERING... (CATERING NOTICE REQUIRED BEFORE EVENT(SEE PAGE#2) TOBACCO SALES ... (ANNUAL TOBACCO SALES APPLICATION REQUIRED) *** SEASONAL,MOBILE & NEW FOOD ONLY*** REQUIRED TO CALL HEALTH DIV.FOR INSPECTION PRIOR TO PERMIT BEING ISSUED Q:\Application FormsT00DAPPREV2018.doc L 1 PLEASE CALL 508-862-4644 OWNER INFORMATION: FULL NAME OF APPLICANT A)y(6,e, SOLE OWNER: YES/NO � OWNER PHONE # ,�O R 34, ADDRESS .Z4- j ��T X�'�z�-1�U3� � �_�if�2101ejo-S E4 I i-g �a CORPORATE OWNER: )) L It=-v,,-1,; L. C. FEDERAL M CORPORATE ADDRESS: Sig M- PERSON IN CHARGE OF DAILY OPERATIONS: j?/� Ra7/� 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.M 5 6y,)C 25 / ZS- l 24:> 1. 1/0 1 5,9 ut�2S o z /O 7 / i7 (*j 2. LFs L/& b6V L/,J SIGNATURE APPLICANT DATE ***FOOD POLICY INFORMATION*** SEASONAL FOOD SERVICE:All seasonal food establishments,including mobile trucks must be inspected by the Health Div. prior to openinS!! 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/bealthdivision/applications.asp. 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.3 1"each calendar year. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED APPLICATIONS)AND REQUIRED FEES BY DEC 1 st. Q:\Application FormsTOODAPPREV2018.doc 1 Town of Barnstable For Office Use Only: Initials: $ Date Paid $ » » Inspectional Services Check# STABM Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-7904644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health Fee: $85.00 MAIL TO: TOWN OF BARNSTABLE PUBLIC HEALTH DIVISION 200 Main Street HYANNIS,MA 02601 FAX 508 790-6304 PLEASE INCLUDE THE REQUIRED FEE OF$85.00 APPLICATION FOR A TOBACCO SALES PERMIT V� Z-L-4c'-E ESTABLISHMENT NAME (D/B/A) ADDRESS OF BUSINESS ox MAILING ADDRESS (IF DiFFERENT FROM ABOVE) OWNER'S NAME: LAST FIRST MIDDLE 4, d e✓lin KA<;l ccltA Do you currently possess a state license to sell tobacco products? Yes No Each employee who sells tobacco products must receive and understand Chapter 371 of the Town of Barnstable Code (copy provided herein) and the Massachusetts General Law Chapter 270, Section 6.00 (a copy is provided on the next page). Each employee who sells tobacco products must sign the Employee Signature Form (provided herein). fl Signature Date l Z U / C:\Users\Dan\AppData\Local\Packag 'crosoft.windowscommunicationsapps_8wekyb3d8bbwe\LocalState\Files\SO\5016\TOBACC 0 APP2019 dob[6384].docx TOBACCO SALES Employee Signature Form This form is for official use to indicate that the employee(s) of this establishment received and understood Chapter 371 of the Town of Barnstable Code and Chapter 270 Section 6 of the Massachusetts General Laws which describes the penalties for selling and/or giving tobacco products to any person under the age of twenty-one(21). Below is Section 371-9. of the Town of Barnstable Board of Health Regulation: Sales to Minors—4 371-9.Sale and Distribution of Tobacco Products. 1. No person shall sell or provide a tobacco product, as defined herein,to a person under The minimum legal sales age. The minimum legal sales age in the Town of Barnstable is 21 years of age. 2. Identification: Each person selling or distributing tobacco products,as defined herein, shall verify the age of the purchaser by means of a valid government-issued photographic identification containing the bearer's date of birth that the purchaser is 21 years old or older. Verification is required for any person under the age of 27. The following employee(s) received and understood Section 371-9 of the Town of Barnstable Board of Health Prohibition of Smoking Regulation and Chapter 270 Section 6 of the Massachusetts General Laws: 04n�!� — emA ofl, r Z N 18 Si a Printe sine r Date am'd rt.( 4ew L I,;L /to Signat&e Pt7mteb Name Date Cca-tq ScWweolde waAcL i a. Signature Printed Name Date Signs Printed Names Date Signature Printed Name Date S,ig6ature Printed Name Date Signature Printed Name Date C:\Users\Dan\AppData\Local\Packages\microsoft.windowscommunicationsapps_8wekyb3d8bbwe\LocalState\Fi les\SO\5016\TOBACC 0 APP2019 dob[63841.docx Monday,October 15,2018 14:50 Massachusetts Department of Environmental Protection-Drinking Water Program BACTERIOLOGICAL REPORT r.�.,. ,. ,,,. r h x�: ,..��.�� .... _ . . ._ ,,,, u , pp edSampleSrte��Iormation secio sib: cJr t R,Y, VLMl rl PWS ID# 4020016 PWS Name Old Vtlla�e Store . CIty/Town- '� Barnstable,MA CLASS: '.S( y r% Cf€',..�. ni( F7.4r4r _'•E' "^cylafi ha,lar,1.''F F ,.,. •;Q:,e.., qan-:...r. ,fh,:,' .',..r`•r „c...N :.,,.. y �, r, o ., a :� aJt�7Ptui.�xa,ft yr:["rY✓',4�.w 1es�:.:,�hi,.:. �.I cz,;, sr 7 a t� .. .... II....L�1�AL��. ..� y ,: , ti„ r •,, ,t.� ��: ?� t�,k. 1 U,.re.�3,'yF , fit;•�+.",,I.x t:a,a�P.x-� :wt� Asir°°a✓u al.t ;gin s., : � •, :: ,,� ,RMA°T�IO1�:�1Re.e �:, � � > _! : :: ' .,:: �•�'� � , �r�' � r ..,��t r�111111 t :,.\ rs may.•, k�,:�I1R`f�'OCISI>s tn z-,..x_ Primary Lab MA Cert.# M-MA063 Primary Lab Name: lEnvirotech Laboratories,Inc. Subcontracted? N Analysis Lab MA Cert.# IM-MA063--1 Analysis Lab: lEnvirotech Laboratories,Inc. Resubmit Indicator: joriginal Reason For Resubmission: Collection Date of Original Sample: p TC Method E.Coli Method Fecal Coliform HPC Method Chlorine Ddethod ENZ.SUB.SM9223 Lab Sample Notes: DEP APPROVED SAMPLE SITE INFORMATION � �,� A rt O F E4L ace: orrG rft A"tit,,a.. •.vr TG:. ! ,.nn d%:ti d,lh ✓hipV'I-. ,�",,J t {_r 1 n.:w r a h}i<:, i ` r}r k�;. a :.,,.r 7t+,. 1 �k .,�rcon'i�trr�. ,. mt�1 �^ ,/•�O�,LE�r O. .,. to >,: ,,�:^o- ^., t 1 C'OL`L: G'�[?i)rD �` 9,r,.3,.:.„.....,sr ,:.::.... ,:. __ ,rt.:..,,,, „:<. .:,QO � .,_r:l... ,v 2k, :,:'E+ :, J'i'•,,. ,.,� r. „r- ,. t�1:,7 �ra�,� x�,�- ,.fl�ir�a n ,,.:,� ...:,: ,. i,. +. , , 'w• , ,. w:. ., .�.... ......... '�'t� .., h ff .:,, ,. .:,IJ ,..:,. er „D- rt '%�,.:. .t.::., ,F i nr.. ...l...z.}t~, ...:, � •. :�,,. r .- .. 1J, _. � , i:, , .. , � ., c. Y,. � � r: .,.,B �, ;��+> `� a ,�,: ,. ,:. � f >: �.., 1f,Pla w Y. h ,.. � ,.,..t..... P „ noa...w., ,.. .. 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T P �.... ...... .......< ., .� ^,i' .i. �h' ..,,.:, M rs.: Codel+.. ..1�.__.. _._. .,,.,'r _ :...,., .._,. .- ,. ...... _. `'' -__.a..�.-,� . . �?arr 1811, w eta�.sr _. -�,._�v..: � G, 1 n'r�:,:t. �-.: s �,:....t...,:,.,i�'a�',z},a`.s"�,z�s�� x��,RW 01G Raw Water A 10/10/20.18 13:10 10/10i2018 17:15 DPM DEP-181967A PT 10001 Finished Water A 10/10/201$ . 13:15 10/1012018 17:15 DPM DEP-181967E RS 001 Kitchen Sink A 10/10/2018 13:20 10/10Y201$ 17:15 DPM DEP-181967C 1 DEP Sample Type,Location code#and DEP approved Sample Site Location must correspond to the sample information on your DEP Total Coliform Samplin.g Plan. 2 SWTR systems:HPC samples shall be taken at the same distribution sites and at the same time as total coliform,whenever chlorine residual is not detected at the sample site. 3 Sample Type:RS-Routine Distribution Sample,RO-Original Site Repeat,UR-Upstream Repeat,DR-Downstream Repeat,AR-Additional Repeat,RW-Raw Water,PT-Plant Tap,SS-Special Sample. 4 Report as 4/100mL,P(present),A(absent),or Too Numberous To Count:TNTC-1(invalid)or TNTC-P(present). 5 Collected appropriate number of repeat samples within 24 hours of laboratory notification for coliform-positive or invalid samples. Notify DEP of any routine or repeat E.Coli or fecal positive results by the end of the business day. c� ,, 1 7 � PW €' �p,�r ae',— ix,,f i>•�� r t'1 Y4ze I certcfry under ena sties o law ihatd Quam tJt a � �ppersonautl:grc�edvtc�ltlt +t. Laboratory Authorized Signature Ronald Saari jar llq r r),� ouith►sform an�thettnforlreafion c'anxared�fierern rstrue aacr�`a' aedw and Date DATE 10/15/2018 . ��Sl r "I,�'k`.r.:l'd'YA,,av �5...4.4':•111 ..ui�i^f}J,a�,5:�3•.�.. �4:t,' ��� .v'�.�: DEP Review Status: ❑Accepted 0 Disapprove Review Co meets: i Page 7 of l CHAIN OF CUSTODY FORM S R. Client: Bennett Environmental Assoc: PWS: {� f � Cass: J 1573 Main Street Project. JJ �" � �� .I �� 1I`u'�,���a� �' PO BOX 1743 Town: Brewster,MA 02631 M F Ph.# 508-896-1706 Lab ID# Bottle# Date: Time: Sample Location: Location Sample Analysis: v I ° Code: Type: I 1 : f 1 ',u 9 SAMPLED BY: DEP REPORTS: Yes No Other i Relinquished: DaW ime, R' rve Datemme Received • �' iry/�ti �lo_' f • Relinquished: DateTime Received: Datemme Received: `pp INC TpN� PUBLIC OF BARNSTABLE.. HEALTH.INSPECTOR,s Establishment Name: - Date: Page: ( of ' OFFICE HOURS BARNSTABLE. 2 0 MAIN STREALTHEET 3:30 9:30 A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified 3:30-4:30 P.M. M;i9: HYANNIS,MA 02601 MON.-FRS. No Reference R-.Red Item PLEASE PRINT CLEARLY 50s-862 4644 � FOOD ESTABLISHMENT INSPECTION REPORT r Name 1 et V) Date 3llYlL2 Tyge of Tyoe of Inspection / -aj w,,�' �^� ra Routine ��`^ ^^ Address Risk Food Se a-inspe ion / Level Retail nspection a Telephone Residential Kitchen Date: Mobile Pre-operation �� r� Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint 4- Person in Charge(PIC) '� Time A Bed&Breakfast HACCP - In: /!J/,,",` Other Inspector VL � Out: ,, Each violation checked requo9s an explanation on the narrative page(s)and a citation of specific provision(s)violated. Y Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ JA 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 I d / ❑ 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 J IV (� 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 4 ,_ ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories 1 Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) r)//� Corrective Action Required: ❑ No ❑,Yes Non-critical(N)violations must be corrected immediately or Overall Rating vvv within 90 days as determined by the Board of Health. ❑ Voluntary Compliance. ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ 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 non-critical violations 9 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If if no critical violations observed,4 too 6 von-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot C=2 critical violations and less than-9 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 o ed,7 to 8 non-critical violations. If 1 critical refrigeration. 29.Special Requirements (590.009) within 10 days of receipt of this order. violation, to 8 on-critical violations=C. Inspector'egna ign ture Prir)t: 30.Other DATE OF RE-INSPECTION: (/ 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 PI 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 15 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to 7-102.11 Common Name-Working Containers*Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 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 7-202.11 Restriction-Presence and Use* 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rated or 7-204.12 Chemicals for Washing of Food* Produce,Criteria* POPULATIONSHSP HIGHLY SUSCEPTIBLE 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Warewashin 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 Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 DrinkingWater from an Approved System* 4=601.11(A) Clean Utensils and Food Contact Surfaces of Eggs=Immediate Service 145°F 15 sec* PP Y Not Otherwise Processed to Eliminate Equipment* ( )( ) Pathogens 590.006(A) Bottled Drinking Water* 3-401.11 A 2 Comminuted Fish,Meats&Game * e"e"/1I12007 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* * 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* 4-702.11 Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-30111 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* foodborne illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. $ 2-401.11 Eating,Drinking or Using Tobacco* 3-403.11 A&D PHFs 165°F 15 sec* Receiving/Condition ( ) ( ) 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11(C) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 3-202.15 Package Integrity Critical and non-critical violations,which do not relate to the foodborne 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk actors listed above,can be ound in the 3-101.11 Food Safe and Unadulterated* f f 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 1g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification 13 Handwashing Facilities * 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 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* 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. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements �.009 3-502.11 Specialized Processing Methods* 30. 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. `�p1ME Tq, TOWN OF BARNSTABLE ,HEALTH INSPECTOR'S Establishment Name: - Date: .Page: I ov 2- OFFICE HOURS LIC HEALTH BAR E. Pu62 0 MAN STREEETSION - 3::30-0-4:30 P.M.:30A.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MONr esv. �e� HYANNIS, MA 02601 508-8 -62-4646FRI 44 No Reference R-Red Item PLEASE PRINT CLEARLY 8-8 ' FOOD ESTABLISHMENT INSPECTION REPORT Name Date �0 Type o T Inspection outi e Address J, Risk Food SE Re-inspection Level Retail Previous Inspection `-� c� 8 Telephone Residential Kitchen Date: � � Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness �.� Caterer General Complaint Person in Charge(PIC) 7 �I Time Bed&Breakfast HACCP (� !� In: / - Other Inspector �� Out: /_T t✓ 1 I 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) r FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals f \ 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 J ❑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 ? /chi✓ ❑ 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) 111((( \ Corrective Action Required: El No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating V"\ within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent 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 4von-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. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation=F is scored automatically if: no hot C=2 critical violations and less than 9 non-critical. If no critical ' water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8non-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) be in writing and submitted to the Board of Health at the above address 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 gnature Print: 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's i at re Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N Violations related to Foodborne Illness Violations 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 i 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* j 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from ) 3-202:12. Additives* Duties Cooked and RTE Foods.* 19 PHF 2-103.11 Person-in-Charge � 3-302.14 Protection froni i7na'ppioved Additives*. 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 7-101.11 Identifying Information-Original Containers* 590.003(C) Responsibility of the Person-in-Charge to on Name-Working Containers* 590.004(F) Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 ° mm Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 1307-102.11 Co on Storage*- Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 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 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- 1.11( 1Unopened 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 ConsuAnimal er Food That 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 Pathogens* eg ce,e uuzoor 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 * 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec Shellfish* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 4-703.11 Methods of Sanitization-Hot Water and StuffingContaining.Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* g 590.009(A)-(D) Violations of Section temporary and - ide in cater- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 02.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 3-2 3-2 2.18 Wild Mushrooms* practices 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 should be debited under#29-Special 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding 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 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 3-203.12 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 .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 Labeling of Ingredients* Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 590.004(J) 9 9 y' ty 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 .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. yip THE ro o TOWN OF BARNS-TABLE - - HEALTH IN HOURSR's Establishment Name: - Date: Page:- 2- of PUBLIC HEALTH DIVISION 8:06-9:30 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, MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY °39 >� 508-862-4644 rFOM"� FOOD ESTABLISHMENT INSPECTION REPORT Name Date e o lyne f Inspection s Routine' �U Address �p Risk Re-inspection �. - �.�.- �� � Level Retail Previous Inspection I , 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 V Out: WVA Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Y LAA (�r�Y 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 l�(�✓ EMPLOYEE HEALTH PROTECTION FROM CHEMICALS fA ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic ChemicalsVz� _ FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) 7 Cat ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures '- ❑ 5.Receiving/Condition ❑ 17.Reheating 1 r ❑ 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 I ❑ 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 CL Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Cective 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 Y Y � ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspensio C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ Emergency Closure Other: checked indicate violations of 105 CMR 590.000/Federal Food Code. Voluntary Disposal ❑ 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. 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 25.Equipment and Utensils B=One critical violation and less than 4 non-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 27.Physical Facility 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) 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 Requirements (590.009) within 10 days of receipt of this order. violation,4 t on-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspecto Sig lure 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 PI s Sign a Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N ,....,. _ ... - _.•...M�-_"'�..........-._�'�•..•...- .s .,`- .-e..yti„-,=.. -..-_ .,►�++�.�.r.+r•••.w..�,�.•;�-.-.-.r-.�.._-�•.�. .�-. ,.,� ..J.---�... .z.ri..t:._ ..�.*^--.,.,._ .,�_,. :.-.- 3. -� a,�^'. ..^C_'---..-s,-., •.+i. _ - _ � .. ,..---.. ,. --. ..er._ -..- .._ _ ,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 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 Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F 15 590.004(F) 590.003(C) Responsibility of the Person-in-Charge to EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying in Information-Original Containers* Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 7-102.1 I Common Name-Working Containers* 2 Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 20 Time as a Public Health Control 590.003(F) Responsibility of A Food Employee or An 3-302.15 Washing Fruits and Vegetables 7-202.11 Restriction-Presence and Use* 3-501.19 Time as a Public Health Control* 590.003(G) Reporting by Person in Charge* Applicant To Report To The Person In Charge* * 7.202.12 Conditions of Use* 590.004 11 Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 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 Rated or 7-204.12 Chemicals for Washing of Food Produce,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 Com liance'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 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 Wazewashing-Hot Water Monitoring* 3-801.1](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 Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of 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* Eg cti-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* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Contact Surfaces of Equipment* * 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min Eggs* Shellfish and Fish From an Approved Source i nil F gg 4 702.11 Frequency of Sanitization of Utensils s and Food 3-401.11(A)(2) Ratites,Infected Meats-155°F IS sec* 3-201.14 Fish and Recreationally Caught Molluscan Contact Surfaces of Equipment* Shellfish* 3-401.1](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 Requirements.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) Commercially Processed RTE Food-140°F* (Blue Items 23-30) 3-202.11 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* 13 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* 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 26. 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. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Forrnback6-2doc *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. `OFINE ro TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: �`�V `"'`V`" Date: 2 Page: l 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 Mbsq: �0 MONHYANNIS,MA 02601 -FRI. 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 8-8 ' FOOD ESTABLISHMENT INSPECTION REPORT Name t ��� S+W� Dat� L� .Z. Tyne of f Inspection k gRgrati s -0utine 0,ae- t S 1 Address (� Vj Risk Food Sery spection �6 , La LevelCAIJA- ID a aI Previous Inspection V L�If� 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 i S .n In:) Other Inspector y1� Out: (. 1S- W C 1 Each violation checked require 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) ❑ 7� _ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ S `eA Action as determined by the Board of Health. Allergen Awareness 590.009(G) l,l FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities 1� . 6-- - 01,'YyV Gr l20 EMPLOYEE HEALTH PROTECTION FROM CHEMICALS .�N� a �si,.n {� ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives 1'L,4&• KW ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals I _ FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) l �,//ff��// t /(�•, ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures LaGLJr/4�t ❑ 5.Receiving/Condition ❑ 17.Reheating `Ll6 t= �91 ❑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 y 6� 718.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for HSP r®A 1^ �/.I u^' Cf- -N A>1 ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY 1 �J ❑ 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) 3 �l ® Corrective Action Required: ❑ Jo El 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 o checked indicate violations of 105 CMR 590.000/Federal Food Code. ❑ Embarg ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: 23.Management and Personnel (FC-2)(590.003) This report,when signed below by a Board of Health member or its agent A=zero critical violations and no more than 3 non-critical violations. F=3 or more critical violations.9 or more non-critical violations, 24.Food and Food Preparation (FC-3)(590.004) constitutes an order of the Board of Health. Failure to correct violations regardless of the number of critical,results in an F. 25.Equipment and Utensils (FC-4(590.005 B=One critical violation and less than Orion-critical violations 9 ) ) cited in this report may result in suspension or revocation of the food if no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot 26.Water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 critical violations and less than i non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of be in writing and submitted to the Board of Health at the above address violations observed,7 ti anon-critical violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590.008) 9 violation,4 to 8rion-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.�V-y ump er screened from public view Permit Posted? 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 n ,t ,� Dumpster Screen? Y N ��l�` 1 v 0 Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont-) FOOD PROTECTION MANAGEMENT PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 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* g g 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 Se oration-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 WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated ( ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004 A-B Compliance with Food Law* * 3-801.11(D) Raw or Partially Cooked Animal Food and ( ) P 4-501.111 Manual Wazewashin Hot Water 7.206.12 Rodent Bait Stations 3-201.12 Food in a 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 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* Eg ctm 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 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- Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 2-301.14 When to Wash* A 1 b All Other PHFs-145°F 15 sec* Other practices sho9 violations relating to good retail 590.004(C) Wild Mushrooms* 3-401.11( )( )( ) 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding Requirem nos]d 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 CommerciallyProcessed RTE Food-140°F* (Blue Items 23.30) 3-202.15 Package Integrity ( ) Critical and non-critical violations,which do not relate to the foodbome 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 13 Handwashing Facilities 3-501.14 A CoolingCooked PHFs from 140°F to 70°F 3-203.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(.n 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 I FC-7 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 1 Conformance with Approved Procedures* S:590Fomrback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 690.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Page: of oFt�r TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name f�! A`f'� 1C/ ateqMW : v` c OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNsrAs�E. = 200 MAIN STREET fn 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified ;39: .0� HYANNIS,MA 02601 �lY/ //l MON.-FRI. NO Reference R-Red Item PLEASE PRINT CLEARLY PrED MP.a VVV �" �VVJ _ 508-862-4644 m FOOD ESTABLISHMENT INSP CT REPORT Name ate Tvoe of insoection p Routin Address isk ood Se a i'�i etail Previoi Telephone Q Residential KitchenDate:Mobile Pre-op Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP ' Other Inspector 'OO N U74 'L'111 OON t: Each violation checked requires an explanation on the narrativ page(s)and a citation of specific provision(s)violated. Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items ) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate corrective Tobacco 590.009(F) ❑ 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 9 ❑8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑21.Food and Food Preparation for,HSP (� I �yJ ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ®/,9H 19 ❑ 11.Good Hygienic Practices ❑22.Posting of ConsumerAdvisorie _t tl v 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 t C N Official Order for Correction: Based on an inspection today,the em ❑ 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 6=One critical violation and less than 4 non-critical violations 9 if no critical violations observed,4 to 6nnn-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 i non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of )( ) be in writing and submitted to the Board of Health at the above address violations observed,7 to 8 non critic I viola ons. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7 590.008 9 vi atio to 8 non-critical violatio s= 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspe s Si a 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 PIC Signatur 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 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs 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 3-501.16(B) Cold PHFs Maintained At or Below 41°F/45°F Poisonous or Toxic Substances 15 * 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* 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 * ( ) 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 Reservice 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 F9 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 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 1 g 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 I 3-401.11A(1)(2) Eggs-155°F 15 sec Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Utensils and Food Contact Surfaces of 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* EJ/crave 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.l l(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* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS 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.l l(C)(3) Whole-muscle,Intact Beef Steaks 145°F* kitchen operations should be debited under Game and Wild Mushrooms Approved By �,301 1 I 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 2-401.11 Eating,Drinking or Using Tobacco* * Requirements. 5 Receiving/Condition g• g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140°F* (Blue Items 23.30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the foodbome * 12 Prevention of Contamination from Hands 3-403.11 E 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 13 Handwashing Facilities 3-202.18 Shellstock Identification* 3-501.14(A) Cooling Cooked PHFs from 140°F[0 70°17 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* 1 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 1'29_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:590Fomrback6-2doc *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. TOWN OF BARNSTABLE HEALTH INSPECTOR,s Establishment Name: Date: Page: of v`e, ro OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30 A.M. BARNS7'ABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS. g, MON.-FRI. ,639•p e HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item, PLEASE PRINT CLEARLY RFD MP+ FOOD ESTABLISHMENT INSPECTION REPORT Nam D e of T Inspection p o Rout, v111 Address Ris rv' e-inspection Leve Re Previous Inspection Telephone eotial Kitchen Date: Mobile Pre-operation Owner HACCP YIN Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC)12 Time Bed&Breakfast HACCP 2an 'A In: Other PAT 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) ❑ 77 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 i ❑ 3.Personnel with Infectious.Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) L ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures NO Y ❑5.Receiving/Condition ❑ 17.Reheating ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling tt Q ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding l 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 LSOIf ❑ 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: -Les- Non-critical(N)violations must be corrected immediately or Overall Rating J a, 0 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 Other: Voluntary Disposal ❑ 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 (FC4)(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 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical'Facility (FC-6)(590.007) aggrieved by this order,you have a.right to a hearing. Your request must 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 anon-critical violations. If 1 critical refrigeration. 29.Special Requirements � (590.009) within 10 days of receipt of this order. violation,4 to 8rion-critical violations=C. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from m public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N s nature P�yin\t: c 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* Other* g g 3-501.16(A) Hot PHFs Maintained At or Above 140°F* 2 590.003(C) Responsibility of the Person-in-Charge[0 7-102.11 Common Name-Working Containers* * Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F 7-201.11 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* 590.00411 - Variance Re uirements 3-304.11 Food Contact with Equipment and Utensils 7-203.11 Toxic Containers-Prohibitions* ( ) q 590.003(G) - Reporting by Person in Charge* Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* * 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Resumed Food and Reservice of Food 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated g - - -. Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 4 Food and Water From Regulated Sources y Food Contact Surfaces 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashin Hot Water 7.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 7-206.13 Tracking Powders,Pest Control and Raw Seed Sprouts Not Served* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY Concentration and Hardness* 22 3-603.11 Consumer Advisory Posted for Consumption of 3-202.16 Ice Made From Potable Drinking Water* 3-401.11A(1)(2) Eggs-155°F 15 sec 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 _ - Sg Not Otherwise Processed to Eliminate Equipment* 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* ex°'me v1nooi 4-602.11 Cleaning Frequency of Utensils and Food - g 9 Y Animals-155°F 15 sec 590.006(B) Water Meets Standards in 310 CMR 22.6* 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* p 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS x 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 N$SPListed Chemical* Ratites-165°F 15 sec* Sources* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.1l(C)(3) Whole-muscle,Intact Beef Steaks 145'F* kitchen operations should be debited under Game and Wild Mushrooms Approved By 2-301-1 l' Clean Condition-Hands and Arms* Regulatory Authority 3-401.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-20218 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3 401.11(A)(1)(b) All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail 3-201.17 Game Animals* 11 Good Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special Requirements. 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) Commercially Processed RTE.-Food Food-140°F* (Blue Items 23.30) 3-202.15 Package Integrity 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 TagslR-ecords: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 Cooling Cooked PHFs from 140°F to 70°F 3-202.18 Shellstock Identification ( ) g 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 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 1 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 31-502.11 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. q," TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: Of ' Py�' - 4 OFFICE HOURS PUBLIC HEALTH DIVISION 8:66-9:30 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, y MON.-FRI. i639,s�o HYANNIS, MA 02601 sos-esz 4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'EON1P� FOOD EST BLISHMENT INSPECTION REPORT c - Nam j/ ' a e a of T e sec ion A�- sv O ions Rq6ne /V Address i is ice on Level ra Previous InspectionTelephone ial 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 .� Inspecto 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 on L 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 Yr V FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ` f ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures ❑ 5.Receiving/Condition ❑ 17.Reheating L ❑ 6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding WN `�� PROTECTION FROM CONTAMINATION, ❑ 20.Time As a Public Health Control �r(J`r ❑ 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 ./-� ✓ LC Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: r N Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Empl s riction/Exclusion ❑ Re-inspecti n chedule S p 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 4non-critical violations 9 26.water,Plumbing and Waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If I f no critical violations observed,4 to 6 non-critical violations=B. Seriously Critical Violation=F is scored automatically if: no hot d ti l i violations an a 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must C=2 criticalless 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 violation,4 to 8 non-critical violations=C. 29.y uirements (590.009) within 10 days of receipt of this order. 30. DATE OF RE-INSPECTION: Inspector's Signature Print: 31. creened from public view Permit Posted? N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N Sign a Pri t: 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 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 7-101.11 Identifying Information-Original Containers* 590.004(F) 2 Other*590.003(C) Responsibility of the Person-in-Charge to 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* 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* 7-203.11 Toxic Containers-Prohibitions* 590.004(11)) Variance Requirements 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* - REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions 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 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Tem eratures* 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(rEMPERATURE 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* 3-0Ol.11 A(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* gS Not Otherwise Processed to Eliminate Equipment* 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 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 Surf aces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Stuffing Containing Fish,Meat,Poultry or 590.009 A Violations of Section 590.009 A - D in cater- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* ( )-�) ( ) ( ) Ratites-165°F 15 sec* Sources* 70 Proper,Adequate Handwashing ing,mobile food,temporary and residential Game and Wild Mushrooms Approved By - * 3-401.l l(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* A 1 All Other PHFs-145°F 15 sec* Other 590.009 violations relating to good retail - 3-401.11( )( )(b) 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. 5 Receiving/Condition - � - g. 8 g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C Commercial] Processed RTE Food-140'F* (Blue Items 23-30) 3-202.15 Package Integrity ( ) y Critical and non-critical violations,which do not relate to the 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* F1 g Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12' Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F hem 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 3402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures 1 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. 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. TOWN OF BARNSTABLE HEALTH INSPECTOR's Establishment Name: Date: Page: of OFFICE HOURS PUBLIC HEALTH DIVISION 8:00-9:30A.M. BABNSI'ABLE. ` 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified MASS' MON.-FRI. e.0� HYANNIS, MA 02601 No Reference R-Red Item PLEASE PRINT CLEARLY FFD MPS 508-862-0644 FOOD ESTABLISHMENT INSP CT ON REPORT L Nam Da&15(I I AMP-10-fjyj2e of I s ectio ,�. e outine Address Risk od ice ection � Level a Previous Inspection Telephone en Ial Kitchen Date: J � Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP H 'l l 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) ❑ `� v Action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑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: ❑ 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. ElEmbargo ❑ 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 B=One critical violation and less than 4nori-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 9 non-critical. If no critical ' water,sewage back-up,infestation of'rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed, 28.Poisonous or Toxic Materials (FC-7)(590.008 be in writing and submitted to the Board of Health at the above address 7 to 8 non-critical violations. If 1 critical refrigeration. ) violation,4 to 8rion-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other •. DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public viewN AA Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N #Seats Observed Frozen Dessert Machines: Outside Dining Y N 'PIC ature Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Dumpster Screen? Y IN Y N r 111✓✓✓r / VV Jc�� `/ �7JV 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 FoodsAdditives* 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 3-50L16(B) Cold PHFs Maintained At or Below 41°F/45 590.004(F) °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* 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* Storage*- Applicants* - 3-302.11(A) Food Protection* 7-201.11 Separation20 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 490.003(E) 90.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Returned Food and Rearedor of Food* 7-204.12 Chemicals for Washin Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 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 F9 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* 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 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 Equipment 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 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff crave iiuzooi 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 3-201.15 Molluscan Shellfish from NSSP Listed * Stuffing Containing Fish,Meat,Poultry or 590.009 A D Chemical Ratites-165°F IS sec* ( )-( ) Violations of Section 590.009(A)-(D)in cater- 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. 5 Receiving/Condition g. g g 3-403.11(A)&(D) PHFs 165°F 15 sec 3-202.11 PHF's Received at Proper Temperatures* 2 401.12 Discharges From the Eyes,Nose and Mouth* 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 PreventingContamination When Tasting* * (Blue Items 23-30) 3-202.15 Package Integrity g 3-403.11(C) Commercially Processed RTE Food-140°F Critical and non-critical violations,which do not relate to the foodbome * 12 Prevention of Contamination from Hands 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* 13 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 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 129. 1 Special Requirements 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 1996 Food Code or 105 CMR 590.000. `gyp THE Tpk, TOWN OF BARNSTABLE HEALTH INSPECTORS Establishment Name: Date: Page: of .P tea• - .. OFFICE HOURS rl' PUBLIC HEALTH DIVISION � a:oo-saoA.nn. BARNSTABLE. • 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified �A ,6;.A�O� HYANNIS, MA 02601 M-8 -FRI. No Reference R-Red Item PLEASE PRINT CLEARLY FFO M FOOD ESTABLISHMENT INSPECTION REPORT PS 50862�644 Name Date TvDe o Type of Inspection ov Routine Address Risk oo rvic spectio Leve pection TelephoneJF ential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness L Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP In: Other Inspector Out: dn 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 of 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 Asa Public Health Control R 4 ❑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 ❑ 1.1.Good Hygienic Practices ❑ 22.Posting of Consumer Advisories L 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 91\\ 1 �� within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑.Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ 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 an_d 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 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 itnon-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 n violations tical.violations. If 1 critical refrigeration. 28.Poisonous or Toxic Materials (FC-7)(590:008) 9 violation,4 to 8non-Critical violations=G. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Dumpster screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N ANY- #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Sign 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 Crosi-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.* * 19 PHF Hot and Cold Holding 2-103.11 Person-in-Charge Duties - 3-302.14 Protection from Unapproved Additives Contamination from Raw Ingredients 7 5 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* * 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 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* 7-204.11 Sanitizers,Criteria-Chemicals* REQUIREMENTS FOR 3-306.14(A)(B)Resumed Food and Rrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) � Removal of Exclusions and RestrictionsA 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 17.206.12 Rodent Bait Stations* 3-801.11(D) Raw or Partially Cooked Animal Food and 3-201.12 Food in a Hermetical] Sealed Container* Sanitization Temperatures* Raw Seed Sprouts Not Served* Y P 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. L16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11 A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 5-101.11 Drinking Water from an Approved System* 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 Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Eff-ti-11112001 4-602.11 Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces of Equipment* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Shellfish and Fish From an Approved Source 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* Eggs* 4--702.11 - -Frequency of Sanitization of Utensils and Food 3-401.11(A)(2) J 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 SPECIAL REQUIREMENTS Stuffing Containing Fish,Mealat,,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* 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 3-401.1.. Raw Animal Foods Cooked in a Microwave appropriate 2-301.11 Clean Condition-Hands and Arms* the a ro riate sections above if related to � 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* _ - 3 401.11(A)(1)(b) All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 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 3-202.15 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* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from.140°F to 70°17 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 .009 r 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* - 8-103.12 1 Conformance with Approved Procedures* S: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 114E rqr, TOWN OF BARNSTABLE. HEALTH INSPECTOR,s Establishment Name: Date: Page: of 1 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 p1A9 �, HYANNIS,MA 02601 MON.-FRI. No Reference R-Red.Item PLEASE P NT CLEARLY �p t6S9•n 0 508-862-4644 - rEOMP� FOOD ESTABLISHMENT INSPECTION REPORT Name Iu Dat Type of Type of Inspection p Gat Routine._____ Address Risk pod Se �RiVinspection- 'Level Retal - rev�o�us Lr�spection 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) ❑ r FOOD PROTECTION MANAGEMENT ❑ 12.Prevention of Contamination from Hands ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ") ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMElfEMPERATURE 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 �05 ❑ 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. Fl� ❑ Voluntary 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 B=One critical violation and less than 4npn-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 C=2 critical violations and less than 9 non critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must 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 anon-critical violations. If 1 critical refrigeration. within 10 days of receipt of this order. violation,4 to 8npn-critical violations C. 29.Special Requirements (590.009) y p 30.Other DATE OF RE-INSPECTION: Inspector's Signature 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 PI 's Signature/ f �# ri t: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N !1. ,r� r J �• / - ` „�/J�- w►_J Dumpster Screen? Y N Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions Interventions and Risk Factors(Red Items 1-22) and Risk Factors(Red Items 1-22) (Cont.) FOOD PROTECTION MANAGEMENT _ PROTECTION FROM CONTAMINATION PROTECTION FROM CHEMICALS 3-501.14(C) PHFs Received at Temperatures According to 1 590.003(A) Assignment of Responsibility* 8 Cross-contamination 1q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* 590.003(B) Demonstration of Knowledge* 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives* 3-501.15 Cooling Methods for PHFs Cooked and RTE Foods.* P.HF.Hot and Cold Holding 2-103.11 Person-in-Charge Duties 3-302.14 Protection from Unapproved Additives* 19 _ Contamination from Raw Ingredients 7 5 590 004(F) 7-102.11 Common Name-Working Containers*Poisonous or Toxic Substances 3-501.16(B) Cold PHFs Maintained At of Below 41°F/45°F : EMPLOYEE HEALTH 3-302.11(A)(2) Raw Animal Foods Separated from Each 7-101.11 Identifying Information-Original Containers* 2 590.003(C) Responsibility of the Person-in-Charge to Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F* Require Reporting by Food Employees and Contamination from the Environment 3-501.16(A) Roasts Held At or Above 130°F* Storage* - Applicants* 3-302.11(A) Food Protection* 7-201.11 Separation g 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 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 3-306.14(A)(B)Resumed Food and Reated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition of Adulterated or Contaminated � ) Food 7.204.14 Drying Agents,Criteria* 21 3-801.11(A) Unpasteurized Pre-Packaged Juices and FOOD FROM APPROVED SOURCE 3-701.11 Discarding or Reconditioning Unsafe Food* 7-205.11 Incidental Food Contact,Lubricants* Beverages with Warning Labels* 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* 4-501.111 Manual Wazewashing-Hot Water 7.206.12 Roden[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 Pe 7-206.13 Tracking Powders,Pest Control and 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water Monitoring* 3-801.11(C) Unopened Food Package Not Re-Served* 3-202.13 Shell Eggs* Sanitization Temperatures* TIME/TEMPERATURE CONTROLS 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-Temp.,pH. 16 Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* Concentration and Hardness* 3-401.11A(1)(2) Eggs-155°F 15 sec 22 3-603.11 Consumer Advisory Posted for Consumption of 4-601.11(A) Clean Utensils and Food Contact Surfaces of E Immediate Service 145°F 15 sec* Animal Foods That are Raw,Undercooked or 5-101.11 Drinking Water from an Approved System* gSs' Equipment* Not Otherwise Processed to Eliminate 590.006(A) Bottled Drinking Water* 3-401.11(A)(2) Comminuted Fish,Meats&Game Pathogens* Ef°tm 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)_ "Y Violations of Section 590.009(A)-(D)in cater- ) 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Ratites-165°F 15 sec* ing,mobile food,temporary and residential 10 Proper,Adequate Handwashing 3-401.11 C 3 Whole-muscle,I Beef Steaks 145°F* kitchen operations should be debited under Game.and Wild Mushrooms Approved By ( )( ) e-muscntact ee en 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. r violations* Othe 590.009 relatingto good retail * 2-301.14 When to Wash 3-401.11 A 1 b All Other PHFs-145°F 15 sec* 590.004(C) Wild Mushrooms ( )( )O practices should be debited under#29-Special Good Hygienic Practices P P 11 Y9 3-201.17 Game Animals* 17 Reheating for Hot Holding 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 Hands 3-403.11(E) Remaining Unsliced Portions of Beef Roasts* illness interventions and risk factors listed above,can be found in the 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 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 3-203.18 Shellstock Identification ( ) Item Good Retail Practices FC 590.000 3-203.12 - Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-361.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 30._7 Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* S:590Fofmback6-2doc '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 114E.p�,- TOWN OF BARNSTABLE _ HEALTH INSPECTOR'S Establishment Name: Date: Page: of OFFICE HOURS ARE PUBLIC HEALTH DIVISION 8:00-9:30 A.M. 200 MAIN STREET 3:30-4:30 P.M. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified mass MON.-FRI. HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY 'EON1P� FOOD ESTABLISHMENT INSPECTION REPORT �J Name e o e-o Ins ection 1 O erafio S R�outine� v > Addressl Risk C' R"'leTispection Level Previous Inspection Telephone 4iiisidential Kitchen Date: Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint - Person in Charge(PIC) �t Time Bed&Breakfast HACCP 4 In: Other i I . Inspector Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. J 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 9 '�T < YnJ„o/ 4 ❑ 1.PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS &-' �•h7 ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives r t ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) - _ _ ❑4.Food and Water from Approved Source ❑ 16.Cooking Temperatures lr ❑ 5.Receiving/Condition ❑ 17.Reheating l �� ❑6.Tags/Records/Accuracy of Ingredient Statements ❑ 18.Cooling y �, ❑ 7.Conformance with Approved Procedures/HACCP Plans ❑ 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20.Time As a Public Health Control ❑ 8.Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9.Food Contact Surfaces Cleaning and Sanitizing ❑ 21.Food and Food Preparation for HSP (✓�❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY - ❑ 11.Good Hygienic Practices ❑22.Posting of Consumer Advisories 1 Violations Related to Good Retail Practices(Blue Items) Total Number of Critical Violations Critical(C)violations marked must be corrected immediately. (blue&red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ® ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction:Based on an inspection today,the items ❑ Embargo ❑ 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 re ardless of the number of critical,results in an F. B=One critical violation and less than 4non-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. 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 a back-up,infestation of rodents or insects,or lack of C=2 critical violations and less than 9 non-critical. If no critical water,sews 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must g in r of Health at the above address violations observed,7 to 8non-critical violations. If 1 critical refrigeration. _ be writing and submitted the Board 28.Poisonous or Toxic Materials (FC-7 590.008) 9 tted to )( violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. Inspector's Signature Print: 30.Other DATE OF RE-INSPECTION: r . 31.Dum ster from public view VIA p screened o Permit PostedPrevious Pumping Date Grease Rendered Y N � . Y N Grease Trap p g G {C #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's Signal. i Print: Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y NCA 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 1 q Food or Color Additives Law Cooled to 41°F/45°F Within 4 Hours* * * , 3-501.15 Cooling Methods for PHFs 590.003(B) Demonstration of Knowledge 3-302.11(A)(1) Raw Animal Foods Separated from 3-202.12 Additives 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 of ToxiE 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 _ Othei* 7-10211 Common Name-Workin Containers** 3-501.16(A) Hot PHFs Maintained At or Above 140°F* . Require Reporting b'y 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(i1)(B)Returned Food and AdulteReserrated or of Food* 7-204.12 Chemicals for WashingProduce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions Disposition ofAdulterated 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* I 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 Mantial 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 arid 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 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Clean Eggs Utensils and Food Contact Surfaces of E s-Immediate Service 1457F 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* E.ff dive 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 3-401.1l(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* 4-703.11 Methods u Sanitization-Hot Water and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs SPECIAL REQUIREMENTS Chemical Stuffing Containing Fish,Meat,Poultry or 3-201.15 Molluscan Shellfish from NSSP Listed _ * 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* foodborne 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 11 3-201.17 Game Animals* 17 Reheating for Hot Holding Good Hygienic Practices 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* * (Blue Items 23-30) 3-202.15 Package Integrity g g 3-403.11(C) Commercially Processed RTE Food-140°F 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* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours and From 70°F to 41°F/45°F Item Good Retail Practices FC 590.000 Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 * 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3A02.12 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 1.008 HACCP Plans 6-301.12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 30. Other 3-502.12 Reduced-Oxygen Packaging Criteria* 8-103.12 Conformance with Approved Procedures* - 1. S:590Formback6-2doc *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000: p THE ro TOWN OF BARNSTABLE _ HEALTH INSPECTOR'S Establishment Name: Date: Page: of o OFFICE HOURS PUBLIC HEALTH DIVISION 6:00-9s0A.M. BARNSTABLE,4 200 MAIN STREET 3:30-4:-FP.. Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Verified .Ass MON. RI HYANNIS,MA 02601 508-862-4644 No Reference R-Red Item PLEASE PRINT CLEARLY FOOD STABLISHMENT INSPECTION REPORT o Dat yne of o-o-N s ec ion Name a c ` �_ O erPions ou' iL� Ci Address ;� k / Re-inspection �� ! el nesi Previous Inspection Telephone ential Kitchen Date: -� C�+i - Mobile Pre-operation Owner HACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed 8 Breakfast HACCP In: Other 1J Inspector Out: �-t Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. `L 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 f„ ❑ 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 f ` / 1 Z ❑3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals t n FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ppl f/L ❑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 va*u Critical(C)violations:marked must be corrected immediately. (blue 8+red items) Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ 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. B=One critical violation and less than 4non-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. 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 9 non-critical. If no critical water,sewage back-up,infestation of rodents or insects,or lack of 27.Physical Facility (FC-6)(590.007) aggrieved by this order,you have a right to a hearing. Your request must violations observed,7 to 8 non-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 violation,4 to 8'non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. Signature Print: Sig 30.Other DATE OF RE-INSPECTION: Inspector's _ 31.Dumpster screened from public view �( AA � 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 Dumpster Screen? Y N - .. r.. ,�� .+...�. .`. r +`4"`. r'vi�A.�=�.r1..-.y-5,�-k- 1 -.,.`,j '�Y+'7 �r,�.� tit .- ..- _. r -�.'��• r ..�-. ...r �.s � - .-�.. r- � _ ... � -v . _ ... Violations related to Foodborne Illness Violations Related to Foodborne Illness Interventions a Interventiolit and Risk Factors(Red Items 1-22) and Alsk Factors(Red Items 1-22) (Cont) r - 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 2-103.1 Y 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* 2 Other* 3-501.16(A) Hot PHFs Maintained At or Above 140°F 590.003(C) Responsibility of the Person-in-Charge to - 7-102.11 Common Name-Working Containers* * 7-201.11 Separation-Storage*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* - 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* 3-304.11 Food Contact with Equipment and Utensils*- Applicant To Report To The Person In Charge* 7.202.12 Conditions of Use* 590.004 11 Requirements 590.003(G) Reporting by Person in Charge* 7-203.11 Toxic Containers-Prohibitions* ( ) Variance 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 Rlated 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 Watei 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 Roden[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 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. 1 g Proper Cooking Temperatures for PHFs CONSUMER ADVISORY 3-202.16 Ice Made From Potable Drinking Water* - Concentration and Hardness* 3-001.11A(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* €g 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)-(D)in cater- 3-201.15 Molluscan Shellfish from NSSP Listed _ Chemical* 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 3-001.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 165°F* foodbome illness interventions and risk factors. 2-301.14 When to Wash* * Other 590.009 violations relating to good retail 590.004(C) Wild Mushrooms* 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 3-201.17 Game Animals* 11 Good,Hygienic Practices 17 Reheating for Hot Holding practices should be debited under#29-Special ` Requirements. 5 Receiving/Condition 2-001.11 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) 3-202.11 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 8 Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 18 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 3-202.18 Shellstock Identification* 13 Handwashing Facilities 3-501.14(A) Cooling Cooked PHFs from 140°F to 70°F 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 PP 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. Poisonous or Toxic Materials I FC-7 1.008 HACCP Plans 6-301:12 Hand Drying Provision 29. Special Requirements 1.009 3-502.11 Specialized Processing Methods* 130. Other 3-502.12 1 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: f 1 lb .10 ►-h h a-m �V-c L-A Ov- -C�" - . 1b i ► n ca 01 Ones - _ . f �tt i r i I UIT, 41 vLc�- ip, oF.H�E rok TOWN OF BARNSTABLE HEALTH INSPECTOR'S Establishment Name: Date: Page: of ., q. '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 p 63S.a m� HYANNIS,MA 02601 MON.-FRI. No Reference R-Red Item PLEASE PRINT CLEARLY rFC MPS 508-862-4644 FOOD ESTABLISHMENT INSPECTION REPORT Name Dat e o17 j lyge of Inspect ion outine M. Address sk on C el Previous Inspection Telephone ential Kitchen Date: Mobile Pre-operation Owner ACCP Y/N Temporary Suspect Illness Caterer General Complaint Person in Charge(PIC) Time Bed&Breakfast HACCP L 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) ❑ C 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 Q EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2.Reporting of Diseases by Food Employees and PIC ❑ 14.Approved Food or Color Additives y.. ❑ 3.Personnel with Infectious Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) bbb 1! ❑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 POPU TIONS(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) Sy Corrective Action Required: ❑ No ❑ Yes Non-critical(N)violations must be corrected immediately or Overall Rating within 90 days as determined by the Board of Health. ❑ Voluntary Compliance ❑ Employee Restriction/Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension C N Official Order for Correction: Based on an inspection today,the items ❑ Embargo ❑ 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 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 if no critical violations observed,4 to 6 non-critical violations=B. 26.Water,Plumbing and waste (FC-5)(590.006) establishment permit and cessation of food establishment operations. If Seriously Critical Violation t F is scored automatically if: la 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 violation,4 to 8 non-critical violations=C. 29.Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: Inspector's Signature Print: 31.Duyper screened from public view Permit Posted? Y N Grease Trap Previous Pumping Date Grease Rendered Y N r #Seats Observed Frozen Dessert Machines: Outside Dining Y N PIC's MS.ire/ t Print: / Self Service Wait Service Provided Grease Trap Size Variance Letter Posted Y N Dumpster Screen? Y N / r 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.) F 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 $ 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 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 E chIdentifying •*'` - -' - 590:004(F)P >a 7-101.11 Identi in Information-Ori mal Containers 2 590.003(C) Responsibility of the Person-in-Charge to Other* g g 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 r _ _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* Requirements * 3-304.11 Food Contact with Equipment and Utensils* 7-203.11 Toxic Containers-Prohibitions* 590.004(11) Variance Re q 590.003(G) Reporting by Person in Charge Contamination from the Consumer 3 590.003(D) Exclusions and Restrictions* 7-204.11 Sanitizers,Criteria-Chemicals* _ REQUIREMENTS FOR _ _ 3-306.14(A)(B).Returned Food and Reservice of Food* 7-204.12 Chemicals for Washing Produce,Criteria* HIGHLY SUSCEPTIBLE POPULATIONS HSP 590.003(E) Removal of Exclusions and Restrictions 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 3-202.14 Eggs and Milk Products,Pasteurized* i 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 r 5-101.11 Drinking Water from an Approved System* Eggs 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 d-11112001 4-602.11_ Cleaning Frequency of Utensils and Food Animals-155°F 15 sec* 590.006(B) Water Meets Standards in 310 CMR 21.0* 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 3-201.15 Molluscan Shellfish from NSSP Listed Stuffing Containing Fish,Meat,Poultry or 590.009(A)-(D) Violations of Section 590.009(A)-(D)in cater- - - Chemical* _ Ratites-165°F 15 sec* in mobile food,temporary and residential Sources* 10 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* 3-001.12 Raw Animal Foods Cooked in a Microwave the appropriate sections above if related to P 3-202.18 -- Shillstock-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 s 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec 590.004(C)- . Wild Mushrooms _ _ _ _ _ __ 11 " Good Hygienic Practices practices should be debited under#29-Special 3-201.17 Game Animals* 17 Reheating for Hot Holding Requirements. 5 Receiving/Condition - - - - 2.401.11 _._.Eating,Drinking or Using Tobacco* 3-403.11(A)&(D) PHFs 165°F 15 sec* 3-202.11 PHF's Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and Mouth* _ 3-403.11(B) Microwave-165°F 2 Minute Standing Time* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES * 3-301.12 Preventing Contamination When Tasting* 3-403.11 C CommerciallyProcessed RTE Food-140°F* (Blue Items 23.30) 3-202.15 Package Integrity ( ) Critical and non-critical violations,which do not relate to the foodbome 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 $ Tags/Records:Shellstock 590.004(E) Preventing Contamination from Employees* 78 Proper Cooling of PHFs following sections of the Food Code and 105 CMR 590.000 * 3-501.14 3-202.18 Shellstock Identification 13 Handwashing Facilities A( ) Cooling Cooked Fr from 140°F to Item Good Retail Practices FC 590.000 3-203.12 Shellstock Identification Maintained* Conveniently Located and Accessible Within 2 Hours andnd From 70°F to 41°F/45 45°F Tags/Records:Fish Products 5-203.11 Numbers and Capacities* Within 4 Hours* 23. Management and Personnel FC-2 .003 5-204.11 Location and Placement* 3-501.14(B) Cooling PHFs Made from Ambient 24. Food and Food Protection FC-3 .004 3-402.11 Parasite Destruction* Temperature Ingredients to 41°F/45°F 25. Equipment and Utensils FC-4 .005 3-402.12 Records,Creation and Retention* 5-205.11 Accessibility,Operation and Maintenance Within 4 Hours* 26. Water,Plumbing and Waste FC-5 .006 590.004(J) Labeling of Ingredients' Supplied with Soap and hand Drying Devices 27. Physical Facility FC-6 .007 7 Conformance with Approved Procedures/ 6-301.11 Handwashing Cleanser,Availability 28. 1 Poisonous or Toxic Materials FC-7 .008 HACCP Plans 6-301.12 Hand Drying Provision 129. 1 Special Requirements 009 3-502.11 Specialized Processing Methods* 130. 1 Other 3-502.12 Reduced-Oxygen Packaging Criteria* _ - __ ". • _ 8-103.12 Conformance with Approved Procedures* t; 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 Bennett Environmental Associates, Inc.P.O. Box 1743 � -� Invoice w 1573 Main Street ?, Date Invoice# Brewster MA 02631 BEA; 1/19/2018 109729 508-896-1706 Bill To Project Address Dan Devlin — Certified Public Water Supply Operator PWS ID#4020016 P.O. Box 159 Old Village Store W. Barnstable,MA 02668 2455 Meetinghouse Road West Barnstable Job Number Billing Period Terms Due Date Contract Date 10761 November&December 2017 Net 30 2/18/2018 2/23/17 Task Code Description Hours/Qty Rate Serviced Amount PWSO Fee Public Water Supply Operator Fee: November 2 116.06 232.12 and December 2017 Total of Professional Services 232.12 Your pre-payment has been applied to this invoice,leaving no balance due. r � Please indicate invoice number when remitting Total Invoice $232.12 payment. Amounts past due are subject to a service charge of Payments/Credits $0.00 1.5% per month. Please remit to Bennett Environmental Associates,Inc. Thank you. Total Project Balance -$2.40 J J 3 0 01 Old Village Store Opening Menu Sandwiches made to order based on the below listed items Bread Choices: Sub Rolls—Wraps—White & Wheat Bread Meats: Roast Beef Turkey Ham Bologna Salami Pepperoni Pastrami Corned Beef Chicken Breast Cheeses: American Provolone Swiss Cheddar Muenster Monterey Jack Other: Tuna Salad Chicken Salad Egg Salad Salads to Go - Cole Slaw Potato Salad Macaroni Salad Hot Dogs(with Sauerkraut, chili) Meatball Subs Condiments : Tomato, Lettuce,Peppers, Pickles, Onions, Mayonnaise, Sprouts Mustard,Ketchup, Relish. Salt&Pepper Sink [Deli Case Front Counter -� 41 Message Page 1 of 1 McKenzie, Marybeth From: Stanton, David Sent: Wednesday, July 01, 2015 3:50 PM To: Desmarais, Donald; Miorandi, Donna; McKean, Thomas; McKenzie, Marybeth; O'Connell, Timothy; Parziale, Jim Subject: 2455 Meetinghouse way FYI, A building permit may be coming in for this property. It sounds like they want to convert a food establishment out back into an apartment. The food establishment out front(old village store) is currently using the bathrooms in the former food establishment area outback to comply with the 2 bathroom requirements per Board of Health Regulation as they only have one bathroom in the front food establishment area. If they eliminate the bathrooms in the back, they will need either a variance from the Board of Health or to install a second bathroom up front for the old village store. Thanks, Dave J-G V,2 61 V, 7/17/2015 - J�ii wtt EIcV rdd 9e � �� .� �`� a0`i�� ❑ Operation of a stable with uncorrected Please call the Health Division (508) 862— If you do not have horses stabled at the perm remove your permitted stable from the datab will have to be arranged with the health insp These issues must be rectified by JUKE 1, 2 w 14, 2015 Board of Health Meeting. Failure t JUNE 1, 2015, shall result in automatic sche Board of Health. This meeting will take plac Town Hall located at 367 Main Street, 2nd FI hearing mayor may not result ir�the suspen You will be given the opportunity to testi evidence, and other official information r� PER ORDER OF THE BOARD OF HEAL Thomas McKean Agent CC: Wayne Miller, M.D., Chairman QASTABLE\LETTERS\Unpermited Stable Warning Letter 2015.dc f �n r 17�.26pH F1 11 0 ACTH Bu ° BEDROOM SaR &2<R 42IR ;o Fire Wall ° KITCHEN 10'-4"x 3'-9" ==(Existing II- 1668 Ir ]668 g 906B ^ O N L I VI N G 20'-1"x 13'-'1" v N sqs � a ^ 2b40VH 90BB Proposed 20'-q" DECK 20,-10"x T-11" C t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map `S Parcel 011 Health Division Application # Date Issued Conservation Division Application Fe G Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH — Preservation/ Hyannis Project Street Address f� Village • ' Ott- �� L� Owner Address Telephone 6 b% `113� 3`1 '2�_ Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation _ Construction Type Lot Size J Grandfathered: ❑Yes 4 No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes gNo On Old King's Highway: ❑Yes V[No Basement Type. ❑ Full X Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing_ new = Half: existing new Number of Bedrooms: existing L new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: Yes No Fireplaces: Existing New Existing wood/coal stove: ❑Yes No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size — Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size —Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use i i APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 5 � \ Telephone Number� �> Address License # 45 Home Improvement Contractor Email .ti(�C ,\ J���Z ( — Worker's Compensation # WLCVLr y ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE Commonwealth of Massachusetts Executive Office of Energy& Environmental Affairs Department of Environmental Protection , Southeast Regional Office•20 Riverside Drive, Lakeville NIA 02347.508-946-2700 " Charles D. Baker Matthew A. Beaton Governor Secretary :r• Karyn E.Polito Martin Suuberg Lieutenant Governor Commissioner X March 11,2015 Al Schofield RE: BARNSTABLE--Public Water Supply Old Village Store Old Village Store 2455 Meetinghouse Way,Route 149 PWS ID#4020016 West Barnstable,Massachusetts 02668 Enforcement NON-SE-15-5D040 Dear Mr. Schofield: Please find attached a Notice of Noncompliance for failure to comply with the Department of Environmental Protection(MassDEP or the Department)certified operator requirements in accordance with 310 CMR 22.00. Please note that the signature on this cover letter indicates formal issuance of the attached document. If you have any questions regarding this document,please contact Charles Shurtleff at 508-946-2879. Since ly, Richard I Rondeau, Chief Drinking Water Program Bureau of Water Resources R/CPS Y:/DWP,archive/SERO/Barnstable-4020016-Enforcement-2015-03-11 Cshur leff/NoC0/15.non.4020016 CERTIFIED MAIL NO. 7013 1090 0000 9295 1535 cc: Barnstable Board of Health This information is available in alternate format Call Michelle Waters-Ekanem,Diversity Director,at 617-292-5751.TTY#MassRelay Service 1-800-439-2370 MassDEP Website:www.mass.gov/dep Printed on Recycled Paper .a NOTICE OF NONCOMPLIANCE THIS IS AN IMPORTANT NOTICE. FAILURE TO TAKE ADEQUATE ACTION IN RESPONSE TO THIS NOTICE COULD RESULT IN SERIOUS LEGAL CONSEQUENCES. The Department of Envi onmental Protection(MassDEP or the Department)became aware that the Old Village Store does not have a Licensed Certified Operator responsible for the public water system at the facility. Please be advised that the Old Village Store is in noncompliance with the certified operator requirements in accordance with 310 CMR 22.00. Attached hereto is a writt:n description of(1)the activity constituting a violation,(2)the requirements violated,(3)the action the Department now wants you to take and(4)the deadline for taking such action. If you fail to take any action the Department now wants you to take with regard to the water supply by the prescribed deadline, or if you otherwise fail to remain in compliance in the future with requirements applicable to you,you could be subject to legal action, including,but not limited to, criminal prosecution, court-imposed civil penalties, or civil administrative penalties.Administrative penalties may be assessed for every day from now on that you are in noncompliance with the requirements referred to herein.This notice concerns only observed violations of the Department's water supply requirements. The Department reserves its rights to proceed with respect to any and all other violations of laws administrated by the Department. 2 4� NOTICE OF NONCOMPLIANCE NONCOMPLIANCE SUMMARY NON-SE-15-5D040 NAME OF ENTITY IN NONCOMPLIANCE: Old Village Store PWS ID 44020016 LOCATION WHERE NONCOMPLIANCE OCCURRED OR WAS LAST OBSERVED: Old Village Store,2445 Meetinghouse Way,West Barnstable,Massachusetts 02668 DATE WHEN NONCOMPLIANCE OCCURRED OR NOTIFICATION WAS ISSUED: On March 9,2015,the Massachusetts Department of Environmental Protection(MassDEP or the Department)became aware that the Old Village Store is in violation of the Drinking Water Regulations by not being operated by a properly licensed Primary and Secondary certified operator as required by the Drinking Water Regulations. DESCRIPTION OF NONCOMPLIANCE: Based on a letter of resignation from Donald Rugg,which was received by MassDEP on March 9, 2015,the Department was made aware that the referenced facility is currently not operated by a properly licensed certified primary or secondary operator. DESCRIPTION OF REQUIREMENTS NOT COMPLIED WITH: In accordance with the MassDEP drinking water regulations, 310 CMR 22.11B, (1) Operation. "Every public water system shall be operated at all times by a Primary and Secondary Operator for the treatment and distribution of drinking water,unless otherwise authorized in writing by the Department..." ACTION TO BE TAKEN AND THE DEADLINE FOR TAKING SUCH ACTION: NO LATER THkN March 27,2015,the Old Village Store shall submit to the MassDEP, Southeast Regional Office two completed and executed"Certified Operator Compliance Notices". A copy of said notice is attached for your convenience. If you have any questions concerning this matter,please contact Charles Shurtleff at(508)946-2879. DATE: BY: Richard J. Rondeau, Chief Drinking Water Program Bureau of Water Resources 3 OLD VILLAGE STORE OLD OWNERS 2008-2014 FILE IN ATTIC pug 01 1411:41 a p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 2455 Meeting House Way Property Address Al Schofield _ Owner Owner's Name information is required for every west Barnstable MA 02.668 7-30-14 page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms ""��auulnprrq�i on the computer, I ���� jH OF Aq 7�i" use onlythe tab V 'ol •� `r '� 1. Inspector: s�• . c key to move your cursor-do not James D.Sears =�; JAMES m e the return Name of Inspector key. = CapewideEnterprises,LLC %* ' F7 - �.� w Company Name '-'� Ti -- 153 Commercial Street Company Address Fit., � �.._... Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number license Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and Complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-31-14 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. L5ins•3113 Title 6 Official Insp Subsurface Sewage Disposal System-Page 1 of 17 Aug 01 1411:41 a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2455 Meeting House Way Property Address AI Schofield Owner Owner's Name information is required for every West Barnstable MA 02668 7-30-14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Village Store and Cheeze Shop. Note: Cheese shop was a. rest. in the past. Cheeze shop closed. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. . The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. k A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): tMns.3M 3 Tine 5 Offldat InspeV lon Form:Subsurface Sewage Disposal Syslem•Page 2 of 17 Aug 01 1411:42a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 2455 Meeting House Way Property Address Al Schofield Owner Owner's Name information is required for every west Barnstable MA 02668 7-30-14 page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired_ B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t.lns•3113 Titre 5 ORciaf Inspeaton Fume Subsudace Sewage olsposat system•Page 3 of 17 Aug 01 1411:42a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 2455 Meeting House Way Property Address Al Schofield Owner Owner's Name information is required for every West Barnstable MA 02668 7-30-14 page. City/rown state Zip Code Date of Inspedion B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: `*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than day flow,/£.4cjljAv C 15ins•3113 Title 5 ORaaal f spedion Form:Subsurface Sewage Disposal System.Page 4 or 17 pug 01 1411:52a p.1 Commonwealth of Massachusetts _ Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 2455 Meeting House Way Property Address AI Schofield Owner Owner's Name information is required for every West Barnstable MA 02668 7-30-14 page. Cityrrown Stale Tip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well- El ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form-] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd_ For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.3113 T)Ua 5 Offlclal Inspection Form:SubsuRace Sewage Disposal System-Pape 5 0117 Aug 01 1411:52a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form ti Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 2455 Meeting House Way Property Address AI Schofield Owner Owner's Name information is West Barnstable required for every MA 02668 7-30-14 page. cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): — Number of bedrooms (actual): DESIGN flow based on 310 GMR 15.203(for example: 110 gpd x#of bedrooms): t5ks•3113 Title 5 official Inspection Formc SLOsufaw sevrage Disposal System-Page 6 of 17 Aug 01 1411:52a p,3 Commonwealth of Mass achusetts AM- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 2455 Meeting House Way Property Address Al Schofield Owner Owners Name information is West Barnstable required for every MA 02668 7-30-14 page. CitylTown Slate Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal G.T. 1500 Gal Septic Tank D Box,Two Pits and Leaching Field Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ❑ No Laundry system inspected? F Yes ❑ No Seasonal use? ❑ Yes [] No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercialllndustrial Flow Conditions: Type of Establishment: Village Store and Cheese Shop Design flow(based on 310 CMR 15.203): NA GaHons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? 0 Yes ❑ No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: Well Water t5ins•3113 Title 5 Offidal hspsaon Form:Subsumoe sewage Disposal System-Page 7 of 17 Aug 01 1411:53a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 2455 Meeting House Way Property Address Al Schofield Owner Owner's Name information is required for every West Barnstable MA 02668 7-30-14 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA —Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 3500 Gal. gallons How was quantity pumped determined? Pump Truck Reason for pumping: Maint after inspection Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): G.T. 15ins-3/13 InUe 5 Ofridel hs pec5on Forrtc 9tdmuf®w Sewage Disposal Sy9[etll•Page 5 of 17 Aug 01 1411:53a p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2455 Meeting House Way Property Address Al Schofield Owner Owner's Name information is required for every West Barnstable MA 02668 7-30-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: # G.T. NA/ 1500 GAL. Tank and pits 1982 permit # 82-276. Leachfi 89-500 1 7- e Id 1989 Permit 30-14 New D Box&Line Change Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting,evidence of leakage, etc.): Pipeing 4" PVC SCH 40 Septic Tank(locate on site plan): V. Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 Gal.Precast H-10 Dimensions: Sludge depth 3" t51ns-3113 Title 5 Offidal Inspectlan Form:SubsLaface Sewage Oisposal System-Page 9 or 17 Aug 01 1411:53a p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 2455 Meeting House Way Property Address Al Schofield Owner Owners Name information is required for every West Barnstable MA 02668 7-30-14 page. Cityfrown State Zip Code Date of Inspection D. System information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness & Distance from top of scum to top of outlet tee or baffle B. Distance from bottom of scum to bottom of outlet tee or baffle 1 Q, How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet bee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 8"below grade.Two inlet tee's. Outlet tee. No sign of leakage or over loading. Main pump after inspection. Grease Trap(locate on site plan): Depth below grade: 8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 1000 Gal.Precast H-10 Scum thickness 8" Distance from top of scum to.top of outlet tee or baffle 8. Distance from bottom of scum to bottom of outlet tee or baffle 28" Date of last pumping: NA Date t5ins-3113 Tide 5 O(fldel Inspection Fwm:Subsurtaoe Sewage DisPosal Syslem Page 10 o:17 Aug 01 1411:54a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2455 Meeting House Way Property Address Al Schofield Owner Owners Name information is West Barnstable MA 02668 7-30-14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): G.T. is a 1000 Gal. precast H-10 Tank. Tank and covers at 6"below grade. In and out let tee's. Tank at working level. No sign of leakage or over loading. Maint pump afther inspection. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: — gallons Design Flow: g a I Ions per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ns•3M3 Title 5 Official Inspectlon Perm:Subsurface Sewage Disposal System-Page 11 or 17 Aug 01 1411:54a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2455 Meeting House Way Property Address AI Schofield Owner Owner's Name informad for every tion is requi re West Barnstable MA 02668 7-30-14 page. Cdyrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-20" below grade w/cover at 6' below grade. Box is new 7-30-14. Two lines out. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): `If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Tdle 5 Official hispedion Form Subswraos Sewage Disposal System-Page 12 of 17 Aug 01 1411:54a p.9 Commonwealth of Massachusetts IvyTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2455 Meeting House Way Property Address Al Schofield Owner Owner's Name inform is West Barnstable requiredd revery MA 02668 7-30-14 page_ Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ® leaching fields number, dimensions: 12'x28' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal. H-10 precast pit's and leach field. Pit(#1)at 18" below grade w/steel c cover at grade.w/3Water.0ne inlet,no tee has outlet tee. Pit(#2) 3' Below grade w/cover at 6,,. 18" Water pump after inspection. Camera out to field. No sign of run back or holding water. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction _ .._.. Indication of groundwater inflow ❑ Yes ❑ No 151rs•3113 Tllle 5 Official trspao6on Form:Subsurface Sewage Disposal System•Page 13 of 17 Aug 01 1411:55a p.10 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 2455 Meeting House Way Property Address AI Schofield Owner Ovvner's Name information is required for every west Barnstable MA 02668 7-30-14 Cityrrown State Zip Code Date of inspection page. P P� D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 50tfdal Inspection Force Subsuurfare Sewage Disposal System•Page 14 of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2455 Meeting House Way Property Address Al Schofield _ Owner Owners Name information is required for every West Bamstable MA 02668 7-30-14 ^— page. CitylTovm State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 2- hand-sketch in the area below drawina attached se arately I 5'Wx25'L Leach Field wl 3.5'stone around �1 7 6 :ULU Za%Wr 4 1500 Gatton G Septic Tank 3 � _000 Gatton Grease Trap I 0 A 1 B A 1-15' B L-13" rear of louliding 2-21.5' 2-15' 1 O 0 / 3-18.6 (far right Slde) 4-26' 4-29' 5-38-3' 5-38' i 6-56' 6-59' I i 7-59' 7-72' Former Restaurant 4 .24 f Vett Country Store � l I 2445 Meeting House Way Rt149 West BArnstoble, NA 02668 TUe 5 Olifdal tupeoicn arm:sw5ufacs Sexage Disposal System Aug 01 1411:55a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J 2455 Meeting House Way Property Address Al Schofield Owner Owner's Name informrequire for is West Barnstable MA 02668 7-30-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� Estimated depth t high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health- explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain_ U.S.G.S. well SDW 252 at 46'w/2'ADJ. You must describe how you established the high ground water elevation: U.S.G.S. well SDW 252 at 46'w/2'ADJ. Bottom of pit at 7'-6"below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official tnspedion Form:Subsurrace Sewage Disposal System•Page 16 of 17 f, Aug 01 1411:56a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form 1= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2455 Meeting House Way Property Address Al Schofield Owner Owner's Name information is West Barnstable MA 02668 7-3D-14 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Tdle 5 Oftal Inspection Form:Subsurfeoe Sewage Disposal System•Page 17 of 17 f ` Barnstable � �KMEr Town of Barnstable AHmm Regulatory Services Department 'ca #' + ll1RNSTABM +• 1 s 9 Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO April 30, 2008 R b� Sharon Soles • ` Meetinghouse Trust 9 Shannon Way DO Brentwood, NH 03833 c�- ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 2455 Meetinghouse Way, W. Barnstable MA was last inspected on April 16, 2008,by Mike Hudson, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • The outlet baffle on the septic tank is broken and needs to be replaced as soon as possible to keep system operating properly. The inlet cover on the grease trap is broken and needs to be replaced to keep water run off from entering grease trap. You are ordered to repair or replace the septic system within Two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. GP ER OF THE B ARD OF HEALTH c ean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL# 7006 2150 0002 1038 7282 Q:\SEPTIC\Letters Septic Inspection Failures\2455 Meetinghouse Way.doc Commonwealth of Massachusetts Title 5 Official Inspection Form 4 s "°" A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Z?-5 33 2445 Meetinghouse Way- Route 149 G—t 2.y�`J> 4� Property Address The Meeting House Trust, Sharon Soles-Trustee LA q 1 Owner Owner's Name lew information is required for every West Barnstable MA 02668 04/16/08 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your r y cursor-do not Mike Hudson use the return Name of Inspector _ key. Septic-wiz Environmental Services � V�I Company Name ' 31 Midway Drive c_ Company Address Centerville MA 026$2 _ City/Town State Zip Bode --5 508-367-5669 DEP#4254 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority lt4 04/29/08 Inspect s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ti 2445 Rt 149-T5 Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: The system conditionally passes by DEP standards. The outlet baffle on the septic tank is broken and needs to be replaced as soon as possible to keep system operating properly. The inlet cover on the grease trap is broken and needs to be replaced to keep water and run off from entering the grease trap. See Page 16 ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 2445 Rt 149-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M ,•'�` 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: N ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: JA C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 2445 Rt 149-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''� 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): 0/4 ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool �/� _ ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 2445 Rt 149-T5 Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M ,•'°�V 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 2445 Rt 149-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 2445 Rt 149-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,. 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. Cityrrown State Zip Code Date of Inspection D. System Information �J 1% - Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Country Store/Restaurant Design flow(based on 310 CMR 15.203): 1,075 gal./day Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): maximum seating is 25 persons Grease trap present? ® Yes ❑ No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: well Last date of occupancy/use: 2006 Date Other(describe): 2445 Rt 149-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Barnstable BOH, Property owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): (1) 1000 gallon grease trap, (1) 1500 gallon septic tank, (1) 1000 gallon leach pit acting as additional septic tank to 12'x28' leachfield Approximate age of all components, date installed (if known)and source of information: Leach field 19 years, installed 10/89 via as-built permit, septic tank and leach pit 26 years Were sewage odors detected when arriving at the site? ❑ Yes ® No 2445 Rt 149-T5 Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 50'+feet Comments(on condition of joints, venting, evidence of leakage, etc.): pvc joints in good condition Septic Tank(locate on site plan): Depth below grade: 10"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/Ayears Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 5'8"Wx10'6"Lx5'8"H-1500 gallon Sludge depth: 4'10" (2"thickness) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured probe w/rag, tape, mirror, flood light 2445 Rt 149-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M s 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank and grease trap should be pumped quarterly for commercial operation. inlet tees in good shape, outlet baffle broken and needs immediate repair, all liquid levels normal, tank appears structurally sound w/no evidence of leakage. Grease Trap (locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 4'10"Wx8'6"Lx5'8"H-1000 gallon Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" Date of last pumping: November 07 via Wind River Environmental Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): System has been pumped quarterly by Wind River Environmental, inlet and outlet tees in good shape, all liquid levels normal, no signs of leaks or structural problems Q/A- - Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 2445 Rt 149-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owners Name information is required for every West Barnstable MA 02668 04/16/08 page. CityrTown State Zip Code Date of Inspection - D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: bate Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): 1' Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 2445 Rt 149-T5 Inspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: (1) 1000 gallon ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: (1) 12'Wx28'L ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil sandy loam, no signs of hydraulic failure or ponding, no damp soil or abnormally lush vegetation over sas 2445 Rt 149-T5,lnspection•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) )� Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): / Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scup layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 2445 Rt 149-T5 Inspection-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pi inrOw ontPrc the buildina. 5'Wx25'L Leach Field w/ 3.5'stone around 7 6 5 6' (R=6') Leachpit 1000 gallon 4 1500 Gallon Septic Tank 3 O � i�le4_ cover �-o be topIccecQ � 1000 Gallon 2 Grease Trap O 1 A B A l-15' B 1-13" 1 0 0 / + rear of building 2-21.5' 2-15' (far right side) 3-18.6 3-23' 4-26' 4-29' 5-38.3' 5-38' 6-56' 6-59' 7-59' .7-72' Former Restaurant Well Country Store 2445 Meeting House Way Rt149 West BArnstable, MA 02668 2445 Rt 149-T5 Inspection•0810E Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 10 —� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M °�< 2445 Meetinghouse Way- Route 149 Property Address The Meeting House Trust, Sharon Soles-Trustee Owner Owner's Name information is required for every West Barnstable MA 02668 04/16/08 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope � S 1 ® Surface water � o o -�- ® Check cellar N i l\ ® Shallow wells tJ I-N Estimated depth to ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Reviewed as-built plans and engineering notes, spoke to health agent. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed USGS water resource and topographic maps. You must describe how you established the high ground water elevation: Reviewed USGS water resource maps and topographic maps for site location. Reviewed file and engineering notes from Barnstable Board of Health. 2445 Rt 149-T5 Inspection•08l06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable THE r, Regulatory Services iARNSTABM ; Thomas F. Geiler,Director ArEDyp Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of.Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division,agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. 04J.7/2K'.8 11:52 5084201536 ALEERT J SCHULZ EP PAGE 02/16 A.aIZ.-9,7_2ri013 M87SQ4�75 P.002 09-26 ARDITO,SWEENEY & ASSOC ®,� Camrtnonv+raalth of Massachusetts ff' 'al Inspection A�Ir4, r- H ��#�� Icy `1'- _' s�efa�Sewage Dispogst 9ysiem Form-Mot for VoluntRry Assessmr,ts y ��� 2"S Meat 1n h uea Wa - PmpertyAddf s he Meetin House Teas Sharron soles a Trustee ---�--- igrrfter me'. A 02668 0416103 Ir4!*gF4340191s l3afr15�bi® Staff 2P co e 68—m Of IP1spe�id" rQV..1tAUWJ:i f�1r::,.lerif' , ow" n MAIN must be sub � rniftd on this form.inaPeon forrrus may rjen be altered in any lnyrr ways A. General Informalti®n af,the raarr�c;ie uox c rily thol't* 1. Ins tor; r'tm L.,,rtc,v,l!PtUr -- 6:1huf dm ro ; Mike Hudson qi;>n ifti:PIatIOYro Name of jmapemr t„v. ire tL,-�Environmesttal Services 31 Rdlld t?nve r,wS Corrpany Addrem MA 111__�.ff'�dO1 C;erit�111rlile $Eatze �m :'�de �0l�.3679 DEP 4254 Tak0ame KurptpAr UCSF�leumber l 1 certfy that I have personally inspected the se"ge dispel system at this ado rests and that the infOrMO On reported belovlr Is ttu@,a�Ur3�gttd �n � or fu^rncte Of a aro�i6 i �anoe efi on site was performed based on my training and expel on an l;Irml 16.340 of sewage disposal systems.t am a DEP wr sYstOfn I"s r Po to 'Title s(31t)'G`MR 1s.000).The system: ItsSes ❑ Candibonally Passes ❑ Fails ® Needs Further Evatuation by the Local Approving Authority 04M 6109 lentil Ps Sgnaat �� The system inspect*r shall submit a copy of this inspection report to the Appmn ing Authority(®onrd of Health®r DEP)within 30 days of romp%ting this Inspection.If the SYsteM 9S a shared systern®r has a design flow of 10,000 gpd cr ,greater,the inspector and the system owner shall submit the roportto the 9pprrapIF12te regional office of the DEP.The original should be S&Tj to the system ouu ar and copies sent to the buyer,tf applicable,and the approving autherl�r- ""TM9 report Mly descritm conditlons at the tirrto of MPeCtio "d under t pn btu tit cwWliin the ons Of O retell at That time.This insprec tion does not address h*W the s m a re the same or dMiMrit ewditicns of 11M. q*%owl Mparjw raw WIRVINA VMNP D"**d spatam•Parse P'x q W ,•.;5¢!:&4Q.93r ad19A Al2fl4S 04/1!r I20 °8 11:52 5084201536 ALBERT J SCHULZ EP PAGE 03,116 AF1;i•-17-2008 09!,26 ARDITO,SWRENEY & ASSOC 5097904775 P.003 a� Comrfiomsalth of Wlmachusettts ff Title ic6a6 inspection S bsurbee swage OiBposal Syttwn Form-Notfor VoluntarY AsseSsrm" 2445 Meeti hVm—pefty Address ouse tNa Rout® no Mn Soles-Trustee rAr'11W owners tame gyp, 02666 041'161� is!a9r �°¢ke,9 is UV�t 6�Yf1S�bl ���� p4 en�pte[an Fd9>3ti:ti:'19'v9P'::v10Yp .Qt82O B. certification (=nt) inspection Summary:Check A.B,G,D or Ei n&VYS complete all of Secdon O A) System Passes: ® I have not fou1 303 or in 310 any 1CMR 15.304indrexist Arty fire criteria not ed are � in310CMR 1 indi®tad below. �orr�ment*,' asses by DEP standards.The outlet baffle on tho septic tank' Th®system , s(�totae:n and needs to i replaced soon as possible to;sap systern operating property.The in''At ecYYr:r�ota the grease trap is ®r®ken nd needs eo be re faced I�kee wajpr and run off out of the B' Sys,Conditionally Passes: ® to be one or more system components as descf�d in the"�ndit9oe�2t Fuss°eee�on need replaced or repaired,The system,upon con+Plet an of the reptac®rrrerri�'a air, ss approvv ed hN the Board of Haalth,will pass. Answer yes, no or next det®rmined(Y, N, NO)in ttte®for the following statr;tterrfs.If'not aemrmined`please explain, ® The Septic lank is metal and over 20 years old'or the sepfic rank(whether rnr-tal of not)is structurally unsound,exhibits substantial infiltration or exfiiltraMW a+°tank f2ilurs is iMMiFtent System will pass inspection If the existing tank Is replaced vAth a complying septic rank approved by th®13o8M of Wealth. s A metal Fian�i dflooertlnll pass that tite bnk is ass tttar¢ZO years old s�waillon if it Is structurally sound.not �b�r°�and if a Certifi�te of O®mp 9 AID Explain: le Elevei in the diWbutirt box due Observation of sewage backup or breek o b Ld or high sidled or urn warseven der buhi box.Syst a gall to broken of obstructed pipe(s)or due to a pow inspection V(with approval of Board of Wealb): broken plpe(s)are replaced ® obstruction is removed ;tr�AE�l�9ai8.Y�trmgoal�v 00 7/20%'.8 11:52 5084201536 ALEERT J SCHULZ EP PAGE 04/16 R:a'I;~i.7r�o0 09:26 ARDITO,SWEENEY & ASSOC 5007' C4775 P.004 commonwealth of Massachwfta is Eli!ME rP I Inspection Form :aim u� Title ida LL _)� 1 rrn Not for VoluflMly Assessmen'S Y s py Subwr%eg Bawage p[sposal System po Route5;- 2448 Meertin house Wa meryy Addresx Tle qy Add House Trust Shamn Sales-Trustee flilel Ome $Name MA �02668 €� C.4�'96d4� err�e�era:;itlevn to VUe�13amstable �q€�it���! �s�vt�r,�r Stag 7Jp Code �ct�@a• C,ltYliawn i . certification (cant.) 13) System Conditionally Passes(cons): distribution box is leveled or replaced N®Exptain: ® The system required pumping more then 4 times a year due to broKeTr,C?Obsti'ucted pipes),Y�0-- system will pass insp%don ff(vAth approval of the Board of Health)., ® brow pipe(s)are replaced (� obstruction Is removed N® Eacpl M 'NJ 0) Further Evaluation is Required by the Soard of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety er the environment 1. System will pass unles Board of Health determines In accordance with 310 CMR 'yM(l)(b)that de®system is not functioning In a manner which we'll prat public health, safety and the envilmnment: ® Cesspool or privy is within W feet of a surface crater ® Ceaspod Of privy is within So feet of a bordering vegetated�metlaad or a gait marsh X System will fal unless the Board of Health(and public ldlfet491 SUPP10r, if any) determines that the sy3tern is funedaning In a manner that proteed"thO public heallr, safety and environment: ® The sysWm has a septio tank and soil absorption system(SAJ)and 2he MS Is within 100 feet of a susfaee meter supply or tributary to A surfaw w2W supply'. The system has a septic tank and SAS and the SAS is Ath in a Zom�1 of a public w supply. nate v water The system has a septic to nk and SAS and me SAS is witr€in S0ti of a p supply well. Rt Id!0-9S Ir®psd6n. 71tt!S OP.Ie4nt tfaoar!!on Fe�en:;�p�rtsoe 0�_�'�'.gaga 2 a(1 5 0�1I rI'z0'?2 11:52 5084201536 ALBERT J SCHULZ EP PAGE 05/16 y nl.• .•.17-21)09 09;'27 ARDITO,SWEENEY & ASSOC r'0873f1k':775 P.005 commonwealth of mass"husem � t fficisl Inspection Form Title 5 0 p SGtn±i n � a Disposal System IFonYr-Not for Voluntary Asaessmei ( . __.ti Subs 9 e �, - �,YS y' 2�Meetin house Wa -Route 149 ssr Address Th Masse Trus Sharon Soles-Trustee ---� CeroR�c o"Ce$Wme o�r1(i1Dl it1@Ceti-glijfo kI !fl]®5t or:Qtri°pit i'�Or��:r�rp �� w State Zp C®®e g�tisrtw B. Cartificaflon (corn.) C) Fuaer EvAluatlon is Required by the SMYd of HeaRh (coat:): ® The aysGam has a se4c tank and$AS and&a SAS is less than 100 feet but 50 feat or rnore frorj a private water supply well"*. Method Lsed to determine distance: This slralem passes if the well water analysis,performed at a 0 EP Qer'fieu vaba:'aiory,for colif "i bete t8 indicates absent and the presence Of ammonia nitrogen and nitrate rih ag2r'Is equal to or lless than 5 ppm, provided that no other failure criteria are triggered,A COPY 1 the,ae1®lysis must be attached to this tbrm. 3. Othen ®) stern Future CfFt6rta Applicable to All Systems: You indicate"Ygsr'or-No"to each of the following tee an 1a>sae'sr on�� Yes r4o ® Backup of sewage into faoQity or system oomponent due to OVIMOSded or Clogged SPAS or cesspool ® ® 01schaMe or ponding Of effluent to the surface Of use ground or surface w®t€:rs due to an overloaded or dogged SAS or cesspool Static liquid level in Sloe distribution box above outlet invert due to an Overloaded or clogged SAS or cesspool ® Liquid depot In cesspool is less than S'below IrweA or available volume is less than'A day Flow ® Required pumping more than 4 times►n the last year NOT due to clogged or obstructed pipe(s). Number of times purnped6_--. Any portion of the SAS,cessp®el or privy is below high ground wales elevation_ Any portion of cesspool or privy is within 1 DO feet of a surface water supply or ® tributary to a surface water supply. SiUo 3 91'Itld PmOs�tPl f•�nn!� � 0jgpMW Sygt=.Paps a,a i N 014/ _T/20z'8 11: 52 5084201536 ALEERT J SCHULZ EP PAGE 06f16 AF-R-17-2(ios 09:'27 ARD,T,TO,SWEENEY & ASSOC _ d5790 775 P.006 P• :'Li1! II ,dk.+ fW.I LCI IVIIM1O ilN6lwl. 4 commonwealth of MassachuSi is _ la Title 5 Official Inspection Form fji Subsurbw Sewage®ftpoaal System Form-Not for Voluntary Assessments �I fyj . A `V,' l� 6S1AY�MIO 1'�use YYG �A�� \ter °Gel �i�D®f�3�61(E89 The Meetin douse Trast Sharon Soles-Trustee --- cownc:a fuse MA 0266� 1�llMing i1�i��rraa�tlar�i:5 1fi0 t> arnstable ZIP Cade Dace air Inspeair is9qull�;i4.�,•u�eq State �it�ft�n �e Certification (cont) ®f Systsm Facture Criterla Applicable to All Systefris(cant.): Yes No ® ® Any pordon'of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspw1 or privy is within 50 feet Of a prlvam wgter supply well. ® ® Any portion Of a GMpool or privy is toes than 100 f�-'61 but groate+r than 50 teat: frm a priva*ouster supply W811 with no acceptable d�t a�I�paca it s1s. his m posses V the well crater anaVS s,p Istiorator r,for fecal eotifortn b®cte►ia Indicator @b e® Ind the than 5 per, of aenmonla nitrogen and nitrate nit" al to provided that no other failure criteria are triggeredL A Copy of the anaoWIs and chain of custody Must be attached to this forma ® The systern Is a awspool searing a facility with a design flows of 20ON pd- 10'onmpd, ® The tern ttil�l 1 have deLerrnlned t81at one-or more of tht.above failure trite'a exist as desaibed in 310CMR 15.303,thorefolo ttiG system fails.The s owner mould oon the Board of Halal to 69�mrfll;n0 what will be ne ssary to correct the failure. li) Large Systems: To be considered a(sage system the sySWM Must wrier a fac ty with a g design IRow of`t0,000 gpd to Is,000 gpd- For large sysoems,you m st indicate either"yes°or,no" to each of the,MI&Ang,in addition to the questions in Section B. Yea No the tern is within 400 feet of a surface drinking water supply ® ® the 5ystern iswithin 200 fat of a tributary to a surFace drinldng meter supplgr the torn is located in a nitrogen Sensitive aP*(j Rntearn Wellhead Proteetion A —IWPA)or a mapped Zone 11 of a public cater supply well if you have answered" "to any quegbon in Section E the sOMM is.Wnsidem.1 a significOnt tiri�t, ar answered"yam'in 5 onto above the Isrge system has failed.Thy ®r®r oper�lor of any large systarn considered a sigr lficant threat under 5ectliOn E 8r failed under SecWq ®shall upgrade the syatem in accordance wil h 310 CMR 15.304.The systarn owner should contact tm appropriate m9lonal office of the De rtment 11106 OMW Ynsoadw fvrw 810me s SgwP Diewsa1 Syron•F+Ce 5ot 16 0411/2KB 11:52 5084201536 ALBERT J SCHULZ EP PAGE 0/16 API -t.i-2. :06. 09:27 ARDITO,SWEENEY & ASSOC 5087904 ?5 P.007 commonwealth of Massachusetts e��w nm ' P Title 5 Official Inspection F®rrn , sr 9t'� ate aeeS wage Disposal�►mte3m ForM-Not for Voluntary assessmenft F f' ui Se'a s ^ � � hOUSS Way.Route 149 ®---� Peropen+J Address The Mee}tix us Hoe Trust Sharon Soles- nsstee tt�,wrr awnar's Warne Mp, 02668 Cb4J16J08 �- BetiPherili;&"is, �1 SantB�ble reg�;�ind f'or evIVY Slate Zip Coda patA of 11aptdiol9 us e. CiW'= Ce Checklist Check if the following have been done.You must indicate'�ee or"no"as tc dxac:'rt&the following: Y" No I& ❑ purnpin information was provided by the owner,occuPant, or Board of Health Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal 1lCv,5 in the previ®us two wa(!,k period? Have large volumes of water been introduced to tM myMet'n reosntly or as pars of this inspection? btained and ® Were as built plans of the 5yyst M o examined?(If trie.y were not avalilabfe note as NSA) ® Was the faculty or dwelling inspected for signs of severe Uck up? ® Was the srie inspected fbr sign of break out? ® ® Were®II System components,excluding the SAS, lo=ted on site? ® Were the se3pile tank manholes uncewered,opened,and thel interior of the tank inspected for the oondldon of ft baffles or tW.material of construction, elitnens+ons,depth of li�iuid, depth of sludge and depth of Scum? ® ® Was the facility owner(and occupants if different fmm ownw)provided with information on the proper mairttenance of subsurface savrage disposal systarns? The sWa and location of the Soil Absorption S)jftt,n,f�2.lUb)on the eke hm Wen determined based on: F-xisting information. For examPle, a plan at the Board of'Kaalth. ®eterminead in the tleld(if arty+of the failure 066a related to Part C iS et isgua approximation of distance is unaroeptable)[310 GARB 15.302(6)1 Ye:rB Rt SO.,PS Sao,Min me S orr4w lmwpce n Fame&Dfuhe*9e dp®dpa w System•Pan®e416 04117/20c`8 11:52 5084201536 ALEERT J SCHULZ EP PAGE 08f16 AL'Iti- i'-43r'!0� 09•:27 ARDITO,SWEENEY ASSOC g;087904775 P.008 Q Co mtol9vlrmlll ®f gllassachusetis 1 aPTitle 5 official Inspection Form° l� ►: I Not far Voluntary P Assessments .subsueaee Sewage Disposal s nr Form- z 2445 Mestin house INa •let:te 1dg '�" ProD��tY��eese The Meeting Hou TrUM Sharon Soles-T 9elAreiL`x' ®uutlBPe Plate AAA �68 6�d IG1� I�yr�:rii�„rV'd�e►'a�, �e5t® matable 51t4jLt'8�1br nnary stme Zip Code Gee A$p9spe�tl�n ®e SYStem InformalAoln Residential Flow Condltiom= -Number of bedrooms(design): Number of bedrooms(acWal): DESIGN flow based an 310 CMR 162D3(for example: 110 gpd x#of bedroorns): —'�'— Number of currant residents; Does residence have a garbage grinder, ❑ Yes ❑ tk Is laundry on a separate sewage system?jif yes separate inspection requIRA ® Yes ❑ No Lsundry system inspected? ❑ Yes ❑ N9 Seasonal use? ❑ Yes ❑ No WaW meter readings, if available(last 2 y®8M US89e ON)): Sump pump? ® Yes No Last date Of occupancy: Ccmmeccialfindustrial Flow Condit8orm: Co_ uri ' S�rellRestaurant Type of Establishment 1107 5 Design How(based on 210 CHAR 15.203): dons perdalr(W) ' mayamumtlin�is 25 persons r,° Basis of design flow(seatsrpersonstsci t°, etc.): Grease trap presenr Yes ❑ P>Io Indatr'lal waM holding tank present? ® Yes ® No Non-sanitary waste discharged to the Title 5 system? ® Yes No well ---- Water meter readirs9s, if available: 2006 _ �— Last date of occupancy/use: Date —"-"^ Other(des***): - ;l4 4°I lei to TS b °Ma41tle 1 Cfl1o1a1lnspe®on faen:�Cwfee6 S C�sp�s�l 50*n-PW 7 oMs 04/1 +-20E°8 11:52 5084201536 ALEERT J SCHULZ EP PAGE 09/16 .4P).R-i7-2008 09.28 ARDITO,SWEENEY & ASSOC 50879047175 P.009 e CommamNealth of massachuseds . . � Title 5 Official Inspection Form an ram-Not for Voluntary Assessmenffi Di v�IP submriace Sewage Disposal item F., u 2445 Meetin house Wa R,eute 1d9 —� The Mgdnp House Trust.Sharon Sales-Trustee 6yuraa�: owrert Naffe S. MA� D266a3 Ctd11ClOS rrPti�rt.we Pt t' VNeSt arroetaOle Suit® code Date ofImPaction t25;f l�i+:el`Per�,vEH'� Pitj!(Pautflt D. System Information (coat.) General Inform S11611111 )Pumping Records: Barnstable 6OH Pro a ®owner Souroe of information: Was system pumped as part cf the inspection? yes ® No NIA If yes,volume pumped: gallows How war,quantity pumped determined? NIA E Reason for purnping: Tye of System: Septic tank, distribution box,soil absorption System ® Single cwspool ® overflow cesspool ® Privy ® Shared system (Sues or no)(if yes,attach previous insPection records, if any) Innovative/Alternative technology.Attach a copy of the curry-nt ape,Fatlon and Cl nnairrtenanoe connect(to be obislned from system owner) ® Tlght lank.Attach a copy of the®EP aPproVW. j� other(describe): (1) 1000 gallon grease trap,(1)1500 gallon septic lank,(1)1000 gallon leach pit actin as addi'oval se is tank to 12'48'leachfleld Approximate age of ail components,date installed(if known)And source of information: Leach field IS veers,installed 111J89 vie as-bruit its tic ink and felt:,0 rs Were sewage odors detected when arriving at the site? Yam; ® No �.9k5�Wia=7 e N�e�n-�0108 TNe 5OIR0�11ns�Cn Porerc 9�a9ufi��tP O�s�atl�ya°'i`'pagv'���o 0411;/20E:8 11:52 5084201536 ALBERT J SCHULZ EP PAGE 10116 Ai-i-,—'7•-2008 39:28 ARDIMSWEENEY & ASSOC 50S?904?719 P.Dio Comnlanw ith of Massachusa is Title 5 Official Inspection Form n eSSMeltS subsurface Sewage deposal System Fain'•Not for Voluntary Ass 2445 Meethouse VVa -Reut® 149 Propady Address The hfieetlr�House Trust,Sharon Soles-Trustee t„;a nor @wner's I�mve MAOMS r CW16106 E�1f[6f@�19�ICIr16S' � M.Nrnal" wp (its of1�apeCUan u1a4,i�i11i Tar emary Oilyrrmnl StxM Code SyStSM lnformatfon (oont.) HuHding Sewer(locate on siM plan): 221 Depth below grade: Coat Mateft of construction: ®cast On 40 PVC [J adder(explain)' 50'+ 13'rsiance from pdvate water supply well or zm ion line: foe— -- Comments(on condition Of joints,ventirtg, evidence of leakag®.etr~): . .einls� eod Condition Septic Tank(locate on site plan): D®pth below grade' teat Material of construction: ®concrete ® mil fiberglass ®Po"Iftl®ne ®otW(exp4kin) MIA If tank is metalk list ag®' years Is age confirmed by a Ceftifleate of Compliance?(attach a copy of certiftcMte) I� Yes IS Ind .618" X11a1VIX5811114-1500 gallon Dimenssoera3: - -- -- 4'10"g"thlcknes; Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness �--- Distance from top of scum to top of outlet tee or baffle 1A7' .�., Distanco from bottom of soarm to bottom of outlet tee or beftie -- _ Insured probe w/rag, tape, How were dirnettsfons determined? rnirn®r ftood li ht Yc.c abcw Iruaoctiai ra.e,:s> s�06paee�8ycen•ft@.Old 9 �:-m,e;e,®_I�,napsaJer.aaer� 04/17!20f`8 11:52 5084201536 ALBERT J SCHULZ EP PAGE 11/16 :17-- i:108 09:28 ARDITO,SWEENEY & ASSOC a0®7JG4775 P.011 2, v �k Commonwealth of Massachusetts qg� 4; � ��t� 5 OTT, Inspection Form `-r '"' Assessments ' ` ��w ftb vkce sevnge Disposal SySt@ln Form Not W Voluntary 2445 Meetin house Vlla -Route 149 -' foaerty Addmsa The Wbleedn House Tntst Shaeon So(�-Trustee - aun"er ors roame t1�11£Jpg iwfow,ra ifz'ki. ®ere ar InsRe Wait BamStsble MA OAS s ��i a!el Rare:va ry stme Zip code �i6st I CAYfMWa D. System Information (cant.) Comments(cm purnping re®ommendations Inlet and outlet bee or baffle concUOM�Icl:;u�ural intlegri Y, liquid levels as related tocutlet invert;evid;�ce of leakage,eta): Septic tank and gr�trap St Ould be pumped quarterly fgr ocmmercc�l operation.ir�(at ®s in g®ad shape,outlet barite broken and needs immediate repair,all liquid levels nurmai,tank appears stmeturally sound wl no evidence le®ke Geese Trap(love on site plan); Deter below"w. tmr Material of consirrtction: ®concrete ® metal ®fibergit3Ss 0 polyethylene ®oftr(explain): 4�1�"'Vtfx3��ml.�A"Ha1QO0 gallon Dimensions. Scum thickness Distance from top of scum to top of outlet tee or baffflo 17, Distance ftm bottom of scum to bottom of outlat tree or baffle Nwember 07 via Wind River Date of last pumping_ EnvIronrnenrl _ Commerce(on Pumping recommendations,inlet and outlet tee or ball a cGIditien,structural Integ"14, liquid levels as r+elaW to outlet inv®rt,evidence of leakage,etca): System has bow pumped quarterly by VAnd liver Environmental, inleIi and O-Laat toes in good shaPe�all liquid Ie�ls ttAtArNtal,no al s of leer ex Lip roblemf t•F -a Tight or Holding Tank(tank must be pumped at time of inspection)(lomte on sfte Plan):1 Depih below graft. mm� Material of censtrvcion: ®concrete ®mete) ®fibargtm 0 polyedtylene ❑other(explain): D�Si OW System ft2C i'..4�$ `Lllg•'fi81ns[ ^OWNYIKe 8 GtfiGal►I�$6700n f91+n.$ubetsRaoa • 9i9 v4'19 0411 7/2&:8 11:52 5084201536 ALBERT J SCHULZ EP PAGE 12,116 Kpli-.1 7-20013 09:25 ARDITO,SWEENEY & ASSOC 50f37�o477r P.012 rommonwealth of Massachuse is tolY�—c5! Tide 5 official Inspection Form l Al°l °� essments " a su�>rfa®®8CVIr3®®DISpa9at Faeeh.Not fi0r Voluntary A88 2445 M®etJ house Wa -13oute 1�19 pa®perly Adldmss `tote lylgetin Hour®Trust• shar>3n Soles-Truster P--- DIM* ours Narne MA p� tb4�9�1 .m s fia ��tRenrt u<,, ��— UI t Barrt9r�ble y oste Of I sspeftr ?tRtl;tli:�Ld J�1 tituctry S1atc �Cod EAade, D. SYStern information (cont.� Tight or Hokfing Yank(conL) Dimensions: Capacity: gallons Design Flow: gallons Per day — Alarm present: M Yes ❑ No Alarrn level' Auarrn In%wrking or(*' ❑ YeS No Dom of lost pur:tping' Deng _ Comrnerlts(condliion®l'alanm and fiWt sia lb2hes,ere.p: Attach copy of currant pumping contract(required). Is copy attached"r yes ❑ Wi Distribution Box(if present must be opened)(locate on site plan)• Depth of liquid level above outlet invert i ornments(note it box is level and distrlbutlon to outlets equal,any evidenoo of rAllds carryover,any evidence of leakage into or out of box,etc.): jt ® pump Chamber(locate on site plan): pumps In working order. ® yea ❑ No ,4{arrns in working order. yes No ;��!;DEr gate.9b tr�oeettnn•Q@?46 11Ro S OtOdN MYSpEe0d1 ram:l3ub�6fmm C 6lseoaal�'M9R-PRv 19 re 16 0411/28c 8 11: 52 5084201536 ALBERT J SCHULZ EP PAGE 13/16 A; lR-'-7-2C!06 09129 ARDITO,SWEENEY & ASSOC a097304775 P.M IN& Comflnonvvealth of yassaciht]s01" n MES Title 5 official Inspection Form .� [11 a Subsurface Sewage Di>rtp®sal System Fot7rt-Plat for Voluntary 4 445 IVfe®dn house�_A U- 149 Properi�r Addeo®® �l,e M®etin House Trust S> aron oles-Trustee - m i;iu,ntl�rOMWS Name �IIl4_ (14_� srrl radllt�;l ra i'!. a �2rn5table stftxlp Coda bw o4 InopectiUn I a��e�I Oda!�wes�r CkY/Tftn ®o System lttforMation (font.). cornmerm(nota condition of pump member,condition of pumps and 2ppurmnances,eN-). MI Absorpllkn SYSt AM(ems)(locate on sloe plan,excavadon rtot.rpquirad), if SAS not located,explAin why: Type. 1 t00Q alien leaching pits number. leaching chambers number. ® leaching galleries number -- leaching trenches number, lend, �— leaching films number,dimensions; (1) 12'W�Qa'L � overflow cesspool r.o pool number ® innovativelalternative system Typelneme of technology: Cangp�erTts (nova condition of$all,signs of hydrauflc Failure,level of POnding, damp soil, cond[ton a vegetatlon, etc.). Soil sandy loam, no signs of hydraulic failure or pending, no damp sailor abnoemally lush vegetaTian ever sas VWe;W•1,10-'reftpW1n-0 Tidy6OfiddlegeatpnPeen:s®wHeoe�ue��I,paaolBYaoan't'��� t5 041171205°8 11: 52 5084201536 ALBERT J SCHULZ EP PAGE 14116 r-2C1CIO 09:29 ARDITO,SWEENEY & ASSOC 5087904775 P.01A a� Camw'rtoMmalth of MassaChusetts y.i Inspection Form Voluntary pssessmer � =oer Not for Subeorface Se"9e QiepA6®I Syst0 -4 s al 2445 Meeti house W -Route 1d4 tmpefty Adduces The Maetln i Wause Test.Sl7aton soles-YruSfee owmes N3m �/lA 'F�' '""Al`'�l' Wept 6aMS1able i'a�aW%1WAjt5e cjuaorY A Zip 68 U3ffi Gt tYtSDs�Lten ;sage, f,°�yrlPDam Da system Informatioln (cunt.) pools(cesspool must be pumped as Pert of hNspection){late on:gite plan)_ Number and configuration Depth—top of liquid to inlet invert Depth of sofrds layer Depth of scum layer Oiimnsions of cesspool Materials of ccins$uclion Indication of gMundvamr inflow � Yes ® No 00mrnents(note condiVon of soil,signs cf hydraulic failure, level of ponding, comlit5®n of vegetation, VP—Y �p privy(locate on site plan)_ Materials af'construetion: Dimensions 1Depth of sallds Comments(note condition of soil,signs of hydraulic failure, level of pondin g,col1diflon of vege�tion, n4� !'.� '1�Ifl®pa�� 89G6 Tdb S ARm��v ^ e7mPeaa 6e� exaaoval SsrRw�+ P�40 or 15 04i 1'i'12K2, 1,1:52 5084201536 ALBERT J SCHULZ EP PAGE 15116 09•:2s ARDITO,SWEENEY & ASSOC �i0B7SO4?75 P.015 Comen®nwealth of Massachusetts o Form , Official Inspection o i�i �. Title Eftvosar sys�em FormSubsurface SeW2 -Not for Voluntary AsMSSlTt!'► S s OWE of 4 S — e Fel'."AddMC6 The Nifte House Tru Stla n Soles-Tt� e� c'�su ownees Name MA a2668 6419�J� IYi'<<:rt71t?19�n is. ��> arn5tabi� state Zip Code •date of Insp®drari cayfrown D. SYSIem information (cont.) SEt 1t®f Sewage DrsOesat System.Provide a 3k�fth of ft sewage diSp�I SYMOM includhg Its to at Least two permanent r+eftrence landmarks or benchrr'►2ft.t.ocaEe all weft v�ltlhin 10�feet. 1_ocat�where Ql�r'�e.au9lat asirmv wr mm the bundi d. S,Vx25'L Lem •/ 3.55'S'tone aroLod 7 6 3 6` tR�6'3 Leac�,psr Iona gatlsn 4 ISM &Aan septic Tank 3 10®Q �tlon Z Grose Trnp 1 A 1-15' A 2�L�'l 1 V O 1 + ,•tar of ladtd9�g 3-a 3-23' tfw- right swe" 4--P-6° 4-29' 5-126.3' S•30' G-JE6' 6-S9° 7-in, p-72 Farmer .. (aestauront wait country Stare w� 244S tmee'tng House 11Q�668�9 West JArn6" %bte, MA �rssree•Sli�t°: tee ®^ rA* awmhDdonForm 1AIA cn �eflutt i9��an�veget�er95 9 0�1f'1 '�20e'8 11:52 5084201536 ALBERT J SCHULZ EP PAGE 16,116 09:29 ARDITO,S►�EENEY & ASSOC 5097904776 P.016 e€ C®fr►M®nw®asth of Massachusetts p Official Inspection Form t i� mu ���I� ,assessments Bubsutf ee Sewage Disposal System Form-Not for,Voluntary 511 i r;sL g' Meebn house 1N -Route�49 i �erpr Addrms leAeettn House Trt�t, Mn Sales-Trustee o wmrs name MA 02668 1,,fi3tYt't�e41 %I; IdVeStat0 at lnVacglon se,rlei o Le!'gar a;nre t city/TownState �Ip soda D. System Inf®rMafion (Cont.) Site Ehmm., Ig Check Sbpe 1 Surlbft war O C?v 1 ® Check cellar rj 4, ® Shallow wells r 4 Estimeted depth to ground ulster: feet Please indleate all methods used to determine the high ground water elevation: ® Obtained from System design plans on record If checked, daw of design plan reviewed: oel>e [� Observed site(abutting propeVObsenratlon hole within t5h ket Qf SAS) ® Checked with local Board of Health-explain: Rgoriewed 8"llilt plans 2ttd fl4ineeting nd$es ® Checked With local 8=vat0rs, Ingtalt®rs-(attach docurYl'entaton) ® Accessed USES database e eVlsin: Revlewed USGS vu�r resource and'low rash maw. You must daser be how you established the high:ground water elevatiOn: Reviewed USGS water resource maps and topographic crops for site location, Reviewed hie and en ineerill rtot�e from Barnstable Board of Health �qa;i�1 9,6g••'Pd IASpO�®91^Q�8 Tide saMdei Imp gkinFDRn:£iL9B ggp�ge DIV00�•Pape NLI ys d 120c'.8 11:52 5084201536 ALBERT J SCHULZ EP s PAGE 01/16 LAW OFFICES OF AL BEET J. ;,,�CHULZ ATTORNEY AT LAW WILLIAM CHARLES PLACE 7 PARKER ROAD ®STERVILLE, MASSACHUSETTS 02555-2034 TELEPHONE: (500) 4.28-0950 FACSIMILE: (508) 4204 6363 FACSIMILE COVER SHEET �{ �II .°w "S. [3.Michael I. C ulre a a 0y 1 AGr,,S(including this cover sheet)' << 1,2 w • y. 1,�. fin®inf�r�at�on contained an this Aa, swmda u lIV9,32. si ralcil Q;:1�`0�� a cup ant is a®nfident�al infurFaaat�on'ntended fog the individual it is d;:c��8tt'�cls�t��s�. �f ynu are not the intended recipient,y�ua are htrel➢y.ra0tifaesi 4h2.r;tide dyi�;;c �.Pa�.re, diss� in�fion or copyim�of this c®ac�rnw�nication is strictly prohibited- " you 1,�.,��Er�; !PE Leg� d this communication in error,Please immediately notify us by telephone and In's-turn the en'gindi message to us aria the U.S.Mail. ''thank you. No. �O G �( Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Mispo8al 6pstem CDnstrurtion permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. Jg55 wa*;eTwC_440oSS WAq Owner's Name,Address,and Tel.No. ;LT i 4q W o k /4 t i<4.t97 S d 4E 0 G i eE_7> !� Assessor's Map/Parcel ( -5 -7 IZT- t o Installer's Name,Address,and Al.No. ,517Q_44 17—$$77 Designer's Name,Address,and Tel.No. U' 4D�lDE �Tc�2�Q1Sc3 (.LG � A .¢ P&-25 H Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) r 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 of Healt Signe Date 11 Q —,;Poi Application Approved by Date 7 3 0' Application Disapproved by Date for the following reasons Permit No. — 49k Date Issued 3 �-� / J } No. /- — �" ;�' Fee O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OFtiBARNSTABLE, MASSACHUSETTS 01pprication for Bisposat Wpsirm Construction Permit Application for a Permit to Construct(° ) Repair(� Upgrade( ) Abandon( ) ❑Complete System NfIndividual Components Location Address or Lot No. ;L4155 w4eeT#j6j400S-E u,,, %4 Owner's Name,Address,and Tel.No. IX--[ 14q W.V1 14C1r4-ab 5d4 09:i ZD Assessor's Map/Parcel ( D 7 V-T l .g . Installer's Name,Address,and Al.No. S pg-CE 7 7-$$77 Designer's Name,Address,and Tel.No. c'�40 (DE EQ�S25 C.LG N IA Go u ST .F p Type of Building: Dwelling No.of Bedrooms .'Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) a:. Other Fixtures - Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title - Size of Septic Tank Type of S.A.S. r Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: i w 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 of Healt Signed Date -, 7" O -�.01 Application Approved by Date 3 Application Disapproved by Date for the following reasons Permit No. )L_ 'C� L) Date Issued ---------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ?/BARNSTABLE,MASSACHUSETTS I` Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded n�t' ( ) Abandoned( )by �L6 e-uj(t)E "C �i����sES at has been constructed in accordance l with the provisions of Title 5 and the for Disposal System Construction Permit No. - /�ated 3 /7 Installer &?,/7W .tS6_r (-LC- Designer AJ A #bedrooms Approved design flow gpd The issuance of this permit shall not be constrted as a guarantee that the system will ction�esigne Date - J Inspector - -------------- ----------'' ---L ------------------------------------------ - - --------------_------------------------ ------- No. d`q I Fee /O a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30isposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at ,?CV r;Z- k6zrj Cy /P-T 149 (l( T L 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. c Provided:Construction must a complet I withi three years of the date of this pe trm t. Date �7 M � / % Approved by J _ . --��No. . Fee ,THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippricattori for Bigpogal bpgtemc Cougtruction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete System i❑Individual Components Location Address or Lot No. -.q� I 'n t e p,1 �2 Ljgf Owner's Name,Address,and Tel.No. A 1�Sah �y e, Assessor's Map/Parcel A4vq ry (O Q 3--7 7 p Installer's Name,Address,and Tel.No. C4jLWi cJ{ t("S' Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) P.O q C44311 � 19 f b V Date last inspected: —'GC--Loa 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 of H th. gne Date b Application Approved Date 4 Application Disapproved by. - Date for the following reasons Permit No. Date Issued v.-. . .y-F.,r.. � .� �..,..+.+'.-.^r< . .trr•�::�..e+�.^_""" `-' .so.r +.r"`W...� rr� ."'�^ �k �i:e No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for Mitpogal *pttem Construction Permit Application for a Permit to Construct O Repairs({.)- Upgrade O Abandon Compll System O ❑ �ete ❑Individual Components Location Address or Lot No. _V415-Tsi �,('+✓1� F4,fie W4/ Owner's Name,Address,and Tel.No. A I'i Assessor's Map/Parcel W 6 3"-7 Installer's Name,Address,and Tel.No.C4,W J4 '" Designer's Name,Address and Tel.No. - �Z��� Type of Building: Dwelling No.of Bedrooms Lot Size \� sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) P_,p(+�c.�ti„�9,tii t S4vt Date last inspected: d (o—too 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 Cdde and not to place the system in operation until a Certificate of IN Compliance has been issued by this Board of lth. � igned Date Application Approved y Date 0' Application Disapproved y: Date for the following reasons Permit No. t�(�1S G� Date Issued G 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 e (),k Q-�`� p—1 1 Z, ( S at ?,1414V 41 e,6h L4j W o±!, t.() . !t/1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. t �-'' c3 dated Installer C.► c rc��,•e E:, kU 0/�)—? Designer #bedrooms Approved design flow gpd The issuance of this permit shal notbe c strued as a guarantee that the system ll'fun io as designed. Date �l�1,e Inspector No. C U Fee THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwi5po5al i�pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair) Upgrade ( ) Abandon ( ) System located at �.yc j M e',f hh L ,, _Q)A W,. t,t1�°�I _j3fffK1 t'r and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construc'ion m 't be completed within three years of tfhe date of this I47ermi Date APPLved by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...----- . .... ....................OF.-.......-.................--.-........ Appliratioo for Ui4pooal lgorkii Tooitrortion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at* 4:; ....... -........................... .. .. .....4 .. Location-Address or Lot No. W staller Address UType of Building Size Lot............................Sq. feet �--� Dwelling—No. of Bedrooms_______ ___________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .. ........ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ...----•-----------------------•--------•-------••-----•-•---•-•••-•-•---••-•-----•----....--••-•-•-•••-•---•-•-••---••••-••-••....-------------•--••. 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 ( ) aPercolation Test Results Performed by.......................................................................... Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---__-----..-.---------. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••-•••••••--••-•-•--•--•--•--••••-•-••••••-••••••••---•••----•••••••----•-•-•-•-•-•..............•--......................................................... 0 Description of Soil----------------------------------------------------------------•-----------------------------------------------------•----------------------------------•.....-•.-•--- x V -••••---••••-•-•-••-••-••-•••-•••-••-•---•-•••-•••-•••---••---•------••--•---••••••-------•••-•--•••-•......-•-----••••-•-•--•..........................................................--------•----- ..---•-----------------•-----...-------------------------------------------------------••----••••-•------•-•----• ------..-- ... ------------••--•--- --• .......•--•,......•............. U Nature of Rep ' s or Alteratio —A er when applicable....Am- .. �1 ---------.. , - ........................................................... -------------•--------------------------------......----•------.----- . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITiU, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued b the bo r of health. Signed.•. . -- ................. ..................... -- --•-•--•--•--••••--- . .........'. Date Application Approved By................... ------•--•• -------- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•------•-•-•------••-•••••....... .....••---••••---...----•---•---••-•-•-•--•....----•-•-•----------•------------•--- ••------ ••------•--•-••------•-----•-•-•••-••---------••-•---....-•--- 1� Date Permit No....... .21......S -•-•----------------- Issued....................................................... Date _ 1" 1► F:ns.......2:t:-......... r...f" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F................................_..........---------------................_------•-----•. Appliration for Disposal Works T. nstrurtion Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at 1. Location-Address r or Lot No. .e....._..... ............. " a rstner �� !:- Adds � . .......: . :: � . aller Address d Type f Building Size Lot............................Sq. feet U Dwelling —No. of Bedrooms__.-_- Expansion Attic Garbage Grinder 111 Other—Type of Building . :� ' ......... No. of persons............................ Showers ( ) — Cafeteria ( ) QI 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ •... •------------------------ -...... -........... --.--------------------- •...... •...... •-•----.............. ----- •-------------------------------------- --••'- ODescription of Soil......................................................................................................................................................................... x U •-•------------------------- •------------------------------------------------------------ ----------------- •------------- ---------------------------------------- ------------------------------------- UW __________________________________________________________________________________________________________________ ___________ ____ _ ....................... .......................... Nature of Rep s or Alterati s—A wer when applicable =� ..... ... f�.2� ----•--•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLi� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the board of health. Signed•:;-� �. --- .......................... .. --.....-'-'; .._...... Date Application Approved By-••-------'••---C V SJ---- I---'e'Ll"L ,;r ....................... ...---- v� N Date P Application Disapproved for the following reasons--------------------------------------'--...............................---..................................... ...................'•----...--••---••------•---•-...-----------------'---...----•-------•-----------.......--------'------------•--'-------------------------------------....---------------------'-'--- _ Date c PermitNo....... .f....... /`'_...................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................% ......OF............ sr'�a .w...��-?2................................. Trrtifiratr of Toutpliattrr THIS_IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired) by.....•......(_` -' ........... .,......314 .................................................................................................... > 5 auer at...................1 --t (u- �' ... - �P., `?!.....-----------•----------------•-. has been installed in accordance with the provisions of 'I'Ir IF, 5 of The State Sanitary Code as described in the c^ application for Disposal Works Construction Permit No---- --------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ... CO UE® AS`A rG UARANT THAT THE SYSTEM pl F PCT1 SFACTORY. DATE............. / Inspector :�•. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4�...........OF......., k.��..................................... No.?...................... FEE2..f .... Disposal. Vorkv Tonstrtutott rrutit Permission is hereby granted............. �' ..-----. ----•----------------------•----•------•--.......-•---------.................--- to Construct ( ) or Repair ) an Individual Sewage isposal—System at No.-'---"'f. ..... r -"'-'-....? �� ...j Street clel as shown on the application for Disposal Works Construction Permit Noe121--_Y ... Dated.......................................... e r lvT Board of Health DATE--------'••-f- - 1--•--•---•----------------------'--.. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS a r f s� No._9.L='2:.?4!5' FEE......cb ......... THE COMMONWEALTH OF MASSACHUSETTS _ BOAR® OF HEALTH .................. ........................OF........................................------------..-..------------.-........-..------- Appliration for 11ispntial Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: i S ........................... .._.. - Location-Address or Lot No. •--••--•-----•.............................................•---•---•----........._................ ......-----•---....•--•-•-...----..............--•--...---........._............................-- • Owner ••---••-----•-••••---•••-•----••Address a .--•-••-•G Installer Address dType of Building Size Lot___________ ...............Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria 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------------------------------•-------- aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------•............... 0 Description of Soil........................................................................................................................................................................ -- - x -----•---•- --�----- - - ................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------•------------------------------•----•---•-------•--•--•--••--•--•------•--•••--------•-----••......-----•--•-••-•--•••----•-•----------------•----•--••--••••--•--....----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT!- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board,of health. Si ed••-- '�J�•-•. ................. ..---•-••••••- D to Application Approved BY •--•--•-•--- '-/ r_._.. ,/�% ......................... - ----- Date Application Disapproved for the following reasons________________________________________________________________________________________________ ______________ s' -----------------------•---...----....---....-__.....---------------------•------•----...._..-------........---------••-••---------••----------•-------------•---•----------..__._...•------••--••------- D,ate PermitNo......................................................... Issued....................................................... Date le F>ms........ Y::" ........ THE COMMONWEALTH OF MASSACHUSETTS y„ . BOAR® OF HEALTH ...•........... .... ....................O F.........................................------------------.._............................ AVVlirFatiou for Disposal Works Cfnnstrnriiun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: y Location-Address or Lot No. ---•...................................•---•--..--................................................ ..........-..............................................................................._.--•- a Owner Address ---- ................................................... .................................................................................................. Installer Address PQ d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------ ---------------------------------------- ---------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow.__...................._....................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1---------------minutes per inch Depth of Test Pit.................... Depth to ground water.........._-_-_----____. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ------•-----------------------------------------------------------------------------------------------------------------------------------------------•------ O Description of Soil......... 7._ / W g��------.. .. .II ....Ss ?'•e t .., U Nature of Repairs or Alterations—Answer when applicable._.__........................................................................................... Agreement: . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. � D e Application Approved By--------- �,'. J��J -�'--�j��-�- A---------- " O- Date Application Disapproved for the following reasons:................................................................................................................ -----....-•--------------•-•----•--------•--•--------------..................------------..........------I-•••••••----•-------•----•--------------------•••---•••-•---•••-•--•-••------------------------ Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF.......... �..`.:::"............................................................... Tntifiratr of TompliFanrr THIS IS CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------- s..---------------......------------. . ------------....--------...........------------------........-----------.......------.....------------ ` ,,,✓ Installer at...... d - - ------........ -a.......-=�-��'-�-� --------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----- 2-- ........ da.ted................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISF CT DATE....................................................6. --- Inspector ��� < MY� THE COMMONWEALTH OF MASSACHUSETTS r - BOARD OF HEALTH w ti ...OF........_... .^.... No.A.Z-:e2 46 FEE................... Disposal Works Tonstrnrtion Vprrmit M Y g _....._._Permission is hereby rante ...t �.... to Construct .-°r Re lair Kan Individual Sewage Dispos Syst ��- ff _..._ �c at No..---.. . ,R.... ---et ----- ; Street as shown on the application for Disposal Works Construction Permit No.._...ry...............,, Dated.............................4...._......_. /1`7 ........:�-.... .✓:/...-.,%.!!' ...................................................... DATE DATE................................ ,. ..�_ _....... 0" 'Board of Health - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - ._ram _.. .... TOWN C BAItN3'rABLE �..'rY LOCA. JN ,, f Q _SEWAGE # OQ V`ItLAGL�_ 4SSESSOR'S. MAP fa LOT INSULLER'S NAME &t PHONE NO. 7i, Jr SEPTIC TANK CAPACITY LEACHING ACILITY:(typie) (size) NO. OF BEDROQMS PRIVATE WBL OR PUBLIC WATER _ BUILDER OR OWNAOZ ER nAT pElt'-T ISSUED: !? 4 9 DATE COLIPLIA'NCE ISSUED VARIANCE GRANTED: Yes a AS e � Otte � 4 r� �> :.. `� 1 ,� "�Ii' 362-4541 926 main street rt 6A ' yarmouthport mass. 02675 down cope engineering civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court RichardR.Fairbank P.E. surveys December 31, 1986 site planning Nancy Leitner, Health Agent sewage system Barnstable Health Department designs Barnstable Town Hall 367 Main Street Hyannis, MA 02601 inspections Reference: Old Village Store - Route 149, West Barnstable, MA permits Dear Nancy: Septic plans were supplied to us for the Old Village Restaurant and Pizza (behind the Old Village Store) by the Barnstable Health Department. According to these plans, the leaching facility consists of two 1000 gal. leach pits. Assuming two feet of stone around each, the leaching capacity of the system is 1099 gal./day. The maximum seating capacity of the restaurant, as recorded at the health department, is 25, which would give a 875 gal./day flow rate. The store was assigned a flow rate of 200 gal./day by the Health Department, so the ccxnbined flow rates of the restaurant and the store is 1075 gal./day. Therefore, the existing leaching facility for the restaurant is capable of handling the additional flow fran the store. Maintaining proper pitch, the pipe fran the sink in the store should be run to the grease trap, in order to connect into the sytem. Yours truly, Arne H. Ojala, R.L.S., P.E. LW/1mW cc: Tan Stoner Old Village Store Route 149 West Barnstable, MA 02668 f �FTHE rO� TOWN OF BARNSTABLE 00, y OFFICE OF i BAHH9TABLE =MASS. BOARD OF HEALTH y p� 1639.0 MAR367 MAIN STREET A� p`\ HYANNIS, MASS. 02601 June 24, '1982 Mr. John Klimm Ch4i.rman Board of Selectmen Town of Barnstable Dear Mr. Klimm: Mr. William Mitchell , of the Cape Cod Model Railroad, claims that The Village Store, Route 149 , West Barnstable, has installed a septic system on property leased to the Model Railroad. This is Lombard Farm property owned by the Town. Title 5 , of the State Environmental Code, requires that systems be located no closer than ten feet to a property line. We have requested that the Engineering Department, of the D.P.W. , survey the property lines to ascertain if the complaint is valid. In the meantime, we are withholding a Food Service Permit for The Village Store until the situation is resolved. Mrs. Jessie Mazzur informed our secretary that on the Lombard Farm property, there are no property lines. If there are property lines involved, the Selectmen could possibly grant an easement to allow the system. The Board of Health would then have to grant a variance from Title 5, of the State Environmental Code. We do not feel that this system as presently installed will create any environmental problems nor affect the Cape Cod Railroad Club in any manner. Very truly yours, jpAh M.Te' Y 15Arector of Pu is Health JMK/mm a THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I MFU(�J DATA \~ CONCRETE, FORMS. INC.: r � 4'{VIATTAPOISETT SEPTIC TANKS PLANT 367 WHiTE'S PATH SO: YARMOUTH, MA55 a .. x = Phone: 7te 8 9549, P. O. Box 517 � � �e. Phone Artier.No. k Name f€Y: IV - t -.Address c e o a eaAeg pa RCC+' DSE PiUA y ` r: A M 0 QUAM- DEgCRIPfiOM PRICE 1. 00 ,a CN Al ,w " f ' r I�L,r TOTAL OIn 1pll k _ d noims and return gN r.. 5 _ 3 1692 ec'd y .H.M:'MESERVE CO.. HYANNIS.,mASS-02601 cl [ - - -- - - - -- - - - - -- - - - -- - - 3 cl � \ F�ECTMEN9 140 _Q_ ' , 1* 0 =A� CAPE COO, MASSACHUSETTS PLEASE REPLY TO: 28 Hamblin's Hayway Marstons Mills, MA 02648 July 169 1982 Selectman Flynn Barnstable Town Hall 367 Main Street Hyannis, MA 02601 Dear Sir: We feel that it is time that we approach you on the subject of our lease and the problem of the septic system of.the "Tea Room" of the Village Store. I think it is only fitting to first give you a little history on our club. The Cape Cod Model Railroad Club was started back in 1968 by a group of model railroad enthusiasts from all over Barnstable county. In 1970 the club purchased a baggage car from the New Haven Railroad for $150.--- The car had been used as a freight office and storage area by the N. H. Railroad in Hyannis. The club purchased it and had it moved to its present location in West Barnstable at which time the club secured a lease from the town. At this time the club consisted of approximately twenty members, each paying $12 a year in dues.. With this-money, the club proceeded to -restore the car both inside and out over the course of the next two years. In approximately 1972 construction of an HO guage railroad was started, and, even today, the club is still building and refining this layout. In 1978 the club was incorporated as a non-profit organization in the state of Massachusetts, and we are recognized as such by the state and federal government. The membership is now approximately thirty people of both sexes and range in age from twelve to seventy. From all paris of the Cape, of this thirteen membe residents of the town of Barnstable. We meet t ork and run trains at the club on Wednesday and Friday nights at the d visitors are always welcome. The club exists to further the bby by ai people who are becoming interested in the hobby by offering a p e advice and counsel are available. -C���L�- CAPE COD CENTRAL IA CAPE COD. MASSACHUSETTS PLEASE REPLY TO: Selectman Flynn July 16, 1982 In 1981 we purchased a Delaware & Hudson caboose.—We are currently _ restoririg. the caboose and .are •now trying�to,solicit new members to start ~ an N guage layout in-it. �nawtixre +=r•trri��.*:•n.--+=- ,.. -Every'November we open our club on a Sunday to ge the neral public for our annual "open house" at which time our members operate our layout from 1 P.M. to 5.•p:m. We ask a donation of $1 per person with a limit of $2 for a family no matter how many people in the family. The money we raise. here, along with our dues, goes to pay our rent,electric and gas bills, to bus materials, to construct and maintain our layouts, and to maintain the actual physical property of our club. I The current dues for a fall membership are $24 and a junior membership fee is $2 and an associate membership is $5. ."-We usually raise about $400 during our open house. As the club grows we hope to add an 0 guage layout, a library and an open area to hold meetings. The need to have a working relationship with bth your board and the community becomes more important as we grow. --I As this growth happens, we would need more room. Perhaps the lot to the west for another car to sit on,or,with even better growth, the lot to our south to construct a building in which we, could work on larger guages and have a good workshop and an area to hold meetings and show railroad films. As I stated earlier, we have been a tenant since 1970. As you know. An 1975 Judge Knight declared the leases invalid. When we were presented with I' .the proposed lease, it contained a clause which stipulated we hold a $25,000 insurance policy. The premium for this was a little over $100. At this �- point we had approximately twenty members paying $12 a year. As you can see, this constituted a financial hardship to -the club, .so we approached the town council, -a Mr. 'Bodureau, about this problem. The town council said - he would recommend that the clause be waived and said,he would approach the I selec on our behalf. I am sure one thing or the other had come along to dis his attention away from this, and no lease has ever been secured. Since 197 a club has been paying $48 a quarter or $192 a year. This is 1 the fee s ted.in the .1975 proposed lease. Over-the years when our easurer w t to the town hall, he spoke to Mrs. Measure, with whom he paid the , a t getting a lease and was told she would approach the selectmen. y -C CLC� t f CAPE COD CENTRAL K 140dal liaab V 10" A CAPE COO, MASSACHUSETTS PLEASE REPLY TO: Selectman.Flynn t July 16, 1982 We definitely have let_this- drag on way-too-long and_should have more actively pursued this .ourselves. ^ _ When we found out about -the_-Lombard Trust Advisory .Commi'ttee.-we.went-.to_ y their last meeting Ito explain our-problem, as-you are aware. We were well received, and they passed three motions in our behalf. .The first was to ask town council to prepare a new lease for us. The second was to ask that when the lease is prepared, the. clause about the $25,00 be deleted or drastically reduced. This was done because we only occupy land and are not near any structure owned by the town or the trust. We do hold insurance S)r fire in the combined amount of .59500 to cover the cost of removing the debris should the cars burn. We also hold liability insurance in the amount of $100,000 to cover us should someone get hurt while at the car. We would like to invite your board to visit the club to see our operation and this might also influence you on the request we made to extend the proposed lease for a term of twenty years because it is not very easy to find a home for our club. cars. ~ We've been a tenant for twelve years,and the location is centralized for our members. We now would like to give you our explanation of the problems with the store. We received a notice that Mrs. Rogers was seeking permission to open a "Tea*, Shop" and to this we had no objections It was not until after-the new septic system was installed that we disco d that -it was apparently installed over the 'lot line and on-the lot t rent. We held a meeting, and it was decided to advise the town of this v o ation. Apparently there was never a proposed layout done by a professio engineer as required by the State code. This is done to insure t the s em is of adequate size and located properly on the property with the ct 'stances as required by the code. CAPE COD CENTRAL d del -� CAPE COD,";MAS"SACHUSETTS _ ` - PLEASE REPLY TO: ' Selectman Flynn ... A?. -Page=4 m, 14 --Page-4 July 169 1982 ` It has now come to our attention .that back -in 1972 Mrs. Rogers had a cesspool""—" _ installed in the same•general-area-to add bathroom and sink facilities-to` the store. This system was again installed on the wrong lot .and since the -,.-,,new system is.for a-new...use;-,it' should conform to the current .laws. -- • • - ��''R1dMeWYM+W'f n�wn:++y*iM The permit -for the system was_-given based on a hand drawn plan done,we believe by the contractor, .showing the system to be located behind the store on the other side. When the contractor came to install the system, he was concerned about being able'.to get his equipment under the electric wires, so it was installed where it now sits. When Mrs. Rogers found out we had registered a complaint, she approached us and asked that we allow her to open and work on having the problem resolved. We did not believe we had the right to"allow the use of the system and felt''` the town was the only one to make the decision. So, we advised her of this and told her that she should have the system moved as it would be the quickest way to open .since going through appeals takes time. We -understand that you have now given her permission to open. We are happy to see her'to be able to open, but would like to know what the conditions were to waive the requirements of the state sanitary code. We have prepared a plan (enclosed) in which we will give up a portion of • ' the lot which we rent from the town. As you can see, we are willing to give up approximately 25' which will put the system on her side of the lot lines and a variance be granted to waive the distance from the septic tank and leaching pits. All we ask.is that we pick up the same 25' on the other end and widen the end where the point was on the present lot we rent. This would allow our members to .park on our lot and not out in the unoccupied lot listed to the town. _ U%o tely, as you know, the""`Board of Health has told us that we are in violat the State Health Code. .If we are to comply with his mandate, we will n this area of land to install our septic system. Thus, we would not be abl o offer the land swap as earlier stated. CAPE COD CENTRAL del Iq-alb '0 CA CAPE COO, MA:SSACHUSETTS PLEASE REPLY TO: Selectman Flynn P age July 16, 1982 In the section of the code quoted; in~the Board of-Health's.-letter, there is— .a direct reference-to"the term "structure". >xWe _do.:not consider our cars -�$ -f.h � structures since they are on wheels and are not permanently affixed to the ..,property. -Also, the :lot we"rent .from the trust ,does not have.,any water . ..it, which would be necessary if we.are'to'comply to the health officer's letter, as we discussed in our phone conversation on the evening of July 13.` -I do hope you are right that-there 1s.a solution agreeable to all parties involved. If it is necessary-to hold a joint meeting'of all parties, an evening meeting would be appreciated since many members of our board work during the day. -If this is not possible, some retired members of our club could meet with you. "I do feel-that holding the"meeting on the property in question would give '- all parties a chance to see what has been done and then discuss what could . be done. We have also suffered some vandelism since this has started. It seems someone tore the steps off our platform which we use to.enter and exit from our cars. We would appreciate az3y help that your board can give to our club. Your attention;to 'these matters would- be greatly appreciated. Sincerely, CAPE COD MODEL RAILROAD CLUB, INC. Vito C. Marotta mlp Enclosure- CAPE COD CENTRAL 3 i 5D� 1 {{ r7H� Y�'L I 7 •,, r G �r 3 T flc� s ` i 1 +j 1 f I 1 :i ENNETT ENVIRONMENTAL ASSOCIATES, INC. LICENSED SITE PROFESSIONALS,ENVIRONMENTAL SCIENTISTS,GEOLOGISTS,ENGINEERS 1573 Main Street,P.O.Box 1743 (508)896-1706 Brewster,MA 02631 fax(508)896-5109 LETTER OF TRANSMITTAL TO: DATE: JOB NUMBER: MassDEP/DWP 7/6/2015 BEA15-10761 1 Winter Street 5th Floor Boston,MA 02108 REGARDING: Attention:Tio Yano Old Village Store PWS ID#4020016 SHIPPING METHOD: TNC Violation-Notice of Noncompliance NON-BO-15-5D007 Regular Mail ❑ Pick Up ❑ Priority Mail ❑ Hand Deliver ❑ Express Mail Other ❑ Certified Mail Green Card/RR COPIES DATE DESCRIPTION 1 7/6/2015 Transient Non-Community Violation Response Form 1 4/14/2015 Letter of Transmittal(cover for original submittal of operator forms)with DEP stamped green card 1 4/14/2015 Operator Compliance Notices with COD-1 [Old Village Store: 1 Primary,3 Secondary] 1 7/6/2015 2014 Public Water Supply Annual Statistical Report with eDEP Summary/Receipt(filed 7/2/15) For review and comment: ❑ For approval: ❑ As requested: For your use: ❑ REMARKS: Please find enclosed the TNC Violation Response Form,the Operator Compliance Notices with COD-1,and a copy of the eDEP filed 2014 Annual Statistical Report,with eDEP Summary/Receipt,for the Old Village Store in Barnstable,MA. Please contact me directly if you have any questions or need additional information. Thank you. cc.Barnstable Health Division(regular mail) FROM: TME/lr If enclosures are not as noted,kindly notify us at once v, Massachusetts Depcartanent ofEnvironniental Protection Bureau of-Resource Protection-Drinking>W atei Prograin TRANSIENT NON-COAMU ITY VIOLATION RESPONSE FORM(><'NCVRF) M.G.L.c,21-A see.16,310 CMR 5.00 Attention: MassDEP/Drinking Water Program Generallnformation DATE: 6/8/2015 PWS NAME: OLD VILLAGE STORE RE: NON - BO- 15 - 5D007 2455 MEETINGHOUSE WAY PWSID: 4020016 ROUTE 149 CLASS: NC WEST BARNSTABLE MA 02668 CITYffO.WN: WEST BARNSTABLE m Location Where Noncompliance Occurred: OLD VILLAGE STORE Description of Corrective Action Taken under N.G.L.c. III sec. 169-160 and 310 CZAR 22 r 0 My public wafer system has taken the following actions to correct the violations listed in the above referenced NON.(please check all that apply) IJescrl flan®f t/iol an:-='= =c=1} !?u ❑ My system DID submit the 2014AnnualStatistical report to MassDEP by the required deadline Within 30 gays of receiving the above referenced NON I am submitting this form and a copy of the eDEP Failure to submit the 2014 Annual receipt that proves that my system submitted this report by the deadline. Statistical report to the rA My system DID NOT submit the 2014 Annual Statistical report. Within 30 days of receiving the above Department by March 16,2015,as required by 310 CMR 22.15; referenced NON I am submitting this form and(select one): I will complete,sign and submit an electronic Annual Statistical Report via eDEP ❑ a signed Hardship Application Form.Within 30 days of receiving the paper copy of the Annual Statistical Report I will complete,sign and submit it. My system HAS the required Certified Operator and DID report to the MassDEP this change in operator status as required.Within 30 days of receiving the above referenced NON I am submitting proof that my system has the required Certified Operator and had properly notified the Department.See attached photocopies of the license(s),contract(s)and other supporting documentation that proves my system submitted this information by the deadline.I have completed the Certified Operator Status Table below. My system HAS the required Certified Operator but DID NOT report to the MassDEP any changes in operator status as required. lNithin 30 dan of receiving thgilbovg referenced NON I am submitting proof that my Operating a public water system system has the required Certified Operator.See attached photocopies of the licenses)and contract(s).I have withouta certified operator-as completed the Certified Operator Status Table below. required by 310 CMR 22.11 B(1); ❑ My system DID NOT have the required Certified Operator.Within 30 days of receiving the above referenced f`IM my system has(select one): ❑ Obtained the services of a Certified Operator of the required certification grade and completed and submitted a Public Water System Certified Operator Compliance Notice form to the Board for verification and signature.See attached copy of the completed form.I have completed the Certified Operator Status Table below. ❑ Applied to the Board for a temporary six-month emergency certification(copy attached). I umferstand that w fhln six monfhs of recalptof the above referenced MOAT mtr system must be_olrerated by personnel that fulfill the certified operator requirement as stated In$10 CMR 22 9913(1)and R). ❑ I vdll report all future changes in my system's Certified Operator status to DEP within 24 hours of such changes.I will also provide MassDEP with written documentation of the change within 30 days. [] My system DID submit a Cross Connection Control Program(CCCP)Plan to DEP by the required deadline. Failure to submit a cross- Within 30 days of receiving the above referenced NON I and submiting this form,two(2)copies of connection control program plan to the completed CCCP Plan Questionaire for TNC Public Water Systems and documentation that proves that the Department,as required.by 310 CMR 22.22(3); my system submitted this report by the deadline. ❑ My system DID NOT submit a Cross Connection Control Program(CCCP)Plan. Dithin 30 days of receiving the above referenced NON 1 am submitting this form and two(2)copies of the completed CCCP Plan. My system was unable to meet some or all of the corrective action requirements identified in the above referenced NON.An explanation is attached.I understand that I may be subject to further enforcement action. :Ge_itifeil_Operator=Staffs_Table'; Name/Address/Phone# Licence# Grade Approximate dates of planned routine monthly site inspection Certified operator 493 Air]ire Rd. Todd M. Everson 22222 1T 3/25/15,4/14/15, 5/14/15,6/16/15, 7/14/1,5,8/1 /15 Owner,Owner Representative,Water Commissioner or other Responsible Party: Print Name: Todd U., Ev.r-on Tiffe; Certified Operator Phone#:(508)896-1706 L-L Signatu - Date: 7/6/15 Email address:teversor>Lbennett-lea.COM ce:Mas DEPI DWP egional Office,Local Board of Health Please complete and return this response form to:MassDEPIDWP,I Winter Street,5th Floor,Boston,MA 02108,Attention:Tio Yano BEN E TT ENWRON E TAL A SOC I T„ ' 9 INC. LICENSED SITE PROFESSIONALS,ENVIRONMENTAL SCIENTISTS,GEOLOGISTS,ENGINEERS 1573 Main Street,P.O.Bog 1743 (508)896-1706 Brewster,MA 02631 fax(508)896-5109 LETTER OF TRANSMITTAL TO: DATE: JOB NUMBER: MA Dept.of Environmental Protection 4/14/2015 BEA14-10761 Southeast Regional Office BRP-Drinking Watex Program Attn:Charles Shurtleff REGARDING: 20 Riverside Drive Public Water System Certified Operator Compliance Notice Lakeville,MA 02347 ® Typical Duties of PWSO SHIPPING METHOD: Old Village Store,PWS ID#4020016 Regular Mail ❑ Pick Up ❑ Priority Mail ❑ Hand Deliver ❑ Express Mail 0 Other ❑ Certified Mail 0 Green Card/RR 0 COPIES DATE DESCRIPTION 1 4/14/2015 Operator Compliance Notices with COD-1 [Old Village Store: 1 Primary,3 Secondary] For review and comment: ❑ For approval: 0 As requested: ❑ For your use: 0 REMARKS: Please find attached the Operator Compliance Notices and COD-1 Form for the above referenced Public Water System. Please feel free to contact me directly if you have any questions or need additional information. Thank you. FROM: TAW& If enclosures are not as noted,Idndly notify us at once 1 i 0 Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ! ❑Agent 0 Print your name and address on the reverse "" ti. ,i ❑Addressee + so that we can return the card to you. 7 ;' : ;B Received by(Printdd Pjame). I;;C.Date of Delivery I ® Attach this card to the back of the mailpiece; . - or on the front if space permits. E. D. Is delivery address,difl`e�entfroln itemtl? ❑Yes I 1. Article Addressed to: If YES:enter deliv`erytaddressl'•below:� ❑No I I Chas Shesrt9ef`r MA DEP Bureau of Resource Protection � G Drinking Water Program 20 Riverside Drive 3. Service Type Lakeville,MA 02347 ❑Certified Mall° ®Priority Mall Express' ❑Registered I].Return Receipt for Merchandise ❑'Insured Mail ❑Collect on Delivery I 4. Restricted Delivery?(Extra Fee) ❑Yes I a A 7014 0150 0001 0292 4959 � (T— _ PS Form 3811,July 2013 Domestic Return Receipt a ero 0 Er ni �, r ❑-' . ru Postage $ 'Fi Certified Fee , ReturnReceipt Fee ,t Postma i::;: Q (Endorsement Required) Here Restricted Delivery Fee :?i -'' E3 (Endorsement Required) » C3 Total Charles Shurtleff zr Sanf7 MA DEP Bureau of Resource Protection 'q Drinking Water Program �7 E3 Street [L or PO 20 Riverside Drive cry s Lakeville,MA 02347 l a d C0CM Massachusetts Department of Environmental Protection Ll Bureau of Resource Protection — Drinking Water Program West Barnstable City1rown PublicWater SystemOld Village Store PWS Name 4020016 Operator Compliance Notice PWS ID A. Certification - Important:When Todd M. Everson filling out forms M �® Pri t pe tor's�.atn on the computer, <> 1 use only the tab c�-' — - � key to move your Operator's S19nature Date P cursor-do not Dan Devlin, Owner use the return Print System Owner's Name and Title key. wo M-h Sysfem Owners.Sign/lb a Date emm S. System Information PWS must Old Village Store 4020016 complete the Public Water System Name PWS ID COCM and the 2455 Meetinghouse Road appropriate Street Address "COD"Duty Form for the system. West Barnstable MA 02668 See Instructions. City/Town State Zip Code 603-320-8099 djdevlinl @gmail.com Phone E-mail Address System Type: ❑ Community ❑Non-transient Non-community ®Transient Non-community Population in Winter 100 Population in Summer 250 Distribution Class: ❑ I ❑ II ❑ III ❑ IV ❑VND ®VSS Treatment: ❑Yes ® No Treatment Class: ❑ I ❑ 11 ❑ III ❑ IV If yes, please specify treatment types and purpose of treatment and chemicals used: C. Operator Information. Todd M. Everson Print Name 1573 Main Street, P.O. Box 1743 Street Address Brewster MA 02631 CityfTown State Zip Code 508-896-1706 teverson@bennett-ea.com Phone E-mail Address 20481122222/20659 VSS/1T12T(OIT) ® OIT or ® Full License# Grade cocm.doc—rev.11-09 PWS Certified Operator Compliance Notice-Page 1 of 3 4 c®cm Massachusetts Department of Environmental Protection Bureau of Resource Protection — Drinking Water Program West Barnstable Public Water to e l le Ci Oldd Village illage Store PWS Name Operator Compliance Notice PWSID16 D. Operator Information (cont'd) Will assume responsibility as the[® primary/❑ secondary] operator for 1 hours per day 1 days per weeklmonth and will be able to respond to an emergency within 60 minutes. Please list the names and PWS ID#'s of all other systems which you currently operate. (Attach list if necessary.) Refer to Attached Public Water System Name PWS ID# Public Water System Name PWS ID# Public Water System Name PWS ID# Public Water System Name PWS ID# Please describe any sanctions the Board has levied on your operator's license in the past 3 years: E. Typical Duties and Responsibilities Please choose the"Typical Duties and Responsibilities"(COD)sheet that applies to your system. System owner and operator are to jointly complete the sheet that best describes'the system. That sheet becomes part of this notice.The notice is not complete without this duties sheet attached. Duties sheets are provided separately at httr)://www.mass.gov/dep/water/approvals/dwsforms.htm#opcert. Check appropriate form: ® CODA ❑ COD-2 ❑ COD-3 ❑ COD-4 ❑COD-5 ❑ COD-6 ❑ COD-7 ❑ COD-8 ❑ COD-9 F. Other Duties List other duties to be operator's responsibility: Liason to local authorities. List other duties to be the systern's responsibility: cocm.doc—rev.11-09 PWS Certified Operator Compliance Notice-Page 2 of 3 COCIVI Massachusetts Department of Environmental Protection Bureau of Resource Protection — Drinking Water Program West Barnstable City/Town u bl isWater SystemCertified Old Village Store �+ PWS Name ®pastor ® pliancy ®tire PWS016 ID G. For NlassDEP Use Only MassDEP Office Print Name Title Signature Date ❑ Approved ❑ Denied Comments: Original gets mailed back to PWS; copy to certified operator; copy to MassDEP-Boston; and copy for MassDEP-Region. cocm.doc—rev. 11-09 PWS Certified Operator Compliance Notice-Page 3 of 3 PROJECT EXPERIENCE PUBLIC WATER SUPPLY BENNETT ENVIRONMENTAL ASSOCIATES,INC.-PUBLIC WATER SUPPLY FACILITIES (Todd M.Everson,VSS#20481 Full;1T#22222 Full;2T#20659 OIT) Project Date Public Water System. PWS ID# B001-3026 Current Wicked Oyster-Wellfleet 4318052 B004-3960 Current Adventure Bound Camping,Cape Cod-Truro 4300017 B005-4120 Current Eastham Elementary School-Eastham 4086002 BEA09-10088 Current Hole in One/Fairway Pizzeria-Easthan 4086034 BEA09-10102 Current Harborside Village Condo's-Wellfleet 4318040 BEA10-10157 Current First Congregational Church of Plympton 4240007 BEA11-10305 Current Inn at the Oaks-Eastham 4086090 BEA11-10342 Current Adventure Bound Camping,Cape Cod @ Horton's-Truro 4300001 BEA11-10353 Current Pleasant Water,Inc.-Wellfleet 4318091 BEA12-10411 Current Blackfish Variety-Wellfleet 431809,6 BEA12-10433 Current Lobster Shanty-Eastham 4086035 BEA12-10434 Current Truro Motor Inn-Truro 4300026 BEA12-10451 Current Seatoller-Eastham 4086045 BEA12-10484A Current Wellfleet Apartments-Wellfleet 4318107 BEA14-10647 Current Bocce Italian Grill 4318050 BEA14-10651 Current YMCA Camp Lyndon 4261004 BEA14-10680 Current Barnstable.Community Building 4020024 Page 1 of 1 C0CM LAMassachusetts Department of Environmental Protection Bureau of Resource Protection — Drinking Water Program West Barnstable 1� A1% cityFrown Public Water alystemkAftified Old Village Store PWS Name Uperator Compliance Notice 402 PWS 0016 ID A. Certification Important:When Samantha rarrenkopf filling out forms Print Operators Name,, on the computer, 7D use only the tab N key to move your 01pe—rato�s SignatureDate cursor-do not Dan Devlin, Owner use the return Print System Owner's Name and Title key. 5/ Sysfe—m Givnel—k9l 'ature* Date' B. System Information Pws must Old Village Store 4020016 complete the Public Water System Name PWS ID COCM and the 2455 Meetinghouse Road appropriate Street Address "COD'Duty Form for the system. West Barnstable MA 02668 See Instructions. City[rown State Zip Code 603-320-8099 djdevlinl@gmaii.com Phone E-mail Address System Type: F1 Community F-1 Non-transient Non-community ®Transient Non-community Population in Winter 100 — Population in Summer 250 Distribution Class: F1 ii El III El IV ❑VND VSS Treatment: 0 Yes No Treatment Class: El I El 11 El III E] IV If yes, please specify treatment types and purpose of treatment and chemicals used: C. Operator Information Samantha Farrenkopf Print Name 1573 Main Street, P.O. Box 1743 Street Address Brewster MA 02631 CityTrown State Zip Code 508-896-1706 sfarrenkopf@bennett-ea.com Phone E-mail Address 22338 VSS El OIT or 0 Full License# Grade cocm.doc—rev.11-09 PWS Certified Operator Compliance Notice-Page 1 of 3 C®CM Massachusetts Department of Environmental Protection Bureau of Resource Protection — Drinking Water Program West Barnstable CityfTown Public ter System Colertified Old Village Store PWS Name 4020016 Operator Coomphance Notice PWS ID D. Operator Information (cont'd) Will assume responsibility as the[❑ primary/® secondary] operator for 1 hours per day 1 days per weeldmV and will be able to respond to an emergency within 60 minutes. Please-list the names and PWS ID Vs of all other systems which you currently operate. (Attach list if necessary.) Refer to Attached Public Water System Name PWS ID# Public Water System Name- PWS ID# Public Water System Name PWS ID# Public Water System Name PWS ID# Please describe any sanctions the Board has levied on your operator's license in the past 3 years: E. Typical Duties and Responsibilities Please choose the"Typical Duties and Responsibilities"(COD)sheet that applies to your system. System owner and operator are to jointly complete the sheet that best describes the system. That sheet becomes part of this notice.The notice is not complete without this duties sheet attached. Duties sheets are provided separately at http://vvww.mass.gov/dep/water/approvals/dwsforms.htm*opcert. Check appropriate form: ® COD-1 ❑COD-2 ❑ COD-3 ❑ COD-4 ❑ COD-5 ❑ COD-6 ❑ COD-7 ❑ COD-8 ❑ COD-9 F. Other Duties List other duties to be operator's responsibility: Liason to local authorities. List other duties to be the system's responsibility: cocm.doc—rev.11-09 PWS Certified Operator Compliance Notice-Page 2 of 3 COCi'� Massachusetts Department of Environmental Protection LA to 'ified Bureau of Resource Protection — Drinking Water Program West Barnstable clyTrown rublic Water System 'erl Old Village Store PWS Name 02016 aerator lac tic PVSID O. For MassDEP Use Only MassDEP Office Print Name Title Signature Date ❑ Approved ❑ Denied Comments: Original gets mailed back to PWS; copy to certified operator; copy to MassDEP-Boston; and copy for MassDEP-Region. cocm.doc—rev.11-09 PWS Certified Operator Compliance Notice-Page 3 of 3 PROJECT EXPERIENCE PUBLIC WATER SUPPLY BENNETT ENVIRONMENTAL ASSOCIATES,INC.-PUBLIC WATER SUPPLY FACILITIES (Samantha garrenkopf,VSS#22338 gull) Project Date Public Water System PWS 1D# BO01-3026 Current Wicked Oyster-Wellfleet 4318052 B004-3960 Current Adventure Bound Camping,Cape Cod-Truro 4300017 B005-4120 Current Eastham Elementary School-Eastham 4086002 BEA09-10088 Current Hole in One/Fairway Pizzeria-Eastham 4086034 BEA09-10102 Current Harborside Village Condo's-Wellfleet 4318040 BEA11-10305 Current Inn at the Oaks-Eastham 4086090 BEA11-10342 Current Adventure Bound Camping, Cape Cod @ Horton's-Truro 4300001 BEA11-10353 Current Pleasant Water,Inc.-Wellfleet 4318091 BEA12-10411 Current Blackfish Variety-Wellfleet 4318096 BEA12710433 Current Lobster Shanty-Eastham 4086035 BEA12-10434 Current Truro Motor Inn-Truro 4300026 BEA12-10451 Current Seatoller-Eastham 4086045 BEA12-10484A Current Wellfleet Apartments-Wellfleet 4318107 BEA14-10647 Current Bocce Italian Grill 4318050 BEA14-10651 Current YMCA Camp Lyndon 4261004 BEA14-10680 Current Barnstable Community Building 4020024 Page 1 of 1 COCIi>i Massachusetts Department of Environmental Protection Bureau of Resource Protection — Drinking Water Program West Barnstable Citylrown rublicCertifiedOld Village Store PWS Name wFerator Compliance Nob ce PWS ID 6 PWS D A. Certification Important:When Joseph Smitl j 1 filling out forms Print Oper#or's Na on the computer, use only the tab -- key to move your erator`s Signature �! Date cursor-do not Dan Devlin, Owner use the return Print System Owner's Name and Title key. Sysem gnace Date /Eff1p1 Y�•r _ B. System Information Pws must Old Village Store 4020016 complete the Public Water System Name PWS ID COCM and the 2455 Meetinghouse Road appropriate Street Address "COD"Duty Form for the system. West Barnstable MA 02668 See Instructions. Citylrown State Zip Code 603-320-8099 djdevlinl@gmail.com Phone E-mail Address System Type: ❑ Community ❑Non-transient Non-community ®Transient Non-community Population in Winter 100 Population in Summer 250 Distribution Class: ❑ I ❑ II ❑ III ❑ IV ❑VND ®VSS Treatment: ❑Yes ® No Treatment Class: ❑ I ❑ 11 ❑ III ❑ IV If yes, please specify treatment types and purpose of treatment and chemicals used: C. Operator Information Joseph Smith Print Name 1573 Main Street, P.O. Box 1743 Street Address Brewster MA 02631 City/Town State Zip Code 508-896-1706 jsmith@bennett-ea.com Phone E-mail Address 22623 VSS ❑ OIT or ® Full License# Grade cocm.doc—rev.11-09 PWS Certified Operator Compliance Notice-Page 1 of 3 cOcm Massachusetts Department of Environmental Protection LA r%Bureau of Resource Protection - Drinking Water Program West Barnstable lip ter a yste rttt'I ie Cild Village Old Village Store PWS Name 4020016 Upwator Uompflance Notice PWS ID D. Operator Information (cont'd) Will assume responsibility as the [ ❑ primary/ ® secondary] operator for 1 hours per day 1 days per week/montfl' and will be able to respond to an emergency within 60 minutes. Please list the names and PWS ID#'s of all other systems which you currently operate. (Attach list if necessary.) Refer to Attached Public Water System Name PWS ID# Public Water System Name PWS ID# Public Water System Name PWS ID# Public Water System Name PWS ID# Please describe any sanctions the Board has levied on your operator's license in the past 3 years: E. Typical Duties and Responsibilities Please choose the"Typical Duties and Responsibilities"(COD)sheet that applies to your system. System owner and operator are to jointly complete the sheet that best describes the system. That sheet becomes part of this notice. The notice is not complete without this duties sheet attached. Duties sheets are provided separately at http://Www.mass.gov,der)/water/approvals/dwsforms.htm#oi)cert. Check appropriate form: ® COD-1 ❑COD-2 ❑ COD-3 ❑ COD-4 ❑ COD-5 ❑ COD-6 ❑COD-7 ❑ COD-8 ❑ COD-9 F. Other Duties List other duties to be operator's responsibility: Liason to local authorities. List other duties to be the system's responsibility: cocm.doc—rev. 11-09 PWS Certified Operator Compliance Notice-Page 2 of 3 COCM Massachusetts Department of Environmental Protection LI I Bureau of Resource Protection — Drinking Water Program West Barnstable cityrrown Public Water Sysiem 'ertified Old Village Store PWS Name 4020016 Operator �� Notice PWS ID Oa For MassDEP Use Only MassDEP Office Print Name Title Signature Date ❑ Approved ❑ Denied Comments: Original gets mailed back to PWS; copy to certified operator; copy to MassDEP-Boston; and copy for MassDEP-Region. cocm.doc—rev.11-09 PWS Certified Operator Compliance Notice-Page 3 of 3 PROJECT EXPERIENCE PUBLIC WATER SUPPLY BENNETT ENVIRONMENTAL ASSOCIATES,INC.-PUBLIC WATER SUPPLY FACILITIES (Joseph Smith,VSS 922623 Full) Project Date Public Water System PWS ID# BO01-3026 Current Wicked Oyster-Wellfleet 4318052 BO04-3960 Current Adventure Bound Camping,Cape Cod-Truro 4300017 BO05-4120 Current Eastham Elementary School-Eastham 4086002 BEA09-10088 Current Hole in One/Fairway Pizzeria-Eastham 4086034 BEA09-10102 Current Harborside Village Condo's-Wellfleet 4318040 BEA10-10157 Current 'First Congregational Church of Plympton 4240007 BEAI I-10305 Current Inn at the Oaks-Eastham 4086090 .BEAll-10342 Current Adventure Bound Camping,Cape Cod @ Horton's-Truro 4300001 BEAII-10353 Current Pleasant Water,Inc.-Wellfleet 4318091 BEA12-10411 Current B'ackfish Variety-Wellfleet 4318096 BEA12-10433 Current Lobster Shanty-Eastham 4086035 BEA12-10434 Current Truro Motor Inn-Truro 4300026 BEA12-10451 Current Seatoller-Eastham . 4086045 BEA12-10484A Current Wellfleet Apartments-Wellfleet 4318107 BEA14-10647 Current Bocce Italian Grill 4318050 BEA14-10651 Current YMCA Camp Lyndon 4261004 BEA14-10680 Current Barnstable Community Building 4020024 Page 1 of 1 COCM Massachusetts Department of Environmental Protection LA Bureau of Resource Protection —Drinking Water Program West Barnstable City/Town i c i Old Village Store PWS Name r t0rVFeulo""ompflance Notice PWS ID 6 PWS D A. Certification Important:When DavidiP. tie jnd filling out forms Print Op' to�'s Na "e' on the computer, , {` use only the tab key to move your Operators ignMuure Date H cursor-do not DanDvitnlOwner use the return key. Print System Owner's Name and Title LV J_✓ System wner's Sign;3ttire—_ — Date ` B. System Information PWS must Old Village Store 4020016 complete the Public Water System Name PWS ID COCM and the 2455 Meetinghouse Road appropriate Street Address "COD"Duty Form for the system. West Barnstable MA 02668 See Instructions. City/Town State Zip Code 603-320-8099 djdeviinl@gmail.com Phone E-mail Address System Type: ❑ Community ❑Non-transient Non-community ®Transient Non-community Population in Winter 100 -Population in Summer 250 Distribution Class: ❑ I ❑ II ❑ III ❑ IV ❑VND ®VSS Treatment: ❑Yes ® No Treatment Class: ❑ 1 ❑ II ❑ III ❑ IV If yes, please specify treatment types and purpose of treatment and chemicals used: C. Operator Information David C. Bennett Print Name 1573 Main Street, P.O. Box 1743 Street Address Brewster MA 02631 City/Town State Zip Code 508-896-1706 dbennett@bennett-ea.com Phone E-mail Address 20486/11638/20656 1 D/VSS/2T(OIT) ® OIT or ® Full License# Grade cocm.doc—rev.11-09 PWS Certified Operator Compliance Notice-Page 1 of 3 LAMassachusetts Department of Environmental Protection COW Bureau of Resource Protection — Drinking Water Program West Barnstable Public ate y to 6 011dd Villlle 'fled CiVin age Store PWS Name er t®r o dance A is Nonce P�?OD16 D. Operator Information (cont'd) Will assume responsibility as the[❑ primary/® secondary] operator for 1 hours per day 1 days per week�mont_la� and will be able to respond to an emergency within 60 minutes. Please list the names and PWS ID#'s of all other systems which you currently operate. (Attach list if necessary.) Refer to Attached Public Water System Name PWS ID# Public Water System Name PWS ID# Public Water System Name PWS ID# Public Water System Name PWS ID# Please describe any sanctions the Board has levied on your operator's license in the past 3 years: E. Typical Duties,and Responsibilities Please choose the"Typical Duties and Responsibilities" (COD)sheet that applies to your system. System owner and operator are to jointly complete the sheet that best describes the system. That sheet becomes part of this notice. The notice is not complete without this duties sheet attached. Duties sheets are provided separately at http://www.mass.gov/dep/water/approvals/dwsforms.htm#opcert. Check appropriate form: ® CODA ❑ COD-2 ❑ COD-3 ❑ COD-4 ❑COD-5 ❑ COD-6 E] COD-7 ❑ COD-8 ❑ COD-9 F. Other Duties List other duties to be operator's responsibility: Liason to local authorities. r List other duties to be the system's responsibility: cocm.doc—rev. 11-09 PWS Certified Operator Compliance Notice-Page 2 of 3 PROJECT EXPERIENCE PUBLIC WATER SUPPLY BENNETT ENVIRONIV NTAL ASSOCIATES,INC.-PUBLIC WATER SUPPLY FACILITIES (David C.Bennett,VSS#11638 Full;1D#20486 Full;2T#20656 OIT) Project Date Public Water System PWS]D# B001-3026 Current Wicked Oyster-Wellfleet 4318052 B004-3960 Current Adventure Bound Camping,Cape Cod-Truro 4300017 B005-4120 Current Eastham Elementary School-Eastham 4086002 BEA09-10088 Current. Fairway Pizzeria/Hole in One-Eastham 4086034 BEA09-10102 Current Harborside Village Condo's-Wellfleet 4318040 BEAT 1-10305 Current Inn at the Oaks-Eastham 4086090 BEA11-10342 Current Adventure Bound Camping Cape Cod @ Horton's-Truro 4300001 BEA11-10353 Current Pleasant Water,Inc.-Wellfleet 4318091 BEAT 1-10411 Current Blackfish Variety-Wellfleet 4318096 BEA12-10433 Current Lobster Shanty-Eastham 4086035 BEA12-10434 Current Truro Motor Inn-Truro 4300026 BEA12-10451 Current Seatoller-Eastham 4086045 BEA12-10484A Current Wellfleet Apartments-Wellfleet 4318107 BEA14-10647 Current Bocce Italian Grill 4318050 BEA14-10651 Current YMCA Camp Lyndon 4261004 BEA14-10680 Current Barnstable Community Building 4020024 Page 1 of 1 Massachusetts Department of Environmental Protection COD-1 Bureau of Resource Protection — drinking water program `typical Duties & Responsibilities of a Certified ®pastor PWS Type: Year-Round Noncommunity Treatment: None Operator Grade Required: VSS Operator Owner Shared Important:When 1. Be responsible for the day-to-day operation and management of the ❑ ® ❑ filling out forms system. on the computer, 2 Ensure the delivery of safe drinking water at all times by complying with use only the tab ❑ ❑ key to move your Massachusetts Drinking Water Regulations. cursor-do not use the return 3. Inspect the system monthly(source, storage, and distribution). ❑ ❑ key. 4. Test, flush, clean, and disinfect the water distribution system and storage ❑ ❑ .. 'rrn tanks when necessary. v\rp 5. Develop, and maintain for accuracy, a site plan showing the water source, ❑ ® ❑ 7 a map of the water distribution system and sample location and all other appropriate appurtenances. 6. Collect/oversee collection of water samples as specified by MassDEP. ® ❑ ❑ 7. Ensure that all samples are delivered to and analyzed by a Massachusetts ® ❑ ❑ certified laboratory. PWs must 8. Report all results to MassDEP within the time frames specified. ® ❑ ❑ complete the COCM and the appropriate 9. Conduct a sanitary survey of the system as specified by MassDEP. ❑ ❑ "COD"Duty Form for the system. 10. Complete and submit to MassDEP the Annual Water Supply Statistical El Elsee Instructions. Report and all other required forms in a timely manner. 11. Notify MassDEP of violations and issue public notices as necessary. ❑ ❑ 12. Review the sample monitoring schedule and locations annually. ® ❑ ❑ 13. Protect the water distribution system and storage facilities from corrosion ❑ ❑ effects. 14. Observe pump motors routinely to detect unusual noises, vibrations, or ❑ ❑ excessive heat. 15. Inspect, adjust, and clean pump seals, packing glands, and any ❑ ❑ mechanical seals when necessary. 16. Be present during water system repairs and maintenance and/or oversee ❑ ❑ the maintenance of the public water system conducted by other individuals such as staff or contractors. 17. Be present within 24 hours of fecal or second Total Coliform positive or ® ❑ ❑ other water system failures. 18. Record quantity of water pumped from source monthly. ❑ ❑ 19. Develop, implement,and keep up to date a cross connection control ❑ ❑ program, a preventive maintenance schedule, an operation and maintenance budget plan, an emergency response plan, a safety program plan, and a source protection program plan. 20. Ensure the accuracy of water meters and other flow measuring devices ❑ ❑ annually or as necessary. 21. Delineate the wellhead protection zone. ❑ ❑ Assigned Duties,Responsibilities coda (Old Village Store)•rev.11109 Typical.Duties&Responsibilities of a Certified Operator. Year-Round Noncommunity PWS-N-VSS•Page 1 of 2 Massachusetts Department of Environmental Protection COD-1 Bureau of Resource Protection —drinking water program `typical Duties & Responsibilities of a Certified Operator PWS Type: Year-Round Noncommunity Treatment: None Operator Grade Required: VSS Operator Owner Shared 22. Identify all potential sources of contamination within the wellhead ❑ ❑ protection zone. 23. Troubleshoot mechanical equipment,water quality/quantity problems, and ❑ ❑ take corrective actions as necessary. 24. Keep abreast of changes in the drinking water regulations. ® ❑ ❑ 25. Attend training programs and workshops for certification renewal as ® ❑ Elneeded. 26. Accompany regulatory agencies during on-site inspections. ❑ ❑ 27. Troubleshoot to locate the causes of water quality complaints and respond ❑ ❑ . to consumer complaints in a timely fashion. 28. Discuss with consumers their concerns of water quality and quantity. ❑ ® ❑ 29. Develop and maintain a complaint log book. ❑ ® ❑ 30. Keep accurate records and maintain a filing system for correspondence. ❑ ❑ 31. Develop, maintain, and keep up to date a public water system standard ❑ ❑ operational and maintenance manual which contains at a minimum: a)the most recent version of 310 CMR 22.00, Drinking Water Regulations; b)the Department's Guidelines and Policies for Public Water Systems; c)the Standard Monitoring Framework;and d)other pertinent correspondence or documents. 32. Report emergencies to MassDEP and board of health (BOH)within ❑ Elspecified time frames. 33. Conduct or ensure the annual Emergency Response Program (ERP) ❑ ® El is completed. 34. Post MassDEP-provided annual Consumer Confidence Report. ❑ ® ❑ Estimated Time:The annual estimated time required to perform all the duties and responsibilities listed above is approximately 12 to 24 hours. Exceptions to the staffing requirements may be allowed by the Department. Contact your regional office for further information. Contract Services: A public water system may contract for the services of a certified operator to perform all or some of the duties listed above with written approval from MassDEP.A contract certified operator should spend approximately one hour per on-site visit to perform the various duties listed above. This time may vary from system to system as will the frequency of visits depending on the specific needs of each system as identified by MassDEP. In some cases, the certified operator can supervise the operation without being present on a daily basis provided the certified operator has a person working with the system on a daily basis under his or her supervision. Assigned Duties,Responsibilities cod1(Old Village Store)•rev.11/09 Typical Duties&Responsibilities of a certified Operator Year-Round Noncommunity PWS-N-VSS•Page 2 of 2 Massachusetts Department of Environmental Protection TransactionVY Here is the file you requested for your records. To retain a copy of this file you must save and/or print. Username: TODDEVERSON Transaction ID: 753915 Document: Public Water System Annual Statistical Report Size of File: 516.37K Status of Transaction: Submitted Date and Time. Created: 7/6/2015:8:39:18 AM Note: This file only includes forms that were part of your transaction as of the date and time indicated above. If you need a more current copy of your transaction, return to eDEP and select to "Download a Copy" from the Current Submittals page. Massachusetts Department of Environmental Protection Bureau of Water Resources(BWR)—Drinking Water Program Public Water Supply Annual Statistical Report Reporting Year 2014 2014 Public Water Supply Verification Please verify the information below and then click the Continue button. PWS ID: 4020016 PWS Name: OLD VILLAGE STORE PWS Street Address Line 1: 2445 MEETINGHOUSE WAY PWS Street Address Line 2: ROUTE 149 City/Town: WEST BARNSTABLE State: MA Zip Code: 02668-0000 Class: TNC Legally Responsible Party Contact Information The Legally Responsible Party is that individual who has the ultimate authority to ensure that your system is in compliance with the federal and state drinking water regulations.This may be the owner of a private facility,a town or school official or other similarly authorized person. Book/Page: First Name . Middle Initial Last Name Company Name OLD VILLAGE STORE OF WEST BARNSTABLE, LLC Phone Number 5083623701 Street Address 1 2455 MEETINGHOUSE ROAD Street Address 2 City/Town WEST BARNSTABLE State MA Zip Code 02668 Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)-Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class:TNC Svstem Inf®rrmati®n UNC1 . 1.PWS Street Address OLD VILLAGE'STORE PWS Name _ 2455 MEETINGHOUSE WAY I ROUTE 149 un ��•,Y.,e�- a.« _ PWS Street Address Line 1— PWS Street Address Line 2 �WESTBARNSTABLE '�MassachusettsT L02668_ City/Town State Zip Code • 508-362-3701 �-� (�._. �.�� Phone Number Fax Number(if available) Web Site Address of PWS(if available) 2.PWS Mailing Address OLD VILLAGE STORE Mailing Name L2455 MEETINGHOUSE WAY ROUTE 149 Mailing address Line 1 Mailing address Line 2 Massachusetts 02668 City/Town State Zip Code 3.Is this a Seasonal System t'Yes !o No IfYes,List the dates. Opens: 0101 Closes: 1231 MM/DD MM/DD 4.PWS Off Season Mailing Address(if applicable) - - - -- - Off Season Mailing Name Off Season Mailing address Line 1 Off Season Mailing address Line 2 City/Town State Zip Code Off Season Phone Number Off Season Fax Number(if available) Off Season Address Starts I E = I.Off Season Address Ends: MM/DD MM/DD 5.Owner/Responsible Person: This is a new owner DEVLIN -- 508-362-3701 Owners Name-First,Middle Int, Last-one name only(if not municipal): Phone Number 6.Primary Contact: This is a new contact 777 DANIEL I L__J i �DEVLIN 508-362-3701 Name(First, Middle Int,Last)•one name only- Phone Number djdevlin l @gmail.com I r - Massachusetts Department.of Environmental Protection PWSID#: 4020016 I Bureau of Water Resources(BWR)—Drinking Water Program Name: OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE L11 Reporting Year 2014 PWS Class: TNC Email Address(For Emergency Purposes) Re-enter the mail Address 7.Certified Drinking Water Operators employed by the PWS: No Data Found Name Grade License Number Function Begin- End-Date Date ITO'DD M,EVERSON -•—� 2T OITNSS/iT 22659/20481/222 9 PRIMARY DISTRIBUTION OPERATOR -;'; 4/13/2015 r__ To Add an operator, begin typing a license#in the field below. Pick the license number from the list and then click the "Add Operator'button. License Number: 8.Primary Certified Operator Contact Information: Primary Distribution Certified Operator Contact Information OODD I'"' EVERSON �� i508-89� 6 08-896-1706 5 -5109 Name Phone Number Fax Number Mailing address information is provided to MassDEP by the Division of Professional Licensure 493 AIRLINE RD- - �o � L_.._. --� ---- ---- --- -- Mailing Address 1 Mailing Address 2 IB3REWSTER ���p� Massachusetts Town/City State Zip Cade E-Mail Address Re-Enter E-Mail Address Primary Treatment Certified Operator Contact Information Name Phone Number Fax Number Mailing address information is provided to MassDEP by the Division of Professional Licensure Mailing Address 1 Mailing Address 2 _ Alabama a l � � 1 J L Town/City State Zip Code E-Mail Address Re-Enter E-Mail Address If you use a contract certified operator,does your system have a signed Public Water System Certified Operator Compliance Notice approved by the DEP r N/A r'Yes r No! Mailing address information is provided to MassDEP by the Division of Professional Licensure Mailing Address 1 Mailing Address 2 Town/City State Zip Code E-Mail Address Re-Enter E-Mail Address 9.Does your facility have tenants? rrYes 6 No Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)—Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class: TNC If Yes,please list each tenant(attach additional pages as needed)and their type of business: Business Name Type of Activity(e.g.cafe,day care, Mjghtindustry) 10.If you use a contract certified operator,does your system have a signed Public Water System Certified Operator Compliance Notice approved by the DEP Yes 11.Owner Type: PRIVATE 12.Federal Employment Identification Number(FEIN): (FEIN)-Do NOT provide SSN 13.Is this system a not-for-profit organization Yes (0- No If yes,indicate Tax Exempt code(e.g.,501C): 14.Pop ulationServed(DailyAverage): Winter Population(October March): 100 i Summer Population(April September): 250 By what method was the population Census Type: Other figured Other Description: IESTIMATE,OCCUPANCY 15.Distribution Meter information: a.Number of Service Connections: 1 b.Percentage of service connections that are metered: 100 16.System Information a.Number of Distribution Systems: 1 b.Finished Water Storage Capacity in Million Gallons(MG): 10 [Conversion factor is(#of gallons)/(1,000,000)=MG) c.Pumping Capacity(GPM): I 0 17.Cross Connection Control Program Have you surveyed all facilities within your service area for cross connection(s) L(--Yes Noo _ If Yes,when was the cross connection survey completed? s�.----� Date(mm/dd/yyyy) If No,when do you expect to finish the survey? a-�-�-- Date(mm/dd/yyyy) Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)—Drinking Water Program Name: OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class: TNC Surveyor Personnel Information To add a surveyor,enter the certification ID#in the field below and then click the"Add Surveyor"button. MassDEP Certification ID Number All testable devices are to be tested and inspected by a licensed tester(RPBP's semi-annually,DCVA's annually).If there are any RPBP's or DCVA's installed at this facility,list the testable device locations and 2014 test dates(attach additional pages if necessary). RPBP Devices Device Location I Test#1(for Reporting Year) I Test#2(for Reporting Year) DCVA Devices LDevice Location I Test Date(for Reporting Year) 18.Emergency Response Actions: a. Has your system completed an Emergency Response Plan(ERP).(DO NOT submit your ERP to MassDEP.MassDEP will review the ERP during your next sanitary survey.) T Yes (o No I have made changes to the ERP(attach copies of all changes.) r I have made no changes to the ERP. b. Does your system have an Emergency Response(ER)annual training plan EYes (0 If Yes, please use the eDEP attachment feature to submit the plan.Describe the training performed during the reporting period, including the types of training,the date(s)of training,and number of staff and local officials trained on each date and their job titles. c.Is your system registered for the Health and Homeland Alert Network(HHAN) r Yes 6 No d. Has your system signed the agreement and joined the Massachusetts Water and Wastewater Agency Response Network C` Yes 0 No e. How often does your system test the following Alarms: Other Frequency: Interlocks: Other Frequency: Back-up power sources: � Other Frequency: f.List and describe all Level 3 or higher ER incidents during the reporting period. Date of ER incident I Level I Description X.Comments or additional information regarding this section: NEW OWNER AS OF 3/11/2015.NEW OPERATOR AS OF 4/13/2015.INFORMATION HEREIN BASED ON WORK DONE UNDER PREVIOUS OWNER. _ Massachusetts Department of Environmental Protection PWSID#:4020016 • ''A Bureau of Water Resources(BWR)—Drinking Water Program Name: OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class: TNC Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(B1MR)-Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class:TNC Water Production & Consumption Information How to report in Gallons vs..Million Gallons When Converting gallons to Million gallons,decimal point moves 6 places to the left. If Reporting in Gallons(Gal)If Reporting iin Million Gallons(MG) Example 1 45,562,100 45.5621 Example 2 340,212 0.340212 Example 3 631,020,000 631.02 Example 4 96,543 0.096543 Volume Units _allons(GAL) Million Gallons(MG) r No Meter FINISHED Water Production and Consumption Summary for Reporting Year: Finished Water means water that is introduced into the distribution system of a public water system and is intended for distribution and consumption without further treatment,except as treatment necessary to maintain water quality in the distribution system(e.g.booster disinfection,addition of corrosion control chemicals). (4)Netfirfished Water 2 Amount of finished 3 Amount of finished that entered our (1)Amount of finished ( ) ( ) y Month water from own water purchased from water sold to other distribution system(1) sources(GAL) other systems(GAL) systems(GAL) +(2)-(3)=(4)(GAL) January L1,720--_—� - �� 1,720 ---� February 4,460 --� —�� �4,460 March �3, 440 (00 _�s- 107 3,840 � 1 April 2.310 �{{ (L�0 � 1 2,310 May 2,000 0 10 M 2,000 June 2,910 _ I SOS' 0 -® 2,910 _—� July 260 � .� i� B 2,260 August 1,900J �0 - rt m if 1,900 September 4,600 —�1 � October 3,400 3,400 November 12,850 �� �0 2,850 December 175 s� 10 3,756 TOTAL E36,000 0 Maximum Daily Finished Water Consumption: Volume(GAL):= I Dater i Massachusetts Department of Environmental Protection PWSID#: 4020016 Bureau of Water Resources(BWR)—Drinking Water Program Name:OLD VILLAGE STORE ILI ' Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class: TNC RAW Water Production and Consumption Summary for Reporting Year: Raw Water means water in its natural state,prior to treatment and is usually the water entering the first treatment process of a water treatment plant. r Same as finished water(it is not necessary to complete Table if same volume— as above Month (1)Amount of raw water (2)Amount of raw water (3)Amount of raw water (4)Net raw Water pumped from own purchased from other sold to other systems Consumption(1)+(2)- sources(GAL) systems(GAL) (GAL) (3)_(4)(GAL) January o ____�. �� _] 10 r February 0 0 '0 March I0 _ _� �01� April L�__. .. m � May ��0 _ Imo—__ June ro— July 0s_ ---i 0 tQ August I� L = September LE _ �! October 0 �- 1 110 November 0 � 0®s-� 0 p� December �� _ lIFT 0� ®�sa TOTAL Maximum Daily Raw Water Pumping: Volume(GAL):F Date: Summary of Water Sold Sold Water System Name r_ IPWS ID# Total Volume Sold (Water type Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)—Drinking Water Program Name: OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class: TNC Metered Finished Water Consumption by Service Type U.S. EPA requires every PWS to report what their water is used for in order to characterize each system. In this table, report the percentages of metered water for each category below,ONLY for those categories over 10%. For municipal water suppliers, most of the water will be reported as Residential Area. If any other categories are more than 10%of your metered use,report it in the appropriate category.If any category is less than 10%,do NOT report it.The precentage do NOT have to add to 100%,since water use in some categories will be less than 10%and therefore is not reported. ONLY report uses for categories over 10% of total metered use. Report ALL metered water use in the Water Management Distribution System Form(if appropriate) % Primary Type Primary Type Service % Service Area Area (7,Yes Day Care Center (" Yes Other Residential Yes Dispenser 1 070 t? Yes Other Transient Yes Homeowners Association t' Yes Recreation Area r Yes Hotel/Motel r Yes Residential Area Yes Highway Rest Area r Yes Restaurant Yes Industrial/Agricultural t Yes Retail Employees {' Yes Interstate Carrier Yes School t' Yes Institution r Yes Sanitary Improvement District (',Yes Medical Facility El Yes Summer Camp r Yes Mobile Home Park r Yes Secondary Residences t' Yes Mobile Home Park,Principal Residence C Yes Service Station r Yes Municipality Yes Subdivision C Yes Other Area C Yes Water Bottler Yes Other Non-Transient Area I LD I Yes Wholesaler ElYes Commercial X.Comments or additional information regarding this section I Massachusetts Department of Environmental Protection PWSID#:4020016 t Bureau of Water Resources(BWR)—Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class:TNC Source Protection 8 IWPA IWPA_ 1.Mass DEP assigned IWPA ID#: 111513 IWPA Radius in Feet#: 1422 2.DEP Source IDs and Names of the withdrawal points in IWPA. Source Zone Zone SourcelD Pollution Sources Comments Name Radius Control i BUILDING,ROAD, PWS DOES NOT HAVE ZONE I CONTROL ZONE I HAS I 4 0200 1 6-01G WELL#1 100 N PARKING PARKING LOT,COMMERCIAL BLDGS,RD WELL#I 3.MassDEP SWAP Program Identified Potential Sources of Contamination(PSC),please update with current water supply protection area inventory information. i PSC Description Quantity Ground Threat Comments RAILROAD TRACKSNARDS 1 H RESIDENTIAL FUEL OIL STORAGE NUMEROUS M RESIDENTIAL LAWN CARE/GARDENING NUMEROUS M RESIDENTIAL SEPTIC/CESSPOOL NUMEROUS M STORMWATER.DRAINS/RETENTION BASINS NUMEROUS L i TRANSPORTATION CORRIDOR 1 M 4.Did your inspections of the IWPA identify any new land uses or activities that pose a threat to drinking water quality? No ..�.:.o If YES, please describe: 5.Did your inspection identify any violations of state or local land use controls? Yes r If YES,please describe the violation(s),reporting and resolutions: 6.If YES,did you report those violations to the municipality(i.e.building inspector,board of health,planning board)? � es f:No Comments or Additional Information regarding this section: LIMassachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)—Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class:TNC Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)—Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE 4 Reporting Year 2014 PWS Class:TNC Treatment Plants No Data Found Comments or additional information regarding this section Massachusetts Department of Environmental Protection PWSID#:4020016 r- Bureau of Water Resources(BWR)-Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class:TNC Pump Stations Pump _ ----_- ---- 1.Pump Information WELL#1 PUMPING STATION MEETINGHOUSE WAY Pump Station Name Location Status: IA ��l Availability: ACTIVE Number of Pumps: 1 Number of Emergency Pumps: p Raw or.Finished Water: Fa MaximumAggregate Capacity(Gallons per , 6 -- --- Minutes): . Standby/Emergency Power: N - Primary Pump Details Suction Type: �-1 Suction Head ft): Suction Size(inches): L _ Motor Horse Power: 1 Motor Type: SUBMERSIBL Motor Control: - Discharge Type: - � Discharge Size(inches): Installation Date � � Model#: ELL- Pump Manufacturer: I GOULD _ � a 2.Related Sources Table(if applicable) �4020016-01 G �� j ELL#1 L �_ - Comments or additional information regarding this section Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)—Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class:TNC St®r_aae_Facilities-- Show all storage facilities Storage Facility Edit Delete 30 GALLONS AMTROL TANK N— vN ^N"u ;BASEMENT OF STORE — ry Storage Facility Name Location Status: �A F_ �vy R� j Availability: ACTIVE E Storage Type: HYDROPNEUMATIC STORAGE TANK Capacity(MG): l M_ Material: STEEL Installation Date ; —( s. - Comments or additional information Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)-Drinking Water Program Name:OLD VILLAGE STORE ' Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class:TNC Ground Water Sources Individual Ground Water Source Statistics - -------- --- - - - -- Source ID: 4020016-01G Source Name:I�i WELL#1 Location: RTE 149 BARNSTABLE Status: A Source Availability: ACTIVE Withdrawal Units: GAL Latitude: 41.706633 January: a 1,720j Longitude:- 70.374485 - February: --+ 4,460� Source Watershed: CAPE CO9 March: _ 3,840�� Well Type: GRAVEL-PACKS April 132 0 Well Depth(ft.):(�a 0 �j May: 2,000 Well Casing Height ft):C-0 June: Well Casing.Depth(ft.): �_ 1 July:�, 2,260� Screen Length ft): ®0 August:� -Y 1,900 September: _ a Pump Setting(ft):= 0 October: 3,4001 November: —�— 2,885 Approved Daily Pumping _ _ December: _ Volume(MGD): � 0 j L._______._._ 3,750' Source Metered: _. Yes Total Amount Pumped:[_= 360 0 Date of Meter Total#of Days Pumped:W _ Installation: 365 Type of water metered _ Maximum Single Day for source: RAlN Pumped Volume: Last Meter Calibration: Date of Maximum -'-�� Amount Pumped:L---- Massachusetts Department of Environmental Protection PWSID#:4020016 -' Bureau of Water Resources(BWR)—Drinking Water Program Name: OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class: TNC Comments or additional information regarding this section 2014 WATER METER READINGS RECORDED BY PREVIOUS OPERATOR UNDER PREVIOUS OWNER. Massachusetts Department of Environmental Protection PWSID#:4020016 Bureau of Water Resources(BWR)—Drinking Water Program Name:OLD VILLAGE STORE Public Water Supply Annual Statistical Report City:WEST BARNSTABLE Reporting Year 2014 PWS Class:TNC Purchased Water Sources No Data Found Comments or additional information regarding this section .7/2/2015 eDEP-MassDEP's OnlineFiling System MassDEP Home i Contact i Privacy Policy MassDEP's Online Filing System Usemame:TODDEVERSON Nickname:EVERSONTODD CAW= N y r—DEP Foratts99', My Profiteuk Help Not1fications Receipt Forms Attach Files Signature Receipt b Summary/Receipt print receipt FExit Your submission is complete. Thank you for using DEP's online reporting system. You can select"My eDEP" to see a list of your transactions. DEP Transaction ID: 753915 Date and Time Submitted: 7/2/2015 12:04:06 PM Other Email : Form Name: Public Water System Annual Statistical Report PWS ID: 4020016 PWS NAME: OLD VILLAGE STORE SIGNATURE: Todd Everson System Information (TNC)(4020016) Water Production & Consumption Information(4020016) Source Protection - IWPA (4020016) Treatment Plants(4020016) Pump Stations(4020016) Storage Facilities(4020016) Ground Water Sources(4020016) Purchased Water Sources(4020016) My eDEP MassDEP Home i Contact Privacy Policy MassDEP's Online Filing System ver.12.15.1.0©2015 MassDEP https:/Iedep.dep.mass.gov/Pages/PrintReceipt.aspx 1/1 . rt , „ _,x . . , ,, .:r -. ,. ..�..:�. w> ., 'r`+'7<^waap+i•s+ ,:e>._. -io.-..�.-w.,�:._,> .Film+} _n. .ra._%+::,- r:+s ` '- , - - .,:-., s ,.:.. , u y i}' :, .. w y " ,. ... ,.Ii , u v_ - -.. _ i . . . .. } v.' , - , ., .: : i � : Y ,1�"-.4IIL I,--W.�'"Q'-�1-I�--,1.,�I i.'—1,p,-.:,��-;,I 0 1,,I-I Y I.,�t-1,--I;'�1,,---.,i1,�.��-�I'to��-:I.,I,,I,-I I,..�..-�I�I t-.,--.:-,,�---,T-I 1,;,,-I�":II,�,�-'A�1�:��,-!,:�-I,�"1,,�"�1"L-t-,:�',�I,I-1 I�--�-,�1��,-�I,,I A',,--��.-�,,,,"�*..1--,-,,�I�.1��-.,,—z.�1!-,I'-�.�,,A-,;,,"--�.�-����--�1,'��.,;��.:I��-I�—�:�--.j�:--�,I��!�"I1,,�.iI I:o.--*,:7I A-N,.�`-��-�,��-t-:,v�.W.,.,-I�j-.-I Y,�-,I I.-:.'�",�--,��T��,�..a�:,.,,—7':I.I:.--.k-*1�_�1,"�--�"—,a--�".:I,:-"!.,1 7,�I.�-:.I-N.,:-:-,-r-1-."����.-7:,-�.I.:"1,�—�:.�,I---I,--�-�.;I,�;,.I1,."a,t,-�7:-1--�"�,�-�,.�',-",P�I 1�1:�-��I,-I I n:���:�.�.I;�:,.-Av:v::-i,,1��,:.&-I,.-�,--,1 W I,I-",�.,a�,.--'I-,,�"-,'-y-��,,.o-.I,��-.--"1,��, e .. ,.:: - - , -: _ a }f: ,. n,,. 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